WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY  2012  PNLE  PEARLS  OF  SUCCESS  

 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
PERIOPERATIVE  NURSING    
  E.  The  Surgical  Team  
A.     Major   Types   of   Pathologic   Process   Requiring   Surgical    
Intervention  (OPET)   Surgeon  
• Obstruction   –   impairment   to   the   flow   of   vital   fluids   • Performance   of   the   operative   procedure   according   to   the  
(blood,urine,CSF,bile)   needs  of  the  patients.  
• Perforation  –  rupture  of  an  organ.   • The   primary   decision   maker   regarding   surgical   technique   to  
• Erosion  –  wearing  off  of  a  surface  or  membrane.   use  during  the  procedure.  
• Tumors  –  abnormal  new  growths.   Assistant  Surgeon  
  • Assists   with   retracting,   hemostasis,   suturing   and   any   other  
B.    Classification  of  Surgical  Procedure   tasks   requested   by   the   surgeon   to   facilitate   speed   while  
  maintaining  quality  during  the  procedure.  
According  to  PURPOSE:   Anesthesiologist  
• Diagnostic   –   to   establish   the   presence   of   a   disease   condition.   (   • Selects   the   anesthesia,   administers   it,   intubates   the   client   if  
e.g  biopsy  )   necessary,   manages   technical   problems   related   to   the  
• Exploratory  –  to  determine  the  extent  of  disease  condition  (  e.g   administration   of   anesthetic   agents,   and   supervises   the   client’s  
Ex-­‐Lap  )   condition  throughout  the  surgical  procedure.  
• Curative  –  to  treat  the  disease  condition.   Scrub  Nurse  
           *    Ablative  –  removal  of  an  organ   • Assists  with  the  preparation  of  the  room.  
           *  Constructive  –  repair  of  congenitally   • Scrubs,   gowns   and   gloves   self   and   other   members   of   the  
                                                                     defective  organ.   surgical  team.  
           *  Reconstructive  –  repair  of  damage  organ   • Prepares   the   instrument   table   and   organizes   sterile   equipment  
• Palliative   –   to   relieve   distressing   sign   and   symptoms,   not   for  functional  use.  
necessarily  to  cure  the  disease.   • Assists  with  the  drapping  procedure.  
  • Passes   instruments   to   the   surgeon   and   assistants   by  
According  to  URGENCY   anticipating  their  need.  
  • Counts  sponges,  needles  and  instruments.  
• Monitor  practices  of  aseptic  technique  in  self  and  others.  
Classification   Indication  for   Examples  
• Keeps  track  of  irrigations  used  for  calculations  of  blood  loss  
Surgery  
Circulating  Nurse  
Emergent  –  patient     -­‐  severe  
• Responsible  and  accountable  for  all  activities  occurring  during  
requires  immediate   Without  delay   bleeding  
a   surgical   procedure   including   the   management   of   personnel  
attention,  life  threatening   -­‐  gunshot/  stab  
equipment,   supplies   and   the   environment   during   a   surgical  
condition.   wounds  
procedure.  
-­‐  Fractured  skull  
• Ensure  all  equipment  is  working  properly.  
Urgent  /  Imperative  –   Within  24  to  30   -­‐   kidney   /  
• Guarantees  sterility  of  instruments  and  supplies.  
patient  requires  prompt   hours   ureteral  stones  
• Monitor  the  room  and  team  members  for  breaks  in  the  sterile  
attention.  
technique.  
Required  –  patient   Plan  within  a   -­‐  cataract   • Handles  specimens.  
needs  to  have  surgery.   few  weeks  or   -­‐  thyroid  d/o   • Coordinates   activities   with   other   departments,   such   as  
months   radiology  and  pathology.  
Elective  –  patient  should   Failure  to  have   -­‐  repair  of  scar  
have  surgery.   surgery  not   -­‐  vaginal  repair  
 
catastrophic   F.    Principles  of  Surgical  Asepsis  
 
Optional  –  patient’s   Personal   -­‐  cosmetic  
Ø Sterile   object   remains   sterile   only   when   touched   by   another  
decision.   preference   surgery  
sterile  object  
 
Ø Only sterile objects may be placed on a sterile field
C.  Preoperative  Meds.  5A’s  
Ø A  sterile  object  or  field  out  of  range  of  vision  or  an  object  held  
Anxiolitics  (Tranquilizers  &  Sedatives)  
below  a  person’s  waist  is  contaminated    
           *  Diazepam  (  Valium  )  
Ø When   a   sterile   surface   comes   in   contact   with   a   wet,  
           *  Lorazepam  (  Ativan  )  
contaminated   surface,   the   sterile   object   or   field   becomes  
           *  Diphenhydramine  
contaminated  by  capillary  action  
Analgesics  
Ø Fluid  flows  in  the  direction  of  gravity  
           *  Nalbuphine  (  Nubain  )  
Ø The   edges   of   a   sterile   field   or   container   are   considered   to   be  
Anticholinergics  
contaminated  (1  inch)  
           *  Atropine  Sulfate  
 
