Chapter 1. LONG ESSAYS (10 MARKS) : 15.206.227.228 - 02-June-2021 09:40:43

Chapter 1.
LONG ESSAYS (10 MARKS)

Table of Contents
........................................................................................................................................................ 3
................................................................................................................................................ 3
NURSING DIAGNOSIS—1 ................................................................................................................. 5
NURSING DIAGNOSIS—10 ............................................................................................................... 7
................................................................................................................................................ 8
.............................................................................................................................................. 10
Objective/planning ..................................................................................................................... 33
Nursing intervention .................................................................................................................. 33
Objective ................................................................................................................................. 37
Intervention .............................................................................................................................. 37
Objective ................................................................................................................................. 38
Intervention .............................................................................................................................. 38
Objective ................................................................................................................................. 38
Intervention .............................................................................................................................. 38
Objective ................................................................................................................................. 39
Intervention .............................................................................................................................. 39
Objective ................................................................................................................................. 39
Intervention .............................................................................................................................. 39
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Objective ................................................................................................................................. 39
Intervention .............................................................................................................................. 39
Nursing diagnosis ...................................................................................................................... 40
Nursing interventions ................................................................................................................. 40
Health Teaching to Prevent Complications .................................................................................... 42
Nursing interventions ................................................................................................................. 44
.............................................................................................................................................. 57
.............................................................................................................................................. 65
.............................................................................................................................................. 65
.............................................................................................................................................. 66
.............................................................................................................................................. 76
1. Answer the following about pyogenic meningitis.
a. List the Aetiology
b. Pathophysiological basis of clinical manifestations.
c. Nursing care of patient with pyogenic meningitis who is unconscious and whose body temperature ranges
between 103°F and 104°F.
a. Aetiology of pyogenic meningitis
Meaning: Meningitis is an inflammation of the layers of meninges (pia and arachnoid usually).
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Aetiology
• Causative organisms for pyogenic meningitis is meningococci—commonest (above 4 years), pneumococci (above
45 years) streptococci, Haemophylus influenzae (with in 4 years) and others
• Middle ear infection (commonest)
• Droplet infection from nasopharynx, sinuses, mastoid
• Infection from the danger area of the face
• Cerebral abscess, embolism, head injury, infection from the scalp, etc.
• Certain viruses.
Predisposing factors
• Chronic malnutrition
• Poverty
• Overcrowding
• Immunosuppression from AIDS
• Carcinomatosis
• Splenectomy
• Asplenia
• Diabetes
• Chronic alcoholism
• Pneumonia
• CSF shunts
• Invasive procedures such as lumbar puncture and cranial surgeries.
a. Pathophysiology and clinical manifestation
Due to above cause the causative organisms enter the brain and cause infection. As a result the pia-arachnoid is
congested and infiltrated with inflammatory cells. A thin layer of pus forms and this may later organise to form
adhesions. These may cause obstruction to the free flow of CSF leading to hydrocephalus or may damage the cranial
nerves at the base of the brain. The CSF pressure raises rapidly the protein content increases and there is cellular
reaction, which varies in type and severity according to the nature of the inflammation and the causative organism.
Clinical manifestation
Clinically in average cases of meningitis the following three stages are seen:
1. Stage of meningeal irritation
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• Temperature is raised to 102°F to 104°F (39 to 40 Centi), which may be associated with slight chill. This occurs
within 2 days of infection.
• Headache, which is tremendous, bursting or splitting in type localized in the occipital or at times in the frontal
region. It may radiate upwards and downwards in the neck. This is a characteristic symptom of meningitis.
• Restlessness and irritability.
• Photophobic patient lies keeping his backside towards the light or keep the eyes closed in presence of light.
• Delirium, convulsion and meningeal cry.
• Generalized flexed attitude, hudded up position may be seen.
• Neck or cervical rigidity.
• Kerning's sign is positive. After flexing the hip joints at right angle if the leg is tried to be extended at the knee,
spasm of the hamstring muscles will prevent it and patient complains of pain when conscious.
• Brudzinski's sign.
Neck sign: During flexing the neck both the lower limbs are flexed.
Leg sign: During testing for Kernig's sign in one leg, opposite leg will be flexed.
• Tachycardia
• Respiratory rate is normal or hurried.
• Pupils are irregular and irregularly react to the light.
• 40 per cent of patient develop a rose rash, which may be petechial and purpuric in nature.
• Reflexes planter reflex is flexor in type jerks is brisk sphincteric reflexes are normal.
1. Stage of meningeal compression
• Headache becomes more intense, convulsions and vomiting starts, it is projectile in nature.
• High temperature continues, patient gradually becomes drowsy and confused.
• Pulse rate becomes slow and bounding.
• Respiration may show Cheyne-Stokes or Biot's type of breathing.
• Neck rigidity and Kernig's sign are present.
• Pupils are slightly dilated but still react to light.
• Oculomotor palsy particularly bilateral 6th nerve palsy may develop.
• Plantar reflex may become extensor, jerks are still brisk and sphincteric retention develops.
• Ophthalmoscopic examination may reveal papilloedema
1. Stage of coma or paralysis
• Patient becomes deeply comatose.
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• High temperature, increased respiratory rate and pulse rate.
• Neck rigidity and Kernig's sign may disappear.
• Pupil's are widely fixed and do not react to light.
• Limbs are flaccid, planter reflex is extensor, jerks are lost.
• Involuntary evacuation of urine and faces may develop.
• Papilloedema becomes prominent.
• Bedsores may develop.
a. Nursing care of patient with pyogenic meningitis
NURSING DIAGNOSIS—1
Ineffective airway clearance related to accumulation of secretions.
Maintaining the airway
• Position the patient in a lateral or semiprone position, which permits the jaw and tongue to fall forward and thus,
facilitates drainage of secretions. Unconscious patient must not be allowed to remain on their back.
• Tracheotomy or endotracheal incubation may be necessary.
• Suctioning is performed to remove secretions.
• Under medical direction, elevate the head of the bed to 30° angle helps to prevent aspiration of secretions.
• The chest is auscultated periodically for crackles, rhonchi or absence of breath sounds.
Altered body temperature hyperpyrexia related to the infectious process.
Attaining thermoregulation.
High fever in the unconscious patient may be caused by pyogenic meningitis.
• Remove all bedding over the patient (with possible exception of a light sheet.)
• Switch on the fan and open the windows.
• Application of cold sponge.
• The use of the hypothermia blanket and equipment is usually effective in controlling neurogenic hyperthermia.
• Administer repeated doses of antipyretics as prescribed.
Altered fluid and nutritional balance related to inadequate fluid and diet.
Attaining fluid and nutritional balance.
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An unconscious patient is unable to ingest oral fluids or meet nutritional requirements. So nasogastric feeding has
to be started.
• When feeding a patient nasogastrically it is important to aspirate the stomach before feeding.
• A residual exceeding 50 ml may result in gastric distension and vomiting. If possible the patient head should be
elevated and the patient given 100 to 150 ml of preparatory feed, gradually increasing until 400 to 500 ml are given
at each feeding.
• An unconscious patient requires high protein and adequate fluids in the order of 2000 to 2500 ml a day.
• If patient has increased body temperature, then increase the fluid intake.
Potential for altered oral mucous membrane related to pooling of secretion.
Maintaining healthy oral mucous membranes.
• Regular oral care to the patient prevents the risk of parotitis.
• The mouth is cleansed with mouth sponges or swabs to remove secretions and crusts and to keep the membranes
moist.
• Apply a thin coating of white paraffin on the lips, which prevents lip drying, cracking and the formation of
encrustations.
Potential for altered skin integrity related to impaired mobility.
Maintaining skin integrity.
• To prevent skin break down special attention is given to an unconscious patient because they are insensitive to
external stimuli.
• Use wrinkle free bed.
• Position the patient once in every 2 hours.
• Avoid dragging the patient in the bed because it creates a shearing force and friction on the skin surface.
• The patient's nails should be kept well clipped to prevent skin damage.
• Maintaining correct position is important so, use of footboard prevents foot drop and eliminates the pressure of
bedding on the toes. Trochanter rolls supporting the hip joints keep the legs in a good position. The arm should be
abducted, the fingers lightly flexed and the hand in a position of slight supination.
Potential for altered corneal integrity sensory deficit.
Maintaining corneal integrity.
• Some unconscious patients lie with their eyes open and have inefficient or absent reflexes. So clean the eyes with
cotton wool ball moistened with sterile normal saline to remove debris and discharge.
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• Instill artificial tears every two hours.
• Ensure that the patient's eye does not come in contact with bedding.
• Pull the skin on the corner of the eye towards the side so that the eye will be closed and then apply a plaster so
that the eye remain closed.
Potential for urinary retention related to lack of innervation.
Preventing urinary retention.
• The unconscious patient is either incontinent or has urinary retention. The patient's bladder is palpated at intervals
to determine whether urinary retention is present.
• If there are signs of urinary retention insert an indwelling catheter and attach to a closed drainage system.
• Since the catheter is a major cause of urinary infection, the patient is observed for fever and cloudy urine.
• Inspect the area around the urethral orifice for suppurative drainage, and regular urethral toilet.
• To prevent traction of the urethra, the urinary catheter should be attached to the inner thigh of a female patient and
either to the abdomen or horizontally to the side of a male patient.
• An external penile catheter (condom catheter) can be used for the unconscious male patient who can urinate
spontaneously, although involuntarily.
Altered bowel function related to innervation. Promoting bowel function.
There is a risk of diarrhoea from infection, antibiotics and hyperosmolar fluids. Frequent loose stools are also an
indication of faecal impaction. Immobility and lack of dietary fibre may cause constipation.
• The nurse should monitor the number and consistency of bowel movements and perform a rectal examination for
signs of faecal impaction.
• The patient may require an enema every alternative day to empty the lower colon.
• Administer a glycerine suppository, which stimulates bowel emptying as per prescription.
Potential for injury related to sensory deficit. Promote safety.
• Protect the patient with padded side rails bed.
• Every measure that is available and appropriate for calming and quietening the disturbed patient should be carried
out.
• Provide complete bedrest in a railed cot and also isolate the patient.
Potential for sensory deficit related to unconsciousness.
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Promoting sensory stimulation.
• Provide diversion in the form of music or other conversation.
• Encourage loved ones to talk to the patient and attempt to arouse the patient by touching and stimulating the senses.
• Orient the patient periodically to the present situation.
• Avoid making any negative comments about the patient's status and prognosis in the patient's presence.
Self care deficit related to unconsciousness. Attaining self-care.
Unconscious patient is dependent on the nursing staff for all activities of daily living.
• Carry out the activities of daily living.
• Teach the relatives to carry out the care activities.
• As soon as consciousness returns, the nurse begins to teach, support, encourage and supervise these activities until
the patient gains independence.
Altered family process related to hospitalization.
Supporting the patients loved ones.
• Provide constant information and reinforcement about patient condition to their relatives.
• Permit loved one to involve in-patients care, if they wish.
1. Mr. Ramu 42 years, a clerk is admitted with a diabetic gangrene of the right foot, posted for below-knee
amputation.
a. List the indications for below-knee amputation.
b. Psychological preparation of Ramu and his family for the surgery.
c. Identify the three important post-operative nursing diagnosis and plan appropriate nursing actions
according to priority.
a. Meaning: Amputation is the total or partial surgical removal of extremity. Amputation is considered surgical
reconstructive procedures
Indications
1. Importance of knee joint.
2. Energy requirement for walking.
3. Helps to walk with an aid.
4. It permits more natural gait.
a. Psychological preparation of Ramu and his family for the surgery.
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The amputation is a result of trauma or an acute or chronic disease process, the patient will need to adapt to loss and
a change in body function and image.
• Grieving should be anticipated and the nurse can facilitate the patient coping with grief by developing a supportive
relationship with both the patient and family.
• Advise the patient to accept the loss of body part (i.e. depression withdrawal, denial, frustration).
• Encourage the patient as well as their family members to express their fears and concerns.
• Nurse need to clarify all their doubts and give appropriate explanation wherever required.
• Make the patient and family to recognize that modification of body image takes time.
• See that patient perceives the procedure of amputation and its effect on his lifestyle.
• Avoid giving unrealistic and misleading reassurance to the patient as well as family.
• Disability of the patient represents multiple losses for the individual and family so the nurse needs to support the
patient and family by telling them that a grief response is normal and a needed part of healing.
• Make the patient and family to know the reality of loss.
• Show other patient who has undergone with same procedure and doing their work.
• Once the patient is aware of the loss he will be out of grief.
• Advise the patient and family members that the availability of prosthesis and their use.
• Acceptance and support of the patient and loved ones through a trusting relationship during all phases of the process
will assist them in dealing with the loss.
• Support available from family and friends promote acceptance of the loss.
a. Identify the three important postoperative nursing diagnosis plans and appropriate nursing actions according to
priority
1. High risk for fluid volume deficit related to haemorrhage from disrupted surgical homoeostasis.
• Monitor the patient for systemic symptoms of excessive blood loss like hypertension, tachycardia, diaphoresis
and decreased alertness.
• Watch the patient for excessive wound drainage.
• Keep tourniquet attached to the end of bed to apply to residual limb (stumb) if excessive bleeding occurs.
• Do dressing as required using aseptic technique.
• Maintain accurate record of the bloody drainage on dressing and in drainage system.
• Monitor intake and output chart.
2. Altered tissue perfusion related to edema and tissue responses to surgery and prosthesis.
• Control oedema while elevating residual limb to promote venous return.
• Use air splint if prescribed to control oedema.
• Maintain pressure dressing while using sterile dressing secured with elastic bandage.
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• Intimate to the surgeon if rigid cast dressing comes off.
3. Altered body comfort pain related to surgical procedure and phantom sensation.
• Assess patients pain experience.
• Administer prescribed medication to control postoperative pain.
• Use non-pharmaceutical pain management techniques like progressive muscle relaxation and imagery.
• Inform the patient that if he/she feels increasing discomfort intimate immediately, because it may indicate
presence haematoma infection or neurosis.
• Anticipate complaint of pain and sensation located in the missing limb (phantom pain).
• Encourage patient activity to decrease awareness of phantom limb pain.
• Reassure patient that phantom limb pain will diminish over time.
1. Mrs. Shanthi is admitted with chronic renal failure and is being treated with haemodialysis.
a. Explain the principles underlying haemodialysis.
b. Explain the diet instructions shanthi need to follow.
c. List the complications of chronic renal failure.
a. Meaning: Haemodialysis is a process of cleansing the blood of accumulated waste products. It is used for patients
with end-stage renal failure or for acutely ill patients who require short-term dialysis.
Principles
The objective of haemodialysis is to extract toxic nitrogenous substances from the blood and to remove excess water.
1. Vascular access
It is necessary to maintain an extracorporeal circulation for haemodialysis.
Two principle techniques are used:
• Double-lumen catheters placed in major veins: Veins accessed include the internal jugular, subclavian and the
femoral. Lifespan of these catheters is often limited, due to thrombosis or infection.
• Scribner shunts: These consist of Teflon tips and siliconised rubber tubing placed to connect an artery and a vein,
at the ankle or wrist. The tubing is then separated for connection to the dialyser.
1. Anticoagulation
Haemodialysis machines are equipped to infuse heparin at a rate sufficient to prevent clotting of the extracorporeal
circuit. The efficiency of anticoagulation is monitored by the activated clotting time (ACT).
1. Dialysis prescription
The duration of each cycle is 3 to 4 hours; either daily in catabolic patients or alternate days can treat most patients.
Dialysis regimes are adjusted to maintain a predialysis urea concentration less than 30 mmol/litre, adequate control of
potassium and phosphate and normal extracellular fluid volume status.
a. Explain the diet instruction Shanthi need to follow.
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• Advise the patient that the fluid allowance is depended on urine output plus 1000 ml.
• Advise the patient to restrict protein intake to 1.0 to 1.5/kg of ideal body weight. (IBW).
• For all clients with renal failure at least 70 per cent of protein intake should come from eggs, milk, poultry and
meat. Because these foods are considered to have high biological value, because they contain the essential amino
acids.
• 100 gm of carbohydrates and an appropriate amount of fat are prescribed to maintain an intake of 2000 to 2500
calories per day.
• Lowering the protein intake decreases the metabolic end products of urea, potassium, phosphate and hydrogen.
• Commercially prepared products that are high in calories and low in protein, sodium and potassium are available.
These products containing only the essential amino acids can also be used as dietary supplements.
• The amount of sodium restriction is 2 to 4 gm so that patient should be instructed to avoid foods known to be
high in sodium such as cured meat, pickled foods canned soups and stews, frankfurters cold cuts, soya sauce.
• The amount of potassium restriction is 40 to 70 mg. Foods with high potassium levels that should be avoided are
dried fruits legumes, oranges, bananas, melons, deep green and deep yellow vegetables, beans and peas.
• Protein, sodium, potassium, phosphorus and fluids are controlled to meet each client's needs.
• Protein sources should be of high biological value.
• Sufficient calories and nutrients are provided to meet daily requirements.
• With in the limit, allow the patient to choose food and fluids intake.
• Provide hard candy, gum, and lollipops to improve taste.
• Provide frequent mouth care.
• Monitor blood, weight, urea, nitrogen, serum creatinine, albumin, and total protein and serum electrolytes.
a. List the complications of chronic renal failure
• Hypertension
• Hyperhomocysteinaemia
• Hyperlipidaemia
• Left ventricle hypertrophy
• Congestive heart failure
• Stroke
• Hyperkalaemia
1. a. What is cardiac catheterization?
b. How is the patient prepared for cardiac catheterization?
c. Identify the probable complications of cardiac catheterization and the preventive measures. (1+3+6=10
marks)
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a. Cardiac catheterization
Meaning: Cardiac catheterization is an invasive diagnostic procedure in which one or more catheters are introduced
into the heart and selected blood vessels in order to measure pressures in the various heart chambers, to determine the
oxygen saturation of the blood by sampling specimens and to detect any obstruction in the normal path of blood flow.
a. Preparation of patient for cardiac catheterization
Cardiac catheterization is an investigation procedure performed in a cardiac catheterization laboratory by a cardiologist,

and it takes from 90 minutes to 3 hours.
• Explain the procedure and its purposes to the patient who has been admitted to hospital the day before investigation.
• Ask the patient to sign a consent form once the investigation has been fully explained to him.
• Prepare the catheter insertion site aseptically by shaving.
• Explain to the patient the sensations he/she is likely to experience during the procedure that is dizziness as the dye
is injected, and the table will move during the positioning, palpitations and hot flushes because of the dye.
• Administer sedative to the patient as prescribed to ensure adequate sleep at night.
• Advise the patient to fast for to 6 hours before the procedure.
• Administer prophylactic antibiotics as per instructions.
• Administer premedication as prescribed.
• The day of investigation collect all ornaments or valuables and hand over to the family members or keep under lock
and key as per institution policy.
• Ask the patient to remove any if any dentures.
• Provide O.T. gown to the patient to wear.
• Escort the patient from ward to the cardiac catheterization department.
• Attach ECG leads for constant monitoring.
• Prepare the catheter insertion site aseptically and drap the patient with sterile towel.
• Cardiac catheterization is a relatively simple technique usually requiring only a local anaesthetic and mild sedation
for the patient.
a. Probable complication and preventive measures
Cardiac catheterization imposes more patient risk. Although infrequent, complications can become life threatening.
Observe the patient closely during the procedure and afterward until he/she is stable. Keep in mind that some
complications arise in both left sided and right-sided catheterization others result only from cauterization of one side.
Left or right sided catheterization
a. Cardiac tamponade
• Perforation of heart wall by catheter.
b. Arrhythmias
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• Cardiac tissue irritated by catheters.
c. Haematoma or blood loss at insertion site
• Bleeding at insertion site from vein or artery damage.
d. Hypovolaemia
• Diuresis from angiography contrast medium
e. Infection (systemic)
• Poor aseptic technique.
• Catheter contamination
f. Infection at insertion site
• Poor aseptic technique
g. Myocardial infarction
• Emotional stress induced by procedure
• Plaque dislodged by catheter tip that travels to a coronary artery.
• Occlusion of diseased artery by contrast media or catheter during procedure.
h. Pulmonary oedema
• Excessive fluid administration
i. Reaction to contrast medium
• Allergy to iodine
Preventive measures
• Cardiac catheterization is performed based on need only.
• Watch the puncture (or cut down) sites for haematoma formation and check the peripheral pulses in the affected
extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity every
15 minutes for one to two hours and every one to two hours until stable after catheterization.
• Evaluate extremity temperature and colour and any patient complaints of pain, numbness or tingling sensations in
the affected extremity to determine signs of arterial insufficiency. Report changes promptly.
• Watch for arrhythmias by observing the cardiac monitor or by listening to the apical heart rate.
• If protocol requires see that the patient remains in bed with little movement of the involved extremity until the
following morning.
• Report any complaint of chest discomfort immediately.
• Discomfort at the site is expected.
Administer pain medication as prescribed.
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1. a. Explain the clinical manifestations in acute appendicitis with a supportive rationale. (5 marks)
b. How will you prepare your client for an emergency surgery. (5 marks)
a. Meaning: Appendicitis is an inflammation of the appendix, a narrow blind tube that extends from the inferior part
of the caecum.
• Acute appendicitis begins with poorly localized colicky abdominal pain. This is due to midgut visceral discomfort
in response to appendiceal inflammation and obstruction.
• Pain first noticed in the periumbilical region.
• Central abdominal pain is associated with anorexia, nausea and usually one or two episodes of vomiting which
follow the onset of pain (Murphy sign).
• The patient often gives a history of discomfort.
• With progressive inflammation the parietal peritoneum in the right iliac fossa becomes irritated producing more
intense, constant and localized somatic pain.
• Coughing or sudden movement exacerbates the right iliac fossa pain.
• During the first 6 hours there is rarely any alteration in temperature or pulse rate. After that, slight pyrexia (37.2-37.7
degree centigrade) with corresponding increase in pulse rate to 80 or 90 usual. In 20 per cent of case there is no
pyrexia or tachycardia.
• There are two clinical syndromes of acute appendicitis, i.e. catarrhal (non-obstructive appendicitis and acute
obstructive appendicitis).
• The acute obstructive appendicitis is characterized by a much more acute course. The onset is abrupt and generally
abdominal pain from the start.
• The temperature may be normal and vomiting is common. So signs and symptoms may mimic acute intestinal
obstruction. The cardinal features are, low-grade pyrexia, localized abdominal tenderness, muscle guarding and
rebound tenderness.
• Pointing sign is present, i.e. on inspection of the abdomen may show limitation of respiratory movement in the lower
abdomen. Then ask the patient to point where the pain began and to where it moved.
• Mc Burney's point is present, i.e. on gentle superficial palpation of the abdomen, beginning in the left iliac fossa
moving anticlockwise to the right iliac fossa, will detect muscle guarding over the point of maximum tenderness.
• Rovsing's sign is also present, i.e. deep palpation of the left iliac fossa may cause pain in the right iliac fossa.
• Presence of psoas sign, i.e. when patient lie with the right, hip flexed for pain relief this is due to an inflamed
appendix lies on the psoas muscle.
• Emergency surgery: It is a situation requires immediate surgical intervention. Here surgical intervention involves
removing the appendix (i.e. appendectomy) within 24 to 48 hours of onset of symptoms.
Prepare for surgery

