ملزمة تمريض باطني جراحي الترم الثاني2 التميز +الريادة

Medical surgical nursing theory II )‫تمريض باطني جراحي نظري مستوى ثاني (مساعدين‬
Respiratory disorders
Introduction
_ The function of the respiratory system is to exchange gases (oxygen and
carbon dioxide) with the external environment; the respiratory system
maintains the level of these gases within a narrow range, regardless of the
demand for oxygen.
_ Respiration, which the central nervous system controls, is regulated by
metabolic demands and cardiac output.
Assessment of respiratory system
_ Nursing history:-
◆ The nurse asks the patient about his chief complaint.
◗ A patient with a respiratory disorder may report the following signs or
symptoms:
- chest pain, - cough, - dyspnea, - orthopnea, - shortness of
breath,
- or wheezing.
◗ The patient may also report hemoptysis, increased sputum production, or a
change in the characteristics of his sputum.
◆ The nurse then questions the patient about his present illness.
◗ Ask the patient about his symptom, including
- when it started, - associated symptoms, - location, - duration,
- frequency, - and precipitating - and alleviating factors.
◗ If the patient has dyspnea, ask him to rate it on a scale of 0 to 10, in which 0
means no dyspnea and 10 means the worst dyspnea experienced.
◗ If the patient has orthopnea,
ask him how many pillows he uses to sleep.
◗ Ask if the patient’s cough is productive or nonproductive.
Is the cough recent?
If not recent, how long has he experienced it?
Has it changed recently?
◗ When a patient produces sputum,
ask him to estimate the amount produced in teaspoons
or another common measurement;
ask him at what time of day he coughs the most;
question him about the color and consistency of his sputum;
ask whether its character has changed recently. If so, how?
Does he cough up blood?
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◗ If a patient wheezes,
ask when the wheezing occurs.
What makes the patient wheeze?
Does he wheeze loudly enough for others to hear it?
What helps stop the wheezing?
◗ If the patient has chest pain,
ask him where the pain is located,
what it feels like,
what characteristics it has,
whether it moves or radiates,
how long it lasts,
what causes it to occur,
and what makes it better;
have him rate the pain on a scale of 0 to 10 (with 0 being no pain
and 10 worst pain experienced).
◗ Ask about the use of prescription and over-the-counter drugs, herbal
remedies, vitamin and nutritional supplements, and alternative or
complementary therapies used.
◆ The nurse asks about medical history.
◗ Question the patient about other respiratory disorders—such as
allergies, asthma, cystic fibrosis, pneumonia, tuberculosis,
and upper respiratory tract infections.
◗ Ask the patient if he has undergone chest or lung surgery.
◆ The nurse then assesses the family history.
◗ Ask about a family history of chronic obstructive pulmonary disease (COPD),
pneumonia, or Tuberculosis.
◗ Determine if there’s a family history of lung cancer.
◆ The nurse obtains a social history.
◗ Ask about smoking habits and environmental exposure to irritants such as
asbestos.
◗ Question the patient about his tolerance for exercise.
_ Physical assessment:-
◆ The nurse begins with inspection.
◗ Observe the patient’s general appearance;
note the patient’s position.
Is he sitting upright?
Leaning forward?
In a tripod position?
◗ Take note of his level of awareness and general appearance.
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Does he appear relaxed?
Anxious?
Uncomfortable?
Is he having trouble breathing?
◗ Note deformities,
masses, or scars of the chest;
look for chest wall symmetry at rest and with inspiration;
note the anterior-posterior chest diameter;
observe chest wall movement. Is it paradoxical, or uneven?
◗ Note tracheal deviation;
look for spinal abnormalities such as kyphosis;
note whether the costal angle is enlarged.
◗ Observe the patient’s respirations,
noting rate, depth, rhythm, and inspiratory-expiratory ratio;
look for the use of accessory muscles with breathing, pursed lip
breathing, nostril flaring, and retracting.
◗ Observe the color of the patient’s skin, lips, mucous membranes,
and nail beds; check nails for clubbing.
◆ Next, the nurse uses palpation.
◗ Palpate the chest for temperature, dryness, crepitus, pain, and tactile
fremitus.
◗ Check for respiratory excursion.
◆ Then the nurse percusses the heart.
◗ Percuss the anterior and posterior chest, noting lung boundaries and
movement of the diaphragm.
◗ Also note percussion sounds; describe any abnormal ones, including the
location and size of the area.
◆ The nurse continues with auscultation.
◗ Auscultate the anterior, posterior, and lateral chest, comparing breath
sounds.
◗ Classify each sound according to its intensity, location, pitch, duration, and
characteristic; note whether the sound occurs during inhalation, exhalation,
or both.
◗ Auscultate for vocal fremitus, noting bronchophony, egophony, and
whispered pectoriloquy.
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Asthma
_ Description
◆ Asthma is a chronic reactive airway disorder that involves episodic,
reversible airway obstruction resulting from bronchospasms,
increased mucus secretions, and mucosal edema.
◆It’s characterized by airway inflammation, intermittent airflow obstruction, and
bronchial Hyperresponsiveness.
◆ Asthma can result from several types of triggers.