Anti-­‐Ulcer  (Proton  Pump  Inhibitors)  
G.  PACU/RR  Care  
           *  Omeprazole  (  Losec  )  
 
           *  Famotidine  
ü Maintaining  a  Patent  Airway  
Antibiotics  
ü Assessing  Status  of  Circulatory  System  
 
ü Maintaining  Adequate  Respiratory  Function  
D.  Preoperative  Teachings  
ü Assessing  Thermoregulatory  Status  
Ø Incentive Spirometry
ü Maintaining  Adequate  Fluid  Volume  
Ø Diaphragmatic Breathing
ü Minimizing  Complications  of  Skin  Impairment  
Ø Coughing
ü Maintaining  Safety  
Ø Turning
ü Promoting  Comfort  
Ø Foot and Leg exercise
 
• Teaching should be done morning/afternoon before the day of
surgery  
• Best Method: Return Demonstration  

POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY  2012  PNLE  PEARLS  OF  SUCCESS  
 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
  Intestinal   • NGT  insertion  as  needed  
H.    Parameter  for  Discharge  from  PACU/RR   Obstruction   • Administered  IVF  as  ordered  
  (  3rd-­‐5th  day  postop)   • Prepare  for  possible  surgery  
• Activity.  Able  to  obey  commands   Constipation   • Adequate  hydration  
• Respiratory.  Easy,  noiseless  breathing   • High  fiber  diet  
• Circulation.  BP  within  20mmHg  of  preop  level   • Encourage  early  ambulation  
• Consciousness.  Responsive   Paralytic  Ileus   • Encourage  early  ambulation  
• Color.  Pinkish  skin  and  mucus  membrane   WOUND    
  Wound  Infection   • Keep  wound  clean  and  dry  
I.  Post  Operative  Complications   • Surgical  aseptic  technique  
  when  changing  dressing  
Problem   Nursing  Intervention   • Antibiotic  therapy  
  Wound  Dehiscence    
RESPIRATORY     • Apply  abdominal  binders  
Pneumonia   • Deep  breathing  exercises     • Encourage  high  protein  diet  
  • Coughing  exercise   and  Vit.C  intake  
  • Early  ambulation   • Keep  in  bed  rest  
Atelectasis   • Deep  breathing  exercises   Wound  Evisceration   • Semi-­‐Fowlers,  bend  knees  to  
  • Coughing  exercise   relieve  tension  on  the  
• Early  ambulation   abdominal  muscles  
Pulmonary   • Turning   • Splinting  on  coughing  
Embolism   • Ambulation   • Cover  exposed  organ  with  
• Anti  embolic  stockings   sterile  ,  moist  saline  dressing  
• Reassure,  keep  him/her  quite  
• Compression  devises  
and  relaxed  
• Prevent  massaging  the  lower  
• Prepare  for  surgery  and  repair  
extremities  
of  wound  
CIRCULATION    
 
Hypovolemia   • Fluid  and  blood  replacement  
 
Hemorrhage   • Fluid  and  blood  replacement   ONCOLOGY  NURSING  
• Vit.k  and  hemostat    
• Ligation  of  bleeders   A.  Benign  VS  Malignant  Neoplasm  
• Pressure  dressing    
Thrombophlebitis   • Early  ambulation   Characteristic   Benign  Neoplasm   Malignant  Neoplasm  
  • Anti  embolic  stocking   Speed  Growth   Grows  slowly   Usually  grows  rapidly  
  • Encourage  leg  exercise   Usually  continues   Tends  to  grow  relentlessly  
  • Hydrate  adequately   to  grow  throughout   throughout  life  
  • Avoid  any  restricting  devices   life  unless    
  that  impaired  circulation   surgically  removed  
  • Avoid  massage  on  the  calf  of   Mode  of   Grows  by  enlarging   Grows  by  infiltrating  
  the  leg   Growth   and  expanding   surrounding  tissues  
  • Initiate  anticoagulant  therapy   Always  remains   May  remain  localized  (in  
URINARY     localized;  never   situ)  but  usually  infiltrates  
Urinary  Retention   • Monitor  I  &  O   infiltrates   other  tissues  
• Interventions  to  facilitate   surrounding    
voiding   tissues  
• Urinary  Catheterization  as   Capsule   Almost  always   Never  contained  within  a  
needed   contained  within  a   capsule  
Urinary   • Monitor  I  &  O   fibrous  capsule   Absence  of  capsule  allows  
Incontinence   Capsule   neoplastic  cells  to  invade  
Urinary  Tract   • Adequate  fluid  intake   advantageous   surrounding  tissues  
Infection   • Early  ambulation   because   Surgical  removal  of  tumor  
  encapsulated   difficult  
• Aseptic  catheterization  as  
tumor  can  be  
needed  
removed  surgically  
• Good  perineal  hygiene  
Cell   Usually  well   Usually  poorly  
GASTRO-­‐INTESTINAL    
characteristics   differentiated   differentiated  
Nausea  and   • IV  fluids  until  peristalsis  
   