i. Psychosocial aspects of preparation: All patients are somewhat fearful of surgery. Mainly due to fear of unknown,
post-operative pain, the hazard of death, anaesthesia hazards, financial security, and the problem of being separated
from loved ones and former activities.
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• Almost all patients feel helpless when first admitted into the hospital.
• Preoperative patients are given proper explanations about hospital routines, visiting hours, mealtimes, the location
of the chapel, etc.
• Give full explanation of all procedures that the patient may undergo, which will help to reduce anxiety and fear.
• The patient should be made aware of the reasons for X-ray and laboratory procedures, how they will be performed,
and what discomfort may be experienced. The reasons for all nursing measures are explained. It is believed that
the calm, emotionally prepared preoperative patient is able to withstand the induction of anaesthesia better and
also experiences less postoperative nausea and vomiting and fewer postoperative complications.
ii. Physical examination: A complete physical examination should be performed to all patients, paying special
attention to cardiac and respiratory systems.
iii. Preoperative diagnostic tests: Carry out the routine diagnostic tests and specific tests ordered to the client based
on their health status to identify potential problems that would interfere with the surgery.
iv. Informed consent: Any one undergoing any invasive procedure must sign a permit. This legal document signifies
that the client is giving informed consent for the procedure.
v. Preoperative teaching: Preoperative teaching is an important aspect of the patients surgical preparation. Well-
informed patients have less difficulty in undergoing anaesthesia and have a shorter, less complicated postoperative
hospital stay. Preoperative teaching decreases anxiety and encourages clients to participate actively in their own
care. These are deep breathing, coughing, turning and extremity exercises.
vi. Preparing the skin: This main idea is to reduce the number of bacteria that will be carried into the deeper tissues
from the skin when surgeon makes the incision.
• The areas of the preparation should always be wider and longer than the area of the proposed incision, because
the surgeon may unexpectedly need to make a longer incision.
• The area around the surgical site should be cleaned through either by shaving or by using depilatory cream.
vii.Preparing the patient gastrointestinal tract: The patient's gastrointestinal tract needs special preparation before
surgery. Its main aim is to reduce the possibility of vomiting and aspiration during anaesthesia and also prevent
contamination from faecal material during surgery. Gastrointestinal tract is prepared as fallows:
• The restriction of foods and oral fluids is essential to prevent vomiting during surgery so patient should have
nothing by mouth (NPO) that is the solid food must be with held 7 to 10 hours before the surgery.
• Patient who is extremely deliberated or malnourished may receive intravenous infusion of glucose amino acids
or plasma up to the movement of the surgery.
• Two or three enemas are generally given the evening prior to operations to prevent contamination of the peritoneal
cavity from the spillage of faecal matter during surgery.
• Tubes for gastric or intestinal suction are sometime inserted in order to remove gastric or intestinal contents.
viii.Preparing for anaesthesia: The anaesthesiologist usually visits the patient and examines generally for evidence of
pulmonary problems or upper respiratory infections and investigates the patient's smoking habits then he discusses
with patient and plans the type of anaesthesia to be given.
ix. Preparing the patient for operation theatre
• Administer preoperative medications as ordered.
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• Records vital signs.
• Ask the patient to void before the surgery.
• Give the patient oral hygiene and remove any dentures.
• Remove and store the patient's jewellery.
• Dress the patient in a clean gown, covering the hair.
• Remove colored nail polish, because the operating room personnel frequently check the patient's nail beds for
cyanosis.
• Check the patient's identification band for accuracy and to make certain that it is secured.
• Administer preoperative medications to allay anxiety, decrease the flow of pharyngeal secretions, reduce the
amount of anaesthesia to be given, and create amnesia for the events that precede surgery.
• Send the patient to operation theatre with all the patient's documents accompanied by a nursing personnel.
1. a. What are the causes and clinical features of intestinal obstruction? (2 marks)
b. How are the patients prepared for laparotomy? (4 marks)
c. Explain the nursing interventions after surgery? (4 marks)
a. Intestinal obstruction
Meaning: Intestinal obstruction occurs when intestinal contents cannot pass through the GI tract and it requires prompt
treatment.
Causes: It is classified into mechanical and non-mechanical.
Mechanical: In this common causes are:
• Adhesions (this develops normally after abdominal surgery).
• Hernias (strangulated inguinal hernia).
• Neoplasm's.
• Carcinoma is the most common cause of large intestine obstruction followed by volvulus and diverticular disease.
• Pseudo-obstruction is an apparent mechanical obstruction caused by collagen vascular diseases and neurological
and endocrine disorders (mostly found in idiopathic).
Non-mechanical: It results due to neuromuscular or vascular disorder.
• Paralytic (a dynamic) ileus (most common cause)
• Some degree of abdominal surgery
• Inflammatory reactions like acute pancreatitis, acute appendicitis, electrolyte abnormalities, and thoracic or lumbar
spinal fractures.
Clinical manifestations
There are 4 cardinal features:
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• Pain
• Vomiting
• Distension
• Constipation
1. Pain: First symptom, occurs suddenly and severe.
• Colicky in nature and usually centered around the umbilicus (small bowel) or lower abdomen (large bowel).
• Pain coincides with increased peristaltic activity.
2. Vomiting: The content of the vomitus depend on the site of obstruction. As obstruction progresses the character of
the vomitus alters from digested food to feculent material due to the pressure of enteric bacterial overgrowth.
3. Distension: In small bowel the degree of distension is dependent on the site of obstruction and is greater the more
distal the lesion.
• It is delayed in colonic obstruction and may be minimal and absent in the presence of mesenteric vascular
occlusion.
4. Constipation: This may be classified as absolute (that is neither faeces nor flatus is passed) or relative (where flatus
is passed)
• Absolute constipation is a cardinal feature of complete intestinal obstruction.
Other manifestations
1. Dehydration: Because of the loss of water and sodium chlorides in the ileum. Common in small bowel obstruction
due to repeated vomiting and fluid sequestration. This results in dry skin and tongue, poor venous filling and sunken
eyes with oliguria.
2. Hypokalaemia: A low potassium level in the blood due to dehydration.
3. Pyrexia: Presence of obstruction may indicate:
• The onset of ischaemia.
• Intestinal perforation.
• Inflammation associated with the obstructing disease.
4. Abdominal tenderness: Localized tenderness indicates pending or established ischaemia.
a. Preparation of the patient for laparotomy
Laparotomy is the term used to describe any operation that involves opening the abdominal cavity.
• Provide psychological support to the patient while giving appropriate explanation.
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• Naso-gastric tube may be used to decompress the bowel. Naso-gastric tubes should be inserted before surgery to
empty the stomach and relieve distension.
• Decompression of the large intestine should be attempted unless necrosis or perforation is present. Enemas, rectal
tubes, sigmoidoscopy, and colonoscopy may be used.
• Colon-decompression catheters may be passed through partially obstructed areas via a colonoscope to decompress
the bowel before surgery.
• Intravenous infusions that contain normal saline solution and potassium should be given to maintain fluid and
electrolyte balance.
• Total parental hyperalimentation may be necessary in some cases to correct nutritional deficiencies.
• Improve the clients’ nutritional status before surgery.
Refer Question Number - 5
a. Nursing intervention
• Provide the patient a left lateral position to prevent aspiration of the vomitus and secretion.
• A client should be monitored closely for signs of dehydration and electrolyte imbalance.
• A strict intake and out put record should be monitored.
• Four fluids should be administered as ordered.
• Serum electrolyte levels should be monitored closely.
• Clients are often restless and constantly change their position to relieve the pain. Analgesics are often with held
until the obstruction is diagnosed. Because they mask other signs and symptoms and decrease intestinal motility.
• The nurse should provide comfort measures, promote a restful environment and keep distractions and visitors to
a minimum.
• Nurse assists with insertion of intestinal tubes it is easier if patient relaxes, takes deep breaths and swallows when
instructed.
• Check the patency of the drainage tubing.
• Check the amount and colour of the drainage.
• Check for any oozing of secretions from the site of surgery.
• Mouth care is important, because vomiting leaves a terrible taste in the client's mouth and faecal odour may be
present.
• Encourage the patient to brush teeth frequently.
• Apply jelly or water soluble lubricant for lips.
• Check the nose for signs of irritation from the nasogastric tube. This area should be cleansed and dried daily with
application of water-soluble lubricant. Check nasogastric and intestinal tubes for every 4th hourly for patency.
1. Mrs. Rathnamma, 65 years, is admitted for colostomy.
a. List the indications for colostomy?
b. What are the types of colostomy?
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a. Discuss the nursing management of a patient after colostomy?
a. Meaning: Colostomy is an operation in which an artificial opening is made into the colon as the anterior abdominal
wall to permit the escape of faeces and flatus.
Indications
• Ulcerative colitis
• Colorectal cancer
• Crohn's disease
• Polyps of the large intestine
• Diverticular disorders
• Peritonitis
• Large bowel obstruction
• Strangulated and necrotic hernia
• Adhesions that cause bowel dysfunction
a. Types
1. Temporary and permanent colostomy
If the colostomy was done to relieve an obstruction which can be corrected by a resection of the bowel or to divert
the faecal stream to permit healing of a portion of the bowel it will be a temporary colostomy.
A permanent colostomy is usually performed in conjunction with an abdominoperineal resection. After the sigmoid
colon is resected the proximal end is brought out through the abdominal wall and sutured to it to form a permanent
opening for the elimination of faeces.
2. Double: Barreled, loop and end colostomy
• In double barrel colostomy the colon is resected and both ends are brought through the abdominal wall, creating
two stomas. The proximal stoma is where stool is eliminated. The distal stoma is non functional and is often
called a mucous fistula.
• A loop colostomy is made when a loop of bowel is brought out above the skin surface and held in place by a
plastic rod. This prevents the colon from slipping back into the abdominal cavity.
• An end colostomy consists of a single stoma from the proximal end of the severed colon, with removal of the
distal portion of the bowel.
3. Wet and dry colostomy
Dry colostomy refers to an opening of the left side of the colon where the faecal content is usually soft and formed.
Wet colostomy refers to an opening of the right side where the faecal content is liquid.
Nursing management
Stoma care
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• The stoma should be pink in colour. A dusky blue stoma indicates ischaemia and brown-black stoma indicates
necrosis.
• The nurse should assess and document stoma colour every 8 hours until the stoma remains pink for 3 days.
• Apply a skin barrier to protect the peristomal suture line and skin surrounding the stoma.
• The skin should be washed with warm water and dried thoroughly before the barrier is applied.
Care of skin
• Protect the skin with an open-ended, transparent, plastic, odour-proof pouch.
• Observe and collect the drainage.
• Select the pouch that, it should fit snugly to prevent leakage around the stoma.
• Advise the patient to bathe or shower before putting on the clean appliance.
• Apply a tape to the sides of the flange to keep secure during bath.
• Pat the skin with a gauze pad to dry completely, taking care to avoid rubbing the area.
• Apply the skin barrier around the stoma to the skin from faecal drainage.
Care of drainage bag
• Measure the stoma to determine correct size of the bag.
• Select the pouch that should be 0.6 cm larger than the stoma.
• Clean the skin and apply a skin barrier before pouch is applied.
• To control odours arising from the body excreta, insert a readily soluble deodourizing tablets in the appliance.
• Powdered charcoal, two crushed aspirin tablets or a teaspoon of baking soda may be sprinkled into the bag to absorb
odours.
• Ask the patient to assume a comfortable sitting or standing position and gently push the skin down from the adhesive
flange while pulling the bag up and away from the stoma.
• Apply gently pressure, which prevents traumatizing the skin as well as preventing the spillage of any liquid faecal
contents.
• Record the volume, color and consistencies of the drainage.
• Each time the appliance changed observe the skin for irritation or excoriation.
Nutritional needs
• Advise the patient to take a low residue diet to decrease the amount of bulk and undigested food, to allow the stoma
and bowel to heal and also to decrease the swelling from surgery.
• Teach the patient to avoid foods that cause gas (beans, cabbage, onion, sprouts and cheeses) odour (eggs, garlic,
fish, cabbage, alcohol), diarrhoea (alcohol, beer, cabbage, spinach, green beans, coffee, spicy foods, fruits (raw)) or
that are causing constipation (nuts, popcorn, seeds chocolate, vegetables (raw), celery, corn).
• Advise the patient to take 1 to 2 litres of fluid daily.
Colostomy irrigation
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The colostomy irrigations will stimulate the bowel to function at a specific time everyday or every other day.
• The patient who establishes regularity may need to wear only a pad or cover over the stoma.
• The patient who cannot or chooses not to establish regularity by irrigations must wear an appliance at all times.
• All equipment should be assembled before the irrigation.
• Provide a comfortable position making the patient to sit in chair in front of the toilet.
• Clear tubing of all air by flushing it with fluid.
• Attach tubing to irrigating cane.
• Hang the container on hook or IV pole 40 to 53 cm above the stoma.
• Apply irrigating sheath and place bottom end in bedpan or toilet bowl.
• Lubricate catheter.
• Insert catheter 7 to 10 cm.
• Release clamp or squeeze bulb to begin flow give only 500 ml of warm water at first. Gradually increase amount
each day to 1000 ml maximum.
• Allow the solution to flow slowly over 15 minutes.
• Clamp the tubing and remove irrigating tip when the desired amount has entered.
• Allow 20 to 30 minutes for the solution and feces to be expelled close off the irrigating sheath at the bottom to
allow ambulation.
• Cleanse, rinse and dry peristomal skin well.
• Replace the colostomy drainage pouch.
• Wash and rinse all equipment and hang to dry.
Self care concept
• Teach the patient and family members the procedure and to take a return demonstration.
• See that the patient is able to identify all necessary equipment and supplies used for colostomy irrigation.
• See that the patient fallows skin care, odour control, and stoma care, identifies signs and symptoms of complications
and also knows the importance of fluids and food in the diet.
• Assess and instruct the patient in irrigation procedure.
• Advise the patient to accept the ostomy.
• Provide psychological support to the patient while concerning about body image, sexual activity family
responsibilities and changes in lifestyle.
• Ask the patient to verbalise his feelings freely and allow him to talk with another person who has an ostomy to
know the personal feelings.
Education to the patient and family
• Educate the family regarding the need for adjustment.
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• Encourage the patient and family to verbalise their concern.
• See that the patient and family understand about the care of stoma, type of food intake and use of appliances before
they return home.
• See that the patient and family is tension free and relaxed before going to the home.
• Review the stoma care and irrigation procedure from the patient before discharge from the hospital.
• Instruct the family members that who are close to the patient should assume responsibility for purchasing the
equipment and supplies that will be needed at home for colostomy irrigation.
Prevention of complications
• Advise the patient to loss weight if she is obese because this may cause prolapse of the stoma.
• Instruct the patient to follow proper stoma irrigation procedure to prevent perforation.
• Advise the patient to follow proper skin and stoma care and also to avoid constipation because stoma retraction
faecal impaction and skin irritation are the common complications of colostomy.
• Advise the patient to take medications as prescribed with out fail.
• Educate the patient to do deep abdominal breathing and coughing exercises to prevent pulmonary complications
like pneumonia and atelectasis.
1. a. Define congestive cardiac failure (CCF)?
b. Clinical manifestation of patient with left sided heart failure?
c. Medical and nursing management of patient with CCF? (1+2+7 = 10 marks)
a. Definition: Congestive cardiac failure (CCF) Is defined as the pathophysiologic state in which impaired cardiac
function is unable to maintain an adequate circulation for the metabolic needs of the tissues of the body. It may be
acute or chronic. The term congestive heart failure in which the patient has evidence of congestion of peripheral
circulation and of lungs.
b. Clinical manifestation of left sided heart failure:
Left sided failure results from ventricular dysfunction, which causes blood to back up through the left atrium and
into the pulmonary veins.
• Increased heart rate
• Left ventricular hypertrophy
• Poor oxygen exchange
• Pulmonary oedema
• Dyspnoea (shallow respiration up to 32 to 40/min)
• Orthopnoea, paroxysmal nocturnal dyspnoea
• Cough (dry hacking caused by alveolar irritation from fluid accumulation
• S3 heart sound (from vibrations of ventricle wall due to resistance to ventricular filling).
a. Medical management: The basic objectives in the treatment of patient with cardiac failure are the following:
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• To promote rest in order to reduce the workload on the heart.
• To increase the force and efficiency of myocardial contraction through the action of pharmacological agents.
• To eliminate the excessive accumulation of body water by means of diuretic therapy diet and rest.
1. Digitals: It is a treatment of choice in case of CCF. It increases the force and strength of cardiac contraction and
also decreases the conduction speed within the myocardium and slows the heart rate. This action provides more
complete emptying of the ventricles thus diminishing the volume remaining in the ventricles during diastole. The
digoxin normal dose is 1 to 2 ng/ml. The topical heart rate is taken before digitalis is administered.
• The serum digitalis level is checked by the nurse before administering the drug.
2. Diuretic: It is used in heart failure to mobilize oedematous fluid, reduce pulmonary venous pressure, and reduce
preload. If excess vascular volume is excreted, blood volume returning to the heart can be reduced and cardiac
function is improved. Thiazide diuretics are usually the first choice because of their convenience, safety, and
effectiveness. It should be administered in the morning.
• The intake and output chart should be maintained.
• Record weight daily to know the effectiveness of treatment.
• The skin turgor is examined for evidence of oedema or dehydration.
3. Vasodilator: It is replacing digitalis therapy as the primary treatment for clients with CHF who also have normal
sinus rhythm. These drugs reduce systemic vascular resistance and pulmonary and peripheral venous pressure.
4. Diet: Sodium restricted diet is indicated for the prevention, control or elimination of oedema in cardiac failure.
• Advise the patient to take low-sodium diets and not to use or buy processed foods.
Nursing management
Promotion of Rest
• Provide complete bed rest (both physical and mental) to the patient which reduces the work of the heart, increases
heart reserve and reduces blood pressure.
• Provide a semi-Fowler's positions to relieve dyspnoea.
• Support the lower arms with pillows to eliminate the fatigue.
• If the patient has orthopnoea make the patient to sit on the side of the bed with feet supported on a chair, the heads
and arm resting on an over the bed table and lumbosacral spine supported by a pillow.
Relief of anxiety
Because of inability to maintain adequate oxygenation, patients in cardiac failure are apt to be restless and anxious.
They feel breathlessness and it become exaggerated at night.
• Raise the head of the patient bed and keep a night light on.
• Instruct the family members or close friend to be there with the patient always to provide necessary reassurance.
• Observe the patient always for possible respiratory irregularities like Cheyne– Stokes respiration if it is present test
the effect of oxygen inhalations administered as prescribed each night just before the hour of sleep.
• Administer small doses of morphine as prescribe for extreme dyspnoea.
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• Provide physical comfort as much as possible to the patient.
• Advise the patient and family to avoid situations that tend to promote anxiety.
Attainment of normal tissue perfusion

• Advise the patient to do moderate daily exercise which in turn help the blood flow to peripheral tissues.
• Adequate oxygenation and appropriate diuretic will also help to provide good tissue perfusion.
• Encourage the patient to take adequate rest, which is essential to promote adequate tissue perfusion.
• Advise the patient to prevent bedsore, phlebothrombosis and pulmonary embolism.
Change the position every 2 hours to practice deep breathing and leg exercises and to use elastic stockings which
will help venous return to the heart.
Knowledge about self-care

