كتاب التمريض الجديد2022

Medical Surgical Nursing
Nursing Management for the Common Diagnostic Test

The nurse must understand the common diagnostic test and its uses, how prepare
Pt. & provide safe & appropriate care & monitor the patient carefully after the
test. Her we discussed the common diagnostics test that may be used in determine
disorders in different body systems. The specific will discuss in each chapter.
Outlines
- Radiologic (X-ray) tests
- Computed tomography (CT) Scan
- Angiography
- Ultrasonography
- Biopsy
- Nuclear (radioisotope) scans
- Endoscopy
- Magnetic resonance imaging (MRI)
Objectives
On completion of this chapter the student will be able to:
1. List common diagnostic test & it’s using.
2. Discuss how prepare Pt. for common diagnostic test
3. Explain nursing care for Pt. post applying diagnostic test
Test Uses of Patient Posttest NI

description test preparation
Radiologic ● Detecting ● Have the patient ● Cover the
(X-ray) lung diseases remove clothing patient’s with a lead
Visualization or tumors and metal objects. shield.
of the lungs, ● Diagnosing ● Instruct the patient ● Don’t perform
heart, and bony COPD to take a deep breath this test on a
structures ● Identifying and hold it while the pregnant patient.
infections X-ray is taken.
● Diagnosing
X-ray of the abnormal rib
abdomen conditions
Or kidneys, ● Detecting
ureters, cardiomegaly
and bladder ● Identifying
location of
central lines and
ETT
● Identifying fluid
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or air accumulation
●Detecting
abdominal masses,
bowel obstructions,
perforation
●Detecting renal
and bladder masses
and some renal
calculi
Computed ● Visualizing ● If dye is used, ● Check for allergies to
tomography(CT) tumors, edema maintain nothing- reaction to dye and acute
Multidimensional ● Identifying by-mouth (NPO) 3 renal failure. If an
visualization of a herniated disks to 8 hours before allergic reaction occurs,
body part using a ● Visualizing chest the test & check for administer an
computer lesions allergies antihistamine as
controlled, ● Visualizing liver, ●Tell the patient to prescribed.
focused X-ray pancreas, spleen, remain still during the ● Monitor for
beam of various gallbladder, test and breathe steadily. hypoglycemia or
speeds; contrast reproductive ● If the patient is acidosis in patients who
media may be tract, and undergoing a cerebral withheld metformin
used to enhance abdominal cavity CT scan, remove hair prior to the test.
visualization for abnormalities pins and jewelry, and ● Encourage the patient
such as tumors administer a sedative, as to drink fluids.
prescribed.
● Explain that flushing or
nausea may occur after
injection of contrast
media.
● Patients taking
metformin should be
instructed to withhold
medication for 48 hours
prior to the test and for a
period of time after the
test.
Angiography ● Identifying ● Instruct the patient to ● Observe the patient

X-ray of arterial femoral fast for 3 to 8 hours for signs of hemorrhage
blood vessels artery occlusion before the test. or hematoma at the
using contrast ● Detecting arterial ● Mark peripheral pulses insertion site.
media (dye) peripheral vascular with a pen. ● Monitor vital signs.
disease ● Tell the patient to ● Document the type of
● Checking for expect a warm, flushing Vascular closure device
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aneurysms & sensation when the dye is used and status of the
tumors injected. dressing.
● Determining ● Check for allergies to ● Ambulate the patient
status of iodine per the standards for the
cerebral circulation type of closure device
● Determining used.
condition ● Check the peripheral
of coronary arteries pulses bilaterally.
● Identifying blood ● Compare color and
flow dynamics temperature in
●Complications extremities.
Hematoma, arterial occlusion ● Monitor the patient
■A hematoma occurs when blood accumulates under the skin at for allergic reactions to
the IV site. the dye, ( diaphoresis,
Nursing Actions hypotension, wheezing,
- Observe the client for changes in temperature, swelling, angioedema, and
color, loss of pulse, or pain. Laryngospasm).
- Notify the provider immediately if symptoms persist. ● Monitor the patient for
- Apply pressure to the hematoma site. signs of cerebral emboli,
Air embolism such as slurred speech,
■Air enters the arterial system during catheter insertion. confusion, and hemi
Nursing Actions paresis (one-sided
✓ Place the client on his left side in the Trendelenburg weakness).
position. ● Encourage the patient
✓ Monitor the client for a sudden onset of shortness of to drink adequate fluids.
breath, decrease in SaO2 levels, chest pain, anxiety, and air
hunger
✓ Notify the provider immediately if symptoms occur,
administer oxygen therapy, and obtain ABGs.
✓ Continue to assess the client’s respiratory status for any
deterioration.
Ultrasonography ● Identifying gallstones ● Explain the test to ● Tell the patient he can
Visualization of ● Differentiating the patient based on resume activity and diet
underlying soft between liver masses the body site being as ordered.
tissues and body and other causes of evaluated. ● Monitor the patient for
structures using jaundice ● For a trans- signs and symptoms of
high-frequency ● Diagnosing renal abdominal scan, perforation or bleeding.
sound waves that masses which requires a full ● Tell the patient to
echo from the ● Determining fetal bladder, instruct the avoid alcohol and
underlying body presence and growth; patient to drink driving for 24 hours after
parts, producing visualizing uterus, several glasses of the test if I.V. sedation
scans, wave ovaries, and fallopian water and not to void. was used.
forms, or sounds tubes ●For a kidney,
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● Assessing blood flow gallbladder,

and detecting occlusion spleen, or abdominal
or aneurysm scan, instruct the
● Assessing heart valve patient to fast for
movement and heart 8 to 12 hours before
size, position, and shape the test.
(echogram)
● Evaluating thyroid
gland size and structure
● Detecting abdominal
aneurysms
Biopsies ● Detecting ● Check the patient’s ● Report abnormal
E.g.: tumors platelet count and prothrombin times to the
Liver biopsy ●Diagnosing coagulation studies; practitioner.
Removal of hepatocellular disease, contraindicated in ● Tell the patient that the
hepatic tissue by especially cirrhosis a patient with a test requires supine
way of needle platelet count less positioning and
aspiration for than 100,000/μL. placement of the right
microscopic ● Maintain NPO status hand under the head.
examination for 6 to 8 hours ● Have the patient
before the test. practice exhaling and
● Give vitamin K, if holding his breath in that
prescribed, before position.
and after the test. ● Place the patient on his
● Administer a right side for 2 hours
sedative as after the test to apply
prescribed. pressure on the liver and
● Tell the patient to prevent
report use of aspirin, Hemorrhage.
(NSAIDs), or ● Monitor vital signs
anticoagulants and assess for pain in the
chest or shoulder; give
an analgesic as
prescribed.
● Observe the
patient for signs of
hemorrhage and
pneumothorax.
Nuclear ▪ Determining size, ● Tell the patient not ● Encourage fluid intake
(radioisotope) shape, and position to eat for 4 hours to hasten radioisotope
scans , IV. ▪ Detecting infection before the scan. elimination over 1 to 2
administration of ▪ Screening for ● Explain that images days.
a radioisotope ischemic heart will be taken at 10- to ● Remember that no
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followed by disease 15-minute intervals radiation precautions

imaging in 10 to over 1 to 2 hours. are needed after the test.
60 minutes; used ● Tell the patient to
for variety of remain still during
reason based on the test
target organ(
heart, lung, liver,
brain, )
Endoscopy Detecting tumors or ●Maintain NPO ●Maintain NPO status
Visualization of inflammation status until the gag reflex
the internal ● Obtaining sample for ●Administer pretest returns.
hallow organ culture medications ●Place the patient on his
using a flexible ● Biopsy accessible ●If orally , have the side to prevent aspiration
endoscope ● Removing foreign patient remove ● Monitor vital signs
Its named based bodies and excessive dentures ●Note any complication
on site E.G: secretions e.g.: bleeding, pain
cystoscopy, ● Locating bleeding
gastroscopy, sites
Bronchoscopy
Magnetic ● Detecting ● Have the Pt. remove metal objects, such as

resonance abnormalities in all jewelry & hairpins.
imaging (MRI) body parts, including ● Identify surgeries or wounds with metal
Visualization of bones and joints implants, or pacemakers, which would be a
body parts by ● Studying bone contraindication to MRI.
exposing body structure ● Prepare the patient for being placed inside
cells to small the large, doughnut shaped electromagnet.
magnets and ● Have the patient take pre procedure
tracking the anxiolytic for claustrophobia, if ordered.
cells’ reaction ● Tell the patient to remain still during the
test.
● Tell the patient to expect loud clicking
sounds during the test.
Nursing Care Management of Clients with Cardiovascular Disorders
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Outlines
1. An overview abuts anatomy and physiology of cardiovascular system (CVS).
2. Specific laboratory & diagnostic procedures to CVS.
3. Common cardiovascular system disorders (CVD):
A. Vascular disorders
1- Hypertension
2- Atherosclerosis
3- Thrombophlebitis & Deep Vein Thrombosis (DVT)
4- Varicose Veins
B. Cardiac disorder
1- Coronary Artery Diseases
Angina Pectoris Acute Myocardial Infarction (MI)
2- Inflammatory heart diseases ( pericarditis, myocarditis &
endocarditis)
3- Valve heart diseases
4- Congestive heart failure (CHF)
4. Pre-Post – Operative Care For Cardiac Surgery
5. Nursing care plan for common CVS disorders
Objectives
On completion of this chapter the student will be able to:
1. Describe the anatomy and physiology of CVS.
2. Define the related terms and abbreviations.
3. Identify Common risk factors ,S &Symptoms and complication of CVD
4. Explain common therapeutic measures used for patients with CVD.
5. Apply nursing Care plan related to CVD.
6. Provide Pt. education related to CVD
Introduction
A. The heart is hollow, muscular organ locate in the center of the thorax. The
CVS consists of the heart, the major blood vessels that empty into or exit directly
from the heart, and a vast network of smaller peripheral blood vessels. The heart
itself is about the size of a person’s fist; it is weight approximately 300gram.
B. Three distinct layers of tissue make up the heart wall. The outer layer is the
pericardium, which is composed of fibrous and loose connective tissue. The
middle layer, the myocardium, consists of muscle tissue and is the force behind
the heart’s pumping action. The inner layer, the endocardium, is composed of a
thin, smooth layer of endothelial cells. Folds of endocardium form the heart
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valves. The endocardium is in direct contact with the blood that passes through
the heart.
C. The valves of the heart are membranous structures that ensure that blood
passes through the heart in a one-way, forward direction. In a normal heart, the
valves do not allow blood to backflow, or regurgitate, into the chamber from
which it has come
D. The function of the cardiovascular system is to supply body cells and tissues
with oxygen-rich blood & nutrients and eliminate carbon dioxide (CO2) and
cellular wastes.
Where are the following cardiac valves located? (A) Mitral valve; (B)
tricuspid valve; and (C) pulmonic valve
E. Heart rate fluctuates according to stimulation from the autonomic nervous
system, baroreceptors, and chemoreceptors. What effect of the following on
heart rate?—(A) anxiety; (B) fever; (C) hypothyroidism; (D) caffeine; and (E)
athletic conditioning
Factors That Alter Heart Rate
Increase Heart Rate Decrease Heart Rate
• Exercise ➢ Rest
• Fever ➢ Hypothermia
• Hyperthyroidism ➢ Hypothyroidism
• Hypoxia ➢ Athletic conditioning
• Dehydration ➢ Drugs: Cardiac
• Shock and hemorrhage glycosides (digoxin
• Anxiety [Lanoxin]), central nervous
system depressants
• Caffeine
(morphine), calcium channel
• Drugs: Central nervous system
blockers (verapamil ]), beta-
stimulants (cocaine, methylphenidate )
adrenergic blockers (atenolol
, adrenergic drugs (epinephrine,
[Tenormin, propranolol
isoproterenol , anticholinergic drugs
[Inderal])
(atropine)
• Alcohol withdrawal
Cardiac output is the amount of blood pumped out of the left ventricle each
minute. In a healthy adult, cardiac output ranges from 4 to 8 L/min (the average
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is approximately 5 L/min).
Stroke volume is the amount of blood pumped per contraction of the heart.
The stroke volume averages about 65 to 70 mL.
The following formula is used to calculate cardiac output:
Cardiac output = heart rate × stroke volume
If a person’s heart rate is 84 beats per minute (bpm), what is the cardiac
output?
Function of the heart
•Automaticity: ability to initiate an electrical impulse
•Excitability: ability to respond to an electrical impulse
•Conductivity: ability to transmit an electrical impulse from one cell to another
cell in the heart.
•Contractility: ability of cardiac muscle to stretch as a single unit and recoil.
•Rhythmicity: ability to repeat the cycle with regularity
Physical examination of CVS

Begins with inspection
• Observe the patient’s general appearance
• Note the skin colour
• Note any clubbing, edema, and skin lesions
• Observe the chest and thorax
• Inspect the neck ( visible pulsations & jugular vein distention)
• Look for pulsations, symmetry of movement
Uses Palpation:
• Palpate pulses
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• Palpate extremities for skin temperature, edema, capillary refill time, &
turgor
Percusses the Heart
• Percuss the left border of the heart, noting the sound change from resonance
to dullness
Auscultation the heart and vessels
➢ Use the diaphragm of the stethoscope to listen over the mitral or apical area
for 1 minute; note heart rate & rhythm
➢ Proceed sequentially through the auscultatory landmarks and listen for first
and second heart sounds
➢ Listen for extra sounds
• Tack complete History
• Measures Vital signs
• Measure Weight
• Assess Pain
Assessing Blood Pressure and Pulse for Postural Changes

• Have the client lie down for at least 3 minutes.
• Take the client’s blood pressure and pulse.
• Assist the client to a sitting position.
• Be prepared to steady or assist the client should he or she become dizzy
• Reassess the BP and pulse within 30 seconds after the client sits.
• Repeat the assessments with the client standing.
• Determine the difference in systolic and diastolic BP in the upright
position from that recorded in the previous position.
✓ The client manifests postural changes if the blood pressure is lower than
10 mm Hg from the previous measurement and the heart rate increases 10% or
more from the previous measurement
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• Current health status: - Ask the following questions:
Physical assessment findings:-

Subjective data Objective data
1. Dyspnea. 1. Hypertension
2. Paroxysmal nocturnal dyspnea 3. Skin color
3. Orthopnea. abnormalities(pallor, cyanosis)
4. Chest and leg pain. 4. Abnormal heart sounds.
5. Fatigue and weakness. 5. Lower limb edema.
6. Cough. 6. Arrhythmias.
7. Syncope. 7. Jugular venous distention
8. Palpitations. 8. Respiratory distress.
9. Vascular bruits.
1. How long have you had this problem? When did it begin?
2. Does anything precipitate, exacerbate, or relieve?
Don’t forget If your patient is female, to ask these questions:
1. Have you begun menopause?
2. Do you use hormonal contraceptives or estrogen?
3. Have you experienced any medical problems during pregnancy?
4. Have you ever had gestational hypertension?
Diagnostic Tests (investigation):
Graphic procedures
Electrocardiogram (ECG)
Stress testing (exercise ECG).
Laboratory tests
1. Complete blood picture (CBC).
2. Cardiac enzymes are used to detect myocardial infarction.
3. Blood coagulation tests to examine the ability of the blood to clot.
4. Serum lipids (cholesterol and triglyceride).
5. Serum electrolytes as potassium (K+), Sodium (Na+), Calcium (Ca-).
6. Organ function test (Liver and Kidney).
7. Homodynamic studies.
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Radiological procedures
1. Cardiac catheterization.
2. Chest X-ray.
3. Echocardiograph and Doppler ultrasound.
4. Angio cardiograph.
Nursing considerations of ECG:

Electrocardiography (ECG) is the graphic recording of the electrical currents
generated by the heart muscle. During electrocardiography, color-coded
electrodes matched to corresponding lead wires connect the client to the
recording machine.
Exercise electrocardiography (also known as a stress test,) is more diagnostic
than resting ECG because it demonstrates how the heart functions when subjected
to activity.
• Tell the patient that an ECG only takes about 10 minutes and causes no
discomfort.
• Explain that he must lie still, relax, breathe normally, and remain quiet.
• Withhold medications, as ordered, before the stress test.
• Keep in mind that evaluation of the recording will guide further treatment
• Treat chest pain if present (as ordered).
Nursing considerations of Exercise ECG:

1. Patient must not eat food, drink caffeinated beverages, or smoke cigarettes
for 4 hours before the test.
2. Explain that should wear loose, lightweight clothing and ,comfortable shoes
3. Have emergency equipment available during stress testing.
4. Obtain a resting ECG and baseline vital signs.
5. Monitor vital signs, and assess the patient for signs and symptoms of
cardiovascular instability during and after the stress test.
6. Inform patient to report any chest pain, leg discomfort, breathlessness,
or fatigue.
7. The stress test is canceled if the client develops chest pain, severe dyspnea,
elevated BP, confusion, or dysrhythmias.
8. Check the practitioner’s orders to determine which cardiac drugs should be
administered or withheld before the test.
• Beta- adrenergic blockers, for example, can limit the patient’s ability to
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raise his heart rate.

9. Inform the patient that he may receive an injection of thallium during the
test so that the doctor can evaluate coronary blood flow.
10. VS. will be monitored for 10 to 15 minutes in following first hour.
Nursing considerations of Cardiac catheterization and coronary

angiography;
Cardiac catheterization is a diagnostic test performed in an operative setting.
It can be done for a variety of purposes of:
- Determining size and structure of cardiac chambers
- Measuring pressures and volumes in cardiac chambers
- Determining valve structure and function
- Determining pressure in pulmonary vessels
- Determining extent of damage from heart disease
- Determining condition of coronary vessels
- Facilitating infusion of thrombolytic agents into occluded coronary arteries
- Performing angioplasty, atherectomy, and stent insertion
Nursing management pre-posttest

• Make sure the patient understands why he’s scheduled for catheterization.
• Check with the practitioner before withholding any medication.
• Have the patient fast for 3 to 8 hours.
• Scrub and clip hair around the catheter insertion site
• Have the patient remove dentures and jewelry
• Have the patient void before receiving the pretest medication
• Obtain baseline vital signs
• Explain that he may receive a mild I.V. or oral sedative before or during
the procedure and that a local anesthetic will be used at the insertion site.
• Administer pretest medications, such as an antihistamine
• Ask the patient if he’s allergic to contrast media or shellfish; document any
allergies and report them to the practitioner
• For the first hour: monitor VS every 15 minutes , inspect the dressing
frequently for signs of bleeding, check skin color, temperature, and pulses
• An absent or weak pulse may signify an embolus to the insertion. If the
patient’s vital signs change or if he has chest pain , inform physician
• After the first hour, assess the patient every 30 minutes for 2 hours, then
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every hour for 4 hours, then once every 4 hours.

• Check the patient’s lab values — especially the BUN “Blood Urea
Nitrogen” and creatinine levels — and report abnormal values to the
practitioner.
• Monitor peripheral pulses below the insertion site
• After the test, maintain pressure to the insertion site, and keep the extremity
flat and immobilized, & maintain bed rest for 4 to 6 hours
• Check the catheter insertion site for hemorrhage or hematoma; apply ice
if needed.
• Document the type of vascular closure device used and status of the dressing.
• Have emergency equipment available
Discharge Instructions
- Rest for the next 3 days, and avoid heavy lifting, strenuous activity
- Do not drive or climb stairs for the next 24 hours
- Do not take a tub bath until the puncture site is healed
- Change the bandage in 24 hours
- If pain or swelling of the puncture site occurs, notify your physician
- If the puncture site begins to bleed, hold pressure over the site and call
emergency services number
Four important parameters are used to asses homodynamic status which

are:
- C.V.P. central venous pressure.
- Pulmonary artery (PA) pressure.
- Cardiac output.
- Intra-arterial pressure.
Vascular disorders
Hypertension
Blood pressure (BP) is the force produced by the volume of blood in arterial
walls.
BP = COP x PR
Definition:
Hypertension refers to an intermittent or sustained elevation in diastolic or
systolic blood pressure.
Hypertension, is a condition in which the average of at least two or more
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readings on different dates is above pre-hypertensive levels .

• Readings should be taken after the patient has been resting comfortably,
back supported in the sitting or supine position, for at least 5 minutes and at
least 30 minutes after smoking or coffee ingestion.
• Blood pressure is affected by cardiac output (CO), peripheral vascular
resistance (PVR; the ability of the vessels to stretch), the viscosity (thickness)
of the blood, and the amount of circulating blood volume.
➢ Decreased stretching ability of blood vessels, increased blood viscosity,
and/or increased fluid volume may cause an increase in blood pressure
Classification of blood pressure in adults 18 years or older
BP Systolic BP Diastolic BP
Classifications
Normal <120 mmHg <80 mmHg
Prehypertension 120–139 mmHg 80–89 mmHg
Stage1 140–159 mmHg 90–99 mmHg
hypertension
Stage 2 >=160 mmHg >=100 mmHg
hypertension
Types of hypertension
1. Essential or Primary Hypertension : is the chronic elevation of blood
pressure from an unknown cause (idiopathic) represent 90% to 95% of all
cases
2. Secondary hypertension; elevated BP with a specific cause that often can
be identified and corrected.
3. Malignant hypertension / hypertensive crisis: is a severe, fulminant form
of hypertension common to both types.
4. Isolated systolic hypertension (ISH) is a systolic pressure of 140 mm Hg
or greater and a diastolic pressure of 90 mm Hg or less. This type of
hypertension occurs mainly in the elderly
Predisposing factors of primary hypertension:

a. Non-Modifiable risk factors: family history of hypertension, age, DM.
b. Modifiable risk factors:
- Stress - Obesity - Sedentary lifestyle
- Oral contraceptives use
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- High dietary intake of sodium or saturated fats.

- Excessive caffeine, alcohol, smoking.
Causes to secondary hypertension
• Sleep apnea
• Drug-induced or drug-related: Estrogen use
•Chronic kidney disease
• Primary aldosterone’s
• Reno vascular disease
• Long-term corticosteroid therapy
•Thyroid or parathyroid disease: hyperthyroidism, hypothyroidism
•Cushing syndrome: Excess glucocorticoid may act through salt and water
retention
Systolic blood pressure: is the pressure that the heart pumps against to force
blood from the left side of the heart to the aorta and to major arteries.
Diastolic blood pressure: is the pressure required to permit filling of the
ventricles before the next systole cycle
Pulse pressure: which is the value of the difference between the systolic and
diastolic pressures, may be used to indicate perfusion problems.
The mean arterial pressure, or MAP (or MABP): is the average pressure
attempting to push the blood through the circulatory system, must be greater
than 60 mmHg in order to adequately perfuse organs.
MAP is calculated by taking one-third of the difference between the ( SBP
and DBP )+ DBP For a patient with a BP of 110/80 the MAP will be 90
Signs and symptoms may include:

• Be discovered only during a routine physical examination or when the client
experiences a major complication, may be asymptomatic, So hypertension,
considered ‘‘the silent killer
• Throbbing occipital headaches upon waking
• Drowsiness •Confusion •Dizziness • Fatigue
• Insomnia •Nervousness •Nosebleeds •Blurred vision
• Angina or dyspnea may be the first clue to hypertensive heart disease
Complications include:
Elevated blood pressure damages the small vessels of the heart, brain, kidneys,
and retina. The results are a progressive functional impairment
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• Left ventricular hypertrophy • Angina • Stroke • Heart failure

• MI “Myocardial infarction” • Peripheral arterial disease
• Transient ischemic attack • Nephropathy • Retinopathy
Investigation:
Diagnostic tests are performed to determine the extent of organ damage.
• Measures Blood pressure
• Ventricular hypertrophy depicted on EKG or chest x-ray.
• Blood test to look for associated cardiovascular risks.
• Elevated cholesterol and triglyceride levels, indicating to atherosclerosis
• Check electrolytes for imbalance—sodium, potassium, chloride, CO2.
• Monitor BUN” blood urea nitrogen” and creatinine for renal function, a sign
of impaired organ damage. BUN level is greater than 20 mg/dl and creatinine
level is greater than 1.5 mg/dl, suggesting renal disease
• Ophthalmologic test .
• Glucose test to check for diabetes mellitus
Treatment:-
Non-pharmacologic interventions are tried first, and then medications are
prescribed.
There is a four-step treatment plan based on stage of the client’s
hypertension :
Hypertension lifestyle modifications
L —Limit salt, caffeine, and alcohol.
Step 1:
I —Include daily potassium and calcium.
• Lifestyle changes F—Fight fat and cholesterol.
• Reduce caloric intake and exercise to E—Exercise regularly.
S—Stay on your blood pressure regimen.
reduce weight
T—Try to quit smoking.
• Low-sodium diet Y—Your medications are to be taken daily.
• No smoking L—Lose weight.
E—End-stage complications will be avoided.
• Reduce alcohol intake
• Reduce caffeine intake
Step 2: Begin medication
• Administer diuretics to reduce circulating blood volume: e.g. Furosemide
• Beta-adrenergic blockers to lower heart rate and cardiac output:
e.g. propranolol
• Calcium channel blockers to cause peripheral vasodilatation, e.g. verapamil
• Administer ACE to inhibit the rennin angiotensin aldosterone system.
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In diabetes, ACE inhibitors delay the progression of renal disease: e.g.

Captopril
Step 3:• Increase dosages of currently administered medication
Step 4:
• Combination of agents in above classes
• Multiple drugs may be needed to control blood pressure
Example of Antihypertensive Agents

Drug Mechanism Side Effects Nursing
of Action Considerations
Beta ▪ Block Hypotension, ▪ Administer with
Adrenergic beta1- and bradycardia, meals.
Blockers beta2- bronchospasm, ▪ Advise client not
propranolol adrenergic CHF, to discontinue
(Inderal) Receptors depression, medication
▪ Decrease hypoglycemia abruptly.
renin levels ▪ Monitor for fluid
retention, rash, and
difficulty breathing.
▪ Monitor blood
glucose level in
clients with
diabetes.
Alpha- Relax vascular Hypotension, ▪ Administer first
Adrenergic smooth muscle dizziness, dose just before
Blockers by blocking drowsiness, bedtime to reduce
prazosin alpha1 receptor nausea, potential for
sites for palpitations syncope.
epinephrine ▪ Monitor client for
and postural
norepinephrine hypotension.
▪ Caution client to
change positions
slowly.
Nursing Interventions:-
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1. Monitor blood pressure with multiple readings—lying, sitting, and standing,

bilateral both arms.
2. Record fluid intake and output.
3. Reduce stress by providing a quiet environment.
4. Explain to the patient:
• No smoking—smoking contributes to cardiovascular disease, raising BP
• Change to a low-sodium and low-cholesterol diet—salt adds to elevated
BP in some patients by contributing to fluid retention; lower cholesterol
intake lowers risk for associated hyperlipidemia.
• Reduce alcohol intake—reduces risk for end organ damage from alcohol
intake.
• Reduce weight—decreased risk for obesity, better BP control
• Exercise regularly can help control weight and reduce cardiovascular risk.
• Call physician when BP is elevated.
• Be specific about the names, actions, dosages, and side effects of prescribed
medications
• Adhere to the treatment regimen even feel well
• Follow directions; never increase, decrease, or omit a prescribed drug
• Plan regular and convenient times for taking medications and measuring BP
• Don't double up on doses when a dose is missed
• Avoid hot baths, excessive amounts of alcohol, and strenuous exercise
within 3 hr of taking medications that promote vasodilation
• Many medications cause orthostatic hypotension.
The effects of orthostatic hypotension can be reduced by rising slowly from
bed, sitting on the side of the bed for a few minutes, standing slowly, and
beginning to move if no symptoms develop
Atherosclerosis
Atherosclerosis: is an abnormal accumulation of lipid, or fatty substances and
fibrous tissue in the vessel wall.
Arteriosclerosis characterized by irregularly distributed lipid deposits in the
intimae of large and medium-sized arteries, causing narrowing of arterial lumens
and proceeding eventually to fibrosis and calcification.
What is the Difference between Arteriosclerosis and Atherosclerosis?

Arteriosclerosis refers to the loss of elasticity or hardening of the arteries wall
that accompanies the aging process.
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Atherosclerosis is a condition in which the lumen of arteries fill with fatty

deposits called plaque (narrowing of the artery).
Causes of Atherosclerosis:
Certain factors that can damage the inner area of the artery (endothelium) and
can trigger atherosclerosis include:
• High Blood Pressure
• High-fat diet
• Cigarette Smoking
• Inactivity, obesity, diabetes mellitus
• High levels of sugar in the blood
• Infections with Chlamydia pneumonia
• Stressful lifestyle
Genetics - some clients are genetically predisposed to produce cells with
reduced numbers of receptors for binding with cholesterol; therefore, they are
more likely to develop high lipid levels
Obese people with metabolic syndrome who are prone to diabetes tend to have
lower levels of leptin, which regulates energy metabolism
Signs and Symptoms of Atherosclerosis:

Atherosclerosis produces symptoms and complications according to the
location and degree of narrowing of the arterial lumen
Carotid Arteries:
These arteries provide blood to the brain, when the blood supply is limited
patients can suffer stroke and may experience:
Weakness , Difficulty breathing , Headache , Facial numbness , Paralysis
Coronary Arteries: these arteries provide blood to the heart, when the blood
supply to the heart is limited it can cause angina and heart attack, symptoms
include:
Vomiting, Extreme anxiety , Chest pain, Coughing , Feeling faint.
Renal Arteries: these supply blood to the kidneys; if the blood supply becomes
limited, there is a serious risk of developing chronic kidney disease, and patient
may experience:
Loss of appetite , swelling of the hands and feet, Difficulty concentrating
Peripheral arterial disease: the arteries to the limbs, usually the legs, are
blocked. The most common symptom is leg pain, either in one or both legs,
19
usually in the calves, thighs or hips. The pain may be described as one of
heaviness, cramp, or dullness in the leg muscles.
Other symptoms may include:
A: Vascular
•Capillary refill greater than 3 seconds
•Diminished peripheral pulses
•Dry skin •Loss of hair on extremities
•Pallor in nail beds •Thickened nails
• Leg cramps
B: Cardiac
•Chest pain • Diaphoresis • Dizziness • Fatigue
• Nausea •Shortness of breath • Weakness
Diagnosing for Atherosclerosis

A diagnosis will be based on the medical history of a patient, test results and a
physical exam.
Blood tests: blood sugar, fat and protein. If there are high levels of fat and
sugar it can be an indicator that you're at risk of developing the condition.
Physical exam
• The doctor will listen to the arteries using a stethoscope to see if there is an
unusual "whooshing" sound reflecting turbulence of flow - called a bruit. If a
bruit is heard then it can mean there is plaque obstructing blood flow.
• There may also be a very weak pulse below the area of the artery that has
narrowed. Sometimes there is no detectable pulse.
• An affected limb may have abnormally low blood pressure
• There may be signs of an aneurysm (pulsating bulge) behind the patient's
knee or in their abdomen
• Where blood flow is restricted, wounds may not heal properly
Ultrasound: It can check your blood pressure at distinct parts of the body;
changes in pressure indicate where arteries may have obstruction of blood flow
Computed tomography (CT) scan: A CT scan uses X-ray images to create
detailed pictures of the inside parts of the body. It can be used to find arteries
that are hardened and narrowed.
Treatment Options for Atherosclerosis
•Diet—low fat, low cholesterol • Smoking cessation
•Increased exercise—walk 30 minutes daily • Lowering lipid levels
20
A. Lifestyle Changes: The changes will focus on weight management,

physical activity and a healthy diet. Your doctor may recommend eating foods
high in soluble fiber and limiting your intake of saturated fats, sodium and
alcohol.
B. . Medication: The doctor may prescribe medications to prevent the buildup
of plaque or to help prevent blood clots (anti-platelets).
Other medications such as statins may be prescribed to lower cholesterol
and Angiotensin-converting enzyme (ACE) inhibitors to lower blood pressure.
C. Surgery: Severe cases of atherosclerosis may be treated by surgical
procedures, such as
1. Angioplasty involves expanding the artery and opening the blockage, so
that the blood can flow through properly again.
2. CABG is another form of surgery that can improve blood flow to the heart
by using arteries from other parts of the body to bypass a narrowed coronary
artery.
Prevention of Atherosclerosis :
- Eliminate any risk factors you might have. The best way to do this is by
living a healthy lifestyle.
- Diet: Try to avoid saturated fats; they increase levels of bad cholesterol
foods that high in unsaturated fats are: olive oil , avocados , walnuts , oily
fish , nuts , seeds
- Exercise: improve fitness level and lower blood pressure. help lose weight
- Smoking: should quit as soon as possible
-
Thrombophlebitis
Thrombophlebitis is an inflammation of a vein accompanied by clot formation.
Phlebothrombosis is the development of a clot within a vein without
inflammation.
Deep vein thrombosis (DVT) is the most serious form of thrombophlebitis
because pulmonary emboli can result
This may be the result of injury to the area, may be precipitated by certain
medications or poor blood flow, or may be the result of a coagulation disorder.
Causes of Thrombophlebitis
Three factors, Virchow’s triangle, are involved in the formation of a
21
thrombus:
Factors Type Example
1.Venous • Reduction of  Shock, heart failure, myocardial
Stasis blood flow infarction atrial fibrillation.
• Dilated veins  Vasodilators
• Decreased  Immobility, sitting for long
muscle periods as in traveling, fractured
contractions hip, paralysis, anesthesia, surgery,
obesity, advanced age . Varicose
veins, venous insufficiency
2.Venous Faulty Venipuncture, venous cannulation at
Wall Injury valves same site for >48 hours, venous
catheterization, surgery, trauma,
burns, fractures, dislocation, IV
medications (potassium,
chemotherapy drugs, antibiotics, IV
hypertonic solutions), contrast agents,
diabetes, cerebrovascular disease
3.Increased Anemia, malignancy, anti-thrombin
blood III deficiency,
coagulation oral contraceptives, estrogen therapy,
smoking, discontinuance of
anticoagulant therapy, dehydration,
malnutrition, polycythemia,
leukocytosis, thrombocytosis, sepsis,
pregnancy
Signs and Symptoms:-

1. May be asymptomatic
2. Edema, tenderness, & warmth in affected area as part of an inflammatory
response
3. Palpable tender cord
4. Positive Homan’s sign , pain on dorsiflexion of the ipsalateral foot(
unreliable sign)
5. Cramping because blood flow to the area is impaired due to the presence of
the clot
22
6. If the clot dislodges from the vein and travels to the lung, other symptoms
will develop (S&S of pulmonary embolism):
• Difficulty breathing (dyspnea) when the clot has traveled to the lungs
• Rapid breathing >20 breaths per minute (tachypnea) because of a clot in the
lungs
• Chest pain in the area of clot
• Crackle sounds in lungs in the area of clot
Diagnosis:-
1. The primarily diagnosis based on the appearance of the affected area.
Frequent checks of the pulse, blood pressure, temperature, skin condition,
and circulation may be required.
2. Ultrasound determines if blood is flowing to the affected area.
3. Photoplethysmography depicts any defects in venous filling in the affected
area.
4. Lab work to look for clotting disorders.
Treatment:- depends on whether an artery or a vein is occluded and the

degree of occlusion
1. Anticoagulation to prevent further occurrences, thrombolytic to dissolve
current clot & narcotics to relieve pain.
2. Administer anti-inflammatory medication to decrease the inflammation
within the vessel : Aspirin, indomethacin
3. Administer anticoagulant medication to prevent the clot from becoming
larger: Heparin, warfarin. list 4 of contraindications to anticoagulant therapy
4. Limit activity initially to diminish risk of moving clot—bed rest
Nursing Interventions:-
The goals are to relieve pain, prevent pulmonary emboli, thrombus
enlargement, and further thrombus development.
• Monitor breathing because changes in respiratory status can signal that a clot
has dislodged and moved to the lung.
• Monitor labs because the patient is receiving anticoagulants. Monitor for
therapeutic effect and adverse effects & assesses IV infusions , PT & PTT
hourly
23
•Assess for signs of bleeding and keeps protamine sulfate on hand for
reversing heparin and vitamin K on hand for reversing oral anticoagulants.
• Apply warm moist compresses over affected area because it enhances blood
flow to area.
• Examines extremities & compares skin color, temperature, capillary refill
time, tissue integrity; measures each calf & palpates peripheral pulses.
• Explain to the patient:
• Report signs of bleeding—anticoagulant may be too much.
• Report signs of clotting—pain in affected area, shortness of breath—
patient may have underlying clotting disorder.
• Move frequently when allowed—decease chances of developing another clot.
• Don’t cross legs—avoid constriction of lower extremity vessels.
• Don’t use oral contraceptives—increases risk of clot formation.
• Elevate affected area.
•Avoid sitting and standing for prolonged time.
• Bleeding precaution & wearing ant embolism stockings to prevent venous
stasis
Varicose Veins
Definition: Varicose veins or varicosities
are dilated, tortuous veins .The saphenous
leg veins commonly are affected because they
lack support from surrounding muscles
Types:
1- Primary varicose veins
- Originate in the superficial system
- Half of patients have a family history
2- Secondary varicose veins
Result from deep venous insufficiency and incompetent perforating veins or
from deep venous occlusion causing enlargement of superficial veins that are
serving as collaterals.
- Dull ache or pressure sensation in the legs after prolonged standing.
Etiology:-
1- The vein in the lower trunk and extremities become congested and tortuous.
24
2- Results from weakness of valves or loss of elasticity of vessel wall.