Vomiting   returns  
Recurrence   Unusual  when   Common  following  surgery  
• Progressive  diet  (  clear  liquid  
surgically  removed   because  tumor  cells  spread  
then  full  fluids,  soft  then   into  surrounding  tissues  
regular  diet)  
Metastasis   Never  occur   Very  common  
• Anti  emetics  as  ordered  
Effect  of   Not  harmful  to  host   Always  harmful  to  host  
Hiccups   • NGT  insertion  as  needed   Neoplasm   unless  located  in   Causes  disfigurement,  
• Hold  breath  while  taking  a   area  where  it   disrupted  organ  function,  
large  swallow  of  water   compresses  tissue   nutritional  imbalances  
• Breath  in  and  out  on  a  paper   or  obstructs  vital   May  result  in  ulcerations,  
bag   organs   sepsis,  perforations,    
• Anti  emetics  as  ordered  
POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY  2012  PNLE  PEARLS  OF  SUCCESS  
 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
Prognosis   Very  good   Depends  on  cell  type  and   Client  Education  
Tumor  generally   speed  of  diagnosis   ü Avoid close contact with others until treatment is completed
removed  surgically   Poor  prognosis  if  cells  are   ü Maintain daily activities unless contraindicated, allowing for extra
poorly  differentiated  and   rest periods as needed
evidence  of  metastatic   ü Maintain balanced diet
spread  exists   ü Maintain fluid intake ensure adequate hydration (2-3 liters/day)
Good  prognosis  indicated  if   ü If implant is temporary, maintain bedrest to avoid dislodging the
cells  still  resemble  normal   implant.
cells  and  there  is  no   ü Excreted body fluids may be radioactive; double-flush toilets after
evidence  of  metastasis   use
  ü Radiation therapy may lead to bone marrow suppression
   
B.  Recommendations  of  the  American  Cancer  Society  for  Early   Nursing  Management  
Cancer  Detection   ü Exposure to small amounts of radiation is possible during close
1.  For  detection  of  breast  cancer   contact with persons receiving internal radiation: understand the
ü Beginning at age 20, routinely perform monthly breast self- principles of protection from exposure to radiation: time, distance,
examination   and shielding
ü Women  ages  20-­‐39  should  have  breast  examination  by  a   Ø Time: minimize time spent in close proximity to the
healthcare  provider  every  3  years   radiation source; a common standard is to limit contact time
ü Women  age  40    and  older  should  have  a  yearly  mammogram   to 30 minutes total per 8-hour shift;
and  breast  self-­‐examination  by  a  healthcare  provider   Ø Distance: maintain the maximum distance 6 feet possible
from the radiation source
           
Ø Shielding: use lead shields and other precautions to reduce
 2.  For  detection  of  colon  and  rectal  cancer  
exposure to radiation
ü All persons age 50 and older should have a yearly fecal occult
ü Place client in private room
blood test  
ü Instruct visitors to maintain at least a distance of 6 feet from the
ü Digital  rectal  examination  and  flexible  sigmoidoscopy  should  
client and limit visitors to 10-30 minutes
be  done  every  5  years  
ü Ensure proper handling and disposal of body fluids, assuring the
ü Colonoscopy  with  barium  enema  should  be  done  every  10  
containers are marked appropriately
years  
ü Ensure proper handling of bed linens and clothing
      ü In the event of a dislodged implant, use long-handled forceps and
3.  For  detection  of  uterine  cancer   place the implant into a lead container; never directly touch the
ü Yearly papanicolao (Pap) smear for sexually active females and implant
any female over age 18   ü Do not allow pregnant woman to come into any contact with
ü At  menopause,  high-­‐risk  women  should  have  an  endometrial   radiation
tissue  sample   ü If working routinely near radiation sources, wear a monitoring
          device to measure exposure
4.  For  detection  of  prostate  cancer   ü Educate client in all safety measures
ü At age 50, have a yearly digital rectal examination  
ü At  age  50,  have  a  yearly  prostate-­‐specific  antigen  (PSA)  test E.  External  Radiation  Therapy  (Teletheraphy)  
   
