Read free for 30

Search
days

Download 1 of 59 ( Search document )

Enjoy thousands of titles when you subscribe

Read free for 30 days

Only ₱129/month a/er. Cancel anytime.

Medical Surgical Nursing

Uploaded by Chey Dianne Seriña
! 100% (7) · 4K views · 59 pages
More

" # $ % & '

Save 100% 0% Embed Share Print

Download 1 of 59 ( Search document )

MEDICAL-SURGICAL NURSING REVIEW

Course Outline

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

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

Pain – the fifth vital sign

an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Basic Categories of Pain:

1. Acute Pain – sudden pain which is usually relieved in seconds or after a few weeks.
2. Chronic Pain (Non-Malignant) – constant, intermittent pain which usually persists even after healing
of the injured tissue
3. Cancer-Related Pain- May be acute or chronic; may or may not be relieved by medications
Pain Transmission:
1. Nociceptors are called pain receptors. These are the free nerve endings in the skin that respond to
intense, potentially damaging stimuli.
2. Peripheral Nervous System
3. Central Nervous System
4. Descending Control System

Factors Influencing Pain Response

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

Characteristics of Pain
1. Intensity –mild, moderate, excruciating
2. Timing – morning or evening, duration may be longer or shorter
3. Location
4. Quality – burning, aching, stabbing
5. Personal Meaning to pain – tolerance to pain may be different from one person to the other due to
some personal reasons such as economic reasons, work condition, etc.
6. Aggravating and Alleviating factors – patient’s environment
7. Pain Behaviors - facial expressions with pain
Pain Assessment
1. Evaluate: Cause, Location, Character and Intensity
2. Numeric Pain Scale – 5-severe pain -! 0 – no pain
3. Descriptive Pain Scales – mild, moderate, severe
4. Visual Analogue Scales
5. Faces Pain Scale

Nurse’s Role in Pain Management

1. Identify goals for Pain management
a. Decrease intensity, duration or frequency
b. Factors in identifying goals:
i. Severity of pain

115

ii. Harmful effects of pain to the client

iii. Duration of the pain

2. Establish Nurse-Patient Relationship and Teaching

a. Acknowledge the verbalization of pain by the client
b. Relieve patient’s anxiety
c. Teach measures how to relieve pain
3. Provide Physical care
a. Teach and assist in self-care
b. Environmental conditions
c. Application of ice/heat on painful area

4. Manage anxiety related to Pain

a. Teach about the nature of pain that may be felt by the client and reassure him/her
b. Teach alternative measures to relieve pain
c. Stay with the client/ frequent communication with the client

5. Pain Medications may be administered as:

a. Balanced Anesthesia – given to avoid experiencing pain
b. PRN – “Pro Re Nata” – as needed
c. Preventive – taken before pain is felt
d. Individualized Dosage
e. Patient-Controlled Analgesia (PCA) – patient takes medication if pain felt is becoming
intolerable

6. Non-pharmacologic Interventions
a. Cutaneous Simulation and Massage
b. Ice and heat therapies
c. Transcutaneous Electrical Nerve Stimulation
d. Distraction
e. Relaxation Techniques
f. Guided Imagery
g. Hypnosis

II. PERIOPERATIVE CARE

o Phases of Perioperative Nursing

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

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

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

4. Physical Assessment and preparation

a. Physical Preparation – NPO, remove dentures, jewelries, clothesetc.
b. Nutritional & Fluid Status – should be well hydrated
c. Drug or alcohol Use – may experience delirium or intoxication to
anesthetic drugs because ormal doses do not usually take effect to
these patients and require heavier dose to achieve anesthetic effect.
d. Respiratory Status - teach breathing exercises
e. Cardiovascular Status – should have controlled and stable
cardiovascular functioning before operation to prevent intraoperative
problems
f. Hepatic & Renal Functions – normal functioning is important in
absorbing anesthetic drugs

116

g. Endocrine Functions- important in monitoring to prevent

hypo/hyperglycemia, thyrotoxicosis, acidosis
h. Immune Functions – allergies esp. to anesthetic drugs
i. Psychosocial Factors – emotional and psychological preparation to
ensure cooperation fom the patient with the procedures
j. Spiritual & Cultural Beliefs - blood transfusions, transplants, ligation,
etc are against other culture & religion.

