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UTZ Is The Best Test To Confirm AAA
UTZ Is The Best Test To Confirm AAA
Acne Vulgaris
Inflammatory disease of sebaceous follicles due to blockage of sebaceous glands
Initial manifestation : Closed comedones( “ whiteheads “ ), open comedones
( “blackheads”)
Nursing Diagnosis : Body image disturbance
Nursing Interventions : Instruct patient to wash face gently with mild soap 1-2
times daily. Instruct patient to use benzoyl peroxide and never squeeze pimples
Use of Isotretinoin ( Accutane ) for treatment can cause birth defects. Instruct
patient to use contraceptives during the entire duration of the therapy unitl a
month thereafter. Avoid exposure to sunlight and use sunblock when using these
medications.
Acromegaly
oversecretion of growth hormone(anterior pituitary), long lasting stimulation
affecting skeletal growth in adult by enlarging certain bones and tissues
Initial manifestation : coarse facial features, increased shoe size, increased
intracranial pressure due to tumor headache and blindness
Laboratory Data : elevated serum human growth hormone and blood sugar levels
Priority Nursing Diagnosis : body image disturbance
Nursing Interventions :
provide emotional support
prepare client for surgery and deligently monitor VS and
Neurologic Status post-op
Monitor for signs and symptoms of diabetes
octreotide ( Sandostatin) to decrease GH
Addison’s Disease
Adrenal hypofunction usually due to autoimmune disease
Initial Manifestation :Hypotension; bronze skin pigmentation is a common sign
Laboratory Data : Hyponatremia, hyperkalemia, hypoglycemia
Nursing Diagnosis : Fluid volume deficit
Nursing Interventions :
Monitor fluid and electrolyte balance
Explain the need for lifelong medications of glucocorticoids and
mineralocorticoids
Maintain high sodium, low potassium diet
Advice patient to avoid infection , trauma or stress, it increases the risk for
addisonian crisis( IV hydrocortisone and saline soln for addisonian crisis)
Anemia , aplastic
Main Problem : Bone marrow hypoplasia or aplasia resulting in
pancytopenia( decreased WBC, RBC and platelets)
Initial manifestation – abnormal bleeding( purpura , petechiae,
ecchymosis,epistaxis , melena and dyspnea)
Laboratory data: decreased WBC , RBC and Platelet Count
Nursing diagnosis: risk for infection; risk for injury
Interventions: prepare the patient for bone marrow transplant
Assess for signs and symptoms of bleeding
Anemia , Pernicious
Main Problem : Reduced vitamin B 12 Absorption due to the absence of the
intrinsic factor usually related to gastrectomy and atrophy of the gastric mucosa
Initial manifestation : Fatigue ; beefy red tongue or glossitis a common sign
Laboratory Data : Schillings test reveals low value urinary excretion of ingested
vitamin B12 < 10% in 24 hours
Nursing Diagnosis : Activity Intolerance
Nursing interventions : Teach patient monthly IM Vit B12 injections for life.
Inform patient to report tingling sensation in
the lower extremities indicating
complication – peripheral neuropathy
ANAPHYLAXIS
Main Problem : Dramatic widespread acute atopic/allergic reaction which causes
vascular collapse
Initial manifestation : Sudden onset of rapidly progressive urticaria , respiratory
distress and hypotension which can lead to shock
Diagnostic data : Skin testing to determine allergen
Nursing Diagnosis : Risk for altered airway clearance related to bronchial edema
Nursing Intervention : Observe for respiratory complications (laryngeal edema ),
watch out for signs and symptoms of shock.
Maintain airway patency – prepare suction and intubation set
Early stages – no loss of consciousness – epinephrine IM with loss of
consciousness – epinephrine IV
CPR for cardiac arrest
After emergency give antihistamines [diphenhydramine(Benadryl) ] and
corticosteroids
Prevent recurrence by avoiding exposure to known allergens
Aphasia
Main problem an acquired disorder of communication resulting from brain
damage.Speech difficulty /change usually caused by right sided hemiplegia(left
brain involvement)
Initial manifestations :
Expressive Aphasia – difficulty expressing self in understandable speech
Receptive Aphasia – does not comprehend spoken or written word
Global Aphasia – combination of both
Nursing Diagnosis : Impaired Verbal Communication
Interventions : Give the patient enough time to speak and respond and speak
clearly and slowly while facing patient
Provide visual cues like pictures and gestures when talking to the patient
( verbal and non-verbal)
Approach on the visually unaffected side
Arrythmias
Main Problem : Abnormal electrical conduction or automaticity changes in the
heart rate or rhythm which affects cardiac output and blood pressure
Initial manifestation : Hypotension and deteriorating level of consciousness
Diagnostic Data : ECG tracing reveals the following:
Atrial Fibrillation- irregular atrial rhythm > 400 beats / min. indiscernible PR
interval and no P waves
Ventricular Tachycardia- ECG shows rate of 140 – 220 bpm, wide and
bizarre QRS complex and no P waves
Ventricular fibrillation - ECG shows rapid and chaotic ventricular rhythm,
wide and irregular QRS complexes and no visible P waves.