  Ø The radiation oncologist marks specific locations for radiation
C.    American  Cancer  Society’s  seven  warning  signs  of  cancer   treatment using a semipermanent type of ink
(uses  acronym  CAUTION  US):   Ø Treatment  is  usually  given  15-­‐30  minutes  per  day,  5  day  per  
  1.  Change  in  bowel  or  bladder  habits   week,  for  2-­‐7  weeks  
  2.  A  sore  that  does  not  heal   Ø The  client  does  not  pose  a  risk  for  radiation  exposure  to  other  
  3.  Unusual  bleeding  or  discharge   people  
  4.  Thickening  or  lump  in  breast  or  elsewhere    
  5.  Indigestions  or  difficulty  in  swallowing   Side  Effects  
  6.  Obvious  change  in  wart  or  mole   § Tissue damage to target area (erythema, sloughing, hemorrhage)  
                   7.  Nagging  cough  or  hoarseness   §  Ulcerations  of  oral  mucous  membranes  
  §  GIT  effects  such  as  nausea,  vomiting,  and  diarrhea
                   8.  Unexplained  Anemia   § Immunosuppression
                   9.  Sudden  loss  of  weight      
   Client  Education    
D.    Internal  Radiation  Therapy  (Brachytheraphy)   ü Wash the marked area of the skin with plain water only and pat
  skin dry; do not use soaps, deodorants, lotions, perfumes, powders
Sources  of  Internal  Radiation   or medications on the site during the duration of the treatment; do
ü Implanted into affected tissue or body cavity not wash off the treatment site marks
ü Ingested as a solution ü Avoid  rubbing,  scratching,  or  scrubbing  the  treatment  site;  do  
ü Injected as a solution into the bloodstream or body cavity not  apply  extreme  temperatures  (Heat  or  Cold)  to  the  
ü Introduced through a catheter into the tumor treatment  site  ;  if  shaving,  use  only  an  electric  razor
  ü Wear  soft,  loose-­‐fitting  over  the  treatment  area
Side  Effects     ü Protect  skin  from  sun  exposure  during  the  treatment  and  for  at  
§ Fatigue least  1  year  after  the  treatment  is  completed;  when  going  
§ Anorexia outdoors,  use  sun-­‐blocking    agents  with  sun  protector  factor  
§ Immunosuppression (SPF)  of  at  least  15
§ Other side effects similar to external radiation ü Maintain  proper  rest,  diet,  and  fluid  intake  as  essential  to  
    promoting  health  and  repair  of  normal  tissues
   
   

POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY  2012  PNLE  PEARLS  OF  SUCCESS  
 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
Nursing  Management     Cardiac  Action  Potential  
ü Monitor for adverse side effects of radiation Ø Depolarization/Contraction/Systole  -­‐  electrical  activation  of  
ü  Monitor  for  significant  decreases  in  white  blood  cell  counts   a   cell   caused   by   the   influx   of   sodium   into   the   cell   while  
and  platelet  counts potassium  exits  the  cell  
ü Client  teaching  (refer  to  later  sections  for  management  of   Ø Repolarization/Resting/Diastole   -­‐   return   of   the   cell   to   the  
immunosuppression,  thrombocytopenia   resting   state   caused   by   re-­‐entry   of   potassium   into   the   cell  
  while  sodium  exits  
   
CARDIOVASCULAR  NURSING   D.  Cardiac  Catheterization  (  Coronary  Angiography  /  
  Arteriography  )  
A.    Heart  Circulation   Ø Insertion  of  a  catheter  into  the  heart  and  surrounding  vessels  
Ø Is  an  invasive  procedure  during  which  physician  injects  dye  
into  coronary  arteries  and  immediately  takes  a  series  of  x-­‐ray  
films  to  assess  the  structures  of  the  arteries  
Pretest:  Ensure  Consent,  assess  for  allergy  to  seafood  and  
iodine,  NPO,  document  weight  and  height,  baseline  VS,  blood  
tests  and  document  the  peripheral  pulses  
Intra-­‐test:  inform  patient  of  a  fluttery  feeling  as  the  catheter  
passes  through  the  heart;  inform  the  patient  that  a  feeling  of  
warmth  and  metallic  taste  may  occur  when  dye  is  
administered  
Post-­‐test:  Monitor  VS  and  cardiac  rhythm  
Ø Monitor  peripheral  pulses,  color  and  warmth  and  sensation  of  
the  extremity  distal  to  insertion  site    
Ø Maintain  sandbag  to  the  insertion  site  if  required  to  maintain  
pressure  
Ø Monitor  for  bleeding  and  hematoma  formation  
 
 
E.    Coronary  Arterial  Diseases  
 
ANGINA     Coronary  artery  bypass  
PECTORIS   Levine’s  Sign:   surgery  
  initial  sign  that   Ø Greater and lesser
4  E’s  of   shows  the  hand   saphenous veins are
Angina   clutching  the  chest   commonly used for
 