• Plan and teach activities of daily living to the patient to minimize breathlessness and fatigue.
• Instruct the patient that when his unable to tolerate breathlessness and fatigue associated with normal activities meet
the doctor for advise.
Health education
• Encourage the patient gradually to resume the normal activities.
• Encourage the patient to avoid activities that precipitate the symptoms.
• Encourage the patient to take adequate rest while having regular rest period, shortening working hours and avoiding
emotional upsets.
• Instruct the patient to take medications as prescribed and to use salt restricted diet.
• Encourage the patient to increase walking and other activities gradually and also see that they do not cause fatigue
and dyspnoea.
• Advise the patient to avoid extreme heat and cold which increases the work of the heart.
• Advise the patient to be alert for reappearance of previous symptoms if it is present meet the doctor.
• Encourage the patient to report immediately to the doctor if he/she experiences gain in weight, loss of appetite,
shortness of breath on activity, swelling of ankles, feet or abdomen, persistent cough, frequent urination at night.
• Educate the patient that cardiac failure can be controlled if the patient follows prescribed therapeutic programme,
careful follow-up, maintenance of correct weight, sodium restriction, prevention of infection, avoidance of noxious
agents such as coffee and tobacco and avoidance of unregulated or excessive exercise all aid in preventing the onset
of cardiac failure.
1. a. What do you mean by bronchiectasis?
b. Write the signs and symptoms?
c. Write the medical and nursing management? (1+3+6 = 10 marks)
a. Meaning: Bronchiectasis is defined as an abnormal and a irreversible dilation of the bronchi and broncholes.
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b. Signs and symptoms: It can be localized or generalized.
• Chronic cough with foul smelling sputum production, haemoptysis and recurrent pneumonia.
• Sinusitis is common.
• Rupture of the pulmonary vessel leads to massive haemoptysis. Haemoptysis may be mild sticky or massive
depending upon the rupture.
• Clubbing of fingers.
• Crepts, metastatis abscess (often to the brain).
• Amyloidosis and cor pulmonale are late complications occurring in cases uncontrolled for years.
• Repeated episodes of pulmonary infection
• Exertional dyspnoea, fatigue, weight loss, anorexia, and fetid breath.
c. Medical management
• Specific treatment (treatment of cause, e.g. if TB, treatment of TB, if IgA deficiency, treatment with
immunoglobulins)
• Antibiotics for the treatment of infection
• Bronchodilators (if excessive secretions are present because it causes obstruction)
• Postural drainage and mucolytic agents.
Nursing management
i. Ineffective breathing pattern related to increased airway resistance caused by mucus production.
• Provide comfortable position while giving bed rest in high Fowler's position.
• Administer bronchodialtors as ordered.
• Administer humidified oxygen.
• Auscultate breath sounds every 1 to 2 hours.
• Premedicate the patient with bronchodialtors before doing deep-breathing and coughing exercises or chest
physiotherapy.
• Teach the patient to breath slowly and deeply through the nose and to exhale 2 to 3 times through pursed lips.
ii. Ineffective airway clearance related to ineffective cough excessive mucus production and fatigue.
• Monitor and control enviournment for possible allergens like dust, smoke and flowers.
• Auscultate, percuss and palpate lungs to assess sounds.
• Assess patient's ability to cough effectively.
• Teach effective cough techniques.
• Administer bronchodialtors and chest physiotherapy as ordered.
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• Observe and note character and quantity of coughed or suctioned sputum and secretions.
iii. Activity intolerance related to fatigue secondary to exertion and inadequate oxygenation
• Evaluate fatigue in relationship to work of breathing.
• Plan 1 to 2 hours of rest periods.
• Provide total care for client at onset with progressive self care as tolerated.
• Provide small amounts of liquids, progressing to soft diet.
iv. High risk for respiratory infection related to increased pulmonary function and ineffective airway clearance.
• If sputum is muco-purulent, obtain sputum Gram's stain and culture and sensitivity.
• Administer antibiotic as prescribed.
• Monitor vital signs every 4th hourly.
• Provide deep breathing and coughing exercises.
• Monitor all respiratory treatments that are administered.
v. Altered health maintenance, knowledge deficit related to maintenance of health.
• Administer bronchodialtors as ordered.
• Assess patient's response to bronchodialtors, hydration and increased activity.
• Assess patients understanding and develop teaching plan for home care including proper balance of rest and
activity, names, actions, side effects, frequency and dose of prescribed medications.
• Advise the patient to take adequate fluid intake.
• Explain the factors that may contribute to infections and assist in planning preventive measures.
• Instruct the patient to rest in bed to prevent over exertion.
• Advise to avoid chilling and excessive fatigue.
• Advise the patient to maintain a proper oral hygiene.
• Instruct the family members to serve foods to the patient in a attractive manner because foods that are appealing
may increase the desire to eat.
• Educate the patient and family about the availability of measures and pertusis vaccines, because this prevents
the future occurrence bronchectasis.
• Advise the patient to stop smoking and to decrease exposure to pollution.
1. Mr. Kareem is admitted with second-degree burns of chest, back, neck and both hands.
a. How do you calculate percentage of burns? (2 marks)
b. Discuss fluid plan. (2 marks)
c. Explain the care of burn wound. (6 marks)
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a. To estimate the total body surface area burn, the “Rule of nines” is used. This measures the percentage of the body
burned by dividing the body into multiples of nine. According this formula the percentage of burns is calculated
as follows:
Head and neck – 9 per cent

Chest and abdomen – 18 per cent
Back – 18 per cent
Both hands – 18 per cent
Both legs – 18+18 per cent
Perineum – 1 per cent
Total – 100 per cent
Mr. Kareem got burn of chest, back, neck and both hands:
Chest – 9 per cent

Back – 18 per cent
Neck – 1 per cent
Both hands – 9 + 9 = 18 per cent
Total = 46 per cent
Mr. Kareem got 46 per cent of burns.
b. Fluid plan
1. Consensus formula – 2 to 4 ml/kg/%BSA
= half to be given first 8 hr
Second half to be given next 16 hr.
2. Evan's formula – 1 ml/kg body weight × BSA. Half to be given first 8 hr.
3. Brooke Army formula – 4 ml/kg body weight/BSA. Half to be given first 8 hr. Second half to be given next 16 hr.
4. Parkland/Baxter formula – 4 ml/kg body weight/BSA. 1/3rd to be given first 8 hr 2/3rd to be given next 16 hr.
According to consensus formula, if patient weight is 60 kg then 2 ml × 60 × 46 per cent of burns = 5520 ml.
Out of 5520 ml half, i.e. 2760 ml is to be given in first 8 hours, second half to be given over next 16 hours.
a. Care of burn wound
Care of burn wound is different in each phase.
Emergent phase: In this phase the goal of wound care are to; cleanse and debride the area of necrotic tissue and
debris that would promote bacterial growth. Minimize further destruction to viable skin. Promote client comfort.
• Cleaning and debridement can be done in bed during this procedure, loose, necrotic skin is removed and large
blisters may be opened to eliminate media for bacterial growth.
• All burned areas with hair (except eyebrows) should be shaved, including the head and perineum.
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• Daily shaving is required to minimize pathogen accumulation.
• Clean the wound with the surgical detergent, disinfectant or cleansing agent and also patient may be cleaned 2 times
daily to limit the amount of bacterial growth.
• Infection is the most serous threat, which causes sepsis, to control this, open and closed method of wound treatment
is used.
• In open method the patient burn is covered with a topical antibiotic and has no dressing.
• In closed method uses sterile gauze dressings impregnated with or laid over a topical antibiotic.
• The dressing is changed 2 to 3 times every 24 hours.
• When wounds are exposed nurse should wear mask gown and gloves.
• Use sterile gloves while applying ointments and dressings.
• Nurse should follow careful hand washing technique to prevent cross-infection.
Acute phase
In this stage wounds are observed daily.
• Active debridement of wound care done by nursing staff.
• If the eschar is thick and hard as in full thickness burns a grid escharotomy is performed.
• Eschar is removed down to subcutaneous tissue or fascia, depending on the degree of injury. Then the graft must
be placed on clean viable tissue to achieve good adherence.
• Donor skin is taken from the patient for grafting by means of a dermatome, which removes a thin layer of skin
from an unburned site.
Rehabilitation phase
In this stage the patient and family will be caring the burn wound.
• Nurse has to instruct the patient and family about the need for dressing and wound care.
• Advise the patient to apply an emollient cream (e.g. Nivea) routinely on healed areas to keep the skin supple and
to decrease itching and flaking.
• Inform the patient the need for reconstructive surgery (for major burns) before leaving the hospital.
1. a. What are the indications of urinary diversion? (5 marks)
b. What are the different approaches for urinary diversion? (5 marks)
a. Meaning: Urinary diversion is the removal of urinary bladder (cystectomy) with diversion of the urine to an external
device.
Indications
• To treat cancer of the bladder
• To treat neurogenic bladder
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• To treat congenital anomalies
• To treat strictures, trauma to the bladder
• To treat chronic infections with deterioration of renal function.
a. Different approaches for urinary diversion
1. Ureterosigmoidostomy—here ureters are excised from bladder and anastomosed into sigmoid colon.
Urine flows into colon and empties via rectum.
Advantages
• No need for external drainage appliance
• Urinary control via rectum.
Disadvantages
• Urination via rectum is necessary every 2 to 3 hours.
• Absorption of fluid and electrolytes via bowel mucosa takes place.
• Possibility of hypochloremic acidosis.
• Possibility of reflux from colon to kidney.
• High risk of ascending urinary tract infection
1. Ileal conduit—ureters are implanted into part of ileum or colon that has been resected from intestinal tract,
abdominal stoma is created.
Advantages
• Good urine flow with few physiological alterations.
Disadvantages
• External appliance is necessary to drain urine continually.
1. Cutaneous ureterostomy—ureters are excised from bladder and brought through abdominal wall, and stoma is
created. Ureteral stomas may be created from both ureters or ureters may be brought together and one stoma is
created.
Advantages
• No need for major surgery as ideal conduit.
Disadvantages
• External appliance is necessary because of continuous urine drainage.
• There is possibility of stricture or stenosis of small stoma.
1. Nephrostomy: Insertion of catheter into pelvis or kidney, procedure may be done to one or both kidneys.
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Advantages
• No need for major surgery.
Disadvantages
• High risk of renal infection.
• Predisposition of calculus formation from catheter.
1. Mr. Kumar 50 years old businessman is admitted for CVA.
a. What are the causes for the CVA? (4 marks)
b. Nurses role in rehabilitation of Mr. Kumar. (6 marks)
a. Meaning: A CVA is the abrupt or rapid onset of neurological deficit resulting from disease of the blood vessels that
supply the brain. A CVA is a sudden loss of brain function from disruption of the blood supply to a part of the brain.
Causes
i. Cerebral thrombosis: Cerebral arteriosclerosis and slowing of the cerebral circulation are major causes.
ii. Cerebral embolism: The emboli usually lodge in the middle cerebral artery or its branches where it disrupts the
cerebral circulation.
iii. Cerebral ischaemia: Insufficiency of the blood supply to the brain is mainly due to atheromatous constriction of
the arteries supplying the brain.
iv. Cerebral haemorrhage: Rupture of a cerebral blood vessel with bleeding into the brain tissue or spaces surrounding
the brain. Haemorrhage may occur outside the dura mater (extradural/epidural), beneath the dura mater (subdural),
in the subarachnoid space (subarachnoid) and with in the brain substance (intracerebral).
a. Explain the nurse's role in the rehabilitation of Mr. Kumar
Meaning: Rehabilitation is the process of maximizing the client's capabilities and resources to promote optimal
functioning related to physical, mental, and social well-being.
Goals of rehabilitative management:
• To prevent deformity
• To maintain function, and
• To restore function.
Nurses role: Rehabilitation begins on the day the patient has the stroke, the care is intensified during the rehabilitative
phase requiring a multi disciplinary team approach, the nursing staff are in a good position to reinforce the care given
by physiotherapists and the speech therapist.
1. Position the patient to prevent deformity: Correct positioning in bed is of prime importance in preventing abnormal
positioning which could lead to increased spasticity contractures and pressure sores and a reduction in patients
opportunity to achieve maximum potential:
• To position the patient a pillow is placed in the axilla to prevent adduction of the affected shoulder. Pillows are
placed under the arm, which is in a slightly flexed position with each joint positioned higher than the preceding
one.
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• Carefully place patient in positions to oppose the developing spasticity. As an alternative to the supine and lateral
positions the upright position may be used as the patient progresses.
• Change the patient's position every two hours, and best be achieved by rolling the patient from side to side.
• The amount of time spent lying on the affected side may be limited, because of impaired sensation.
• A posterior splint may be applied to the affected limb at night to prevent flexion of the affected extremity during
sleep.
• A palmar splint may be applied to the flaccid upper extremity to support the hand and wrist in a functional
position.
• A sling to be applied on the affected arm if the patient complains of pain or if the arm is very flaccid, but the nurse
must ensure that the patient continues to exercise the affected arm and the affected arm supported on a pillow.
2. Retraining the affected extremities through exercise.
The affected extremities are exercised passively and put through a full range of movement four or five times a day to
maintain joint mobility, prevent contractures, gain motor control, prevent further deterioration of the neuromuscular
system and to enhance circulation.
• Encourage the patient to exercise the affected limbs at interval throughout the day to prevent contractures.
• Supervise and support the patient to move and turn.
• Encourage frequent short periods of exercise.
• Encourage relatives to become involved in the patient care.
3. Gaining independence in activities of daily living, because the patients loss of sensory/perceptual ability:
• Approach the patient from the unaffected side.
• Place bedside table, a call bell for awareness.
• Place affected limbs within field of vision.
• Increase tactile sensation to affected side by touching, stroking.
• Avoid referring to right and left if spatial disorientation is a problem.
• Encourage the patient to turn head from side to side.
• Ensure the patient that he can wear spectacles if required.
4. To restore language function:
• The patient should be given psychological support as much as possible.
• While communicating the patient, the nurse should face the patient and establish eye-to-eye contact.
• The nurse should speak slowly, in short phrases, pausing in between.
• Ensure that the patient understands what is being asked.
• Conversation should be confined to practical matters and supplemented with gestures.

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• Consistency is important, so the same word or gesture is repeated, each time instructions are given and questions
are asked. Sensory inputs should be given while providing communication cards and visual pictures. Encourage
to read and write and to use games, videos, and television to stimulate interest.
5. To restore swallowing:
• Observe for any vomiting, regurgitation or diarrhoea.
• Institute oral feeding on the return of the cough and swallow reflexes.
• Remind patient to chew on the unaffected side. Inspect mouth for food collecting between cheek and gums.
• Give frequent oral hygiene.
6. Elimination
• Establish and maintain a bladder and bowel management programme.
• Attend to patients promptly when they need to eliminate.
• Reassure the patient that regaining control of elimination will become established.
• Encourage independence in patients attending their own elimination needs.
7. Preparing for ambulation:
As soon as possible the patient is assisted out of bed. A hemiplegic patient tends to loss the sense of balance and
needs first to learn sitting balance before learning to stand.
• Adjust the height of the bed.
• Assist the patient into the sitting position by swinging legs over the side of the bed.
• Ensure the feet are flat on the ground.
• Increase sitting time as rapidly as the patient's condition permits. Once sitting balance is achieved, standing
balance is developed.
• To achieve standing balance, place chair parallel to the head of the bed on the patients affected side.
• Patient should wear strong, supportive walking shoes.
• Place the patient into a sitting position then help the patient come to the standing position.
• As soon as standing balance is achieved patient is ready to walk and nurse needs to assist.
• Use parallel bars when patient start to walk.
• A chair should be ready when patient feels sudden fatigue or dizziness.
• If the patient cannot manage ambulation, the physiotherapist can acquire a wheel chair to suit a particular patient.
8. Achieving self-care:
• Encourage the patient for personal hygiene as soon as possible.
• The nurse should carry out all self-care activities on the unaffected side.
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• The nurse should encourage activities that can be carried out with one hand, such as combing the hair, shaving,
brushing teeth and eating.
• Encourage the patient for dressing.
9. Discharge:
The nurse should arrange a home visit with an occupational therapist and physiotherapist to assess the need to make
home adaptation.
10.Education of relatives and friends:
Close relatives and friends should be given advise concerning the expected outcome, and although they should be
sympathetic and supportive throughout rehabilitation phase.
1. Mrs. Rajam is admitted with lump in the right breast. Write the nursing care following mastectomy, in the
nursing process format.
Meaning of Lump: It is a benign or malignent lesion.
Meaning of Mastectomy: A surgical removal of the breast.
Ineffective individual coping related to mastectomy.
Objective/planning
Patient begins adaptation to emotional stressors
• Client utilizes resources to increase coping.
• Effective coping is identified supported and strengthened.
Nursing intervention
• Access client's stressors, resources, supports, and problem solving skill. There is a lot of hope for women with
breast lump.
• Encourage asking questions and seeking information.
• Allow time for client to verbalize fears and anxieties.
• Reinforce positive self care behaviour and each step in getting well. Ineffective coping may lead to prolong
depression or other psychiatric, social or emotional disorders.
• Refer to other professional like social worker, psychologist, family counselor and community support groups for
emotional and psychosocial counseling as needed.
Impaired skin integrity related to mastectomy and placement of drains.
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Objective/planning
• Client exhibits healing of incisions as evidenced by no drainage, no sutures present and absence of infection.
• Client demonstrates appropriate care of her incision at discharge.
• Client identifies potential complications and appropriate signs and symptoms to report to the physician or nurse.
• Assess dressing for bleeding or drainage.
• Empty drain, measure and record drainage during each shift. Note colour and consistency. Good healing is important
to the overall health and recovery of the woman.
• After dressing change observe incision for healing there should be no indications of infections, haematoma
formation, tenderness or purulent drainage. Poor wound healing or infection may cause radiation therapy or
chemotherapy to be delayed.
• Begin teaching wound care at the first dressing.
• Teach indications of infections, haematoma or recurrence of breast cancer in the incision (a growing lump).
• Instruct that after the incision heals she may massage the area with cocoa butter to keep skin soft and improve
healing. Redness, swelling will fade with time.
Impaired physical mobility related to modified radical mastectomy.
Objective/planning
• Client demonstrates knowledge related to potential modality problems.
• Client progresses toward full range of motion (ROM). Full ROM of arm and shoulder will return by 2 to 3 months
postoperatively.
• Client identifies potential complications and signs and symptoms of oedema to report to health care team.
• Assess for signs of infection or impairment of circulation. It is possible to regain full range of motion.
• Arm should be elevated on pillow when lying or sitting. Using the arm improves circulation.
• After anaesthesia wears off begin ambulation and begin flexion and extension of fingers, wrist, and lower arm.
• Begin ADL with arm on operative side. Dress self. If radiation therapy is needed the woman will need to have her
arm above her head to keep it safely out of the treatment field.
• Limit upper arm ROM to level of the shoulder only. It is possible to regain full range of motion.
• After auxiliary drain is removed begin progressive full ROM of upper arm. Because the lymph nodes have been
removed the woman is more vulnerable to trauma, oedema and infection.
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• Use pain medication as needed to allow exercise with out pain hindrance.
• Teach ROM exercises to use at home after drain is removed.
• Avoid infection and trauma to operative site and left arm. Teach hand care. Client must follow this for the rest of
her life.
• Teach client to avoid burns while cooking or smoking, avoid sunburn and insect bites, avoid cuts, pinpricks and
scratches.
• Avoid strong detergents, harsh chemicals and abrasive compounds.
• Wear protective gloves when doing dishes and cleaning.
• Instruct to contact the physician if the arm or hand becomes red and swollen or feels hot.
Altered nutrition related to vomiting and stomatitis secondary to chemotherapy.
Objective/planning
The client will take adequate nutrition as evidenced by absence of vomiting, control stomatitis, consumes adequate
calories daily and no loss of weight.
• Provide oral hygiene and topical analgesics. This helps to reduce nausea and vomiting and thus improves the dietary
pattern.
• Administer adequate dosage of antiemitics.
• Serve different taste of food in an attractive manner.
• Instruct to take high calorie and high protein foods.
• Monitor weight and dietary pattern.
Knowledge deficit regarding postoperative arm exercises, care, breast prosthesis, chemotherapy and radiation therapy.
Objective/planning
• Client understands postoperative arm exercise and care, breast prosthesis chemotherapy and radiation therapy.
• Teach the patient to perform hand and wrist movements and to flex and extend the elbow hourly.
• Encourage the self-care activities like feeding, combing hair, washing face etc and other activities that use arm.
• Help the women to meet common psychosocial, physical and cosmetic needs.
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• Help the women to wear a temporary lightweight prosthesis immediately after the sutures and drains are removed.
This may help the woman's adjustment to the loss of her breast.
• A cotton breast form or cotton padding is inserted into a pocket sewn into a lightweight brassiere is a good temporary
substitute.
• A permanent prosthesis should be introduced once the wound is completely healed.
• Educate the woman the importance of radiation therapy and chemotherapy. This clears misunderstanding about this
treatment and clarifies their doubts.
• Teach the patient about the name of medication, method of administration, side effects and its management,
complications and preventive measures. If any complication report to nurse or physician.
1. a. Explain the various types of radiation therapy? (5 marks)
b. What are the health education you will give to a patient undergoing radiotherapy? (5 marks)
a. Meaning: Radiation therapy is a high-energy ionizing radiation used to treat malignancies. Radiation therapy
may be used as a primary adjuvant or a palliative treatment modality. As a primary treatment modality, radiation
therapy is the only treatment used and provides local cure of the early stage Hodgkin's disease. In adjuvant setting,
radiation therapy can be used either preoperatively or post-operatively to aid in the destruction of cancer cells. In
addition it can be used in conjunction with chemotherapy to treat disease in sites not readily accessible to systemic
chemotherapy such as the brain.
Types of radiation therapy: It can be administered from a variety of sources. Sources can be divided into those used
outside the body (external radiation therapy) and those used inside the body (internal radiation therapy).
1. External radiation therapy: It is usually administered by high energy X-ray machines (e.g. The betatron and linear
accelerator) or machines containing a radio isotope [cobalt 60 (60 co)].
Advantages: The high-energy X-ray machines are their skin sparing effect. This means that the maximum effect of
radiation occurs with in the tumour deep in the body and not on the skin surface.
Neutron beam therapy delivered from a cyclotron particle accelerator is currently used to treat many types of cancers
including salivary gland tumours, sarcomas and tumours of the prostate and lung.
2. Internal radiation therapy: Internal radiation therapy involves the placement of specially prepared radioisotopes
directly into or near the tumour itself or into the systemic circulation. The two major types of internal radiation
therapy are the sealed source in which the radioactive material is enclosed in a sealed container and the unsealed
source in which the radioactive material is administered systematically by injection or orally.
a. Sealed-source radiation therapy (Brachytherapy): It includes intracavity and interstitial therapy. In intracavity
therapy the radioisotope usually 137 cesium or 226 radium (226 Ra) is placed into an applicator then placed
into the body cavity for carefully calculated time usually 24 to 72 hr. This therapy is used to treat cancers of the
uterus and cervix. In interstitial therapy the radioisotope of choice (e.g. iridium 192, iodine 125, 137 cesium,
gold 198, or radon 222) is placed into needles, beads, seeds, ribbons or catheters and then implanted directly into
the tumour. For example, clients with prostrate cancer may receive implanted seeds as therapy. Implants may
be left in the tumour either temporarily or permanently depending on the half-life of the radiation source used.
b. Unsealed-source radiation therapy: It is used in systemic therapy radioisotopes may be administered I.V or
orally. For eg sodium phosphate is administered I.V to treat polycythaemia vera. 131 iodine is given orally in
very low doses to treat Graves’ disease or in high doses to treat thyroid cancer.
a. Health education
• The patient who is receiving radiation therapy and his family needs to be informed about the therapy and its safety.
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• Nurse should answer to the patient question what ever he/she asks and remove their fear and tension.
• Explain to the patient about actual procedure for delivering radiation, equipment used, duration of the procedure,
possible need for immobilization during the procedure and absence of new sensation during the procedure.
• Advise the patient not to use ointments, lotions, or powders on the area. The area needs to be exposed for radiation.
• Gentle oral hygiene is essential to remove debris and prevent irritation.
• If the patient experiences systemic changes such as weakness and fatigue he/she may need assistance for activities
of daily living and personal hygiene.
• The patient should be instructed to be on bed rest while the radioactive implant is in place.
• The patient needs to be informed regarding the radiation therapy. Only the patient should be in the room where
therapy is given. So he/she should not feel isolated, because professional should not be exposed frequently only
the limited time they needs to be exposed.
1. Mr. John 20 year's college student is admitted with the history of epilepsy. Write comprehensive nursing
care of Mr. John.
Meaning: Epilepsy is a transient, excessive and abnormal electrical discharge of brain neurons.
Comprehensive Nursing Care Plan
Ineffective breathing pattern related to neuromuscular impairment secondary to tonic phase of seizure.
Objective
To clear breath sounds appropriate rate rhythm and depth.
Intervention
• Loosen constricting clothing.
• Assess breathing pattern.
• Observe for labored respiration, tachypnea, bradypnea, dyspnea, apnea and cynosis.
• Provide manual ventilation when necessary.
• Insert oral airway only after seizure activity has seized.
• Administer oxygen when needed.
• Be prepared to assist with endotracheal intubation.
• Be prepared to obtain arterial blood gases.
Ineffective airway clearance related to tracheobronchial obstruction.
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Objective
Absence of airway obstruction.
Intervention
• Observe for signs of airway constriction.
• If vomiting occurs turn client's head gently to side and remove as much vomitus as possible after the seizure.
• Suction airway if necessary.
• Administer oxygen when needed.
• Be prepared to assist with endotracheal intubation.
• Be prepared to obtain arterial blood gases.
• Establish and maintain patent airway.
• Do not permit smoking in bed.
High risk for injury related to seizure activity and subsequent impairment physical mobility secondary to postictal
weakness or paralysis.
Objective
Prevent injuries.
Intervention
• Do not permit smoking in bed.
• If client has experienced frequent seizures recently, take axillary rather than oral temperature.
• If client anticipates a seizure may occur, assist to a safe location or position.
• Remain calm with the patient.
• Use seizure precaution as appropriate.
• Remove potentially harmful objective from surrounding area.
• Gently guides arm or leg movements to prevent injury during the seizure.
• Refrain from moving or restraining client during a seizure.
• Assist in determining whether operation of a motor vehicle or dangerous machinery is appropriate for client.
• Assist with activities of daily leaving as necessary after the seizure
• Encourage mobility as tolerated.
• Provide information about the hazards of immobility.
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Impaired verbal communication related to transient aphasia secondary to postictal state.
Objective
Improve verbal communication.
Intervention
• Explain the reason for the possible transient aphasia to client and family.
• Communicate with slow simple statements in postictal state.
• Provide written documentation of communication.
Ineffective individual coping related to perceived loss of control, denial of diagnosis or misconceptions regarding
disease.
Objective
Improve the coping strategies and clarify the misconceptions
Intervention
• Explore reasons for denial.
• Implement an individualize teaching plan about causes and mechanisms of seizures, effectiveness of drugs in
controlling seizure, inaccuracy of myths about epilepsy and avoidance of precipitating factors
• Explain state law regarding driving, pros and cons of medical ID tags, moderation in drinking and eating, exposure
to stress and avoidance of hazardous activities.
Altered health maintenance related to lack of knowledge about management of epilepsy.
Objective
Improve the knowledge regarding epilepsy and its management.
Intervention
• Provide education about seizure activity and therapeutic management including diagnosis and treatment, lifestyle
adjustments and community resources.
1. Mr. Sridhar 50 years old man with cirrhosis of liver admitted in the hospital.
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a. Define cirrhosis of liver. (2 marks)
b. What are the signs and symptoms of patient suffering with cirrhosis of liver? (3 marks)
c. Explain the nursing care of the patient suffering with cirrhosis of liver. (5 marks)
a. Definition: Cirrhosis of liver is the disorganization of the liver architecture by widespread fibrosis and nodule
formation. Or cirrhosis of liver refers to scarring of the liver.
b. Signs and symptoms: Emaciation, ascites, splenomegaly, lower leg oedema, prominent abdominal wall veins (caput
medusae), internal haemorrhoids, palmar erythema, spider naevi, altered hair distribution, amenorrhoea, atrophy of
testicles, gynaecomastia, bleeding tendency, especially gastrointestinal.
• Anaemia, renal failure, infections, encephalopathy, initial or recurrent symptoms of hepatitis (Jaundice) and
oesophageal varices.
c. Nursing care
Nursing diagnosis
1. Altered nutrition less than body requirement related to anorexia, impaired liver function, decreased absorption of
fat soluble vitamins and diarrhoea.
2. Activity intolerance related to bed rest, lack of energy and altered respiratory function, (ascites pressing on fluid).
3. High risk for injury related to continued intake of hepatotoxins.
4. High risk for haemorrhage related to deficiency of clotting factors.
5. Knowledge deficit related to disease and long-term treatment.
Nursing interventions
• Complete bed rest and other supportive measures to permit the liver to reestablish its functional ability. Rest is very
important which permits the liver to restore itself by limiting the demands of the body and increase the liver blood
supply. Body weight, fluid intake and output are measured and recorded daily.
• Give Fowler's position with backrest if the patient has ascites
• Administer the oxygen if liver failure, to oxygenate the weakened cells.
• Provide a nutritious high protein diets supplemented by vitamins of the B-complex vitamin A, C, K and folic acid.
• Proper nutrition is important so every effort is made to encourage the patient to eat. Patient is encouraged to eat
small frequent meals and provide according to their likes and dislikes.
• Patient who is unable to take oral food and fluid administer nasogatric feeding or parenteral hyperalimentation.
• Administer oxygen soluble forms of fat-soluble vitamins – A, D and E according to doctors order.
• Provide low protein diet temporarily to patient who has signs of impending or advancing coma.
• Change the position frequently to prevent pressure sore. Presence of subcutaneous edema, immobility of the patient
and jaundice causes increased susceptibility to skin breakdown.
• Advise to avoid irritating soap and adhesive tape to prevent trauma to the skin.
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• Protect the patient with padded side rails. Apply pressure at injection site and avoiding injury from sharp objects,
because these patients are more vulnerable for bleeding (Diseased liver's ability to synthesis prothrombin and
substances used in blood coagulation will be decreased).
Once the patient planed for discharge the nurse should instruct the following:
• Completely to stop taking alcohol.
• Sodium restriction for larger time or permanently
• Adequate rest and well balanced diet.
• Teach the patient to change his lifestyle.
• Advise the family members to cope up with the patient while with drawing his alcohol.
1. Rani a 60-year-old woman has been admitted for the treatment of osteoporosis.
Answer the following:
a. Explain the pre-disposing factors for osteoporosis.
b. Write the specific diagnostic investigations.
c. Explain the major complications and health teaching plan to prevent those complications.
a. Meaning
Osteoporosis is a disorder in which there is a reduction of total bone mass.
The predisposing factors are:
• Advanced age
• Hereditary tendencies including blonde or red hair, freckles and fair skin
• Female
• Post-menopausal
• Thin small framed body
• Use of antacids
• Inactive or bedridden
• Use of laxatives
• Calcium deficient diet
• Cushing's disease
• Vitamin D deficiency
• Parkinson's disease
• Heavy cigarette smoking
• Dementia
• Heavy caffeine intake
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• Bilateral oopherectomy
• Alcohol consumption to excess
• Endocrine disorders
• Long-term corticosteroid use
• Type II diabetes
• Long-term heparin use
• Scoliosis
• Long-acting psychotropic drugs
• Rheumatoid arthritis with no disability
• High protein diet
• Anorexia and bulimia with resultant amenorrhoea
• Excessive exercise.
a. Write the specific diagnostic investigations
1. X-ray of the bone which shows the site of fracture, they cannot predict the loss of bone mass.
2. Bone mineral density (BMD) when the osteoporosis is not evident on X-ray this method is used. Bone density scans
or bone densitometry scan help to confirm the disease of bone mass in a particular bone in any area of the body.
3. Absorptiometry or densitometry – This test measure the bone mass in various sites in the body.
4. Serum calcium—normal
5. Serum phosphorus—normal
6. Alkaline phosphates—normal
7. Serum osteocalcium—elevated
8. Urinary calcium – Initially high, then returns to normal
9. Bone biopsy: It is performed when the diagnosis by noninvasive measure is unreliable and there is no positive
response to therapy.
a. Major Complications
1. Fracture
2. Kyphosis
3. Paralytic ileus.
Health Teaching to Prevent Complications