Premature Ventricular Contractions- irregular intervals between QRS
complexes
Asystole – no atrial or ventricular rate
Nursing Diagnosis : Ineffective tissue perfusion: cardiopulmonary
Decreased cardiac output
Nursing Interventions : Watch out for hypotension and decreased urine output
Assist with measures to treat underlying cause ( electrolyte replacement , oxygen
therapy and pulmonary care)
Hook on cardiac monitor and assess Level of consciousness, RR, PR , BP and
fluid and electrolyte balance
Perform ACLS measures
Early defibrillation for VT and VF
Cardioversion for atrial dysrhythmias
Administer antiarrythmics (Lidocaine,Inderal,Cordarone)
for arrythmias and PVC’s
– hypotension common side effect
Perform CPR and intubation prn
prepare patient for possible pacemaker insertion
Angina Pectoris
Main Problem _ Insufficient coronary blood flow results to inadequate oxygen
supply causing intermittent chest pain
Initial Manifestation : squeezing , burning , pressing , chocking , aching or
bursting left sternal chest pain lasting not more than 20 minutes. The patient often
says , “It feels like gas or heartburn or indigestion “ .
Laboratory Data : ECG reveals ST segment depression
Nursing Diagnosis : Pain
Administer nitroglycerine sublingually to relieve the pain. Teach the patient that a
burning sensation under the tongue after nitroglyvcerine indicates that the drug is
potent. The drug may also cause facial flushing or headache
Prepare patient for PTCA ( percutaneous Transluminal Coronary Angioplasty ) by
informing the patient that a balloon tipped catheter will be introduced through a
guide wire into a coronary vessel .
Appendicitis
MAIN PROBLEM : Inflammation of the appendix due to obstruction of the
intestinal lumen
Initial manifestation : right lower quadrant abdominal pain with rebound
tenderness. Lessenignof pain indicates rupture of the appendix
Laboratory Data : Elevated WBC and urinalysis negative for UTI ( ruled out )
Nursing Diagnosis : Pain and Potential for injury
Interventions : Place patient in any position of comfort if appendix has not yet
ruptured , if it is ruptured place patient in high fowler’s position to prevent
upward spread of infection. Administer antibiotics as ordered . Avoid applying
hot compress on the RLQ . No analgesics , antispasmodics and enema during
observation phase.
Prepare patient for appendectomy and teach post op interventions/responsibilities.
Arthritis , gouty
Main Problem : Metabolic disorder of uric acid formation and excretion
Initial manifestation : Initially asymptomatic . A common sign is dusky red hot
swollen joint(inflamed painful), usually the big toe. Pathognomonic : Formation
of Tophi
Laboratory Data : Elevated urate crystals in synovial fluids and elevated serum
uric acid
Nursing Diagnosis : Pain
Interventions :
Teach patient to Maintain purine restricted diet
( avoid organ meats , alcohol , legumes, sardines). Increase oral
fluid intake
Avoid aspirin and diuretics as these interfere with uric acid
excretion. Alkalanize urine – fruit, vegetables and milk.
Use bed cradle to prevent linen from coming in contact with the
inflamed joint which aggravates the pain
Common Complication : Uric Acid Kidney stone formation
Encourage compliance to anti gout medications:
Allopurinol- blocks formation of uric acid, Colchicine – analgesic
and anti-inflammatory, Probenecid – reduces uric acid
Sulfinpyrazone – reduces uric acid in the blood
Arthritis , osteo
Degeneration of the articular cartilage in the joints
Initial Manifestation : Pain and swelling in a weight bearing joint, usually
aggravated by activity
Laboratory Data : X – ray
Nursing Diagnosis : Pain
Interventions : Priority : Minimize Discomfort – Implement:
W- eight control
H- ot compress or ice packs
A – spirin use
T – runk assistive devices – cane
Arthritis , Rheumatoid
Main Problem : systemic recurrent inflammation of the synovial lining of the
joints, usually upper extremities.More common in women
Initial manifestation : Morning stiffness relieved by warm bath or soaks
Laboratory Data : elevated ESR and (+) rheumatoid factor
Nursing Diagnosis : Pain related to joint inflammation
Interventions : Teach patient to take aspirin regularly as ordered even in the
absence of symptoms , instruct the patient that tinnitus is a side effect of aspirin.
Apply moist heat for 15 – 30 minutes to reduce muscle spasm. Use ice packs
during acute phase to decrease pain
Asthma
Main Problem : Abnormal Bronchial hyperactivity to certain substances and
conditions
Initial manifestation : dyspnea and wheezing(asymptomatic between attacks)
Laboratory data : PFT’s during attacks show decreased forced expiratory volumes
, elevated immunoglobulin E , ABG reveals respiratory Acidosis, peak flow levels
below normal
Nursing diagnosis : Ineffective Breathing Pattern related to bronchospasm
Interventions :
Assess precipitating factor and eradicate these sources
Instruct patient to avoid 3 E’s ( exercise specially in cold weather,
environmental factors like dust , emotional factors )
Position patient in orthopneic position and encourage patient to do pursed lip
breathing
Administer medications – Bronchodilators and corticosteroids usually via
nebulization
Autonomic dysreflexia
Main Problem : Exaggerated autonomic responses to local stimuli below the level
of the spinal cord injury. Occurs in clients with lesions above T6 after spinal
shock has subsided
Initial manifestation : Pounding headache or severe hypertension
Nursing Diagnosis : Urinary retention related to effects of spinal cord injury
Interventions :
Catheterize the patient to prevent bladder distention. Relieve fecal
impaction and pressure on skin which can precipitate attacks .