  Pectoris     bypass graft procedures
B.    Heart  Sound     Chest  pain:    
  ü Excessive characterized  by   Percutaneuos  
Ø Tricuspid  valve  (lub)  -­‐  RT  5th  intercostal,  medial   physical sharp  stabbing   Transluminal  Coronary  
Ø Mitral  valve  (lub)  -­‐  LT  5th  intercostal,  lateral   exertion pain  located  at  sub   Angioplasty  (PTCA)  
Ø Aortic  semilunar  valve  (dub)  -­‐  RT  2nd  intercostal   ü Exposure to sterna  usually   Ø Mechanical dilation of
Ø Pulmonary  semilunar  valve  (dub)  -­‐  LT  2nd  intercostals   cold radiates  from  neck,   the coronary vessel wall
  environment back,  arms,   by compresing the
S1    -­‐  due  to  closure  of  the  AV(mitral/tricuspid)  valves   ü Extreme shoulder  and  jaw   atheromatous plaque.
S2    -­‐  due  to  the  closure  of  the  semi-­‐lunar  (pulmonic/aortic)  valves   emotional muscles      
S3  –  Ventricular  Diastolic  Gallop   response   Nursing  Management:  
                 Mechanism:  vibration  resulting  from  resistance  to  rapid     ü Excessive Dyspnea    
                                                       ventricular  filling  secondary  to  poor  compliance   intake of Tachycardia   NTG  Tablets(sublingual)  
S4    -­‐  Atrial  Diastolic  Gallop   foods or Palpitations   Give  3  doses  interval  of  3-­‐
heavy meal Diaphoresis   5minutes  
Mechanism:  vibration  resulting  from  resistance  to  late    
    ü Keep  the  drug  in  a  dry  
                                       ventricular  filling  during  atrial  systole  
Heart  Murmurs   ECG:  may  reveals   place,  avoid  moisture  
Ø Incompetent  /  Stenotic  Valve   ST  segment   and  exposure  to  sunlight    
Pericardial  Friction  Rub   depression   ü Change  stock  every  6  
Ø It  is  an  extra  heart  sound  originating  from  the  pericardial  sac   T  wave  inversion     months  
Ø Mechanism:  Originates  from  the  pericardial  sac  as  it  moves   ü Offer  sips  of  water  
Ø Timing:  with  each  heartbeat   before  giving  sublingual  
  nitrates,    
C.  ECG    
NTG  Nitrol  or  
Transdermal  patch  
ü Avoid  placing  near  hairy  
areas  as  it  may  decrease  
drug  absorption  
ü Avoid  rotating  
transdermal  patches.  

   
 

POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY  2012  PNLE  PEARLS  OF  SUCCESS  
 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
Myocardial   Chest  pain   Nursing  Management   RESPIRATORY  NURSING  
Infarction   Usually  radiates   Goal:  Decrease  myocardial    
(MI)   from  neck,  back,   oxygen  demand   A.  Chronic  Obstructive  Pulmonary  Diseases  
  shoulder,  arms,      
Death  of   jaw  &  abdominal   ü Administer narcotic Chronic  Bronchitis   Smoking   ü Consistent productive
myocardial   muscles   analgesic as ordered: (Blue  Bloaters)   Air   cough
cells  from   (abdominal   Morphine Inflammation  of  the   pollution   ü Dyspnea on exertion
inadequate   ischemia):  severe   ü Administer  oxygen  low   bronchi  due  to     with prolonged
oxygenation,   crushing   flow  2-­‐3  L  /  min     hypertrophy  or   expiratory grunt
often  caused     ü Enforce  CBR  in  semi-­‐ hyperplasia  of  goblet   ü Anorexia and
by  sudden   Not  usually   fowlers  position  without   mucous  producing  cells   generalized body
complete   relieved  by  rest  or   bathroom  privileges   leading  to  narrowing  of   malaise
blockage  of  a   by  nitroglycerine   ü Instruct  client  to  avoid   smaller  airways   ü Cyanosis
coronary     forms  of  valsalva   ü Scattered rales/rhonchi
artery   N/V   maneuver    
  Dyspnea   ü Monitor  urinary  output   Bronchial  Asthma   Allergens   ü Cough that is productive
Characterized   Increase  in  blood   &  report  output  of  less   Reversible  inflammatory   ü Dyspnea
by  localized   pressure  &  pulse   than  30  ml  /  hr:   lung  condition  caused  by   ü Wheezing on expiration
formation  of   Hyperthermia:   indicates  decrease   hypersensitivity  to   ü Tachycardia,
necrosis   elevated  temp   cardiac  output   allergens  leading  to   palpitations and
(tissue   Skin:  cool,  clammy,   ü Resumption  of  ADL   narrowing  of  smaller   diaphoresis
destruction)   ashen   particularly  sexual   airways   ü Mild apprehension,
with   Mild  restlessness   intercourse:  is  4-­‐6  weeks   restlessness
subsequent   &  apprehension   post  cardiac  rehab,  post   ü Cyanosis
healing  by     CABG  &  instruct  to:  
scar  formation   ECG:   ü Instruct  client  to  assume   Bronchiectasis   Recurrent     ü Consistent productive
&  fibrosis   ST  segment   a  non  weight  bearing   Permanent  dilation  of   LRTI   cough
  elevation   position   the  bronchus  due  to   Congenital   ü Dyspnea
T  wave  inversion   ü Client  can  resume  sexual   destruction  of  muscular   disease   ü Presence of cyanosis
Widening  of  QRS   intercourse:  if  can  climb   and  elastic  tissue  of  the   Presence   ü Rales and crackles
complexes   or  use  the  staircase   alveolar  walls   of  tumor   ü Hemoptysis
  Chest   ü Anorexia and
The  Most  Critical  Period     trauma   generalized body
6-­‐8  hours  because  majority     malaise
ü
of  death  occurs  due  to  
arrhythmia  leading  to   Pulmonary   Smoking   ü Productive  cough  
premature  ventricular   Emphysema   Pollution   ü Dyspnea  at  rest  
contractions  (PVC)   Terminal  and   Hereditary   ü Prolonged  expiratory  
*Lidocaine:  DOC  for   irreversible  stage  of   Allergy   grunt  
arrhythmia   COPD  characterized  by  :   ü Resonance  to  
    hyperresonance  
  • Inelasticity of alveoli ü Decreased  tactile  
F.  Congestive  Heart  Failure   • Air trapping fremitus  
Inability  of  the  heart  to  pump  blood  towards  systemic  circulation   • Maldistribution of ü Decreased  breath  
  gasses sounds    
I. Left  sided  heart  failure   • Overdistention of ü Barrel  chest  
Ø 90% - Mitral valve stenosis thoracic cavity ü Anorexia  and  
Ø Pulmonary Symptoms (Barrel chest) generalized  body  
    malaise  
II. Right  sided  heart  failure   ü Rales  or  crackles  
Ø Tricuspid valve stenosis ü Pursed-­‐lip  breathing    
Ø Venous congestion symptoms  
   