◗ exposure to tobacco or wood smoke.
◗ breathing polluted air.
◗ inhaling other respiratory irritants, such as perfumes or cleaning products.
◗ exposure to airway irritants at the workplace.
◗ breathing in allergy-causing substances (allergens), such as molds, dust, or
animal dander.
◗ upper respiratory tract infection, such as a cold, influenza, sinusitis, or
bronchitis.
◗ exposure to cold.
◗ dry weather.
◗ emotional excitement or stress.
◗ physical exertion or exercise (exercise-induced asthma).
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◗ reflux of stomach acid (gastroesophageal reflux disease, or GERD).
◗ ingestion of sulfites, an additive found in some foods and wine.
◆ Comorbidities include GERD, drug-induced asthma, and other allergic
reactions, such as eczema, rashes, and temporary edema.
_ Signs and symptoms:-
◆ Overall signs and symptoms of asthma range from mild wheezing and
dyspnea to life-threatening respiratory failure; signs and symptoms of
bronchial airway obstruction may persist between acute episodes.
◆ An asthma attack may begin dramatically, with simultaneous onset of severe,
multiple signs and symptoms, or insidiously, with gradually increasing
respiratory distress .
◆ Exposure to a particular allergen is followed by a sudden onset of dyspnea
and wheezing and by tightness in the chest accompanied by a cough that
produces thick, clear, or yellow sputum (cough, dyspnea, and wheezing are
the three most common signs and symptoms of asthma).
◆ An attack often starts during the night or in the early morning.
◆ Physical findings may include visible dyspnea, use of accessory respiratory
muscles, complaints of chest tightness, diaphoresis, increased
anteroposterior thoracic diameter, and hyperresonance.
◆ Tachycardia, tachypnea, mild systolic hypertension, and pulsus paradoxus
may occur as the exacerbation progresses.
◆Inspiratory and expiratory wheezes may occur, along with wheezing and
coughing (which may be exercise-induced), a prolonged expiratory phase of
respiration, and diminished breath sounds.
◆ The occurrence of cyanosis, confusion, and lethargy indicate the onset of life-
threatening status asthmaticus and respiratory failure.
_ Diagnosis and treatment:-
◆ ABG analysis provides the best indication of an attack’s severity and may
reveal hypoxemia during an acute attack; in acutely severe asthma, Pao2 is
less than 60 mm Hg, Paco2 is 40 mm Hg or more and pH is usually
decreased; normal Paco2 during an acute attack may signal impending
respiratory failure.
◆ Radioallergosorbent testing shows increased serum immunoglobulin E levels
as a result of an allergic reaction.
◆ A complete blood count (CBC) including WBC count and differential shows
increased eosinophil count in acute phases.
◆ Chest X-rays may show hyperinflation, flattened diaphragms, areas of focal
atelectasis, pneumothorax, or pneumomediastinum.
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◆ Pulmonary function tests commonly show decreased peak flow rates and
forced expiratory volume in 1 second, low-normal or decreased vital capacity,
and increased total lung and residual capacities, although results may be
normal between attacks.
◆ Skin testing may identify specific allergens.
◆ Bronchial challenge testing shows the clinical significance of allergens
identified by skin testing.
◆ Pulse oximetry measurements may show decreased oxygen saturation.
◆ Peak flow monitoring reveals a result of less than 80% of personal best; a
reading below 50% of personal best indicates a severe exacerbation.
◆ Treatment involves identifying and avoiding precipitating factors and
desensitizing the patient to specific antigens.
◆ Generally, asthma medications are divided into two categories: quick relief for
relief of immediate symptoms and long-acting medications to control the
underlying inflammation.
◗ Quick-relief bronchodilators include an albuterol sulfate inhaler used as
needed.
◗ Quick-relief anticholinergics for bronchospasms include ipratropium bromide.
◗ Corticosteroids, such as systemic methylprednisolone, prednisolone, and
prednisone, prevent exacerbation and progression during moderate or severe
exacerbations.
◗ Corticosteroids for persistent asthma include inhaled corticosteroid of
fluticasone (Flovent), beclomethasone (QVAR), budesonide inhaled
(Pulmicort Turbuhaler), and mometasone inhaled (Asmanex).
◗ Long-acting beta-agonist or combination drugs include salmeterol inhaled
(Serevent), formoterol inhaled (Foradil), fluticasone and salmeterol inhaled
(Advair), and budesonide and formoterol inhaled (Symbicort).
◗ Leukotriene antagonists (antileukotrienes) include montelukast (Singulair).
◗ Anticholinergic bronchodilators include tiotropium inhaled (Spiriva).
◗ Monoclonal antibodies such as omalizumab (Xolair) and anti-inflammatory
agents such as nedocromil sodium (Tilade) inhaled before exercise reduce
bronchospasm.
Nursing interventions:-
◆ Give prescribed inhalers and asthma medications.
◆ Place the patient in high Fowler’s position.
◆ Encourage pursed-lip and diaphragmatic breathing.
◆ Administer prescribed humidified oxygen.
◆ Adjust oxygen according to the patient’s vital signs and ABG values.
◆ Assist with intubation and mechanical ventilation, if appropriate.
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◆ Perform postural drainage and chest percussion, if tolerated.
◆If the patient is intubated, suction as needed.
◆ Treat the patient’s dehydration with I.V. or oral fluids as tolerated.
◆ Keep the room temperature comfortable.
◆ Use an air conditioner or a fan in hot, humid weather.
◆Monitor the patient’s vital signs, intake and output, response to
treatment, signs and symptoms of the ophylline toxicity, breath sounds,
ABG results, pulmonary function test results, pulse oximetry,
complications of corticosteroid treatment, and anxiety level.
Hemothorax
_ Description:-
◆ Hemothorax is the presence of blood in the pleural cavity; it typically
accompanies pneumothorax.
◆It may result from chest trauma,
 lacerated liver,
 penetrating trauma,
 perforated blood vessels,
 perforated diaphragm,
 pleural damage that causes bleeding,
 rib fracture.
◆ In hemothorax, blood collects in the pleural layer, compressing the lung on
the affected side; this lung compression compromises gas exchange.
◆ Chest pain,
 cyanosis,
 dyspnea,
 tachypnea commonly occur.
◆ With marked blood loss,
 hypertension
 shock may occur.
◆ Asymmetrical lung expansion is accompanied by decreased breath sounds
on the affected side.
◆ Chest X-ray,
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 CBC,
 ABG studies are commonly prescribed.
◆ A chest tube is inserted, and a water seal or suction is used to facilitate
drainage.
◆ Thoracotomy may be indicated if blood loss is severe.
◆If total blood loss is severe, the patient is treated with I.V. fluids and
transfusion.
_ Nursing interventions:-
◆ Administer oxygen to maintain adequate oxygenation, improve Pao2,
and reverse hypoxemia.
◆ Teach techniques for effective coughing and deep breathing to prevent
atelectasis and promote lung expansion.
◆Maintain the integrity of the chest tube system to facilitate blood
drainage from around the lung and promote lung expansion.
◆ Check the chest tube insertion site for crepitus, which indicates air
leakage into tissue and may indicate a leak in the chest tube system.
- An air leak in the system may indicate that the lung is damaged,
causing air to leak from the lung into the pleural space.
- If the air leak is outside the chest cavity (such as from the chest tube),
air entering the system may increase air accumulation in the pleural
space.
◆ Encourage frequent position changes to prevent complications of
immobility and promote lung expansion.
◆ Provide an analgesic as needed to reduce anxiety, relieve pain, and
ease coughing and deep breathing.
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Pleural effusion
_ Description
◆ Pleural effusion is an accumulation of fluid in the pleural space (the thin
space between the visceral and parietal pleura); although it isn’t a
disease itself, it occurs secondary to other disease states.
◆ Empyema is the accumulation of pus and necrotic tissue in the pleural
space; blood (hemothorax) and chyle (chylothorax) may also collect in this
space.
◆ A pleural effusion can be classified either as
 exudative (caused by inflammation of the pleura)
 transudative (caused by excessive hydrostatic pressure or decreased
osmotic pressure.
◗ Common causes of exudative effusions are
 bacterial
 fungal empyema
 pneumonitis,
 chest trauma,
 collagen disease,
 malignancy,
 myxedema, pancreatitis,
 pulmonary embolism,
 subphrenic abscess,
 tuberculosis.
◗ Common causes of transudative
effusions are
 heart failure,
 hepatic disease with ascites,
 hypoalbuminemia,
 peritoneal dialysis.
◆ The most common symptoms are
 pleuritic pain
 dyspnea.
◆ Physical examination may
 reveal decreased chest wall movement,
 decreased breath sounds over the affected area,
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 dullness on percussion.
◆ Infection from empyema may
 produce
 cough,
 fever,
 night sweats.
◆ Chest X-ray can diagnose pleural effusion;
 CT scan of the chest,
 bronchoscopy,
 pleurocentesis,
 ultrasonography.
◆ The underlying cause should be treated if it can be identified.
◆ Thoracentesis is performed to remove fluid; chest tubes may be placed for
continued drainage.
◆ Thoracotomy may be needed if thoracentesis isn’t effective.
◆ An antibiotic is prescribed to treat empyema; the specific antibiotic used
depends on the causative organism.
◆ Explain thoracentesis to the patient, and support him during the
procedure.
◆ Watch for respiratory distress or pneumothorax after thoracentesis.
◆ Administer oxygen to improve oxygenation.
◆ Encourage deep-breathing exercises and incentive spirometry to
promote lung expansion.
◆ Maintain the integrity of the chest tube drainage system; monitor the
amount, color, and consistency of drainage; and check for air leaks.
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Pneumonia
_ Description
◆ Pneumonia is an acute lung infection with inflammation accompanied by
accumulation of exudate in the alveoli .
Classification
Pneumonia can be classified as:
• community-acquired pneumonia;
• hospital-acquired pneumonia;
• aspiration pneumonia;
• pneumonia in immunocompromised patients.
◆ The risk of pneumonia increases with
 aspiration,
 central nervous system depression,
 chronic illness,
 COPD,
 dehydration,
 existence of a tracheostomy opening,
 immobility,
 immunosuppression,
 intubation, pain in the thoracic cavity,
 use of general anesthesia.
◆ It may result from
 a bacterial,
 fungal,
 viral infection
 from exposure to a chemical irritant,through aspiration or gas inhalation.
◆ Pneumonia remains a major cause of morbidity and mortality among elderly
and chronically ill people.
Clinical manifestations
The clinical manifestations of pneumonia are:
• fever;
• pleuritic chest pain;
• tachypnoea (25–45 breaths per minute) and possibly orthopnea;
• tachycardia;
• a productive cough with purulent, blood-stained sputum;
• general symptoms including anorexia, headaches and muscle
pains;
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• on auscultation, there may be reduced breath sounds, crackles or
dullness.
 Chest X-ray,
 ABG studies,
 sputum culture (for bacterial infection), and serologic testing (for viral
infection) may be prescribed.
 blood analysis, typically showing a raised white cell count;
 blood pressure monitoring;
 blood urea measurement;
 pulse oximetry;
 blood culture;
◆ Needle or open biopsy may obtain lung tissue specimens (for fungal
infection), and cold agglutinins may reveal antibodies associated with
Mycoplasma pneumoniae infection.
◆ Pneumonia is treated with antibiotics to eradicate the infecting organism.
◆ A bronchodilator is used to open narrowed airways.
◆ Teach effective coughing and deep breathing to improve airway
clearance.
◆ Provide adequate hydration to liquefy secretions; thin secretions are
easier to expectorate.
◆Implement chest physiotherapy; postural drainage uses gravity to clear
secretions, and percussion and vibration loosen secretions, making
them easier to cough up.
◆ Administer oxygen to aid ventilation, improve Pao2, and preserve
oxygenation.
◆ Suction the patient’s airway as needed to maintain patency and to clear
secretions.
◆ Advise the patient to limit activity and to rest for long periods to
decrease oxygen consumption.
◆ Provide pain medication as needed to allow effective coughing and
deep breathing.
◆Maintain adequate nutrition to offset the increased use of calories
secondary to infection.
◆ Teach the patient how to contain secretions to reduce the risk of
spreading infection.
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◆ Practice good hand hygiene techniques to reduce the risk of spreading
infection.
◆ Teach relaxation and stress-reduction techniques; anxiety can
compromise the immune system and increase the risk of infection.
Pulmonary edema
_ Description
◆ Pulmonary edema is the collection of fluid in the interstitium and alveoli
of the lungs as pressure rises in the pulmonary vessels.
◆It can result from
 ARDS,
 fluid overload,
 left-sided heart failure,
 mitral stenosis,
 MI,
 pulmonary emboli.
 pulmonary edema, the left ventricle can’t effectively pump blood from the
heart.
 With increased resistence to left ventricular filling, fluid backs up into the
lungs .
 Surface tension increases, the alveoli shrink, and the lungs become stiff,
making breathing more difficult.
◗ Hypoxemia and an altered V˙/Q˙ ratio develop.
◗ Fluid moves into the larger airways, where it’s coughed up as pink, frothy
sputum.
 Tachycardia
 tachypnea may be accompanied by narrowed pulse pressures
 hypotension; third and fourth heart sounds may be present;
 skin may be cold and clammy.
◆ Dyspnea, increased respiratory rate, orthopnea, and pulmonary hypertension
may occur.
◆Jugular veins may be distended, and PAWP may be elevated.
◆ Coughing may produce blood-tinged or pink, frothy sputum.
◆ Lung auscultation may reveal dependent crackles.
◆ Other signs and symptoms may include confusion, decreased urine output,
diaphoresis, drowsiness, lethargy, and restlessness.
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◆ Chest X-ray,
 pulse oximetry,
 ABG studies typically are prescribed.
◆ A PA catheter is inserted to measure pressures.
◆ A diuretic is administered to decrease edema.
◆ Other drugs that may be administered include an inotropic drug to increase
myocardial contractility, nitroglycerin to reduce preload an afterload, I.V.
nitroprusside to reduce preload and afterload, and a vasopressor to maintain
blood pressure.
◆Intubation and mechanical ventilation may be necessary to treat respiratory
distress.
◆ Morphine is administered to decrease preload, respiratory rate, and anxiety.
◆ Patients who don’t respond to drug therapy may be treated with an intra-
aortic balloon pump, which temporarily assists the failed left ventricle, or with
surgery (such as angioplasty, coronary artery bypass grafting, or valvular
repair), depending on the underlying heart condition.
◆ Administer oxygen to aid ventilation, improve Pao2, and reverse
hypoxemia.
◆ Place the patient in semi-Fowler’s position to maximize oxygenation
and increase comfort.
◆ Carefully monitor fluid intake and output to assess the effectiveness of
diuretic therapy and prevent sudden increases in venous return caused
by oral and I.V. intake.
◆Medicate for pain as needed to reduce anxiety and increase comfort.
◆ Frequently change the patient’s position to prevent pressure ulcers and
encourage lung expansion.
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Tuberculosis
_ Description
◆ Tuberculosis (TB) is an infectious disease that commonly affects the
lungs; it typically occurs only after repeated, close contact with a
person infected with Mycobacterium tuberculosis.
◆ Risk factors for TB include
 alcoholism,
 immunosuppression,
 low economic status,
 and malnutrition;
 elderly people,
 populations in crowded areas (for example, shelters and prisons),
 and immigrants from areas with high incidences of TB (such as Africa,
Southeast Asia, and the Caribbean islands) are also more susceptible.
◆ The incidence of TB has increased in proportion to the increase in patients
who are infected with the human immunodeficiency virus.
◆M. tuberculosis is spread by
 way of infected airborne droplets;
 after infected droplets are inhaled into the terminal bronchioles, localized
pneumonia develops, initiating an inflammatory response.
◗ Tubercles form and grow in the lungs.
◗ The lesion center forms a yellow, cheesy mass called caseous necrosis.
◗ Healing begins, walling off the initial infection, and adenopathy occurs.
◗ Systemic infection may develop in the absence of appropriate treatment.
◆ Within 6 weeks of exposure to the infected droplets, cellular immunity occurs,
and skin test results become positive.
◆ Latent TB infection can become active TB disease years after exposure,
when resistance is lowered.
 Anorexia,
 weight loss,
 chills, fever,
 chest pain,
 coughing up blood or sputum,
 night sweats may occur in patients with active TB disease.
 Lung ausculation may reveal crackles, pleural effusions, and rhonchi.
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◆ The Mantoux TB skin test or the Quanti FERON - TB Gold test, a gamma
interferon blood test for TB, can be used to test for M. tuberculosis infection.
◆ Abnormalities seen during a chest X-ray may suggest TB, but can’t be used
to diagnose TB.
◆ The presence of acid-fast bacilli on a sputum smear or other specimen after
indicates disease.
◆ A positive culture for M. tuberculosis confirms the diagnosis of active TB
disease.
◆ Preventive treatment with isoniazid for 9 to 12 months is recommended for
other members of the patient’s household, those with recently converted
positive skin tests, and those with positive skin tests (depending on medical
history)
◆If the patient has active TB disease, an antituberculotic is used for 6 to 9
months; isoniazid with rifampin usually is the first choice; other
antituberculotics include ethambutol, and pyrazinamide.
◆ Teach the patient how to contain airborne droplets and secretions to
reduce the risk of spreading the infection.
◆ Practice good hand hygiene techniques to reduce the risk of spreading
the infection.
◆ Explain disease transmission to the patient and the need for prolonged
therapy to help increase his compliance with the treatment plan.
◆ Teach the patient about the prescribed drugs, including how to
recognize adverse reactions (especially the symptoms of
hepatotoxicity).
◆ Encourage the patient to maintain adequate dietary intake to maintain
nutritional status, build strength, and improve the body’s defense
mechanisms.
◆ Weigh the patient daily to assess nutritional status.
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Gastrointestinal disorders
❖Introduction
- The GI, or digestive, system breaks down food and prepares it for absorption
by the body’s cells; nonabsorbable ingested substances pass through the
system and are eliminated as solid waste.
- Although not part of the alimentary canal, the liver, gallbladder, and pancreas
are essential accessory components of the GI system.
❖ Nursing history
- The nurse asks the patient about his chief complaint.
◆ The patient with a GI problem may report a change in
- appetite.
- heartburn.
- nausea, or vomiting.
- pain.
◆ The patient may also report a change in
- bowel habits, such as (constipation, diarrhea, or stool characteristics)
- The nurse then questions the patient about his present illness.
◆ Ask the patient about his symptom, including when it :-
- started, associated symptoms,
- location, radiation, intensity, duration, frequency,
- precipitating and alleviating factors.
◆ Ask about the use of
- prescription and over-the-counter drugs,
- herbal remedies,
- vitamin and nutritional supplements; ask about the use of laxatives.
◆If the patient’s chief complaint is diarrhea, find out if he recently traveled
abroad.
◆ Ask the patient about changes in
- appetite and in bowel habits (e.g., a change in the amount,
appearance, or color of his stool or the appearance of blood in it)
- difficulty eating or chewing.
_ The nurse asks about medical history.

◆ Question the patient about other GI disorders, such as
- gallbladder disease,
- GI bleeding,
- inflammatory bowel disease, or ulcers.
◆ Also, ask about previous abdominal surgery or trauma.
_ The nurse then assesses the family history

◆ Ask about a family history of diseases with a hereditary link,
- such as alcoholism,
- colon cancer,
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- Crohn’s disease,
- stomach ulcers, and ulcerative colitis.
◆ Also, question the patient about a family history of chronic diseases.
_ The nurse obtains a social history.