• An adequate calcium intake in a lifetime decreases fracture risk hence advise the patient naturally available calcium
intake particularly diary products such as milk, curd and cheese may help to prevent or slow down the onset of
osteoporosis.
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• Vitamin D plays an important role in calcium absorption and in the normal mineralisation of new bone. Our body
derives vitamin D from two sources— sunlight and food. Hence advise the patient to expose to the early morning
sunlight and to take naturally available vitamin D such as butter, eggs and fatty fish such as herring, makerel and
salmon.
• In case of female oestrogen therapy after menopause will be advised by the doctor.
• Encourage active and passive exercise. Instruct them that no immobilization.
• Ask them to do mild work but not to do strained work like lifting heavy weights etc. Because these will make the
patient vulnerable for fracture.
1. Mrs. Rupa 22 years has been admitted with 60 per cent burns of second degree.
a. How do you assess and administer the fluid requirement of this patient for the first 48 hr? (4 marks)
b. Discuss the problems can develop. Explain the preventive measures. (6 marks)
a. Meaning
An injury that results from direct contact or exposure to any thermal, chemical, electrical, or radiation source are
termed as burns.
A second degree (deep partial-thickness) burns involves destruction of the dermis and upper layers of the dermis, and
injury to deeper portions of the dermis. The wound is painful, appears red and weeps fluid. Blanching of the burned
tissue is followed by capillary refill. Hair follicles remain intact.
Fluid plan for Mrs. Rupa is as follows:
1. Consensus formula – 2 to 4 ml/kg/per cent BSA= half to be given first 8 hr
2. Evans formula – 1 ml/kg body weight/ BSA=Half to be given first 8 hr
3. Brooke Army formula – 4 ml/kg body weight/BSA = Half to be given first 8 hr.
4. Parkland/Baxter formula – 4 ml/kg body weight/BSA = 1/3rd to be given first 8 hr 2/3rd to be given next 16 hr.
Mrs. Rupa 22 years weighs approximately 50 kg for 48 hours.
According to Consensus formula
2 ml × 50 kg × 60 per cent BSA = 6000 ml In this half that is 3000 ml to be given first 8 hr.
Second half that is 3000 ml to be given the next 16 hr. For other 24 hours this can be reimplemented.
a. Problems that patient can develop
1. Potential for fluid volume excess related to resumption of capillary integrity and fluid shift from interstitial to
vascular compartment.
2. Potential for infection related to loss of skin barrier and dysfunctional host defense mechanisms.
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3. Alteration in nutrition less than body requirements related to hypermetabolism.
4. Impaired skin integrity related to thermal injury
5. Alteration in comfort pain, itching and skin and joint tightness related to exposed nerves and wound healing.
6. Impaired physical mobility related to burn wound, edema, pain and joint contractures.
Nursing interventions
1. Restoring normal fluid balance:
• To reduce the risk of fluid overload and congestive heart failure, monitor the patient's IV and oral fluid intake.
• Maintain intake and output chart and record weight daily.
• Administer cardio tonics and diuretics according to the doctors’ order to promote increased urine output.
• Position the patient comfortably with the head of the bed raised to promote lung expansion and gas exchange
(if not prohibited).
2. Preventing infection:
• Provide clean and safe environment to the patient
• Maintain aseptic technique while performing procedures like wound care, insertion of intravenous lines, urinary
catheters or tracheal suctioning.
• Protect the patient from cross contamination from other patient, staff member, visitors and equipment.
• Tube feeding, reservoirs and drainage containers are changed regularly.
• Wear mask, gown and gloves when wounds are exposed.
3. Maintaining adequate nutrition:
• Provide a diet that is high in protein and calories.
• Instruct the family members that sandwiches made with peanut, butter, meat, cheese and milkshakes may be
offered between meals and in the late evening.
• If caloric goals cannot be met by oral feeding, a nasogastric tube is inserted which can be utilized for continues
feeding.
• Vitamins A and D, trace elements such as copper and zinc and fatty acid supplements also should be administered
to the patient.
4. Improving skin integrity through wound care:
• Clean the wound and rest of the body including the hair daily.
• The nurse frequently should do wound care and dressing.
• Apply topical antibacterial agents for wound covering
• Provide donor site care
• Observe and report any signs of poor graft or loss of skin integrity after healing.
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• Provide additional nutritional support because it is essential for normal granulation and healing.
5. Relieving pain and discomfort:
• Pain is more severe in second-degree burns because exposed nerve endings are sensitive to cool, moving air. So
cover the wound with a sterile dressing.
• Offer analgesics and relaxation breathing, transcutaneous nerve stimulator or other appropriate measures.
6. Promoting physical mobility:
• Nurse should teach the patient deep breathing exercises. Turning and repositioning prevent atelecatasis and
pneumonia. It also helps to control edema, to prevent pressure sores and contractures.
• Teach the patient both active and passive range of motion exercises
• Apply splints or functional devices to extremities for contracture control.
• When lower extremities are involved apply elastic pressure bandage before the patient is placed on an upright
position.
1. Mr. Shankar aged 35 years is admitted to ICU with chest injury after a road accident. He has been taken
for an emergency operation.
a. What are the various causes of respiratory failure?
b. As a nurse how do you look after this patient in maintaining the airway?
c. What are the complications the patient can develop during the postoperative period and how do you prevent
them. (3+3+4=10 marks)
a. Meaning: Respiratory failure is a condition in which an arterial oxygen pressure (PaO2) is less then 50 mmHg and
an arterial carbon dioxide pressure (PaCO2) is greater than 50 mmHg at sea level.
It is classified into 2 types, pulmonary and non-pulmonary disorders
1. Pulmonary disorders (with in the lung)
• Severe infection
• Pulmonary oedema
• Pulmonary embolism
• Cancer
• Chest trauma
• Severe atelectasis
2. Nonpulmonary disorders (out side the lung)
• CNS disturbance secondary to drug overdose, anaesthesia, head injury
• Neurological disorders – poliomyelitis
• Spinal cord injury
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• Prolonged mechanical ventilation.
a. Nursing care:
• Assess the condition of the patient because obstruction of the airway caused by the accumulation of secretions
and or broncho-spasm occurs frequently
• Instruct the patient to cough if possible
• Position the patient by elevating the head of the bed 45° (if tolerated) or by using a reclining chair bed may
maximize thoracic expansion.
• Provide a side-lying position to the patient if there is any possibility of tongue obstructing the airway.
• Teach the patient about the coughing and breathing exercises
• Perform chest physiotherapy
• Provide ventilator support
• Administer oxygen if needed as per order.
• Place oral or nasal airway near the bedside and it can be used when necessary
• If the cough is ineffective in removing secretions, naso-pharyngeal or nasotracheal suctioning is indicated
• Suction the patient every 2 hourly
• Before suctioning hyperoxygenate the patient
• If bronchial secretions are thick, viscid or mucoid, administer sterile normal saline which liquidify the mucous.
b. Potential complications:
1. Respiratory insufficiency
2. Tension pneumothorax and mediastinal shift
3. Subcutaneous emphysema
4. Pulmonary embolus
5. Pulmonary oedema
6. Cardiac dysrhythmias
7. Haemorrhage, haemothorax, hypovolaemic shock
8. Thrombophlebitis.
Prevention of complications
Monitor for signs and symptoms of respiratory failure like increased rate of breathing, dyspnoea, use of accessory
muscles, cyanosis and restlessness.
• Monitor for signs and symptoms of tension pneumothorax like severe dyspnoea, tachypnea tachycardia, extreme
restlessness, progressive cyanosis and shift of larynx and trachea to the unaffected side.
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• Observe for subcutaneous emphysema around incision in the chest and neck.
• Assess for progression of emphyma by periodically marking the chest with a skin marking pencil at outer periphery
of emphysematous tissue.
• If neck involvement occurs measure neck circumference at least every 2 to 4 hr.
• Monitor for signs and symptoms of pulmonary embolus like chest pain, dyspnoea and fever, haemoptysis and
indication of right-sided heart failure.
• Monitor for signs of acute pulmonary oedema like dyspnoea, rales, persistent cough, frothy sputum and cyanosis.
• Monitor intravenous flow rates. Consult physician if fluid amount exceeds 125 ml/hr.
• Assess cardiac monitors.
• Assess dressing and the incisional area every 4 hr for any evidence of bleeding.
• Assess closed chest drainage system for signs of bleeding.
• Monitor for signs of hypovolaemic shock like increased pulse, decreased blood pressure, cool, pale, clammy skin,
restlessness and altered level of consciousness.
• Monitor for thrombophlebitis like unilateral leg oedema, calf tenderness, redness, unusual warmth, etc.
• Encourage client to perform leg exercises.
• Discourage placing pillows under knees, crossing the legs or prolonged sitting.
1. Mr. Ravi aged 40 years is admitted with chronic renal failure.
a. Write the clinical features of CRF. (4 marks)
b. Explain the nursing care of Mr. Shankar who is on haemodialysis. (4 marks)
c. Complications of haemodialysis. (2 marks)
a. Meaning: Chronic RF or end-stage renal disease is a progressive irreversible deterioration in renal function in which
the body's ability to maintain metabolic and fluid and electrolyte balance fails, resulting fatally in uraemia.
Clinical features of CRF