Place patient in sitting position to help lower blood pressure . Administer
antihypertensives
Bronchiectasis
Main Problem : Chronic abnormal dilation of bronchi and destruction of
bronchial walls leading to multiple respiratory complications
Initial Manifestation : Chronic cough that produces copious, foul smelling,
mucopurulent secretions, possibly totaling several cupfuls daily
Laboratory Data : Bronchoscopy helps identify source
chest x-ray shows peribronchial thickening,
areas of atelectasis and scattered cystic changes
Pulmonary Function tests detect decreased volumes
Nursing Diagnosis : Ineffective airway clearance related to secretions
Impaired gas exchange related to alveolar exudate
Nursing Interventions :Assess respiratory status and level of consciousness to
detect early signs of hypoxia and decompensation
Administer antibiotics as necessary
Teach and perform Respiratory Physiotherapy - deep breathing and coughing,
postural drainage and chest percussion(done early morning and before bedtime)
Teach importance of quitting smoking and avoidance of milk products
Burns
Main Problem : Traumatic injury caused by thermal , electrical , chemical or
radioactive agents
Initial Manifestations : 1st Degree – pinkish skin with pain
2nd degree – reddish with painful blisters
3rd degree – eschar , charred , painless
Laboratory Data : Hyperglycemia , anemia
Nursing Diagnosis : Decrerased cardiac output related to fluid shifts
Interventions :
On strict MIO .
Administer fluids as ordered during acute phase by fluid replacement calculations
using body weight multiplied by BSA burned based on rule of nines. ½ of the
total volume to be infused on the first 8 hours then the remaining ½ infused in the
next 16 hours.
Maintain a high calorie , high protein diet
Treat pain with IV narcotics, provide tetanus prophylaxis and topical
antimicrobial therapy. Institute reverse isolation in severe cases. Administer pain
medications prior to ROM ,ambulation and whirlpool therapy
Cancer , Bladder
Main Problem : Presence of malignant cells in the bladder
Initial Manifestation : Painless hematuria
Laboratory data : Elevated Acid Phosphatase
Nursing Diagnosis: Altered urinary Elimination
Interventions : Prepare patient for surgery and chemotherapy
Encourage patient to verbalize fears
Cancer Breast
Main Problem : Presence of malignant tumors usually in the upper outer quadrant
of the left breast. It is associated with nulliparity or having the first child after age
35
Initial manifestation : skin dimpling and edema(peau d’ orange .Painless mass
most common sign
Laboratory Data : Mammography reveals the presence of non – palpable lesion.
Baseline mammography should be made between age 35 – 40 . Q2 years 40 – 50
years old if w/o predisposition ;yearly for high risk women;yearly after age 50.
Nursing Diagnosis : Knowledge deficit of breast cancer and mastectomy
Interventions : Prepare patient for chemotherapy , radiation and surgery. Teach
patient how to perform Self Breast examinations. Done monthly , a week after
menstruation since the breast are less tender at this time. The best position is
lying down with pillow under shoulder of breast being examined.
Inform the patient that Mammography will involve placing the breasts between
two X-ray plates. Avoid use of deodorant ,lotions or powder
In post mastectomy patient elevate affected arm to prevent lympedema and to
avoid activities that increase infection like gardening and sewing. No BP taking ,
venipuncture and constrictive clothing on the affected arm
Cancer , Cervix
Main Problem : presence of malignant cells in the cervix associated with multiple
sexual partners and history of sexually transmitted disease
Initial manifestation : initially asymptomatic , postcoital bleeding is common
manifestation
Laboratory data : pap smear reveals presence of malignant cells
Nursing Diagnosis : Knowledge deficit of cervical cancer and chemotherapy
Interventions : Instruct patient to avoid douching and sexual intercourse 24 hours
before Paps’ Smear
Stress the importance of lifelong follow up visits to detect response
to treatment.
Prepare patient for chemotherapy , radiation and surgery
Cancer , Esophagus
Main Problem : Malignant tumor in the esophagus related to alcoholism and
smoking
Initial manifestation : Dysphagia – presenting symptom
Laboratory Data : Barium Swallow with fluoroscopy reveals large masses.
CT scans may be employed to evaluate extent of tumor
Nursing Diagnosis : Altered Nutrition
Interventions : Prepare patient for surgery , radiation therapy and chemotherapy.
Administer antacids and analgesics as ordered
Prepare patient for tube or gastroctomy feedings and short
course hyperalimentation
Post operatively instruct patient to avoid overeating
raw fruits and vegetables
Cancer ,Larynx
Main Problem : presence of malignant cells in the larynx associated with smoking
and alcoholism
Initial Manifestations : Hoarseness or voice change, tickling sensation in the
throat
Laboratory data : Laryngoscopy and Biopsy reveals malignant cells
Nursing Diagnosis : Knowledge deficit of laryngeal cancer
Interventions : Prepare patient for radiation , chemotherapy and surgery . teach
patient to avoid cold air
Instruct patient that swimming is not recommended post –
laryngectomy.