3- Risk factors include anything that constricts or interferes with venous return
E.G:
➢ Prolonged standing as blood pools distally with gravity
➢ Obesity and pregnancy (fetus), enlarged liver, or abdominal tumor
contribute to
➢ Venous congestion.
➢ Thrombophlebitis because the inflammatory process may damage vein valves
➢ Long time standing up may raise the probability of having varicose veins
➢ Advanced age- loss of vein wall elasticity
• The congestion veins, over time, cannot recoil and remain distended leads to
venous hypertension that forces fluid to move into interstitial spaces of
surrounding tissue.
• Venous congestion and local edema may diminish arterial blood flow,
impairing cellular nutrition
Varicose veins can appear in various parts of the body, including:

• Legs (most common)
• Rectum (hemorrhoids)
• Pelvis
• Vagina
• Uterus (womb)
• Esophagus (esophageal varices)

• The veins are blue or dark purple
• Heaviness or fullness in legs
• Leg fatigue
• Leg cramping that intensifies at night.
• Lipodermatosclerosis - fat under the skin just above the ankle can become hard,
resulting in the skin shrinking
• Swollen ankles
• Telangiectasia in the affected leg (spider veins)
• There may be a shiny skin discoloration near the varicose veins, usually brownish
or blue in color
• Venous eczema (stasis dermatitis) : the skin at the affected area is red, dry
25
and itchy
• When suddenly standing up, some patients may experience leg cramps
( restless legs syndrome)
Complications:-
•Bleeding. •Thrombophlebitis. • Chronic venous insufficiency.
Therapeutic interventions:-
1- Treated with conservative measures:
- Leg elevation. - Weight loss. - External compression stockings
- Avoiding prolonged periods of sitting or standing
2- Sclero-therapy injecting a chemical into the vein.
3- Surgical therapy
• Involves extensive ligation and stripping of the greater and lesser saphenous
veins, affected veins are ligated (tied off) above and below the area of
incompetent valves.
• Reserved for patients who are very symptomatic, suffer from recurrent
superficial vein thrombosis, and/or develop skin ulceration
• May be indicated for cosmetic reasons.
• Formation of thrombi by compression
• Postoperative early ambulation is essential to prevent the complications.
Nursing Care of Clients with Varicose Veins:

1. Instruct client about the importance of weight loss and exercise if obese.
2. Administer analgesics as ordered.
3. Have client use support stockings as ordered.
4. Instruct the patient to avoid prolonged standing, sitting or crossing legs
5. Provide specific care for the client following a vein ligation.
a. Elevate the foot of the bed for first 24 hours.
b. Observe vital signs and incisions for indications of hemorrhaged.
c. Maintain compression with dressings.
d. Assist the client with ambulation.
e. Monitors for swelling in the operative leg &its effect on circulation
f. Helps the client ambulate as soon as possible to promote venous circulation,
reduce edema, and prevent venous thrombosis. E.g. Provides adequate fluid.
Coronary artery disorder
26
Coronary artery disease (CAD) is a term applied to obstructed blood flow

through the coronary arteries to the heart muscle
The condition my unrecognized. During situations that increase myocardial
oxygen demand (E.G. exercise, emotional stress), the compromised coronary
arteries cannot adequately oxygenate the myocardium.
✓ When the myocardial tissue becomes ischemic (deprived of oxygen),
clinical manifestations of CAD, such as angina pectoris or myocardial infarction
occur.
Risk Factors for Coronary Artery Diseases

Inherited Behavioral
▪ Men have more risk factors ▪ Smoking: Causes vasoconstriction and
▪ Diabetes mellitus: increases myocardial oxygen demand.
Increases the risk of Decreases HDL.
hypertension, obesity, and ▪ Sedentary lifestyle (exercise helps
elevated blood lipids. decrease risk factors of obesity,
▪ Increased lipid levels hypertension, and hyperlipidemia)
▪ Genetic predisposition ▪ Obesity (person with an apple-shaped
▪ Hypertension : increases body (carries most weight in the
myocardial oxygen demand abdomen) Increases the workload
▪ Age: increased incidence of the heart and risk of hypertension,
after age 50. diabetes, glucose intolerance,
hyperlipidemia.
▪ Stress response can narrow arteries and
raise blood pressure
▪ High-fat diet
Angina Pectoris
Definition: Angina pectoris is a clinical syndrome usually characterized by
episodes or paroxysms of pain or pressure in the anterior chest.
➢ It is the clinical manifestation of reversible myocardial ischemia.
Risk factor:- Factors That Increase Cardiac Workload

Physical exertion: - which can precipitate an attack by increasing myocardial
oxygen demand.
Exposure to cold: which can cause vasoconstriction and an elevated blood
27
pressure, with increased oxygen demand?

Eating a heavy meal: which increases the blood flow to the mesenteric area
for digestion, thereby reducing the blood supply available to the heart muscle.
Stress or any emotion-provoking situation: causing the release of
adrenaline and increasing blood pressure, which may accelerate the heart rate
and increase the myocardial workload?
The major symptom of angina generally is sub sternal or anterior chest pain
that may radiate to the arms, neck, jaw, and shoulders; it may be described as
mild-to-moderate pressure, tightness, squeezing, burning, indigestion, choking,
or mild soreness; the patient may exhibit Levine’s sign (clenched fist over
sternum)
Related signs and symptoms include shortness of breath, diaphoresis, nausea,
increased heart rate, and pallor, weak or numb feelings in the arms and hands,
and unexplained anxiety
✓ The diagnosis of angina pectoris depends principally upon the history,

which should specifically include the :
• Circumstances that precipitate and relieve angina.
• Characteristics of the discomfort.
• Location , radiation, duration of attacks, and effect of nitroglycerin.
Types, causes, symptoms & treatment

Typ Causes Symptoms Treatment
es
Stable Coronary ✓ Chest pain that lasts 15 ▪ Rest, sublingual
Angina occlusion minutes or less and nitrates,
that may radiate ▪ Anti-hypertensive,
accompanies ✓ Similar pain severity, lifestyle changes
exertion or frequency, and
emotional stress duration with each
and is relieved episode
by rest or
nitroglycerin
28
Unstable Progressive ✓ Chest pain of ▪ Sedation, IV

Angina worsening of increased frequency, nitroglycerin,
stable angina, severity, and duration oxygen,
with more than ✓ Poorly relieved by rest antihypertensive,
90% coronary or oral nitrates ▪ Anticoagulant or
occlusion ( ✓ Client at risk of MI ▪ Antiplatelet
increases in within therapy,
severity, and ✓ 18 months of angina’s ▪ Revascularization
duration ) onset procedures
Varia Arterial ✓ Chest pain that ▪ Nitrates or calcium
nt spasm in occurs at rest channel blockers
Angin normal or (usually between
a diseased 12
coronary and 8 AM), is
arteries sporadic
occurring over 3 to 6 months,
during and diminishes
periods of overtime, ST
rest. elevation rather than
depression on ECG
Micro Constriction of ✓ Prolonged chest pain Heart-healthy habits
vascular myocardial that accompanies exercise and trials with
Angina capillaries too and is not always medications
small for standard relieved by medication like a nitrate, beta
cardiac tests to blocker, or calcium
detect channel
blocker
Remember PQRST (A method of pain assessment) as following:

Symbol Factor Questions to Ask Patient
P Precipitating What events or activities precipitated
events the pain?
29
Q Quality of pain What does the pain feel like?

R Radiation Where is the pain located?
of pain Does the pain radiate to other areas?
S Severity of pain On a scale of 0 to 10, indicate, what
number
Would you give the pain?
T Timing When did the pain begin? Has the
pain changed since this time? Have
you had pain like this before?
Relieving/ aggravating factors' angina is aggravated by continued activity

and subsided with the administration of nitroglycerin tablet sublingual and
rest.
Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min must
be differentiates an MI from angina
Diagnostics tests:
1. Electrocardiogram during episode:
• T-wave inverted with initial ischemia
• ST-segment changes occur with injury to the myocardium (heart muscle).
• Abnormal Q-waves due to infarction of myocardium.
2. Labs: troponins, CK-MB, which is an enzyme released by damaged cardiac
tissue 2 to 6 hours following an infarction, electrolytes.
3. Chest x-ray to determine signs of heart failure.
4. Coronary Arteriography
5. Stress testing
Treatment:-
The goal of treatment
✓ Decrease myocardial oxygen demand and increase myocardial oxygen supply
✓ Precipitating factors—such as exercise, overexertion, emotional upset, cold
weather, and large meals, identified and avoided if possible
✓ Cardiovascular interventions are used to maintain adequate blood flow
through the coronary arteries.
1. 2 to 4 liters of oxygen.
30
2. Administer beta-adrenergic blocker: has a cardio protective effect,

decreasing cardiac workload and likelihood of arrhythmia.
• Drugs like propranolol, atenolol
3. Administer nitrates: aids in getting oxygenated blood to heart muscle.
• Nitroglycerin: sublingual tablets or spray; timed-release tablets.
• Topical nitroglycerin; paste or timed-released patch.
4. Aspirin for antiplatelet effect.
5. Analgesic: typically morphine intravenously during acute pain. The
medicine is very fast-acting when given this way and will decrease myocardial
oxygen demand as well as decrease pain.
6. The following should be watched separately.
A. Percutaneous Tran's luminal coronary angioplasty. This is a nonsurgical
procedure in which a long tube with a small balloon is passed through blood
vessels into the narrowed artery. The balloon is inflated, causing the artery to
expand.
B. Coronary artery stent. This is a small, stainless steel mesh tube that is placed
within the coronary artery to keep it open.
C. Coronary artery bypass graph (CABG). This is a surgical procedure in
which a vein from a leg or an artery from an arm is removed and graphed to
coronary arteries, bypassing the blockage and restoring free flow of blood to
heart muscles.
7. Low-cholesterol, low-sodium, and low-fat diet.
Nursing Intervention:-
• Monitor vital signs.
• Notify physician if systolic blood pressure is less than 90 mmHg.
• Notify physician if heart rate is less than 60 beats per minute.
• Assess chest pain each time the patient, reports it. (Remember PQRST).
• Monitor cardiac status using a 12-lead electrocardiogram (EKG).
• Record fluid intake and output. Assess for renal function.
• Place patient in a semi-Fowler's position (semi-sitting with knees flexed).
Explain to patient:
• Rest when pain begins to decrease oxygen demands.
• Take nitroglycerin when any pain begins: it helps dilate coronary arteries and
get more oxygen to heart muscle.
• Avoid stress and activities that bring on an angina attack.
31
• Call emergency if the pain continues for more than 10 minutes or as the
patient is taking the third nitroglycerine dose (1 sublingual dose every 5
minutes, if BP allows, for maximum of 3 doses).
• Stop smoking! Smoking is associated with heart disease.
• Adhere to the prescribed diet and exercise plan:
• Lower cholesterol and fat intake to decrease further plaque build-up
• Decrease excess salt intake to help BP control.
• Slowly increase exercise to build up activity tolerance. Possibly exercise
with cardiac rehabilitation.
• How to recognize the symptoms of a myocardial infarction. Angina is a
warning sign of an impending acute MI
What are the key points for using sublingual nitroglycerin & precaution?
Acute Myocardial Infarction (MI)
Definition: Myocardial infarction or “heart attack” is an irreversible injury to

and eventual death of myocardial tissue that results from ischemia and hypoxia.
o MI, commonly known as a heart attack, results in the death of heart muscle.
My be partial or complete blockage of a coronary artery, which decreases the
blood supply to the cells of the heart. Cardiac conduction, blood flow, and
function can be dramatically altered
Etiology and Risk factors:-

• Atherosclerosis •Tobacco use •Hyperlipidemia
• Metabolic disorders
• Clot that develops in association with the atherosclerosis within the vessel
• Coronary artery spasm and hemorrhage

• Chest pain that is unrelieved by rest or nitroglycerin.
• Pain that radiates to arms, jaw, back and/or neck.
• Shortness of breath.
• Nausea or vomiting
• Maybe asymptomatic, known as a silent MI, which is more common in
diabetic patients
• Heart rate >100 (tachycardia) because of sympathetic stimulation, pain, or
low cardiac output
32
• Urine output: Less than 25 ml/hr due to lack of renal blood flow.
• Variable blood pressure MIs are classified based on:
• Anxiety ✓ Affected area of the heart
(anterior, anterolateral)
• Restlessness ✓ Depth of involvement
• Feeling of impending doom ✓ ECG changes produced
• Pale, cool, clammy skin; sweating (diaphoresis)
• Sudden death due to arrhythmia usually occurs within first hour
Complications Of Myocardial Infarction

•Dysrhythmias •Cardiogenic shock
•Heart failure/pulmonary edema • Emboli
• Ventricular aneurysms, rupture of muscles or valves of the heart, septal
rupture
•Pericarditis (inflammation of the heart muscle)
Diagnostic tests:-
EKG:
• T-wave inversion: sign of ischemia.
• ST-segment elevated or depressed; sign of injury.
• Significant Q-waves: sign of infarction.
• Blood chemistry:
• Elevated creatine kinase MB (CK-MB).
• Elevated troponin I- and troponin T-proteins elevated within one hour of
myocardial damage.
•Increased white blood count (WBC) due to inflammatory response to injury
• MRI
• Echo cardiograph.
Treatment:-
Treatment is focused on reversing and preventing further damage to the
myocardium.
✓ Administer oxygen, aspirin.
✓ Administer antiarrhythmics because arrhythmias are common as are
conduction disturbances.
• Amiodarone, Lidocaine, Procainamide.
33
✓ Electrical cardioversion for unstable ventricular tachycardia. In

cardioversion, an initial shock is administered to the heart to re-establish sinus
rhythm.
✓ •Administer antihypertensive to keep blood pressure low.
• Hydralazine.
✓ Percutaneous revascularization.
✓ Administer thrombolytic therapy within 3 to 12 hours of onset because it
can re-establish blood flow in an occluded artery, reduce mortality, and halt the
size of the infarction.
• Alteplase, Streptokinase, Anistreplase, Reteplase.
•Heparin following thrombolytic therapy.
✓ Administer calcium channel blockers as they appear to prevent
reinfarction and ischemia, only in non–Q-wave infarctions.
• Verapamil, Diltiazem.
✓ Administer beta-adrenergic blockers because they reduce the duration of
ischemic pain and the incidence of ventricular fibrillation; decreases mortality.
•Propranolol, Nadolol, Metroprolol.
✓ Administer analgesics to relieve pain, reduce pulmonary congestion, and
decrease myocardial oxygen consumption (Morphine).
✓ Administer nitrates to reduce ischemic pain by dilation of blood vessels;
helps to lower BP (Nitroglycerin).
✓ Fluid restriction
✓ Low-sodium diet advanced to diet as tolerated; no caffeine
✓ Bed rest with bedside commode/bathroom privileges
✓ Daily weights
✓ Cardiac rehabilitation
✓ Percutaneous coronary interventions
✓ Intracoronary stents
✓ Myocardial revascularization–CABG
✓ Low-fat, low-caloric, low-cholesterol diet.
✓ Promote energy conservation
Nursing Intervention:- Monitor

➢ Vital signs every 15 min until stable, then every hour
➢ Serial ECG, continuous cardiac monitoring
➢ Location, precipitating factors, severity, quality, and duration of pain
➢ Hourly urine output – greater than 30 mL/hr indicates renal perfusion
34
➢ Laboratory data (cardiac enzymes, electrolytes, ABGs)

➢ Administer oxygen (2 to 4 L/min).
➢ Obtain and maintain IV access.
Explain to the patient:

• Change to a low-fat, low-cholesterol, and low-sodium diet.
• The difference between angina pain and myocardial infarction pain.
• When to take nitroglycerin
•Smoking cessation.
• Limit activities.
• Stress reduction.
• Need for cardiac rehabilitation.
• Lifestyle changes such as increase in exercise, diet changes.
Angina MI
› Precipitated by exertion or stress › Can occur without cause, often in the
› Relieved by rest or nitroglycerin morning after rest
› Symptoms last less than 15 min › Relieved only by opioids
› Not associated with nausea, › Symptoms last more than 30 min
epigastric distress, dyspnea, anxiety, › Associated with nausea, epigastric
diaphoresis distress, dyspnea, anxiety, diaphoresis
Prevention of CAD:
❖ Encourage the client to maintain an exercise routine.
❖ The client should have cholesterol level and blood pressure checked regularly.
❖ The client should consume a diet low in saturated fats and sodium.
❖ If the client is a smoker, promote smoking cessation.
Valvular heart disease

➢ In the normal heart, blood flows in one direction because of the presence of
heart valves It is classified as:
●Stenosis – Narrowed opening that impedes blood moving forward.
●Insufficiency – Improper closure – some blood flow backward (regurgitation).
Valvular heart disease can have congenital mainly in children or acquired
causes
35
● Three types of Acquired Valvular heart disease & causes:

o Degenerative disease – Due to damage over time from mechanical stress.
The most common cause is hypertension.
o Rheumatic disease – Gradual fibrotic changes, calcification of valve cusps.
The mitral valve is most commonly affected.
o Infective endocarditis – Infectious organisms destroy the valve.
Streptococcal infections are a common cause.
●Valves on the left side are most commonly affected due to higher pressures.
●With age, fibrotic thickening occurs in the mitral and aortic valves. The aorta
is stiffer in older adult clients, increasing systolic blood pressure and stress on
the mitral valve.
●Marfan syndrome (connective tissue disorder that affects the heart and
other areas of the body)
Clinical Manifestations (S & S):

➢ Left-sided valve damage causes increased pulmonary artery pressure, left
ventricular hypertrophy and decreased cardiac output, resulting in orthopnea,
paroxysmal nocturnal dyspnea, and fatigue.
➢ Right-sided valve damage results in dyspnea, fatigue, increased right
atrial pressure, peripheral edema, jugular vein distention, and hepatomegaly.
Mitral Mitral Aortic Aortic
Stenosis Insufficiency Stenosis Insufficiency
• Diastolic • Systolic ➢ Systolic ➢ Diastolic
murmur murmur murmur murmur
• Atrial • Chest pain ➢ S3 and/or ➢ S3 sounds
fibrillation • Atrial S4 sounds ➢ Sinus
• Palpitations fibrillation ➢ Angina tachycardia
• Jugular • Palpitations ➢ Syncope ➢ Palpitations
venous • Jugular venous ➢ Decreased ➢ Angina
distention distention SVR ➢ Widened
• Pitting • Pitting edema ➢ Narrowed pulse Pressure
pulse ➢ Forceful
edema • Crackles in
• Hemoptysis pressure pulse
lungs
➢ Diaphoresis
• Cough • Possible
• Dysphagia diminished
• Hoarseness lung sounds
36
• (Peripheral • Exertional
edema jugular dyspnea
vein distention, • Orthopnea
ascites, Acute:
hepatomegaly o Pulmonary
(right-sided edema
heart failure in o Shock
severe Complications:
pulmonary ▪ Emboli
hypertension) ▪ Heart failure
Tricuspid Tricuspid Pulmonic Pulmonic
Stenosis Insufficiency Stenosis Insufficiency
➢ Diastolic ➢ Systolic ▪ Systolic ➢ Dyspnea,
murmur murmur murmur weakness,
➢ Atrial ➢ Supraventricular ▪ Angina fatigue
dysrhyth tachycardia ▪ Syncope ➢ Chest pain
mias ➢ Conduction ▪ Cyanosis ➢ Peripheral
➢ Decrease delays edema, jugular
➢ cardiac ➢ “Fluttering” vein distention,
output neck hepatomegaly
vein sensations (right sided heart
failure)
➢ Auscultation
reveals diastolic
murmur in
pulmonic area
Diagnostic Procedures
• Chest x-ray shows chamber enlargement, pulmonary congestion, and valve
calcification.
• History and physical examination
• 12-lead electrocardiogram (ECG) shows chamber hypertrophy.
• Echocardiogram shows chamber size, hypertrophy, specific valve
dysfunction, ejection function, and amount of regurgitant flow.
• Exercise tolerance testing/stress echocardiography is used to assess the
impact of the valve problem on cardiac functioning during stress.
37
• Radionuclide studies determine ejection fraction during activity and rest.

• Angiography reveals chamber pressures, ejection fraction, regurgitation,
and pressure gradients.
Therapeutic Interventions for Cardiac Valvular Disorders

➢ Rheumatic fever prophylaxis
➢ Prophylactic antibiotic therapy considered
➢ Anticoagulant therapy
➢ Medication therapy : Digitalis , Diuretics , Beta blockers
Angiotensin-converting enzyme inhibitors (ACEIs )
➢ Percutaneous balloon valvuloplasty
➢ Surgical: Valvuloplast , Annuloplasty , Valve replacement
Nursing Assessment for Patients with Cardiac Valvular Disorders

Subjective Data
Health History ❖ Infections—rheumatic fever, endocarditis,
Respiratory streptococcal or staphylococcal, syphilis
Cardiovascular ❖ Congenital defects
Medications ❖ Cardiac disease—myocardial infarction,
Knowledge of cardiomyopathy
Condition ❖ Dyspnea at rest, on exertion, when lying or that
Coping skills awakens patient?
❖ Cough or hemoptysis?
❖ Any palpitations, chest pain, dizziness, fatigue,
activity intolerance?
Objective Data
Respiratory • Vital signs, noting tachycardia, rapid
Cardiovascular respirations, dyspnea, hypotension, or
Integumentary hypertension
Diagnostic Test • Crackles, wheezes, tachypnea
Findings • Murmurs, extra heart sounds, dysrhythmias,
edema, jugular vein distention, Corrigan’s pulse,
increased or decreased pulse pressure
• Clubbing; cyanosis; diaphoresis; cold, clammy
skin; pallor
• Fluid intake and output
• Current weight and fluctuations during treatment
• Level of activity tolerance
Nursing Care
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✓ Monitor current weight, and note recent changes.

✓ Assess heart rhythm (can be irregular or bradycardia, assess for murmur).
✓ Administer oxygen and medications as prescribed.
✓ Assess hemodynamic monitoring.
✓ Maintain fluid and sodium restrictions.
✓ Teach clients who are self-administering digoxin to:
• Count pulse for 1 min before taking the medication. If the pulse rate is irregular
Or the pulse rate is outside of the limitations set by the provider (usually less
than 60/min or greater than 100/min), the client should hold the dose and
contact the provider.
• Take the dose of digoxin at the same time every day.
• Do not take digoxin at the same time as antacids. Separate the two medications
by at least 2 hr.
• Report signs of toxicity, including fatigue, muscle weakness, confusion,
visual changes, and loss of appetite.
Congestive heart failure (CHF)
➢ The heart is a double pump: the right side pumps deoxygenated blood to the
lungs for oxygenation, and the left side pumps oxygen-rich blood into the
systemic circulation.
➢ This process provides a continuous supply of oxygen and nutrients for
cellular metabolism and a mechanism to eliminate carbon dioxide (CO2) and
metabolic wastes
➢ An estimate of the heart’s efficiency as a pump is its ejection fraction, the
percentage of blood the left ventricle ejects when it contracts. Normally, a
healthy heart ejects 55% or more of the blood that fills the left ventricle during
diastole. It measured using an echocardiogram.
Definition: Heart failure (HF) is a clinical syndrome that occurs as a result of

the inability of the ventricle(s) to fill or pump enough blood to meet the body’s
oxygen and nutrient needs.
- The heart is unable to pump sufficient blood to maintain adequate circulation.
The term congestive heart failure (CHF) describes the accumulation of
blood and fluid in organs and tissues from impaired circulation.
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❖ Classify to acute or chronic HF, right or left-sided HF.

• Left-sided heart (ventricular) failure results in inadequate left ventricle
(cardiac) output and consequently in inadequate tissue perfusion. Forms include
the following:
- Systolic heart (ventricular) failure (ejection fraction below 40%,
pulmonary
Congestion)
- Diastolic heart (ventricular) failure (inadequate relaxation or “stiffening”
prevents ventricular filling)
• Right-sided heart (ventricular) failure results in inadequate right ventricle
output and systemic venous congestion (peripheral edema).
• An uncommon form of heart failure is high-output failure, in which
cardiac output is normal or above normal.
Severity of heart failure is graded on the New York Heart Association’s
functional classification scale indicating how little, or how much activity it
takes to make the client symptomatic (chest pain, or shortness of breath).
Class I: Client exhibits no symptoms with activity.
Class II: Client has symptoms with ordinary exertion.
Class III: Client displays symptoms with minimal exertion.
Class IV: Client has symptoms at rest.
Causes of HF include:-
Left-Sided Right- High- Cardiomyopathy
Heart sided output heart
Failure heart failure
failure
-Hypertension -Left-sided -Increased -Coronary artery disease
-Coronary artery heart failure metabolic need -Infection or
disease, angina, - MI -Septicemia (fever) inflammation of the heart
MI -Pulmonary -Anemia muscle
-Valvular disease problems -Hyperthyroidism -Various cancer
(mitral and aortic) (COPD, treatments
pulmonary -Prolonged alcohol use
fibrosis)
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Right-Sided Heart Left-Sided Heart Failure

Failure
• Jugular vein distention • Dyspnea on exertion
• Dependent edema: legs, • Pulmonary congestion (dyspnea, cough,
ankles, sacrum bibasilar crackles & wheezing)
• Ascites • Dry hacky cough, especially supine
• Weight gain • Orthopnea(Inability to breathe unless
• Splenomegaly sitting upright)
• Hepatomegaly • Paroxysmal nocturnal dyspnea (awakened
• GI pain, anorexia, nausea by breathlessness)
• Fatigue, weakness • Cheyne-Stokes respirations
• Tachycardia • Cyanosis
• Nocturia • Tachypnea, tachycardia
• Frothy sputum (can be blood-tinged
• Manifestations of organ failure, such as
oliguria
Diagnostic Tests
• History and physical examination
• Electrocardiogram
• Chest x-ray examination
• Exercise stress test
• Nuclear imaging studies
• Echocardiography
• Coronary angiography
• Cardiac catheterization
• Serum laboratory tests: ABGs, CBC, electrolytes, liver enzymes, BUN,
creatinine, thyroid function
• Urinalysis
• Hemodynamic monitoring
• Human B-type natriuretic peptides (h BNP): Elevated in heart failure,
this test direct the aggressiveness of treatment interventions.
➢ A level below 100 pg/mL indicates no heart failure.
➢ Levels between 100 to 300 pg/mL suggest heart failure is present.
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➢ A level above 300 pg/mL indicates mild heart failure.

➢ A level above 600 pg/mL indicates moderate heart failure.
➢ A level above 900 pg/mL indicates severe heart failure.
Medical Treatment:- examples of drug therapy and precautions

aims at improving cardiac output , treatment underlying disease.
✓ Administer diuretics: reducing blood volume, decrease preload.
• Loop diuretics (furosemide), Thiazide diuretics (hydrochlorothiazide) &
Potassium-sparing diuretics (Aldactone)
• Administer furosemide IV no faster than 20 mg/min.
• Loop and thiazide diuretics can cause hypokalemia, and potassium
supplementation may be required..
✓ Administer Angiotensin-converting enzyme (ACE) inhibitors to
decrease afterload E.G. captopril (Capoten)
o Monitor clients taking ACE inhibitors for hypotension
o Monitor client for angioedema (swelling of the tongue and throat), a
decreased sense of taste, or a skin rash.
o Monitor for increased levels of potassium
✓ Administer beta blockers: which help to raise ejection fraction, and
decrease ventricular size.
✓ Administer inotropic agent to strengthen myocardial contractility &
improve cardiac output: (Digoxin, dopamine, dobutamine).
➢ For a client taking digoxin, take the apical heart rate for 1 min. Hold the
medication if apical pulse is less than 60/min or more than 100/min.
➢ Observe the client for digital’s toxicity (nausea and vomiting).
➢ Dopamine, dobutamine, administered via IV. The ECG, blood pressure, and
urine output must be closely monitored.
✓ Administer vasodilator prevent coronary artery vasospasm and reduce
preload and afterload, decreasing myocardial oxygen: E.G. Nitroglycerine.
✓ Administer anticoagulants E.G. warfarin.
❖ Assess for contraindications(peptic ulcer disease, history of cerebrovascular
accident, recent trauma)
❖ Monitor bleeding times
❖ Teach client bleeding precaution
✓ Reduce fluids as fluid overload is a causative factor in CHF.
✓ High Fowler’s position to ease breathing and enhance diaphragmatic
excursion.
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✓ Supplemental oxygen to meet increased demand of myocardium.

✓ Low-sodium diet to prevent additional fluid retention.
• Monitor vital signs and look for changes.
• Record fluid intake and output: weigh daily to assess for fluid overload.
• Position patient in High Fowler’s position to ease breathing.
• Administer oxygen as ordered because it helps to decrease workload of heart.
• Assess for shortness of breath and dyspnea
• Check ABGs, electrolytes (especially potassium if on diuretics), SaO2, and
chest x-ray findings.
• Assess for signs of medication toxicity (digoxin toxicity).
•Encourage bed rest until the client is stable.
•Encourage energy conservation by assisting with care and ADLs.
• Maintain dietary restrictions as prescribed (sodium & fluid intake restricted).
•Provide emotional support to the client and family.
•Provide five to six small meals of soft or easily chewed foods.
•Encourage the client to rest after eating and to avoid spicy, gas-forming, and
High-fiber foods to lessen heartburn and flatulence
Surgical Interventions
1. Ventricular assist device (VAD)
2. Heart Transplantation
Complications of Heart Failure

1. Acute pulmonary edema , is fluid accumulation in the lungs, which
interfere with gas exchange in the alveoli.
Clinical S & S:
sudden dyspnea, wheezing, orthopnea, restlessness,
cough (often productive of pink, frothy sputum)
cyanosis, tachycardia, severe apprehension, peripheral pulses disappear
hypotensive . ABGs indicate severe hypoxemia (low PaO2), hypercapnia (high
PaCO2), and a pH below 7.35
Nursing care
➢ Administer prescribed medications to improve cardiac output.
➢ Teach the client about measures to improve tolerance to activity, such as
alternating
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periods of activity with periods of rest.