• CRF occurs suddenly in majority of patient it begins with one or more symptoms like fatigue, lethargy, headache,
general weakness and gastrointestinal symptoms like anorexia, nausea, vomiting, diarrhoea, bleeding tendencies
and mental confusion.
• Decreased salivary flow, thirst, a metallic taste in the mouth.
• Loss of smell and taste.
• Parotitis or stomatitis
• Metabolic abnormality
• Drowsy, respiration becomes Kussmaul in character
• Deep coma
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• Convulsions
• A white powdery substance, “uraemia frost”, composed of urates, appears on the skin.
a. Nursing care of patient who is on haemodialysis
I. Altered fluid volume, related to effect of ultra filtration during dialysis.
• Assess predialysis vital signs, CVP readings (if available), breath sounds, heart sounds, weight and intake and
output.
• Assess degree of fluid accumulation in tissues before dialysis.
• Determine appropriate degree and rate of ultra filtration for the treatment.
• Monitor BP every ½ hour or more often.
• Adjust degree and rate of ultrafiltration according to patient response
• Administer replacement fluids as ordered and indicated
• Administer plasma expanders if hypotension persists according to the physician prescription
• Check predialysis levels of K, Na, Ca and carbon dioxide.
• Inform physician if serum levels indicate need for change in dialysate bath components.
• Observe ECG changes and muscle weakness for signs of hypokalaemia.
• Observe for intolerance to fluid removal if both sodium levels are lower than serum level.
• Allow time for equilibrium between blood and tissue spaces if post-dialysis serum levels are ordered.
II. Knowledge deficit related to illness and need for dialysis.
• Assess patient or family's level of knowledge regarding kidney function, disease, reason for dialysis and prospect
for recovery.
• Assess ability and readiness to learn.
• Identify barriers to learning
• Provide information appropriate to the readiness and ability to learn, including functions of kidney, reasons for
patients loss of function, signs and symptoms related to loss of renal function, current treatment plan including
realistic prospects for recovery of renal function.
• Encourage patient and family members to ask questions and clarify their doubts.
III.Disturbance in self concept, feeling of lack of control related to dependency on dialysis.
• Spend time with the patient to discuss about his feelings.
• Support patient and his family through grieving process.
• Teach the patient and reinforce information about disease process and need for dialysis.
• Orient the patient to reality and explain regarding return of kidney function and need for dialysis.
• Encourage the patient to learn self care following dialysis.
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IV.Potential for injury related to vascular access and complications secondary to insertion and Maintenance of vascular
access.
• Maintain a sterile environment during catheter insertion
• After subclavian catheter insertion, obtain chest X-ray to observe for signs of pneumothorax, cardiac irregularities
or excessive bleeding.
• Check for bilateral breath sounds.
• Maintain a sterile technique in handling vascular access.
a. Complications of Haemodialysis
1. Hypotension caused by excessive ultra filtration, loss of blood into the dialyzer, dialyzer membrane
incompatibility, and antihypertensive drug therapy
2. Electrolyte imbalance
3. Infection
4. Bleeding due to heparinzation
5. Equipment problem
6. Hypovolaemia
7. Haemolysis
8. Pyogenic reaction
9. Arrhythmias
10.Dialysis disequilibrium
11.Unco-operative; denial, depression and anger
12.Pruritus
13.Hepatitis B.
1. Write the nursing process of a patient with MI.
Meaning: It is condition in which death of myocardial tissue occurs, due to atheroselerosis of the coronary arteries.
Altered body comfort chest pain related to reduced coronary blood flow.
• Assess characteristics of chest pain including location, duration, quality, intensity, and presence of radiation,
precipitating and alleviating factors. Pain is an indication of myocardial ischaemia, assisting the client in quantifying
pain may differentiate pre-existing and current pattern.
• Assess respiration, B.P. and heart rate with each episode of chest pain. Respirations may be increased as a result of
pain and associated anxiety. Release of stress induced catecholamines will increase heart rate.
• Obtain 12 lead ECG on admission then each time the chest pain recurs for evidence of further infarction
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• Serial ECG and stat ECG's record changes that can give evidence of further cardiac damage and location of
myocardial ischaemia.
• Monitor patient in response to drug therapy. if pain persists inform physician. Pain control is a priority as it indicates
ischaemia.
• Provide a calm and efficient care to the patient. Calm and quite enviournment decreases external stimuli, which
aggregate anxiety and cardiac strain and limit coping abilities.
• Stay with the patient untill he is relieved from discomfort and limit visitors. Which promote rest.
Altered electrical activity dysrhythmias related to electrical instability.
• Teach the patient and family about need for continuous monitoring. Continual monitoring keeps staff aware of
myocardial changes and Family anxiety is decreased.
• Keep alarms on and set limit at all times. Indicative of early cardiac decomposition and potential loss of cardiac
output.
• Assess apical heart rate. Auscultate for change in heart sound. Dysrhythmias are the most common complication
after MI. Antidysrhythmics reduce myocardial irritability. Altered potassium levels can affect cardiac rhythmic.
Administer intravenous cardiac medications in emergency.
Decreased cardiac output related to negative isotropic changes in the heart secondary to myocardial ischaemia, injury
or infarction.
• Note rhythm strips every shift if dysrhythmias occur.
• Measure pulse rate and QRS segments with each strip if any deviation in this note and report to the physician.
• Administer antidysrhythmics as ordered.
• Monitor serum potassium levels.
• Maintain a patent intravenous line or heparin lock at all times.
• Assess mental status of the patient and be alert if he/she experiences restlessness or decreased responsiveness.
• Assess lung sounds and monitor for crackles and rhonchi. Cerebral perfusions are directly related to cardiac output
and aortic perfusion by hypoxia and electrolyte and acid-base variations.
• Assess heart sounds and inform physician if the presence of gallop, murmur and increased heart rate.
• Be alert if patient's urine out put is < 30 ml/hr, presence of jugular or neck vein distension, weakness, fatigue,
decreased activity level, shortness of breath with activity and abnormalities in vital signs.
• Urinary output less than 30 ml/hr may reflect reduced renal perfusion and glomerular filtration as a result of reduced
cardiac output.
• If client has pulmonary artery catheters record haemodynamic parameters every 2 to 4 hours.
• Haemodynamic pressure reflects intra-vascular function.
• Maintain haemodynamic stability by monitoring the effects of beta-blockers and inotropic agents.
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Impaired gas exchange related to decreased cardiac output.
• Administer oxygen as ordered. Which increases amount of oxygen available for myocardial uptake.
• Monitor arterial blood gases as ordered. Presence of hypoxia indicates need for supplemental oxygen.
• Assess patients skin capillary refill, level of consciousness and vital signs every 2 to 4 hours. It provides data on
adequacy of tissue perfusion and oxygenation.
• Prepare for intubations and mechanical ventilation if hypoxia increases. Mechanical ventilation may be necessary
to oxygenate the client adequately.
Anxiety and fear related to hospital admission and fear of death.
• Limit nursing personnel and provide continuity of care. Continuity of care promotes security and development of
rapport with and trust of health care providers. Accurate information about the situation reduces fear strengthens
client nurse relation ship.
• Encourage the patient family to ask questions.
• Allow client or family to verbalize fears.
• Provide a calm quiet and comfortable environment for patients and family. Providing calm and quite environment
enhances coping mechanism as well as reduces myocardial workload and oxygen consumption.
High risk for constipation, treatment, bed rest, pain medication and nil per orally or soft diet.
• Provide adequate bulk food in the diet and adequate fluid intake. Bulk food and fluid with in the colon prevent
straining.
• Monitor effectiveness of softeners or laxatives. Stool softeners decreases myocardial workload of straining.
• Instruct on prevention of straing.
Altered health maintenance related to myocardial infarction and implications for lifestyle changes.
• Teach the patient anatomy and physiology of the heart, atherosclerotic process, definition of heart attack healing
process of heart and the role of collateral circulation. Disease information helps the patient to understand the
underlying problems or overall heart functions.
• Assist the client in identifying his or her own risk factors. Risk factors identification helps the client to change his
lifestyle.
• Provide guidelines for a diet low in cholesterol and saturated fat. Guidelines of the diet help the client family to
follow once they are at home.
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High risk for activity intolerance related to imbalance between oxygen supply and demand.
• Monitor vital signs before, immediately after activity, and 3 minutes later. Vital signs should return to baseline in
3 minutes.
• Monitor the patient for tachycardia, dysrhythmias, dyspnoea, diaphoresis, or pallor after activity. Those symptoms
indicate myocardial oxygen deprivation that may require decrease in activity, change in medications or use of
supplemental oxygen.
• Provide assistance with self care activities and provide frequent rest periods especially after meals.
• Increase myocardial workload and cause vagal stimulation and resultant bradycardia or ectopic beats.
• Increase activity as per cardiac rehabilitation as well as nurse and physician orders. Gradual increase in activity
increases strength and prevents over exertion, enhances collateral ci0rculation, and restores normal lifestyle as much
as possible.
1. Sri Lakshman admitted in a state of deep unconsciousness with severe dehydration. Answer the following
questions in relation to his condition.
a. What are the causes for unconsciousness and how do you assess the level of unconsciousness? (5 marks)
b. Identify the nursing problem of an unconscious patient and institute appropriate nursing actions according
to the priority. (5 marks)
a. Unconsciousness: is a state caused by different health problems.
Causes of unconsciousness:
I. Supratentorial mass lesions:
• Epidermal haematoma
• Subdural haematoma
• Intracerebral haematoma
• Cerebral infarction
• Brain tumour
• Brain abscess
II. Subtentorial lesions:
• Brain infarction
• Brainstem tumour
• Brain haemorrhage
• Cerebellar haemorrhage
• Cerebellar abscess
III.Metabolic and diffuse cerebral disorders
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• Ischaemia anoxia
• Postictal states and concussion
• Infection (Meningitis encephalitis)
• Subarachnoid haemorrhage
• Exogenous toxins
• Endogenous toxins and deficiencies.
Assessment of level of consciousness by Glasgow coma scale.
The most important part of neurological examination is the assessment of the level of ‘consciousness. This is done to
determine the state of alertness and level of arousability.
Glasgow coma scale eye open

• Spontaneous 4
• To speech 3
• To pain 2
• No response 1
Best motor response
• Obeys 6
• Localizes pain 5
• Withdraws 4
• Abnormal flexion 3
• Extends 2
• Nil 1
Verbal response
• Oriented 5
• Confused conversation 4
• Inappropriate words 3
• Incomprehensible sound 2
• Nil 1
Total 3-15
a. Nursing problems and actions according to priority
Ineffective airway clearance related to inability to clear respiratory secretions.
• Position the patient in a lateral or semiprone position. This permits the jaw and tongue to fall forward. Also it
facilitates drainage of secretions.
• Do not allow an unconscious patient to remain on his back.
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• Remove the accumulated secretions in the pharynx to prevent danger of aspiration.
• Elevate the head of the bed to a 30° angle to prevent aspiration of secretions.
• Suction whenever is required.
• Auscultate the chest for at least every 8 hours for crackles, ronchi, or absence of breath sounds.
• If patient is intubated and is on mechanical ventilation, maintain the patency of the endotracheal tube or
tracheostomy.
• Provide frequent oral care.
• Monitor arterial blood gases and maintain ventilator settings.
High risk for fluid volume deficit related to inability to ingest fluids.
• Administer intravenous solutions and blood transfusions for patients with intracranial conditions.
• Restrict the quantity of fluids to be administered. This is to minimize the possibility of producing cerebral edema.
• Never give fluids by mouth to the patient who cannot swallow.
• Test the patient swallowing reflex without choking by giving him a wet swab to suck.
• Provide liquid feedings to the patient through the nasogastric tube
Altered oral mucus membranes related to mouth breathing, absence of pharyngeal reflex, and inability to inability to
ingest.
• Inspect the patient mouth for dryness, inflammation and the presence of crusting.
• Provide frequent mouth care to prevent parotitis.
• Rinse and clean the mouth carefully to remove secretions and crusts and to keep the membranes moist.
• Apply glycerin on the lips to prevent drying, cracking and the formation of encrustations.
• Assess the sides of the mouth and lips for ulceration if the patient has an endotracheal tube.
High risk for impaired skin integrity related to immobility or restlessness.
• Give special attention because these patients insensitive to external stimuli.
• Position/regularly turn the patient to avoid pressure
• Avoid dragging the patient up in bed because it creates shearing force and friction on the skin surface.
• Give importance to the pressure points, maintain correct body position, use footboard to prevent foot drop.
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Impaired tissue integrity of cornea related to diminished or absent corneal reflex.
• Clean the eyes with cotton balls moistened with sterile normal saline to remove debris and discharge.
• Instill artificial tears every 2 hours
• Take care to avoid contact with cornea.
• Close the eye by gently pulling on to the sides of the eye and maintain it closed by applying plaster onto the sides
• Cover the eye with gauze piece to prevent corneal abrasions from the cornea coming in contact with the eye patch.
Ineffective thermoregulation related to damage to hypothalamic centre.
• Record body temperature through rectal or axilla (Because of the damage of the heat-regulating centre in the brain
or severe intracranial infection, neurosurgical patient often develops very high temperature).
• Remove all bedding over the patient
• Administer repeated doses of aspirin or acetaminophen as prescribed
• Provide cool water sponging
• Switch on fan
• Use hypothermia blanket and equipment to control neurogenic hypothermia.
• Monitor body temperature frequently to assess the patient condition.
Altered urinary elimination incontinence or retention related to the unconscious state.
• Palpate the patient's bladder at intervals to know whether urinary retention is present.
• Catheterize the patient if urinary retention is present
• Observe the patient for fever and cloudy urine to identify urinary tract infection.
• Inspect the urethral orifice for suppurative drainage.
• Once the urinary catheter is removed use an external penile catheter (condom catheter) for male unconscious patient
and absorbent pad for the female unconscious patient who can urinate spontaneously.
• Once the patient regains his consciousness provide bladder-training programme.
Altered bowel elimination diarrhoea and/or constipation related to the unconscious state.
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• Evaluate abdominal distension by listening for bowel sounds and measuring the girth of the abdomen with a tape
measure.
• Monitor the number and consistency of bowel movements and perform a rectal examination for signs faecal
impaction.
• Administer a glycerin suppository, which stimulates bowel emptying (if constipation is present).
• Administer stool softeners as prescribed with the tube feedings.
Altered family process related to sudden crisis of unconsciousness
• Assist family members to mobilize their own adaptive capacities.
• Clarify information to the family members about the patient's condition.
• Permit the family to be involved in the care of their loved one.
• Listen and encourage family members to ventilate their feelings and concerns.
• Supporting them in their decision making process concerning post-hospitalization management and job placement
1. a. Define nephrotic syndrome. (2 marks)
b. List the causes for nephrotic syndrome. (4 marks)
c. Explain the dietary management for nephrotic syndrome. (4 marks)
a. Definition
Nephrotic syndrome is a group of disease having different pathogenesis but characterized by similar clinical findings
of massive proteinuria, hypoalbuminaemia, oedema, hyperlipidaemia and lipiduria.
a. Causes of nephrotic syndrome
1. Primary glomerular disease.
• Membraneous proliferative glomerulonephritis
• Primary nephrotic syndrome.
• Focal glomerulonephritis
• Inherited nephrotic disease.
2. Extrarenal causes.
Multisystem disease
• Systemic lupus erythematosus
• Diabetes mellitus
• Amyloidosis
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Infections
• Bacterial (streptococcal, syphilis)
• Viral (hepatitis, human immunodeficiency virus infection)
• Protozoal (malaria)
Neoplasm
• Hodgkin's disease
• Solid tumours of lungs, colon, stomach, breast.
• Leukaemias
Allergens (e.g. Bee sting, pollen)
Drugs
• Pencillamine
• Nonsteroidal anti-inflammatory drugs
• Captopril
• Heroin.
a. Dietary management of nephrotic syndrome
• The diet should attempt to provide sufficient protein and energy to maintain a positive nitrogen balance and to
produce an increase in plasma albumin concentration and disappearance of oedema.
• These patients should receive diet high in protein that is up to 1.5 g/kg/day. This helps to improve serum albumin
level and to prevent protein malnutrition.
• Provide sodium-restricted diet and instruct the patient to restrict water.
• The diet should contain normal to increased amounts of protein (1 g/kg body weight daily) and high in calories.
• Restrict sodium <1.0 gm/day to control edema.
1. Enumerate the factors leading to congestive cardiac failure (CCF) and describe briefly the pathophysiology
of CCF. Explain the nursing management of patient with CCF.
Meaning: CHF/CCF is a cardiovascular state in which the heart is unable to pump adequate amount of blood to meet
the metabolic needs of the tissues.
Factors precipitating HF
There are certain factors that can precipitate HF in a person with heart disease. It includes:
• Dysrhythmias, which lead to ineffective mechanical pumping.
• Reduction or cessation of cardiac therapy, either pharmacological or dietary.
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• Infections, either viral or bacterial.
• Emotional or physical stress increases the circulatory needs like anxiety, excitement, exercises.
• Anaemia, which causes reduction in the oxygen carrying capacity.
• Thyrotoxicosis, which causes an increased HR.
• Pregnancy
• Nutritional deficiency such as beriberi, thiamin deficiency.
Pathophysiology of CCF
Proper cardiac functioning requires each ventricles to pump out equal amount of blood over time. If the amount of
blood returned to the heart becomes more than ventricles can handle, the heart can no longer be effective to pump.
Such conditions cause heart failure. This may affect one or both of the heart pumping systems, there fore heart failure
can be classified as right sided or left sided heart failure.
Nursing management of patient with CCF

The basic objectives in the treatment of the patients with cardiac failure are:
• To promote rest to reduce the workload on the heart
• To increase the force and efficiency of myocardial contraction through the action of pharmacological agents.
• To eliminate the excessive accumulation of body water by means of diuretic therapy, diet and rest.
1. Decreased cardiac output related to HF.
• Assess vital signs and heart rhythm every 15 minutes to one hour.
• Monitor dysrhythmias hourly
• Monitor lung and heart sounds every 2 to 4 hours.
• Administer oxygen as prescribed to improve tissue hypoxia.
• Monitor urine output hourly, noting changes in colour and volume output. Diuresis is expected and promoted
once the client is digitalized and diuretics.
• Assess for changes in mental status every 4 hours. Adequate cerebral perfusion requires adequate cardiac output.
• Feed the client small meals, and provide a rest period after meals.
2. Fluid volume excess related to reduced glomerular filtration, decreased cardiac output and increases sodium water
retention.
• Monitor intake and output every 2 hours during acute phase
• Maintain Fowler's position to facilitate breathing.
• Provide frequent oral care, at least every 4 hours.
• Weigh the client daily to monitor response to diuretic therapy (Body weight is a more sensitive indicator of fluid
balance than an intake and output).
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• Provide the client with a low sodium diet.
• Fluid restrictions may also be used until diuresis is achieved.
3. Impaired gas exchange related to fluid in alveoli.
• Auscultate breath sounds every 2 to 4 hours.
• Encourage the client to turn, cough and deep breathe to clear to the airway and to facilitate oxygen delivery.
• Maintain Fowler's position to facilitate diaphragmatic expansion and ventilation.
• Administer oxygen as ordered to improve tissue oxygenation.
4. High risk for decreased peripheral tissue perfusion related to decreased cardiac output and vasoconstriction.
• Monitor the client's peripheral pulses every 4 hours.
• Note colour and temperature of the skin.
• Keep the extremities warm to promote vasodilatation to decrease preload.
• Encourage active range of motion or provide passive range of motion to decrease venous pooling.
5. High risk for activity intolerance related to decreased cardiac output.
• Intervene nursing care activity with respiratory periods.
• Monitor the client's response to each activity, noting the development of dyspnoea, tachycardia angina
hypotension, diaphoresis and dysrhythmias.
• Assess the vital signs prior to any major activity that is getting into the chair, walking, etc. immediately after
and 3 minutes later.
• Instruct the client to avoid activities that increased cardiac work load during acute stages of care.
6. High risk for impaired skin integrity related to decreased peripheral tissue perfusion and immobility.
• Turn the patient from side to side every 2 hours.
• Use heel protectors or elevate the client's calf.
• Wash the lower legs carefully and apply lotion to maintain skin integrity.
7. High risk for anxiety related to decreased cardiac output, hypoxia and fear of death or serious consequences.
• Provide for psychological rest by maintaining a calm environment. Allow the client to ask questions and answer
for his questions.
• Explain the cause of the disease and teach measures to prevent further attacks.
• Explain the prognosis of the disease in his words, which the patient can understand.
1. a. Classify anaemia. (2 marks)
b. Describe the common laboratory investigations for anaemia. (4 marks)
c. Explain why? (4 marks)
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i. Anaemia occurs in patients with total gastrectomy.
ii. CCF occurs in chronic and untreated anaemia.
a. Classification of anaemia
1. Acquired anaemias
• Iron deficiency anaemias
• Megaloblastic anaemias (Anaemias due to deficiencies of vitamin B12 and folic acid)
• Pernicious anaemia
• Anaemias of bone marrow failure
• Aplastic anaemia
• Hemolytic anaemia
• Secondary anaemias
2. Anaemias due to excessive blood loss
• Acute post-haemorrhagic anaemia
• Anaemia due to chronic blood loss
3. Congenital anaemias
• Haemoglobinopathies, i.e. sickle cell anaemia and thalassaemia.
• Haemolytic anaemias due to intrinsic red cell defects.
a. Common laboratory investigations
I. Complete blood count (CBC)
A. Red blood count
1. Haemoglobin
2. Haematocrit
B. Red blood cell indices
1. Mean cell volume (MCV)
2. Mean cell haemoglobin (MCH)
3. Mean cell haemoglobin concentration (MCHC)
4. Red cell distribution width (RDW)
C. White blood cell count
1. Cell differential
2. Nuclear segmentation of neutorphils
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D. Platelet count
E. Cell morphology
1. Cell size
2. Haemoglobin cenitent
3. Anisocytosis
4. Poikilocytosis
5. Polychromasia
II. Reticulocyte counts
III.From supply studies
A. Serum iron
B. Total iron binding capacity
C. Serum ferritin marrow ironstain
IV.Marrow examination
A. Aspirate
1. E/G ratio (ratio of erythroid to granulocyte precursors)
2. Cell morphology
3. Iron stain
B. Biopsy
1. Cellularity
2. Morphology.
Anaemia occurs in patients with gastrectomy

Total gastrectomy brings to a complete halt, the production of “intrinsic factor” the gastric secretion that is required
for the absorption of vitamin B12 from the gastrointestinal tract. Therefore unless this vitamin is supplied by parenteral
injection throughout life the patient inevitably suffers from vitamin B12 deficiency, which leads in time a condition
identical to that of a patient with pernicious anaemia in relapse. This can be avoided by IM administration of 100-200
µg of vitamin B12.
CCF occurs in chronic and untreated anaemia