5. Pre-operative drugs – given 20-60 mins.pre-operative

o Makes patient drowsy, keep siderails up

6. Proper positioning

Semi-Fowlers HOB elevated at 30 Head injury, pot-op cranial surgery,

degrees post-op cataract removal, increased
ICP, dyspneic patients

Fowlers HOB elevated at 45 Head injury, pot-op cranial surgery;

degrees post-op abdominal surgery; post-op
thyroidectomy, post-op cataract surgery,
increased ICP; dyspnea

High-Fowler’s HOB elevated at 90 Pneumothorax, hiatus hernia

degrees

Supine/ Dorsal Lying on back w/ small Spinal cord injury, urinary

Recumbent pillow under head catheterization

Lying on abdomen with Amputation of legs/feet, post lumbar

head turned to the side puncture, post myelogram, post
tonsillectomy & adenoidectomy (T&A)

Lateral / Side lying Lying on side, weight Post-abominal surgery, post

on the lateral side, the tonsillectomy & adenoidectomy (T&A),
lower scapula and post-liver biopsy ( right side down), post
lower iliac. pyloric stenosis (right)

Lying on side, weight Unconscious client

on the clavicle,
humerus and anterior
aspect of the iliac.

Lying on back with Perineal, rectal & vaginal procedures

knees and legs bent
and raised on a stir up

Trendelenburg Head & body lowered, Shock

feet elevated

Reverse Head elevated , feet Cervical traction

Tredelenburg lowered

Elevate extremity Support with pillows Post-op surgical procedure on

extremity, cast, edema,
thrombophlebitis

117

Prone
Supine Lateral Recumbent

Sim’s Position Reverse High-Fowler’s

Trendelenburg

Jack-Knife Lithotomy

B. Intra-operative Care

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

Principle: STERILE TO STERILE, CLEAN TO CLEAN

Sterile objects touches only sterile surfaces/objects
Clean objects touches only clean surfaces/objects

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

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

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

118

a. General Anesthesia via Inhalation

b. General Anestheisia via Intravenous
c. Regional Anesthesia - local anesthesia
d. Conduction Blocks/ Spinal Anesthesia – Epidural & Spinal Block
- for operation below the waist line
- patient is awake during operation

4. Perform sponge count, instrument count and needle count

5. Aseptic technique in handling and preparing all instruments and supplies
6. Applies grounding device to prevent electrical burn during use of electrosurgical
equipment
7. Proper documentation

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

III. ALTERATIONS IN HUMAN FUNCTIONING

1. DISTURBANCES IN OXYGENATION

Arterial Blood Gas

Normal Value

pH Measure of acidity or alkalinity 7.35 – 7.45

pCO2 Partial pressure of carbon dioxide respiratory 35 -45

parameter influenced by lungs only

pO2 Partial pressure of oxygen; measure of amount 80-100

oxygen delivered to lungs

HCO3 Bicarbonate, metabolic parameter influenced only by 22-26

metabolic factors

Respiratory Normal Value Respiratory

Acidosis Alkalosis

pH 7.35 – 7.45

pCO2 35 -45

Normal Compensation HCO3 22-26 Normal Compensation

a. Administer NaHco3 Nursing Intervention a. Breathe into paper

b. Get rid of CO2 bag or cupped
c. Bronchodilators hands
d. Monitor ABG b. Oxygen

119

Metabolic Normal Value Metabolic

Acidosis Alkalosis

pH 7.35 – 7.45

Normal Compensation Normal Compensation

pCO2 35 -45

HCO3 22-26

a. Treat underlying cause Restore fluid loss which may be

(Starvation, systemic cause by vomiting, gastric
infections, renal failure, suction, alkali ingestion,
Diabetic acidosis, Nursing Intervention excessive diuretic
Keratogenic diet,
diarrhea, excessive
exercise)
b. Promote Metabolic
good air Normal Value Metabolic
exchange Acidosis 2
Alkalosis
c. Give NAHCO3 via IV
pH 3

7.35 – 7.45
pCO
Normal Compensation CHRONIC OBSTRUCTIVE PULMONARY DISEASE Normal Compensation
HCO 35 -45
- A group of conditions assoc. w/ chronic obstruction of airflow entering or leaving the lungs