➢ Positioning the client in high-Fowler’s position.
➢ Administration of oxygen, and/or intubation and mechanical ventilation.
➢ IV morphine (to decrease anxiety, respiratory distress, and decrease venous
return).
➢ IV administration of rapid-acting loop diuretics, such as furosemide (Lasix).
2. Cardiogenic shock
Clinical S & S: tachycardia, hypotension, inadequate urinary output, altered
level of consciousness, respiratory distress (crackles, tachypnea), cool, clammy
skin,decreased peripheral pulses, and chest pain.
Nursing Care
➢ Monitor breath sounds. Assess for crackles or wheezing.
➢ Monitor heart sounds.
➢ Administration of oxygen; possible intubation and ventilation may be
required.
➢ IV administration of morphine, diuretics, and/or nitroglycerin to decrease
preload; IV administration of vasopressors and/or positive inotropes to increase
cardiac output and to maintain organ perfusion &Continuous hemodynamic
monitoring.
Client and Family Teaching Heart Failure

➢ Measure pulse and blood pressure daily.
➢ Check weight at the same time each day using the same scale
➢ Schedule rest periods to reduce or eliminate fatigue and dyspnea.
➢ Increase activities such as walking when able to do .
➢ Identify and avoid events that produce stress.
➢ Elevate the legs while sitting.
➢ Follow the diet prescribed by the physician.
➢ Avoid extreme heat, cold, or humidity.
➢ Report a heart rate less than 60 or more than 120 beats/minute before taking
digitalis.
➢ Contact the physician if swelling in the legs, ankles, feet or weight suddenly
increases.
Inflammatory Disorders
44
Rheumatic Carditis
Rheumatic Carditis refers to the inflammatory cardiac manifestations of
rheumatic fever in either the acute or later stage.
Rheumatic fever occurs as an autoimmune reaction to an upper respiratory
(throat) group A beta-hemolytic streptococci infection ,most common in
children after 2-3 weeks from infection.
As the antibody response arises, WBCs migrate

to the endocardium, causing inflammatory debris
to accumulate as vegetation’s around the valve
Accumulated fibrous fluid that interferes with
the heart’s ability to stretch and fill with blood
leads to increase heart rate.
Risk factors to rheumatic fever:-

1- Recurrent infection (sore throat & tonsillitis).
2- It typically occurs between ages 5 and 15
3- Malnutrition, overcrowding
4- Lower socioeconomic status.
5- Immunosuppression
Signs and symptoms of streptococcal pharyngitis include:

• Fever (38.9_C to 40_C [101_F to 104_F])
• Chills
Polyarthritis (inflammation of more than one joint
• Sore throat (sudden in onset)
• Diffuse redness of throat with exudate on oropharynx
• Enlarged and tender lymph nodes
• Abdominal pain (more common in children)
• Acute sinusitis and acute otitis media
➢ If signs and symptoms of streptococcal pharyngitis are present, a throat
culture is necessary to make an accurate diagnosis.
➢ All patients with throat cultures positive for streptococcal pharyngitis must
adhere to Penicillin that is the most common antibiotic prescribed
Inflammatory Description of Relevant information
45
disorder disease process

Pericarditis Inflammation • Commonly follows a respiratory infection
of • Can be due to a myocardial infarction
the • Findings include chest pressure/pain,
pericardium friction rub auscultated in the lungs, shortness of
breath, and pain relieved when sitting and leaning
forward
• Can be due to a viral, fungal, or bacterial

Myocarditis Inflammation of infection, or a systemic inflammatory
the myocardium disease (Crohn’s disease)
• Findings include tachycardia, murmur,
friction rub auscultated in the lungs,
cardiomegaly, chest pain, and
dysrhythmias
Rheumatic An infection of the • Preceded by an upper respiratory
endocarditis endocardium due infection
to • Produces lesions in the heart
streptococcal • Occurs with half of the clients who have
bacteria rheumatic fever
• Findings include fever, chest pain, joint
pain, tachycardia, shortness of breath,
rash on trunk and extremities, friction
rub, murmur, and muscle spasms
Infective An infection of the • Most common in IV drug users or clients
Endocarditis / endocardium due who have cardiac malformations
Bacterial to streptococcal or • Findings include fever, flulike
endocarditis staphylococcal symptoms, murmur, petechiae (on the
bacteria trunk and mucous membranes), positive
blood cultures, and splinter hemorrhages
(red streaks under the nail beds)
Diagnostic assessment:-
❖ Positive throat culture for group A-beta hemolytic streptococci.
❖ Increase in cardiac enzymes to look for other causes of chest pain
❖ Positive C-reactive protein, ESR which are elevated in inflammation
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❖ Increase in WBC because it may be of infectious origin

❖ Echocardiogram to assess for damage to valves
❖ Blood cultures to detect a bacterial infection
❖ ECG ,detect a murmur & Echocardiography reveal inflamed heart layers
Treatment:-
• Administer non-steroidal anti-inflammatory medication (Ibuprofen) to
decrease inflammation, fever and pain:
• Glucocorticosteroid (Prednisone) to treat inflammation
• Administer antibiotics (Penicillin) if an infectious process is confirmed
•Benzodiazepine (Diazepam) to treat anxiety
• Repair or replacement of heart valves due to permanent damage.
➢ Auscultate heart sounds (listen for murmur).
➢ Assess breath sounds in all lung fields (listen for friction rub).
➢ Review ABGs, SaO2, and chest x-ray results.
➢ Administer oxygen as prescribed.
➢ Monitor vital signs (watch for fever).
➢ Monitor ECG, and notify the provider of changes.
➢ Monitor for cardiac tamponed and heart failure.
➢ Obtain throat cultures to identify bacteria to be treated by antibiotic therapy.
➢ Administer antibiotics as prescribed.
➢ Administer antipyretics as prescribed.
➢ Assess onset, quality, duration, and severity of pain.
➢ Administer pain medication as prescribed.
➢ Encourage bed rest.
➢ Provide emotional support to the client and family, and encourage the
verbalization of feelings regarding the illness.
Cardiac Surgery
Open heart surgery is any type of surgery where the chest is cut open and
surgery is performed on the muscles, valves, or arteries of the heart.
Open heart surgery is sometimes called traditional heart surgery.
Indication for open heart surgery
47
➢ Repair or replace heart valves, which allow blood to travel through the
heart
➢ Repair damaged or abnormal areas of the heart
➢ Put in medical devices that help the heart to beat properly
➢ Replace a damaged heart with a donated heart (heart transplantation)
➢ Coronary artery bypass surgery (CABG)
1. Preoperative care
● Obtain an accurate and complete medical history.
● Assess the patient’s physiologic status before surgery. Baseline vital signs,
integrity of pulses and extremities, neurologic status, respiratory status, height,
weight, nutritional status, elimination patterns, and psychological status
● Teach the patient and family about the surgery and the immediate
postoperative period in the intensive care unit. Prepare them for postoperative
equipment that will
be used, such as pulmonary artery lines, chest tubes, I.V. lines, indwelling
urinary catheters, and equipment for mechanical ventilation and cardiac
monitoring.
● Discuss specific issues with the patient and family. For example, the patient
should always report pain. (Reassure a patient who will be intubated and unable
to speak that
pain will be detected , Bloody drainage in the chest tube is normal, as is feeling
the need to void while the urinary catheter is in place. The tubes and lines may
restrict patient movement, but the nurse should help the patient to prevent injury.
2. Intraoperative procedure
● The patient is placed on a cardiopulmonary bypass machine, which drains
blood from the left ventricle and atrium and passes it through a pulsatile or roller
pump
to the femoral artery or descending aorta. Pulmonary circulation isn’t
interrupted.
● Myocardial tissue is preserved during surgery by arresting the heart with a
cardioplegic solution, which usually is cold (39.4° F [4.1° C]). External cooling
also may be achieved with a slush saline solution administered into the
pericardium.
● After the patient is cooled sufficiently, bypass grafts, which are usually
harvested from saphenous veins in the legs, are placed surgically from the aorta
48
to sites distal to the occlusions on coronary arteries.

● After the procedure is completed, the blood in the bypass machine is slowly
warmed, and the patient’s body temperature is returned to normal. While the
incisions are closed, epicardial pacing wires are placed grounded, and chest tubes
are inserted.
3. Postoperative care
● Achieve and maintain body temperature. Monitor cardiovascular function
with serial blood pressure, hemodynamic monitoring (cardiac output, central
venous pressure, pulmonary artery wedge pressure, systemic vascular resistance),
and electrocardiogram evaluations, and maintain it with various medications.
●Monitor drainage from chest tubes in the mediastina area, and assess peripheral
pulses.
● Turn the patient every 2 hours to promote drainage. A sudden change in
drainage color to bright red, hemorrhaging that lasts more than 1 minute, or
cessation of drainage are abnormal; report them to the practitioner immediately.
● Monitor respiratory status. Maintain an open airway at all times. Promote
aggressive pulmonary hygiene.
● Inform the practitioner if the patient doesn’t awaken 1 to 3 hours after surgery.
●Report any neurologic change from the baseline value.
● Maintain adequate renal circulation. Postoperative renal insufficiency is
caused by complications of extracorporeal circulation during surgery and can
lead to the need for hemodialysis if permanent damage occurs.
● Document daily weight and fluid intake and output. Monitor serum
electrolytes frequently.
● Make the patient as comfortable as possible; for example, by administering
an opioid analgesic or positioning for comfort.
● Organize activities so that the patient can rest frequently. A structured
program of early, progressive ambulation and activity can be helpful, but must
allow for individual differences.
● Provide a program of cardiac risk modification. Encourage participation in a
cardiac rehabilitation program.
Complications of open heart surgery:-

1-Cardiovascular complication
• Bleeding: because of intra-operative anticoagulation
49
• Cardiac tamponed (describes a condition in which the heart is compressed

by blood that has accumulated in the pericardium or in the anterior
mediastinum).
• Myocardial infarction
• Ventricular dysfunction
• Cardiac arrest
2-Non cardiac complication:-
• Neurological complication (cerebrovascular accident).
• Respiratory complication (atelectasis, Plural effusion).
• Gastrointestinal complications (gastrointestinal bleeding, illus, pancreatitis,
Cholecystitis, and intestinal ischemia or infarction).
• Renal complication (acute renal failure acute tubular necrosis prescribed by
prolonged hypertension or hypovolemia).
• Sepsis (is presence of microorganisms or their toxins in the blood stream).
• Wound complication (sternal dehiscence and superficial deep wound
infection).
Application of Nursing care plan for common cardiovascular disorders

Examples of Nursing Diagnosis:
1. Decreased cardiac output Related to reduce stroke volume.
Expected outcomes
▪ Patient maintains hemodynamic stability.
▪ Patient exhibits no arrhythmias.
▪ Patient maintains adequate cardiac output.
Nursing interventions and rationales
➢ Monitor and record level of consciousness (LOC), heart rate and rhythm,
oxygen saturation (using pulse oximetry), and blood pressure at least every 4
hours, or more often if necessary.
Rationale: to detect cerebral hypoxia possibly resulting from decreased
cardiac output.
➢ Auscultate heart and breath sounds at least every 4 hours. Report abnormal
sounds as soon as they develop.
Rationale: Extra heart sounds may indicate early cardiac decompensating.
Adventitious breath sounds may indicate pulmonary congestion and decreased
cardiac output.
➢ Measure and record intake and output.
50
Rationale: Reduced urine output without reduced fluid intake may indicate
reduced renal perfusion, possibly from decreased cardiac output.
➢ Promptly treat life-threatening arrhythmias to avoid the risk of death.
➢ Weigh the patient daily before breakfast to detect fluid retention.
➢ Inspect for pedal or sacral edema to detect venous stasis and decreased
cardiac output.
2. Acute Pain May be related to Decreased myocardial blood flow,

Increased cardiac workload/oxygen consumption
Expected outcomes
Report anginal episodes decreased in frequency, duration, and severity.
Demonstrate relief of pain as evidenced by stable vital signs, absence of
muscle tension and restlessness.
Nursing interventions:-
➢ Instruct patient to notify nurse immediately when chest pain occurs.

➢ Assess and document patient response/effects of medication.
➢ Identify precipitating event, frequency, duration, intensity, and location of
pain.
➢ Observe for associated symptoms, e.g., dyspnea, nausea/vomiting,
dizziness, palpitations, desire to micturate.
➢ Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on
left side).
➢ Place patient at complete rest during anginal episodes
➢ Provide light meals. Have patient rest for 1 hr after meals.
➢ Provide supplemental oxygen as indicated.
➢ Administer anti-anginal medication(s) promptly as indicated: Nitroglycerin:
sublingual
➢ Elevate head of bed if patient is short of breath.
➢ Monitor heart rate / rhythm.
➢ Monitor vital signs every 5 min during initial anginal attack.
➢ Stay with patient who is experiencing pain or appears anxious.
3. Activity intolerance Related to an imbalance between oxygen supply and

demand.
51
Expected outcomes
▪ Patient states a desire to increase his activity level.
▪ Patient identifies controllable factors that cause fatigue.
▪ Patient demonstrates skill in conserving energy while carrying out activities
of daily living (ADLs) to tolerance level.
Nursing interventions and rationales
➢ Discuss with the patient the need for activity, which will improve physical
and psychosocial well-being.
➢ Identify activities the patient considers desirable and meaningful to enhance
their positive impact.
➢ Encourage the patient to help plan activity progression. Make sure you
include activities he considers essential to help compliance.
➢ Instruct and help the patient to alternate periods of rest and activity to
reduce the body’s oxygen demand and prevent fatigue.
➢ Identify and minimize factors that diminish exercise tolerance to help
increase activity level.
➢ Monitor physiologic responses to increased activity (including respirations,
heart rate and rhythm, and blood pressure) to ensure they return to normal a
few minutes after exercising.
➢ Teach the patient how to conserve energy while performing ADLs: for
example, sitting in a chair while dressing, wearing lightweight clothing that
fastens with Velcro or a few large buttons, and wearing slip-on shoes. These
measures reduce cellular metabolism and oxygen demand.
Nursing Management for clients with Respiratory
52
System Disorders
Outlines:
1. An overview abut anatomy and physiology of respiratory system
2. Specific laboratory & diagnostic tests to respiratory system.
3. Assessment of respiratory system disorders.
4. Common respiratory system disorders and their nursing management.
5. Nursing care plan for respiratory system disorders.
Objectives
At the end of this chapter, the student will be able to:
1. Describe the structures of the upper and lower airways
2. Enumerate functions of respiratory system.
3. Identify mechanism of breathing.
4. Identify elements of a respiratory tract assessment.
5. Discuss preparation and care of clients having respiratory diagnostic
procedures.
6. Distinguish among disorders of the respiratory system
7. Discuss common respiratory tract disorders
8. Describe nursing care for clients experiencing respiratory tract disorders
9. Relate treatment modalities for clients experiencing problems with
airway management
10. Apply nursing care plan for respiratory tract disorders.
Brief anatomy of respiratory system:

➢ The respiratory system is divided into upper and lower respiratory tract. The
upper respiratory tract consists of the nose, the Para nasal sinuses, the pharynx,
and the larynx. The lower respiratory tract includes the trachea, the bronchi, the
bronchioles, the lungs, and alveoli.
➢ The primary function of the respiratory system is gas exchange. This
consists of the transfer of oxygen and carbon dioxide between the external
environment and blood.
➢ As air enters the nose, it is warmed, filtered, and humidified. It passes through
oropharynx, laryngopharynx, and larynx, the trachea, right and left main stem
bronchi of lungs, bronchioles, alveolar ducts, and alveolar sacs.
➢ The actual air exchange occurs at the alveolar-capillary membrane.
➢ This exchange of oxygen and carbon dioxide provides the cells of the body
53
with oxygen, which is needed for cellular metabolism. It also removes the waste
product, carbon dioxide
➢ The lungs contain alveoli, small sacs on the terminal ends of bronchioles.
Alveoli are lined with surfactant, which decreases surface tension and prevents
collapse of alveoli. Capillaries located around these alveoli are the site of
exchange of oxygen and carbon dioxide.
Ventilation: Movement of air into and out of the lungs sufficient to maintain
normal arterial oxygen and carbon dioxide tensions
Respiration: process of gas exchange with the blood diffusion of O2 & CO2
across the alveolar-capillary membrane
Inspiration: Movement of oxygen into the lungs
Expiration: Removal of carbon dioxide from the lungs
Perfusion : Flow of blood in the pulmonary circulation
Diffusion: Transfer of a substance from an area of higher
concentration or pressure to an area of lower concentration
or pressure; exchange of oxygen and carbon dioxide across
the alveolar capillary membrane and at the cellular level
Explain the differences between ventilation

& respiration?
List factors impact on gas exchange?
Assessment of respiratory system disorders:
1. History :
A. Chief complaint
Local Manifestation
• Cough : chronic, paroxysmal, dry , productive
• Excessive Nasal Secretion
• Expectoration of Sputum mucoid, purulent, muco-purulent, rusty, Hemoptysis
• Pain pleuritic , inter-costal, generalized chest pain
• Dyspnea- shortness of breath
Systemic Manifestations
✓ Hypoxemia insufficient oxygenation of the blood
✓ Cyanosis bluish, grayish discoloration of skin & mucous membranes
✓ Hypoxia inadequate tissue oxygenation/ Decreased oxygen in inspired air
✓ Hypercapnia CO2 in arterial blood above normal limits
✓ Hypocapnia CO2 in arterial blood below normal limits
54
B. Past medical history

It includes health history of both patient and family members. This history
includes:
• Review patient and family data related to the upper and lower respiratory
disorders.
• Obtained data regarding common childhood diseases and vaccinations.
• Ask patient about occurrence of past respiratory diseases (tuberculosis,
bronchitis)
• Obtain information regarding medication that patient is taking.
• Ask Pt. about any respiratory alteration (dyspnea, cough, sputum
production ,etc)
For Pt. suffer from dyspnea, what are the questions must be asking them?
C. Surgical history
• Ask about any history of surgical procedure to upper and lower respiratory
system.
D. allergies
• Ask about history of allergies. Ask also about precipitating and aggravating
factors such foods, medications, fume, and dust.
E. Occupational, social history and dietary history
• Lifestyle and alcohol consumption are also very relevant to respiratory
diseases.
G. Smoking history
• Ask about type and number of smoked cigarettes currently and in the past.
Ask also about passive smoking.
2. Physical examination:
a. Inspection
◗ Observe the patient’s general appearance; note the patient’s position. Is he sitting
upright? Leaning forward?
◗ Take note of his level of awareness and general appearance. 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-
55
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
b. Palpation: for temperature, dryness, crepitus, pain & swelling
➢ Tenderness
Palpate the chest wall where patient complains of pain.
Intercostal tenderness may be due to inflamed pleura (e.g., tuberculosis).
➢ Mass / Swelling
Determine nature of any mass or swelling with: (site, temperature, tenderness,
size, consistency, surface, mobility ).
➢ Position of trachea
Normally, trachea is on midline & may slightly deviate to the right.
Abnormal tracheal deviations may be due to diseases of lungs as (effusion).
List the Common Abnormalities of the Chest?
➢ Chest expansion
Place thumbs of both hands at level of 7th rib posteriorly and extend fingers of
both hands outward over posterior or anterior chest wall.
c. Percussion
➢ Place middle finger of non-dominant hand on the chest and with the tip
of middle finger of dominant hand strike middle phalanx.
✓ Percuss the anterior and posterior chest describe any abnormal ones,
including the location and size
d. Auscultation
a. Instruct person to sit upright &take a deep breath in & out
slowly through the mouth.
b . Auscultate both sides of chest, making sure to auscultate
posteriorly, laterally, and anteriorly. Note whether the sound
occurs during inhalation, exhalation, or both
c. Compare both sides at each site.
Chest X-ray (CXR).
3. Common diagnostic and lab tests: Chest computed tomography (CT) scan.
✓ Sputum culture Chest magnetic resonance imaging
✓ Arterial blood gases (ABG). (MRI).
Bronchoscopy
✓ Pulmonary function tests (Spirometry) Lung biopsy
✓ Skin test Discussed before
✓ Thoracentesis will discuss in practical
56
Sputum studies
Purpose and description:
▪ Analysis of sputum for screening pathogenic bacteria or tumor cells.
a. Culture and sensitivity test
b. Acid-fast bacillus (AFB)
c. Cytological exam
Related nursing care:
• Explain the procedure to the client.
• Collect a sputum specimen early in the morning
• Collect the specimen in a sterile specimen container.
• Instruct the client to rinse the mouth with tap water.
• Instruct the client to take several deep breaths, cough forcefully,
and expectorate into the container.
• Collect at least 1 to 3 mL (1/2 teaspoon).
• Deliver the specimen to the laboratory as soon as possible.
• The container should be transported in a sealed plastic bag.
Arterial blood gases (ABG)
Arterial blood gasses are done to establish the oxygen, carbon dioxide, and pH
levels of the blood. If the patient has acidosis or alkalosis, it will be identified
with ABGs.
Component Measurements Normal Significance of Abnormal Scores
Range
Blood Acidity or alkalinity 7.35 - Below 7.35 = acidosis
pH of blood 7.45 Above 7.45 = alkalosis
PaC02 Partial pressure of 35 - 45 Elevated or decreased amounts
carbon dioxide in mm Hg indicate respiratory cause of acidosis
arterial blood or alkalosis; also a compensatory
mechanism
P02 Partial pressure of 80 - Below 80 indicates poor ventilation
oxygen in arterial 100 and gas exchange in lungs
blood mm Hg
HC03 Amount of 21 - 28 Elevated or decreased amounts indicate
bicarbonate ion in mEq/L a metabolic cause of acidosis or
arterial blood alkalosis; also compensatory mechanism
Sa02 Saturation of 95 - Decreased amounts indicate poor
oxygen in arterial 100 % ventilation or gas exchange in the lungs;
57
blood; amount of saturations below 70% are considered

oxygen hemoglobin life threatening
is carrying
compared to amount
it is capable of
carrying
Blood pH levels may be affected by any number of disease processes

(respiratory, renal, malnutrition, electrolyte imbalance, endocrine, or
neurologic).
Nursing Actions
✓ Perform an arterial puncture using surgical aseptic technique, and collect a
specimen into a heparinized syringe.
✓ Place the collected and capped specimen into a basin of ice and water to
preserve pH levels and oxygen pressure. The specimen should be transported to
the laboratory immediately.
Post procedure
➢ Immediately after an arterial puncture, hold direct pressure over the site for
at least 5 min.
➢ Pressure must be maintained for at least 20 min if the client is receiving
anticoagulant therapy. Ensure that bleeding has stopped prior to removing direct
pressure.
➢ Monitor the ABG sampling site for bleeding, loss of pulse, swelling, and
changes in temperature and color.
➢ Document all interventions and client response.
➢ Report results to the provider as soon as they are available.
➢ Administer oxygen as prescribed
Performing Pulse Oximetry:
✓ Pulse oximetry is a noninvasive method that uses a light beam to measure
the oxygen content of hemoglobin (SaO2).
✓ The monitoring device attaches to the client’s earlobe or fingertip and
connects to the oximeter monitor
• Explain the procedure to the client.
• Assess potential sensor sites for quality of circulation, edema, tremor, restlessness,
nail polish, or artificial nails.
• Review the medical history for data indicating vascular or other pathology
(e.g., anemia, carbon monoxide poisoning).
58
• Check prescribed medications for vasoconstrictive effects.

• Assess client’s understanding of pulse oximetry.
• Position the sensor so that the light emission is directly opposite the detector.
• Observe the numeric display, audible sound, or waveform on the oximeter.
• Set the high and low alarms according to the manufacturer’s directions.
List conditions that affect ABGs?
Pulmonary Function Tests (PFTs)

- Pulmonary function tests determine lung function and breathing difficulties.
- PFTs measure lung volumes and capacities, diffusion capacity, gas
exchange, flow rates, airway resistance along with distribution of ventilation.
- Helpful in identifying clients for lung disease.
- Commonly performed for clients who have dyspnea.
- Performed before surgical procedures to identify clients with respiratory risks.
- If client is smoker, instruct client not to smoke 6 to 8 hr. prior to testing.
- If a client uses inhalers, withhold 4 to 6 hr. prior to testing.
▪ Lung function test can be used to:
a. Evaluate pulmonary function.
b. Evaluate response to treatment such as bronchodilator.
c. Differentiate diagnosis of pulmonary disease.
d. Determine the cause of shortness of breath.
e. Detect airways narrowing.
▪ Common values that may be measured during pulmonary function testing
include:
 Tidal volume (TV): Amount of air inhaled or exhaled during normal
breathing.
 Inspiratory reserve volume (IRV): Maximum amount of air that can be
inhaled after a normal inspiration.
 Expiratory reserve volume (ERV): Maximum amount of air that can be
exhaled following a normal expiration.
 Residual volume (RV): Amount of air remaining in the lungs after maximal
exhalation.
 Total lung capacity (TLC): Amount of air contained in lungs after a
maximal inspiration.
 Vital capacity (VC): Total amount of air than can be exhaled after maximal
inspiration. It is calculated by adding TV+IRV+ERV.
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 Inspiratory capacity (IC): Total amount of air that can be inhaled following
a normal quiet exhalation. It is calculated by adding TV+IRV.
 Functional residual capacity (FRC): Amount of air remaining in lungs after
normal expiration. It is calculated by adding RV+ERV.
 Forced vital capacity (FVC): Amount of air that can be exhaled forcefully
and quickly after maximum inspiration.
 Minute volume (MV): Total amount of air breathed per minute.
Spirometry procedure
▪ It measures the amount of air breathed in and out and how quickly the air is
inhaled and expelled from the lungs.
▪ During a spirometry test, patient takes a deep breath in and then blows out as
forcefully as possible into a mouthpiece attached to a recording device
(spirometer).
▪ Information collected by the spirometer may be printed out on a chart called a
spirogram.
Related nursing care:
❖ Explain procedure to patient and ask patient not to smoke, exercise
vigorously.
❖ Ask patient if he takes any medication for lung problems.
❖ Ask patient to avoid eating a heavy meal before the test because a full
stomach may prevent lungs from fully expanding.
❖ Instruct the patient that it is normal to feel shortness of breath after the test.
❖ Inform patient to wear loose clothing that does not restrict breathing.
❖ Ask patient to wear denture if he has during the test to help him to form a
tight seal around mouthpiece of the spirometer.
Skin Test (Mantoux Test)
Purpose and description:
▪ It is known as Tuberculin skin test or purified protein derivative (PPD) test. It
is a screen test for tuberculosis. Identify allergic reactions to antigens (i.e.,
Tuberculosis)
▪ This test is done by injecting 0.1 ml of PPD intra-dermal into the inner surface
of forearm. Skin test reaction should be evaluated in between 48 to 72 hours after
injection. Measure induration to determine positive reaction.
Procedure:
60
➢ Draw up 0.1 mL of intermediate-strength PPD.

in a tuberculin syringe (1=2-inch 26- to 27-gauge needle)
➢ Prepare the injection site on the inner aspect of the forearm,
approximately halfway between the elbow and wrist.
➢ Hold the syringe bevel up, almost parallel to the forearm
➢ Inject the PPD to form a pronounced wheal, which indicates
proper intradermal injection
➢ Record the site, name of PPD, strength, lot number, and date
and time of test
➢ Read the test site 48 to 72 hours after injection by palpating the site for
induration. If induration is present, measure it at its greatest width
➢ Erythema (redness) without induration is not significant.
➢ If erythema is present with induration, read the induration only.
Interpret the test results as follows:
➢ Negative reaction—0-to 4-mm induration; no follow-up needed
➢ Doubtful reaction—5- to 9-mm induration; if the client is aware of contact
with someone with active tuberculosis, this reaction is seen as significant
➢ Positive reaction—10 mm or greater induration
List the specific NI to lung biopsy, Bronchoscopy& Thoracentesis?
Common Respiratory System Disorders

Infectious and Inflammatory Disorders
Rhinitis is inflammation of the nasal mucous membranes. It is referred to as the
common cold, that rapidly spread by inhalation of droplets and direct contact with
contaminated articles of infected person. Be caused by infection (viral or bacterial)
.
Sinusitis is inflammation of the sinuses, usually the maxillary or frontal sinus
Pharyngitis, inflammation of the throat, is often associated with rhinitis
Allergic rhinitis is a hypersensitive reaction to allergens, such as pollen, dust,
animal dander, or food
Clinical Symptoms
▪sneezing ▪sore throat ▪watery eyes ▪cough ▪headache
▪rhinorrhea (clear nasal discharge) ▪low-grade fever
▪muscles ach and malaise ▪red, inflamed, swollen nasal mucosa
+ Tenderness to palpation of forehead in presence of Sinusitis
+ Difficulty swallowing in presence of Pharyngitis
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✓ With the common cold, these symptoms continue for 5 to 14 days.

✓ A sustained elevated temperature suggests a bacterial infection
✓ Symptoms of allergic rhinitis will persist as long as the client is exposed to
the specific allergen.
Diagnostic Tests
➢ skin testing to determine allergens.
➢ A blood test for IgE. Antibodies
Nursing Interventions
- Treatment of viral rhinitis is symptomatic (antipyretics, decongestants ).
- Because most colds are caused by viruses, antibiotics are not effective.
Discuss with Pt. , antibiotics used only for identified bacterial infection
- Teach the patient that rest and fluids are the most effective treatment.
- Preventive measures: hand washing and avoidance of individuals with
influenza.
- Immunization is recommended
- The most common complication is pneumonia
- Saline gargles are useful for a sore throat
- For allergic rhinitis, antihistamines
Teach client to maintaining
➢ A healthy lifestyle of adequate rest and sleep
➢ Eating a well-balanced diet
➢ Rest as much as possible.
➢ Increase fluid intake (at least 2,000 mL/day) to assist in liquefying secretions.
➢ Use a vaporizer to help liquefy secretions.
➢ Blow nose with mouth open slightly to equalize pressure.
➢ Wash hands frequently to avoid spreading infection.
➢ Be tested for allergen sensitivity.
➢ Avoid specific allergens.
➢ Use antihistamines and decongestants as ordered.
➢ Promote proper disposal of tissues and use of cough etiquette (sneeze or
cough into tissue, elbow or shoulder and not the hands).
➢ Encourage cessation of tobacco use in any form
Influenza
62
➢ Seasonal influenza or “flu” occurs as an epidemic, usually in the fall and

winter months, it is an acute respiratory disease
➢ Pandemic influenza refers to a viral infection among animals or birds that
has mutated and is becoming highly infectious to humans: H1N1 (“swine flu”)
and H5N1 (“avian flu”).
Clinical Manifestations:
Incubation 1–4 days
period
Onset Sudden Abrupt onset of fever and chills
Severe headache Muscle aches
Progression Anorexia Weakness, apathy, malaise
Severe diarrhea , cough and Hypoxia (avian flu)
Sneezing Sore throat, laryngitis Dry cough
Nasal discharge—rhinitis Conjunctival irritation
Duration Fever may persist for 3 days
Other symptoms usually continue for 7–10 days.
Cough may persist longer
Period of One day before symptoms begin through 5 days after the
contagion onset of illness
Differentiating Upper Respiratory Tract Infections
Nursing Interventions (hospitalized clients)
63
• Maintain airborne and contact precautions

• Provide saline gargles.
• Monitor hydration status, intake and output.
• Administer fluid therapy as prescribed by the provider.
• Monitor respiratory status.
• Encourage clients to begin antiviral medications within 24 to 48 hr. after the
onset of manifestations
• Vaccination is encouraged for everyone over 6 months of age
• Clients who have a history of pneumonia, chronic medical conditions, and
those over age 65, pregnant women, and health care providers are at higher risk
and require vaccination
• Reduce the risk for spreading viruses by thoroughly washing hands
• Increase fluid intake, rest and stay home from work or school.
• Avoid travel to areas where pandemic influenza is identified.
• Be aware of public health announcements and activation of the early
warning system by public health officials
Tonsillitis & Adenoiditis
➢ Thy are masses of lymphoid tissue. The tonsils lie on each side of the
oropharynx. Adenoids, located at the back of the nasal-pharynx.
➢ They filter microorganisms to protect the lungs from infection
➢ Tonsillitis is inflammation of the tonsils
➢ Adenoiditis is inflammation of the adenoids.
➢ Chronic tonsillitis infection leads to enlargement and partial upper airway
obstruction.
➢ Chronic adenoidal infection can result in acute or chronic infection in the
middle ear (otitis media)
Causes:
1. Must common is Group A streptococcus Bacteria 2. Viral infections
Clinical manifestations:
sore throat difficulty or pain on swallowing fever, and malaise
Enlarged adenoids : nasal obstruction noisy breathing & snoring,
Visual examination reveals enlarged and reddened tonsils
White patches appear on the tonsils if group A streptococci are the cause
A throat culture and sensitivity test determines the causative microorganism
and appropriate antibiotic therapy.
Diagnostic tests:
64
Medical history and physical examination. CBC. Throat culture

Medical management:
▪ Treatment of viral tonsillitis involves rest and symptom relief
▪ If bacterial infection is confirmed by throat culture, antibiotics will be
prescribed.
▪ Gargling with salt water (half teaspoon of salt to a cup of warm water)
several times a day may relieve sore throat.
▪ Throat lozenges containing ingredients which are cooling, anesthetic,
antiseptic, and anti-inflammatory.
▪ Corticosteroids such as dexamethasone or prednisone may be prescribed to
reduce inflammation and swelling particularly when it is making difficulty in
swallowing and breathing.
Surgical management:
▪ A peri-tonsillar abscess should be drained either by needle aspiration, or
incision
▪ Tonsillectomy &adenoidectomy operative removal of the tonsils &
adenoid
Nursing management:
❖ After the tonsillectomy, Pt. is maintained in a semi-Fowler’s position
❖ Monitor the patient for bleeding and airway patency
❖ Encourage cold fluids.
❖ Red-colored drinks are avoided
❖ Keep suction equipment available
❖ Encourage patient to drink plenty of fluids to keep throat moist and prevent
dehydration.
❖ Ask patient to gargle with warm saline s several times a day to soothe a sore
throat.
❖ Give patient throat lozenges as prescribed to relieve sore throat.
❖ Instruct patient to use a humidifier in his room.
❖ Give patient analgesic and antipyretic as prescribed to relieve pain and fever.
Perform suctioning if necessary.
❖ Observe patient for complications and instruct him about signs and symptoms
of complications which need physician attention.
❖ At discharge, verbal and written instructions regarding foods to avoid,
smoking cessation, and good oral hygiene are given to patient.
Client and Family Teaching after Tonsillectomy and Adenoidectomy
65
➢ Report any signs of bleeding to the physician—this is particularly important

in the first 12 to 24 hours, and then 7 to10 days after surgery as the throat heals.
➢ Gently gargle with warm saline or an alkaline mouthwash to assist in
removing thick mucus.
➢ Maintain a liquid and very soft diet for several days after surgery—avoid
spicy foods and rough-textured foods
What is the most serious complication of a tonsillectomy? Why? What are
preventive measures & NI?
Epistaxis
Nose bleed either from the anterior or posterior
Etiology
o Dry, cracked mucous membranes
o Trauma, forceful nose blowing
o Nose picking
o Reduces the blood’s ability to clot, e.g. hemophilia or leukemia,
anticoagulant therapy, or chemotherapy
o Cocaine use & HTN
o Rheumatic fever
o Foreign bodies in the nose
Inspection of the nares, using a nasal speculum and light, reveals the area of
bleeding.
Therapeutic & Nursing Interventions

• Direct continuous pressure to the nares for 5 to 10 minutes with the client’s
head tilted slightly forward
• Application of ice packs to the nose & client reassurance
• Cauterization with silver nitrate, electro-cautery, or application of a topical
vasoconstrictor such as 1:1000 epinephrine
• Nasal packing with a cotton tampon
• Pressure with a balloon inflated catheter: inserted posteriorly for a minimum
of 48 hr.
• Monitor bleeding, noting the amount and color of drainage.
• Monitor vital signs and hemoglobin level
• Inspect the back of the throat for bleeding
• Monitor the patient for airway obstruction from slipped packing.
66
• Know how to remove the packing in case of emergency.