◆ Ask about
- work, exercise, diet,
- use of recreational drugs and alcohol, caffeine intake, and hobbies.
◆ Also ask about stress, support systems, and coping mechanisms.
_ Physical assessment.
◆When assessing the abdomen, use this sequence:
1- inspection,
2- auscultation,
3- percussion,
4- palpation;
- palpating or percussing the abdomen before you Auscultate can change
the character of the patient’s bowel sounds and lead to an inaccurate
assessment.
◆ The nurse begins with inspection
- Observe the patient’s general appearance, and note his behavior.
- Inspect the skin for
turgor, color, and texture; note abnormalities such as bruising,
decreased axillary or pubic hair, edema, petechiae, scars, spider
angiomas, and stretch marks.
- Observe the patient’s head for
color of the sclerae, sunken eyes, dentures, caries, lesions, breath
odor, and tongue color, swelling, or dryness.
- Check the size and shape of the
abdomen, noting distention, peristalsis, pulsations, contour, visible
masses, and protrusions.
- Observe the rectal area for abnormalities.
◆ The nurse continues by using auscultation.
- Note the character and quality of bowel sounds in each quadrant.
- Auscultate the abdomen for vascular sounds.
◆ Then the nurse percusses the abdomen.
- Percuss the abdomen to detect the size and location of the abdominal
organs
- Note the presence of air or fluid.
◆ Next, the nurse uses palpation.
- Palpate the abdomen to determine the size, shape, position, and
tenderness of major abdominal organs and to detect masses and fluid
accumulation.
- Note abdominal muscle tone and tenderness.
- Palpate the rectum, noting any abnormalities.
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Gastroesophageal
reflux disease
_ Description
◆ GERD is the backflow of gastric contents or duodenal contents, or both, past
the lower esophageal sphincter (LES) into the esophagus without associated
belching or vomiting.
◆ The disorder occurs when the LES pressure is deficient or pressure in the
stomach exceeds LES pressure.
◆ The degree of mucosal injury is based on the amount and concentration of
refluxed gastric acid, proteolytic enzymes, and bile acids.
◆ Causes include anything that lowers LES pressure, such as
- alcohol,
- smoking,
- hiatal hernia,
- increased abdominal pressure with obesity or pregnancy,
- medications (such as morphine, diazepam, calcium channel blockers,
meperidine, or anticholenergic),
- NG intubation for more than 4 days, and weakened esophageal
sphincter.
Factors affecting LES pressure.
Various dietary and lifestyle factors can increase or decrease lower esophageal
sphincter (LES) pressure.
Take these factors into account when you plan the patient’s treatment program.
Factors that increase LES pressure
● Protein
● Carbohydrates
● Nonfat milk
● Low-dose ethanol
Factors that decrease LES pressure
● Fat
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● Whole milk
● Orange juice
● Tomatoes
● Antiflatulent (simethicone)
● Chocolate
● High-dose ethanol
● Cigarette smoking
● Lying on the right or left side
● Sitting
● Caffeine
_ Signs and symptoms
◆ Burning pain in the epigastric area, possibly radiating to the arms and chest,
results from reflux of gastric contents into the esophagus.
◆ Pain, usually after a meal or when lying down, occurs secondary to increased
abdominal pressure, causing reflux.
◆ Feeling of fluid accumulation occurs in the throat without a sour or bitter taste
because of hypersecretion of saliva.
• Epigastric burning, worse after eating.
• Heartburn.
• Burping (eructation) or flatulence.
• Sour taste in mouth, often worse in the morning.
• Nausea.
• Bloating.
• Cough due to reflux high in the esophagus.
• Hoarseness or change in voice.
_ Diagnosis and treatment.
◆ Diagnosis is based on
- a patient history that reveals heartburn,
- physical examination,
- esophagoscopy,
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- barium swallow, an upper GI series,
- esophageal acidity testing, and an acid perfusion test.
◆ Abdominal pressure may be reduced by eating small, frequent meals and
not eating before bedtime.
◆ Patient positioning may be helpful in reducing abdominal pressure and
preventing reflux (for example, sitting up during and after meal times or
sleeping with the head of the bed elevated).
◆ Antacids may help to neutralize the acidic content of the stomach.
◆ Histamine-2 receptor antagonists may be given to inhibit gastric acid
secretion.
◆ Proton pump inhibitors may be prescribed to reduce gastric acidity.
◆ Cholinergic agents may be given to increase LES pressure.
◆ Smoking cessation is recommended.
NURSING DIAGNOSES
• Risk for imbalanced nutrition: less than what body requires.
• Risk for imbalanced nutrition: more than what body requires.
• Acute pain.
• Chronic pain.
_ Nursing interventions
• Monitor vital signs.
• Assess abdomen for distention, bowel sounds.
• Teach about medication management.
• Teach patient about lifestyle modifications:
• Not to lie down after eating.
• Elevate head of bed.
• Avoid wearing clothing that is tight at waist.
• Avoid acidic foods (citrus, vinegar, tomato), peppermint, caffeine, alcohol.
• Stop smoking.
• Lose weight if overweight.
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Hiatal Hernia
_ Description
This is also known as a diaphragmatic hernia.
A part of the stomach protrudes up through the diaphragm near the esophagus
into the chest.
Patients may be asymptomatic or have daily symptoms of gastroesophageal
reflux disease (GERD).
The hernia may be a sliding hiatal hernia which allows movement of the upper
portion of the stomach including the lower esophageal sphincter up and down
through the diaphragm.
These patients typically have symptoms of GERD. Another type of hiatal hernia
is a rolling hernia in which a portion of the stomach protrudes up through the
diaphragm, but the lower esophageal sphincter area remains below the level
of the diaphragm. These patients do not generally suffer from reflux.
PROGNOSIS
Lifestyle modifications may help control the symptoms of hiatal hernia.
Some patients who do not get adequate control of symptoms or are refractory to
treatment may need surgery to correct the movement through the diaphragm.
SIGNS AND SYMPTOMS
• Sliding hernia:
• Heartburn.
• Difficulty swallowing (dysphagia).
• Burping (eructation).
• Chest pain.
• Rolling hernia:
• Chest pain.
• Shortness of breath after eating.
• Feeling of fullness after eating.
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INTERPRETING TEST RESULTS
• Barium swallow or upper GI study shows hiatal hernia.
TREATMENT
• Administer antacids for patients with reflux symptoms:
- Maalox, Mylanta, Tums, Gaviscon.
• Administer histamine type 2 (H2) blockers to reduce stomach acid:
- ranitidine, nizatidine, famotidine, cimetidine.
• Administer proton pump inhibitors to reduce the production of acid:
- omeprazole, esomeprazole, pantoprazole, rabeprazole, lansoprazole.
• Avoid lying down after eating.
• Modify eating schedule; small, frequent meals.
• Avoid clothing that is tight around the waist.
NURSING DIAGNOSES
• Acute pain.
• Chronic pain.
NURSING INTERVENTION
• Assess abdomen for distention, bowel sounds.
• Teach patient about lifestyle modifications:
• Medication management.
• Not to lie down after eating.
• Avoid wearing clothing that is tight at waist.
• Avoid acidic foods (citrus, vinegar, tomato), peppermint, caffeine,
alcohol.
• Stop smoking.
• Lose weight if overweight.
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Intestinal Obstruction and

Paralytic Ileus
_ Description
◆ Large-bowel obstruction can occur in the
- ascending, transverse,
- descending colon; the rectum;
- several areas simultaneously.
◆ Small-bowel obstruction can occur in any area of the
- duodenum, jejunum,
- ileum or in several areas simultaneously.
◆ Small- and large-bowel obstructions may result from
- infection, tumor,
- intestinal ulcerations with scar formation that lead to obstruction,
volvulus, intussusceptions adhesions, or paralytic ileus.
◆ Complications of small- and large-bowel obstruction include
- hypovolemic shock,
- peritonitis, rupture,
- septicemia, and death.
An intestinal obstruction occurs when motility through the intestine is
blocked.
This may be caused by a mechanical obstruction due to the
- presence of a tumor,
- presence of adhesions from prior surgery,
- infection or fecal impaction.
A paralytic ileus results when motility through the intestine is blocked without
any obstructing mass. This may occur during the
- postoperative period following intra-abdominal surgery,
- during a severe systemic illness (sepsis),
- electrolyte imbalance, or because of a metabolic disorder (diabetic
ketoacidosis).
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Disruption of intestinal function needs to be reestablished for return to
homeostasis.
In most cases the underlying cause must also be corrected in order for the
intestinal function to be restored. Nutritional needs must be met during the
treatment period.
SIGNS AND SYMPTOMS
- Vital sign changes may include
fever and signs of shock, such as hypotension, tachycardia, and
tachypnea.
- Other effects may include
anxiety, dehydration, dry skin, fatigue, malaise, and weight loss.
• Obstruction:
• Abdominal pain (cramping, intermittent or constant).
• Abdominal distention.
• Vomiting of gastrointestinal contents (may eventually include stool as GI
tract backs up).
• Bowel sounds high-pitched.
• Constipation.
• Abdominal tenderness on palpation.
• Paralytic ileus:
• Abdominal pain (constant).
• Vomiting of gastrointestinal contents.
• Bowel sounds diminished or absent.
Diagnosis:-
◆ Diagnosis may require
- patient history,
- physical examination,
- abdominal X-rays (such as flat plate of the abdomen, barium enema, and
GI series),
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- serologic studies, endoscopy, gastric analysis, stool examination,
colonoscopy, and proctoscopy.
TREATMENT
• NPO to rest intestinal tract.
• Nasogastric tube attached to suction the contents from stomach.
• Intravenous fluid replacement with isotonic solution.
• Correction of electrolyte imbalances.
• Parenteral nutrition replacement and vitamin supplementation.
• Administer antiemetics if nausea continues after NG tube in place.
• Monitor electrolytes.
NURSING DIAGNOSES
• Risk for imbalanced nutrition: less than what body requires.
• Risk for imbalanced fluid volume.
• Altered bowel elimination.
- Monitor intravenous access site for irritation, redness, swelling.
- Keep patient NPO.
- Monitor intake and output.
- Replace fluids lost from all sources.
- Monitor vital signs, particularly noting signs of shock (increased pulse and
respiratory rates and decreased blood pressure) and peritonitis or other
infection (increased temperature)
-Administer prescribed medications promptly to maintain therapeutic blood
levels.
- Maintain I.V. therapy to ensure proper hydration because the patient must
maintain nothing-by mouth status.
- Monitor fluid intake and output (including vomitus and diarrhea) carefully;
excessive fluid loss can lead to shock and dehydration.
-Monitor, measure, and record drainage from the NG or intestinal tube; check
drainage for blood and odor, irrigate the tube as prescribed to maintain
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patency, and turn the patient as prescribed to facilitate tube passage to the
obstruction site.
-Measure abdominal girth every 2 to 4 hours to assess distention.
-Auscultate and characterize bowel sounds; high-pitched sounds indicate
anoxia resulting from marked distention or obstruction, whereas absent
sounds indicate ileus or obstruction.
- Monitor eructation (a sign of continuing obstruction) or flatus passage (a sign
of resolving obstruction).
- Monitor the patient for abdominal pain or tenderness, noting its location; pain
may be related to distention or inflammation.
- Encourage the patient to perform deep-breathing exercises every 2 hours;
abdominal distention may elevate the diaphragm and decrease deep
breathing.
- Prepare the patient for surgery, if indicated.
- Keep the patient and family apprised of the situation.
Peritonitis
_ Description
Peritonitis is an acute inflammation of the peritoneum, which is the lining of the
abdominal cavity. Peritonitis may be primary or secondary to another disease
process. It typically occurs due to bacterial presence within the peritoneal
space.
The bacteria may have passed from the gastrointestinal tract or the rupture of
an organ within the abdomen or pelvis. After the introduction of the bacteria
into the abdominal area, an inflammatory reaction occurs.
It is a life-threatening disease process. Patients may develop septicemia from
the bacteria within the abdomen that enter the bloodstream.
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HALLMARK SIGNS AND SYMPTOMS
• Fever.
• Tachycardia.
• Abdominal pain—may be localized or generalized.
• Rebound pain (pain when quickly removing pressure during palpation of
abdomen).
• Rigid abdomen.
• Nausea, vomiting, loss of appetite.
• Decreased bowel sounds.
• Decreased urine output.
Diagnosis
• Elevated white blood cell count (WBC).
• Blood cultures to identify organisms.
• Abdominal x-rays to show free air from perforation.
• Ultrasound to identify causative problem (appendicitis, etc.).
• Peritoneal lavage to analyze fluid for WBC count, bacteria, bile.
• CT scan to identify causative problem (appendicitis, salpingitis, etc.).
TREATMENT
• Intravenous fluids.
• Administer broad-spectrum antibiotics.
• Surgical intervention may be necessary to correct cause of peritonitis.
• Pain management postoperatively.
NURSING DIAGNOSES
• Acute pain
• Impaired tissue integrity
• Impaired skin integrity
• Weigh daily.
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• Monitor intake and output.
• NPO to avoid irritation of intestinal tract, further stress on abdominal organs.
• Position for comfort, head of bed elevated.
• Assess for return of bowel sounds postoperatively.
• Teach patient about home care:
• Pain management.
• Wound care, drains, etc.
• Monitor for signs of infection.
Appendicitis Nursing Care Plan &