Institute alternative modes of communication
Cancer , Ovary
Main Problem : Gynecologic cancer associated with high fat diet and nulliparity
Initial Manifestation : Initial asymptomatic , vague abdominal discomfort like
indigestion is a common symptom
Laboratory data : laparoscopy and Ultrasound reveals the presence of mass
Nursing Diagnosis : Pain
Interventions : Prepare patient for surgery and chemotherapy
Assist the patient to cope with change in body image
Institute effective pharmacologic and non pharmacologic
pain management
Cancer , Prostate
Main Problem : Malignant tumor in the prostate gland
Initial Manifestation : Decreased size and force of urinary stream
Laboratory data : Elevated Prostate Specific Antigen ( PSA ) , elevated acid
phosphatase
Nursing Diagnosis : Pain related to tumor metastases to bone
Interventions : Support patient undergoing radiation therapy
Inform the patient that radical prostatectomy, which involves the
removal of the entire prostate gland, may cause impotence
1) Nursing interventions for patients undergoing radiation therapy include all of the
following except:
a) Monitoring the punch test site for bleeding
b) Teach patient to avoid contact with chemical irritants
c) Using sunblock when outdoors
d) Using layered clothing when sun exposure is possible
Answer : a - skin punch test / skin biopsy is a diagnostic procedure to confirm the
presence of skin cancer
Cancer , Testicular
Main Problem : Malignancy in the testes usually associated with cryptorchidism
Initial manifestations Painless swelling and enlargement of the testes ,
accompanied by sensation of heaviness in the scrotum
Laboratory data : Elevated HCG and alpha feto protein
Nursing Diagnosis : Knowledge deficit
Interventions : Prepare patient for surgery and chemotherapy
Teach patient about testicular self examination .It should be done once a
month while having warm bath or standing in front of mirror. Suspect cancer
when spongy upon palpation
Cardiogenic shock
Main Problem : Extensive damage of the left ventricle due to Myocardial
Infarction
Initial manifestation : decreased systolic pressure
Laboratory Data : Elevated BUN , creatinine and liver enzymes
Nursing diagnosis : Altered cardiac Output ( decreased related to impaired
contractility of the heart
Interventions : Monitor BP , MIO and weight . Evaluate serum electrolytes for
hyponatremia and hypokalemia
Cataract
Main Problem : Opacity of the lens usually associated with aging , prolonged
intake of steroids and chromosomal aberrations
Initial manifestation : painless blurring of vision
Laboratory data : Slit lamp test reveals milky white color of the pupils
Nursing diagnosis : potential for injury related to visual loss
Interventions : Prepare patient for surgery
Postoperatively instruct patient to avoid activities that requires
bending, report sudden eye pain, this indicates hemorrhage and
increased IOP.
Avoid lifting and rapid head movements
Position in fowlers position or instruct patient to lie down on the
unaffected side
Common manifestations:
Hemiplegia and homonymous hemianopsia
Emotional and personality disturbances
Aphasia
Dysphagia
Cardiac Tamponade
Main Problem : Fluid Accumulation in the pericardial sac
Initial Manifestation : hypotension muffled heart sounds is a common sign
Laboratory data : ECG reveals ST and T wave abnormalities
Nursing Diagnosis : Altered cardiac Output
Interventions : prepare the patient for pericardiocentesis. Tjis involves aspirating
the fluid or air from the pericardial sac. Assess for complications
Cor pulmonale
A chronic heart condition, is the hypertrophy of the heart, right ventricle and
associated structure that results from diseases affecting the function and the
structure of the lungs
Chronic productive cough , dyspnea on exertion, edema and fatigue
ABG- decreased Pa O2 < 70 mmHg
CXR and UTZ – suggests R ventricular hypertrophy
ECG- shows arrhythmia during severe hypoxia
Altered Tissue perfusion related to cardiopulmonary changes
Measure ABG levels and administer O2 by mask or cannula as ordered. Monitor
serum K if on diuretics
Low salt , fluid restricted , small frequent feedings
Monitor digoxin level and check radial pulse prior to cardiac glycoside
administration to avoid complications
Reposition and provide meticulous respiratory care
1) Then following are diagnostic tests done to assess the presence of cor
pulmonale except:
a. CXR
b. ECG
c. UTZ
d. Venogram
Cushing ‘s Syndrome
Main Problem : Hypersecretrion of the glucocorticoids by the adrenal glands
Initial Manifestation : Central type or truncal obesity with thin extremities, moon
face , buffalo hump and hirsutism
Laboratory data : Elevated serum cortisol levels, hypernatremia , hypokalemia ,
hypertension , hyperglycemia
Nursing Diagnosis : Altered skin integrity related to impaired healing
Interventions : Maintain patient on high potassium and low sodium diet
Instruct patient that treatment will involve lifelong administration
of glucocorticoid synthesis inhibitors ( Mitotane )
Inform patient about slow wound healing
Cystitis
Main problem : inflammation of the urinary bladder
Initial Manifestation : Frequency and Urgency
Laboratory data : Culture and sensitivity tests reveal the presence of bacteria
usually E coli
Nursing diagnosis ; Altered Urinary Elimination
Interventions : Increase Oral Fluid Intake Instruct the patient to avoid
bubble baths , silk underwear. Cotton underwear is preferred. Maintain acid ash
diet ; (cheese , cranberry , prunes , plums , poultry , eggs)
Diabetes Mellitus
Main Problem : Chronic disorder of cardohydrate , protein and fat metabolism
characterized by an imbalance between insulin supply and demand. Type 1 –
IDDM ( no insulin ) ; Type 2 – NIDDM ( little insulin or insensitivity of cells to
insulin)
Initial manifestation : Polyuria , Polyphagia , Polydipsia and weight loss