• Institute comfort measures
• Caution the patient not to blow the nose for up to 48 hours & avoid bending
• If the cause of the bleeding is dryness, teach the patient to use nasal saline
spray or a room humidifier.
Client and Family Teaching Epistaxis &Surgery for Nasal Obstruction

✓ Apply pressure to the nares with two fingers. Breathe through the mouth; sit
with the head tipped forward slightly to prevent blood from running down the
throat.
✓ Do not swallow blood; spit out any blood oozing from the area. If blood has
been swallowed, the client may see diarrhea and black, tarry stools for a few
days.
✓ Do not blow the nose.
✓ Do not attempt to remove nasal packing
✓ Take pain medications as ordered.
✓ Do not use aspirin or ibuprofen products until bleeding is controlled.
✓ Notify the physician if bleeding persists or if any respiratory problems develop.
✓ Do not bend over.
✓ Do not blow nose.
✓ If sneezing, keep mouth open.
✓ Avoid contact with nose or surrounding tissue.
✓ Keep head elevated with an extra pillow when lying down.
✓ Avoid heavy lifting.
The Heimlich Maneuver for Dislodging an Airway Obstruction practical
Sleep Apnea Syndrome
Characterized by frequent, brief episodes of respiratory standstill during sleep.
Classified according to respiratory muscle effort:
• Central—air movement is absent secondary to absence of ventilatory efforts;
the brain malfunctions in its normal signal to breathe.
• Obstructive—air movement is absent secondary to pharyngeal obstruction;
chest and abdominal movements are present; most common form.
• Mixed—combination of central and obstructive sleep apnea in one apneic
episode
Risk factors:
67
•Overweight •People over 65 years

•Women are more likely to have sleep apnea after menopause
• Heredity, and having smaller airways, allergies, or conditions contribute to
increased airway congestion
• Cigarette smokers •Large neck circumference
•Condition that reduces pharyngeal muscle tone: neuromuscular disease, use of
sedative or hypnotic medications, and frequent and heavy intake of alcohol
Symptoms of Sleep Apnea
• Restless sleep • Morning headaches
• Loud, heavy snoring—often interrupted by silence and then gasps
• Excessive daytime sleepiness—can occur while driving or working
• Loss of energy • Trouble concentrating
• Irritability • Forgetfulness
• Mood or behavior changes, including anxiety or depression
• Decreased interest in sex • Systemic hypertension
• Dysrhythmias • Enuresis
To determine the nature of the sleep apnea, clients undergo
polysomnography
Consists of monitor the client’s respiratory and cardiac status while he or she is
asleep. Specifically, a polysomnogram records a client’s brain activity, eye
movement, muscle movement, respiratory and heart rates; the amount of air that
moves in and out of the lungs; and the oxygen concentration in the blood.
Therapeutic & Nursing Interventions

Treatment for sleep apnea focuses on :
✓ improving the quality of nighttime sleep and daytime wakefulness
✓ reducing risks for cardiovascular problems
Based on severity change their lifestyle:

• Losing weight
• Quitting smoking
• Eliminating alcohol or other medications that depress respirations and
contribute to an inability to maintain an open airway
• Using special pillows to keep clients in a side-lying position when sleeping
• Using allergy medications or saline nasal spray to reduce congestion and
68
dryness
•An oral appliance that assists in adjusting the lower jaw and tongue so that
the airway remains open while the client is sleeping
• Use of noninvasive positive pressure ventilation (NPPV)
• If the cause is obstructive, surgical procedures are done to relieve the obstruction
• Tracheostomy is a successful treatment. Clients may reject this option
• Low flow oxygen at night to relieve hypoxemia
• Client reassurance
• Appropriate counseling for weight loss or alcohol and substance abuse issues
Tracheotomy will discuss details in practical
Acute Bronchitis
It is an inflammation of the mucous membranes that line the major bronchi
and their branches.
Tracheobronchitis is an inflammatory process involves the bronchi and trachea.
Bronchiectasis is a dilation of the bronchial airways found in clients with
COPD
Causes & risk factors :
- Viral infections most commonly
- Clients with viral URIs are more vulnerable
- Fungal infections such as Aspergillus
- Chemical irritation from noxious gas & air contaminants
- Sputum cultures identify the causative bacterial organisms
❖ Initially include: fever, chills, malaise, headache, & a dry, irritating,
nonproductive cough.
❖ Later: the cough produces mucopurulent sputum, blood-streaked
❖ Clients experience paroxysmal attacks of coughing &report wheezing.
❖ Crackles may be heard on chest auscultation.
Diagnostic tests:
✓ Medical history and physical examination.
✓ sputum sample is collected for culture and sensitivity
✓ CBCs , ABGS , Pulse oximetry & Spirometry test
✓ Chest X-ray to detect additional pathology, such as pneumonia
69
Therapeutic & Nursing Interventions:

o Keeping the airways clear of secretions
o Measures to prevent infection
o Bed rest, antipyretics, expectorants, antitussives (drugs used to prevent
coughing), and increased fluids.
o Broad-spectrum antibiotic when sputum culture results are available
o Auscultate breath sounds and monitors vital signs every 4 hours
o Encourages the client to cough and deep breathe every 2 hours
o Teaches the client to wash the hands frequently
o Cover the mouth when sneezing and coughing
o Discard soiled tissues in a plastic bag
o Avoid sharing eating utensils and personal articles with others
Nursing management:
❖ Nursing management for both types of bronchiolitis, include:
❖ Monitor respiratory rate, depth, and pattern, use of accessory muscles.
❖ Auscultate breath sounds.
❖ Provide supplemental humidified oxygen as prescribed.
❖ Monitor ABG and oxygen saturation level.
❖ Monitor for apnea, changes in mental status, restlessness and cyanosis.
❖ Assess vital sign as ordered.
❖ Position patient in semi fowler's position to enhance breathing.
❖ Instruct patient to use pursed lip breathing.
❖ Nasal suction to clear secretions.
❖ Instill normal saline drops as prescribed to relieve nasal congestion.
❖ Maintain IV fluids as prescribed.
❖ Encourage fluids intake as tolerated to prevent dehydration.
❖ Measure intake and output.
❖ Give antipyretic as prescribed to reduce fever and discomfort.
❖ Give bronchodilator as prescribed.
❖ Give antiviral medications (such as Ribavirin) as prescribed.
❖ Encourage bed rest.
❖ Keep smoke-free environment.
❖ Monitor patient for side effects of corticosteroids.
❖ Assist in intubation if mechanical ventilation is indicated.
Pneumonia
70
Definition:
Pneumonia is an inflammatory process affecting the
bronchioles and alveoli ( entire lungs).
Inflammation in the lung tissue, causing damage to mucous
and alveolar membranes, leads to the development of
edema and exudate, which fills the alveoli & reduces the
surface area available for exchange of carbon dioxide
and oxygen.
There are different classification of pneumonia & causes:

a. Affected area
-lobar pneumonia affects only one lobe
-bronchopneumonia generalized pneumonia
b. Etiology
-Bacterial pneumonias are referred to as typical pneumonias
-Viral Pneumonia. As a complication to Influenza viruses
-Fungal Pneumonia , Pneumocystis : pneumonia in patients with AIDS.
-Nosocomial pneumonia (hospital acquired) infection after hospitalized
patients
-Aspiration Pneumonia : aspiration of foreign substances
-Ventilator :associated Pneumonia, develops in intubated Pt.
-Hypostatic Pneumonia. Pts. who have hypo ventilate because of bed rest, or
shallow respirations.
-Chemical Pneumonia. Inhalation of toxic chemicals
Risk Factor
 People with suppressed immune system.
 People who drink excessive alcohol and Smoking.
 Elderly people and prolonged immobility.
 People who have had a recent viral infection(influenza).
 People with chronic diseases such as (COPD , diabetes, heart failure) .
 Patients in hospital particularly on a ventilator
 Impaired LOC, cough or gag reflex & seizures
— Clinical manifestations: Symptoms vary for the different types of

pneumonia
71
• Fever and chills.

• Tachycardia and tachypnea.
• Shortness of breath
• Productive cough of blood-tinged or purulent sputum.
• Chest pain which increase with breathing or coughing.
• Malaise and altered mental status.
• Nausea or poor appetite may be present.
• Auscultation of the chest ( wheezing, crackles, & decreased breath sounds)
• The nail beds, lips, & oral mucosa may be cyanotic due to impaired oxygenation.
Viral pneumonia , blood cultures are sterile, sputum more copious, chills are less
and pulse and respiratory rates are slow
Diagnostic tests:
➢ Physical examination.
➢ Chest x-ray.
➢ ABG analysis.
➢ CBC.
➢ Blood culture.
➢ Sputum and blood cultures before antibiotics
➢ Bronchoscopy.
Medical Management:
▪ Administer humidified oxygen as needed.
▪ Administer antibiotics for bacterial infections.
▪ Administer bronchodilators, analgesics, antipyretics, and cough
expectorants or suppressants, depending on the nature of cough as order
▪ Administer bronchodilators to keep airways open and enhance airflow
Nursing Management:
❖ Antibiotic therapy for bacterial pneumonia
❖ Hydration to thin secretions / increase fluid intake if not contraindication
❖ Supplemental oxygen to alleviate hypoxemia,
❖ Bed rest, chest physical therapy and postural drainage
❖ Auscultates lung sounds &monitors vital signs every 4 hours
❖ Checks oxygenation status with pulse oximetry and monitors ABGs.
❖ Assessments of cough and sputum production
72
❖ Put PT. in the semi-Fowler’s position

❖ Document color, amount, and consistency of sputum
❖ Encourages the client to cough and deep breathe every 2 hr. & ambulate .
❖ Monitors fluid intake and output, skin turgor, vital signs, and serum
electrolytes
❖ Vaccination against pneumococcal and influenza
Teach patient about:

a. Avoid smoking, excessive alcohol intake, and heavy exercises.
b. How to use incentive spirometer.
c. Importance of rest, fluid intake, and nutrition.
Preventing Pneumonia
• Promote coughing and expectoration
• Change position frequently
• Encourage deep-breathing and coughing exercises
• Administer chest physical therapy as indicated.
• Suction client if he or she cannot expectorate.
• Prevent aspiration in clients at risk.
• Prevent infections.
• Cleanse respiratory equipment on a routine basis.
• Promote frequent oral hygiene.
• Administer sedatives carefully to avoid respiratory depression.
• Encourage client to stop smoking
Complications of pneumonia include
✓ Congestive Heart Failure (CHF)
✓ Empyema (Collection Of Pus In The Pleural Cavity)
✓ Pleurisy (Inflammation Of The Pleura),
✓ Septicemia (Infective Microorganisms In The Blood) & secondary infections
✓ Atelectasis, Hypotension, And Shock
Tuberculosis
Definition:
73
▪ It is an infectious disease caused by mycobacterium tuberculosis (M Tb)

which usually affects the lungs but it also may affect any other organ of the body
such as the kidneys, liver, brain, and bone.
✓ M. Tb can live in dark places in dried sputum for months, but a few hours in
direct sunlight, heat, or ultraviolet light destroys it.
▪ It is spread by inhalation of the tuberculosis bacilli (airborne)from
respiratory droplets of an infected person.
▪ Pasteurization, a process widely used in milk and milk products to prevent
the spread of TB
▪ TB is characterized by stages of early infection (primary TB), latency, and
recurrence after the primary disease (secondary TB, reactivation of the initial
infection).
▪ Fibrosis and calcification creates a scar around the tubercle. This is referred
to Ghon complex and is visible on radiography
Person at risk:
 Elderly, infants and health care workers.
 Immunocompromised status (HIV infection kidney disease, & diabetes).
 Close contact with people suffering from TB.
 Living in crowded or unsanitary living conditions (homelessness)
 Lower socioeconomic status
 Treatment which weakens immune system (chemotherapy or long-term
steroids).
• Dyspnea and chest pain from spread of the infection to the pleurae
• Persistent cough which lasts 3 weeks or more
• Shortness of breath due to lung changes
• Nausea , fatigue and loss of appetite (anorexia) leads to weight loss
• Sputum stained with blood (Hemoptysis) & purulent sputum.
• Low-grade fever due to infection, and chills
• Sweats in the late afternoon, and night
Diagnostic test:
✓ Medical history and physical examination
✓ Mantoux test (PPD)
✓ Chest x-ray : detect active lesions in the lungs
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✓ Acid-fast bacilli smear and culture (Sputum examination)

A positive acid-fast test suggests an active infection.
The diagnosis is confirmed by a positive culture for Mycobacterium
tuberculosis.
Nursing Actions
➢ Obtain three early-morning sputum samples.
➢ Wear personal protective equipment when obtaining specimens.
➢ Samples should be obtained in a negative airflow room.
✓ CT scan, MRI, and biopsy when TB affects organs other than lungs.
✓ Quanti FERON-TB Gold : Blood test that detects release of interferon-
gamma (IFN-g) in fresh heparinized whole blood from sensitized people
• TB diagnosis should be considered for any client who has :
Persistent cough lasting longer than 3 weeks, chest pain, weakness, weight loss,
anorexia, haemoptysis, dyspnea, fever, night sweats, or chills.
Prevention
➢ Maintains clean, well-ventilated living areas
➢ If TB suspected in Pt. at hospital respiratory isolation , prevent spread
➢ Patient must wear a mask when travel.
➢ Staff should wear special high-efficiency filtration masks, gowns, gloves, &
goggles, are used when contact with sputum
➢ A vaccine is available
Complications
✓ Spread throughout the body can result in pleurisy, pericarditis, peritonitis,
meningitis, bone and joint infections, genitourinary or gastrointestinal infection,
&infection of many other organs.
Medical management:
✓ Combined therapy with two or more drugs decreases the likelihood of drug
resistance, increases action of the drugs, and lessens the risk for toxic drug
reactions.
1. For latent TB infection:
▪ Treatment for latent TB generally involves either taking a combination of
(Rifampicin and Isoniazid) for three months. In addition, vitamin B6.
2. For active TB disease:
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▪ Patients with active TB are initially placed on respiratory isolation,

combination of many anti-TB drugs for 6 – 9 months
▪ Common course of treatment include:
a. Four drugs (Rifampicin, Isoniazid, Ethambutol, and Pyrazinamide) are
used for the first 2 months.
b. Two drugs (Rifampicin and Isoniazid) are used for the next 4 to 6 months.
3. For Multi drug-resistant TB
▪ Resistance is caused by inconsistent or partial treatment. It is usually occurs
because patients tend to stop taking their medication once they start to feel better.
▪ It often requires special TB drugs. Several antibiotics such as (Capreomycin,
Kanamycin, and Amikacin) are given every day for up to two years.
➢ Repeated sputum cultures are typically taken to see whether the treatment
is effective or not.
Nursing management:
❖ Isolate patient in properly ventilated room and maintain TB precautions until
three consecutive sputum cultures have tested negative
✓ Wear an N95 or HEPA respirator (Specific mask protection)
✓ Place the client in a negative airflow room, and implement airborne
precautions
✓ Use barrier protection
✓ Have the client wear an N95 or HEPA respirator if transportation to another
department
✓ Teach the client to cough and expectorate sputum into tissues, & dispose
properly
❖ Encourage fluid intake and a well-balanced diet for adequate caloric intake
❖ Encourage foods that are rich in protein, iron, and vitamin C
❖ Provide emotional support
❖ Monitor patient's weight weekly
❖ Administer medication as prescribed
❖ Watch for adverse reactions of medications
❖ If patient receives Ethambutol, watch for signs of optic neuritis, instruct
client to report changes in vision immediately. Check patient's vision monthly
and give this medication with food, not be given to children younger than 13
years of age .
❖ If patient receives Rifampicin, watch for signs of observe for :
a. Hepatotoxicity and purpura & hemoptysis.
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b. Reassure patient that the drug temporarily makes body secretions E.G. urine
appears orange
c. Advise the client to report yellowing of the skin, pain or swelling of joints,
loss of appetite, or malaise immediately.
d. Inform the client this medication may interfere with the efficacy of oral
contraceptive
❖ Perform chest physiotherapy to patient several times per day
❖ Exposed family members should be tested for TB
❖ Instruct the client to cover mouth and nose when coughing or sneezing
Teach patient and his family about:
a. How to perform chest physiotherapy.
b. Coughing and deep breathing exercises.
c. Adverse reactions of his medications and importance of report them
immediately to physician.
d. Importance of regular follow up examinations.
e. Importance of eating small frequent, well balanced, and high calorie diet.
f. Signs and symptoms of recurring TB
g. Instruct the client to continue with follow-up care for 1 full year
❖ Teach patient respiratory precautions as:
a. Practice frequent hand washing.
b. Wear a mask when in contact with other people.
c. Cover mouth and nose with fresh tissues when coughing and sneezing.
d. Correct handling and disposing of sputum in plastic bag.
e. Proper dispose of tissues in plastic bags.
❖ Encourage patient to stop smoking.
❖ Evaluate patient's lifestyle, living conditions, financial status.
❖ Monitor patient's compliance with therapeutic regimen.
Chronic Obstructive Pulmonary Disease(COPD)
Definition:
COPD is a group of progressive irreversible lung diseases
It characterized by difficulty exhaling because of airways
are narrowed or blocked by inflammation and mucus.
More effort is required to push air out through
obstructed airways
Atelectasis the collapse of alveoli
Bronchiectasis is characterized by chronic infection and
irreversible dilatation of the bronchi and bronchioles.
▪Chronic bronchitis and emphysema are the two most common conditions that
contribute to COPD.
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Etiology & Risk factors:

➢ Cigarette smoking
➢ Advanced age (affects middle age to older adults)
➢ Long-term exposure to lung irritants such as air pollution
➢ Genetic disorder as alpha-1-antitrypsin deficiency.
Clinical manifestations: Symptoms be worse in the winter months: Why?
✓ Chronic dyspnea
✓ Dyspnea upon exertion
✓ Productive cough that is most severe upon rising in the morning
✓ Hypoxemia
✓ Crackles and wheezes
✓ Rapid and shallow respirations
✓ Use of accessory muscles
✓ Barrel chest ( increased chest diameter with emphysema)
✓ Hyper resonance on percussion due to “trapped air”
(with emphysema)
✓ Irregular breathing pattern
✓ Thin extremities and enlarged neck muscles
✓ Dependent edema secondary to right-sided heart failure
✓ Clubbing of fingers and toes
✓ Pallor and cyanosis of nail beds and mucous membranes (late stages of the
disease)
✓ Decreased oxygen saturation levels (expected reference range is 95% to
100%)
Complications:
Right-sided heart failure (cor-pulmonale): Air trapping, airway collapse, and
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stiff alveoli lead to increased pulmonary pressures & RSHF
Diagnostic tests:
✓ Medical history and Physical examination.
✓ CBCs, increased hematocrit level is due to low oxygenation levels
✓ Chest x-ray, Chest CT scan
✓ ABG analysis (Hypoxemia, Hypercarbia , Respiratory acidosis, metabolic
alkalosis)
✓ Pulse oximetry, sputum culture & Serum electrolytes
✓ Lung function tests: Spirometry is the main test for COPD
✓ AAT (alpha1 antitrypsin) levels used to assess for AAT deficiency
Medical Management:
▪ Smoking cessation is the most essential measure
▪ Bronchodilators to relax airway muscles and reduce airway obstruction
Nursing consideration:
✓ Monitor the client’s serum levels for toxicity (tachycardia, nausea, and
diarrhea)
✓ Encourage client to increase fluid intake, report headaches, or blurred vision
▪ Supplemental oxygen therapy
▪ Chest physiotherapy and postural drainage
▪ Mucolytic and expectorants to liquefy secretions
▪ Antibiotics to treat respiratory infection
▪ Anti-inflammatory agents (Corticosteroids): to decrease airway inflammation
Nursing Considerations
• Watch the client for a decrease in immunity function.
• Monitor the client for hyperglycemia.
• Advise the client to report black, tarry stools.
• Observe the client for fluid retention and weight gain
▪ Mucolytic Agents, help thin secretions making it easier for the client to expel
▪ Intubations and mechanical ventilation if there is respiratory failure.
▪ Teach client Pursed-lip breathing technique:
➢ Take a breath in through the nose and out through the lips/mouth.
➢ Do not puff the cheeks.
➢ Take breaths deep and slow
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▪ Teach client Incentive spirometry :

1. Sit upright unless contraindicated
2. Mark the goal for inhalation
3. Exhale normally
4. Place mouthpiece in mouth, sealing lips around it
5. Inhale slowly until predetermined volume has been reached
6. Hold breath for 2 to 6 seconds
7. Exhale normally
8. Repeat the exercise 10 to 20 times per hour while awake, or as ordered.
▪ Clients who have COPD may need 2 to 4 L/min of oxygen via nasal cannula
Surgical Management:
▪ Surgeries are mainly related to emphysema include:
a. Bullectomy.
b. Lung volume reduction surgery
c. Lung transplant might be an option for patients who have very severe COPD.
Nursing Management:
❖ Check patient's ABGs
❖ Administer humidified oxygen as needed
❖ Encourage smoking cessation
❖ Inform patient to avoid respiratory irritants
❖ Keep patient’s room as dust free as possible
❖ Instruct patient to keep windows closed during windy days
❖ Chest physiotherapy uses percussion and vibration to mobilize secretions
❖ Encourage breathing and coughing exercises & Encourage rest periods
❖ Position patient in semi to high fowler's position to promote lung expansion
❖ Encourage oral fluids intake 2 to 3 L/day to liquefy of secretions
❖ Administer prescribed medications
❖ Encourage frequent small meals as large meals require more energy to digest
❖ Encourage soft, high-protein, high-calorie diet
❖ Monitor body weight
❖ Encourage patient to obtain influenza and pneumonia vaccines at prescribed
times
❖ Home Care:
a. Accept patient's feeling about lifelong restriction of activities
b. Discuss with patient medication schedule and side effects of prescribed
medications.
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c. Review with family and patient signs and symptoms of upper respiratory
tract infection.
d. Instruct patient to inform physician if warning signs occurs as:
▪ Fever.
▪ Changes in sputum color (yellow, green, or blood tinged).
▪ Increasing shortness of breath.
▪ Increasing coughing and wheezing.
Chronic Bronchitis
- Chronic bronchitis is similar to acute bronchitis, with symptoms occurring
for at least 3 months of the year for 2 consecutive years
- The mucus-producing glands in the airways become hypertrophied,
producing excessive thick, tenacious mucus, which obstructs airways
Bronchial Asthma
Definition:
▪ Asthma is characterized by inflammation of the mucosal lining of the
bronchial tree and spasm of the bronchial smooth muscles (bronchospasm).
▪ It is characterized by exacerbations and remissions. Between attacks the
client is generally asymptomatic.
▪ Asthma affects people of all ages but it most often starts during childhood.
Risk Factors and Etiology :

1. Genetic factors( inherited)
2. Unknown cause
3. Allergens such as pollen, foods, medications, animal dander, air pollution,
molds, or dust mites.
4. Environmental irritants, smoking, and respiratory or sinus infection,
emotional upset and exercise common allergen in adult.
5. Weather: sudden changes in weather
6. Expressing strong emotions.
7. Some medications: like beta blockers and aspirin.
8. Respiratory infections such as colds, flu, sore throats.
There are two types of asthma:
1. Allergic asthma (extrinsic), which occurs in response to allergens
2. non-allergic asthma (intrinsic), associated with factors such as upper
respiratory infections, emotional upsets, and exercise
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Acute asthma (asthmatic attack) results from increasing airway obstruction

caused by bronchospasm and bronchoconstriction, inflammation and edema of
the lining of the bronchi and bronchioles, and production of thick mucus that
can plug the airway
• Asthma is typified by: paroxysms of shortness of breath, wheezing, and
coughing and the production of thick, tenacious sputum
• The client frequently assumes a classic sitting position, with the body leaning
slightly forward and the arms at shoulder height, Why?
• Marked prolongation of the expiratory phase
• Chest tightness & dyspnea
• The client’s lips and nail beds
• Inspiratory and expiratory wheezing
• Cough with produce thick, clear sputum
• Poor oxygen saturation (low SaO2)
• Use of accessory muscles & Cyanosis is a sign that the attack is severe and
needs immediate attention
Complications:
o Status Asthmatics
o Respiratory failure.
o Pneumonia
o Atelectasis, and airway obstruction.
Diagnostic tests:
✓ Obtain the client’s history regarding current and previous asthma
exacerbations.
■Onset and duration
■Precipitating factors (stress, exercise, exposure to irritant)
■Changes in medication regimen
■Medications that relieve symptoms
■Other medications taken
■Self-care methods used to relieve symptoms
✓ Chest auscultation: wheezes and diminished breath sounds
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✓ Pulmonary function tests (PFTs) are the most accurate tests for diagnosing
asthma and its severity:
o forced expiratory volume, may be abnormal
o total lung capacity and functional Residual volume increased
o forced expiratory volume and forced vital capacity are decreased
✓ Allergy testing
✓ ABG analysis chest x-ray.
✓ Blood testing, Sputum tests.
Asthma Prevention:
➢ smoking cessation
➢ use protective equipment while working in environments that contain allergen
➢ avoid triggering agents
➢ infection prevention
Medical management:
▪ There are two groups of asthma medications which include:
1. Long term controls
2. Quick relievers
1. Long-Term Control Therapy for Asthma
a. Inhaled corticosteroids: Prevent and reduce airway swelling and decrease the
amount of mucus in the lungs.
b. Other drugs: Oral corticosteroids, inhaled long-acting beta agonists, and
leukotriene modifiers.
2. Quick relievers
a. Inhaled short acting bronchodilators. c. Oral beta agonists.
b. Inhaled short acting beta agonists. d. Theophylline.
Nursing Management:
❖ Obtain history about previous attacks
❖ Obtain a history of allergic reactions to medications before administering
medications.
❖ Identifies medications the patient is currently taking
❖ Monitor pulse oximetry and ABG as ordered for oxygenation and acid-base
balance.
❖ Assess vital sign frequently
❖ Administer oxygen therapy if cyanosis
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❖ Provide rest periods

❖ Place patient in high fowler's position to maximize ventilation
❖ Encourage diaphragmatic and pursed-lip breathing exercises.
❖ Demonstrate the proper use of inhaler
❖ Administer medications as prescribed
❖ Encourage fluids intake to loosen secretions
❖ Encourage patient to identify measures that promote relaxation
❖ Instruct patient to avoid exposure to allergens
❖ Maintain a quiet environment to reduce anxiety and promote respiration.
❖ Reassure patient during an asthma attack
❖ Teach patient and family about purpose and action of medications, triggers to
avoid, proper inhalation techniques, cough and deep breathing exercises, and
when to seek medical assistance.
Pulmonary Emphysema
➢ Emphysema is a chronic disease characterized by abnormal distention of
the alveoli.
➢ Alveoli lose elasticity, trapping air that the client normally would expire.
➢ On microscopic examination, the alveolar walls are broken down capillary
beds are destroyed and fibrous scarring replaces much of the tissue that
impaired gas exchange.
➢ Large air sacs are seen over the lung surface. These sacs can rupture
allowing air to enter the thorax (pneumothorax)
Signs and Symptoms

✓ Shortness of breath with minimal activity (Exertional dyspnea) is the first
symptom of emphysema.
✓ As the disease progresses, breathlessness occurs even at rest
✓ Chronic cough productive of mucopurulent sputum
✓ Inspiration is difficult because of the rigid chest cage
✓ The chest is characteristically barrel shaped
✓ Uses the accessory muscles of respiration(jaw and neck & intercostal
muscles)
✓ Expiration is prolonged, difficult, and often accompanied by wheezing
✓ Lean slightly forward
✓ Neck veins distend during expiration
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✓ In advanced emphysema, memory loss, drowsiness, &confusion

✓ Lung auscultation reveals decreased breath sounds, wheezing, and crackles.
✓ Heart sounds are diminished or muffled
✓ Visual inspection shows a barrel-chested person breathing through pursed
lips and using the accessory muscles of respiration
Diagnostic TEST:
✓ Chest radiography, fluoroscopy, and CT scanning demonstrate hyper
inflated lung fields.
✓ Pulmonary function marked decrease in overall function
✓ ABG analysis usually reveals hypoxemia and respiratory acidosis
Medical Management
The goals of management include:
✓ improving the client’s quality of life
✓ slowing the disease progression
✓ treating the obstructed airways
Treatment includes the following measures:

• Bronchodilators to dilate airways by decreasing edema and spasms and improving
gas exchange
• Aerosol therapy with nebulized aerosols for deep inhalation of bronchodilators and
mucolytic
• Supplemental oxygen may be prescribed
• Antibiotics
• Corticosteroids on a limited basis to assist with bronchodilation and removal of
secretions
• Physical therapy to increase ventilation—deep breathing coughing, chest
percussion, vibration, and postural drainage
Nursing interventions:
➢ Similar to COPD & ASTHMA
Patient and family education

✓ Take medication exactly as prescribed
✓ Contact the physician if adverse drug effects occur, drugs fail to relieve
symptoms, new symptoms appear, symptoms become more severe, or signs or
symptoms of respiratory infection develop
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✓ Drink extra fluids as indicated

✓ Avoid respiratory irritants and people with respiratory infections
✓ Eat a well-balanced diet( a high-protein, high-calorie )
✓ Take Small, frequent meal
✓ Perform breathing exercises as prescribed.
✓ Take frequent rests during the day
✓ Avoid dry-heated areas that can aggravate symptoms
✓ Lose weight to improve breathing if obese
Pulmonary Embolism(PE)
Pulmonary embolism involves the obstruction of one of the pulmonary arteries
or its branches by substance (solid, gaseous, or liquid) E.G. tumors, amniotic
fluid
Emboli originating from DVT are the most common cause
Risk Factors
❖ Long-term immobility
❖ Oral contraceptive use and estrogen therapy
❖ Pregnancy
❖ Tobacco use
❖ Hypercoagulability (elevated platelet count)
❖ Obesity
❖ Surgery (especially orthopedic surgery of the lower extremities or pelvis)
❖ Heart failure or chronic atrial fibrillation
❖ Autoimmune hemolytic anemia (sickle cell)
❖ Long bone fractures
❖ Advanced age
Clinical manifestation (S & S) :
✓ Anxiety
✓ Feelings of impending doom
✓ Pressure in chest
✓ Pain upon inspiration and chest wall tenderness
✓ Dyspnea and air hunger
Physical Assessment Findings

• Cough &blood-streaked sputum • Pleural friction rub
• Tachycardia •Hypotension • Tachypnea
• Crackles and cough • Heart murmur in S3 and S4
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• Diaphoresis • Low-grade fever • Chest pain

• Decreased oxygen saturation levels • Low SaO2, cyanosis
• Petechiae (red dots under the skin) over chest and axillae
• Pleural effusion (fluid in the lungs) • Cyanosis & Shocked
Laboratory Tests
✓ ABG analysis
✓ Chest x-ray and computed tomography (CT) scan
✓ Ventilation-perfusion (V/Q) scan :Images show the circulation of air and
blood in the lungs and can detect a PE
✓ Pulmonary Angiography
Medical treatment:
✓ Anticoagulants: enoxaparin (Lovenox), heparin, warfarin, Why?
✓ Thrombolytic therapy – alteplase and streptokinase dissolves a thrombus
✓ Antipyretic
✓ Analgesic
Surgical Interventions:
Embolectomy : Surgical removal of embolus
Vena cava filter
Nursing Interventions:
✓ Administer oxygen therapy
✓ Initiate and maintain IV access
✓ Administer medications as prescribed
✓ Provide emotional support and comfort
✓ Monitor changes in level of consciousness
✓ Measures VS, ABGs. Pain . PT & PTT. ECG monitoring
✓ Assess for pleading & assume bleeding precautions , bed rest
✓ Assume measures that prevent DVT
✓ Monitor include fluid intake and output
✓ Assesses the client for cyanosis, cough with or without hemoptysis,
diaphoresis, and respiratory difficulty
Chest trauma
• Chest trauma can damage the heart and lungs and cause life threatening
injuries, including pericardial tamponed, hemothorax, tension pneumothorax,
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and flail chest

➢ Chest trauma can result in laceration of lung tissue and cause a change in
the negative intra pleural pressure. Air or blood leaking into the intra pleural
space collapses the lung, resulting in a pneumothorax (air) or hemothorax
(blood) and ineffective ventilation.
Causes:
Blunt trauma (Rapid deceleration / checking, Compression)
Penetrating trauma (MVA", falls, gunshot, stab wounds)
•Recognition of chest injury is focused on careful assessment, clinical
examination and diagnostic imaging.
•Prompt lifesaving treatment of chest injuries involves airway
management, delivery of oxygen, ensuring adequate ventilation, underwater
seal chest drainage and hemorrhage control
•A client with a chest injury must be observed for dyspnea, cyanosis, chest
pain, weak and rapid pulse, and hypotension
The common Tissue hypoxia due to chest injury may result from :
• Inadequate oxygen delivery to the tissues secondary to airway obstruction
• Hypovolemia from blood loss
• Ventilation/perfusion mismatch from lung injury
• Changes in pleural pressures from tension pneumothorax
• Pump failure from severe myocardial injury
Common nursing diagnosis is acute pain related to chest trauma
Flail Chest
The breaking of 2 or more ribs in 2 or more places. Patient is shocked,
cyanosis, breath difficulty, severs pain & crepitus in broken ribs, paradoxical
chest movement (chest movement that is opposite to that usually seen with
respiration).
Medical & Nursing Management
➢ supporting the chest with an elastic bandage or a rib belt assists in
immobilizing the rib fractures
➢ ensure an open airway, administer O2 as needed
➢ monitor oxygenation with pulse oximetry
➢ analgesics for pain , Antibiotics are given to prevent infection
➢ supporting ventilation, clearing lung secretions
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➢ instructs the client about the application and removal of the rib belt or
elastic bandage
➢ instructs the client about taking deep breaths every 1 to 2 hours
➢ assesses and monitors the client for signs of respiratory distress, infection,
and increased pain
➢ observe for patient to develop Pneumothorax and even worse Tension
Pneumothorax
Cardiac tamponed
Occurs when blood accumulates in the pericardial sac that increases pressure
around the heart, leads to prevents the heart chambers from filling and
contracting effectively
With poor pumping the blood pressure starts to drop. The heart rate starts to
increase to compensate but is unable The patient’s level of conscious drops, and
eventually the patient goes in cardiac arrest
A patient with cardiac tamponed exhibits hypotension, tachycardia, and
neck vein distention and requires immediate intervention to reduce the pressure
in the pericardial sac and restore normal filling and contraction of the heart
chambers
Pneumothorax and Hemothorax

Pneumothorax
Term used to describe air that entered the pleural space outside the lungs.
➢ Spontaneous pneumothorax , that occurs without an associated injury
➢ Traumatic Pneumothorax :
Open Pneumothorax. If air can enter and escape through the opening in the
pleural space , occurs when the wound remains open & lung beneath
collapses
Closed Pneumothorax. If air collects in the space and is unable to escape
Tension pneumothorax, air enters the pleural space during inspiration
through a one way valve and is not able to exit upon expiration, resulting
in :
• increased pressure on the unaffected lung
• the heart, great vessels, and trachea shift toward the unaffected side
• blood flow to and from the heart is greatly reduced, causing a decrease
in cardiac output
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Clinical manifestation of tension pneumothorax

•An anxious, agitated patient • Respiratory distress
• Tachycardia • Asymmetrical breathing
• Absent breathe sounds on the affected side
• Distended neck veins if no bleed
• Possible deviated trachea away from the affected side
Clinical manifestation of open pneumothorax:

• Wound or opening on chest wall • Respiratory distress
• Tachycardia, tachypnea • Patient anxiety or agitation
• Asymmetrical breathing •Subcutaneous Emphysema
• Reduced breath sounds on the affected side
➢ Patient with pneumothorax has hyper reasoning chest sound, with
hemothorax has dull chest sound
Spontaneous hemothorax can occur when there has been no trauma

Massive hemothorax
A hemothorax is described as a massive hemothorax in the presence of >1500
ml blood loss in the chest or 200 ml per hour (3 mg/kg/hr)
Signs and symptoms of Massive hemothorax:

• Shocked patient: altered level of consciousness, tachycardia, tachypnea,
hypotensive, & Pallor skin
• Abrasions, wounds, injury to the affected side
• Asymmetrical breathing
• Reduced breath sounds on the affected side
• Frothy, Bloody Sputum (Hemoptysis ).
• Ongoing blood loss in the chest drain bottle
Diagnostic Tests
o History, physical examination, ABGs and chest x-ray examination
o Thoracentesis may be used to confirm hemothorax, will demonstrate in practical
Medical- Surgical and nursing management of pneumothorax& hemothorax:

•High flow oxygen
• Check ABGs, SaO2, CBC, and chest x-ray results
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• Needle decompression
• Chest tube insertion
•Put pt. in high-Fowler’s
•Provide emotional support
•Monitor chest tube drainage
•Administer medications as prescribed
•Assess pain every 4 hr.
•Monitor vital signs, LOC, N&V, I,& O &constipation
•Encourage fluid intake
•Treat for S/S of Shock
Placement of a dressing over the wound
•Monitor Heart Rhythm
•Establish IV Access and Draw Blood Samples
•Airway Control
•Place Flutter valve over catheter or Finger with a Latex Glove
•Assess level of consciousness, skin and mucous membrane color, vital signs,
respiratory rate and depth, and presence of dyspnea, chest pain, restlessness,
lung sounds
•surgical repairs
Nursing Care Plan for Respiratory System Disorders
1- Impaired gas exchange related to ventilation–perfusion inequality, alveoli

destruction, and obstruction of small airways.
Outcomes criteria:
• Demonstrate improved ventilation and adequate oxygenation of tissues by
ABG within normal range and be free from symptoms of respiratory distress.
• Report decrease in dyspnea.
• Shows no signs of restlessness, confusion, or agitation.
❖ Assess and document respiratory rate and depth, restlessness, shortness of
breath, dyspnea, skin color, anxiety, and use of accessory muscles.
❖ Auscultate breath sounds, noting wheezing, and crackles.
❖ Monitor ABG and pulse oximetry as indicated.
❖ Administer humidified oxygen therapy as ordered.
❖ Monitor level of consciousness and mental status.
❖ Administer bronchodilators and expectorants as prescribed.
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❖ Assist patient to assume semi to high fowler's position unless contra-

indicated to promote lung expansion.
❖ Encourage patient and assist with diaphragmatic and pursed-lip breathing
techniques as tolerated.
❖ Encourage coughing and deep breathing exercises as needed.
❖ Encourage expectoration of sputum.
❖ Maintain a patent airway by suctioning as needed. Hyper-oxygenate
patient with 100% before and after suctioning.
❖ Assist with or perform postural drainage and chest physiotherapy as
needed.
❖ Monitor skin and mucous membrane color.
❖ Monitor vital signs as indicated.
2- Ineffective airway clearance related to bronchospasm, increased mucus
production, ineffective cough, and bronco- pulmonary infection.
Outcomes criteria:
• Maintain airway patency with clear breath sounds.
❖ Assess respiration rate and depth, restlessness, anxiety, and use of accessory
muscles.
❖ Auscultate breath sounds. Note adventitious breath sounds as (wheezing,
crackles, rhonchi) and report significant findings.
❖ Establish and maintain a patent airway by suctioning as needed. Hyper-
oxygenate patient with 100% before and after suctioning.
❖ Administer humidified oxygen as prescribed.
❖ Administer mucolytic agents via nebulizer to facilitate removal of secretions
as ordered.
❖ Inspect sputum for quantity, odor, color, and consistency.
❖ Maintain fluid intake of 3000 ml/day unless contra-indicated to liquefy
secretions.
❖ Encourage use of incentive spirometer as indicated to promote lung
expansion.
❖ Encourage deep breathing and coughing exercises as indicated.
❖ Teach and encourage use of diaphragmatic or pursed-lip breathing exercises.
❖ Instruct patient to avoid respiratory irritants such as aerosols and fumes.
❖ Encourage patient to stop smoking and avoid passive smoking.
❖ Assist patient to assume a position of comfort usually semi to high fowler's
position.
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❖ Change patient's position every two hours.