NURSING  MANAGEMENT     Nursing  Management:    
Goal:  increase  myocardial  contraction     ü Enforce CBR
ü Administer medications as ordered ü Low inflow O2 admin; high inflow will cause respiratory arrest
§ Cardiac  glycosides   * most accurate: venturi mask
ü Digoxin  *Antidote:  Digibind   ü Administer medications as ordered
§ Loop  diuretics   Bronchodilators  
§ Bronchodilators   Antimicrobials  
§ Narcotic  analgesics   Corticosteroids  (5-­‐10  minutes  after  bronchodilators)  
ü Morphine  sulfate     Mucolytics/expectorants  
§ Vasodilators   ü Force fluids
§ Anti-­‐arrhythmic  agents   ü Nebulize and suction client as needed
ü Administer O2 inhalation at 3-4 L/minute ü Provide comfortable and humid environment
ü Restrict Na and fluids ü Avoidance of smoking and allergens
ü Monitor strictly VS and IO and Breath SoundsWeigh pt daily and  
assess for pitting edema and abdominal girth daily and notify MD  
ü Provide meticulous skin care  
ü Provide a dietary intake which is low in saturated fats and caffeine  
 
POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY  2012  PNLE  PEARLS  OF  SUCCESS  
 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
HEMATOLOGY  NURSING   instead  encourage  pt.  to  
  ambulate  to  facilitate  absorption  
A.    Blood  Cellular  Components   3. Monitor  SE  
  a. Pain  at  injection  site  
RBC   4-­‐6     b. Localized  abscess  
  million/mm3     c. Lymphadenopathy  
      d. Fever  and  chills  
*  Hemoglobin   Ave.  12  -­‐  18   iron-­‐containing  protein  of  RBC,    
  g/dL   delivers  oxygen  to  tissue   APLASTIC   ü Enforce  complete  BR  
      ANEMIA  –  stem   ü Administer  O2  inhalation  
*  Hematocrit   F:  36-­‐42%   red  cell  percentage  in  whole   cell  disorder   ü Reverse  isolation  
M:  42-­‐48%   blood   leading  to  bone   ü Monitor  for  signs  of  infection  
  marrow   ü Avoid  IM,  SQ  or  any  venipuncture  sites  
      depression  à   ü instruct:  use  electric  razor  when  shaving  
WBC   N  =  5,000-­‐   pancytopenia  (all   ü Medications  as  ordered  
  10,000/mm3     blood  cells   • Immunosuppressants via central
      decreased)  à   venous catheter
*Neutrophils   Most  common   ü First  line  of  defense,     anemia,   • Anti-lymphocyte globulin (ALG) –
  type  of   ü Helpful  in  localizing  the   leucopenia,   given within 6 days – 3 weeks to
  leukocyte  but  a   infection  and  in   thrombocytopenia   achieve maximum therapeutic effect
  short  lifespan   immobilizing  the    
  of  only  10-­‐12   pathogens  until  other    
  hours     WBCs  arrive     GUT  NURSING  
       
      A.  Causes  of  Acute  Renal  Failure  
*Eosinophils   Lifespan=   ü Allergic  Reaction  and  
  hours  to  3  days   Parasitic  Invasion  
     
*Basophils     ü they  are  mediators  in  
    inflammatory  process.  
     