When the patient is anaemic, his Hb per cent is low, the heart will attempt to compensate by pumping faster and
harder in an effort to deliver more blood to hypoxic tissue. This increases the cardiac workload results in tachycardia,
palpitations, dyspnea, dizziness, orthopnoea and exertional dyspnoea. Later congestive heart failure will develop.
1. Mani a 16 years old hotel worker is admitted with acute dysentery.
a. What are the predisposing factors of his illness? (1 mark)
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b. Describe the medical management of dysentery? (4 marks)
c. What preventive health teaching may be given to Mani during his hospitalization and on discharge? (5
marks)
a. Predisposing factors of dysentery
• Overcrowding
• Poor sanitary conditions (in living places)
• Food remaining at temperatures high enough for organisms to incubate and colonize easily.
• Oral-genital sexual contact (both heterosexual and homosexual)
• Contacts with infected persons with living in poor conditions
• Unhygienic conditions
• Food or water contaminated by infected human faeces, flies or the hands of infected food handlers who may
be carriers.
b. Medical management
• For amoebiasis cyst passers, administer Diloxanid furoate 500 mg tid for 10 days.
Or
• Diiodohydroxyquinoline 650 mg tid for 15 to 20 days.
Or
• Iodochlorhydroxy quinoline 250 mg tid for 10 days to be given
Or
• For invasive, give metronidazole 400 to 800 mg tid for 5 days.
Or
• Tinidazole 2 gm daily for 2 to 3 days
Or
• Secnidazole 2 gm single dose followed by diiodohydroxyquinoline 650 mg tid for 15 to 20 days to be given.
c. Preventive health teaching during hospitalization and discharge
• Sanitary disposal of human feces
• Protection of the public water supply
• Raising and preparing food free of contamination
• Wash hands thoroughly with soap and water after defecation and before preparing and eating food
• Fresh fruits and vegetables that cannot be peeled needs to be washed before use
• Patient should avoid oral, anal and oral-genital sexual practices
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• Boil and cool the water before use
• Cover the food always.
• Caution against not to eat fresh uncooked vegetables nor drinking unboiled water.
• Provision must be made for latrine facilities and health teaching to the patient and to use them properly.
• Proper provision for cleanliness, while preparing, processing or serving food.
• Periodical examination of food handlers
• Teach the patient to maintain personal hygiene, enviournmental sanitation and prevent from getting infection.
1. Mrs. Kanthamma 66 is admitted with 50 per cent burns her saree had caught fire from the firewood, while
cooking
a. Describe the methods of burns estimation.
b. Explain the nursing care of Mrs. Kanthamma for first 24 hr on the basis of two nursing diagnoses.
a. Methods of burns estimation
1. Rule of nines: An estimation of the total Body Surface Area (BSA) involved as a result of a burn is simplified
by using the rule of nines. The rule of nines measures the percentage of the body burned by dividing the body
into multiples of nine.
According this formula head and neck = 9 per cent
Anterior chest and abdomen = 18 per cent
Posterior chest and abdomen = 18 per cent
Upper limb = 9 + 9 = 18 per cent
Lower limb = 18 + 18 = 36 per cent
Perineum = 1 per cent
Total = 100 per cent
2. Berkow method: This method is based on Lund and Brower's recognition that the percentage of body surface
area of various anatomic parts, especially the head and legs, changes with growth. By dividing the body into
very small areas and providing an estimate of the proportion of body surface area accounted for by such body
parts, one is able to obtain a very reliable estimate of total surface area involved. This is helpful in estimating
fluid requirements and determining prognosis and surgical intervention.
3. Survival prediction: The very young and the older person are at risk of mortality following burn injuries. The
chances of survival are greater in children (over 5 years of age) and young adults (40 years of age or younger).
Rule of nine shows the effects that age and percentage of body surface burned have on survival rate.
b. Nursing care of patient for first 24 hr based on diagnosis
For the first 24 hr, client survival depends on quick and thorough assessment and intervention. It may be the nurse who
makes the initial assessment of depth, degree and percentage of burn and who co-ordinates the actions of the burn team.
The nurse assesses the adequacy of fluid replacement, provides wound care and offers support to the client and family.
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Altered gas exchange and airway clearance.
• Maintain a patent airway through proper positioning, removal of secretions and artificial airway if indicated. (which
ensures patent airway)
• Provide humidified oxygen which provides humidity to injured tissues and adequate oxygen.
• Assess for respiratory rate, rhythm, and depth, respiratory sounds and signs of hypoxia. Which provides baseline
for further assessment.
• Observe the patient for erythema or blistering of lips or buccal mucosa, singed nares, burns of face, neck chest,
increasing hoarseness, soot in sputum or tracheal tissue in respiratory secretions, which indicate injury to respiratory
tree and or risk of dysfunction.
• Monitor arterial blood gases, increasing partial carbondioxide and decreasing partial pressure of oxygen may indicate
need for mechanical ventilation.
• Monitor patient on mechanical ventilation.
• Encourage the patient to turn, take deep breaths, cough and use incentive spirometry and also suction as needed.
High risk for fluid volume deficit related to evaporative loss plasma loss, and shift of fluid into interstitium secondary
to burn injury.
• An intravenous route is established, preferably through an unburned area if not through cut down section.
• The projected fluid requirements for the first 24 hr are calculated by evaluating the patient's burn injury.
• Formulas have been developed for estimating fluid loss based on the estimated percentage of body surface area
burned and the weight of the patient.
• According to Consensus formula for an adult 2 ml/kg/per cent of Ringer's lactate solution is used 2 ml × 60 kg × 50
per cent. In this 3000 ml is given in the first 8 hours remaining 3000 ml is given next 16 hours.
• Draw the blood specimens for hematocrit, electrolyte and blood gas determinations and for typing, cross matching
and screening.
• An indwelling urinary catheter is inserted so that urine volume and specific gravity should be monitored hourly.
• The amount of urine first obtained is recorded, because it may assist in determining the extent of renal function.
• Report to the physician if urine volume less than 30 ml/hr.
• Assess frequently vital signs and urine output of the patient.
• Monitor the patient for early signs of hypovolaemic shock or fluid overload; including altered mental status change
in respiration and haemodynamic parameters.
• Elevating affected extremities may be indicated to help reduce oedema.
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Altered body comfort pain related to burn injury, treatments and shearing injuries.
• Give IV analgesia as needed.
• Keep client warm
• Elevate burned arms on pillows
• Administer medication for pain 30 minutes before interventions.
• Provide emotional support.
• Reposition client carefully using lifting sheet as necessary.
• Plan diversion activities.
High risk for infection
• Use aseptic measures in all aspects of patient care which prevents bacterial contamination.
• Administer antibiotics and topical antibacterial agents as prescribed, which prevents infection.
• Assess wounds daily for local signs of infection such as swelling, redness, purulent drainage, discoloration (which
indicate bacterial contamination and infection).
• Observe the patient mental status, respiratory rate bowel sounds.
• Assess the patient for signs of septicaemia such as increased pulse, decreased blood pressure, changes in urine out
put, facial flushing, fever.
• Provide adequate nutrition because it is essential for immunological response and healing.
• Assist with or promote optimal personal hygiene, which reduces bacterial contamination from areas adjacent to burn.
Altered body temperature: Hypothermia/hyperthermia
• Provide a warm environment while using blankets or/and heat lights which minimizes evaporative heat loss, while
caring the wound, cover it quickly to minimize heat loss.
• Monitor rectal temperature to assess body temperature frequently.
• Administer antipyretics for elevated body temperature as prescribed.
Altered nutritional status less than body requirement related to increased nutritional requirement and altered
gastrointestinal function.
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• Maintain nasogastric tube on low intermittent suction until bowel sounds returns. Burn injury often produces
paralytic ileus, which results in gastric and abdominal distension; nasogastric suction removes gastric secretions
and prevents vomiting.
• Auscultate for bowel sounds every 4 hours. Absent of bowel sounds and decreased peristalsis may indicate paralytic
ileus, obstruction, or sepsis.
• Aspirate the stomach contents prior to tube feedings, to check for residual volume of gastric contents indicates
inadequate absorption and low pH indicates need for histamin blockers or antacids.
• Administer histamine blockers and antacids as prescribed, which reduce the risk of gastric ulceration common in
burn patients.
• Test stool and gastric contents for occult bleeding which may indicate gastric or duodenal ulcer
1. Mrs. Valli is admitted for cataract surgery. Discuss the pre- and post-operative nursing intervention. (10
Marks)
Meaning: A cataract is an opaque (nontransparent) area of the crystalline lens or its capsule.
Preoperative nursing intervention

a. Reducing preoperative anxiety:
• Explain the surgical procedure to the patient and intimate her that no need to be immobile for days following
surgery or no need to wait until the cataract is mature.
• Educate the patient that surgery is very simple and hospital stay one or two days only.
• Inform the patient and family members that the patient have only little discomfort following surgery.
• Advise the patient after operation she should not bend forwards for extended periods of time and also inform
her to avoid lifting and strenuous activities.
• After giving proper explanation take a consent for the surgery.
b. Preventing injury:
Because of impaired vision, the person with cataract has a tendency to injury so,
• Orientate the patient to bed, ward so that they will be familiar to that after surgery.
• Inform the patient that after surgery her eye will be patched and probably she require assistance while eating
or going to the bathroom.
• Cut the eyelashes using scissors with blades coated with yellow soft paraffin to which the lashes will adhere and
not enter the patient's eye.
c. Preoperative preparation:
• Perform routine investigations to identifying any complication.
• Advise the patient to remove ornaments.
• Provide O.T. gown.
• Nil per orally
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• Sedate the patient preoperatively 2 hours before surgery.
• Administer eye medications as prescribed like antibiotics, a topical mydriatic (Which facilitates removal of the
cataract when the pupil is dilated) and a cycloplegic (to paralyse the muscles of accommodation).
Postoperative nursing intervention

a. Anxiety related to actual or possible loss of vision.
• Encourage the patient to ask questions and clarify their doubts.
• Give careful explanations of all treatment and activities.
• Include the family in planning and teaching.
• Reassure patient about quality of care being received.
b. High risk for fall related to poor vision, possible presence of eye patch.
• Stabilize environment
• Advise use of side rails
• Assist with ambulation and activities of daily living.
c. Pain related to surgical manipulation of tissue and eyelid oedema.
• Apply warm or cold compresses as ordered, using clean wash cloth.
• Teach the patient and family to do this after thorough hand washing.
• Administer analgesics as ordered.
d. Altered health maintenance related to lack of knowledge regarding eye care complications, medications, and activity
restrictions after discharge.
• Review written directions with client and family.
• Return demonstration on compresser, instillation of eyedrops, and eyepads.
• Review activity and reading restrictions.
e. Potential complication, increased introcular pressure.
• Instruct client to avoid activities that increase intraocular pressure, such as bending, coughing, squeezing eyelids.
• Reinforce need to comply with medication routine.
f. High risk for self-care deficit related to impaired vision and activity restrictions.
• Assess current ability related to personal hygiene, dressing, mobility, eating, and toileting.
• Assist client with activities of daily living as needed or requested.
• Contact an occupational therapist if needed for adaptive equipment such as long-handled sponges or reachers.
g. Impaired home maintenance related to poor vision and post-surgical activity restriction.
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• Determine assistance client will need to maintain home environment.
• Assess client's functional abilities and appropriateness of preferred environment for post-surgical recovery.
• Assist client and family with planning for assistance after discharge.
• Assess client's support system.
1. Mrs. Kumar, 40 years old lady and mother of five children, is a known case of peptic ulcer for the last years
and has been on treatment off and on:
a. Causes of peptic ulcer.
b. Signs and symptoms and complications of peptic ulcer.
c. Postoperative care after partial gastrectomy.
a. Meaning: A peptic ulcer is an excavation formed in the mucosal wall of the stomach, the pylorus, the duodenum/
the oesophagus.
Causes: The immediate cause of peptic ulcer is disturbance in normal protective mucosal ‘barrier’ by acid-pepsin,
resulting in digestion of the mucosa.
The aetiology of peptic ulcer may be explained on the basis of multiple factors.
i. Acid-pepsin secretions: There is evidence that some level of acid-pepsin secretion is essential for the
development duodenal as well as gastric ulcer.
ii. Mucus secretion: Any condition that decreases the quality or quantity of normal protective mucus barrier
predisposes to the development of peptic ulcer.
iii. Gastritis: Some degree of gastritis is always presence in the region of gastric ulcer.
iv. Local irritants: Local irritating substances are heavily spiced foods, alcohol, cigarette smoking, unbuffered
aspirin, non-steroidal anti-inflammatory drugs.
v. Dietary factors: Nutritional deficiencies have been regarded as etiologic factors in peptic ulcers, e.g. occurrence
of gastric ulcer in poor socioeconomic strata.
vi. Psychological factors: Stress, anxiety, fatigue and ulcer type personality may exacerbate as well as predispose
to peptic ulcer disease.
vii.Genetic factors: People with blood group ‘O’ appear to be more prone to develop peptic ulcers than those with
other blood groups.
viii.Hormonal factors: Secretion of certain hormones by tumours is associated with peptic ulcers, e.g. endocrine
secretions in hyperplasia and adenomas of parathyroid glands, adrenal cortex and anterior pituitary.
ix. Miscellaneous: Duodenal ulcers occur in association with various other conditions such as alcoholic cirrhosis,
chronic renal failure, hyperparathyroidism, chronic obstructive pulmonary disease and chronic pancreatitis.
b. Signs and symptoms: Peptic ulcers are remitting and relapsing lesions and is summarized by the saying “once a
peptic ulcer patient, always a peptic ulcer patient”. Two major forms of chronic peptic ulcers show variations in
clinical features, which are:
i. Pain: In gastric ulcer, epigastric pain occurs immediately or within 2 hours after food and never occurs at night.
In duodenal ulcer, pain is severe, occurs last at night (hunger pain) and is usually relieved by food.
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ii. Vomiting: Which relieves the pain is a conspicuous feature in patients of gastric ulcer. Duodenal ulcer patients
rarely have vomiting but instead get heart burn (retrosternal pain) and water brush (burning fluid into the mouth).
iii. Haematemesis and melaena: Both may occur together more commonly in duodenal ulcer than in gastric ulcer
patients.
iv. Appetite: The gastric ulcer patients have good appetite but are afraid to eat, while duodenal ulcer patients have
very good appetite.
v. Diet: Patients of gastric ulcer commonly get used to bland diet consisting of milk, eggs, etc. and avoid taking
fried foods, curries and heavily spiced foods. Duodenal ulcer patients usually take all kinds of diets.
vi. Weight: Loss of weight is a common finding in gastric ulcer patients and in duodenal ulcer patients tend to gain
weight due to frequent ingestion of milk to avoid pain.
vii.Deep tenderness: Seen in both types of peptic ulcers. In gastric ulcer it is in the midline of the epigastrium, while
in the duodenal ulcer it is in the right hypo-chandrium.
Complications
i. Haemorrhage: The most frequent site is the distal portion of the duodenum. When the haemorrhage is of large
proportions, most of the blood is vomited. When the haemorrhage is small, much or all of the blood may be passed
in the stools, which will appear tarry black owing to the digested hemoglobin.
ii. Perforation: It may occur unexpectedly, without much evidence of preceding indigestion. Perforation into the free
peritoneal cavity is an abdominal catastrophe and an indication for surgery.
iii. Pyloric obstruction: Occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm
or oedema or from scar tissue that is formed when the ulcer alternately heals and breaks down.
iv. Intractability: An ulcer is one that continues to give problems and is resistant to all forms of treatment.
a. Postoperative nursing care after partial gastrectomy:
i. Positioning the patient: When recovery from anaesthesia is complete, provide a semi recumbent position, for
comfort and easy drainage of the stomach.
ii. Avoiding pulmonary complications:
Administer analgesics as prescribed.
• Encourage deep breathing and coughing exercises which prevents pulmonary complications
• Ask the patient to take deep breaths and to cough hourly in the immediate postoperative period.
iii. Checking nasogastric tube drainage:
Drainage from nasogastric tube may contain some blood for the first 12 hours, but excessive bleeding should
be reported.
• Keep the patient nil per orally until peristalsis returns.
iv. Giving nose and mouth care:
• Clean the nostrils with an applicator stick moistened with water.
• Give mouthwashes frequently to relieve dryness of the mouth.
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• Apply moisturised cream to the lips to help the mouth moist.
v. Attending to fluid needs:
• Administer IV fluids to meet fluid and nutritional needs.
• Once the peristalsis returns remove the nasogastric tube but restrict the fluids by mouth for several hours,
than begun sparingly.
• Provide small amounts of water at first then gradually increase as he can tolerate.
vi. Providing dietary intake:
• Provide a bland foods gradually until the patient is able to eat small meals and drink fluid between meals.
• Offer increments gradually as tolerated and to recognize that each person is different. If regurgitation occurs,
the patient may be eating too fast or too much. It may also may indicate oedema along the suture line is
preventing fluids and food from moving into the interstitial tract.
• If gastric retention occur, it may be necessary to reinstitute nasogastric aspiration.
vii.Encouraging mobility:
• On the first postoperative day, the patient is encouraged to get out of bed. Mobility is then increased daily.
viii.Providing wound care:
• Wound dressings may have serosan-guineous drainage on them because of drainage tubes left in the wound.
Dressings are reinforced or changed if necessary. If there is excessive oozing is present that needs to be
reported.
1. Mrs. Latha, 53 years is admitted with tumour in the colon and is posted for surgery.
a. List the common tumours of the colon (2 marks)
b. Explain the sites where cancer colon is identified (3 marks)
c. Explain the preoperative preparation of Latha for colostomy (5 marks)
a. Common tumours of the colon
It may be classified into benign and malignant.
Benign:
• Adenoma
• Leiomyomas
• Leiomyoblastoma
• Neurilemmoma
• Lipoma and
• Vascular tumours
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Malignant:
• Adenocarcinoma
• Mucinous adenocarcinoma
• Signetring cell carcinoma
• Adenosqamous carcinoma
• Leiomyosarcoma
• Malignant lymphoma
• Carcinoid tumours.
a. Sites of cancer colon identification
• Rectum 30 per cent
• Ascending colon 25 per cent
• Sigmoid colon 20 per cent
• Decending colon 15 per cent
• Transverse colon 10 per cent
a. Preoperative preparation for colostomy
• Assess the patient abdomen and notify any abnormalities like pain, distention, and masses.
• Instruct the patient to take a diet high in calories, protein and carbohydrates but low in residue because
• which provide nutrition and reduce peristalsis.
• Administer total parenteral nutrition if required to provide nutrients and vitamins to the patient.
• Advise the patient to take low-residue or liquid diet to reduce the faecal contents of the bowel.
• Administer laxatives 12 to 24 hours before the surgery as prescribed.
• Administer antibiotics such as sulfonamides and cephalexin 12 to 48 hours before the procedure.
• Administer enema the day before and the day of the surgery to clean and keep bacteria free bowel.
• Administer blood transfusion to correct severe anaemia if it is present.
• Identify patient's level of anxiety and provide psychological support.
• Advise the patient to ventilate their feelings and meet health team members to discuss about treatment and
prognosis.
• Insert a nasogastric tube before the operation, since the passage of a tube into the intestine may take as long
as 24 hours, it is attached to the suction apparatus for the aspiration of intestine contents. This prevents the
accumulation of gas and intestinal fluid around the suture line.
1. Explain in detail about the aetiological factors of peptic ulcer. Write medical and nursing management
implementing nursing process.
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For Aetiology Refer Question no. 29
Medical management of peptic ulcer

i. Antacids: which neutralizes acid, e.g., aluminium hydroxide and magnesium hydroxide. Aluminum tend to cause
constipation and magnesium tend to cause diarrhoea so it can be administered both in combination. Antacids leave
the stomach rapidly, so that frequent doses are required and all antacids have been found to be more effective if
given in the liquid form.
ii. H2 receptor antagonists: are safe and effective by lowering acid secretion in the stomach, e.g. cimetidine,
ranitidine and famotidine. Short-term treatment with cimetidine has resulted in complete ulcer healing but low-dose
maintenance therapy may be needed to prevent recurrence.
iii. Anticolinergic agents: such as atropine, act by blocking parietal cell mascarinic acetylcholine receptor. These agents
decrease gastric acid secretion but not effective as H2 receptor antagonist, e.g. pirenzepine.
iv. Coating agents: e.g. sucralfate, a complex polyaluminum hydroxude salt of sucrose sulfate. It binds to the ulcer bed
for up to 12 hours, whereas relatively little binds to intact gastric/duodenal.
Altered body comfort, pain related to irritated mucosa and muscle spasms:
• Administer medication like antacids, histamine antagonists and anticholinergics as ordered. Antacids neutralize
acidity of gastric secretions. Histamine antagonists interfere with the secretion of gastric acid. Anticholinergic inhibit
the release of gastric acid.
• Advise the patient to avoid an intake of ulcerogenic drugs. Drugs that contain salicylates are irritable to the stomach
mucosa.
• Advise the patient to avoid foods or beverages that are irritating to the stomach lining like spicy, very hot or very
cold, caffeinated foods or beverages, because this stimulates the secretions of hydrochloric acid.
• Instruct the patient to increase intake of water because it is considered a good antacid.
• Instruct the patient to eat slowly and chew small pieces of food. The greater the size of food particles, the greater
the secretions of hydrochloric acids.
• Advise the patient to space meals and snacks at regular interval, because scheduled meals help to keep food particles
in the stomach, which helps to neutralize the acidity of gastric secretions.
Altered nutrition less than body requirements, related to pain associated with eating.
• Instruct the patient to take non-irritating foods, which reduces epigastric pain.
• Suggest the patient to take meals at regular schedule time that helps to neutralize gastric secretions.
• Encourage the patient to take meals in a relaxed atmosphere, which helps to decrease the secretion of hydrochloric
acid.
Activity intolerance related to fatigue and difficulty with sleeping
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• Encourage the patient to take scheduled periods of rest through out the day, which helps maximize energy.
• Suggest measures to conserve energy for activity of daily leaving like sit on a stool while cooking, sit on a chair in
the shower, allow 30 minutes to get dressed in the morning.
• Educate the patient to recognize signs of exhaustion like tachycardia, dizziness, and excessive weakness. Fatigue
stresses the body's normal compensatory mechanism.
Anxiety related to the fear of coping with an acute disease.
• Encourage the patient to ask questions and express his concern and fears as needed.
• Open communication fosters, a trusting relationship, which helps to reduce anxiety and stress.
• Explain the patient the reasons for adhering to a planned treatment, diet restrictions, modified activity levels and
cessation of smoking.
• Help the patient identify anxiety-producing situations.
• Teach the patient stress reducing exercises, like meditation, distractions and imaginary. Decreasing anxiety reduces
hydrochloric acid secretions.
Potential complications: Haemorrhage, perforation, pyloric obstruction related to peptic ulcer.
• Encourage the patient to adhere to his planned treatment schedule, which will minimize complications.
• Educate the patient to be aware of the signs and symptoms indicating one of the following complications like
haemorrhage (tachycardia, dyspnoea and confusion), Perfusion (severe abdominal pain, rigid and tender abdomen),
pyloric obstruction (nausea and vomiting, distended abdomen). Knowledge about complications improves the
patient awareness of his disease condition and influence on behavior modifications.
Knowledge deficit regarding the prevention of symptoms and management of the condition:
• Assess the patient level of knowledge and readiness to learn. Attending to learning is dependent on the Patient's
physical condition, level of anxiety, and mental readiness.
• Teach necessary information like use words at the level of learner, choose a time when the patient is rested and
interested, limit teaching sessions to 30 minutes or less.
• Reassure the patient that the disease can be managed.
• Knowledge can have a positive influence on behavior modifications.
1. List the different approaches and its advantages and disadvantages of prostatectomy.
Meaning: It is the removal of hyperplastic prostatic tissue. There are four different approaches used in removing the
hypertrophied fibroadenomatous portion of the prostate gland. In all four techniques all hyperplastic tissue is removed
leaving behind the surgical capsule of the postate. The transurethral approach is a closed procedure, while the other
three are open surgical procedures.
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1. Transurethral resection: (removal of prostate tissue by instrument introduced through urethra)
Advantages:
• Avoids abdominal incision.
• Safer for surgical risk patient.
• Shorter period of hospitalization and convalescence.
• Lower morbidity rate.
• Causes less pain.
Disadvantages:
• Requires highly skilled operator.
• Recurrent obstruction, urethral trauma and stricture may develop.
• Delayed bleeding may occur.
2. Open surgical removal
Suprapubic prostateatomy
Advantages:
• Technically simple.
• Offers wider area of exploration.
• Permits exploration of cancerous lymph nodes.
• Allows more complete removal of obstructing gland.
• Permits treatment of associated lesions in bladder.
Disadvantages:
• Requires surgical approach through the bladder.
• Control of hemorrhage difficult.
• Urinary leakage around suprapubic tube.
• Convalescence more prolonged and uncomfortable.
3. Perineal prostatectomy:
Advantages:
• Offers direct anatomical approach.
• Permits gravity drainage.
• Particularly efficacious for radical cancer therapy.
• Allows hemostasis under direct vision.
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• Low mortality rate.
• Less incidence of shock.
• Ideal for very old, feeble and poor risk patient with large prostate.
Disadvantages:
• Problem of damage to rectum and external sphincter.
• Restricted operative field.
• Greater potential for infection.
4. Retropubic prostatectomy
Advantages:
• Avoids incision into the bladder.
• Permits easier visualization and control of bleeders.
• Shorter period of convalescence.
• Less bladder sphincter damage.
Disadvantages:
• Cannot treat associated bladder disease.
• Increased incidence of hemorrhage from prostatic venous plexus, osteitis pubis
The above operation of choice depends on:
• The size of the gland
• The severity of the obstruction
• The age of the patient
• The condition of the patient and
• The presence of associated diseases.
1. a. Explain the complications in your client with a diagnosis of hypertension
b. What preventive measures you will explain to the above client on discharge?
a. Complications of hypertension
1. Coronary artery disease
2. Left ventricle hypertrophy – occurs in response to the increased workload placed on the ventricle as it contracts
against higher systemic pressures.
3. Cerebral vascular accident – due to transient ischemic attack due to hypertension.
4. Malignant hypertension.
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5. Renal hypertension.
b. Preventive measures
Prevention of hypertension involves the identification of non-modifiable risk factors and identification and
management of modifiable risk factors.
• Advise the patient to avoid stress-producing situation (which may be associated with occupational factors,
socioeconomic levels and personality characteristics) which may cause increased peripheral vascular resistance
and cardiac output and to stimulate sympathetic nervous activity.
• Advise the patient to lose weight especially if the patient has an intra-abdominal fat.
• Instruct the patient to avoid excessive intake of sodium in the form of chetney, pickle, etc in the diet.
• Educate the patient who has family history of hypertension and DM and patient with increased age to avoid
smoking, consuming alcohol and to practice daily exercise.
• Advise the patient to avoid excessive fat intake and use green leafy vegetables and ruffages in the diet.
• Advise the patient to do regular programme of aerobic (isotonic) exercise, which facilitates cardiovascular
conditioning.
• Advise the patient to avoid intake of alcohol, if he is unable at least restrict (to less than one to 2 ounces/day)
to moderation.
• Advise the patient to restrict coffee intake, he should be instructed to limit 250 mg (2 to 3 cups of coffee), because
it may raise BP.
• Teach the patient relaxation technique like meditation, yoga, biofeedback and psychotherapy.
• Instruct the patient to stop smoking completely.
• Supplement potassium, calcium and magnesium in the diet.
• Advise the patient to have regular follow up.
• Take medication as prescribed by the doctor.
• Advise the patient to avoid foods high in saturated fats and cholesterol like use vegetable oil instead of bulbs,
avoid fried foods use skim or low fat milk and milk products, eat no more than three egg yolks per week. Egg
whites are low in cholesterol, limit the use of organ meats and shell fish.
1. Write medical and nursing management of pulmonary tuberculosis patients.
Medical Management
For short-term treatment 6 to 9 months
A minimum of three drugs should be given for the first 2 months, the duration of treatment must never be shorter
than 6 months.
6 Months:
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Tab isoniaside (INH) 400 mg