Major diseases
You're Reading a Preview 22-26

1. Pulmonary Emphysema – airway is obstructed due to destroyed alveolar walls

2. Chroni a. cTreat
Bronunderlying cause mucus production that obstructs airway
chitis- increased Restore fluid loss which may be
3. Asthma Upload your documents to download. cause by vomiting, gastric
(Starvation, systemic Nursing Intervention
infections, renal failure, suction, alkali ingestion,
Cause: Diabetic acidosis, excessive diuretic
Keratogenic
3
diet, OR Medical Management:
1. Cigarette smoking 1. Bronchodilators
2. Chronic resp diarrhea,
iratoryexcessive
infections
exercise) 2. Antihistamines
3. Family hist ory of COPD 3. Steroids
4. Air pob. ionBecome
llutPromote good air a Scribd member for full
4. access.
AntibioticsYour
exchange
c. Give NAHCO via IV first 30 days are free. 5. Expectorants
Clinical Manifestations: 6. Oxygen therapy at 2LPM – use cautiously
" Few words between breaths
" Pursed-lip breathing CHRONIC OBSTRUCTIVE PULMONARY Nursing Management:
DISEASE
" Cyanosis 1. Administer meds and O2 as ordered
" Distended neck veins Continue for Free2. Promote adequate activities to enhance
" Barrel chest – increased diameter of thorax cardiovascular fitness
" Pulsus paradoxus – 3. Adequate rests
A group of conditions assoc. w/ chronic obstruction of airflow entering 4. Avoor id leaving
allergenstheorlungs
other irritants
" Clubbing of fingers
" Nicotine Stains 5. Ps yc ho lo gical Sup po rt
Major diseases
"1. Pitting
Pulmoedemanary Emphysema – airway is obstructed due to destroyed alveolar walls
"2. exertional
Chronic Bron dyspnea
chitis-orincr
dyspnea
eased at rest production that obstructs airway
mucus
- "3. Enlarged
Asthma pulsating liver
" Cough- with or without sputum production
Cause: Medical Management:
1. Cigarette smoking 1. Bronchodilators
2. Chronic respiratory infections CHRONIC BRONCHITIS
2. Antihistamines
"
3. Family history of COPD “Blue Bloater”
"
3. Steroids
4. Air pollution 4. Antibiotics
"
5. Expectorants
- "AnManifestations:
Clinical inflammation of the bronchi which causes increased mucus6.product ion athe
Oxygen ndrap
chryonic cough
at 2LP M –. use cautiously
- "Chron Few ic words
conditibetween
on is diagn osed if symptoms occur for 3 months and for 2 consecutive years.
breaths
" Pursed-lip breathing Nursing Management:
Cause:
" Cigarette
CyanosisSmoking, infection, pollution 1. Administer meds and O2 as ordered
" Distended neck veins 2. Promote adequate activities to enhance
" Barrel chest – increased diameter of thorax cardiovascular fitness
" Pulsus paradoxus – 3. Adequate rests
" Clubbing of fingers 4. Avoid allergens or other irritants
" Nicotine Stains 5. Psychological Support
Clinical Manifestations:
Pitting edema
exertional Slight gynecomastia
" dyspnea
Productiveor dyspnea
cough at rest
Enlarged Petechiae in midsternal area
" pulsating
Thicker, liver
more tenacious mucus
Cough- with or without sputum production Dyspnea
CHRONIC BRONCHITIS
“Blue Bloater”
120

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

Cause: Cigarette Smoking, infection, pollution

"
"
Clinical Manifestations:
" Decreased exercise tolerance
" Wheezes Slight gynecomastia
Productive cough Petechiae in midsternal area
Thicker,
Medical Management: more tenacious mucus
see COPD Dyspnea

Nursing Management:
1. Reduce or avoid irritants
2. Increase humidity
3. Administer medications as ordered 120
4. Chest physiotherapy
5. Postural drainage
6. Promote Breathing techniques

EMPHYSEMA
“Pink Puffer”
"

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

Cause: Cigarette smoking,Decreased exercise tolerance

Alpha-anti-trypsin deficiency (an enzyme in the alveolar walls)
Wheezes
Clinical Manifestations: Nursing Management:
Medical
1. Management:
Dyspnea on ex see
ertiCOPD
on Position: Sit up and lean forward
2. Tachypnea Pulmonary toilet:
3. Management:
Nursing Barrel-chest Cough->Breathe deeply->Chest physiotherapy-> turn & position
41.. W
Rehdu
eecezesor avoid irritants Frequent rest periods
2. Pi
5. Incr
nkea
ishseski
hunmi codilotyr Nebulization
3. Sh
6. Admallo
iniwste
rarpimdedi
rescat pira s ordered IPPB – Intermittent Positive Pressure Breathing (aerosolized inhalation)
iontisonas
7.
4. Pu
Chrs
esed lip sibot
t phy rehe
athirangpy O2 @ 2LPM