*Monocytes     ü largest  WBC  
    (macrophage)  
*Lymphocytes   B  Cells    
  T  Cells   ü Antibody  response  
NK  Cells   ü Immunity  
ü Anti  tumor  
     
Platelets   N  =  150-­‐450   Promotes  hemostasis  →  
thousand  mm3   prevention  of  blood  loss  →  
promote  clotting  mechanisms  
   
   
B.  Blood  Disorder   B.  Nursing  Management  on  Hemodialysis  
   
IRON  DEFICIENCY   ü Monitor  for  signs  of  bleeding  of  all  hema   § Secure  consent  and  explain  procedure  to  client  
ANEMIA  (IDA)  –   test  including  urine,  stool  and  GIT   § Maintain  strict  aseptic  technique  
chronic  microcytic   ü Enforce  CBR  so  as  not  to  overtire  patient   § Obtain  baseline  data  –  before  and  q30  during  procedure  
anemia  due  to   ü Encourage  increased  iron  diet     ü VS  
inadequate   ü Avoid  tannates  in  tea  and  coffee     ü Wt  
absorption  of  iron   ü Administer  medications  as  ordered   ü Blood  exams  –  secure  all  pre-­‐procedure  
leading  to                                      Oral  iron  preparations  (300mg  OD)   ü I/O  
hypoxemic  tissue                                        NURSING  MANAGEMENT    
injury   1. Administer  with  meals  to  lessen   § Have  client  void  pre-­‐procedure  
GIT  irritation   § Inform  pt  about  bleeding  (blood  is  heparinized)  
2. Use  straw  for  liquid  form   § Monitor  for  signs  of  complications  (BEDSSH)  
3. Administer  with  orange  juice  or   ü Bleeding  
vitamin  C  to  facilitate  absorption   ü Embolism  
4. Inform  client  of  SE/monitor  for   ü DISEQUILIBRIUM   SYNDROME   –   results   from   rapid  
a. Anorexia   loss   of   nitrogenous   waste   products   particularly   UREA  
b. Nausea  and  vomiting   from  the  brain  
c. Abdominal  pain    HPN  
d. Diarrhea/constipation    Disorientation  –  initial  sign  
e. Melena    Nausea  and  vomiting  
                                           Parenteral  Iron  Preparations    Anorexia  
                                         NURSING  MANAGEMENT    Headache  
1. Administer  using  z-­‐tract  method    Paresthesia,  peripheral  
to  prevent  discomfort,    Numbness  
discoloration  and  leakage   ü Septicemia  
2. Avoid  massaging  of  injection  site   ü Shock  
POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE  
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY  2012  PNLE  PEARLS  OF  SUCCESS  
 
PART  6:  MEDICAL  AND  SURGICAL  HEALTH  NURSING  
 
ü Hepatitis   7. Forced  fluids   atrophy  of  the  thyroid  gland  to  
§ Avoid   BP   taking,   phlebotomy,   IV   meds   at   the   site   of   fistula,     prevent/minimize  bleeding  
blood  extraction  to  prevent  compression   and  hemorrhage  
§ Maintain  patency  of  shunt/fistula:    
ü Palpate  for  thrills,  auscultate  for  bruits   POST-­‐OP  
ü Instruct  that  minimal  bleeding  is  expected  since  blood   WOF  signs  of  THYROID  
is  heparinized   STORM  à  agitation,  hyper-­‐
ü Avoid  use  vasodilators,  sedatives,  and  tranquilizers  to   thermia,  HPN.  If  (+)  thyroid  
prevent  hypotension  unless  ordered   storm:  administer  anti-­‐pyretics  
ü Prepare  at  bedside  bulldog  clips  to  prevent  embolism   and  beta-­‐blockers;  VS,  IO  and  
ü Auscultate   for   bruits   and   palpate   for   thrills   (if   (+)   à   NVS  strictly,  siderails  up,  
patent)   provide  hypothermic  blanket  
   