Management
Description
 Appendicitis is inflammation of the appendix.
 When the appendix becomes inflamed or
infected, rupture may occur within a matter
of hours, leading to peritonitis and sepsis.
Risk Factors
 Obstruction by fecalith or foreign bodies,
bacteria or toxins.
 Low-fiber diet
 High intake of refined carbohydrates
Signs and Symptoms/ Assessment
1. Pain in the periumbilical area that descends to the right lower quadrant.
2. Abdominal pain that is most intense at McBurney’s point
3. Rebound tenderness and abdominal rigidity
4. Low-grade fever
5. Elevated white blood cell count
6. Anorexia, nausea, and vomiting
7. Client in side-lying position, with abdominal guarding and legs flexed
8. Constipation or diarrhea
Diagnostic Evaluation
 Diagnosis is based on a complete physical examination and laboratory and radiologic
tests.
 Leukocyte count greater than 10,000/mm 3, neutrophil count greater than 75%;
abdominal radiographs, ultrasound studies, and CT scans may reveal right lower
quadrant density or localized distention of the bowel.
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Primary Nursing Diagnosis
Primary Preoperative Nursing Diagnosis
 Pain (acute) related to inflammation
Primary Postoperative Nursing Diagnosis
 Risk for infection related to the surgical incision
Other Diagnoses that may occur in Nursing Care Plans For Appendicitis
 Imbalanced nutrition: Less than body requirements
 Impaired skin integrity
 Ineffective tissue perfusion: GI
 Risk for deficient fluid volume
 Risk for injury
Medical Management
An appendectomy (surgical removal of the appendix) is the preferred method of
management for acute appendicitis if the inflammation is localized. An open
appendectomy is completed with a transverse right lower quadrant incision, usually at
the McBurney point. A laparoscopic appendectomy may be used in females of
childbearing age, those in whom the diagnosis is in question, and for obese patients. If
the appendix has ruptured and there is evidence of peritonitis or an abscess, conservative
treatment consisting of antibiotics and intravenous (IV) fluids is given 6 to 8 hours prior
to an appendectomy. Generally, an appendectomy is performed within 24 to 48 hours
after the onset of symptoms under either general or spinal anesthesia. Preoperative
management includes IV hydration, antipyretics, antibiotics, and, after definitive
diagnosis, analgesics.
Complications of Appendectomy
 The major complication is perforation of the
appendix, which can lead to peritonitis or an
abscess.
 Perforation generally occurs 24 hours after onset
of pain, symptoms include fever (37.7°C [100° F]
or greater), toxic appearance, and continued pain
and tenderness.
Appendectomy (surgical removal of the appendix)
Pharmacologic Intervention
 Crystalloid intravenous fluids an isotonic solutions such as normal saline solution or
lactated Ringer’s solution 100–500 mL/hr of IV, depending on volume state of the
patient, is used to replaces fluids and electrolytes lost through fever and vomiting;
replacement continues until urine output is 1 cc/kg of body weight and electrolytes are
replaced
 Antibiotics (broad-spectrum antibiotic coverage) to control local and systemic infection
and reduces the incidence of postoperative wound infection
 Other Drugs: Analgesics.
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Nursing Intervention
Preoperative interventions
1. Maintain NPO status.
2. Administer fluids intravenously to prevent dehydration.
3. Monitor for changes in level of pain.
4. Monitor for signs of ruptured appendix and peritonitis
5. Position right-side lying or low to semi fowler position to promote comfort.
6. Monitor bowel sounds.
7. Apply ice packs to abdomen every hour for 20-30 minutes as prescribed.
8. Administer antibiotics as prescribed
9. Avoid the application of heat in the abdomen.
10. Avoid laxatives or enema.
Postoperative interventions
1. Monitor temperature for signs of infection.
2. Assess incision for signs of infection such as redness, swelling and pain.
3. Maintain NPO status until bowel function has returned.
4. Advance diet gradually or as tolerated or as prescribed when bowel sound return.
5. If ruptured of appendix occurred, expect a Penros drain to be inserted, or the incision
maybe left to heal inside out.
6. Expect that drainage from the Penros drain maybe profuse for the first 2 hours.
Documentation Guidelines
Location, intensity, frequency, and duration of pain
 Response to pain medication, ice applications, and position changes
 Patient’s ability to ambulate and tolerate food
 Appearance of abdominal incision (color, temperature, intactness, drainage)
Discharge and Home Healthcare Guidelines
 MEDICATIONS. Be sure the patient understands any pain medication prescribed,
including doses, route, action, and side effects. Make certain the patient understands that
he or she should avoid operating a motor vehicle or heavy machinery while taking such
medication.
 INCISION. Sutures are generally removed in the physician’s office in 5 to 7 days.
Explain the need to keep the surgical wound clean and dry. Teach the patient to observe
the wound and report to the physician any increased swelling, redness, drainage, odor, or
separation of the wound edges. Also instruct the patient to notify the doctor if a fever
develops. The patient needs to know these may be symptoms of wound infection.
Explain that the patient should avoid heavy lifting and should question the physician
about when lifting can be resumed.
 COMPLICATIONS. Instruct the patient that a possible complication of appendicitis is
peritonitis. Discuss with the patient symptoms that indicate peritonitis, including sharp
abdominal pains, fever, nausea and vomiting, and increased pulse and respiration. The
patient must know to seek medical attention immediately should these symptoms occur.
 NUTRITION. Instruct the patient that diet can be advanced to her or his normal food
pattern as long as no gastrointestinal distress is experienced.
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 Upper Gastrointestinal Bleeding Nursing

Management
Description
Upper gastrointestinal bleeding is characterized by the sudden onset of bleeding from the GI
tract at a site (or sites) proximal to the ligament of Treitz. Most upper GI bleeds are a direct
result of peptic ulcer erosion, stress related- mucosal disease, that may evidence as superficial
erosive gastric lesion to frank ulcerations, erosive gastritis (secondary to use or abuse of
NSAIDs, oral corticosteroids, or alcohol) or esophageal varices (secondary to hepatic failure).
In addition to these, Mallory-Weiss tears can cause gastroesophageal bleeding as a result of
severe retching and vomiting, but the bleeding tends to be less severe than in other types.
Hospitalized critically ill patients are at heightened risk for stress related mucosal disease,
particularly if they are intubated and mechanically ventilated and/or evidencing
coagulopathies.
image credit : http://www.practicalpainmanagement.com/
Signs and Symptoms

 Melena and hematemesis
 Pain
 Hypovolemic shock
Physical Examination
Vital signs
 BP < 90 mm Hg
 HR > 100 beats/min
 RR: tachycardia
 Temperature: maybe elevated
Other
 Hematemesis
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 Melena
 Bloody stool with fetid odor
 Coffee ground gastric aspirate
Skin
 Pale, diaphoretic
 Cool, clammy
 Jaundice
Cardiovascular
 Weak, thready pulse
 Capillary refill > 3 sec
Abdominal
 Maybe tender with guarding
 Bowel sounds hyperactive or absent
Acute Care Patient Management
Nursing Diagnosis: Deficient fluid volume related to blood loss from hemorrhage.
Outcome Criteria
 Patient alert and oriented
 Skin, pink, warm, and dry
 CVP 2 to 6 mm Hg
 PAS 15 TO 30 mm Hg
 PAD 5 to 15 mm Hg
 BP 90 to 120 mm Hg
 MAP 70 to 105 mm Hg
 HR 60 to 100 beats/min
 Urine output 30 ml/hr
Patient Monitoring
1. Obtain pulmonary artery pressure, central venous pressure and blood pressure every 15
minutes during acute episodes to evaluate fluid needs and the patient’s response to
therapy.
2. Monitor fluid volume status. Measure intake and output hourly to evaluate renal
perfusion.
3. Measure blood loss if possible.
4. Continuously monitor ECG for dysrythmias and myocardial ischemia.
Patient Assessment
1. Assess patient for increases restlessness, apprehension or altered consciousness, which
may indicate decreased cerebral perfusion.
2. Assess hydration status.
3. Be alert for recurrence of bleedings.
Diagnostic Assessment
1. Review Hgb and Hct levels to determine the effectiveness of treatment or worsening of
the patient’s condition.
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2. Review clotting factors and serum calcium levels if multiple transfusions have been give.
3. Review serial BUN levels.
4. Review serial ABGs to evaluate oxygenation and acid-base status.
5. Review the result of endoscopic evaluation.
Patient Management
1. Maintain a patent airway. Administer supplemental oxygen as ordered.
2. Administer colloids as ordered to restore intravascular volume.
3. Type and crossmatch for anticipated blood products.
4. Evacuate stomach contents with nasogastric tube and initiate lavages with room
temperature water or saline to clear blood clots from the stomach.
5. Continue to monitor the patient closely once stabilized.
6. Vitamin K or fresh-frozen plasma (FFP) may be ordered to correct coagulation
deficiencies.
7. Explain all procedures and tests to the patient to help alleviate anxiety and decreased
tissue oxygen demands.
Cholelithiasis and Cholecystitis Nursing