Laboratory data ; elevated FBS level above 120 mg / dl
Nursing Diagnosis : Alteration in nutrition
Interventions :
D-IET : 50-60%cho , 20-30% FATS , 10-20% CHON
I – NSULIN – TYPE 1
A – NTIDIABETIC AGENTS –TYPE 2
B – LOOD SUGAR MONITORING
E - XERCISE
T – RANSPLANT OF PANCREAS
E – NSURE ADEQUATE FOOD INTAKE
S – CRUPULOUS FOOT CARE
STRICT MONITORING FOR COMPLICATIONS( DKA
for IDDM and HHNKS for NIDDM)
Diabetes Insipidus
Main Problem : Hyposecretion of antidiuretic hormone
Initial manifestation : Polyuria , polydipsia
Laboratory data : fluid deprivation test confirms the disorder
Nursing Diagnosis : Fluid Volume Deficit
Interventions : Maintain Adequate fluid intake
Monitor urine specific gravity
Administer Desmopressin acetate or Vasopressin
intranasally as ordered
Dementia , Alzheimers
Irreversible progressive impairment in the patients cognitive functioning, memory
and personality
Confusion, easy forgetfulness and memory loss( cannot retain or recall recent
information)( confabulates to cover up memory loss)
Cognitive assessment- deterioration of cognitive ability
Mental status exam – reveals disorientation and recall difficulty. Functional
Dementia Scale shows some degree of dementia
Cortical atrophy seen on MRI / CT scan
Altered thought processes
Group therapy and increase social interaction - reminiscence therapy to increase
self esteem )
Provide for a safe , highly structured environment. Maintain consistency and
provide constant orientation
When agitated – redirect focus
Simplify communications , tasks and routines
Diet adequate in folic acid and provide adequate fluids and nutrition
Palliative medical management with:
Anticholinesterase – Tacrine(Cognex), Donepezil (Aricept)
Antipsychotics, Benzodiazepines,Antidepressants and Vitamin E
supplements
Compartment Syndrome
Pressure within a muscle and its surrounding structures increases causing
circulation impairment or interruption caused by application of dressing, tight
casting, burns, closed fractures and crushing injuries
Pain increased with stretching and unrelieved by narcotic analgesics
Paresthesias, pallor, pulseless and paralysis
Diverticulitis
Main Problem _ Inflammation of a pouch or saccular dilation in the colon
( diverticula)
Initial Manifestation : Left lower Quadrant Pain
Laboratory data : Sigmoidoscopy confirms the diagnosis
Nursing Diagnosis : Pain
Interventions : Provide Low Fiber Diet ( avoid vegetables) in diverticulitis, high
fiber in Diverticulosis
Administer Metamucil as ordered
Administer meperidine for relief of pain
Dumping Syndrome
Main Problem : Rapid emptying of the stomach contents into the small intestine
usually a complication of gastric surgery
Initial manifestations : 3 D’s ( Diarrhea , Diaphoresis , Drowsiness)
Laboratory data : non – specific
Nursing Diagnosis : Altered Elimination
Interventions : Maintain patient on supine position after
Meals and withold fluids during meals
Maintain high fat , high protein , dry diet, low in simple
sugars ( fat delays emptying of the stomach
Fractures
Break in the continuity of the bone due to trauma, bone tumors and osteoporosis
Acute pain, cyanosis, loss of function, swelling , deformity and crepitus
Antero posterior lateral X-ray of the area
Acute pain and impaired physical activity
Rest
Immobilize
Cold compress and control bleeding
Elevate
Alleviate pain by giving adequate analgesics/narcotics except in presence of head
injury
Prepare patient for reduction and alignment ( Splinting , casting, application of
traction and surgical fixation (CRIF/ORIF)
Provide adequate care for clients with traction
Glaucoma
Main problem: increased intraocular pressure due to accumulation of aqueous
humor
Initial manifestation : Tunnel Vision , Gun Barrel Vision
Closed angle – with pain
Laboratory Data : Tonometer reading of 25 mm Hg and above
Nursing Diagnosis : Potential for Injury related to visual impairment
Interventions : Explain to the patient that glaucoma cannot be cured but it can be
controlled
Administer Miotics ( pilocarpine )
Mydriatics contraindicated(ATSO4)
Instruct patient to avoid activities that can contribute to
increased IOP
Teach patient about trabeculoplasty – creation of an
opening in the trabecular meshwork to increase the outflow
of aqueous humor.
Gastritis
Acute and chronic inflammation of gastric mucosa causing edema, hemorrhage
and erosion
Abdominal cramping, epigastric discomfort, hematemesis and indigestion
Occult blood in stool and vomitus, decreased Hgb and Hct
Upper GI endoscopy confirms diagnosis when performed within 24 hours of
bleeding
Acute and chronic pain
Risk for fluid volume defict
Altered nutrition less than body requirements
Give IVF and antiemetics. Monitor MIO
Provide bland diet in smaller frequent meals
Administer antacids(between meals) and H2 blockers to promote healing,
anticholinergics and Vit B12
Angiography with vasopressin infused in NSS during bleeding
Teach importance of smoking cessation , avoid spicy foods and caffeine, taking
steroids with milk, foods or antacids and to avoid aspirin containing compounds
Hiatal Hernia
Main Problem :A portion of the stomach is herniated through the esophageal
hiatus of the diaphragm
Initial Manifestation: initially asymptomatic , heartburn is a common
complaint
Laboratory Data: Endoscopy reveals herniation of a part of the stomach
Nursing Diagnosis : Altered Nutrition
Interventions : Maintain the patient in an upright position after meals
Instruct patient to avoid bending
Provide small frequent meals
Avoid anticholinergic drugs and coughing
Hip Fracture
Main Problem : Break in the continuity of the hip bone
Initial manifestation: Shortening and external rotation of the affected leg
Laboratory : Hip X – ray
Nursing Diagnosis : Impaired Physical Mobility
Interventions : Prepare the patient for surgery
Postoperatively maintain the legs in abduction by placing a