  WOF:  inadvertent  or  
ENDOCRINE  NURSING   accidental  removal  of  
  parathyroid  gland  à  
A.  Thyroid  Gland  Disorders   hypocalcemia  or  tetany  [(+)  
HYPOTHYROIDISM   HYPERTHYROIDSM   trousseu’s  signs,  (+)  chvostek’s  
Decreased  T3  and  T4   Increased  T3  and  T4   Give  Ca  Gluc  slowly  to  
Early  Signs   1. Hyperphagia  –  increased   prevent  arrhythmia  and  
1. Weakness  and  fatigue   appetite   arrest  
2. Loss  of  appetite  but   2. (+)  weight  loss  d/t    
(+)  weight  gain  d/t   increased  metabolism   WOF  accidental  laryngeal  
increased  lipolysis   3. heat  intolerance   nerve  damage  à  hoarness  of  
3. Dry  skin   4. moist  skin   voice  à  instruct  client  to  talk  
4. Cold  intolerance   5. diarrhea   immediately  post-­‐op  à  if  (+)  
5. Constipation   6. increased  VS     notify  MD  
6. Menorrhagia   7. CNS  changes    
Late  Signs   a. Irritability   WOF  signs  of  bleeding  à  (+)  
1. Brittleness  of  hair   b. agitation   feeling  of  fullness  at  incision  
2. Non-­‐pitting  edema   c. Tremors   site,  (+)  soiled  dressings  at  
3. Hoarseness  of  voice   d. Restlessness   back  or  nape  area,  notify  MD  
4. Decreased  libido   e. Insomnia    
5. Decreased  VS   f. Hallucinations   WOF  signs  of  laryngeal  spasm  
6. CNS  changes   8. Goiter   à  DOB  and  SOB  à  prep  trache  
a. Lethargy   9. Exophthalmos   set  
b. Memory   10. Amenorrhea    
impairment   10. Hormonal  Replacement  
c. Psychosis   therapy  for  life  
1. Monitor  STRICTLY  VS,   1. Monitor  VS  and  IO  strictly   11. importance  of  FFup  care  
IO  to  determine   to  determine  presence  of   12. wearing  of  medic-­‐alert  
presence  of   THYROID  STORM/Crisis   bracelet  
MYXEDEMA  COMA  a   2. Administer  medications    
complication  of  severe   as  ordered   B.  Insulin  Therapy  
hypothyroidism   a. Anti-­‐Thyroid  Agents:    
characterized  by:   PTU  à  toxic  effects  is   I. Types  of  Insulin  
a. Severe   AGRANULOCYTOSISà   A. Rapid  (SAI)  –  clear,  peak:  2-­‐4  hours  ,  Regular  insulin  
hypotension   fever  and  chills,  sore   B. Intermediate   AI   –   NPH   (Non-­‐Protamine   Hagedorn)   –  
b. Bradycardia   throat  (throat  CS   cloudy,  peak  :  6-­‐12  hours  
c. Bradypnea   pls!),  LEUKOCYTOSIS   C. Long  AI  –  Ultra  lente  –  cloudy,  peak  12-­‐24  hours  
d. Hypoventilation   (CBC  pls!)      
e. Hypoglycemia   b. Methimazole   II. Nursing  Management  
f. Hyponatremia   (Tapazole)   A. Administer   insulin   at   room   temp   to   prevent  
g. Hypothermia   3. High  calorie  diet  to   lipodystrophyà  atrophy/hypertrophy  of  SQ  tissue  
2. Administer  isotonic   correct  weight  loss   B. Insulin  only  refrigerated  once  opened  
fluids  as  ordered   4. Provide  comfortable  and   C. Avoid  shaking  insulin,  roll  between  palms  only  
3. Administer   cool  environment   D. Accuracy  of  administration  is  important  
medications  as   5. Institute  meticulous  skin   E. Rotate  insulin  sites  to  prevent  lipodystrophy  
ordered  –  thyroid   care   F. Use  short  bore  needle  gauge  25-­‐26  
hormones  or  agents   6. Maintain  side  rails   G. No  need  to  aspirate  
(may  cause  insomnia   7. Bilateral  eye  patch  to   H. Administer   insulin   45/90   degrees   angle   depending   on  
and  heat  intolerance)   prevent  drying  of  eyes   amount  to  pt’s  SQ  tissue  
4. Provide  dietary  intake   8. Assist  in  surgical   I. Most  accessible  route:  abdomen  
low  in  calories  to   procedure:  subtotal   J. Aspirate   CLEAR   before   CLOUDY   to   prevent  
prevent  weight  gain   thyroidectomy   contamination  and  promote  accurate  calibration  
5. Institute  meticulous   9.   K. Monitor  for  local  complications:  
skin  care   PRE-­‐OP   1. Allergic  reactions  
6. Provide  comfortable   Administer  lugol’s  solutions/   2. Lipodystrophy  
and  warm   SSRI  to  promote  decreased   3. SOMOGYI’S   PHENOMENON   –   rebound   effect   of   insulin  
environment   vasculature    and  promote   characterized  by  hypoglycemia,  hyperglycemia  

POSSIBLE  TOPICS  ON  MEDICAL  AND  SURGICAL  HEALTH  NURSING  FOR  THE  UPCOMING  JULY  2012  PNLE  
*Patterned  on  the  previous  board  exams  from  December  2006  –  December  2011…  the  purpose  of  this  note  is  to  GUIDE  
students  on  the  possible  topics  that  might  be  part  of  the  upcoming  July  2012  PNLE