Care Plan & Management
Definition
Cholelithiasis
 Refers to formation of calculi (e.g. gallstones) in the gallbladder.
image by: http://www.doctortipster.com/
Cholecystitis
 Is acute or chronic inflammation of the gallbladder.
 Acute cholecystits – may be calculous (with gallstones) or acalculous (with
gallstones).
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 Chronic cholecystitis – may follow acute cholecystitis, although it often occurs
independently. It is usually associated with gallstone formation.
Risk Factors
Cholelithiasis
Results from changes in bile components or bile stasis, associated with:
 Infection
 Cirrhosis
 Pancreatitis
 Celiac disease
 Diabetes mellitus
 Pregnancy
 Hormonal contraceptive use
Cholecystitis
 Obstruction of the cystic duct by an impacted gallstone
 Tissue damage due to trauma, massive burns, or surgery
 Gram-negative septicemia
 Multiple blood transfusion
 Prolonged fasting
 Hypertension
 Overuse of opioid analgesics
Pathophysiology
Cholelithiasis
Calculi usually from solid constituents of bile; the three major types are:
 Cholesterol gallstones – the most common type, thought to form in supersaturated bile
 Pigment gallstones – formed mainly of unconjugated pigments in bile precipitate
 Mixed types – with characteristics of pigment and cholesterol stones.
Gallstones can obstruct the cystic duct, causing cholecystitsi, or the common bile duct, which
is called choledocholithiasis.
Cholecystitis
 In acute and chronic cholecystitis, inflammation causes the gallbladder wall to become
thickened and edematous and causes the cystic lumen to increase in diameter.
 If inflammation spreads to the common bile duct, obstruction of bile drainage can lead to
jaundice. Other possible complications include: (Empyema i.e. pus-filled gallbladder,
perforation, emphysematous cholecystitis)
Assessment/Clinical Manifestations/Signs And Symptoms
Cholelithiasis (up to ½ of persons with gallstones are asymptomatic; however possible
clinical manifestations include the following)
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 Episodic (commonly after a high-fat meal), cramping pain in the right upper abdominal
quadrant or the epigastrium, possibly radiating to the back near the right scapular tip (i.e.
biliary colic)
 Nausea and vomiting
 Fat intolerance
 Fever and leukocystosis
 Signs and symptoms of jaundice
Acute Cholecystitis
 Biliary colic
 Tenderness and rigidity in the right upper quadrant elicited on palpation (i.e. Murphy’s
sign)
 Fever
 Nausea and vomiting
 Fat intolerance
 Signs and symptoms of jaundice
Chronic Cholecystitis
 Pain, which is less severe than in the acute form
 Fever, which is less severe than in the acute form
 Fat intolerance
 Heartburn
 Flatulence
Laboratory and diagnostic study findings
Cholelithiasis
 Biliary ultrasonography (i.e. cholecystosonography) can detect gallstones in most cases.
Cholecystitis
 White blood cell count reveals leukocytosis
 Serum alkaline phosphatase is elevated
 Ultrasonography detects gallstone
 Endoscopic retrograde cholangiopancreatography may reveal inflamed common bile
ducts, gallbladder, and gallstones.
 Percutaneous transheptic cholangiography can identify gallstones within the bile ducts.
Medical Management
Teach the client about planned treatments.
 Chenodeoxycholic acid is administered to dissolve gallstones. It is effective in dissolving
about 60% of radiolucent gallstones. Pigment gallstones cannot be dissolves and must be
excised.
 Nonsurgical removal, such as lithotripsy or extracorpeal shock wave therapy, may be
implemented.
Surgical treatment may be ordered.
Laparoscopic cholecytectomy (usually outpatient surgery) is performed through a
small incision made through the abdominal wall in the umbilicus.
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 Assess incision sites for infection. Instruct the client to notify the health care provider if
loss of appetite, vomiting, pain, abdominal distention, or fever occur.
 Advise the client that he will need assistance at home for 2 to 3 days.
Cholecystectomy is removal of the gallbladder after ligation of the cystic duct and
artery. Inform the client that a T-tube will be inserted to drain blood;
serosanguineous fluids, and bile and that the T-tube must be taped below the
incision
Choledochostomy is an incision into the common bile duct for calculi removal.
Cholecystomy is the surgical opening of the gallbladder for removal of stones, bile,
or pus, after which a drainage tube is placed.
Nursing Diagnosis
 Acute pain secondary to biliary obstruction
 Ineffective coping related to nausea
 Deficient knowledge related to diagnosis
 Impaired gas exchange related to high abdominal surgical incision.
 Impaired skin integrity related to altered biliary drainage after surgical incision.
 Imbalanced nutrition related to inadequate bile secretion.
Nursing Management
Provide nursing interventions during an acute gallbladder attack.
 Intervene to relive pain; give prescribed analgesics
 Promote adequate rest
 Administer IV fluids, monitor intake and output
 Monitor nasogastric tube and suctioning
 Administer antibiotics if prescribed.
Provide adequate nutrition.
 Assess nutritional status. Encourage a high-protein, high-carbohydrate, low-fat diet.
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Hemorrhoids Nursing Care Plan &

Management
Description
Hemorrhoids are vascular masses that protrude into the lumen of the lower rectum or perianal
area.
 They result when increased intra-abdominal pressure causes engorgement in the vascular
tissue lining the anal canal.
 Loosening of vessels from surrounding connective tissue occurs with protrusion or
prolapse into the anal canal.
 There are two main types of hemorrhoids: external hemorrhoids appear outside the
external sphincter, and internal hemorrhoids appear above the internal sphincter.
 When blood within the hemorrhoids becomes clotted because of obstruction, the
hemorrhoids are referred to as being thrombosed.
 Predisposing factors include pregnancy, prolonged sitting or standing, straining stool,
chronic constipation or diarrhea, anal infection, rectal surgery or episiotomy, genetic
predisposition, alcoholism, portal hypertension (cirrhosis), coughing, sneezing, or
vomiting, loss of muscle tone attributable to old age, and anal intercourse.
 Complications include hemorrhage, anemia, incontinence of stool, and strangulation.
 Hemorrhoids are the most common of a variety of anorectal disorders.
Causes/Risk Factors
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Modifiable
 Some factors that are associated with hemorrhoids are occupations that require prolonged
sitting or standing; heart failure; anorectal infections; anal intercourse; alcoholism;
pregnancy; colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or
hepatitis.
 Straining because of constipation, diarrhea, coughing, sneezing, or vomiting and loss of
muscle tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids.
Assessment
Pain (more so with external hemorrhoids), sensation of incomplete fecal evacuation,
constipation, and anal itching. Sudden rectal pain may occur if external hemorrhoids are
thrombosed.
1. Bleeding may occur during defecation; bright red blood on stool caused by injury of
mucosa covering hemorrhoid.
2. Visible and palpable masses at anal area.
Diagnostic Evaluation
External examination with anoscope or proctoscope shows single or multiple hemorrhoids.
1. Barium edema or colonoscopy rules out more serious colonic lesions causing rectal
bleeding such as polyps.
Primary Nursing Diagnosis
Pain (acute or chronic) related to rectal swelling and prolapse
Therapeutic Intervention / Medical Management
High-fiber diet to keep stools soft.
1. Warm sitz baths to ease pain and combat swelling.
2. Reduction of prolapsed external hemorrhoid manually.
Surgical Interventions:
1. Injection of sclerosing solutions to produce scar tissue and decrease prolapse is an office
procedure.
2. Cryodestruction (freezing) of hemorrhoids is an office procedure.
3. Surgery may be indicated in presence of prolonged bleeding, disabling pain, intolerable
itching, and general unrelieved discomfort.
Pharmacologic Intervention
Stool softeners to keep stools soft and relieve symptoms.
1. Topical creams, suppositories or other preparation such as Anusol, Preparation H, and
witch-hazel compresses to reduce itching and provide comfort.
2. Oral analgesics may be needed.
Nursing Intervention
After thrombosis or surgery, assist with frequent repositioning using pillow support for
comfort.
1. Provide analgesics, warm sitz baths, or warm compresses to reduce pain and
inflammation.
2. Apply witch-hazel dressing to perianal area or anal creams or suppositories, if ordered, to
relieve discomfort.
3. Observe anal area postoperatively for drainage and bleeding.
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4. Administer stool softener or laxative to assist with bowel movements soon after surgery,
to reduce risk of stricture.
5. Teach anal hygiene and measures to control moisture to prevent itching.
6. Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate
fluid intake (8 to 10 glasses per day) to avoid straining and constipation, which
predisposes to hemorrhoid formation.
7. Discourage regular use of laxatives; firm, soft stools dilate the anal canal and decrease
stricture formation after surgery.
8. Tell patient to expect a foul-smelling discharge for 7 to 10 days after cryodestruction.
9. Determine the patient’s normal bowel habits and identify predisposing factors to educate
patient about preventing recurrence of symptoms.
Documentation Guidelines
Physical findings:Rectal examination,urinary retention,bleeding,and mucous drainage
1. Wound healing:Drainage,color,swelling
2. Pain management:Pain (location,duration,frequency),response to interventions
3. Postoperative bowel movements:Tolerance for first bowel movement
Discharge and Home Healthcare Guidelines
- Teach the patient the importance of a high-fiber diet, increased fluid intake,
mild exercise, and regular bowel movements.
- Be sure the patient schedules a follow-up visit to the physician.
- Teach the patient which analgesic applications for local pain may be used.
- If the patient has had surgery, teach her or him to recognize signs of urinary
retention, such as bladder distension and hemorrhage,and to contact the
physician at their appearance.
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Fractures Nursing Care Plan & Management

Definition
A fracture is a traumatic injury interrupting bone continuity.
TYPES:
 Closed simple, uncomplicated fractures – do not cause a break in the skin.
 Open compound, complicated fractures – involve trauma to surrounding tissue and break
in the skin.
 Incomplete fractures– are partial cross-sectional breaks with incomplete bone disruption.
 Complete fractures – are complete cross-sectional breaks severing the periosteum.
 Comminuted fractures – produce several breaks of the bone, producing splinters and
fragments.
 Greenstick fractures – break one side of a bone and bend the other.
 Spiral (torsion) fractures – involve a fracture twisting around the shaft of the bone.
 Transverse fractures – occur straight across the bone.
 Oblique fractures – occur at an angle across the bone (less than a transverse)
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Risk Factors
 From crushing force or direct blow
 Sudden twisting motion; persons with osteoporosis are at a particular risk
 Extremely forceful muscle contraction can cause fractures
 Pathological fractures result from a weakness in bone tissue, which may be caused by
neoplasm or a malignant growth
Pathophysiology
Fracture occurs when stress placed on a bone exceeds the bone’s ability to absorb it.
Stages of normal fracture healing include:
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 Inflammation
 Cellular proliferation
 Callus formation
 Callus ossification
 Mature one remodeling
Potential complications of fracture include:
 Life-threatening systemic fat embolus, which most commonly develops within 24 to 72