3- Ineffective breathing pattern related to shortness of breath, increased
mucus production, bronchospasm, and airway irritants.
Outcomes criteria:
• Maintain normal rate, rhythm, and depth of respiration.
• Absence of reported dyspnea.
• Maintain arterial blood gases within normal range.
• Use pursed-lip and diaphragmatic breathing techniques.
❖ Assess respiratory rate, rhythm, and pattern, restlessness, anxiety, mental
status changes, shortness of breath, and use of accessory muscles as indicated.
Report significant findings.
❖ Auscultate breath sounds as indicated. Note adventitious breath sounds as
(wheezes, crackles, rhonchi) and report significant findings.
❖ Administer bronchodilators therapy as prescribed.
❖ Administer humidified oxygen as ordered.
❖ Monitor pulse oximetry as indicated.
❖ Teach patient diaphragmatic and pursed-lip breathing exercises as needed.
❖ Assist patient to assume semi to high fowler's position to promote lung
expansion.
❖ Encourage coughing and deep breathing exercises as indicated.
❖ Assist patient to turn from side to side at least every 2 hours.
❖ Encourage use of incentive spirometer as indicated to promote lung
expansion.
❖ Maintain activity restrictions as ordered. Have patient resume activity
gradually and increase as allowed and tolerated. Maintain rest periods between
activities.
4. Activity intolerance related to fatigue, dyspnea, and hypoxia.
Outcomes criteria:
• Ability to perform activities of daily living with absence of shortness of
breath, dyspnea, or excessive fatigue.
• Verbalization of feeling less fatigued and weak.
• Verbalization of ways to conserve energy when performing activities of daily
living at home before discharge.
• Pace activities and plan for simplification of activities.
❖ Assess patient's ability to perform activities of daily living.
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❖ Maintain oxygen therapy before and during activity as needed.

❖ Instruct patient to decrease activities that require use of accessory muscles.
❖ Instruct patient to report dyspnea, fatigue, or chest pain during and after
activities.
❖ Evaluate patient’s response to activity. Note reports of dyspnea, increased
weakness/fatigue, and changes in vital signs during and after activities.
❖ Maintain activity restrictions as ordered.
❖ Take frequent rest breaks during activities. Explain importance of rest in
treatment plan and necessity for balancing activities with rest.
❖ Instruct client to stop activity if palpitations, chest pain, shortness of breath,
weakness, or dizziness occur.
❖ Assist patient with activities of daily living as necessary.
❖ Teach patient to avoid factors that increase oxygen demands such as smoking,
excess weight, beverages high in caffeine, and stress.
❖ Minimize environmental activities and noise.
❖ Keep supplies and personal articles within easy reach.
❖ Teach patient energy conservation techniques such as using shower chair
when showering and sitting when brushing teeth or combing hair.
❖ Teach patient pursed lip and diaphragmatic breathing techniques and explain
importance of using these techniques during activities.
❖ Increase tolerance to the activity by encouraging patients to do the activity
more slowly or at a shorter time, with more rest or with a lot of help.
Caring for Clients with Gastrointestinal Disorders

Outlines
• Review anatomy and physiology of gastro intestinal system.
• Common laboratory procedures
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• Common GIT somatology (, anorexia, N&V, Diarrhea, Constipation

&Obesity)
• Common disorders:
• Oral inflammation
• Gastro esophageal reflux disease [GERD]
• Gastritis
• Peptic Ulcer Disease (PUD)
• Appendicitis
• Inflammatory bowel diseases(Ulcerative Colitis & Crohn’s disease)
• Hemorrhoids
• Bowel obstruction
• Hepatitis
• Liver Cirrhosis
• Cholecystitis & Cholelithiasis
• Nursing care plan for common nursing diagnosis
Learning objectives:
By the end of this chapter the student will be able to:
➢ Review the anatomy and physiology of gastro intestinal system.
➢ Define related terms
➢ Describe the preparation that the client needs to complete upper and lower
GI series using barium contrast medium
➢ List common GIT problems with its related NI
➢ Describe the causes, symptoms, signs, treatment and prevention of GIT
disorders
➢ Prepare nursing care plan based on steps of NP.& provide care to patients
with GIT disorders
➢ Identify the types and causes of the major types of hepatitis
➢ Provide patient education regarding GIT disorders
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Anatomy and physiology of gastro intestinal tract

The gastrointestinal system divided into two
sections:
The upper GI tract begins at the mouth and ends at
the jejunum.
The lower GI tract begins at the ileum and ends at
the anus.
Accessory structures include: the peritoneum,
liver, gallbladder, and pancreas.
The primary functions of the GI tract are digestion
and distribution of food.
Ingestion - taking food into the mouth
Digestion - break food down into smaller
fragments; mechanical & chemical
Absorption - most molecules enter by active absorption & passive diffusion
Defecation - elimination of indigestible substances
Steps to Assess Patient with GITs disorders:

➢ chief complaint E.G. N & V, abd. pain
➢ ask the patient about his present illness E. G. when it started, frequency ,
➢ ask the patient medical history & family history related to past disorders
➢ Lab. & diagnostic tests
➢ Physical assessment
✓ use this sequence: inspection, auscultation, percussion, and 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
Using Inspection:
◗ Observe the patient’s general appearance, and note his behavior
◗ Inspect the skin for turgor, color, and texture; note abnormalities
◗Observe the patient’s head for color of the sclera, 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
Using Auscultation
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◗ Note the character and quality of bowel sounds in each quadrant

◗ Auscultate the abdomen for vascular sounds
Percusses The Abdomen

◗ Percuss the abdomen to detect the size and location of the abdominal organs
◗ Note the presence of air or fluid
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
➢ Stool Analysis
Stool specimens are collected to identify :
✓ White blood cells (indicating inflammation)
✓ Red blood cells (indicating GI blood loss
✓ Fat (indicating mal-absorption)
✓ Identify infection (bacterial, ova or parasite ) specimens should be fresh and
warm , collect in covered container
✓ Presence of occult blood in the stool is the Hem occult test: positive result
indicates that the client is bleeding or has recently bled, consider food &drugs
altered color
Foods and Medications That Alter Stool Color
Altering Substance Color
Meat protein Dark brown
Spinach Green
Carrots and beets Red
Cocoa Dark red or brown
Sienna Yellow
Barium Milky white
Bismuth, iron, licorice, and Black
charcoal
➢ GI series
Upper: X-ray examination of the esophagus, stomach, and small bowel after
the patient swallows contrast media, such as barium or Gastrografin)
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Lower: X-ray examination of the large intestine by inserting barium by way of

an enema
To remove any residual stool, the client follows prescribed restrictions for 24
to 48 hours before test :
• Low-residue diet 1 to 2 days before the test
• Clear liquid diet the evening before the test
• A laxative the evening before the test
• NPO after midnight
• Cleansing enemas the morning of the test
After test
● Give a laxative, as prescribed
● Note stool color and consistency to ensure that the barium has been passed.
● Inform the patient that the barium may make his stools appear a light
color for several days after the test
● Tell the patient to report lack of bowel movements to the physician;
retained barium can cause bowel obstruction and fecal impaction.
➢ Gallbladder scan I.V. administration of a radioisotope followed by imaging
Determining gallbladder function, Identifying gallstones
Detecting infection of the gallbladder
Tell the patient not to eat for 4 hours before the scan.
Explain that images will be taken at 10- to 15-minute intervals over 1 to 2 hours.
Don’t perform the test on a pregnant patient
Encourage fluid intake to hasten radioisotope elimination over 1 to 2 days.
➢ Liver Function Tests

1. Serum enzyme activity (E.G. alkaline phosphatase)
2. Serum concentrations of proteins (albumin and globulins
3. Bilirubin, ammonia, clotting factors, and lipids .
4. Serum aminotransferases (also called transaminases) are sensitive indicators
of injury to the liver cells and useful in detecting acute liver disease such as
hepatitis .
➢ Proteins are manufactured by the liver. Their levels may be affected in a
variety of liver impairments
• Albumin: Cirrhosis Chronic hepatitis Edema, ascites
• Globulin: Cirrhosis Chronic obstructive jaundice
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• Viral hepatitis
➢ Liver biopsy : is the removal of a small amount of liver tissue, usually

through needle aspiration .
✓ It permits examination of liver cells
✓ Useful when clinical findings and laboratory tests are not diagnostic
✓ Bleeding and bile peritonitis after liver biopsy are the major complications
➢ Gastric analysis : aspirate gastric sample through NGT to pH monitoring
➢ Ct scan, MRI, endoscopy biopsy discussed before
GITS Symptomatology
Anorexia
it is a lack of appetite
✓ The appetite center, which stimulates or suppresses the appetite, is located
in the hypothalamus.
➢ Pleasant or noxious food odors, effects of drugs, emotional stress, fear,
psychological problems, or illnesses may affect appetite.
Signs and Symptoms
Hunger usually is absent, and clients describe having no desire for food
Wight loss vary Vitamin deficiency (B & C vitamins)
Diagnostic tests:
• CBCS • ECG
• Serum albumin, electrolyte, and protein levels
Medical and Nursing Management: Based on risk Factors

➢ Persistent anorexia may require various approaches, such as:
• a high-calorie diet • high-calorie supplemental feedings
• tube feedings • total parenteral nutrition (TPN)
psychological support, psychiatric treatment, or both
Managing Clients With Anorexia

• Provide foods that the client likes during meals.
• Offer nourishing beverages ( milk shakes ) as between-meal snacks.
• If the client is hospitalized encourage family members to bring favorite foods
.
In sever prolonged total parenteral nutrition prescribed.
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• Conduct a daily caloric count if necessary to determine total proteins and

carbohydrates in the client’s diet.
• Serve and keep hot foods hot and cold foods cold.
• Encourage eating in the company of others.
• Formulate a nutritional plan with the client and dietitian
•Obtains a complete medical and allergy (drugs and food) history
• If necessary, arrange for supplementation based on deficiencies
• Consult the physician and dietitian in cases of prolonged anorexia, diarrhea
or constipation
Nausea and Vomiting
Nausea and vomiting are common, if prolonged, weakness, weight loss,
nutritional
deficiency, dehydration, and electrolyte and acid-base imbalances may result.
Nausea is the subjective feeling of the urge to vomit.
Vomiting is the act of expelling stomach contents from the body through the
esophagus and mouth. (forceful ejection of partially digested food and
secretions (emesis)
➢ Vomiting is a protective function to rid the body of harmful substances
➢ Valsalva maneuver, which accompanies the forceful expulsion of stomach
contents, causes dizziness, hypotension, and bradycardia
➢ Causes & Risk Factors:
Visceral • Infections( Peritonitis, Hepatitis, Food

afferent poisoning)Mechanical obstruction (adhesions )
stimulation • Dysmotaility( postvagotomy)
• Hepatobiliary disorders (Acute pancreatitis , Cholecystitis )
• Topical gastrointestinal irritants (Alcohol, NSAI Ds, oral
antibiotics)
• Others ( MI, DM, CHF, pyelonephritis )
Vestibular ✓ Meniere syndrome, motion sickness
disorders
CNS disorders ✓ Increased ICP , CNS tumors, hemorrhage, Migraine
headache Meningitis, encephalitis
✓ Psychogenic (anorexia nervosa)
Irritation of • Chemo- Radiation, therapy , Opioids,
chemoreceptor • Anticonvulsant
trigger zone • Anti-parkinsonism , Digoxin
• Beta-blockers, a antiarrhythmic
• Nicotine, Oral contraceptives
Medical and nursing management:
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o Elimination of the cause e.g. food poising

o Providing IV fluid and electrolyte replacement
o Restricting food intake until the cause of vomiting is eliminated
o Protection of the airway during vomiting is a priority to prevent aspiration
o Place Pt. on their side when they begin to vomit
o Assess amount, odor , content & color of emesis
o After the vomiting is resolved, clear liquids are started
o Keep HOB elevated & emesis basin handy
o Protect airway with suction & positioning
o Provide frequent mouth care
o Control sights & odors
o Reduce anxiety
o Provide quiet, odor-free, visually clean environment
o Give antiemetic's as ordered
o Modify environmental stimuli (cool cloth & dim lights )
o Provide ongoing patient support
o Maintain NPO if severe
o Obtain daily weight on same scale, at same time
o Monitor intake and output and vital signs
o Provide fluids as ordered
o Administer antiemetic's as order
Nutrition Notes Of Client With Nausea

✓ The client should eat small meals and eat and drink slowly.
✓ Dry, salty foods, such as crackers and pretzels, may relieve nausea.
✓ Fried food, spicy food, and foods with strong odors should be avoided.
✓ Cold foods may be preferable to hot foods.
Constipation
It is a term used to describe
o an abnormal infrequency or irregularity of defecation
o abnormal hardening of stools that makes their passage difficult & painful
o a decrease in stool volume
o retention of stool in the rectum for a prolonged period.
Etiology
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✓ Medications such as narcotics, tranquilizers, iron and antacids

✓ Rectal conditions such as hemorrhoids or fissures
✓ Metabolic or neurological conditions, diabetes mellitus, multiple sclerosis
✓ Colon cancer
✓ Low intake of dietary fiber and fluids
✓ Decreased mobility, weakness, and fatigue
✓ Chronic laxative use
The urge to defecate is stimulated normally by rectal distention, which initiates
a series of four actions:
➢ stimulation of the inhibitory recto-anal reflex
➢ relaxation of the internal sphincter muscle
➢ relaxation of the external sphincter muscle and muscles in the pelvic region
➢ increased intra-abdominal pressure
Signs and Symptoms

Abdominal distention
▪ indigestion
▪ rectal pressure
▪ feeling of incomplete emptying
▪ straining at stool
▪ elimination of hard, dry stool
▪ intestinal rumbling
▪ headache, fatigue
▪ decreased appetite
Complications of Constipation
• Fecal impaction
• Pressure on the colon mucosa from stool ,cause ulcers, hemorrhoids and
fissures
• Straining can result in cardiac , neurological ,respiratory complications
• Pt. has a history of heart failure, hypertension, or recent myocardial
infarction, straining can lead to cardiac rupture and death
• Megacolon, dilated loops of the colon
• Perforation of the colon leads to peritonitis
Diagnostic Tests
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self-diagnosed history and physical examination

If complications are suspected, a radiographic examination, Sigmoidoscopy,
and stool testing for occult blood
Medical –Surgical and Nursing Management

✓ Treatment of constipation depends on the cause.
✓ Fiber should be added to the diet
✓ Behavior changes, such as regular timing, proper positioning to defecate
✓ Drinking warm water every morning, 2 to 3 L of water every day, if it is
not contraindicated
✓ Chronic laxative use should be discontinued
✓ Stool softeners such as docusate sodium (Colace) should be used
✓ Enemas and rectal suppositories
✓ Surgical management to complication
✓ Assess normal pattern of defecation, diet and fluid intake
✓ Instruct pt. to setting a specific time for defecation
✓ Place feet on a footstool to promote flexion of the hips to aid defecation
✓ a high-fiber, high residue diet including fresh fruits, vegetables
✓ Increase activity through a daily walking program
✓ Increase fluid if not contraindicated to 2 to 3 L per day, and fiber in the diet
✓ Teach factors leading to constipation and preventive interventions
Diarrhea
It is :
➢ increased frequency of bowel movements (more than three per day)
➢ increased amount of stool (more than 200 g per day
➢ altered consistency (looseness) of stool.
It is usually associated with urgency, perianal discomfort, incontinence, or
combination
➢ Classification and severity of diarrhea are based on the number of
unformed stools in 24 hours (sever, mild). Or based on times to Acute &
chronic (Diarrhea present for longer than 4 weeks)
➢ Classify according to infection (Acute noninflammatory Watery,
nonbloody. Usually mild, self-l limited) & Acute inflammatory : Blood or
pus, fever, caused by an invasive or toxin-producing bacterium
➢ Three major problems associated with severe or prolonged diarrhea include
dehydration, electrolyte imbalances, and vitamin deficiencies
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Etiology
✓ Common cause of acute diarrhea is a bacterial or viral infection
✓ Poor tolerance or allergies to certain foods: additives, caffeine, milk
products, meats
✓ Inflammatory diseases such as Crohn’s disease or ulcerative colitis
✓ Mal-absorption , Viruses infectious
✓ Radiation therapy for cancer
✓ Enteral tube feedings
✓ Certain medications (thyroid hormone replacement, laxatives, antibiotics)
Abdominal cramps& distention Low-grade fever Weight loss
Dehydration, electrolyte disturbances (e.g., hypokalemia)
Acid-base imbalances (metabolic acidosis) Urge to defecate
Diagnostic Tests
The diagnosis of diarrhea is determined by :
o The onset and progression of the disease
o Absence or presence of fever
o Laboratory examinations, and visual inspection of the stool
o Evidence of bacteria, pus, and blood in stool is checked
o CBCS, serum electrolytes
Medical and Nursing Interventions

➢ Replacing fluids and electrolytes is the first priority
➢ Treating the underlying disease & risk factors prevention
➢ Increasing oral fluid intake, using solutions with glucose and electrolytes
➢ Intravenous fluid replacement for rapid hydration( very young or very old).
➢ An elimination diet that contribute to diarrhea.
➢ Encouraged to increase fiber and bulk in the diet to avoid post diarrhea.
➢ Motility of the intestines can be decreased with the use of drugs as order
➢ Dietary supplement used to restore the normal flora.
➢ Antimicrobial agents are prescribed
➢ Ask the patient to describe any symptoms, when they started, and how long
they have been present (abdominal pain, stool consistency, color, odor, and
frequency).
➢ Abdomen is inspected for distention
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➢ Dietary habits and any changes is assessed

➢ Find out if any contributed to diarrhea ( medications, exposure to an
infected person, geographical location
➢ Assess for symptoms of dehydration :wt., I &O, skin turgor
➢ Monitor and record stool characteristics, amount, and frequency
➢ During acute diarrhea nothing is taken by mouth
➢ Give anti-diarrheal medications as ordered
➢ Provide clear liquids, such as water, juices
➢ Limit caffeine, very hot and very cold foods, ( stimulate intestinal motility)
➢ Restrict milk products, fat, whole-grain products, fresh fruits, and
vegetables for several days.
➢ Keep skin clean, dry, and protected with a moisture barrier
➢ Strict infection control precautions that prevent transmission of infection
➢ Encourages bed rest and dizziness precautions
Oral inflammatory lesions
Actinic cheilitis
It is an Irritation of lips
Clinical manifestations
Scaling, crusty, fissure; white overgrowth of horny layer of epidermis
(hyperkeratosis) Considered a premalignant squamous cell skin cancer
Common cause is exposure to sun
Teach patient importance of protecting lips from the sun by using protective
ointment
Intervention
✓ Such as sun block
✓ Instruct patient to have a periodic checkup
Candidiasis (moniliasis /thrush)

Cheesy white plaque that looks like milk curds; when rubbed off, it leaves an
erythematous and often bleeding
Etiology & risk factors
✓ Candida fungus
✓ Predisposing factors include: diabetes, antibiotic therapy,&
immunosuppression
Intervention Antifungal medications
Gingivitis
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Painful, inflamed, swollen gums; usually the gums bleed in response to light
contact
o Poor oral hygiene: food debris, bacterial plaque, & calculus accumulate;
o Swell in response to normal processes such as puberty and pregnancy
Stomatitis
Shallow ulcer with a white or yellow center and red border; seen on the inner
side of the lip and cheek or on the tongue; it begins with a burning or tingling
sensation and slight swelling; painful; usually lasts 7–10 days and heals without
a scar
✓ Associated with emotional or mental stress, fatigue, hormonal factors,
minor trauma (such as biting), allergies, acidic foods and juices, and dietary
deficiencies
✓ Nicotine stomatitis : begins as a red stomatitis; over time the tongue and
mouth become covered with a creamy, thick, white mucous membrane, which
may slough, leaving a beefy red base
✓ HIV infection
✓ Drug allergy (Chemotherapeutic agents, radiation therapy)
✓ Bone marrow depression
Medical & Nursing Intervention

o Instruct the patient in comfort measures, such as saline rinses, and a soft or
bland diet , a soft or liquid diet may be preferred
o Antibiotics or corticosteroids may be prescribed
o Cessation of tobacco use
o Instruct patient regarding side effects of planned treatment
o Prophylactic mouth care for any patient receiving chemotherapy or radiation
therapy
o Strategies to reduce pain: avoid alcohol-based mouth rinses and hot or spicy
foods
o Apply topical anti-inflammatory, antibiotic, and anesthetic agents as prescribed
o Advise the patient to perform mouth care before meals and every 3 to 4
hours
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Esophageal disorders
Achalasia is absent or ineffective peristalsis of the distal esophagus,

accompanied by failure of the esophageal sphincter to relax in response to
swallowing
The primary symptom is difficulty in swallowing both liquids and solids
Hiatus or hiatal hernia
The opening in the diaphragm through which the esophagus passes becomes
enlarged,
and part of the upper stomach tends to move up into the lower portion of the
thorax
Type I, hiatal hernia occurs when the upper stomach and the gastro-
esophageal junction are displaced upward and slide in and out of the thorax
Para-Esophageal Hernia occurs when all or part of the stomach pushes
through the diaphragm beside the esophagus
heartburn, regurgitation, dysphagia, and sense of fullness or chest pain after
eating
Diagnosis is confirmed by x-ray studies, barium swallow, and fluoroscopy
Medical Surgical & Nursing Management:

✓ frequent, small feedings
✓ advised to rest for 1 hour after eating
✓ elevate the head of bed 10- to 20-cm
✓ Surgery in sever, non-response medical therapy
✓ NI similar to GERD
Esophageal varices are swollen, fragile blood vessels in the esophagus.
Gastro esophageal reflux disease [GERD]

Definition of GERD is a condition in which gastric secretions flow upward
into the esophagus. Results from incompetent lower esophageal sphincter
The esophagus can be damaged by acidic gastric secretions and exposure to
digestive enzymes.
Factors contributing to gastro esophageal reflux
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1.Increased gastric volume & pressure

(Excessive ingestion of foods, cancer)
2.Position pushing gastric contents
(such as bending or lying down)
3.Increased gastric pressure (obesity,
tight clothing ,pregnancy)
4.Hiatal hernia
5. Medications that relax the LES (theophylline, nitrates, calcium channel
blockers,& diazepam)
• Epigastric burning, worse after eating
• Nausea , dyspepsia
• Regurgitation: sour liquid coming into the throat or mouth
• Difficulty swallowing (Dysphagia),
• Hoarseness or change in voice & cough / why?
• Heartburn (pyrosis) is a burning, tight sensation that is felt intermittently
beneath the lower sternum and spreads upward to the throat or jaw
✓ Pain worsens with position (bending, straining, laying down).
✓ Pain occurs after eating and may last 20 min to 2 hr.
✓ Pain is relieved by drinking water, sitting upright, or taking antacids
✓ Unlike angina, GERD-related chest pain is relieved with antacids
Diagnosis :
✓ Barium swallow Esophagoscopy
✓ pH monitoring of the normally alkaline esophagus
✓ Biopsy and cytological specimens can be taken to differentiate stomach and
esophageal cancer from Barrett’s esophagus
✓ Radio nuclide tests : detect reflux of gastric contents and the rate of
esophageal clearance

The primary treatment of GERD
✓ diet and lifestyle changes
✓ advancing to medication use :
Antacids , neutralize excess acid(1 to 3 hr. after eating and at bedtime)
Histamine 2 Receptor Antagonists, reduce acid secretion (Take with meals
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and at bedtime)
Proton pump inhibitors, reduce gastric acid by inhibiting the cellular pump
necessary for gastric acid secretion
Prokinetics, increase the motility of the esophagus and stomach
✓ Surgery for patients with complications
Fundoplication, fundus of the stomach is wrapped around and behind the
esophagus through a laparoscope
•Maintain a weight below BMI of 30.
• Monitor vital signs.
• Assess abdomen for distention, bowel sounds.
• Teach about medication management.
• Instruct patient to sleep with head of bed elevated, and avoid lying
down after eating
✓ Teach patient about lifestyle modifications:
o Not to lie down, or supine for 2 hours after eating.
o Eat small meals, avoid late-night eating
o Elevate head of bed approximately 30 degrees.
o Avoid wearing clothing that is tight around the abdomen
o Avoid acidic foods (vinegar, and tomato), peppermint, caffeine, alcohol.
o Stop smoking and lose weight if overweight.
o Take low-fat, high-protein diet
o Caffeine, milk products, and spicy foods should be avoided
Complications
Aspiration of gastric secretion Barrett’s Syndrome (premalignant)
Gastritis
Definition : Gastritis, an inflammation of the gastric mucosa
Mucosal barrier normally protects the stomach tissue from the corrosive action
of HCl acid and pepsin, diffuse back into the mucosa results in tissue edema,
disruption of capillary walls with plasma lost into the gastric lumen, and
possible hemorrhage
Causes & Risk Factors:
✓ Diet : • Alcohol • Spicy , fatty foods
✓ Microorganisms • Helicobacter pylori • Salmonella
✓ Medications : • Aspirin • NSAIDs • Corticosteroids
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•Digitalis • Chemotherapeutic drugs

✓ Stress : • Physiological • Psychological
✓ Trauma
✓ Other Factors • Reflux of bile • Smoking • Radiation
• Naso-gastric suctioning • Endoscopic procedures
✓ Autoimmune diseases : • Systemic lupus • Rheumatoid arthritis
Autoimmune meta-plastic atrophic gastritis (autoimmune atrophic gastritis)
: is an inherited condition in which there is an immune response directed
against parietal cells
Types :
●Acute gastritis has sudden onset, is of short duration, and may result in gastric
bleeding if severe.
●Chronic gastritis has a slow onset and, if profuse, may damage parietal cells
resulting in pernicious anemia.
● Erosive gastritis extensive gastric mucosal wall damage (ulcers) and
increase the risk of stomach cancer.
Clinical manifestation
✓ Dyspepsia, general abdominal discomfort, indigestion
✓ Upper abdominal pain or burning may increase or decrease after eating
✓ Nausea &vomiting
✓ Reduced appetite
✓ Abdominal bloating or distention
✓ Hematemesis (bloody emesis)
✓ Diarrhea & fever with infection
✓ Erosive gastritis:
Black, tarry stools; coffee-ground emesis & Acute abdominal pain
Diagnostic tests:
• CBCs : Hemoglobin and hematocrit decrease.
• Anemia (iron deficiency) due to chronic, slow blood loss.
• Fecal occult blood positive.
• Gastroscopy shows inflammation, allows biopsy.
Medical Surgical & Nursing managements:
Therapeutic Interventions depends on cause and symptoms.
✓ Removal of the irritating substance (gastric lavage) if not contraindicated
✓ Provision of a bland diet of liquids and soft foods
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✓ Medication therapy : Histamine2 antagonists , Antacids, Proton pump

inhibitors
Prostaglandins (Reduces gastric acid secretion)
Anti-ulcer/mucosal barriers (Inhibits acid & forms a protective coating over
mucosa)
Antibiotics : Eliminates H. pylori infection
✓ Surgery is prescribed for clients who have ulcerations or significant bleeding
• Monitor vital signs, electrolytes , intake and output & anemia .Which Type &
Why?
• Monitor stool for occult blood & bleeding.
• Assess abdomen for bowel sounds, tenderness.
• Provide small, frequent meals
• Teach patient : Diet restrictions: avoid alcohol, caffeine, spicy, high-fat acidic
foods.
•IV fluids are given to correct dehydration and electrolyte imbalances
Complications
Gastric bleeding Dehydration
Pernicious & Iron deficiency anemia
Peptic Ulcer Disease (PUD)

A peptic ulcer is an erosion of the mucosal lining of the stomach or duodenum.
➢ Mucosal eroded leads to epithelium is exposed to gastric acid and pepsin,
which can precipitate bleeding and perforation
➢ Helicobacter pylori (H. pylori), is responsible for 80% of gastric ulcers
and more than 90% of duodenal ulcers, transmitted through : oral-oral or
fecal-oral route & contaminated water.
➢ Histamine is released from the damaged mucosa, resulting in vasodilation
and increased capillary permeability and further secretion of acid and pepsin
Risk factors that contribute to PUD include: similar to gastritis

Smoking Chewing tobacco Stress
Excess Caffeine & alcohol ingestion
Steroids, aspirin, and NSAIDs
H. pylori infection
Family history
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Types: 1. Gastric Ulcer( stomach)

2. Duodenal Ulcer (duodenum)
3. Stress ulcers (which occur after major stress or trauma)
Clinical manifestation & Comparison of Gastric and Duodenal Ulcers

Point of Gastric Ulcers Duodenal Ulcers
comp.
Lesion Superficial, smooth Penetrating
margins. Round, oval, or (associated with
cone shaped deformity of duodenal
bulb from healing of
recurrent ulcers).
Location of Predominantly antrum; First 1-2 cm of
lesion in body duodenum
and fundus of stomach
Gastric Normal to decreased Increased
secretion
Incidence Greater in women. Greater in men, but
increasing in women
especially
postmenopausal
Clinical Burning or gaseous Burning, cramping,
manifestations pressure in high left pressure-like pain
epigastrium and back across mid
and upper abdomen. epigastrium & upper
abdomen.
Back pain with
posterior ulcers.
Pain 1-2 hr. after meals. Pain 2-4 hr. after
If penetrating ulcer, meals and
aggravation of midmorning,
discomfort with food & midafternoon, middle
antacids. Rarely occurs of night. Pain relief
at night with antacids and
food. Often occurs at
night
Occasional nausea and Occasional nausea
vomiting, weight Loss, and vomiting. well
malnourished nourished
Diagnostic tests:
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✓ Gastric samples are collected via an endoscopy to test for H. pylori

✓ Upper GI or barium swallow shows areas of ulceration
✓ The urea breath test is performed by having the patient drink carbon-labeled
urea
The urea is metabolized rapidly if H. pylori is present, allowing absorbed
and measured in exhaled into a collection container
✓ Hemoglobin and hematocrit
✓ Symptoms
✓ Stool sample for occult blood

Goals of treatment are to :
Eradicate the bacteria Reduce the acid levels
Promote healing
Medications
Antibiotics Histamine2-receptor antagonists
Proton pump inhibitors Antacids Mucosal protectant
Esophagogastroduodenoscopy (EGD) – Areas of bleeding may be treated
With epinephrine or laser coagulation
Gastrectomy – All or part of the stomach is removed
Antrectomy – The antrum portion of the stomach is removed
Gastrojejunostomy (Billroth II procedure) – The lower portion of the
stomach is excised, the remaining stomach is anastomosed to the jejunum
Vagotomy – A highly selective nerve fibers that disrupt acid production
Pyloroplasty – The opening between the stomach and small intestine is
enlarged to increase the rate of gastric emptying
Common complication is
Nursing care postoperative