wedge pillow between legs
Monitor for signs and symptoms of complications
( petechiae over chest indicates fat embolism)
Hyperparathyroidism
Main Problem : hypersecretion of the parathyroid hormone
Initial manifestation : bone pain
Laboratory Data : elevated serum calcium levels
Nursing Diagnosis : Risk for Injury
Interventions : Prepare the patient for Surgery
Increase oral fluid intake
Provide low calcium diet
Strain all urine
Complication : renal calculi
Hypertension
Main Problem : Persistent BP above 140 / systolic and 90 / diastolic
Initial manifestation : Asymptomatic , occipital headache is a common complaint
Laboratory data : elevated BP
Nursing Diagnosis : Altered Tissue Perfusion
Interventions: Avoid Stimulants
Low salt , low fat diet
Stress reduction techniques
Lifestyle , dietary and behavioral modification
Compliance to HPN pharmacotherapy
Specially maintenance meds
Hyperthyroidism
Main Problem : Hypersecretion of thyroid hormones
Initial manifestation : Fine hand tremors , intolerance to heat is a common
symptom
Laboratory Data : Elevated T3 and T4
Nursing Diagnosis : Risk for Injury
Interventions : Maintain a high calorie , High CHON Diet
Provide adequate rest
Provide acool environment
Elevate head of bed
Propylthiouracil medication is lifetime
Prepare patient for thyroidectomy
Post thyroidectomy – assess for hemorrhage by slipping the
hand behind the neck
Hyperlipidemia
Increased serum levels of two plasma lipids; cholesterol and triglycerides above
200 mg/ dl. Factor causation of atherosclerosis and conductive to arteriosclerosis
Initially asymptomatic
Lipid Profile Test – elevated
Non compliance to therapeutic regimen
Instruct patient to eat salmon and tuna at least several times a week and increase
intake of high fiber foods
Administer antilipidemic drugs with meals –
Clofibrate ( Atromid-S)
and Cholestyramine ( Cuemid)
Hypoparathyroidism
Main Problem : Hyposecretion of parathyroid hormone
Initial manifestations : Tingling sensation around the lips and upper extremities
Laboratory Data : Decreased serum calcium levels
Nursing Diagnosis : Potential ; altered cardiac output
Interventions : Assess for increased signs of neuromuscular irritability
( Chvosteks’ and Trousseau’s Sign)
Provide a quiet room , no stimulus
Provide high calcium , low phosphorus diet
Hypothyroidism
Main Problem : Hyposecretion of thyroid hormone
Initial Manifestation : Fatigue , facial edema is a common sign
Laboratory Data : Decreased T3 and T4 levels
Nursing Diagnosis : Activity Intolerance
Interventions : Maintain low calorie , low cholesterol and low saturated fat diet
Provide warm environment and avoid sedatives
Provide frequent rest periods
Instruct patient that administration of synthroid is lifelong
Hypovolemic shock
Main Problem : Loss of effective circulating blood volume leading to circulatory
collapse resulting to inadequate tissue perfusion
Initial manifestation : narrowing pulse pressure
Diagnostic data ; Decreased BP and Decreased CVP
Nursing Diagnosis : altered Tissue Perfusion
Interventions : Maintain patent airway
Keep patient in modified trendelenburg position
Start fluid replacement immediately
Administer vasopressors as ordered
Hemorrhoids
Varicosities or outpouching of the veins of the hemorrhoids plexus
Internal- painless bleeding in defecation
External – intense rectal itching with bleeding and pain upon defecation
Rectal examination
Pain related to irritation, pressure, sensitivity in recto-anal area
Conservative treatment:
Application of hot and cold compress
Analgesic ointment(nupercaine)
Hot sitz bath
Prepare patient for treatment by ligation, injection of sclerosing agent or preop
and post –op care for hemorroidectomy
Position prone post hemorroidectomy,
Watch out for hemorrhage 24 hours to 10 days post-op when sutures are
sloughing off.
Administer laxative, full diet until few hours before anesthetic is given. Stool
softeners and bulk formers(Metamucil)
Increase bulk and fluids
Meniere’s Disease
Main Problem: Dilation of the endolymphatic system causing degeneration of the
vestibular and cochlear hair cells in the inner ear . It affects cranial nerve VIII
Initial Manifestations : Vertigo usually described by patients as “ I feel like I’m
spinning “ , I feel as if the room is revolving “
Laboratory Data : Caloric Stimulation test reveals moderate nystagmus
Nursing Diagnosis : Risk for Injury
Interventions : Priority Safety Keep the patient in supine position during the
attack
Maintain low sodium diet
Encourage the patient ot stop smoking
Keep the room dark when photophobia is present
Multiple Sclerosis
Main Problem : Chronic Progressive disease of the CNS characterized by small
patches of demyelination in the brain and spinal cord
Initial Manifestations : Intentional Tremors and Diplopia
Laboratory Data : MRI reveals small plaques scattered throughout the CNS
Nursing Diagnosis : Impaired Physical Mobility related to nuscle weakness ; Risk
for injury
Interventions : Promote safety of the client
Teach the patient certain stress management techniques
Encourage daily exercise
Myasthenia Gravis
Main Problem ; Faulty Neuromuscular transmission of the voluntary muscles of
the body due to a deficiency in acetylcholine receptor sites in the myoneural
junction
Initial Manifestation : Descending muscle weakness initially manifested by ptosis
Laboratory Data : CT scan reveals hyperplasia of the thymus gland. Tensilon test ;
increased muscle strength 30 seconds after administration of Endrophonium
Nursing Diagnosis : Ineffective Breathing Pattern
Interventions : Maintain Patent Airway
Instruct the patient to avoid quinidine , morphine and
antibiotics since these may trigger muscle weakness.
Instruct the patient to avoid prolonged talking over the
phone especially before meals since this will weaken the
facial muscles which are also used for eating.