hours after fracture.
 Compartment syndrome, which is a condition involving increased pressure and
constriction of nerves and vessels within an atomic compartment.
 Nonunion of the fracture side
 Arterial damage during treatment
 Infection and possibly sepsis
 Hemorrhage, possibly leading to shock
Assessment/Clinical Manifestations/Signs And Symptoms
 Pain
 Edema
 Tenderness
 Abnormal movement and crepitus
 Loss of function
 Ecchymoses
 Visible deformity
 Paresthesias and other sensory abnormalities
Laboratory and diagnostic study findings
 Radiographs and other imaging studies may identify the site and type of fracture.
Medical Management
The principles of fracture treatment include reduction, immobilization and regaining of
normal function and strength through rehabilitation.
 The fracture is reduced “setting” the bone using a closed method (manipulation and
manual traction (e.g. splint or cast) or an open method (surgical placement of internal
fixation devices like pins, wires, screws, plates and nails) to restore the fracture fragments
to anatomic alignment and rotation. The specific method depends on the nature of the
fracture.
 After the fracture has been reduced, immobilization holds the bone in correct position and
alignment until union occurs. Immobilization is accomplished by external or internal
fixation.
 Function is maintained and restored by controlling swelling by elevating the injured
extremity and applying ice as prescribed.
 Restlessness, anxiety, and discomfort are controlled using a variety of approaches (e.g.
reassurance, position changes, pain relief strategies, including analgesic agents).
 Isometric and muscle-setting exercises are done to minimize disuse atrophy and to
promote circulation.
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 With internal fixation, the surgeon determines the amount of movement and weight-
bearing stress the extremity can withstand and prescribed the level of activity.
 Nursing Diagnosis
 Pain related to fracture, soft tissue damage, muscle spasm, and surgery
 Impaired physical mobility related to fractured hip
 Impaired skin integrity related to surgical incision
 Risk for impaired urinary elimination related to immobility
 Risk for disturbed thought process related to age, stress of trauma, unfamiliar
surroundings, and drug therapy
 Risk for ineffective coping related to injury, anticipated surgery, and dependence
 Risk for impaired home maintenance related to fractured hip and impaired mobility
Nursing Management
1. Prevent infection
 Cover any breaks in the skin with clean or sterile dressing.
2. Provide care during client transfer.
 Immobilize a fractured extremity with splint in the position of the deformity before
moving the client; avoid strengthening the injured body part if a joint is involved.
 Support the affected body part above and below fracture site when moving the client.
3. Provide client and family teaching.
 Explain prescribed activity restrictions and necessary lifestyle modification because
of impaired mobility.
 Teach the proper use of assistive devices, as indicated.
4. Administer prescribed medications, which may include opioid or nonopioid analgesics
and prophylactic antibiotics for an open fracture.
5. Prevent and manage potential complications.
 Observe for symptoms of life-threatening fat embolus, which may include personality
change, restlessness, dyspnea, crackles, white sputum, and petechaie over the chest
and buccal membranes. Assist with respiratory support, which must be instituted
early.
 Observe for symptoms of compartment syndrome, which include deep, unrelenting
pain; hard edematous muscle; and decreased tissue perfusion with impaired
neurovascular assessment findings.
 Monitor closely for signs and symptoms of other complications.
6. Patient education regarding different factors that affect fracture healing
7. Factors that enhance fracture healing
 Immobilization of fracture fragments
 Maximum bone fragment contact
 Sufficient blood supply
 Proper nutrition
 Exercise: weight bearing for long bones
 Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids
8. Factors that inhibit fracture healing
 Extensive local trauma
 Bone loss
 Inadequate immobilization
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 Space or tissue between bone fragments
 Infection
 Local malignancy
 Metabolic bone disease (Paget’s disease)
 Irradiated bone (radiation necrosis)
 Avascular necrosis
 Intra-articular fracture (synovial fluid contains fibrolysins, which lyse the initial clot
and retard clot formation)
 Age (elderly persons heal more slowly)
 Corticosteroids (inhibit the repair rate)
 Risk for Trauma
Risk factors may include
 Loss of skeletal integrity (fractures)/movement of bone fragments
 Weakness
 Getting up without assistance
Desired Outcomes
 Maintain stabilization and alignment of fracture(s).
 Display callus formation/beginning union at fracture site as appropriate.
 Demonstrate body mechanics that promote stability at fracture site.
Nursing Interventions
 Maintain bed rest or limb rest as indicated. Provide support of joints above and below
fracture site, especially when moving and turning.
 Rationale: Provides stability, reducing possibility of disturbing alignment and muscle
spasms, which enhances healing.
 Secure a bedboard under the mattress or place patient on orthopedic bed.
 Rationale: Soft or sagging mattress may deform a wet (green) plaster cast, crack a dry
cast, or interfere with pull of traction.
 Support fracture site with pillows or folded blankets. Maintain neutral position of affected
part with sandbags, splints, trochanter roll, footboard.
 Rationale: Prevents unnecessary movement and disruption of alignment. Proper
placement of pillows also can prevent pressure deformities in the drying cast.
 Use sufficient personnel for turning. Avoid using abduction bar for turning patient with
spica cast.
 Rationale: Hip, body or multiple casts can be extremely heavy and cumbersome.
Failure to properly support limbs in casts may cause the cast to break.
 Observe and evaluate splinted extremity for resolution of edema.
 Rationale: Coaptation splint (Jones-Sugar tong) may be used to provide
immobilization of fracture while excessive tissue swelling is present. As edema
subsides, readjustment of splint or application of plaster or fiberglass cast may be
required for continued alignment of fracture.
 Maintain position or integrity of traction.
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 Rationale: Traction permits pull on the long axis of the fractured bone and overcomes
muscle tension or shortening to facilitate alignment and union. Skeletal traction (pins,
wires, tongs) permits use of greater weight for traction pull than can be applied to
skin tissues.
 Ascertain that all clamps are functional. Lubricate pulleys and check ropes for fraying.
Secure and wrap knots with adhesive tape.
 Rationale: Ensures that traction setup is functioning properly to avoid interruption of
fracture approximation.
 Keep ropes unobstructed with weights hanging free; avoid lifting or releasing weights.
 Rationale: Optimal amount of traction weight is maintained. Note: Ensuring free
movement of weights during repositioning of patient avoids sudden excess pull on
fracture with associated pain and muscle spasm.
 Assist with placement of lifts under bed wheels if indicated.
 Rationale: Helps maintain proper patient position and function of traction by
providing counterbalance.
 Position patient so that appropriate pull is maintained on the long axis of the bone.
 Rationale: Promotes bone alignment and reduces risk of complications (delayed
healing and nonunion).
 Review restrictions imposed by therapy such as not bending at waist and sitting up with
Buck traction or not turning below the waist with Russell traction.
 Rationale: Maintains integrity of pull of traction.
 Assess integrity of external fixation device.
 Rationale: Hoffman traction provides stabilization and rigid support for fractured
bone without use of ropes, pulleys, or weights, thus allowing for greater patient
mobility, comfort and facilitating wound care. Loose or excessively tightened clamps
or nuts can alter the compression of the frame, causing misalignment.
 Review follow-up and serial x-rays.
 Rationale: Provides visual evidence of proper alignment or beginning callus
formation and healing process to determine level of activity and need for changes in
or additional therapy.
 Administer alendronate (Fosamax) as indicated.
 Rationale: Acts as a specific inhibitor of osteoclast-mediated bone resorption,
allowing bone formation to progress at a higher ratio, promoting healing of fractures
and decreasing rate of bone turnover in presence of osteoporosis.
 Initiate or maintain electrical stimulation if used.
 Rationale: May be indicated to promote bone growth in presence of delayed healing
or nonunion.
 Acute Pain May be related to
 Muscle spasms
 Movement of bone fragments, edema, and injury to the soft tissue
 Traction/immobility device
 Stress, anxiety
Possibly evidenced by
 Reports of pain
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 Distraction; self-focusing/narrowed focus; facial mask of pain
 Guarding, protective behavior; alteration in muscle tone; autonomic responses
Desired Outcomes
 Verbalize relief of pain.
 Display relaxed manner; able to participate in activities, sleep/rest appropriately.
 Demonstrate use of relaxation skills and diversional activities as indicated for individual
situation.
 Maintain immobilization of affected part by means of bed rest, cast, splint, traction.
 Rationale: Relieves pain and prevents bone displacement and extension of tissue
injury.
 Elevate and support injured extremity.
 Rationale: Promotes venous return, decreases edema, and may reduce pain.
 Avoid use of plastic sheets and pillows under limbs in cast.
 Rationale: Can increase discomfort by enhancing heat production in the drying cast.
 Elevate bed covers; keep linens off toes.
 Rationale: Maintains body warmth without discomfort due to pressure of bedclothes
on affected parts.
 Evaluate and document reports of pain or discomfort, noting location and characteristics,
including intensity (0–10 scale), relieving and aggravating factors. Note nonverbal pain
cues (changes in vital signs, emotions and behavior). Listen to reports of family members
or SO regarding patient’s pain.
 Rationale: Influences effectiveness of interventions. Many factors, including level of
anxiety, may affect perception of pain. Note: Absence of pain expression does not
necessarily mean lack of pain.
 Encourage patient to discuss problems related to injury.
 Rationale: Helps alleviate anxiety. Patient may feel need to relive the accident
experience.
 Explain procedures before beginning them.
 Rationale: Allows patient to prepare mentally for activity and to participate in
controlling level of discomfort.
 Medicate before care activities. Let patient know it is important to request medication
before pain becomes severe.
 Rationale: Promotes muscle relaxation and enhances participation.
 Perform and supervise active and passive ROM exercises.
 Rationale: Maintains strength and mobility of unaffected muscles and facilitates
resolution of inflammation in injured tissues.
 Provide alternative comfort measures (massage, backrub, position changes).
 Rationale: Improves general circulation; reduces areas of local pressure and muscle
fatigue.
 Provide emotional support and encourage use of stress management
techniques (progressive relaxation, deep-breathing exercises, visualization or guided
imagery); provide Therapeutic Touch.
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 Rationale: Refocuses attention, promotes sense of control, and may enhance coping
abilities in the management of the stress of traumatic injury and pain, which is likely
to persist for an extended period.
 Identify diversional activities appropriate for patient age, physical abilities, and personal
preferences.
 Rationale: Prevents boredom, reduces muscle tension, and can increase muscle
strength; may enhance coping abilities.
 Investigate any reports of unusual or sudden pain or deep, progressive, and poorly
localized pain unrelieved by analgesics.
 Rationale: May signal developing complications (infection, tissue ischemia,
compartmental syndrome).
 Apply cold or ice pack first 24–72 hr and as necessary.
 Rationale: Reduces edema and hematoma formation, decreases pain sensation. Note:
Length of application depends on degree of patient comfort and as long as the skin is
carefully protected.
Administer medications as indicated:
 Narcotic and nonnarcotic analgesics: morphine, meperidine (Demerol),hydrocodone
(Vicodin); injectable and oral nonsteroidal anti-inflammatory drugs (NSAIDs): ketorolac
(Toradol), ibuprofen (Motrin); muscle relaxants: cyclobenzaprine(Flexeril), carisoprodol
(Soma), diazepam(Valium). Administer analgesics around the clock for 3–5 days.
 Rationale: Given to reduce pain or muscle spasms. Studies of ketorolac (Toradol)
have proved it to be effective in alleviating bone pain, with longer action and fewer
side effects than narcotic agents.
 Maintain and monitor IV patient-controlled analgesia (PCA) using peripheral, epidural, or
intrathecal routes of administration. Maintain safe and effective infusions and equipment.
 Rationale: Routinely administered or PCA maintains adequate blood level of
analgesia, preventing fluctuations in pain relief with associated muscle tension and
spasms.
 Risk for Peripheral Neurovascular Dysfunction
 Reduction/interruption of blood flow
 Direct vascular injury, tissue trauma, excessive edema, thrombus formation
 Hypovolemia
Desired Outcomes
 Maintain tissue perfusion as evidenced by palpable pulses, skin warm/dry, normal
sensation, usual sensorium, stable vital signs, and adequate urinary output for individual
situation.
 Remove jewelry from affected limb.
 Rationale: May restrict circulation when edema occurs.
 Evaluate presence and quality of peripheral pulse distal to injury via palpation or Doppler.
Compare with uninjured limb.
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 Rationale: Decreased or absent pulse may reflect vascular injury and necessitates
immediate medical evaluation of circulatory status. Be aware that occasionally a
pulse may be palpated even though circulation is blocked by a soft clot through
which pulsations may be felt. In addition, perfusion through larger arteries may
continue after increased compartment pressure has collapsed the arteriole or venule
circulation in the muscle.
 Assess capillary return, skin color, and warmth distal to the fracture.
 Rationale: Return of color should be rapid (3–5 sec). White, cool skin indicates
arterial impairment. Cyanosis suggests venous impairment. Note:Peripheral pulses,
capillary refill, skin color, and sensation may be normal even in presence of
compartmental syndrome because superficial circulation is usually not compromised
 Maintain elevation of injured extremity(ies) unless contraindicated by confirmed presence
of compartmental syndrome.
 Rationale: Promotes venous drainage and decreases edema. Note: In presence of
increased compartment pressure, elevation of the extremity actually impedes arterial
flow, decreasing perfusion.