Tab rifampicin (R) 600 mg
for adult > 50 kg
Tab pyrazinamide (pz) 2000 mg
Daily for 2 months followed by
Tab isomiazide
Tab rifampicin Daily for 4 months
If for some reason, drug resistance to either INH or Rifampicin is suspected.
Tab Ethambutol – 1500 mg
Tab Streptomycin – 0.75 mg
Should be added to the regim.
9 Months: (Patient who are unable to take Pz, a 9 month regim is added)
Tab Refampicin – 450 mg
Tab Isomiazide – 300 mg Daily for 2 months followed by
Tab Rifampicin – 450 mg
Tab INH – 300 mg Daily for 7 months is given
Note
• All drugs are given in a single dose.
• Use pyridoxine 10 mg daily as supplement when high doses of INH are used.
Nursing management
1. In effective breathing pattern related to decreased lung capacity.
• Administer and teach self-administration of medications as ordered.
• Encourage the patient to take rest.
• Advise the patient to avoid exertion.
• Monitor breath sounds, respiratory rate, sputum production and dyspnea.
• Administer supplemental oxygen as ordered.
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2. High risk for infection transmission related to nature of the disease and patients symptoms.
• Be aware that tuberculosis is transmitted by respiratory droplets or secretions.
• Provide care for hospitalized patient in a negative pressure room to prevent respiratory droplets from leaving
room when door is opened.
• Ensure that all staff and visitors use mask for any contact with the patient.
• Educate the patient to control the spread of infection through secretions, like cover the mouth and nose with
clean cloth while coughing or sneezing.
• Advise the patient not to sneeze into bare hand.
• Advise the patient to wash hands after coughing or sneezing.
• Educate the patient for safe disposal of sputum.
3. Altered nutrition pattern less than body requirement related to poor appetite, fatigue and productive cough.
• Encourage and explain the patient the importance of eating a nutritious diet to promote healing and to improve
defense against infection.
• Monitor patient weight.
• Administer vitamin supplements as prescribed, particularly pyridoxine (vitamin B6) to prevent neuropathy in
patients taking isoniazide.
4. Noncompliance related to lack of motivation and long-term treatment
• Educate the patient about the etiology, transmission and effect of tuberculosis.
• Stress the importance of continuing to take medicine for the prescribed time because bacilli multiply very slowly
and this can only be eradicated over a long period of time.
• Educate the patient about the side effects of each drug, if toxicity of any drug is identified encourage them to
report immediately.
1. Mr. Ganesh 50 years, is admitted for haemodialysis.
a. List the possible causes of chronic renal failure.
b. What are the complications of haemodialysis?
c. Prepare a care plan for Mr. Ganesh.
a. Meaning: Chronic renal failure is a slow, insidious, and irreversible impairment of renal function, uremia usually
develops slowly.
Causes:
Major causes:
• Polycystic kidney disease
• Chronic glomerulonephritis
• Chronic pyelonephritis
• Chronic urinary obstruction
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• Hypertensive nephropathy
• Diabetic nephropathy
• Gouty nephropathy
Primary renal disease:
• glomerulonephritis
• pyelonephritis
• polycystic kidneys
• hypernephroma
Secondary to systemic disease:
• Hypertensive nephropathy
• Diabetic nephropathy
• Gouty nephropathy
• Lupus nephritis
• Renal amyloidosis
• Myeloma kidney
• Nephrocalcinosis
• Hereditary nephropathy
a. Complications of haemodialysis:
• Bleeding
• Infection
• Hypotension
• Hypovolaemia
• Haemolysis
• Pyogenic reaction
• Arrhythmias
• Dialysis disequilibrium
• Unco-operative; denial, depression and anger
• Pruritus
• Hepatitis-B
a. Nursing care plan for prehaemodialysis care
1. Knowledge deficit related to hemodialysis.
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Nursing Intervention
• Explain hemodialysis procedure and its purpose.
• Demonstrate safe aseptic cannula care.
2. Potential for fluid volume excess related to haemodialysis.
• Measure and record weight, tempe-rature, pulse, respirations and blood pressure to have baseline data.
• See that Mr. Ganesh should not gain more than 1.5 kg between treatments.
• Review blood chemistry findings of blood urea nitrogen, creatinine, Na+, K+ and haematocrit.
3. Potential for Infection related to haemodialysis.
• Use sterile technique to initiate haemodialysis needle insertions or shunt connections.
• Anchor connections securely.
• Use disposable gloves and plastic apron clothes to prevent direct contact with blood.
• Identify hepatitis ‘B’ and HIV status of patient, if known.
4. Potential for fluid volume deficit.
Nursing Intervention:
• Minimize blood loss since patient with CRF is anemic.
• Measure intake and output.
• Check bleeding and clotting time.
• Observe haemodialysis system monitors to ensure patient safety.
• Watch for haemodialysis equipment or electrical failure.
• Assess and monitor vital signs throughout procedure.
• Check patient's response to the procedure.
• Infuse normal saline intravenously if patient is hypotensive.
• Check blood pressure, temperature, pulse, respiration and weight. Patient should weigh less have lower blood
pressure and higher temperature than before dialysis treatment.
• Check blood chemistries like blood urea nitrogen, creatinine, Na+, and K+ levels, it should be decreased.
1. Vimal 22 years old man of a village blacksmith is admitted with acute exacerbated bronchiectasis. He had
pulmonary TB identified 3 years back, but treatment was very irregular and stopped before the course of
therapy was completed. Discuss the nursing care of vimal in terms of primary, secondary and tertiary levels
of care. (3+4+3=10 marks)
Vimal is a young blacksmith is occupation itself is one of the risk factor of T.B. Since he has discontinued the T.B.
treatment before the course of therapy was completed, he came and admitted with acute exacerbated bronchiectasis.
So the nursing care of Vimal as follows:
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Primary level nursing care

• Educate the patient about the tuberculosis disease process, its transmission and its effects.
• Stress the patient the importance of continuing to take medicine for the prescribed time because bacilli multiply
very slowly.
• Inform the patient and family to be aware, that TB transmitted by respiratory droplets or secretions and educate them
to control the spread of infection through secretion while covering the nose and mouth when coughing or sneezing,
washing hands after sneezing or coughing and disposing safely the used tissues for secretions
• Inform the patient the availability of BCG vaccine and its use in prevention of TB
• Educate the client about bovine tuberculosis, which is caused by unboiled milk from infected cow.
Secondary level of care

Since the patient treatment is interrupted he comes under the treatment of category II. It consists of
Isoniazide (H) 300 mg.
Rifampicin (R) 450 mg.
Pyrazinamide (Z) 750 mg.
Ethnambutol (E) 800 mg.
It has to be taken daily for two months as a initial phase followed by continuous phase that is
Isoniazide (H) 300 mg.
Rifampicin (R) 450 mg.
Ethnambutol (E) 800 mg to be taken for another 8 months.
• Observe the patient daily for medication intake
• Tell the patient that rifampicin should be taken in empty stomach.
• Explain the patient not to get embarrassed with orange colour urine, which is common side effects of rifampicin.
• Administer and teach self-administration of medication as prescribed.
• Administer vitamin supplements as ordered, particularly pyridoxin (vitamin B6) to prevent peripheral neuropathy
in patients taking isoniazide.
• Second line drugs such as capreomycin, kanamycin, ethionamide, paraaminosalicylic acid and cycloserine
(saromycin) are used in patient for retreatment
• Encourage rest and avoidance of exertion.
• Provide supplemental oxygen as ordered.
• Monitor the patient weight.
• Encourage and explain the importance of eating nutritious diet to promote healing and improve defense against
infection.
• Sputum smears may be obtained every two weeks until they are negative. Sputum cultures do not become negative
for 3 to 5 months.
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• Steam inhalation to keep the secretions thin.
• Instruct the patient to avoid noxious fumes, dusts, smoke and other pulmonary irritations.
• Encourage intake of fluid to reduce viscosity of sputum and make expectoration easy.
• Employ percussion and vibration to assist in mobilizing secrections.
• Assist with postural drainage positioning for involved segment to drain bronchiectasis areas by gravity this assist
in reducing degree of infection and symptoms.
• Provide small frequent meals and liquid supplements during symptomatic period.
• Provide a balance diet with rich in protein.
• Encourage dental care, because sputum production may effect dentition.
Tertiary Level of Care

• Advise the patient to change his occupation because it increases the severity of the symptoms.
• Participate in observation of medication taking weekly pill counts or other programs designed to increase compliance
with treatment for TB.
• Inform the patient to prevent spread of infection while safely disposing the secretions until the physician says that
his free from TB.
• Follow up care to be made.
• Encourage to engage in physical activity throughout day to help in mobilize mucus.
1. a. What is Bronchitis?
b. Explain pathophysiology and list the clinical manifestations of bronchial asthma.
c. Write nursing management of patient who is suffering from bronchial asthma. (2+3+5 marks)
a. Bronchial asthma
It is a syndrome in which repeated attack of breathlessness and wheezing occurs due to irreversible narrowing of
airway.
a. Pathophysiology
When the person is exposed to an allergen or antigen, a large amount of antibody, that is, IgE is produced and this
antigen attacks to the mast cells which are found in the lungs, as a result mast cell products (cell mediators) are released
such as histamine, bradykinin, leukotrinase, prostagladin and slow reactive activating substance of anaphylaxis.
The release of these mediators from the lung tissue affects the smooth muscle and glands of the airway causing
bronchospasm, or broncho-constriction, mucus plugging, vascular congestion, and narrowing of the vessels.
Clinical Manifestations
• Wheezing
• Non-productive cough
• Dyspnoea
• Chest tightness
• Prolonged expansion that is 1:3 or 1:4 (normal inspiratoryexpiratory ratio is 1:2)
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• Restlessness
• Increased anxiety
• Increased pulse and respiratory rate.
a. Nursing Management
I. Impair gas exchange related to brochoconstriction and mucosal oedema
• Provide comfortable position that is Fowler's position
• Auscultate breath sounds every 1 to 2 hours
• Assess blood pressure, heart rate, respiratory rate and level of consciousness every 15 minutes until stable
and then every 2 to 4 hours
• Administer bronchodilators as prescribed
• Administer oxygen as prescribed.
II. Ineffective airway clearance related to increased thick mucus secretions and fatigue
• Cough and deep-breath adequately to expectorate secretions
• Demonstrate skill in conserving energy while attempting to clear airway
• Provide chest physiotherapy or postural drainage
• Give steam inhalation as per requirement
• Encourage to take more warm fluid/liquid intake
• Administer brinchodilator or steroid therapy as prescribed
III.Anxiety related to inability to breath and interference with activities
• Verbalize fears related to breathing problems
• Encourage the patient to express his fears and concerns about his illness and answer his questions honestly
• Encourage him to identify and comply with care measures and activities that promote relaxation
• Demonstrate measures to decrease anxiety during an attack
• Reassure the patient during as asthma attack and stay with him
• Place the patient in semi-Fowler's position and encourage diaphragmatic breathing.
IV.High risk for infection related to decreased pulmonary function, ineffective airway clearance and possible steroid
therapy
• If effective sputum is mucopurulent, obtain sputum for culture and sensitivity and also Gram's stain
• Administer antibiotics as prescribed
• Monitor TPR every 4th hourly
• Monitor all respiratory treatments that are administered
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• Provide deep breathing and coughing exercises
V. Knowledge deficit related to health maintenance
• Teach the patient and family members about diaphragmatic and pursed lip breathing
• Teach the patient how to use an oral or turbo-inhaler
• Supervise the patients drug regimen, checking for proper use of a metered dose inhaler
• Show the patient how to breath deeply
• Instruct him to coup up secretions accumulated overnight and to allow time for medications to work.
• Emphasize consistency of medications for maximum benefits, even though he is feeling well
• Instruct the patient to drink plenty of oral fluids to help loosen secretions and maintain hydration
• Tell the patient to eat well-balanced diet to prevent respiratory infection and fatigue
• Teach him to avoid substances that trigger an attack
• Encourage the patient to take light nutritious and well balanced diet and not full stomach meal particularly at
night because it causes discomfort in breathing
• Avoid foods and place, which is allergic to the patient if occupation induces allergy, change of occupation
is needed
• Advise to carry bronchodilators and to take whenever he gets an attack of wheezing.
1. a. Define status asthmaticus.
b. Pathophysiology of status asthmaticus.
c. Nursing management of a patient with status asthmaticus. (2+3+5=10 marks)
a. Status asthmaticus
It is a severe and persistent asthma that lasts longer than 24 hours and does not respond to conventional therapy. Status
asthmaticus occurs if bronchospasm is not controlled and symptoms are prolonged.
a. Pathophysiology
A combination factors like construction of the bronchiolar smooth muscle, swelling of bronchial mucosa and thickened
secretions, contribute to one pathophysiological problem like a decrease in the diameter of the bronchi. Another
problem is the ventilation-perfusion abnormality that results from hypoxaemia and respiratory acidosis or alkalosis.
There is a reduced PaO2 and an initial respiratory alkalosis with a decreased PaCO2 and the pH. As the severity of
status asthmaticus increases, the PaCO2 increases and the pH falls, reflecting respiratory acidosis.
I. Ineffective airway clearance related to bronchospasm
• Assist patient to a sitting position with head slightly flexed, shoulders relaxed and knees flexed and allow for
adequate chest expansion
• Increase the frequency and dose of inhaled bronchodilators
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• Administer continuously bet-aadrenergic agonist nebulizer therapy
• If patient is not responding to beta adrenergic agonist administer aminophyllin IV as per prescription
• Administer injection methylpredni-solone IV every 4 to 6 hours and sometimes injection magnesium sulfate
IV is given because it acts as bronchodilators
• Insert arterial catheter to facilitate frequent ABG monitoring
• Auscultate lung sounds after treatment to note results
• Administer supplementary oxygen
• Assess the patient skin turgor to identify signs of dehydration and administer IV fluids as per prescription
because patients metabolic rate is increased
• Provide assistance by mechanical ventilation if required (if there is no response to treatment)
• Monitor patient for first 12 hours or until status asthmaticus is under control.
II. Anxiety related to difficulty in breathing, actual loss of control and fear of suffocation
• Provide a calm and quite environ-ment
• Stay with the patient to promote safety and to provide reassurance
• Encourage verbalization of feelings, perceptions and fears to identify problem areas so concentrated planning
can take place
• Instruct the patient on the use of relaxation techniques to relieve muscle tension and to promote ease of
respiration.
III.Ineffective therapeutic regimen management related to lack of information
• Teach the patient how to use an oral or turbo-inhaler
• Supervise the patient drug regimen, checking for proper use of a metered dose inhaler
• Emphasize consistency of medications for maximum benefits, even though he is feeling well
• Advise the patient to carry bronchodilators and to take whenever he gets an attack of wheezing (tightness of
the chest, sweating and dysponea)
• Advise the patient avoid emotional stressful situation.
1. Mrs Geetha 30 years, is admitted with glomerulonephritis.
a. What are the causes of glomerulonephritis?
b. Explain the nursing management of Mrs Geetha.
c. List the complications of chronic glomerulonephritis. (2+6+2 marks)
a. Meaning
Glomerulonephritis is an inflammatory disease of the glomerulus. Inflammation occurs as a result of the deposition of
antigenantibody complexes in the basement membrane of the glomerulus or from antibodies that specifically attack
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the basement membrane. The resulting immune reaction in the glomerulus causes inflammation, which in turn causes
the glomerulus to be more porous, allowing proteins, white blood cells and red cells to leak into the urine.
Causes
The glomerular injury is usually causes by immunological processes. Three major immunological mechanisms are
recognized;
i. Antigen-antibody complexes formed extrarenally are trapped in glomeruli and initiate the inflammatory process,
this is a common reaction responsible for glomerulonephritis
ii. Antibodies are formed against an antigen in or produced by the glomerular basement membrane, initiating
glomerular inflammation
iii. Activation of the alternative complement pathways
The common cause of glomerulonephritis is the beta-hemolytic Streptococcus, although a wide range of other
infectious organisms have been implicated as possible causes. The patient history usually reveals that the renal
disturbance follows an infection such as a sore throat or respiratory infection of some form, by a latent period of 2 to
4 weeks. In some instances, the infection may have been so mild that little or no attention was given to it at the time.
I. Altered nutrition less than body requirement related to anorexia and increased metabolic demands
• Encourage for high caloric and low protein diet
• Carbohydrates are increased liberally to provide energy and reduce catabolism of protein
• Advise to take salt restricted diet.
II. Fluid volume excess related to reduced urine output
• Provide bed rest and elevate head of the bed to provide comfort and diuresis
• Monitor daily weight
• Inform to restrict sodium and fluid intake
• Maintain intake and output chart
• Restrict fluid as much as possible and relieve thirst by offering hard candies, lemon slices or ice chips
• Elevate oedematous extremities
• Administer diuretics as ordered
• Monitor blood pressure every 2 to 4 hours and instruct client to report symptoms related to elevated blood
pressure (headache, blurred vision, loss of balance, nose bleeds)
• Limit activity as ordered
• Administer antihypertensive as prescribed.
III.Fatigue related to increased metabolic demands and anaemia
• Provide complete bed rest both physically and mentally