Intestinal obstruction
Blockage of intestinal lumen causing gas, fluid and digested material substance to
accumulate near the obstruction and increase peristalsis.H2O and electrolytes are
then secreted into the blocked bowel causing inflammation and inhibiting
absorption
Abdominal distention, cramping pain, decreased or absent bowel sounds
Abdominal X-ray – increased amount of gas in the bowel
Acute pain related to abdominal distention
Constipation related to inability of stool to pass through obstructed area
Place patient on NPO and fluid and electrolyte replacement through IVF infusion
Assess bowel sounds,mio,vs and labs- stoll exams and measure abdominal girth to
assess for distention
Semi-fowlers for comfort , bedrest and quiet envt.
Administer analgesics( Demerol)and antibiotics(Gentamycin)
Teach and monitor pre-op and post –op care for bowel resection with or without
anastomosis
Avoid constipating food
GI decompression using NGT, Miller abbott or cantor tubes maintained position
and low intermittent suction
1) The priority nursing diagnosis for patients with bowel obstruction are Constipation
related to inability of stool to pass through obstructed area and:
a) Fluid volume deficit, potential for
b) Pain
c) High risk for infection
d) Potential for non – compliance
Myocardial Infarction
Main Problem : Destruction of the cardiac tissue due to reduced coronary blood
flow
Initial Manifestation : lower sternal pain not relieved by rest and nitroglycerine ,
characterized as crushing or excruciating
Laboratory Data : Elevated CPK and Troponin , ECG reveals ST segment
elevation or depression and T wave inversion
Nursing Diagnosis : Pain related to decreased tissue oxygenation
Interventions: Morphine / Demerol to relieve pain
Oxygen Administration
Nitroglycerine
Aspirin
Position in semi-fowler’s
Maintain low fat , low cholesterol and low sodium diet
Osteoporosis
Main Problem : Loss of bone matrix leading to bone weakness predisposing it to
fractures. Usually associated with smoking , menopause , immobility and
hyperparathyroidism
Initial manifestation : asymptomatic
Laboratory Data : X- ray reveals decrease in bone density
Nursing Diagnosis : Potential for Injury
Interventions ; Increase Vit D and Calcium in the diet
Estrogen replacement therapy for post menopausal women
Encourage patient to perform active weight bearing exercises like brisk
walking , jumping rope , hiking , tennis and bal;lroom dancing.
Swimming does not meet criteria for resistance needed for prevention of
osteoporosis
Metabolic acidosis
state of excess acid accumulation and deficient base bicarbonate
drowsiness and Kussmauls respiration, CNS depression, lethargy and stupor
ABG reveals pH < 7.35 and HCO3 level < 24 mEq / L
Impaired gas exchange
Assess and correct underlying cause
Watch out for increased serum potassium,frequent monitoring of vital signs , labs
and level of consciousness
Keep sodium bicarbonate ready and institute seizure precautions.
Teach urine and blood tests for sugar or acetone.
Encourage strict adherence to OHA or insulin therapy
Metabolic Alkalosis
Clinical state marked by decreased amounts of acid and increased amounts of
base bicarbonate
Confusion, hypoventilation, irritability, picking at bedlinens and twitching
ABG pH . 7.45 and Bicarbonate level > 28 mEq / L
High risk for injury related to metabolic alkalosis
Alteration in tissue perfusion and Impaired gas exchange
Assess and Treat underlying cause
Measure I and O and watch out for tachycardia and hypotension indicating
hypokalemia
Avoid the use of alkaline agents such as antacids, bicarbonate of soda and no
administration of IVF with increased concentration of bicarbonate or lactate
Acidifying agent- ammonium Chloride IV and potassium Chloride – supplements
IV ( not given to clients with hepatic and renal diseases and given on slow
infusions to prevent hemolysis)
Respiratory Acidosis
Acid – base disturbance characterized by excess CO2 in the blood( hypercapnia)
>45 mmHg resulting from reduced alveolar ventilation
Restlessness and confusion
ABG – Ph below normal < 7.35 ; pCO2 > 45
Impaired gas exchange
Ineffective breathing pattern
Monitor pulmonary function tests
Prepare patient for intubation and /or mechanical ventilation if with hypoxemia,
decreased level of consciousness and respiratory distress.
Administer antibiotics, sodium bicarbonate and bronchodilators as needed
Chest physiotherapy, suctioning and O2 with humidification
Eradicate underlyingt cause by intubation and Mech. Ventilation, removal of
foreign body and dialysis to remove toxic drugs.