 Assess entire length of injured extremity for swelling or edema formation. Measure
injured extremity and compare with uninjured extremity. Note appearance and spread of
hematoma.
 Rationale: Increasing circumference of injured extremity may suggest general tissue
swelling or edema but may reflect hemorrhage. Note: A 1-in increase in an adult
thigh can equal approximately 1 unit of sequestered blood.
 Note reports of pain extreme for type of injury or increasing pain on passive movement of
extremity, development of paresthesia, muscle tension or tenderness with erythema, and
change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to
physician at once.
 Rationale: Continued bleeding and edema formation within a muscle enclosed by
tight fascia can result in impaired blood flow and ischemic myositis or
compartmental syndrome, necessitating emergency interventions to relieve pressure
and restore circulation. Note: This condition constitutes a medical emergency and
requires immediate intervention.
 Investigate sudden signs of limb ischemia (decreased skin temperature, pallor, and
increased pain).
 Rationale: Fracture dislocations of joints (especially the knee) may cause damage to
adjacent arteries, with resulting loss of distal blood flow.
 Encourage patient to routinely exercise digits and joints distal to injury. Ambulate as soon
as possible.
 Rationale: Enhances circulation and reduces pooling of blood, especially in the lower
extremities.
 Investigate tenderness, swelling, pain on dorsiflexion of foot (positive Homans’ sign).
 Rationale: There is an increased potential for thrombophlebitis and pulmonary emboli
in patients immobile for several days. Note: The absence of a positive Homans’ sign
is not a reliable indicator in many people, especially the elderly because they often
have reduced pain sensation.
 Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in
mentation.
 Rationale: Inadequate circulating volume compromises systemic tissue perfusion.
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 Test stools or gastric aspirant for occult blood. Note continued bleeding at trauma or
injection site(s) and oozing from mucous membranes.
 Rationale: Increased incidence of gastric bleeding accompanies fractures and trauma
and may be related to stress or occasionally reflects a clotting disorder requiring
further evaluation.
 Perform neurovascular assessments, noting changes in motor and sensory function. Ask
patient to localize pain and discomfort.
 Rationale: Impaired feeling, numbness, tingling, increased or diffuse pain occur when
circulation to nerves is inadequate or nerves are damaged.
 Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between the first
and second toe, and assess ability to dorsiflex toes if indicated.
 Rationale: Length and position of peroneal nerve increase risk of its injury in the
presence of leg fracture, edema or compartmental syndrome, or malposition of
traction apparatus.
 Assess tissues around cast edges for rough places and pressure points. Investigate reports
of “burning sensation” under cast.
 Rationale: These factors may be the cause of or be indicative of tissue pressure,
ischemia, leading to breakdown and necrosis.
 Monitor location of supporting ring of splints or sling.
 Rationale: Traction apparatus can cause pressure on vessels and nerves, particularly
in the axilla and groin, resulting in ischemia and possible permanent nerve damage.
 Apply ice bags around fracture site for short periods of time on an intermittent basis for
24–72 hr.
 Rationale: Reduces edema and hematoma formation, which could impair circulation.
Note: Length of application of cold therapy is usually 20–30 min at a time.
 Monitor hemoglobin (Hb), hematocrit (Hct), coagulation studies such as prothrombin
time (PT) levels.
 Rationale: Assists in calculation of blood loss and effectiveness of replacement
therapy. Coagulation deficits may occur secondary to major trauma, presence of fat
emboli, or anticoagulant therapy.
 Administer IV fluids and blood products as needed.
 Rationale: Maintains circulating volume, enhancing tissue perfusion.
 Split or bivalve cast as needed.
 Rationale: May be done on an emergency basis to relieve restriction and improve
impaired circulation resulting from compression and edema formation in injured
extremity.
 Assist with intracompartmental pressures as appropriate.
 Rationale: Elevation of pressure (usually to 30 mm Hg or more) indicates need for
prompt evaluation and intervention. Note: This is not a widespread diagnostic tool, so
special interventions and training may be required.
 Review electromyography (EMG) and nerve conduction velocity (NCV) studies.
 Rationale: May be performed to differentiate between true nerve dysfunction, muscle
weakness and reduced use due to secondary gain.
 Prepare for surgical intervention (fibulectomy, fasciotomy) as indicated.
 Rationale: Failure to relieve pressure or correct compartmental syndrome within 4–6
hr of onset can result in severe contractures or loss of function and disfigurement of
extremity distal to injury or even necessitate amputation.
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 Gas Exchange, risk for impaired
 Altered blood flow; blood/fat emboli
 Alveolar/capillary membrane changes: interstitial, pulmonary edema, congestion
Desired Outcomes
 Maintain adequate respiratory function, as evidenced by absence of dyspnea/cyanosis;
respiratory rate and arterial blood gases (ABGs) within patient’s normal range.
 Monitor respiratory rate and effort. Note stridor, use of accessory muscles, retractions,
development of central cyanosis.
 Rationale: Tachypnea, dyspnea, and changes in mentation are early signs of
respiratory insufficiency and may be the only indicator of developing pulmonary
emboli in the early stage. Remaining signs and symptoms reflect advanced
respiratory distress or impending failure.
 Auscultate breath sounds, noting development of unequal, hyperresonant sounds; also
note presence of crackles, rhonchi, wheezes and inspiratory crowing or croupy sounds.
 Rationale: Changes or presence of adventitious breath sounds reflects developing
respiratory complications such as atelectasis, pneumonia, emboli, adult respiratory
distress syndrome (ARDS). Inspiratory crowing reflects upper airway edema and is
suggestive of fat emboli.
 Handle injured tissues and bones gently, especially during first several days.
 Rationale: This may prevent the development of fat emboli (usually seen in first 12–
72 hr), which are closely associated with fractures, especially of the long bones and
pelvis.
 Instruct and assist with deep-breathing and coughing exercises. Reposition frequently.
 Rationale: Promotes alveolar ventilation and perfusion. Repositioning promotes
drainage of secretions and decreases congestion in dependent lung areas.
 Note increasing restlessness, confusion, lethargy, stupor.
 Rationale: Impaired gas exchange or presence of pulmonary emboli can cause
deterioration in patient’s level of consciousness as hypoxemia or acidosis develops.
 Observe sputum for signs of blood
 Rationale: Hemoptysis may occur with pulmonary emboli.
 Inspect skin for petechiae above nipple line; in axilla, spreading to abdomen or trunk;
buccal mucosa, hard palate; conjunctival sacs and retina.
 Rationale: This is the most characteristic sign of fat emboli, which may appear within
2–3 days after injury.
 Assist with incentive spirometry.
 Rationale:Increases available O2 for optimal tissue oxygenation.
 Administer supplemental oxygen if indicated.
 Rationale: Decreased Pao2 and increased Paco2 indicate impaired gas exchange or
developing failure.
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 Monitor laboratory studies (Serial ABGs;Hb, calcium, erythrocyte sedimentation rate
(ESR), serum lipase, fat screen, platelets) as appropriate.
 Rationale: Anemia, hypocalcemia, elevated ESR and lipase levels, fat globules in
blood, urine, sputum, and decreased platelet count (thrombocytopenia) are often
associated with fat emboli.
 Administer medications as indicated: Low-molecular-weight heparin or heparinoids such
as enoxaparin (Lovenox), dalteparin (Fragmin), ardeparin (Normiflo);Corticosteroids.
 Rationale: Used for prevention of thromboembolic phenomena, including deep vein
thrombosis and pulmonary emboli. Steroids have been used with some success to
prevent or treat fat embolus.
 Impaired Physical Mobility
May be related to
 Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb
immobilization)
 Psychological immobility
 Inability to move purposefully within the physical environment, imposed restrictions
 Reluctance to attempt movement; limited ROM
 Decreased muscle strength/control
Desired Outcomes
 Regain/maintain mobility at the highest possible level.
 Maintain position of function.
 Increase strength/function of affected and compensatory body parts.
 Demonstrate techniques that enable resumption of activities.
 Assess degree of immobility produced by injury or treatment and note patient’s
perception of immobility.
 Rationale: Patient may be restricted by self-view or self-perception out of proportion
with actual physical limitations, requiring information or interventions to promote
progress toward wellness.
 Encourage participation in diversional or recreational activities. Maintain stimulating
environment (radio, TV, newspapers, personal possessions, pictures, clock, calendar,
visits from family and friends).
 Rationale: Provides opportunity for release of energy, refocuses attention, enhances
patient’s sense of self-control and self-worth, and aids in reducing social isolation.
 Instruct patient or assist with active and passive ROM exercises of affected and
unaffected extremities.
 Rationale: Increases blood flow to muscles and bone to improve muscle tone,
maintain joint mobility; prevent contractures or atrophy and calcium resorption from
disuse
 Encourage use of isometric exercises starting with the unaffected limb.
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 Rationale: Isometrics contract muscles without bending joints or moving limbs and
help maintain muscle strength and mass. Note: These exercises are contraindicated
while acute bleeding and edema is present.
 Provide footboard, wrist splints, trochanter or hand rolls as appropriate.
 Rationale: Useful in maintaining functional position of extremities, hands and feet,
and preventing complications (contractures, footdrop).
 Place in supine position periodically if possible, when traction is used to stabilize lower
limb fractures.
 Rationale: Reduces risk of flexion contracture of hip.
 Instruct and encourage use of trapeze and “post position” for lower limb fractures.
 Rationale: Facilitates movement during hygiene or skin care and linen changes;
reduces discomfort of remaining flat in bed. “Post position” involves placing the
uninjured foot flat on the bed with the knee bent while grasping the trapeze and
lifting the body off the bed.
 Assist with self-care activities (bathing, shaving).
 Rationale: Improves muscle strength and circulation, enhances patient control in
situation, and promotes self-directed wellness.
 Provide and assist with mobility by means of wheelchair, walker, crutches, canes as soon
as possible. Instruct in safe use of mobility aids.
 Rationale: Early mobility reduces complications of bed rest (phlebitis) and promotes
healing and normalization of organ function. Learning the correct way to use aids is
important to maintain optimal mobility and patient safety.
 Monitor blood pressure (BP) with resumption of activity. Note reports of dizziness.
 Rationale: Postural hypotension is a common problem following prolonged bed rest
and may require specific interventions (tilt table with gradual elevation to upright
position).
 Reposition periodically and encourage coughing and deep-breathing exercises.
 Rationale: Prevents or reduces incidence of skin and respiratory complications
(decubitus, atelectasis, pneumonia).
 Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel
routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy.
 Rationale: Bed rest, use of analgesics, and changes in dietary habits can slow
peristalsis and produce constipation. Nursing measures that facilitate elimination may
prevent or limit complications. Fracture pan limits flexion of hips and lessens
pressure on lumbar region and lower extremity cast.
 Encourage increased fluid intake to 2000–3000 mL per day (within cardiac tolerance),
including acid or ash juices.
 Rationale: Keeps the body well hydrated, decreasing risk of urinary infection, stone
formation, and constipation
 Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein
content until after first bowel movement.
 Rationale: In the presence of musculoskeletal injuries, nutrients required for healing
are rapidly depleted, often resulting in a weight loss of as much as 20 to 30 lb during
skeletal traction. This can have a profound effect on muscle mass, tone, and strength.
Note: Protein foods increase contents in small bowel, resulting in gas formation and
constipation. Therefore, gastrointestinal (GI) function should be fully restored before
protein foods are increased.
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 Increase the amount of roughage or fiber in the diet. Limit gas-forming foods.
 Rationale: Adding bulk to stool helps prevent constipation. Gas-forming foods may
cause abdominal distension, especially in presence of decreased intestinal motility.
 Consult with physical, occupational therapist or rehabilitation specialist.
 Rationale: Useful in creating individualized activity and exercise program. Patient
may require long-term assistance with movement, strengthening, and weight-bearing
activities, as well as use of adjuncts (walkers, crutches, canes); elevated toilet seats;
pickup sticks or reachers; special eating utensils.
 Initiate bowel program (stool softeners, enemas, laxatives) as indicated.
 Rationale: Done to promote regular bowel evacuation.
 Refer to psychiatric clinical nurse specialist or therapist as indicated.
 Rationale: Patient or SO may require more intensive treatment to deal with reality of
current condition, prognosis, prolonged immobility, perceived loss of control.
 Skin/Tissue Integrity, impaired: actual/risk for
May be related to
 Puncture injury; compound fracture; surgical repair; insertion of traction pins, wires,
screws
 Altered sensation, circulation; accumulation of excretions/secretions
 Physical immobilization
Possibly evidenced by (actual)
 Reports of itching, pain, numbness, pressure in affected/surrounding area
 Disruption of skin surface; invasion of body structures; destruction of skin layers/tissues
Desired Outcomes
 Verbalize relief of discomfort.
 Demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing as
indicated.
 Achieve timely wound/lesion healing if present.
 Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration,
duskiness, blanching.
 Rationale: Provides information regarding skin circulation and problems that may be
caused by application or restriction of cast, splint or traction apparatus, or edema
formation that may require further medical intervention.
 Massage skin and bony prominences. Keep the bed linens dry and free of wrinkles. Place
water pads, other padding under elbows or heels as indicated.