✓ Monitor incision for evidence of infection.
✓ Place the client in a semi-Fowler’s position to facilitate lung expansion.
✓ Monitor nasogastric tube drainage. Scant blood may be seen in first 12 to 24 hr.
✓ Notify the provider before repositioning or irrigating the nasogastric tube
(disruption of sutures).
✓ Monitor bowel sounds.
✓ Advance diet as tolerated to avoid undesired effects (abdominal distention,
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diarrhea).
✓ Administer medication as prescribed
➢ Instruct client to avoid foods that cause distress
➢ Monitor for orthostatic changes in vital signs and tachycardia as these
findings are suggestive of gastrointestinal bleeding
➢ Administer saline lavage via nasogastric tube, if prescribed
➢ Administer medication as prescribed
➢ Decrease environmental stress
➢ Encourage rest periods
➢ Encourage smoking cessation and avoiding alcohol consumption
➢ Educate the client to take vitamin and mineral supplements due to decreased
absorption after a gastrectomy, including vitamin B12, vitamin D, calcium, iron,
and float
➢ Consume small, frequent meals while avoiding large quantities of
carbohydrates as directed
Complications:
❖ Perforation & bleeding Gastro duodenal contents escape through the
perforation into the peritoneal cavity , leads to peritonitis, septicemia,
and hypovolemic shock
• Sudden, sharp pain, hematemesis or melena
• Rebound tenderness, rigid, board-like abdomen
• Knee-chest position reduces pain
• S & S OF hypovolemic shock (hypotension, tachycardia, dizziness, confusion)
Surgical treatment : cleaning the peritoneal cavity, closing the perforation,
and possibly a vagotomy and hemigastrectomy or pyloroplasty
❖ Pernicious anemia
❖ Dumping syndrome is a group of manifestations that occur following eating.
o A shift of fluid to the abdomen is triggered by rapid gastric emptying or
high-carbohydrate ingestion.
o Fluid shift into the bowel, creating a decrease in plasma volume along with
distention of the bowel lumen and rapid intestinal transit.
o The patient usually describes feelings of generalized weakness, sweating,
palpitations, and dizziness , occurs within 15 to 30 minutes of eating, last
about 1 hour after eating
Client Education to avoid Dumping syndrome
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➢ Lying down after a meal slows the movement of food within the intestines.
➢ Limit the amount of fluid ingested at one time.
➢ Eliminate liquids with meals, for 1 hr. prior to, and following a meal.
➢ Consume a high-protein, high-fat, low-fiber, and low- to moderate-
carbohydrate diet.
➢ Avoid milk, sweets, or sugars (fruit juice, sweetened fruit, honey, syrup, jelly).
➢ Consume small, frequent meals rather than large meals
Appendicitis
Appendicitis is inflammation of a narrow, blind protrusion called the vermiform
appendix located at the tip of the cecum in the right lower quadrant (RLQ) of the
abdomen.
Causes:
Common cause of appendicitis is obstruction of the lumen by accumulated feces
Obstruction results in distention; accumulation of mucus and bacteria, and venous
gangrenous which can lead to gangrene, perforation, and peritonitis
• Abdominal pain begins peri-umbical within hour, becomes localized to
the right lower quadrant at Mc-Burney’s point( midway between the umbilicus
& the right iliac crest) , pain is persistent and continuous
• Coughing, sneezing, and deep inhalation increase the pain
• Rebound tenderness (pain when manual Pressure on the abdomen is
suddenly removed)
• Rigidity of the abdomen (abdomen feels more firm when palpating)
• Low-grade fever
• Nausea, vomiting, loss of appetite & pain with defecation &urination
• Positive Rovsing’s
Examiner deeply palpates the left lower abdominal quadrant, client feels
pain in the RLQ,
• Psoas Sign
Pt. keep the right leg flexed for comfort & experience pain if
Straightened
Precautions When Assessing a Client for Appendicitis
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• Avoid multiple or frequent palpation of the abdomen (causing rupture)

• Perform the test for rebound tenderness at the end of the examination. A
positive response causes pain and muscle spasm (difficult to complete )
• Do not administer laxatives or enemas , heating pad ( rupture)
• Pain medication is used carefully preoperatively to maintain awareness of pain
(rupture of appendix)
❖ Increase pain intensity & body temperature indicates to perforation
Diagnostic Tests
CBC. reveals elevated leukocyte and neutrophil counts.
Ultrasound or CT scan reveals an enlargement in the area of the cecum.
Medical Surgical & nursing Management:

✓ The patient is kept NPO and surgery is done immediately If no perforation
or peritonitis.
✓ Cold application and semi-Fowler’s position may help reduce pain
Appendectomy Surgical removal of the appendix
After surgery
• Intravenous fluids until diet resumed.
• Pain medications & Antibiotics after surgery as needed
• The patient is usually NPO until GI functioning returns,
•The diet initially consists of clear fluids and is advanced as tolerated
•Vital signs and abdominal data are collected (peritonitis).
• Pain control to promote early ambulation
• Monitor surgical site for drainage
➢ Monitor vital signs & intake and output
➢ Assess pain level for changes.
➢ Monitor abdomen for distention, presence of bowel sounds& bowel function.
Bowel Disorders
Irritable bowel syndrome (IBS)
It is a disorder of altered intestinal motility in which the colon does not
contract in a normal pattern that lead to alternating between diarrhea and
constipation.
Etiology
• Hereditary tendency • More common in women
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• Young to middle aged • Infections the menstrual cycle

• Eating large meals containing a large amount of fat
• Caffeine & Alcohol • Stress
Clinical manifestation (S & S)
▪ Abdominal bloating & Cramping
▪ Abdominal pain due to changes in bowel pattern and consistency
▪ Nausea , Anorexia Belching , Diarrhea & Constipation
Diagnostic Tests
History and physical examination Stool examination
Barium enema Upper GI series, and Sigmoidoscopy
Medical & Nursing managements:

Medications
✓ Aldosterone (Lotronex): Indicated for IBS with diarrhea
✓ Lubiprostone (Amitiza): increases fluid secretion in the intestine to promote
intestinal motility
✓ Antispasmodics, Antidepressants
➢ Review strategies to reduce stress.
➢ Instruct the client to limit intake of irritating agents (gas-forming foods, caffeine)
➢ Encourage a diet high in fiber & high-bran
➢ Avoid foods that contain dairy, eggs, and wheat products
➢ Drink 2 to 3 L of fluid per day
➢ Eating smaller, frequent meals
➢ Stress management, behavioral therapy
Ulcerative Colitis & Crohn’s disease:

Both are An inflammatory disease of the intestine & ulcerations in the
mucosal layer.
Ulcerative colitis is usually limited to the colon , multiple ulcerations and
diffuse inflammation occur in the superficial mucosa and sub mucosa of the
colon , while ,Crohn’s disease can involve any segment of the GI tract from the
mouth to the anus, commonly occurs in the terminal ileum.
Diverticulitis is inflammation and infection of the bowel mucosa
Caused by a combination of factors of :

• environmental factors(pesticides, tobacco, radiation, and food additives)
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• genetic predisposition • infection • allergy • Psychological stress

• alterations in the function of the immune system
• diet low in fiber may predispose a client to ulcerative colitis
• smoking – Smokers (Crohn’s disease) and nonsmokers (ulcerative colitis)
The pattern of inflammation differs between ulcerative and Crohn’s disease
colitis
Clinical manifestations & Comparison of Ulcerative Colitis and Crohn’s

Disease
Characteristic Ulcerative Colitis Crohn’s Disease
Course Exacerbations, remissions Prolonged, variable,
Edema and inflammation of Inflammation and
the rectum and sigmoid ulceration of the GIT,
colon often at the distal ileum.
Clinical
Manifestations
Location Rectum, left colon Ileum, right colon
Bleeding Common—severe Usually not occur
Perianal Rare—mild Common
involvement Rare Common
Fistulae Severe Less severe
Diarrhea Less common Common
Mal-absorption
and malnutrition
Diagnostic
Study Findings
Radiography Diffuse involvement Regional, discontinuous
No narrowing of colon lesions
No mucosal edema Narrowing of colon
Sigmoidoscopy Stenosis rare Thickening of bowel wall
Shortening of colon Mucosal edema
Abnormal inflamed Stenosis, fistulae
mucosa May be unremarkable unless
accompanied by perianal
Others fistulae
Abdominal x-ray and CT scan, Barium enema,
Colonoscopy
Therapeutic Corticosteroids, Corticosteroids,
Management sulfonamides; sulfasalazine sulfonamides
Bulk hydrophilic agents Antibiotics
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Antibiotics Parenteral nutrition

Proctocolectomy, with Partial or complete
ileostomy colectomy, with
Supplemental vitamins and ileostomy or
minerals including anastomosis
vitamin B12 may needs Supplemental vitamins and
minerals including
vitamin B12
Systemic Toxic megacolon(Massive Small bowel obstruction
Complications dilation of the colon) Right – sided
Perforation Hemorrhage hydronephrosis
Malignant neoplasms Nephrolithiasis
Pyelonephritis Cholelithiasis
Nephrolithiasis Arthritis
Cholangio-carcinoma Retinitis, iritis
Arthritis Retinitis, Iritis Erythema nodosum
Erythema nodosum
Clinical manifestations specific to Crohn’s Disease

✓ Abdominal pains (unrelieved by defecation)
✓ Pains after eating, Pt. not eat to avoid the pain
✓ Poor absorption & diarrhea(< 10/24hr.) leads to weight loss
✓ Chronic diarrhea leads to fluid deficit and electrolyte imbalance
Clinical manifestations specific to Ulcerative Colitis

• Primary symptoms Abdominal pain ,profuse diarrhea with mucus, pus & blood
• Fecal urgency , Pt. passing >10 liquid stools a day
• Anorexia, weight loss, cramping, vomiting, fever, and dehydration
• Potential for fluid and electrolyte imbalance( loss of calcium).
• Anemia as a result of rectal bleeding
Lab. test findings

• Anemia—low hemoglobin and hematocrit due to blood loss and diarrhea
• Elevated erythrocyte sedimentation rate due to inflammation
• Electrolyte disturbance due to diarrhea and poor absorbance of nutrients.
Medical Surgical & Nursing Managements:

Medications : Used to:
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Relieve symptoms Induce remission Postpone surgery Improve QOL

• Anti-inflammatory • Sulfonamides • Corticosteroids
• Immunomodulators • Antidiarrheal • Vit.b12, iron
Clients who do not have success with medical treatment or who have
complications
(bowel obstruction , perforation, peritonitis & bleeding).
Colectomy with or without ileostomy
Surgical repair of fistulas
Nursing Innervations & Pt. educations:

➢ Instruct the client to seek emergency care for signs of bowel obstruction or
perforation (fever, severe abdominal pain, vomiting).
➢ Instruct clients who have extreme or long exacerbations that NPO status and
administration of TPN promotes bowel rest while providing adequate nutrition.
➢ Educate the client to eat foods that are high in protein and calories, and low
in fiber.
➢ Assist the client in identifying foods that trigger clinical manifestations.
➢ Advise the client that small frequent meals reduce occurrence of
manifestations.
➢ Inform client that dietary supplements ( high in protein and low in fiber) be
used.
➢ Monitor for electrolyte imbalance, especially potassium. Diarrhea can cause
a loss of fluids and electrolytes.
➢ Assess perianal skin for irritation , emotional status, coping skills
➢ Foods that cause gas or diarrhea avoided( high-fiber foods, caffeine, spicy
foods, and milk products).
➢ Monitor I&O , nutritional status and assess for dehydration.
➢ Educate the client regarding vitamin supplements and B12 injections, if
needed.
➢ Take history of symptoms, including the onset, duration, frequency, and
severity
➢ Teach proper skin care of perianal area to avoid skin breakdown.
➢ Teach dietary modification, and which foods to avoid.
➢ Teach medication use, schedule, and side effects.
➢ Teach importance of follow-up care.
➢ Teach wound care for postoperative patients.
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➢ Assess abdomen for bowel sounds, tenderness and masses.

➢ Assess postoperative wound for signs of infection, drainage.
➢ Wound & ostomy care postoperatively
Hemorrhoids
Hemorrhoids are dilated veins outside or inside the anal sphincter
Internal hemorrhoids usually protrude each time the client defecates but retract
after defecation, as mass enlarge remain outside the sphincter
An increased anal pressure and weakened connective tissue that normally
supports the hemorrhoidal veins are common causes
Risk Factors
✓ Chronic straining Pregnancy Prolonged constipation
✓ Prolonged sitting or standing Portal hypertension
✓ Local symptoms of burning, itching, and pain.
✓ Passing dry, hard stool causes the hemorrhoids to bleed
✓ External hemorrhoids :Small, reddish-blue lumps at the edge of the anus
✓ Internal hemorrhoids may be asymptomatic, bleed after defecation
Diagnostic tests:
•An anoscope, an instrument for examining the anal canal
•Proctosigmoidoscope, allows visualization of internal hemorrhoids
•A colonoscopy rules out colorectal cancer ,which has similar symptoms
•Visual inspection and digital examination

Warm soaks ,, Ointments, creams, suppositories, & pads that contain anti-
inflammatory agents (e.g., hydrocortisone) or / and anesthetics (e.g.,
benzocaine) used to shrink mucous membranes and relieve discomfort
Stool softeners
✓ Band ligation, infrared coagulation, cryotherapy, laser treatment(non-
surgical)
✓ Hemorrhoidectomy (surgical excision of hemorrhoids) , severe symptoms
➢ Teaching measures to prevent risk factors as constipation
➢ Be aware that even though the procedure is minor, the pain is severe.
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Opioids are usually given initially

➢ Sitz baths are started 1 or 2 days after surgery
➢ Packing inserted into the rectum to absorb drainage , it usually is removed
1-2 postoperative day
➢ Assess for rectal bleeding. The patient may be embarrassed when the
dressing is changed, and privacy should be provided.
➢ Pt. may resists the urge to defecate due to pain , so that pain medication
given
➢ before the bowel movement to reduce discomfort
➢ If the patient does not have a bowel movement within 2 or 3 days, an oil
retention
➢ enema is given.
➢ A high-fiber diet and increased fluid intake prevent constipation and reduce
straining
➢ Teach Pt. the importance of diet, care of the anal area, symptoms of
complications
Intestinal obstruction
Intestinal obstruction occurs when intestinal contents cannot pass through the
GI tract
o The obstruction may occur in the small intestine most common or colon
and can be partial or complete, simple or strangulated
o A simple obstruction has an intact blood supply, and a strangulated one does
not
o When fluid, gas, and intestinal contents accumulate proximal to the
obstruction, distention occurs
o Location of the obstruction determines the extent of fluid, electrolyte, and
acid-base imbalances
o Bowel sounds are hyperactive above the obstruction and hypoactive below
Causes classified as mechanical (90%)or non-mechanical (10%)

1. Causes of mechanical bowel obstruction
• Compression of intestine by adhesions, tumors, fibrosis
• Volvulus (twisting) or intussusception (telescoping) of bowel segments
• Hernia (bowel becomes trapped in weakened area of abdominal wall)
• Fecal impactions
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• Foreign body (parasite, coin)

2. Causes A non-mechanical bowel obstruction / Paralytic ileus
(lack of intestinal peristalsis and bowel sounds)
o Neurogenic disorders (manipulation of the bowel during major surgery and
spinal fracture) 12 to 36 hours after abdominal surgery
o Vascular disorders (emboli and atherosclerosis of the mesenteric arteries)
o Electrolyte imbalances (hypokalemia)
o Inflammatory responses (peritonitis or sepsis)
o Adverse drug effects (e.g., narcotics, cholinergic blockers).
Clinical manifestations based on location of obstruction:

Small and large Small bowel Large intestine
bowel obstructions obstructions
obstructions
 Obstipation : the inability • Severe F and E I • Minor F and E I
to pass a stool and/or flatus • Metabolic alkalosis Metabolic acidosis
for more than 8 hr. despite • Visible peristaltic • Significant abdominal.
feeling the urge waves distention
 Abdominal distention • Abdominal pain • Intermittent
 High-pitched bowel • Profuse, sudden abdominal cramping
sounds above site of projectile vomiting • Infrequent vomiting
obstruction with with fecal odor; • Diarrhea or “ribbon-
hypoactive bowel sounds vomiting relieves like” stools around an
below, absent bowel pain impaction
sounds later in process
Strangulation causes severe, constant pain that is rapid in onset.
Diagnostic Studies
✓ CT scans and abdominal x-rays are used.
✓ Sigmoidoscopy or colonoscopy may provide direct visualization of an obstruction
in the colon.
✓ An elevated WBC count may indicate strangulation or perforation.
✓ Elevated hematocrit (Hct) values may reflect hemoconcentration.
✓ Decreased hemoglobin (Hgb) and Hct values may indicate bleeding from a
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neoplasm or strangulation with necrosis.

✓ Serum electrolytes, blood urea nitrogen (BUN), and creatinine are
monitored frequently to assess the degree of dehydration.
Medical Surgical & Nursing Management: based on causes

o Initially NPO , inserting an NG tube, IV fluid therapy, adding potassium to
IV fluids after verifying renal function, and analgesics for pain control
Medications
✓ Prokinetics to promote gastric motility
✓ Broad spectrum antibiotics (strangulation)
Procedure varies based on cause of obstruction, include : lysis of adhesions,
colon resection, colostomy creation (temporary or permanent), embolectomy,
thrombectomy, resection of gangrenous intestinal tissue, or complete
colectomy.
Nursing Care
Non-mechanical cause of obstruction
➢ Nothing by mouth with bowel rest.
➢ Assess bowel sounds.
➢ Provide oral hygiene
➢ Administer IV fluid and electrolyte replacement (particularly potassium).
➢ Pain management, as prescribed (once diagnosis identified).
➢ Encourage ambulation.
Mechanical cause of obstruction

➢ Prepare for surgery and provide preoperative nursing care.
➢ Withhold intake until peristalsis resumes.
➢ Monitor vital signs for changes.
➢ Assess abdomen for bowel sounds, tenderness.
➢ Monitor intake and output.
Generally
➢ Nasogastric tube inserted to decompress the bowel
o Maintain intermittent suction as prescribed.
o Assess NG tube patency and irrigate every 4 hr, or as prescribed.
o Monitor and assess gastric output.
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o Monitor nasal area for skin breakdown.

o Provide oral hygiene every 2 hr.
o Monitor vital signs, skin integrity, weight, and I&O.
o Clamp the NG tube during ambulation.
➢ Monitor the patient closely for dehydration and electrolyte imbalances, abd. pain
➢ Provide comfort measures and promote a restful environment
➢ Measure VS, bowel sounds, urine output below 50 mL/hour indicate to shock .
➢ If an intestinal tube has been inserted, monitors its progress
Complications
● Dehydration (potential hypotension; small bowel obstruction)
● Electrolyte Imbalance (small bowel obstruction)
●Metabolic Alkalosis, vomiting, leading to a loss of gastric hydrochloride
●Metabolic Acidosis, due to non-reabsorption of alkaline fluids
Hepatobiliary dysfunction
✓ The liver is especially important in the

regulation
of glucose and protein metabolism
✓ The liver manufactures and secretes bile,
which has
a major role in the digestion and absorption of
fats
in the GI tract.
✓ It removes waste products from the bloodstream and
secretes them into the bile .
✓ The bile produced by the liver is stored temporarily in the gallbladder until
it is needed for digestion, at which time the gallbladder empties and bile enters
the intestine
✓ The liver is located behind the ribs in the upper right portion of the
abdominal cavity
Functions Of The Liver

Glucose , Drug , Protein, & Fat Metabolism Ammonia Conversion
Vitamin and Iron Storage Bile Formation Bilirubin Excretion
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Assessment Health History

If liver function test results are abnormal, the patient may need to be evaluated for :
• Was exposed to hepatotoxic substances or infectious agents .
• Patient‘s occupational, &travel history assist in identifying exposure to
hepatotoxins
• Patient‘s history of alcohol and drug use
• Lifestyle behaviors (Injectable drug use, sexual practices )
• Current and past medical conditions, previous blood transfusion
Physical Examination
o Assess the patient for pallor, jaundice (skin, mucosa, and sclera)
o Assess the extremities for muscle atrophy, edema
o Observe the skin for petechiae or ecchymosis areas, spider and palmar
erythema
o Asses patient‘s cognitive status (recall, memory, abstract thinking) and
neurologic status are assessed .
o Palpate abdomen to assess liver size and to detect any tenderness over the
liver. A palpable liver presents as a firm, sharp edge with a smooth surface
o Tenderness of the liver implies recent acute enlargement with consequent
stretching of the liver capsule .
o Enlargement of the liver is an abnormal finding requiring evaluation
Diagnostic Evaluation
• Liver Function Tests
More than 70% of the parenchyma of the liver may be damaged before liver
function test results become abnormal .
1. Serum enzyme activity (E.G. alkaline phosphatase )
2. Serum concentrations of proteins (albumin and globulins ,)
3. Bilirubin, ammonia, clotting factors, and lipids .
4. Serum aminotransferases (transaminases) are sensitive indicators of injury to
the liver cells and are useful in detecting acute liver disease such as hepatitis
.
• Liver Biopsy
• Ultrasonography, computed tomography (CT), and magnetic resonance
imaging (MRI) are used to identify normal structures and abnormalities
of the liver and biliary tree
126
• A radioisotope liver scan may be performed to assess liver size and hepatic
blood flow and obstruction
Among the most common and significant symptoms of liver disease are :
1. Jaundice, resulting from increased bilirubin concentration in the blood (
Hemolytic
Hepatocellular & obstructive)
2. Portal hypertension, ascites, and varices, resulting from circulatory changes within
the diseased liver and producing severe GI hemorrhages and marked
sodium and fluid retention
3. Nutritional deficiencies, which result from the inability of the damaged liver
cells to metabolize certain vitamins ;
4. Hepatic encephalopathy or coma, reflecting accumulation of ammonia in the
serum due to impaired protein metabolism by the diseased liver
5. Edema and Bleeding
6. Pruritus (severe itching)and Other Skin Changes
Liver Cirrhosis
Cirrhosis is a chronic progressive disease of the liver characterized by
extensive degeneration and destruction of liver cells
Types & Risk Factors of Cirrhosis

A. Alcoholic Cirrhosis
• In which the scar tissue characteristically surrounds the portal areas.
• Caused by chronic alcoholism
B. Post necrotic cirrhosis
• In which there are broad bands of scar tissue.
• Caused by viral hepatitis or certain medications or toxins
C. Biliary Cirrhosis
• In which scarring occurs in the liver around the bile ducts.
• Caused by chronic biliary obstruction or autoimmune disease
• Early symptoms include:
Anorexia Dyspepsia Flatulence Nausea & Vomiting
Change in bowel habits (diarrhea or constipation) Ankle edema
Fever and Abdominal Pain Unexplained epistaxis
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• Later manifestations , severe and result from liver failure and portal
hypertension includes :
o Jaundice due to decreased ability of the liver to conjugate and excrete bilirubin
o Weight loss due to metabolism deficiency , Hypotension from bleeding
o Ascites (accumulation of serous fluid in the peritoneal or abdominal cavity)
o Peripheral Neuropathies Clubbing & White of fingers nails
o Dependent peripheral edema of extremities and sacrum
o Palmar erythema (redness, warmth of the palms of the hands)
o Spider angiomas (red lesions, vascular in nature with branches radiating on
the nose, cheeks, upper thorax, shoulders) . Skin lesions result from an increase
in circulating estrogen because the liver cannot metabolize steroid hormones
o Liver Becomes Small And Nodular
o Asterixis (liver flapping tremor) characterized by rapid, non-rhythmic extension
o and flexion of the wrists and fingers
o Fetor hepaticus (liver breath) – fruity or musty odor
o Petechiae (round, pinpoint, red-purple lesions)
o Ecchymosis (large yellow and purple-blue bruises)
o Nosebleeds, hematemesis, melena (decreased synthesis of prothrombin, &
deteriorating hepatic function)
o Hematologic disorders such as anemia, leukopenia, and thrombocytopenia
are probably caused by splenomegaly that results from backup of blood from
the portal vein into the spleen (portal hypertension). Coagulation problems
result from the liver’s inability to produce prothrombin and other factors
essential for clotting.
o Sodium and water retention and potassium loss occur as a result of
hyperaldosteronism
Possible Diagnostic findings

• Increased unconjugated and conjugated bilirubin levels
• Increased enzyme levels of AST (SGOT), ALT (SGPT), and GGT
• Low RBC count—cells appear large
• Decreased leukocytes and thrombocytes
• Low fibrinogen level
• Prolonged PT
• Decreased platelet count
• Low serum albumin level
• Increased globulin level
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• Hypokalemia
• Abdominal x-rays show hepatomegaly.
• Abdominal CT scan shows hepatomegaly, ascites.
• Ultrasound shows hepatomegaly, ascites, and portal vein blood flow.
• Liver biopsy shows fibrosis and regenerative nodules.
• Esophagogastroduodenoscopy (EGD) to detect esophageal varices.

Medications Administrations of:
✓ Diuretics: Decrease excessive fluid in the body
✓ Beta-blocking agent: Used for clients who have varices to prevent bleeding
✓ Lactulose (Cephulac): Used to promote excretion of ammonia from the
body through the stool
✓ Non absorbable antibiotic
❖ Paracentesis , used to relieve ascites Discussed Practically
❖ Endoscopic variceal ligation
Surgical:
Surgical bypass shunting Liver transplantation
➢ Monitor oxygen saturation levels
➢ Provide comfort measures
➢ Have the client sit in a chair or elevate the head of the bed to 30° with feet
elevated (ascites)
➢ In the presence of ascites, measure abdominal girth daily
➢ Observe the client for potential bleeding complications & encourage
bleeding precautions
➢ Monitor the client closely for skin breakdown
➢ Encourage washing skin with cold water and applying lotion to decrease the
itching
➢ Monitor the client for signs of fluid volume excess
➢ Keep strict intake and output, obtain daily weights, and assess ascites and
peripheral edema
➢ Monitor vital signs and pain level
➢ Monitor the client for deteriorating mental status(LOC)
➢ Maintain on nutritional status ( High-carbohydrate, high-protein, moderate-
fat, and low-sodium diet with vitamin supplements)
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Nutrition Notes for Client with Cirrhosis

• It is individualized according to symptoms and tolerance
• Fat is restricted for clients with fat malabsorption (steatorrhea).
• Sodium is restricted to 2–3 g per day when ascites is present.
• Fluid restriction is imposed in clients with hyponatremia & edema
• A high-calorie diet is recommended for clients with malnutrition, weight
loss, or infection.
• Adequate calories are essential to ensure protein sparing.
• A high-protein diet is used to prevent muscle wasting
• A carbohydrate controlled diet is used for clients with diabetes or insulin resistance.
• Small frequent meals and the use of nutritional supplements
Hepatitis
Hepatitis is an inflammation of the liver cells
Common Risk factors:

❖ Exposure to hepatotoxic chemicals or drugs
❖ After lengthy alcohol abuse
❖ Invasion with an infectious microorganism
❖ Viral hepatitis is the most common type
Prevention Strategies
✓ Community health educational interventions on transmission
✓ Follow vaccination recommendations according to the CDC
✓ Follow isolation precautions according to the CDC.
✓ Reinforce and use safe injection practices.
- Aseptic technique for the preparation and administration of parenteral medications.
- Sterile, single-use, disposable needle and syringe for each injection.
- Use single-dose vials as often as possible.
- Use needleless systems or safety caps.
✓ Use personal protective equipment, such as gown, gloves, and goggles,
appropriate to the type of exposure.
o Hepatitis A: Incontinent clients.
o Hepatitis B or C: Exposure to blood
✓ Proper hand hygiene (before preparing and eating food, after using the toilet
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or changing a diaper).
✓ When traveling to underdeveloped countries, drink purified water, and
avoid sharing eating utensils and bed linens
Type Route of Risk Factors
Transmission Infectivity
Hepatitis A ▪ Fecal-oral oClose personal contact Most infectious during 2
(HAV) route with an infected wk. before onset of
▪ Ingestion of individual( feces symptoms. Infectious
contaminated saliva)
until 1-2 wk. after the
food or water oInfected water, food,
and equipment start of symptoms
Hepatitis B ▪ Blood oUnprotected sex with Before and after
(HBV) infected individual symptoms appear.
oInfants born to Infectious for 4-6 mo.
infected mothers
Carriers continue to be
oContact with infected
blood, plasma; infectious for life
needles, syringes,
surgical or dental
equipment
oInjection drug users
oSexually transmitted
Hepatitis C ▪ Blood o Drug abuse 1-2 wk. before
(HCV) o Sexual contact symptoms appear.
Continues during
clinical course. 75%-
85% go on to
develop chronic
hepatitis C and
remain
Hepatitis D ▪ Coinfection o Same as HBV
(HDV) with HBV
Hepatitis E ▪ Fecal-oral o Ingestion of
(HEV) route contaminated
food or water
o Poor sanitation
Risk Factors for Acquiring Blood-borne Hepatitis

• History of illicit IV drug use
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• Occupational exposure through sharps injuries

• Perinatal exposure (child born to woman who has hepatitis)
• Blood transfusion
• Organ transplant
• Impaired immune response
• Exposure to contaminated equipment that penetrates the skin
• Sexual contact with infected person
• Hemodialysis
A. Incubation Period: virus replicates within the liver, virus found in blood,
bile, and stools (for hepatitis A). At this point, the client is considered infectious
Anorexia Fatigue Nausea & Occasional Vomiting
Right Upper Quadrant Abdominal Discomfort
Headache Low-Grade Fever Skin Rashes
B. Acute Phase : Icteric ( Jaundice) Or Anicteric
darken urine stools light or clay colored Pruritus
C. Convalescence/ Post icteric phase begins as jaundice is disappearing:
liver enlargement, malaise, and fatigue; other symptoms subside; liver function
tests begin to return to normal

Medications
✓ Hepatitis A & B Immunization is recommended pre-exposure prophylaxis
✓ Post exposure prophylaxis, the vaccine and hepatitis B immune globulin
(HBIG)
✓ hepatitis A immune globulin (HAIG) are used
✓ No specific treatment for acute viral hepatitis
✓ Supportive : antiemetic’s
✓ Antiviral medications
✓ Combination therapy (interferon & ribavirin)
✓ Nucleoside and nucleotide analogs
✓ Adequate nutrients and rest seem to be most beneficial for healing and liver
cell regeneration
✓ B-complex vitamins and vitamin K, are frequently used
✓ If anorexia, nausea, and vomiting are severe, IV solutions of glucose or
supplemental enteral nutrition therapy may be used
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Aimed to relief of discomfort, resume normal activities, and return to normal
liver function without complications
➢ Most clients will be cared for in the home unless they are acutely ill.
➢ Enforce contact precautions if indicated.
➢ Limit the client’s activity in order to promote hepatic healing.
➢ Provide a high-carbohydrate, high-calorie, low- to moderate-fat, and low- to
moderate-protein diet, and small, frequent meals to promote nutrition and
healing.
➢ Small, frequent meals may be preferable to three large ones
➢ To promote hepatic rest and the regeneration of tissue, administer only
necessary medications.
➢ Monitor vital signs.
➢ Assess abdomen for bowel sounds, tenderness, ascites
➢ Educate the client and family regarding measures to prevent the
transmission of the disease with others at home (avoid sexual intercourse until
hepatitis antibody testing is negative, avoid alcohol, avoid over-the-counter
medications or herbal medications, use proper hand hygiene).
➢ Comfort measures to relieve pruritus
➢ Diversional activities, such as reading and hobbies, help in reduce stress.
➢ Measures to stimulate the appetite, such as mouth care, attractively served
meals in pleasant surroundings
➢ Assess the patient for Bleeding tendencies, symptoms of encephalopathy
➢ Instruct the patient to have regular follow-up for at least 1 year after
the diagnosis of hepatitis & teaching regarding drugs
Preventive measures for HAV include :

▪ personal and environmental hygiene
▪ health education to promote good sanitation
▪ hand washing is essential and is probably the most important precaution
▪ teach about careful hand washing after bowel movements and before eating
For HBV prevention:
• best way to reduce HBV infection is to: identify those at risk, screen them
for HBV, and vaccinate those who are not infected
• good hygienic practices(hand washing and using gloves when expecting
contact with blood & blood products)
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• close contacts of the patient who are HBsAg negative and antibody
negative
should be vaccinated
• sexual precautions & partner should be vaccinated
• razors, toothbrushes, and other personal items should not be shared
• screening of blood, organ, and tissue donors
• drug abuse preventions
Prevention HCV , are similar to those for HBV but no vaccine available
Surgical: in sever encephalopathy
• Liver transplantation.
Disorder of the Gallbladder
Gallbladder
• It is a pear shaped, hallow sac like organ
• 7.5 to 10 cm long (3 to 4 inches)
• Lies in a shallow depression on the inferior surface of the liver , connected
to the common bile duct by the cystic duct
Function of gallbladder
o Storage depot for bile.
o During storage, water in bile is absorbed, so that bile is more concentrated
o When food enters the duodenum, the gallbladder contracts and the sphincter
of allows the bile to enter the intestine
o The bile salts assist in emulsification of fats in the distal ileum
Cholecystitis & Cholelithiasis

Cholecystitis: inflammation of the gallbladder
Cholelithiasis: the presence of calculi in the gallbladder
Cholecystectomy: removal of the gallbladder
Cholecystostomy: opening and drainage of the gallbladder
Etiology
• Calculouscholecystitisis the cause of more than 90% of cases of acute
cholecystitis
• Bacteria play a minor role in acute cholecystitis
• Stasis of bile in the gallbladder
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• Gallstones obstructing the cystic and/or common bile ducts Causing bile to
back up and the gall bladder to become inflamed from chemical reaction &
compromising its vascular supply
Risk Factors for Cholelithiasis:

Cause of gallstones is unknown. Cholelithiasis develops when the balance
that keeps cholesterol, bile salts, & calcium is altered so that these substances
precipitate
o More common in females after 40 years of age
o High-fat diet , Sedentary lifestyle
o Obesity (impaired fat metabolism, high cholesterol)
o Genetic predisposition
o Individuals who have type 1 diabetes mellitus (high triglycerides)
o Low-calorie, liquid protein diets
o Rapid weight loss (increases cholesterol)
Two major types of gallstones : Composed of pigment Composed of
cholesterol
✓ Symptoms develop when gallstones partially or totally impair the passage of
bile, causing the gallbladder to become inflamed, swollen, and distended with
bile.
✓ Each time the person eats fatty foods, cholecystokinin( a hormone secreted
by the small intestine) stimulates the gallbladder to send bile for digestion. The
gallbladder responds by contracting forcefully. Digestion problems result from
the reduced or absent bile.
✓ Discomfort results from a combination of the inflammation and contractile
spasms.
✓ If swelling remain unrelieved, the gallbladder become necrotic or rupture,
leading to peritonitis.
o Sharp pain in the right upper quadrant(RUQ), often radiating to the right
shoulder
o Pain with deep inspiration during right subcostal palpation (Murphy’s sign)
o Intense pain (increased heart rate, pallor, diaphoresis) with nausea and
vomiting after ingestion of high-fat food 3to 6 hours
o Rebound tenderness (Blumberg’s sign; performed by the provider only)
o Dyspepsia, eructation (belching), and flatulence
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o Jaundice, urine dark brown; the stools light-colored, steatorrhea (fatty

stools), , and pruritus (accumulation of bile salts in the skin)
o Acute cholecystitis, clients usually are very sick with fever, vomiting,
tenderness over the liver, and severe pain last up to 1 hour called biliary colic
Complications
• Massive infection of the gallbladder, it becomes filled with pus (empyema).
• Perforation of the gallbladder, resulting abdominal infection (peritonitis)
• Formation of abnormal connections between the gallbladder and other organs
(the duodenum, large intestine, stomach), fistulas.
• Obstruction of the intestine by a very large gallstone (gallstone ileus).
• Gangrenous cholecystitis
• Sub phrenic abscess pancreatitis
• Cholangitis (inflammation of biliary ducts), biliary cirrhosis
• Bleeding caused by vitamin K deficiency
Diagnostic TESTS
o Ultrasonography
o Cholecystography
o Endoscopic retrograde cholangio-pancreato-graphy(ERCP)
o Percutaneous-trans-hepatic-cholangiography
o Ultrasound visualizes gall stones and a dilated common bile duct.
o An abdominal CT scan visualize calcified gallstones & an enlarged gall
bladder.
o A hepato -biliary scan (HIDA) assesses the patency of the biliary duct
system after an IV injection of contrast.
Medical Surgical Nursing Managements:

Medications
Analgesics :Morphine sulfate
Bile Acid: gradually dissolves cholesterol-based gall stones, with few
adverse effects
Extracorporeal shock wave lithotripsy (used to break up stones)
Surgical
Cholecystectomy :removal of the gallbladder with a laparoscopic or open
approach
A T-tube may be placed in the common bile duct
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Care of the T-tube

➢ Monitor and record drainage (initially bloody, then green-brown bile).
➢ Expect more than 400 mL of drainage in 24 hr initially, with gradual
decrease in amount.
➢ Instruct client to report an absence of drainage with manifestations of
nausea and pain (may indicate obstruction in the T-tube).
➢ Instruct client to report sudden increases in drainage or amounts exceeding
1,000 mL/day.
➢ Inspect the surrounding skin for evidence of infection or bile leakage( foul
odor, pain, fever)
➢ Maintain flow by gravity and do not raise drainage bag above level of
gallbladder.
➢ Empty the drainage bag every 8 hr.
➢ Clamp the tube 1 to 2 hr before and after meals to assess tolerance to food
post
cholecystectomy, and prior to removal.
➢ Assess stools for color (stools clay-colored until biliary flow is
reestablished).
➢ Monitor for bile peritonitis (pain, fever, jaundice).
➢ Resume activity gradually. Avoid heavy lifting for 4 to 6 weeks
➢ Monitor and document response to food.
Nursing Intervention
• Monitor vital signs
• Assess pain level for adequate pain control.
• Assess postoperative wound for drainage, signs of infection.
• Encourage a low-fat diet (reduce dairy products and avoid fried foods,
chocolate, nuts, gravies).
• Small, frequent meals may be more easily tolerated.
• Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli).
• Promote weight reduction.
• Instruct client to take fat-soluble vitamins or bile salts as prescribed to
enhance absorption and aid with digestion.
Nursing care plan for common GIT diagnosis examples
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ND: Imbalanced Nutrition Less Than Body Requirements related to:

Abdominal distention and discomfort , dysphagia, anorexia , impaired
absorption ,metabolism, nausea and vomiting, high metabolic needs poor
nutritional intake, dietary restrictions, & altered oral mucous membranes .
Expected outcome: Client will maintain weight and optimal nutritional status ,
no further loss of muscle mass.; & meets nutritional requirements
(Pt. Maintenance of adequate nutritional intake)
Interventions Rational
1. Assess nutritional status: 1. Baseline data allow for
a. Weight changes monitoring of changes and
b. Laboratory values (serum electrolyte, evaluating effectiveness of
BUN, creatinine, protein, transferrin, and interventions.
iron levels)
2. Assess patient's nutritional dietary 2. Past and present dietary patterns
patterns: are considered in planning meals.
a. Diet history
b. Food preferences
c. Calorie counts
3. Assess for factors contributing to 3. Information about other factors
altered that may be altered or eliminated to
nutritional intake: promote adequate dietary intake is
a. Anorexia, nausea, or vomiting provided.
b. Diet unpalatable to patient
c. Depression, physiologic status
d. Lack of understanding of dietary
restrictions
e. Stomatitis
4. Provide patient's food preferences within 4. Increased dietary intake is
dietary restrictions. encouraged.
5. Promote intake of high biologic value 5. Complete proteins are provided
protein foods: eggs, dairy products, meats. for positive nitrogen balance needed
for growth and healing.
6. Alter schedule of medications so that 6. Ingestion of medications just
they are not given immediately before before meals may produce anorexia
meals. and feeling of fullness.
7. Explain rationale for dietary restrictions 7. Promotes patient understanding of

relationships between diet and urea
and creatinine levels to renal
disease.
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8.Provide written lists of foods allowed and 8. Lists provide a positive approach
suggestions for improving their taste. to dietary restrictions and a
reference for patient and family to
use when at home.
9.Provide pleasant surroundings at meal- 9. Unpleasant factors that contribute
times. to patient's anorexia are eliminated.
10.Weigh patient daily. 10. Allows monitoring of fluid and

nutritional status.
11.Elevate the head of the bed during meals 11. Reduces discomfort from
abdominal distention and decreases
sense of fullness
12.Offer a diet as prescribed / Consult with 12.provide nutritional meals that
dietitian complement the prescribed diet
13.Encourage client to increase activity. 13.Increased activity promotes
appetite
14.Administer vitamins supplementations 14.May needed for adequate
as orders nutritional intake
15. Provide oral hygiene before meals and 15.Promotes positive environment
pleasant environment for meals at meal and increased appetite; reduces
time unpleasant taste
16. Offer smaller, more frequent meals 16.Decreases feeling of fullness,
bloating
17.Encourage patient to eat meals, 17.Encouragement is essential for
the
patient with anorexia
18.Administer antiemetic’s before meals 18.Prevent nausea and vomiting
19.Provide attractive meals 19.Promotes appetite and sense of
well-being
20.Eliminate alcohol, & irritant food & 20.Reduces GIT symptoms and
drinking that aggravate discomfort discomforts
21. Instruct client to maintain a record of 21.This method helps client to track
nutritional intake and any problems with GI and avoid foods that cause GI
symptoms during or after meals. symptoms
22.Calculate caloric need 22.Meet nutritional requirements
23Ask family members to assist with meal 23.Enhance the client’s ability to eat
planning preferred foods
24Administer NGT feedings , TPN as 24.Provide adequate calories,
ordered Maintain feeding schedule, drip nutrition, and fluid replacement and
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rate, and amount administered support metabolic needs
ND: Acute Pain . related to mucosal erosion, surgical incision, inflammation,

infections, perforation.
Expected Outcome: Client will report that analgesics relieve pain
Interventions Rationales
Monitor pain level using pain rating scale Identify pain level &timely intervention
Identify factors that increase pain
Ask about for factors precipitating and Develop teaching plan
relieving pain
Document the character of the pain
Instruct patient regarding factors that Enhance management of condition
aggravate pain
Instruct patient to avoid foods that cause Avoid pain
discomfort
Administer analgesics as ordered. Provides maximum and effective pain
control
Teach client to splint incision when Splinting reduces pain and discomfort
moving or coughing.
Maintain patency of nasogastric and drains Preventing pressure of accumulated
if present. fluids and reducing pain
Provides calories for energy, sparing Promote wound healing
protein for healing
Appropriately covered Wound with sterile Prevent wound infection
dressings &change frequently
Encourage client to remain on bed rest These measures relieve pressure and
when experiencing discomfort, changing promote comfort
position frequently
Explain the pain management regimen Adequate explanations help the client
understand implementation of the pain-
control plan
Instruct client in non-pharmacologic supplement pain medications and
techniques to relieve pain improve comfort level.
Monitor vital signs Indicate acute pain is present
Provide comfort measures(position) Improve circulation and reduce tension
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associated with pain

Use relaxation techniques Enhance relaxation and improve pain
relief
Ensure functioning of NG tube, & drains Prevent distention and increased pain
Monitor for S&S of infection Infection, can increase pain level
Assess religion, culture, beliefs, and Determine impact on patient’s pain and
environments response to interventions
ND: Anxiety related to diagnostic test results, diagnosis, and surgical procedure.
Expected Outcome: Anxiety will be mild as evidenced by a calm appearance,
appropriate questions, and expressions of fear.
Interventions Rationales
Provide time for client to verbalize fears Being present and supportive
and express needs related to diagnosis and encourages communication
surgery
Allow client to express his or her personal Expressing feelings without being
reaction to the threat to well-being. judged can help reduce fears
Explain tests, procedures, and surgery, Education helps to increase coping
using nonmedical speech and allowing time skills
for questions.
Keep client informed of progress and Adequate explanations make clients
explain delays or changes in plans feel more secure and less anxious
If surgery is emergent (such as in GI Family members will have decreased
hemorrhage), provide explanations to anxiety and be less anxious and better
family member and anticipate questions and able to provide support when seeing
concerns that client will have after surgery. client after surgery
Using nonmedical language Providing understandable explanations
helps client learn information
effectively.
Explaining reasons for procedures Promotes cooperation & express feeling
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Nursing Care Management of Clients With Hematologic Disorders

Outlines:
1. Overview of the structure and function of the hematologic system.
2. General assessment of hematologic system.
3. Diagnostic procedures specific to blood disorders.
4. Blood disorders:
a) Anemia:
▪ Iron deficiency anemia.
▪ Pernicious anemia.
▪ Aplastic anemia.
▪ Sickle cell anemia.
▪ Thalassemia major (Cooley's anemia).
▪ Nursing care for anemic patient (all types of anemia).
▪ Nursing care for sickle cell crisis.
b) Disseminated intravascular coagulopathy.
c) Leukemia.
Objectives
At the end of this chapter the student will be able to:
1. List the component and function of the hematopoietic system
2. Define the related terms
3. Describe the relevant assessments of hematopoietic system
4. Recognize the diagnostic tests commonly performed to diagnose hematopoietic
system disorders
5. Identify the Common risk factors, S &S of hematopoietic system disorders
6. Discuss the nursing management of clients with hematopoietic system
disorders
7. Explain common therapeutic measures used for patients with hematopoietic
system disorders
8. Apply nursing Care plan related to hematopoietic system disorders
9. Provide health education to patients & their family related to hematopoietic
system disorders
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Overview of the structure and function of the hematologic system:

Hematology:
The scientific study of the structure and functions of blood in health and illness.
Blood:
It is the circulatory fluid of the CVs which is circulating constantly through a
closed circuit of tubes.
The hematologic system includes the bone marrow, blood, and blood
components.
Bone marrow, the soft tissue that fills spaces in the interior of the long bones
and spongy bones of the skeleton, manufactures blood cells
Hematologic assessment and diagnostic procedures evaluate blood function
by testing indicators such as erythrocytes (RBC), leukocytes (WBC), platelets,
and coagulation times.
Functions of Blood Components:
COMPONENT FUNCTION
Blood Cells
o Erythrocytes (RBC)  Transport oxygen
o Leukocytes (WBC)  Protect against infection
o Platelets(thrombocytes)  Participate in clotting blood
Plasma :Water  Circulates blood cells and non-cellular
components
 Contributes to blood pressure
 Transfers to other fluid compartments as needed
Plasma proteins
o Albumin  Affects intravascular osmotic pressure
o Fibrinogen  Participates in clotting blood
o Globulin  Carries other protein substances
o Clotting factors  Convert a loose blood clot to a stabilized
blood clot
Nutrients
o Glucose  Provides source of immediate energy
o Amino acids  Provide components for cell growth
o Lipids and repair
o Vitamins  Provide a reserve for cellular energy in
o Electrolytes the absence of glucose
o Hormones  Participate in essential
o Wastes (carbon dioxide, physiologic functions
drug metabolites)  Facilitate a variety of biochemical actions
Perform multiple endocrine functions
 Prevent toxicity when bio-transformed
and excreted
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Characteristics of blood:
• Volume: female: 4-5 l. , Male: 5-6 l.
• Temperature: 38 C (100.4 F)
• PH: 7.35- 7.45
• Viscosity: Whole blood: 4.5- 5.5, plasma : 2
• Specific gravity: 1.048 to 1.o66
Hematopoiesis:
• Process of blood cell production.
• At birth: it is accomplished in the liver,
spleen, thymus, lymph nodes, and red bone marrow.
• After birth: it is confined in the red bone marrow (but some WBCs are still
produced in the lymphatic tissues).
• During childhood: all blood cells are essentially produced in marrow sites
of the flat bones of the skull, clavicle, sternum, ribs, vertebrae, and pelvis.
• After puberty: hematopoiesis becomes localized within the flat bones of the
sternum, ilium, ribs, and vertebrae, sometimes occurring in the proximal ends of
long bones (humorous, and femur).
• All formed elements come from one stem cell or the hemo-cytoblast. Cell
differentiation gives rise to the cell lines with the help of growth factors.
RBCs (Erythrocytes) have a thin membrane through which O2 & CO2 pass
freely. Their major function is to transport O2 to and remove CO2 from the
tissues , its production is regulated by erythropoietin , a hormone released
by the kidneys .
RBC production by red bone marrow , influenced by the blood oxygen level.
Hypoxia stimulates kidneys to secrete erythropoietin, which increases the rate
of RBC production and thus the oxygen-carrying capacity of the blood
The red color of blood is caused by hemoglobin, an iron containing pigment
attached to erythrocytes.
Hematocrit is the percentage of blood cells in a volume of blood
WBCs (leukocytes) migrate from the blood into body tissues to search for and
destroy potentially harmful substances
Plasma , liquid portion of the blood and is about 91% water reminder is
plasma protein. It is the transporting medium for nutrients, wastes, hormones,
enzymes, electrolytes
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Platelets (thrombocytes) are involved in all mechanisms of hemostasis:

vascular spasm, platelet plugs, and chemical clotting, two thirds of platelets
circulate in the blood and one third are sequestered in the spleen, where they
remain unless needed
When a blood vessel is injured, platelets migrate to the injury site. The
platelets release a substance known as glycoprotein IIb / IIIa, which causes the
platelets to adhere and form a clot, that occludes the injured vessel
General assessment of hematologic system:

➢ Assess Client History To :
• Experiences prolonged bleeding from an obvious injury.
• Has unexplained blood loss, as in rectal bleeding, nosebleeds, bleeding gums,
or vomiting blood.
• Feels fatigued with normal activities.
• Becomes dizzy or faints.
• Bruises easily.
• Has frequent infections.
• Feels discomfort in the axilla , groin, or neck.
• Has difficulty swallowing, with localized throat tenderness.
• Has had surgery with lymph node removal or splenectomy, is undergoing
treatment for cancer, or has renal failure—all of which may affect blood cell
volume or lymphatic circulation
• Dietary history & drug history of prescription
➢ Chief Complaint
◗A patient with a hematologic disorder may report any of the following :
aching bones, anorexia, bleeding gums, bruising, dyspnea, fatigue, infection,
lethargy, malaise, nausea, nosebleeds, numbness, paresthesia, swollen and
tender lymph nodes, tarry stools, tingling, vomiting, and, in women, heavy
menses
➢ Questions the patient about his present illness
◗Ask the patient about his symptoms, including when they started, associated
symptoms, location, radiation, intensity, duration, and frequency
◗ Question the patient about what factors make the symptoms feel better or worse
➢ Assesses the family history
• Ask about a family history of blood and lymph disorders, acquired and
genetic
145
• Ask about a family history of cancers involving the blood or lymph

systems
➢ Obtains a social history
◗ Question the patient about use of cigarettes, alcohol, and recreational
drugs
◗ Ask him about occupational or household exposure to radiation or
chemicals
➢ Physical assessment
Inspection
✓ Observe the patient’s general appearance; does he appear alert, confused,
tired, or irritable?
✓ Note the patient’s skin color (normal, extreme redness, pallor), temperature,
and ecchymosis; look for bruising, diaphoresis, dyspnea, lesions, petechiae,
and swelling of the lymph nodes
✓ Note the size and color of his tongue ,tonsils for size and appearance
✓ Ask the patient whether his abdominal girth is enlarged
Auscultation
• Listen to heart sounds, noting abnormal sounds, rhythms, or tachycardia
• Auscultate the abdomen, noting bowel sounds, bruits, friction rubs, or
venous hums
Palpation
◗ Palpate the lymph nodes, noting consistency, mobility, shape, size, location,
and
tenderness; compare nodes on one side of the body with those on the other
side
◗ Palpate the abdomen, noting ascites, enlarged organs, or tenderness
Percussion
◗ Percuss the liver and spleen to estimate size
◗ Note the size and location of other abdominal organs
➢ Diagnostic procedures:
Complete blood count (CBC)
It is a series of tests that include RBC, WBC, MCV, MCH, Hg , and HT
146
Test Reference Range Purpose for Test

RBC • Females: 4.2 to 5.4 o Decreased level can be
million/uL evidence of anemia
• Males: 4.7 to 6.1
million/uL
WBC 5,000 to 10,000/uL ›› ➢ Elevated level can be
evidence of infection.
➢ Decreased level can be
evidence of
immunosuppression
MCV 80 to 95 mm3 ➢ Elevated level can be
evidence of macrocytic
(large) cells, possible
MCH 27 to 31 pg/cell anemia.
➢ Decreased level can be
evidence of microcytic
(small) cells, possible iron
deficiency anemia
Iron Females: 60 to 160 ➢ Elevated level can be evidence of
mcg/dL hemochromatosis, iron excess,
Males: 80 to 180 mcg/dL liver disorder, or megaloblastic
anemia.
➢ Decreased level can be evidence
of iron deficiency anemia, or
hemorrhage.
Platelets 150,000 to 400,000 mm3 ➢ Increased level can be evidence
of malignancy or polycythemia.
➢ Decreased level can be evidence
of autoimmune disease, bone
marrow suppression, or enlarged
spleen.
Hg Females: 12 to 16 g/dL Decreased level can be evidence
Males: 14 to 18 g/dL of anemia
HT Females: 37 to 47% Decreased level can be evidence
Males: 42 to 52% of anemia
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Prothrombi ➢ Increased time can be

n Time 11 to 13 seconds evidence of deficiency or
PT clotting.
➢ Decreased time can be
evidence of vitamin K excess.
activated ➢ Measures the intrinsic
Partial clotting factors.
Thrombopla ➢ Monitored for heparin
stin Time 30 to 40 seconds therapy.
aPTT ➢ Increased time can be
evidence of hemophilia,
disseminated
intravascular coagulation
(DIC), or liver disease.
D-dimer 0.43 to 2.33 mcg/mL ➢ Measures hypercoagulability
of the blood.
➢ Elevated level indicates clot
formation has occurred
Fibrinogen 170 to 340 mg/dL ➢ Reflects available fibrinogen for
levels clotting.
➢ Decreased levels may indicate
decreased ability to clot.
Fibrin Less than 10 mcg/mL ➢ Increases when clot dissolving
degradation activity (fibrinolysis) is
products occurring.
➢ Monitors efficacy of
medications for DIC.
Bone Marrow Aspiration/Biopsy

▪ To definitively diagnose cell type and to confirm or rule out malignancy.
▪ Marrow is examined for the types and percentage of immature and maturing
blood cells
▪ to diagnose causes of blood disorders, such as anemia, thrombocytopenia,
leukemia and other cancers, and infection
Nursing responsibilities before procedure:
▪ Explain the procedure to the client
148
▪ Check the client’s medical record for history of allergies

▪ Ensure that the client has signed the informed consent form.
▪ Inform client may feel pressure and brief pain during the aspiration
▪ Administer a sedative if prescribed
Nursing responsibilities during procedure:
▪ Position the client in a prone or side lying position to expose the iliac crest
▪ Clean patient skin with antiseptic solution.
▪ Attach a pulse oximeter to the client’s finger to monitor oxygenation that
may be compromised when conscious sedation is used
▪ Assist the provider with the test/procedure as needed.
▪ As appropriate, apply pressure to the biopsy site to control bleeding.
▪ As appropriate, place a sterile dressing over the biopsy site.
Nursing responsibilities after procedure:

➢ Monitor for evidence of infection (fever, increased WBCs, pain, and swelling
at the site) and bleeding.
➢ Instruct the client to lie on the site for at least 10 minutes
➢ Limit the client’s activity for approximately 30 minutes after the procedure.
➢ Apply ice to the biopsy site if prescribed.
➢ Avoid aspirin and other medications that affect clotting.
➢ Teach the client to report excessive bleeding and evidence of infection
➢ Teach the client to check the biopsy site daily
➢ If sutures are in place, remind the client to return in 7 to 10 days to removed
➢ Report prolonged bleeding, unusual pain at the site that is unrelieved by
analgesics, fever, and other signs of an infection such as swelling and purulent
drainage.
➢ Delay bathing or showering for 24 hours.
Peripheral Blood Smear:

To determine the variations/ abnormality in RBCS, WBCS and platelets: normal
size
and shape (normocytic), normal color (Normochromic).
Direct Anti-globulin Test (Comb’s test):
Used in cross matching blood when transfusion reaction occurs, test umbilical
cord for erythro-blastosis fetalis and diagnose acquired hemolytic anemia.
Indirect Anti-globulin Test:
149
Identify antibodies to RBCs antigens in the serum of clients who have greater
than normal chance of developing transfusion reactions.
Reticulocyte count:
Used to determine the responsiveness of the bone marrow to the depletion of
circulating RBCs (probably due to hemolytic anemia or hemorrhage).
Blood Disorders: Anemia
Anemia is a deficiency in the number of RBC , the quantity of hemoglobin
(Hg ),
and/or the volume of packed RBCs (hematocrit). Classifying Anemia:
Morphologic classification is
Most anemias result from: based on erythrocyte size and
✓ Massive blood loss (Trauma) color
Etiology of the anemia
✓ Impaired production of erythrocyte
Give an examples?
✓ Destruction of normally formed RBCs.
The most common types include : hypovolemic anemia, iron deficiency anemia,
pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and
hemolytic anemias
❖ Each form of anemia has unique manifestations, all share a common core
of symptoms:
Inadequate Compensatory Decreased RBC
RBC Mechanisms for Lost Function
Volume RBC Function
• Orthostatic • Tachycardia • Dyspnea
hypotension • Tachypnea • Chest discomfort
• Thready • Cool, clammy skin • Acidosis
pulses • Amenorrhea • Constipation
• Oliguria • Headache
• Heart • Vertigo Pallor
murmur • Difficulty
concentrating
• Decreased bowel
sounds
Manifestations based on Severity of Anemia
150
Body Mild Moderate Sever

SystemHg 10 to 14 Hg 6 to 10 g/dL Hg <6 g/dL
g/dL
Integumen None None Pallor, jaundice, pruritus
tary
Eye None None Icteric conjunctiva and sclera,
retinal hemorrhage, blurred
vision
Mouth None None Glossitis, smooth tongue
CVS Palpitati Increased Tachycardia, increased pulse
ons palpitations, pressure, systolic murmurs,
“bounding angina, heart failure, MI
pulse"
Pulmo Exertion Dyspnea Tachypnea, orthopnea,
nary al dyspnea at rest
dyspnea
Neurol None Roaring in Headache, vertigo, irritability,
ogy the ears depression, impaired thought
GIT None None Anorexia, hepato-
splenomegaly, , difficulty
swallowing, sore mouth
Musculosk None None Bone pain
eletal
General None /mild Fatigue Sensitivity to cold, weight
fatigue loss, lethargy
Iron deficiency anemia (IDA)

Develops when iron is insufficient to produce hemoglobin.
Predisposing factors
o Heme cannot be recycled because of blood loss or hemolysis
o Dietary intake of iron is insufficient/ unhealthy dieting
o Absorption of iron from food is inadequate (malabsorption) where Iron
absorbed?
o Need for iron exceeds the reserves: rapid growth, pregnancy, and the female
reproductive years
151
o Acute or chronic blood loss
Signs & Symptoms:

• Usually asymptomatic
• First sign :Reduced energy feel cold all the time
experience fatigue and dyspnea with minor physical exertion.
• Tachycardia even at rest.
• The CBC and hemoglobin, hematocrit, and serum iron levels are
decreased
• Headache, dizziness, palpitations, generalized body malaise,
pallor skin.
• Brittleness of hair, spoon shaped nails
• Atrophic glossitis, fissures at the corners of the mouth, stomatitis, dysphagia
Specific Diagnostic tests:

Serum iron, ferritin, and total iron-binding capacity
Medical &Nursing Management:

Medications, first must be determine the cause and managed it e.g.: blood loss
Iron supplements
❖ Oral iron preparations: ferrous sulfate
o Administer with meals to lessen GIT irritation. Take iron on an empty
stomach (between meals) unless gastric upset occurs
o Use straw for liquid form to avoid staining the teeth.
o Administer with orange juice or vitamin C to facilitate absorption.
o Monitor for (anorexia, N and V, abd. pain, diarrhea or constipation, melena)
o Avoid taking iron simultaneously with an antacid ,interferes with iron
absorption
❖ Parenteral iron preparations: iron dextran
✓ Avoid massaging of injection site. Instead, encourage patient to ambulate to
facilitate absorption.
✓ Monitor for (pain at injection site, localized abscess, lymphadenopathy, fever
,chills, pruritus and urticaria)
Erythropoietin – epoetin alfa

A hematopoietic growth factor used to increase production of RBCs
152
• Monitor for an increase in blood pressure.

• Monitor Hg and HT twice a week.
• Monitor for a cardiovascular if Hg increases too rapidly (> 1 g/dL in 2
weeks).
Blood transfusion in acute, sever anemia's, an immediate improvement in

blood -cell counts and manifestations of anemia
➢ Monitor for signs of bleeding of all body systems
➢ Encourage increased iron diet (green leafy vegetables, organ meat, legumes)
➢ Avoid tea and coffee because it impairs iron absorption.
➢ Administer medication as ordered
➢ Monitor laboratory studies
➢ Monitor responses to therapy by assess S&S
➢ Monitor degree of dyspnea.
➢ Assess for pallor in the skin and conjunctivae
➢ Monitor vital signs
➢ provide diet instruction
➢ Administer supplements , drugs & oxygen as ordered
➢ Assist the patient with self-care activities
➢ Preventive education
➢ Teach the patient about adverse reactions to oral iron therapy, such as black
stools, constipation or diarrhea, and GI disturbances
➢ Nutritional counseling
➢ Assess hemoglobin to measure effectiveness of therapy.
➢ Monitor bowel movements ,increased fluid and fiber :possible constipation
➢ Uses the Z-track technique to administer IM
( iron preferred IV infusion . why?)
Pernicious anemia
Anemia resulting from a cobalamin (vitamin B12) deficiency .
Normally a protein known as intrinsic factor is secreted by parietal cells of the
gastric mucosa that required for vit.B12 absorption in the distal ileum.
Predisposing factors:
• Subtotal / total gastrectomy
• Small bowel resection involving the ileum
• Crohn’s disease (Inflammatory disorders of the ilium )
• Long-term users of H2-receptor blockers and proton pump inhibitors
153
• Hereditary factors
• Autoimmune
• Strictly vegetarian diet
Signs & Symptoms:

+common manifestations above, Pt. with pernicious anemia (vitamin B12)
experience numbness & paresthesia of the hands, feet weakness because vitamin
B12 is necessary for normal neurological function., and sore, beefy red tongue
Diagnostic tests:
✓ Schilling's test: indicate decreased reabsorption of vitamin B12.
✓ Serum cobalamin levels are reduced
✓ Serum test for anti- intrinsic factor antibodies may be done that is specific
for pernicious anemia
✓ Upper GI endoscopy and biopsy of the gastric mucosa
Medical & Nursing Management:

✓ Vitamin B12 supplementation
o High-dose oral and sublingual available for those in whom GI absorption
is intact
o 1000 mg IM or deep SC to decrease irritation, daily for 2 weeks, then
weekly until hematocrit is normal, and then monthly for life
✓ Folic acid supplements : is necessary for the production of new RBCs
Large doses of folic acid may cover vitamin B12 deficiency .
Similar to Iron deficiency anemia plus
➢ Ensure that the patient is protected from burns and trauma because of a
diminished sensation to heat and pain as a result of neurologic impairment
➢ Careful follow-up evaluation of neurologic impairment
Folic Acid Deficiency Anemia

Folic acid is required for deoxyribonucleic acid (DNA) synthesis leading to the
formation and maturation of RBCs.
Causes of folic acid deficiency

o dietary deficiency, especially a lack of leafy green vegetables and citrus fruits
o malabsorption syndromes
154
o drugs that interfere with absorption anti-seizure

o alcohol abuse and anorexia
o hemodialysis treatments, because folic acid is lost during dialysis
Clinical manifestations :
• Similar to those of vit.B12 deficiency.
• Absence of neurologic problems is an important diagnostic finding , that
differentiates folic acid deficiency from vit.B12 deficiency
Diagnostic Tests:
Serum folate level is low (normal is 3 to 25 mg/mL)
Serum cobalamin (vit.B12) is normal
Medical & Nursing Management: Similar to vit.B12 deficiency

Folic acid supplements, 1 up to 5 mg/day by mouth
➢ Do not mix other medications in the syringe
➢ Folic acid :client’s urine dark yellow
➢ Encourage the patient to eat foods containing folic acid
Aplastic anemia:
Definition: stem cell disorder leading to bone marrow depression, fatty and
incapable of production of the necessary blood cells (RBCs, platelets, and WBCs)
, that indicates to Pancytopenia (anemia, leucopenia, thrombocytopenia)
• Exposure to toxic substances (benzene, and its derivatives, insecticides ).
• Chemo-Radio therapy
• Congenital chromosomal alterations
• Bacterial and viral infections of BM (major trauma, hepatitis )
• Drugs :ant seizure medications, antimetabolites, antimicrobials, gold
• Autoimmune basis(idiopathic)
General manifestations of anemia +:
- The patient with neutropenia (low neutrophil count) is susceptible to
infection and is at risk for septic shock and death
155
- Even a low-grade temperature, should be considered a medical emergency.

- Thrombocytopenia (low platelet) may be manifested by a predisposition to
bleeding .
- Progressive weakness, fatigue, pallor, shortness of breath, and headaches
- Progress to:
- Tachycardia and heart failure
- Ecchymosis and petechiae appear on the skin surface
- Blood may ooze/ bleed from mucous membranes,& bleeding into vital organs
Diagnostics:
• CBC: All marrow elements are affected (RBC, WBC, and platelet)
• Reticulocyte count is low and bleeding time is prolonged
• Bone marrow examination: Findings indicate a hypo-cellular marrow with
increased yellow marrow (fat content)
Medical Surgical &Nursing Management:

Based on identifying and removing the causative agent (when possible) and
providing supportive care, preventing complications from infection and
hemorrhage .
Medications:
Administration of steroids to stimulate production of cells in the
weakened BM.
Erythropoietin stimulates the production of RBCs
Neupogen, stimulates the production of WBCs
Immunosuppressive therapy
Surgical:
Bone marrow transplantation
Hematopoietic stem cell transplant (HSCT)
Nursing interventions
➢ Enforce complete bed rest.
➢ Administer O2 inhalation.
➢ Reverse isolation.
➢ Monitor for signs of infection.
➢ Medication as ordered: (immunosuppressant via CVS)
156
➢ Maintain on bleeding precautions

•Use an electric razor for shaving.
• Use a soft toothbrush , Avoid flossing.
• Avoid invasive procedures e.g. enemas,
• Avoid intramuscular injections.
• avoid injury when checking blood pressure
• Avoid blood draws whenever possible.
• Maintain pressure on intravenous (IV) for 5 minutes.
• Encourage use of shoes when out of bed.
• Keep area clutter free .
• Avoid use of drugs that interfere with platelet function, (aspirin &NSAID) drugs.
• Administer stool softeners as ordered to prevent straining.
• Move and turn patient gently.
• Instruct patient to avoid blowing the nose
•Avoid use of Foley catheters and other invasive devices.
➢ Protect Pt. from infection

• Place the patient in a private room.
• Assure that all personnel and visitors wash hands before entering the room.
• Teach the Pt. to wash hands before & after using the toilet before & after eating.
• Prevent staff or visitors with known infections from entering the patient’s room.
• Not handle flowers or plants brought into the room.
• Avoid raw fruits, vegetables, and milk products.
• Strict aseptic technique in dealing with Pt.
• Use strict aseptic technique if invasive procedures are necessary.
• Use acetaminophen (antipyretic) ; aspirin may induce bleeding
Sickle cell anemia

An inherited anemia in which Erythrocytes become sickle- or crescent-shaped
✓ RBC become tangled in the blood vessels and organs
✓ As red cells are broken, increase in the bilirubin level causes jaundice
✓ Normal red cells live about 120 days. Sickled cells are thin wall & easily
broken, so survive only about 15 to 20 days
✓ Hemoglobin A (Hg. A) normally replaces fetal hemoglobin (Hg F) about
6 months after birth
✓ In sickle cell anemia, an abnormal form of hemoglobin, (Hg S), replaces Hg
F. that causes RBCs to assume a sickled shape under hypoxic conditions
157
Pt. with sickle cell anemia suffers from

o episodes of sickle cell crisis from vascular
occlusion
o chronic hemolytic anemia
• Hereditary factors
Clinical manifestation & complications
Acute chest syndrome, pneumonia due to
decreased hemoglobin and SC infiltrates in
the lungs, characterized by coughing,
wheezing, tachypnea, and chest pain.
Hand & foot syndrome :an unequal growth
of fingers and toes from infarction of the small
bones
What is the correlation between sickle cell anemia

and stroke (cerebrovascular accident) & ARF?
Sudden and severe sickling is called a sickle cell crisis.
As more and more sickling occurs, the blood becomes sluggish and does not
flow easily.
It tends to collect in the capillaries and veins of the organs of the chest and
abdomen, as well as joints and bones, and can cause infarction (tissue
necrosis resulting from lack of blood supply). Tissue necrosis results in
pain, fever, and swelling.
Factors of sickle cell crisis include

▪ decreased oxygenation (pneumonia , hypoxia)
▪ exposure to cold
▪ diabetic acidosis
▪ severe infection.
▪ patient who needs surgery.
▪ blood loss dehydration
Common symptoms during sickle cell crises include :
Severe pain and swelling in the joints, especially of the elbows and knees,
as the sickled cells impede circulation.
Abdominal pain with swelling of the spleen and engorgement of the vital organs.
158
Hypoxia occurs as fever and pain increase, causing the patient to breathe rapidly
Diagnosis:
▪ CBC: reveals Decreased hemoglobin, a lowered RBC count, an elevated
WBC count, and a decreased erythrocyte sedimentation rate.
▪ Blood smear that shows sickle-shaped RBCs in circulation. Presence of
abnormal hemoglobin (Hg S)
▪ Sickledex test shows sickling of RBCs when oxygen tension is low.
▪ Hemoglobin Electrophoresis: confirmatory diagnosis for SCA.
▪ Urine analysis
▪ Chest x-ray and chest scan: pulmonary complications.
Medical Surgical & Nursing management:
Medical
✓ Treatment is supportive rather than curative.
✓ Low-dose oral penicillin to help prevent infections
✓ Blood transfusions.
✓ Oxygen therapy
✓ Currently, inhaled nitric oxide, a vasodilation agent
✓ Pt. education to prevent crises and supportive care.
✓ During acute crises, the patient is admitted to the hospital
✓ Sedation and narcotic analgesia
Surgical
Bone marrow transplantation
Splenectomy
Blood Products
Product Use
1. Packed RBC 1. Severe anemia or blood loss
2 .Frozen RBC 2 . Auto-transfusion (blood taken from patient and
3 .Platelets saved for future surgery), prevention of febrile
4. Albumin reactions
5 . Fresh frozen 3 . Bleeding caused by thrombocytopenia
plasma 4 . Hypovolemia caused by hypo-albuminemia
6 .Cryoprecipitate 5 . Provides clotting factors for bleeding disorders;
occasionally used for volume replacement
6 . Bleeding caused by specific missing clotting
factors
Nursing management
➢ Administer O2, medication &blood transfusion as recommended.
159
➢ Maintain adequate hydration.