1) Respiratory acid – base imbalance caused by retention of CO2 which combines with
H2O to form carbonic acid H2CO3 includes the following disorders except:
a) COPD and Asthma
b) hyperventilation
c) CNS depression
d) Pulmonary edema and respiratory paralysis
Answer : b – hyperventilation causes alkalosis
Pancreatitis
Main Problem : Autodigestion of the pancreas
Initial Manifestation : Periumbilical Pain
Laboratory Data : Elevated Serum Amylase
Nursing Diagnosis : Pain
Interventions : Administer Demerol to relieve pain. Morphine contraindicated as
it causes spasm of the spincter of oddi
Maintain low fat diet , patient on NPO during acute phase
Instruct patient to avoid coffee and alcohol
Parkinson ‘ s Disease
Main Problem : Progressive Neurologic Disorder affecting the brain centers
responsible for control and regulation of movement due to depletion of dopamine
Initial manifestation : Bradykinesia
Laboratory data : No Specific
Nursing Diagnosis : Risk for Injury
Interventions ; Maintain Exercise program
Maintain a low protein diet at daytime and high protein at
night because absorption of levodopa which is usually
taken at daytime is slowed down by intake of high protein
foods and vitamin B6
Raynauds disease
Main Problem : VAsospastic condition of arteries of the hands tha occurs with
exposure to cold or stress
Initial Manifestation : Intermittent arteriolar vasoconstriction
Laboratory Data : Allen’s test reveals circulatory problems
Nursing Diagnosis : Altered Tissue Perfusion
Interventions : Avoid cold weather
Wear leather gloves when getting anything from the refrigerator
Stop smoking
Administer vasodilators as ordered
Pulmonary Embolism
Obstruction of blood flow to pulmonary vessels by an undissolved substance( air,
fat, emboli,thrombus) resulting in pulmonary hypertension and possible
iinfarction
Sudden onset of dyspnea, tachypnea, crackles and chest pain
ABG – hypoxemia; pulmonary angiography shows location of embolism and
filing defect
CXR – shows pneumoconstriction pulmonary arterial dilation
Lung scan shows VQ mismatch
Impaired gas exchange
Ineffective tissue perfusion; cardiopulmonary
Monitor ABG and watch out for respiratory distress and assess cardiovascular
status and CVP
Irregular pulse – arrhythmia caused by hypoxemia
Hyperthermia – pulmonary embolism caused by thrombophlebitis
Monitor lab studies – maintain PTT at 1 ½ to 2 times control in patient with
heparin – PT at 1 ½ to 2 times control or INR at 2 -3 in patient receiving
coumadin
Place patient in fowlers position, suction and administer IVF, analgesics,
anticoagulants, diuretics and fibrinolytics as ordered
1) The nursing diagnosis with least significance for patients with pulmonary embolism is:
a) Altered pattern of breathing related to dyspnea
b) Impaired gas exchange related to decreased diffusion
c) Pain related to pleural irritation
d) Anxiety related to hypoxia
Pulmonary Edema
A condition characterized by excessive amount of fluid in the alveoli and
pulmonary interstitial tissues which tends to interfere with effective diffusion of
gases
Dyspnea, orthopnea, crackles paroxysmal nocturnal dyspnea and pink frothy
sputum
Pulmonary function tests decreased VQ ratios, ABG’s indicate hypoxemia
Impaired gas exchange related to right to left shunting and decreased V/Q ratios
Fluid volume excess related to left ventricular failure in cardiogenic pulmonary
edema
Decreased cardiac output related to left ventricular failure in cardiogenic
pulmonary edema
Monitor blood gases
If on ventilator , suction frequently. Maintain oxygenation with ventilator( on
PEEP) or nasal cannula
Restrict fluids and sodium for edema
Administer inotropic drugs(Dopamine and dobutamine) and diuretics in
cardiogenic pulmonary edema
Prevent pulmonary infection with strict asepsis
Maintain nutrition with parenteral or enteral feedings
Pneumothorax
A restrictive respiratory disease occurs when air enters the pleural space as a
result of pulmonary lesion, neoplasms, accidental or surgical opening through the
chest wall. Collapse of the lung due to air in the pleural space.
Hemothorax – blood
Hydrothorax – water
Pyothorax – pus and exudates
Acute symptoms of dyspnea and paradoxical chest movement( absent or restricted
movement on the affected side with decreased or absent breath sounds , may lead
to mediastinal shift)
Lung scan shows VQ ratio mismatches
CXR showing decreased perfusion
ABG showing hypoxemia
Impaired gas exchange
Monitor PFT’s and prepare patient for thoracentesis and observe for
complications of chest tube placements ( constant bubbling in the water seal
chamber– indicates leak; 3 days post insertion can indicate lung re-expansion)
Place patient in high fowlers position and place on O2 therapy as indicated.
Instruct patient to do valsalva maneuver during chest tube removal.
1) The following are measures to promote adequate respirations and maintain proper
function of the drainage bottle system:
a) Prevent movement to prevent displacement of the tube
b) Keep drainage bottles below chest level and position patient flat on bed
c) Constant clamping of the tubes
d) Milking not routinely done
Pyelonephritis
inflammation of the kidney and its pelvis
Flank pain, with frequency,burning and urgency
Chills , muscle spasm, dysuria
Urinalysis and urine C/ S confirms causative agent
Pain alteration in comfort
Stress the importance of medication compliance and bedrest during acute
phase
Relieve flank pain with analgesics , rest massage and external heat application
Sulfonamides and broad spectrum antibiotics, urinary antiseptics ( Bactrim ,
Septra) and
urinary analgesics ( Pyridium)
Increase oral fluid intake up to 4 liters per day and follow up urinalysis every
two weeks for a month then monthly until urine is sterile.
Retinal Detachment
Main Problem : Separation of the sensory retina from the pigment epithelium of
the retine
Initial manifestation : Visual floaters described by patients as cobwebs or curtain
in eyes
Nursing Diagnosis : Potential for Injury
Interventions : Immediate Bedrest
Position patient with the affected side towards the bed , so gravity may
help put the detached retina back into place .
Avoid coughing ,sneezing and straining prepare the patient for eye
surgery.
Ulcerative Colitis
Main Problem : Ulceration of the mucosa of the lower colon and rectum
Initial manifestation : Bloody Mucoid Diarrhea
Laboratory data : Barium enema reveals lesions
Nursing Diagnosis : Pain
Altered Bowel Elimination ; diarrhea
Interventions : Avoid dairy products
Maintain Low Residue and High protein Diet , avoid cold
fluids
Teach patients about familial predisposition