 Rationale: Reduces pressure on susceptible areas and risk of abrasions and skin
breakdown.
 Reposition frequently. Encourage use of trapeze if possible.
 Rationale: Lessens constant pressure on same areas and minimizes risk of skin
breakdown. Use of trapeze may reduce risk of abrasions to elbows and heels.
 Assess position of splint ring of traction device.
 Rationale: Improper positioning may cause skin injury or breakdown.
53
Plaster cast application and skin care:
 Cleanse skin with soap and water.
 Rationale: Provides a dry, clean area for cast application. Note: Excess powder may
cake when it comes in contact with water and perspiration.
 Rub gently with alcohol or dust with small amount of a zinc or stearate powder;
 Rationale: Useful for padding bony prominences, finishing cast edges, and protecting
the skin.
 Cut a length of stockinette to cover the area and extend several inches beyond the cast;
 Rationale: Prevents indentations or flattening over bony prominences and weight-
bearing areas (back of heels), which would cause abrasion or tissue trauma. An
improperly shaped or dried cast is irritating to the underlying skin and may lead to
circulatory impairment.
 Use palm of hand to apply, hold, or move cast and support on pillows after application;
 Rationale: Uneven plaster is irritating to the skin and may result in abrasions.
 Trim excess plaster from edges of cast as soon as casting is completed;
 Rationale: Prevents skin breakdown caused by prolonged moisture trapped under
cast.
 Promote cast drying by removing bed linen, exposing to circulating air;
 Rationale: Pressure can cause ulcerations, necrosis, or nerve palsies.
 Observe for potential pressure areas, especially at the edges of and under the splint or
cast;
 Rationale: These problems may be painless when nerve damage is present.
 Pad (petal) the edges of the cast with waterproof tape;
 Rationale: Provides an effective barrier to cast flaking and moisture. Helps prevent
breakdown of cast material at edges and reduces skin irritation and excoriation.
 Cleanse excess plaster from skin while still wet, if possible;
 Rationale: Dry plaster may flake into completed cast and cause skin damage.
Protect cast and skin in perineal area:
 Provide frequent perineal care
 Rationale: Prevents tissue breakdown and infection by fecal contamination.
 Instruct patient and SO to avoid inserting objects inside casts;
 Rationale: “Scratching an itch” may cause tissue injury.
 Massage the skin around the cast edges with alcohol;
 Rationale: Has a drying effect, which toughens the skin. Creams and lotions are not
recommended because excessive oils can seal cast perimeter, not allowing the cast to
“breathe.” Powders are not recommended because of potential for excessive
accumulation inside the cast.
 Turn frequently to include the uninvolved side, back, and prone positions (as tolerated)
with patient’s feet over the end of the mattress.
 Rationale: Minimizes pressure on feet and around cast edges.
Skin traction application and skin care:
 Cleanse the skin with warm, soapy water;
 Rationale: Reduces level of contaminants on skin.
 Apply tincture of benzoin;
 Rationale: “Toughens” the skin for application of skin traction.
54
 Apply commercial skin traction tapes (or make some with strips of moleskin or adhesive
tape) lengthwise on opposite sides of the affected limb;
 Rationale: Traction tapes encircling a limb may compromise circulation.
 Extend the tapes beyond the length of the limb;
 Rationale: Traction is inserted in line with the free ends of the tape.
 Mark the line where the tapes extend beyond the extremity;
 Rationale: Allows for quick assessment of slippage.
 Place protective padding under the leg and over bony prominences;
 Rationale: Minimizes pressure on these areas.
 Wrap the limb circumference, including tapes and padding, with elastic bandages, being
careful to wrap snugly but not too tightly;
 Rationale: Provides for appropriate traction pull without compromising circulation.
 Palpate taped tissues daily and document any tenderness or pain;
 Rationale: If area under tapes is tender, suspect skin irritation, and prepare to remove
the bandage system.
 Remove skin traction every 24 hr, per protocol; inspect and give skin care.
 Rationale: Maintains skin integrity
Skeletal traction and fixation application and skin care:
 Bend wire ends or cover ends of wires or pins with rubber or cork protectors or needle
caps;
 Rationale: Prevents injury to other body parts.
 Pad slings or frame with sheepskin, foam.
 Rationale: Prevents excessive pressure on skin and promotes moisture evaporation
that reduces risk of excoriation.
 Provide foam mattress, sheepskins, flotation pads, or air mattress as indicated.
 Rationale: Because of immobilization of body parts, bony prominences other than
those affected by the casting may suffer from decreased circulation.
 Monovalve, bivalve, or cut a window in the cast, per protocol.
 Rationale: Allows the release of pressure and provides access for wound and skin
care.
 Risk for Infection
 Inadequate primary defenses: broken skin, traumatized tissues; environmental exposure
 Invasive procedures, skeletal traction
Desired Outcomes
 Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
 Inspect the skin for preexisting irritation or breaks in continuity.
 Rationale: Pins or wires should not be inserted through skin infections, rashes, or
abrasions (may lead to bone infection).
 Assess pin sites and skin areas, noting reports of increased pain, burning sensation,
presence of edema, erythema, foul odor, or drainage.
55
 Rationale: May indicate onset of local infection or tissue necrosis, which can lead to
osteomyelitis.
 Provide sterile pin or wound care according to protocol, and exercise meticulous
handwashing.
 Rationale: May prevent cross-contamination and possibility of infection.
 Instruct patient not to touch the insertion sites.
 Rationale: Minimizes opportunity for contamination.
 Line perineal cast edges with plastic wrap.
 Rationale: Damp, soiled casts can promote growth of bacteria.
 Observe wounds for formation of bullae, crepitation, bronze discoloration of skin, frothy
or fruity-smelling drainage.
 Rationale: Signs suggestive of gas gangrene infection.
 Assess muscle tone, reflexes, and ability to speak.
 Rationale: Muscle rigidity, tonic spasms of jaw muscles, and dysphagia reflect
development of tetanus.
 Monitor vital signs. Note presence of chills, fever, malaise, changes in mentation.
 Rationale: Hypotension, confusion may be seen with gas gangrene; tachycardia,
chills, fever reflect developing sepsis.
 Investigate abrupt onset of pain and limitation of movement with localized edema and
erythema in injured extremity.
 Rationale: May indicate development of osteomyelitis.
 Institute prescribed isolation procedures.
 Rationale: Presence of purulent drainage requires wound and linen precautions to
prevent cross-contamination.
Monitor laboratory and diagnostic studies:
 Complete blood count (CBC);
 Rationale: Anemia may be noted with osteomyelitis; leukocytosis is usually present
with infective processes.
 ESR;
 Rationale: Elevated in osteomyelitis.
 Cultures and sensitivity of wound, serum, bone;
 Rationale: Identifies infective organism and effective antimicrobial agent(s).
 Radioisotope scans.
 Rationale: Hot spots signify increased areas of vascularity, indicative of
osteomyelitis.
Administer medications as indicated:
 IV and topical antibiotics;
 Rationale: Wide-spectrum antibiotics may be used prophylactically or may be geared
toward a specific microorganism.
 Tetanus toxoid.
 Rationale: Given prophylactically because the possibility of tetanus exists with any
open wound. Note: Risk increases when injury or wound(s) occur in “field
conditions” (outdoor, rural areas, work environment).
 Provide wound or bone irrigations and apply warm or moist soaks as indicated.
56
 Rationale: Local debridement and cleansing of wounds reduces microorganisms and
incidence of systemic infection. Continuous antimicrobial drip into bone may be
necessary to treat osteomyelitis, especially if blood supply to bone is compromised.
 Assist with procedures (incision and drainage, placement of drains, hyperbaric oxygen
therapy).
 Rationale: Numerous procedures may be carried out in treatment of local infections,
osteomyelitis, gas gangrene.
 Prepare for surgery, as indicated.
 Rationale: Sequestrectomy (removal of necrotic bone) is necessary to facilitate
healing and prevent extension of infectious process.
 Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-
care, and discharge needs
May be related to
 Lack of exposure/recall
 Information misinterpretation/unfamiliarity with information resources
 Questions/request for information, statement of misconception
 Inaccurate follow-through of instructions, development of preventable complications
Desired Outcomes
 Verbalize understanding of condition, prognosis, and potential complications.
 Correctly perform necessary procedures and explain reasons for actions.
 Review pathology, prognosis, and future expectations.
 Rationale: Provides knowledge base from which patient can make informed choices.
Note: Internal fixation devices can ultimately compromise the bone’s strength, and
intramedullary nails and rods or plates may be removed at a future date.
 Discuss dietary needs.
 Rationale: A low-fat diet with adequate quality protein and rich in calcium promotes
healing and general well-being.
 Discuss individual drug regimen as appropriate.
 Rationale: Proper use of pain medication and antiplatelet agents can reduce risk of
complications. Long-term use of alendronate (Fosamax) may reduce risk of stress
fractures. Note: Fosamax should be taken on an empty stomach with plain water
because absorption of drug may be altered by food and some medications (antacids,
calcium supplements).
 Reinforce methods of mobility and ambulation as instructed by physical therapist when
indicated.
 Rationale: Most fractures require casts, splints, or braces during the healing process.
Further damage and delay in healing could occur secondary to improper use of
ambulatory devices.
 Suggest use of a backpack.
57
 Rationale: Provides place to carry necessary articles and leaves hands free to
manipulate crutches; may prevent undue muscle fatigue when one arm is casted.
 List activities patient can perform independently and those that require assistance.
 Rationale: Organizes activities around need and who is available to provide help.
 Identify available community services (rehabilitation teams, home nursing or homemaker
services).
 Rationale: Provides assistance to facilitate self-care and support independence.
Promotes optimal self-care and recovery.
 Encourage patient to continue active exercises for the joints above and below the fracture.
 Rationale: Prevents joint stiffness, contractures, and muscle wasting, promoting
earlier return to independence in activities of daily living (ADLs).
 Discuss importance of clinical and therapy follow-up appointments.
 Rationale: Fracture healing may take as long as a year for completion, and patient
cooperation with the medical regimen facilitates proper union of bone. Physical
therapy (PT) or occupational therapy (OT) may be indicated for exercises to maintain
and strengthen muscles and improve function. Additional modalities such as low-
intensity ultrasound may be used to stimulate healing of lower-forearm or lower-leg
fractures.
 Review proper pin and wound care.
 Rationale: Reduces risk of bone or tissue trauma and infection, which can progress to
osteomyelitis.
 Recommend cleaning external fixator regularly.
 Rationale: Keeping device free of dust and contaminants reduces risk of infection.
 Identify signs and symptoms requiring medical evaluation (severe pain, fever, chills, foul
odors; changes in sensation, swelling, burning, numbness, tingling, skin discoloration,
paralysis, white or cool toes or fingertips; warm spots, soft areas, cracks in cast).
 Rationale: Prompt intervention may reduce severity of complications such as
infection or impaired circulation. Note: Some darkening of the skin (vascular
congestion) may occur normally when walking on the casted extremity or using
casted arm; however, this should resolve with rest and elevation.
 Discuss care of “green” or wet cast.
 Rationale: Promotes proper curing to prevent cast deformities and associated
misalignment and skin irritation. Note: Placing a “cooling” cast directly on rubber or
plastic pillows traps heat and increases drying time.
 Suggest the use of a blow-dryer to dry small areas of dampened casts.
 Rationale: Cautious use can hasten drying.
 Demonstrate use of plastic bags to cover plaster cast during wet weather or while bathing.
Clean soiled cast with a slightly dampened cloth and some scouring powder.
 Rationale: Protects from moisture, which softens the plaster and weakens the cast.
Note: Fiberglass casts are being used more frequently because they are not affected
by moisture. In addition, their light weight may enhance patient participation in
desired activities.
 Emphasize importance of not adjusting clamps and nuts of external fixator.
 Rationale: Tampering may alter compression and misalign fracture.
 Recommend use of adaptive clothing.
 Rationale: Facilitates dressing and grooming activities.
 Suggest ways to cover toes, if appropriate (stockinette or soft socks).
58
 Rationale: Helps maintain warmth and protect from injury.
 Instruct patient to continue exercises as permitted;
 Rationale: Reduces stiffness and improves strength and function of affected
extremity.
 Inform patient that the skin under the cast is commonly mottled and covered with scales
or crusts of dead skin;
 Rationale: It will be several weeks before normal appearance returns.
 Wash the skin gently with soap, povidone-iodine (Betadine), or pHisoDerm, and water.
Lubricate with a protective emollient;
 Rationale: New skin is extremely tender because it has been protected beneath a cast.
 Inform patient that muscles may appear flabby and atrophied (less muscle mass).
Recommend supporting the joint above and below the affected part and the use of
mobility aids (elastic bandages, splints, braces, crutches, walkers, or canes).
 Rationale: Muscle strength will be reduced and new or different aches and pains may
occur for awhile secondary to loss of support.
 Elevate the extremity as needed.
 Rationale: Swelling and edema tend to occur after cast removal.
59

ملزمة تمريض باطني جراحي الترم الثاني2 التميز +الريادة

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ملزمة تمريض باطني جراحي الترم الثاني2 التميز +الريادة

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Medical surgical nursing theory II )‫تمريض باطني جراحي نظري مستوى ثاني (مساعدين‬

◆ Asthma can result from several types of triggers.

_ The nurse asks about medical history.

_ The nurse then assesses the family history

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image credit : http://www.practicalpainmanagement.com/

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image by: http://www.doctortipster.com/

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Stages of normal fracture healing include:

 Life-threatening systemic fat embolus, which most commonly develops within 24 to 72

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