You're Reading a Preview

5. Postural drainage
6. Promote Breathing techniques EMPHYSEMA
“Pink Puffer”
Asthma
Upload your documents to download.
-A condition where there is an increase responsiveness and/or spasm of the trachea and bronchi due to various stimuli
- A causes
which disordernarrowing veolar walls are destroyOR
where theofalairways ed causing permanent distention of air spaces.
- (+) dead areas in the lungs that do not participate in gas or blood exchange
Cause and Risk Factors:
Cause: Cigarette
1. FaBecome
smoking, tory oaf aScribd
mily hisAlpha-anti-trypsin member
sthma deficiency (an for
enzyme fullinaccess.
the alveolarYour
walls)
2. Allergens: dust, pollens,
Secondary smoke inhalatioNursing Management:
3.
Clinical Manifestations:
1. Dy4. spneaAoinr pex oler
lutition
on first Position: Sit are
30
n
days up and free.
lean forward
2. T 5.achypneSatress Pulmonary toilet:
3. Barrel-chest Cough->Breathe deeply->Chest physiotherapy-> turn & position
Types:
4. Wheezes Frequent rest periods
5.1. PiIm
nkmish
unsoki
longico
c alosrthma - Continue
oIPPB n cfor
Nebulization
hildhoFree
ccurs– iIntermittent od Positive Pressure Breathing (aerosolized inhalation)
6. Shallow rapid respirations
7.2. Pu
No rsn-
edimlimu
p bno lohi
reat gingc asthma - oc
O2cu@rs2LPM
in adulthood and assoc w/ recurrent resp infections.
- usually >35 y/o
3. Mixed, combined immunologic and non-immuno logic
Asthma

Clinical Manifestations: Nursing M anagement:

" Increased tightness of chest, dyspnea
" Tachycardia, tachypnea 1. Promote pulmonary ventilation
-A condition where
" thereDry, hacking, persistent
is an increase cough
responsiveness and/or spasm 2. Facilitate
of the tracheaexpectoration
and bronchi due to various stimuli
" (+) wheezes,
which causes narrowing of airwayscrackles 3. Health teaching
" Pallor, cyanosis, diaphoresis " Breathing techniques
Cause and Risk" Factors:
Chronic barrel chest, elevated shoulders " Stress management
1. Family history of asthma " Avoid allergens
2. " Alledistended
rgens: dusneck t, polveins
lens,
3. "Secorthopnea
ondary smoke inhalation
4. "Air Tenacious,
pollution mucoid sputum
5.t:
Tre atm en Stress
1. Steroids,
Types:
2. Antibiotics
3. Bro
Immnc
unho
oldi
oglaictoarss,thex
mpe
a ctoran- ts occurs in childhood
4.
1. O2, nebulization,
Non-immunologic asthma -aerosol occurs in adulthood and assoc w/ recurrent resp infections.
" - usually >35 y/o
2.
"
3. Mixed, combined immunologic and non-immunologic
Complication: STATUS
" ASTHMATICUS - a life-threatening asthmatic attack in w/c symptoms of asthma
Clinical Manifestations:
" Nursing to
continues and do not respond M atreatment
nagement:
" Increased tightness of chest, dyspnea "
II. PARENCHY M A L D ISO R D
Tachycardia, tachypnea E RS : Promote
" pulmonary ventilation
Dry, hacking, persistent cough 1. Facilitate
" expectoration
(+) wheezes, crackles 3. Health teaching
2.
"
" Pallor, cyanosis, diaphoresis Breathing techniques
"
Stress management 121
" Chronic barrel chest, elevated shoulders
Avoid allergens
distended neck veins
orthopnea
Tenacious, mucoid sputum
Tre atm en t:
1. Steroids,
2. Antibiotics
3. Bronchodilators, expectorants
O2, nebulization, aerosol
4. STATUS ASTHMATICUS -