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• Allow the patient to ask questions and provide appropriate answers for that.
• Encourage the patient to express about any fear or concern, if necessary, help the patient to deal with the
emotional reactions expected during a long-term illness
• Provide diversional activities which may help the patient to cope with prolonged physical immobility.
IV.Risk for impaired skin integrity related to edema
• Assess for skin turgor
• Provide back care every 4th hourly
• Change the position every 2nd hourly
• Provide comfort devices if required
• Ensure active or passive range-of-motion exercises every 4th hourly.
V. Risk for infection related to altered immune response secondary to treatment
• Protect the patient from other infectious disease
• Use sterile technique while providing care
• Wash hands before and after caring the patient
• Encourage the patient and family to avoid situation which causes infection to the patient
• Encourage the patient to treat any infection promptly
• Administer steroids or cytotoxic agents to control the deposition of immune complexes or antibiotic therapy
may be initiated to eliminate infection.
a. Complications of chronic glomerular nephritis
• Renal failure
• Congestive heart failure
• Hypertensive encephalopathy
• Nephrotic syndrome.
1. Mrs. Rachana, 30 years is admitted for thyroidectomy
a. What are the indications for thyroidectomy?
b. What are the complications of thyroidectomy?
c. Prepare a nursing care plan for immediate postoperative care. (2+2+6=10 marks)
a. Indications
• Remission of hyperthyroidism
• Nodular toxic goitre
• Thyroid carcinoma
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• Younger patients with hyperthyroidism
• Hyperthyroidism patients who does not take medications regularly
• Patients who live remote areas without access to satisfactory treatment
• Patients with large or medium sized goitre (>80 gm).
b. Complications
• Damage of laryngeal nerve
• Haemorrhage
• Tetany
• Injury to parathyroid gland
• Oedema at surgical site
• Hypothyroidism
• Hypoparathyroidism.
c. Immediate postoperative care
I. Ineffective airway clearance related to haemorrhage or oedema at surgical site
• Inspect neck dressing every hourly during initial postoperative period, then every 4th hourly
• Provide semi-Fowler's position with an ice bag to reduce swelling
• Monitor the amount of drainage and frequency of dressing reinforcement
• Ask the client to speak every 2 hourly and note changes in tone or hoarseness
• Check with the patient regarding sensation of tightness around the incision site
• Assess for presence of Chvostek's and Trousseau's signs
• Monitor serum calcium levels
• Keep emergency tracheostomy suction equipment, oxygen and IV calcium near the patient for readily
available
• Monitor the patient for signs of respiratory distress, cynosis, tachypnea and noisy respiration.
II. Potential for decreased cardiac output related to hemorrhage
• Record vital signs every 15 minutes in the initial postoperative period then every 4th hourly
• Monitor cardiac rhythm, noting tachycardia or irregularity
• Observe dressing for excessive bleeding like front, back and sides of the neck.
• Identify the changes in level of consciousness
• Administer fluids as prescribed.
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III.Altered comfort pain related to surgical incision
• Provide comfortable position (Semi-Fowler's) with sand bags or pillows to support the neck
• Teach the patient to support the head and neck
• Provide a quite environment to the patient while decreasing stress
• Place fluids and call bell within easy reach of the patient
• Administer pain medications as prescribed.
1. Master Ravi, 14 years has been admitted with acute myelogenous leukaemia.
a. Define leukaemia.
b. List the clinical manifestations of leukaemia.
c. Explain the nursing management of master Ravi based on his problems. (2+3+5=10 Marks)
a. Leukaemia: It is the general term used to describe a group of malignant disorders affecting the blood and blood
forming tissues of the bone marrow, lymph system and spleen.
b. The clinical manifestations of leukaemia are varied based on its types (acute myelogenous leukaemia, acute
lymphocytic leukaemia, chronic myelogenous leukaemia and chronic lymphocytic leukaemia)
• Most of the signs and symptoms evolve from insufficient production of normal blood cells
• Fever and infection result from neutropenia
• Weakness and fatigue from anaemia
• Bleeding tendencies from thrombocytopenia
• The proliferation of leukaemic cells within organs leads to a variety of additional symptoms like pain from an
enlarged liver and spleen, hyperplasia of the gums and bone pain from expansion of marrow.
c. Nursing management of Mr. Ravi
I. Risk for infection related to decreased neutrophils and altered response to microbial invasion and presence of
environmental pathogens
• Monitor for fever and absolute neutrophil count to identify signs of and potential for infection
• Take vital signs every 4th hourly because fever may be the only indication of infection and septic shock
• Report physician immediately if body temperature goes more than 104°F
• Maintain aseptic techniques for initiating and maintaining IV lines, caring for venous access devices or
obtaining blood culture specimens to reduce or introducing infection through the skin
• Teach the patient necessary personal hygiene techniques like hand washing, oral care, skin hygiene, etc.
• Avoid invasive procedures as much as possible like venipuncture, urinary catheters, etc.
• Administer haematopoietic growth factors as ordered to increase patients WBC count, and reduce infection
risk during periods of neutropenia.
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II. Impaired oral mucous membrane related to low platelet count, treatment, disease as manifested by bleeding and
blood-filled bullae.
• Assess oral mucosa daily for the presence of blood-filled bullae in mouth, bleeding, tender gingivae and lips
• Assess underlying gums and mouth for bleeding areas
• Provide oral hygiene with minimal friction
• Use soft-bristle tooth brush, cotton swabs, mild mouth wash to clean mouth without trauma
• Evaluate integrity of nares, especially if nasogastric tube, endotracheal tube or nasal oxygen is in use to
determine need for prophylactic or treatment interventions.
III.Potential complication: Acute blood loss related to decreased platelets, use of antiplatelet aggregating drugs
• Evaluate mucous membranes and skin to detect presence of epistaxis, petechiae, ecchymoses, haematomas
• Test emesis, sputum, faeces, urine, nasogastric secretions and wound secretions regularly for occult blood and
observe for blood to detect potential presence of bleeding
• Assess complete blood count and platelet count daily or more often if warranted to monitor for bleeding
• Do not administer and tell patient not to use aspirin or aspirin-containing products because of their effects
on platelet adhesiveness
• Use ice packing or direct pressure to control active bleeding.
• Teach patient to avoid straining at stool and administering stool softeners as ordered
• Avoid rectal temperature, suppositories and enemas
• Teach the patient to cough, sneeze and blow nose gently
• Administer medications to suppress vomiting and coughing to avoid activities that could cause hemorrhage
IV.Activity intolerance related to weakness and malaise as manifested by difficulty in tolerating increased activity
(e.g. increased pulse and respiratory rate).
• Plan care to alternate periods of rest and activity without tiring the patient
• Strive for a 1:3 rest/activity ratio and assist patient with activity of daily living as needed
• Limit visitors, phone calls, noise and interruptions by hospital staff to reduce demands placed on patient
• Monitor vital signs to evaluate activity tolerance.
V. Imbalanced nutrition less than body requirements related to poor nutritional intake, anorexia and treatment as
manifested by weight loss, vitamin deficiency, below usual body weight.
• Teach patient about foods high in protein, iron, calories and other nutrients to increase intake of essential
nutrients needed for haematopoiesis like liver, green leafy vegetables, fish, legumes, whole grains, egg, dried
fruits, cereals, potatoes, bananas, milk and milk products, citrus fruits, straw berries and nuts.
• Teach and monitor use of a food diary to increase patients awareness of actual intake and increase intake.
• Suggest eating small, frequent meals with snacks90

throughout the day.
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1. Mr. David, 60 years, admitted to neuromedical ward with parkinsonism.
a. What are the causes of parkinsonism and explain the clinical manifestations in terms of pathological changes.
b. Explain the role of nurse in the rehabilitation of Mr. David.
a. Parkinson's disease is a slowly progressing neurologic movement disorder that eventually leads to disability.
Causes
Cause of the most cases is unknown Research suggests several causative factors like,
• Genetics
• Atherosclerosis
• Excessive accumulation of oxygen free radicals
• Viral infections
• Head trauma
• Chronic antipsychotic medication use
• Some environmental exposures.
Pathologic changes
The pathologic process of Parkinson's disease involves degeneration of the dopamine producing neurons in the
substantia nigra of the midbrain, which in turn disrupts the normal balance between dopamine and acetylcholine in the
basal ganglia. Dopamine is a neurotransmitter essential for normal functioning of the extrapyramidal motor system,
including control of posture, support and voluntary motion. When 80 per cent of neurons in the substantia nigra are
lost it gives rise to clinical manifestation.
• Tremor is often the first sign. It can affect handwriting. The hand tremor is described as “poll rolling” because the
thumb and forefinger appear to move in a rotary fashion as if rolling a pill, coin, or other small object.
• Rigidity is the second sign. Resistance to passive limb movement characterizes muscle rigidity. Stiffness of the
neck, trunk and shoulders is common.
• Bradykinesia is one of the most common features. Patients take longer time to complete most activities and have
difficulty initiating movement, such as rising from a sitting position or turning in bed.
• Hypokinesia (abnormally diminished movement)
• Micrographia (shrinking, slow hand writing)
• Dysphonia (soft, slurred, low-pitched, and less audible speech)
• Dysphagia begins to drool and is at risk for choking and aspiration
• Postural and gait problems
• Loss of postural reflexes and the patient stands with the head bent forward and walks with a propulsive gait.
• Excessive and uncontrolled swetting
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• Paroxysmal flushing, orthostatic hypotension gastric and urinary retention, constipation and sexual disturbances.
• Depression
• Dementia (progressive mental deterioration)
• Sleep disturbances and hallucinations.
a. Rehabilitation: is a dynamic, health-oriented process that assists an ill person or a person with disability to achieve
the greatest possible level of physical, mental, spiritual, social and economic functioning.
Parkinson's disease is a slow progressive disease where the patient has impaired physical mobility, muscle rigidity
with weakness and autonomic disturbances. Role of nurse in rehabilitation of Mr. David consists of:
I. Improving mobility and functioning
• Provide a range of motion exercise four times a day
• Emphasize the importance of a daily exercise programme (walk, swim, garden work) to maintain joint mobility.
• Advise the patient to do stretching exercises (stretch-hold-relax) to loosen the joint structures
• Advise the patient to have frequent rest periods
• Encourage to take warm baths, massage passive and active exercises
• Evaluate the effectiveness of the drug programme and adjust as necessary.
II. Gaining independence in self-care
• Teach the patient how to turn and get out of bed like bend the knees and turn upper half of body, the lower half
of the body will follow. To get out of bed, turn on side and then place feet over the edge of bed and push up
with the arm.
• Use assistive devices to help in bathing and grooming, e.g. long-handled bath brush, soap or rope, button aids, etc.
III.Preventing injury
• Remove environmental objects that could cause falls
• Provide assistive devices to support mobility
• Secure a knotted rope to foot of bed to allow patient to pull himself to a sitting position
• Refer to physiotherapist for postural and gait training.
IV.Improving nutritional status
• Teach the patient how to eat with his disability
• Encourage to make conscious effort to chew and to chew first on one side and then the other
• Control the build up of saliva by holding head in an upright position and making a conscious effort to swallow.
• Have patient/family keep a weekly weight chart
• Arrange for supplementary feedings to augment caloric intake.
V. Maximizing residual communication ability
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• Accept the patient's attempts to communicate
• Speech therapy may be given for patient with verbal deficit
• For writing difficulty, develop an alternative method of communication
• Instruct the patient to take a deep breath before speaking, speak in short sentence and practice breathing exercise
regularly
• Exercise facial muscle (smile, frown grimace) for facial mobility.
VI.Providing psychological support and social interaction
• Develop a trusting relationship and adopt positive attitude towards others
• Allow the patient to express his/her feelings of frustration, anger, depression, guilt, etc
• Be supportive and give positive reinforcement for his/her achievements in ADL.
VII.Patient/family teaching
• Patient and family to be taught about the disease condition, treatment and care of patient, etc
• They can be encouraged to participate in supportive group if available.
1. Mrs. Shaheen aged 60 years is admitted to hospital with severe headache and blurring of vision. Her blood
pressure is 200/180.
a. What is hypertension? What are the causes of hypertension?
b. Explain pathophysiology.
c. Write treatment and nursing management using nursing process.
a. Hypertension: It is defined as persistent level of high blood pressure that is systolic pressure is above 140 mmHg
and diastolic pressure is above 90 mm of Hg.
Causes: Based on the causes hypertension is classified as;
• Primary hypertension – From this about 90 to 95 per cent of patients suffer
• Secondary hypertension – From this 5 to 10 per cent of patients suffer.
According to the clinical manifestation, both essential and secondary hypertension may be benign or malignant.
Benign hypertension—is moderate elevation of blood pressure and the rise is slow as the years pass. About 90 to 95
per cent patients of hypertension have benign hypertension.
Malignant hypertension—is marked and rapid increase of blood pressure to 200/140 mmHg or more and the patients
have papilloedema, renal haemorrhages and hypertensive encephalopathy. Less than 5 per cent of hypertensive patients
develop malignant hypertension.
Primary/essential hypertension
• The exact cause is unknown but number of factors are responsible
• Genetic factors—familial aggregation
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• Racial—blacks than whites
• Environmental factors like salt intake, skilled occupation, obesity, higher living standard and patient at stress
• Age—middle aged people
• Sex—females with hypertension appear to far better than males
• Atherosclerosis—contributing factors such as cigarette smoking, elevated serum cholesterol, glucose intolerance.
Secondary hypertension
• Coarctation of aorta
• Renal diseas like parenchymal renal disease, e.g. glomerulonephritis, chronic pyelonephritis, collagen vascular
diseases, polycystic kidney disease, renal artery stenosis
• Endocrine disorders like phaeochromocytoma, Cushing's syndrome, Conn's syndrome, hyperparathyroidism,

acromegaly, primary hypothyroidism, congenital adrenal hyperplasia
• Drugs, e.g. oral contraceptives containing oestrogens, anabolic steroids, corticosteroids, non-steroidal anti-
inflammatory drugs, sympathomimetic agents
• pregnancy with or without eclampsia.
a. Pathophysiology
The pressure exerted by the blood on the walls of the blood vessels is measured as blood pressure. Blood pressure
is determined by cardiac output (CO), peripheral vascular resistance (PVR), the ability of the vessels to stretch, the
viscosity or thickness of the blood, the amount of circulating blood volume. Decreased stretching ability and increased
viscosity and fluid volume increase blood pressure.
Several processes maintain blood pressure by controlling CO and PVR. These processes include the nervous system,
the baroreceptors, the rennin-angiotensin mechanism and the balancing of body fluids. One way blood pressure is
maintained is through adjustment of the CO, which is the amount of blood that the heart pumps out each minute. Heart
rate will increase to pump out more blood in response to either physical or emotional activities to meet the increased
oxygen needs of organs and tissue. Another factor that maintains blood pressure, PVR is the opposition that the blood
encounters as it flows through the vessel. Anything causing blood vessel to become narrower will increase the PVR.
Any time the PVR is increased, more pressure is needed to push the blood along the vessel, so the blood pressure
increases. When PVR is decreased, less pressure is needed, so the blood pressure decreases. Increased arteriolar PVR
is the main mechanism that elevates blood pressure in hypertension.
a. Medical treatment
i. Thiazide—a diuretic, removes sodium, extracellular fluid and potassium while reducing cardiac output. It is given
12.5 to 25 mg daily or twice daily orally.
ii. Vasodilators—it vasodilate arteries, arterioles to reduce after load. It is given in the form of tab. Minoxidil 2.5 to
40 mg twice daily.
iii. Atenolol or propranolol—it blocks β1 heart receptors to reduce heart rate and blood pressure, some reduce peripheral
vascular resistance. It is given 10 to 120 mg orally 2 to 4 times daily
iv. Nifedipine—a calcium channel blocker, blocks entry of calcium into smooth muscles to reduce after load. It is
given 10 to 30 mg 4 times daily.
v. Angiotensin—converting enzyme inhibitor—it blocks conversion of angiotensin-I to angiotensin-II, e.g. captopril

12.5 to 75 mg orally twice daily.
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Nursing Management
I. Decreases cardiac output related to mechanical factors
• Assess and monitor for signs and symptoms of high systemic vascular resistance, i.e. elevated arterial pressure,
increased pulse rate, diminished peripheral pulses, decreased urine output.
• Provide bed rest and limit activities to conserve energy and decrease oxygen demand
• Check blood pressure on admission in both arms, lying, sitting and standing. Compare with arterial pressure,
monitor if available every 4 to 6 hours as indicated use same arm every time
• Maintain parenteral fluids as ordered
• Administer antihypertensive medications as ordered
• Observe for side effects or toxic effects of each medication
• Attach patient to cardiac monitor as indicated for arrhythmias, sudden hypotensive response or hypertensive crisis
• Measure intake and output. Report output if less than 30 ml/hour
• Monitor electrolytes, blood urea nitrogen and creatinine. Check specific gravity as ordered
• Keep nothing by mouth if nausea and vomiting is present
• Maintain a low-sodium, low-fat diet and restrict fluids as ordered.
II. Headache related to increased cerebrovascular-pressure
• Assess quality of pain and presence of associated symptoms such as nausea, vomiting and epistaxis
• Initiate measures to relieve pain and reduce external stimuli like maintaining a quite environment with reduced
lighting, limit activities, avoid sudden jarring motion, limit visitors, use additional comfort measures such as
cold packs and position changes
• Administer pain relieving medications and antiemetics as ordered
• Assist with ambulation because patient may experience dozziness.
III.Potential for cerebral injury related to severe, accelerated or malignant hypertension
• Assess and monitor level of conciousness
• Check neurologic signs every hours during hypertensive crisis
• Notify physician of any sudden changes in pupilary response or movement of extremities
• Maintain seizure precautions as indicated.
IV.Potential for noncompliance
• Assess factors that will influence the patients ability to adhere to the therapeutic plan, financial status, age, culture,
health status occupation
• Identify and clarify any misconceptions the patient has regarding disease state
• Design a programme that is compatible with the patient's lifestyle and personality
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• Provide opportunities to discuss feelings towards recommended life-style changes.
V. Potential for powerlessness
• Assess the patient attitude and feelings toward the health care regimen
• Identity any misconceptions and fears the patient has regarding this chronic illness such as forced dependence
on the health care system
• Encourage the patient to participate in determining the therapeutic plan
• Teach the patient and family members to monitor blood pressure at home and interpret results.
VI.Ineffective health maintenance related to lack of regular exercise regimen
• Instruct the patient to avoid heavy weights lifting, isometric exercises and other activities inappropriate to the
clients physical limitations.
• A gradually increasing programme of aerobic activity such as walking, jogging or swimming can be
recommended.
1. Mr. Ravi is admitted to casuality with the complaints of severe back pain and inability to pass urine. He is
diagnosed to have renal calculi.
a. Write aetiology and clinical manifestations of renal calculi.
b. Explain “Flush therapy.”
c. Write three priority nursing diagnoses and their intervention. (2+2+6=10 marks)
a. Aetiology
• Secondary to infection (recurrent pyelonephritis) or stasis in the urinary tract
• Parathyroid over activity
• Due to concentration of the urine, the condition is said to be more common in tropical climates
• Patients who excrete abundant calcium in the urine (those with bone destruction from metastatic disease or those
with bone decalcification due to chronic illness, e.g. poliomyelitis or tuberculosis arthritis of the spine)
• Excessive intake of calcium and vitamin-D
• Hypersensitive to vitamin-D (e.g. patients with sarcoidosis)
• Hypercalciuria is often idiopathic (i.e. cause unknown)
• Majority of patients with calcium-containing stones no definite cause for their formation
• Metabolic abnormalities (e.g. gout).
Pain – Typical ureteric colic is extremely painful. The pain in the loin is sharp and biting and radiates with greater
severity to the testicle in the male or to the labia in the female.
Strangury – There is a great urge to pass urine every few minutes, but only a drop or two is voided.
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Haematuria – The urine may be tinted with blood or there may be frank haemorrhage. A small stone may be passed
by the patient as a termination of the violent pain with considerable relief. When large fixed stones are present the
pain is a more constant dull ache in the loin.
Occasional bouts of pyrexia occurs as a result of infection.
a. Flush therapy
Most kidney stones are small enough to pass through the urinary tract system without medical treatment. Drinking 10
to 12 glasses of water per day will help to “flush out” the stones called flush therapy.
a. Nursing intervention
I. Pain related to irritation of stone and inadequate comfort measures
• Record vital sign every hourly until severe pain subsides
• Apply moist heat to flank area as needed
• Schedule activity as tolerated between attack of renal colic
• Encourage the patient for more fluid intake that is 3000 to 4000 ml/day (unless contraindicated)
• Administer narcotic analgesics and spasmolytic agents as prescribed
II. Potential complication; urinary obstruction related to presence of stone in path of urine flow
a. Strictly monitor patients urine to determine stone excretion (strain all urine).
b. Maintain intake and output chart.
c. Observe for bladder distension.
d. Inform the physician if oliguria is present.
III.Altered health maintenance related to lack of knowledge about prevention of recurrence
a. Inform the patient about the disease aspect, treatment and side effects of treatment.
b. Advise the patient to avoid milk and milk products who are at risk of developing calcium phosphate stones
and diet that restrict purines who are at risk of developing uric acid stones.
c. Encourage for more fluid intake, i.e. 3000 ml/day at least (unless contraindicated).
d. Inform the patient to strain all urine through a piece of gauze (if necessary) and to bring stone to physician
for analysis.
e. Educate the patient about symptoms of recurrence to be reported like haematuria and flank pain.
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Chapter 1. LONG ESSAYS (10 MARKS) : 15.206.227.228 - 02-June-2021 09:40:43

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Chapter 1.

LONG ESSAYS (10 MARKS)

1. Answer the following about pyogenic meningitis.

a. List the Aetiology

b. Pathophysiological basis of clinical manifestations.

a. Aetiology of pyogenic meningitis

• Middle ear infection (commonest)

• Droplet infection from nasopharynx, sinuses, mastoid

• Infection from the danger area of the face

• Immunosuppression from AIDS

• Invasive procedures such as lumbar puncture and cranial surgeries.

a. Pathophysiology and clinical manifestation

1. Stage of meningeal irritation

• Delirium, convulsion and meningeal cry.

• Generalized flexed attitude, hudded up position may be seen.

• Neck or cervical rigidity.

• Respiratory rate is normal or hurried.

• Pupils are irregular and irregularly react to the light.

1. Stage of meningeal compression

• High temperature continues, patient gradually becomes drowsy and confused.

• Pulse rate becomes slow and bounding.

• Respiration may show Cheyne-Stokes or Biot's type of breathing.

• Neck rigidity and Kernig's sign are present.

• Pupils are slightly dilated but still react to light.

• Oculomotor palsy particularly bilateral 6th nerve palsy may develop.

• Ophthalmoscopic examination may reveal papilloedema

1. Stage of coma or paralysis

• Patient becomes deeply comatose.

• High temperature, increased respiratory rate and pulse rate.

• Neck rigidity and Kernig's sign may disappear.

• Pupil's are widely fixed and do not react to light.

• Limbs are flaccid, planter reflex is extensor, jerks are lost.

• Involuntary evacuation of urine and faces may develop.

• Papilloedema becomes prominent.

• Bedsores may develop.

a. Nursing care of patient with pyogenic meningitis

Maintaining the airway

• Tracheotomy or endotracheal incubation may be necessary.

• Suctioning is performed to remove secretions.

High fever in the unconscious patient may be caused by pyogenic meningitis.

• Switch on the fan and open the windows.

• Application of cold sponge.

• Administer repeated doses of antipyretics as prescribed.

Attaining fluid and nutritional balance.

Maintaining healthy oral mucous membranes.

• Regular oral care to the patient prevents the risk of parotitis.

Maintaining skin integrity.

• Use wrinkle free bed.

• Position the patient once in every 2 hours.

Maintaining corneal integrity.

• Instill artificial tears every two hours.

Preventing urinary retention.

• Administer a glycerine suppository, which stimulates bowel emptying as per prescription.

• Protect the patient with padded side rails bed.

Promoting sensory stimulation.

• Provide diversion in the form of music or other conversation.

• Orient the patient periodically to the present situation.

• Carry out the activities of daily living.

• Teach the relatives to carry out the care activities.

Supporting the patients loved ones.

• Permit loved one to involve in-patients care, if they wish.

a. List the indications for below-knee amputation.