Complication: a life-threatening asthmatic attack in w/c symptoms of asthma

continues and do not respond to treatment
PNEUMONIA
II. PARENCHYMAL DISORDERS:
- An inflammatory process of lung parenchyma assoc. w/ marked increase in alveolar and interstitial fluids

Etiology:
1. Bacterial / Viral – streptococcus pneumoniae, pseudomonas aeruginosa, influenza
2. Aspiration 121
3. Inhalation of irritating fumes

Risk factors:
1. Age: too young and elderly are most prone to develop
2. Smoking, air pollution
3. URTI
4. Altered conciousness
5. Tracheal intubation
6. Prolonged immobility: post-operative, bed-ridden patients
PNEUMONIA
Clinical Manifestations:

-
1. Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure
2. Cough- productive , rusty/ yellowish/greenish sputum, splinting of affected side, chest retration
3. CXR, sputum culture, Blood culture, increased WBC, elevated sedimentation rate
An inflammatory process of lung parenchyma assoc. w/ marked increase in alveolar and interstitial fluids
Nursing Management:
Etiology:
1. Bacterial"/ Viral – streptoco
Promote ccus ventilation-
adequate pneumoniae, pseudomonas
positioning, Chestaephysiotherapy,
ruginosa, influenza
IPPB
2. Aspiration Provide rest and comfort
"
3. Inhalation of irritating fumes
" Prevent potential complications

You're Reading a Preview

Risk factors: " Health teaching: skin care, hygiene
1. Age" : tooDrug
youngtherapy:
and elderly are most prone to develop
2. Smoking, air o pollutAntibiotics:
ion penicillin, cephalosphorin, tetracycline, erythromycin
o Upload your documents to download.
3. URTI Cough suppressants
4. Altered concio o
usne ss
Expectorants
5. Tracheal intubation
" Rest and adequate activity bed-ridden patients
Prolonged immobility: post-operative, OR
6. " Proper Nutrition
Clinical Manifestations:
Become a Scribd member for full access. Your
PULMONARY EDEMA
1. Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure
2. Cough- productive , rusty/ yelfirst 30
lowish/gre days
enish are
spu tum, free.
splinting of affected side, chest retration
"
3. CXR, sputum culture, Blood culture, increased WBC, elevated sedimentation rate
- often occurs"when the left side of the heart is distended and fails to pump adequately
"
Nursing Management:
Clinical Manifestation:o
o Constant irritating cough,
" Promote o
Continue
o dyspnea, crackles, cyanosis
adequate ventilation- for Free
positioning, Chest physiotherapy, IPPB
Provide rest and comfort
Pathophysiology: Prevent potential complications
"
"Health
Fluidteaching: skin care,
accumulation in thehygiene
alveolar sacs due to hypovolemia, fluid congestions in the lungs, alveoli
Drug
aretherapy:
congested
"
Antibiotics: penicillin, cephalosphorin, tetracycline, erythromycin
Nursing Management: Cough suppressants
"
1. Diuretics, low sodium diet, I&O
Expectorants
2. promote effective airway clearance, breathing patterns and ventilation
3. Rest
Moniand
tor Vadequate
S activity
4. Proper
PsychoNutrition
logical support
o
5. Administer medications PULMONARY EDEMA

TUBERCULOSIS

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

Clinical Manifestation:
Constant "cough, dyspnea, crackles, cyanosis
irritating
- A chronic lung infection that leads to consumption of alveolar tissues

EPathophysiology:
tiology: Mycobacterium tuberculosis.
Risk Factors: Fluid accumulation in the alveolar sacs due to hypovolemia, fluid congestions in the lungs, alveoli
Poor living conditions,are congested
overcrowded
1. Poor nutritional intake
Nursing
2. Pr Management:
evious infection
1. Diuretics, low sodium diet, I&O
2. promote effective airway clearance, breathing patterns and ventilation
3. Monitor VS
4. Psychological support
5. Administer medications 122
TUBERCULOSIS

You're reading a preview *

- A chronic lung infection that leads to consumption of alveolar tissues
Unlock full access (pages 9-22) by
Etiology: Mycobacterium tuberculosis.
Risk Factors:
uploading documents or with a
Poor living conditions, overcrowded
1. Poor nutritional intake
2. Previous infection 30 day free trial
Continue for Free
122

You're reading a preview *

Unlock full access (pages 26-32)

by uploading documents or with
a 30 day free trial
Continue for Free