➢ Large amounts of oral and intravenous fluids are given to flush the kidneys
➢ Avoid tight clothing that could impair circulation.
➢ Keep wounds clean and dry.
➢ Provide bed rest to decrease energy expenditure and O2 use.
➢ Encourage patient to eat foods high in calories, with folic acid
supplementation.
➢ Keep arms and legs from extreme cold.
➢ Decrease emotional stress.
➢ Provide good skin care.
➢ Assess circulation in the extremities every 2 hours, pulse oximetry, capillary
refill, peripheral pulses, and temperature.
➢ Frequent pain assessment
➢ Apply warm compresses as ordered to the painful areas
➢ Encourage Pt. to avoid strenuous exercise, cold temperatures and smoking
➢ Analgesics: *Acetaminophen. *Morphine.
*avoid aspirin as it enhances acidosis, which promote sickling.
Thalassemia
Thalassemia is hereditary hemolytic anemias involving inadequate production
of Hg, and therefore decreased RBC production& Hemolysis
✓ Results in an absent or reduced globulin protein
Clinical manifestations: general manifestations of anemia +

✓ Pt. has marked splenomegaly, hepatomegaly, and jaundice from
hemolysis of RBCs
✓ It is life-threatening disease in which growth, both physical and mental,
retarded
Diagnosis:
• Decreased Hg, RBC
• RBCs: increase in number
• Diagnosis is based on symptoms
Complications:
✓ Splenomegaly.
160
✓ Growth retardation in the second decade.

✓ Endocrine abnormalities:
*delayed development of secondary sex characteristics
*DM: due to iron deposits in the pancreas.
*Hyper metabolic rates.
✓ Skeletal complications:
*Frontal &parietal bossing (enlargement).
*Maxillary hypertrophy: leading to occlusion.
*Premature closure of epiphyses of long bones.
*Osteoporosis &pathological fracture.
✓ Cardiac problems: pericarditis, CHF; usual cause of death.
Management:
➢ Frequent and regular transfusion of packed RBCs to maintain Hg levels above
10 g/dl.
➢ Iron therapy with deferoxamine (Desferal)-reduce toxic effect of excess iron
➢ Splenectomy.
➢ Supportive management of symptoms.
➢ Bone marrow transplant.
➢ Prognosis and survival rate is poor because of known cure.
➢ places the client on bed rest
➢ protects from contact with those who have infections
➢ When transfusions are necessary, closely monitors the rate of administration
Polycythemia
It is two separate disorders that are easily recognizable by similar
characteristic changes in RBC count. Blood becomes so thick with an
accumulation of RBCs that it closely resembles sludge. This thickness does not
allow the blood to circulate easily
Laboratory tests show a Hg> 18 mg/dL, the RBC mass > 6 million, and a HT
> 55%
Polycythemia vera (PV) is known as primary polycythemia.
Its cause is unknown.

o In PV, the RBCs, platelets, and WBCs are all overproduced, and the bone marrow
becomes packed with too many cells, spills out into the general circulation,
the organs become congested with cells.
161
Due to hypervolemia, hyper viscosity, and engorgement of capillary beds
- skin takes on a plethoric (dark, flushed), Intense itching
- hypertension , headache, vertigo,& dizziness
- visual changes and ringing in the ears (tinnitus)
- nosebleeds and bleeding gums, retinal hemorrhages,
- exertional dyspnea, and chest pains
o abdominal pain with feeling of fullness
Secondary polycythemia is the result of long-term hypoxia

Etiology:
Pulmonary diseases (COPD) Chronic heart failure
Living in high altitudes Smoking
Management:
first stage is to decrease the hyper viscosity problem
Phlebotomy : withdrawal of blood, which is then discarded.
From 350 to 500 mL of blood are removed each time on an every other day
basis, with the goal being a hematocrit of about 45 percent
Chemotherapeutic agents or radiation therapy, including radioactive
phosphorus, used to suppress production of blood cells
➢ Explain the phlebotomy procedure and reassure the patient
➢ Pt. Ambulatory to help prevent thrombus formation. When bed rest is
necessary, passive and active range-of-motion exercises implemented
➢ Monitor the patient for complications ( bleeding)
➢ Advise the Pt. to report any signs or symptoms of bleeding immediately
➢ Advise the Pt. to takes small meals
➢ Advise the Pt. to drink at least 3 L of water daily
➢ Advise the Pt. to avoidance of tight or restrictive clothing
➢ Advise the Pt. to elevation of feet when resting
➢ Instruct about routine bleeding precautions
➢ Instruct the Pt.to report chest , joint pain, decreased activity tolerance,
&fever,
Disseminated Intravascular Coagulation (DIC)
162
A life-threatening coagulopathy in which clotting and anticlotting mechanisms

occur at the same time
Once this deadly syndrome develops, the progression of symptoms is rapid
Massive clotting in blood vessels leads to organ and limb necrosis. Organs
affected include the kidneys, the brain, GITs and lungs
Etiology:
o Major trauma, broken long bones
o Obstetric complications(retained dead fetus)
o Cancer-related causes such as acute leukemia
o Massive tissue necrosis found in burn injuries
o Abdominal surgery with leakage of the intestinal contents
o Poisonous & snakebites
Abnormal bleeding is a cardinal sign of DIC
Early signs of bleeding include: petechiae, ecchymosis
Bleeding from venipuncture sites, surgical sites, incisions, and GITs
Pain and enlargement of joints
Massive bleeding accompanied by nausea, vomiting, dyspnea, oliguria,
convulsions, coma, shock, major organ system failure, severe muscle, back, and
abdominal pain
Diagnostic Tests:
Hemoglobin, & Platelet levels decreased
PT, PTT, fibrin degradation products , BUN , S creatinine & D-dimer increased
Management:
Early recognition of the condition
Correcting the underlying cause
Administration of blood, fresh frozen plasma, and platelets and the infusion
of cryoprecipitate (containing clotting factors)
➢ Reporting of signs of bleeding, Implement bleeding precautions
➢ Avoid any trauma that might cause bleeding
➢ Instruct client to avoid Valsalva maneuver
➢ Regularly take vital signs
➢ Monitor for signs of organ failure: LOC
163
➢ Monitor laboratory values for clotting factors

➢ Avoid use of NSAIDs.
➢ Administer supplemental oxygen & Anticoagulants (heparin)
Leukemia
Leukemia refers to malignant disorder of the blood characterized by the
uncontrolled accumulation of dysfunctional WBCs.
Overgrowth of leukemic cells prevents growth of other blood components
(platelets, erythrocytes, and mature leukocytes), leading to thrombocytopenia,
anemia, and neutropenia.
Lack of mature leukocytes leads to immunosuppression. Infection is the
leading cause of death among clients who have leukemia.
Lack of platelets increases the client’s risk of bleeding
Leukemia is classified according to the

A. type of white blood cell that is multiplying—i.e., lymphocytes (immune
system cells), granulocytes (bacteria-destroying cells), or monocytes
(macrophage-forming cells).
B. by how quickly it progresses:
o Acute leukemia is fast-growing
o Chronic leukemia is slow-growing and progressively worsens over years
D. precursor cell (myeloid or lymphoid)
Risk Factors: cause of leukemia is unknown

✓ Immunosuppression
✓ Exposure to chemotherapy agents or medications that suppress bone marrow
✓ Genetic factors (hereditary)
✓ Ionizing radiation (radiation therapy, environmental)
✓ Older adult clients often have diminished immune function and decreased
bone marrow function, which increase the risk of complications of leukemia
and lymphoma.
The four types of leukemia that occur most frequently are

Clinical Manifestations Diagnostic Findings
164
Acute Fatigue and weakness, Low RBC count, Hg , HT,

Myelogenous headache, mouth sores, anemia, platelet count. Low to high
Leukemia bleeding, fever, infection, WBC count with
(AML) sternal tenderness, gingival myeloblasts
Most common hyperplasia, mild High LDH. Hyper cellular
leukemia among hepatospleenomegally bone marrow with
adults myeloblasts
Acute Fever, pallor, bleeding, anorexia, Increased immature
Lymphocytic fatigue and weakness. Bone, lymphocytes
Leukemia joint, and abdominal pain. Normal or decreased
(ALL) Generalized lymphadenopathy, granulocytes
Younger than 5; infections, weight loss, Decreased erythrocytes
uncommon after hepatospleenomegally, Decreased platelets
15 headache, mouth sores,
neurologic manifestations:
CNS involvement, increased
intracranial pressure
(nausea, vomiting, lethargy,
cranial nerve dysfunction)
secondary to meningeal
infiltration.
Chronic No symptoms early in disease. Low RBC count, Hg, HT.
Myelogenous Fatigue and weakness, fever, High platelet count early,
Leukemia sternal tenderness, weight loss, low number of monocytes.
(CML) joint pain, bone pain, massive Low leukocyte alkaline
Most cases splenomegaly, increase in phosphatase
involve young sweating
adults
Chronic Detection of disease often during Mild anemia &
Lymphocytic examination for unrelated thrombocytopenia
Leukemia condition, chronic fatigue, Hypo gamma globulinemia.
(CLL) anorexia, splenomegaly and autoimmune hemolytic
Most cases lymphadenopathy, anemia, idiopathic
involve people hepatomegaly. May progress to thrombocytopenic purpura
older than 60 fever, night sweats, weight loss,
fatigue, and frequent infections
The Philadelphia chromosome, which is present in 90% to 95% of patients with
CML, is a diagnostic hallmark of CML
Medical Surgical & Nursing Management
165
Medical
✓ Combination chemotherapy for :
o Decrease drug resistance
o Minimize drug toxicity
o Interrupt cell growth at multiple points in the cell cycle
✓ Corticosteroids and radiation therapy
✓ Erythrocyte and platelet transfusions
✓ Antibiotics are given when secondary infections develop
Surgical
- Bone marrow transplantation
- Stem cell transplantation
Nursing Priorities of care
➢ Prevent infection & injury
➢ Maintain circulating blood volume.
➢ Alleviate pain.
➢ Promote optimal physical functioning.
➢ Provide psychological support.
➢ Provide information about disease process, prognosis, and treatment needs.
➢ Conserve the client’s energy.
Prevention
✓ Use protective equipment, such as a mask, and ensure proper ventilation
while working in environments that contain carcinogens or particles in the air.
✓ Influenza and pneumonia vaccinations are important for all clients who are
immunosuppressed
Complications
● Pancytopenia – decrease in white and red blood cells and platelets
Nursing process for patient with anemia : examples

Nursing Diagnosis
• Fatigue related to decreased hemoglobin and diminished oxygen-carrying
capacity of the blood
• Altered tissue perfusion related to inadequate hemoglobin and hematocrit
• Risk for Infection related to compromised immunity
• Activity Intolerance related to hypoxia
Planning and Goals
166
The major goals for the patient may include decreased fatigue, maintenance of
adequate tissue perfusion, client will be free of infection
Managing Fatigue
• Assist patient to prioritize activities and establish a balance between activity
and rest.
• Encourage patient with chronic anemia to maintain physical activity and
exercise to prevent deconditioning.
Maintaining Adequate Perfusion
• Monitor vital signs and pulse oximeter readings closely
• Administer supplemental oxygen, transfusions, and IV fluids as ordered
• Monitor oxygen saturation
• Report a sustained oxygen saturation value below 90%.
• Give oxygen
Prevent infection
• Implement neutropenic Precautions
Activity Intolerance
• Limit the client’s nonessential activities
• Distribute essential tasks over a long period
• Provide periods of rest
• Administer supplemental oxygen during periods of rapid breathing or
tachycardia
Specific for sickle cell anemia, common nursing diagnosis is pain related to
tissue hypoxia , & peripheral vascular occlusion
167
Nursing Management for clients with Neurological

System Disorders
Outlines:
1. An overview abut anatomy and physiology of Neurological system
2. Specific laboratory & diagnostic tests to Neurological system.
3. Assessment of Neurological system disorders.
4. Common Neurological system disorders and their nursing management.
5. Nursing care plan for neurological system disorders.
Objectives
At the end of this chapter, the student will be able to:
1. Describe the structures neurological system
2. Enumerate functions of neurological system
3. Identify protective mechanism to neurological system
4. Discuss preparation and care of clients having neurological diagnostic
procedures.
5. Distinguish among disorders of the neurological system
6. Discuss common neurological disorders risk factors, S & S, & TTT
7. Describe nursing care for clients experiencing neurological disorders
8. Apply nursing care plan for neurological disorders
9. Provide Pt. & family education
An over view among anatomy & physiology of neurological system
The nervous system is divided into:

❖ Central nervous system (CNS) , consists of the brain and spinal cord
❖ Peripheral nervous system (PNS), consists of cranial nerves and spinal
nerves, which include the nerves of the autonomic nervous system (ANS)
The basic structure of the nervous system is the nerve cell ( neuron) it is:
Sensory neurons (afferent)Transmit information from distal parts of the body
or environment toward the central nervous system
Motor neurons (efferent) Carry motor information from the CNS to the periphery
Axons conduct impulses away from the cell body
Dendrites convey impulses toward the cell body
The corpus callosum: It is a thick collection of nerve fibers that connects the two
hemispheres of the brain and is responsible for the transmission of information from
one side of the brain to the other
168
Synapses
Connects the neuron to another neuron or target tissue (muscle, organ or gland)
Neurotransmitters :
Chemical substances that enhance or inhibit nerve impulses across synapses.
E.g. Acetylcholine; norepinephrine; dopamine;
It control all motor, sensory, autonomic, cognitive, and behavioral activities
What are the three layers of meninges, starting below the skull and
proceeding toward the surface of the brain?
Spinal cord
✓ 18 inches long
✓ extends from brain to small of back
✓ carries messages to and from brain
✓ relays messages to body through spinal nerves
✓ handles reflexes
Cerebrospinal Fluid
- Composed of water, glucose, sodium chloride, and protein
- Acts as a shock absorber for the brain and spinal cord
Normal CSF:
• pH 7.35-7.45
• Specific Gravity: 1.007
• Appearance: Clear, colorless and odorless
169
• Cells: minimal number of WBCs and no RBCs

• Positive Protein
• Positive Glucose (2/3 blood sugar value)
Peripheral nervous system
o Spinal nerves 31 Paris (Cervical 8 ,Thoracic 12 ,Lumbar 5 , Sacral 5 & Coccyx 1)
o Cranial nerves 12 Paris
o autonomic nervous system , main function is to maintain internal homeostasis
Sympathetic nervous system
Parasympathetic nervous system
Cranial nerves
Number Name Function
I Olfactory Sense of smell
II Optic Sense of sight
III Oculomotor Movement of eyeball; constriction of pupil
for bright light or near vision
IV Trochlear Movement of eyeball
V Trigeminal Sensation in face, scalp, and teeth;
contraction of chewing muscles
VI Abducens Movement of eyeball
VII Facial Sense of taste; contraction of facial muscles;
secretion of saliva
VIII Vestibulocochlear Sense of hearing; sense of equilibrium
IX Glossopharyngeal Sense of taste; secretion of saliva; sensory for
cardiac, respiratory, and BP reflexes;
contraction of pharynx
X Vagus Sensory in cardiac, respiratory, and blood
pressure reflexes; sensory and motor to
larynx (speaking); decreases heart rate;
contraction of alimentary tube (peristalsis);
increases digestive secretions
XI Accessory Contraction of neck and shoulder muscles;
motor to larynx (speaking)
XII Hypoglossal Movement of the tongue
Basic Neurological Assessment
170
1 .Assess level of consciousness (LOC),

2 .Obtain vital signs
3 .Check pupillary response to light
4 .Assess strength and equality of hand grip and movement of extremities
5 .Determine ability to sense touch or pain in extremities
Chief complaint
◗ Most complaints : LOC, confusion, memory loss, dizziness, faintness, headache,
numbness and tingling in extremities, seizures, weakness, and difficulty
walking or moving
◗ The patient may report a change in balance or gait
Present illness
◗ Ask the patient about his symptom, including when it started, associated
signs and symptoms, location, radiation, intensity, duration, frequency, and
precipitating and alleviating factors
◗ Ask the patient about any dizziness, numbness, paralysis, seizures, tingling,
tremors, or weakness
◗ Question him about problems with any of his senses or with keeping his
balance, swallowing, urinating, or walking
◗ Ask about headaches and photophobia
◗ Ask the patient how he rates his memory and ability to concentrate
◗ Question him about trouble speaking or understanding people
◗ Ask about difficulties reading or writing
Medical history
◗ Question the patient about other neurologic disorders
◗ Ask about chronic diseases, major illnesses, accidents, injuries, surgeries,
and allergies
Family history
◗ Ask about a family history of neurologic diseases, such as amyotrophic
lateral sclerosis, Cerebrovascular accident (stroke), migraines, and seizures
◗ Question the patient about a family history of diabetes mellitus, coronary
artery disease, and hypertension
Social history
◗ Ask about work, exercise, diet, use of recreational drugs, alcohol, and hobbies
Physical assessment
Assesses neurologic function in these five areas:
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mental status and speech, cranial nerve function, sensory function, motor
function, and reflexes
Glasgow Coma Scale(GCS), an international standardized scale to assess

LOC
Points Best Eye Best Verbal Best Motor
Opening Response Response
6 - - Obeys
5 - Oriented Localizes
pain
4 Spontaneous Confused Withdraws to
conversation pain
3 To speech Inappropriate Abnormal
words flexion
(decorticate)
2 To pain Incomprehensible Extension
sounds response
(decerebrate)
1 Nil/ C Nil Nil/T
Responses within each subscale are added, with the total score quantitatively
describing the client’s level of consciousness. E + V + M = Total GCS E.G. E3
V3 M4 = GCS 13
Highest score = 15 (normal) • Lowest score = 3 (deep coma)
Categories of Consciousness:
Alert:
Responds immediately to minimal external stimuli.
Lethargic:
A state of drowsiness; client needs increased external stimuli to be awakened
Obtunded:
Very drowsy, can follow simple commands when stimulated (i.e. shaking or
shouting)
Stupors:
Awakens only to vigorous & continuous stimulation
Comatose:
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Vigorous external stimulation fails to produce any verbal response.
Assessment of consciousness by using: AVPU.

Is the patient ALERT?
Is the patient responding to your VOICE?
Is the patient only responding to PAIN?
Is the patient UNRESPONSIVE
Common Diagnostic Tests

• Computed tomography (CT) Radiography (X-Ray)
• Magnetic resonance imaging (MRI)
• Cerebral angiography
• Myelography
• Transcranial doppler
• Lumbar puncture and analysis of cerebrospinal fluid
• Electroencephalography (EEG), assesses the electrical activity of the brain
to identify and determine seizure
• Electromyography (EMG)
EEG Nursing Management

➢ Instruct the client to wash his hair prior to the procedure and eliminate all
oils, gels, and sprays
➢ Instruct the client to sleep-deprived because this provides cranial stress,
increasing the possibility of abnormal electrical activity
➢ Increased electrical activity may be stimulated with exposure to bright
flashing lights, or by requesting the client to hyperventilate for 3 to 4 minutes
➢ Client resting in a chair or lying in bed, small electrodes are placed on the
scalp and connected to a brain wave machine or computer to recorded electrical
signals produced by the brain
Intracranial Pressure (ICP) Monitoring

A device inserted by a neurosurgeon into the cranial cavity that records
pressure and is connected to a monitor that shows a picture of the pressure
waveforms
Three Basic Types of ICP Monitoring Systems

1. Intraventricular catheter (ventriculostomy)
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2. Subarachnoid screw or bolt

3. Epidural or subdural sensor
Indications
ICP monitoring is useful for early identification and treatment
Interpretation of Findings
Normal ICP is 10 to 15 mm Hg. Persistent elevation of ICP extinguishes
cerebral circulation, which will result in brain death if not treated urgently
Nursing Innervations
❖ Maintain system integrity at all times. prevent serious, life-threatening
infection.
❖ Inspect the insertion site at least every 24 hr for redness, swelling, and
drainage.
❖ Change the sterile dressing covering the access site per facility protocol.
❖ ICP monitoring equipment must be balanced per facility protocols.
❖ Observe ICP waveforms, noting the pattern of waveforms and monitoring
for increased ICP (a sustained elevation of pressure above 15 mm Hg).
❖ Assess the client’s clinical status and monitor routine and neurologic vital
signs every hour as needed.
Lumbar Puncture: will discussed practically
A small amount of cerebrospinal fluid (CSF) is withdrawn from the spinal
canal and then analyzed to determine its constituents. Its purpose
To determine presence of certain diseases :sclerosis, malignancies and
meningitis
To reduce CSF pressure, instill a contrast medium or air for diagnostic tests, or
administer medication or chemotherapy directly to spinal fluid.
PET and SPECT scans are nuclear medicine procedures that produce three-
dimensional images of the head
Meningitis
✓ It is an inflammation of the meninges, which are the membranes that protect
the brain and spinal cord.
✓ Viral, or aseptic, meningitis is the most common form of meningitis and
commonly resolves without treatment.
✓ Fungal meningitis is common in clients who have AIDS.
✓ Bacterial, or septic, meningitis is a contagious infection with a high
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mortality rate. The prognosis depends on how quickly care is initiated.

There are three vaccines for different pathogens that cause bacterial meningitis
Risk Factors:
Two ways the infectious agent
Viral meningitis can inter the meninges
•Viral illnesses such as the mumps, measles, herpes Blood stream Most common
There is no vaccine against viral meningitis. Usually r/t URI
Direct extension TBI
Fungal Meningitis Invasive procedures
•Fulminant fungal-based infection of the sinuses
Bacterial meningitis:
- Bacterial-based infections, such as otitis media, pneumonia, or sinusitis
- Immunosuppression
- Invasive procedures, skull fracture, or penetrating head wound
Inflammatory response to the infection tends to increase CSF, then ICP
Clinical Manifestation:
•Constant headache
•Nuchal rigidity (stiff neck)
•Photophobia (sensitivity to light)
•Fever and chills
• Nausea and vomiting
• Altered LOC
•Positive Kernig’s sign the examiner flexes the patient’s
hip to 90 degrees and tries to extend the patient’s knee.
It is positive if Pt. experiences pain and spasm
•Positive Brudzinski’s sign is positive when flexion
of the patient’s neck causes the hips and knees to flex
• Hyperactive deep tendon reflexes
• Tachycardia • Seizures
• Petechiae (meningococcal meningitis)
• Restlessness, irritability
Laboratory Tests
Urine, throat, nose, and blood culture and sensitivity to identify possible
infectious bacteria and an appropriate antibiotic
CBC: Elevated WBC count
Cerebrospinal fluid (CSF) analysis : Results indicative of meningitis
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❖ Appearance of CSF – cloudy (bacterial) or clear (viral)

❖ Elevated WBC
❖ Elevated protein
❖ Decreased glucose (bacterial)
❖ Elevated CSF pressure
New enteroviral diagnostic test (counterimmunoelectrophoresis) :
o determine whether infectious agent is viral or protozoa
o indicated if the client has received antibiotics before the CSF was collected
CT scan and MRI: identify increased intracranial pressure
Encephalitis : Inflammation of brain tissue
Medical Nursing Management:

Medications
✓ Ceftriaxone, cefotaxime with vancocin
✓ Antibiotics given until culture and sensitivity results are available
✓ Anticonvulsants(Phenytoin) if client experiences a seizure
✓ Corticosteroid, Acetaminophen
✓ Ciprofloxacin ,rifampin: Prophylactic antibiotics given to individuals in
close contact with the client
➢ Isolate the client as soon as meningitis is suspected
➢ Maintain isolation precautions per hospital policy
➢ Implement fever-reduction measures, such as a cooling blanket
➢ Report meningococcal infections to the public health department
➢ Decrease environmental stimuli:
o Provide a quiet environment.
o Minimize exposure to bright light (natural and electric).
➢ Maintain bed rest with the head of the bed elevated to 30°.
➢ Monitor the client for increased ICP discussed later on
➢ Maintain client safety, such as seizure precautions
➢ Replace fluid and electrolytes as needed
➢ Assess and record vital signs, neurologic status, fluid intake and output,
skin, and lung fields at regular intervals
➢ Head and neck movement require attention
➢ Progressive range-of-motion (ROM) exercises and warm baths, Muscle
rigidity
Complications
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Increased ICP Septic emboli

Syndrome of inappropriate antidiuretic hormone (SIADH)
Cranial nerve damage , blind or deaf
Cognitive deficits ( memory impairment to profound learning disabilities
Seizures and Epilepsy
A seizure is a paroxysmal, uncontrolled electrical discharge of neurons in the
brain that interrupts normal function
It is abrupt, abnormal, excessive and uncontrolled electrical discharge of
neurons within the brain that cause alterations in LOC , changes in motor ,
sensory ability and/or behavior
Risk Factors
• Genetic predisposition
• Acute febrile state: among infants and children younger than the age
of 2 years
• Head trauma
• Abrupt cessation of antiepileptic drugs
• Cerebral edema
• Metabolic disorder and toxic conditions
• Cerebrovascular disease
• Brain tumor
• Alcohol withdrawal
• Allergies
• Hypoxia
Triggering Factors
• Increased physical activity
• Excessive stress
• Hyperventilation
• Overwhelming fatigue
• Acute alcohol ingestion
• Excessive caffeine intake
• Exposure to flashing lights
• Specific chemicals, such as cocaine
Clinical manifestations: based on types

1. Generalized seizure / tonic-clonic seizure/ grand mal seizure
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✓ begin with an aura (alteration in vision, smell, hearing, or emotional feeling)

✓ begins for only a few seconds with a tonic episode (stiffening of muscles)
✓ and loss of consciousness to 2-min clonic episode (rhythmic jerking of the
extremities) follows the tonic episode
✓ breathing may stop during the tonic phase and become irregular during the
clonic phase
✓ cyanosis can accompany breathing irregularities.
✓ biting of the cheek or tongue can occur during clonic phase.
✓ incontinence can also accompany a seizure.
✓ during the postictal phase, a period of confusion and sleepiness follows the
seizure.
a. Tonic seizure
o During a seizure, only the tonic phase is experienced.
o The seizure usually lasts 30 seconds to several minutes.
o A loss of consciousness occurs.
o This type of seizure is much less common than a tonic-clonic seizure.
b. Clonic seizure
- Only the clonic phase is experienced.
- The seizure lasts several minutes.
- During this type of seizure, the muscles contract and relax.
- This type of seizure is much less common than a tonic-clonic seizure.
c. Absence seizure
✓ Absence seizures are most common in children.
✓ The seizure consists of a loss of consciousness lasting a few seconds.
✓ This type of seizure is associated with blank staring.
✓ Seizure activity also may include unconscious, involuntary behavior
associated with eye fluttering, smacking of the lips, and picking at
clothes called automatisms.
✓ Baseline neurological function is resumed after seizures
d. Myoclonic seizure
• Myoclonic seizures consist of brief jerking or stiffening of the
extremities, which may be symmetrical or asymmetrical.
• This type of seizure lasts for seconds.
e. Atonic or a kinetic seizure
- Atonic or a kinetic seizures are characterized by a few seconds in which
muscle tone is lost.
- The seizure is followed by a period of confusion.
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- The loss of muscle tone frequently results in falling.

2. Partial or focal/local seizure
Complex partial seizure
• associated automatisms (behaviors that the client is unaware of, such as lip
smacking or picking at clothes).
• cause a loss of consciousness for several minutes.
• amnesia may occur immediately prior to and after the seizure.
Simple partial seizures
o Consciousness is maintained throughout simple partial seizures.
o Seizure activity may consist of unusual sensations, a sense of autonomic
abnormalities, such as changes in heart rate and abnormal flushing,
unilateral abnormal extremity movements, pain or offensive smell
Seizure may progress through several phases:
1. prodromal phase with signs or activity that precedes a seizure
2. aural phase with a sensory warning
3. ictal phase with full seizure
4. postictal phase, which is the period of recovery after the seizure
Diagnostic & Laboratory Tests

Descriptions of the seizures and the patient’s health history
Electroencephalogram
CBC, serum chemistries, liver and kidney function, and urinalysis
CT scan and MRI & Cerebral angiography can rule out a structural lesion
Medical Surgical & nursing management:

Medications
Anti-seizure drugs, stabilizing the nerve cell membranes and preventing
the spread of the epileptic discharge
If seizure control is not achieved with a single drug, the drug dosage and
timing changed
✓ Therapeutic levels are determined by blood tests
✓ Medications should be taken at the same time every day
✓ Be aware of drug-drug adverse effects
✓ Routine oral hygiene and dental visits, medications cause oral gum
overgrowth
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Placement of a vagal nerve stimulator : device implanted into the left chest
wall and connected to an electrode placed on the left vagus nerve, to
administer intermittent stimulation of the brain via stimulation of the vagal
nerve, at a rate specific to the client’s needs
Excision of the portion of the brain causing the seizures for intractable
seizures(open craniotomy), Anterior temporal lobe resection
Seizure Precautions
▪ Pad side rails
▪ Keep call light within reach.
▪ Assist patient when ambulating.
▪ Keep suction and oral airway at bedside
Nursing Care During a Seizure

• Stay with patient.
• Do not restrain patient.
• Protect from injury (move nearby objects).
• Loosen tight clothing.
• Turn to side when able to prevent occlusion of airway or aspiration.
• Suction if needed.
• Monitor vital signs when able.
• Be assist with breathing if necessary.
• If the patient falls to the floor, move furniture out of the way
• Don’t force an airway or anything else into the patient’s mouth
• Observe and document progression of symptoms, duration, time of onset
Nursing Care After the Seizure

• Keep the patient on one side to prevent aspiration. Make sure the airway is
patent.
• There is usually a period of confusion after a grand mal seizure.
• A short panic period may occur during or immediately after a generalized
seizure.
• The patient, on awakening, should be reoriented to the environment.
• If the patient becomes agitated after a seizure use gentle restraint.
• A major responsibility of the nurse is to observe and record the sequence of
symptoms.
• The nature of the seizure usually indicates the type of treatment that is required
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• Allow the client to rest if necessary

• Check vital signs
• Assess for injuries
• Perform neurological checks
• Reorient and calm the client
• Institute seizure precautions including placing the bed in the lowest position
and padding the side rails to prevent future injury
• Determine if client experienced an aura
• Try to determine possible trigger
• Patients with poorly controlled seizures should not operate motor vehicles
• Advise the patient to avoid oral thermometers, which can be swallowed or
broken if a seizure occurs
• Instruct the patient to avoid alcohol and nicotine; these stimulants can
precipitate a seizure
• Tell the patient he should always carry identify cation stating that he has
seizures and listing the name and phone number of his practitioner
• Refer the patient to the Epilepsy Foundation for additional support and
strategies for living with epilepsy
Headaches
Types and causes:
Primary Secondary Headache

Headache - Head and neck trauma
Tension - Blood vessel problems in the head and neck
Migraine - Non-blood vessel problems of the brain
Cluster - Medications and drugs (including withdrawal from those
drugs)
No organic - Infection
cause that can - Changes in the body's environment
be identified - Problems with the eyes, ears, nose throat, teeth and neck
- Psychiatric disorders
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Comparison Types of Headaches
Pattern Tension Migraine Cluster

Site Bilateral, band Unilateral may Unilateral, radiating up
like pressure at change sides, or down from one eye
base of skull commonly anterior
Quality Constant, Throbbing, with Severe, bone-crushing
tightness pulse
squeezing
Frequency Cycles for many Periodic, cycles of months or years between
years several months to attacks that occur in
years clusters over a period of
2 to 12 wk.
Duration 30 min to 7 days 4 to 72 hr. 5 min to 3 hr.
Time & Not related to Gets better with Nocturnal, awakens
mode of time Sleep patient from sleep
onset Onset after
awakening
Associated Palpable neck Nausea, Facial flushing or
symptoms and vomiting pallor
shoulder muscle Irritability, Unilateral
tension, stiff sweating lacrimation, ptosis,
neck, Photophobia and rhinitis
tenderness psychic
phenomena
Family history
(in 65%)
Diagnostic Studies.
✓ Careful history taking is the most important diagnostic tool.
✓ Electromyography (EMG) may reveal sustained contraction of the neck,
scalp, or facial muscles.
✓ If tension-type headache is present during physical examination, increased
resistance to passive movement of the head
The data must be obtained
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• What is the location? Is it unilateral or bilateral? Does it radiate?

• What is the quality dull, aching, steady, boring, burning, intermittent,
continuous, paroxysmal?
• How many headaches occur during a given time?
• What are the precipitating factors, if any (environmental, such as sunlight
and weather change; foods; exertion; other)?
• What makes the headache worse (coughing, straining)?
• What time (day or night) does it occur?
• Are there any associated symptoms, such as facial pain, lacrimation
(excessive tearing), or scotomas (blind spots in the field of vision)?
• What usually relieves the headache (aspirin, NSAIDs, ergot preparation,
food, heat, rest, neck massage)?
• Does nausea, vomiting, weakness, or numbness in the extremities accompany
the headache?
• Does the headache interfere with daily activities?
• Do you have any allergies?
• Do you have insomnia, poor appetite, loss of energy?
• Is there a family history of headache?
• What is the relationship of the headache to lifestyle or physical or emotional
stress?
• What medications are you taking
Medications
Abortive therapy to alleviate pain(NSAIDs) , Antiemetics
Client Education
➢ Review “Three R” approach with client :
- Recognize migraine manifestations.
- Respond and seek provider.
- Relieve pain and manifestations
➢ Remain in a cool, dark, quiet environment.
➢ Elevate the head of the bed as desired.
➢ Educate women over age 50 about risk factors for cardiovascular disease
and stroke.
➢ Review trigger avoidance and management.
o Educate about foods with Tyra mine (such as pickles, caffeine, beer, wine,
aged
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o cheese, artificial sweeteners)

o Review current medications
o Discuss anger issues and handling conflict.
o Reinforce the need for adequate rest and sleep.
o Review travel involving a change in altitude.
o Reinforce the need to avoid light glare or flickering lights.
o Review client’s menstrual cycle pattern and hormone fluctuations.
o Discuss avoiding intense environmental odors, perfumes, and tobacco smoke.
➢ Educate client about use of complementary and alternative therapies
Herniated Disks
Displacement of intervertebral disc

When the disk between two vertebrae herniated, it moves out of its normal
anatomical position. Vertebrae separated by disks which serve as shock
absorbers for the vertebral column
Fibrous, tough outer ring of the disk& tears, allows escape of the nucleus
pulpous ( the soft inner portion of the disk).
Displacement of the disk compresses nerve
roots, causing symptom
Etiology: Fall lifting a heavy object

a motor vehicle accident
Cervical disk :
o Pain and muscle spasm in the neck.
o Decreased range of motion
o Hand and arm pain is unilateral .
o Numbness or tingling in the extremity.
o Asymmetrical weakness and atrophy of
specific muscle , indicators of significant nerve compression.
Thoracic herniated disks are not common, least mobile

Lumbar disk :
• Low back pain, pain radiating down one leg
• Paresthesia Weakness, Difficulty Walking
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• Muscle spasm , pain limit range of motion.

• A severely herniated L5–S1 disk may affect bowel /bladder continence must
reported immediately
The WHAT’S UP? mnemonic used to assess symptoms of herniated disks

pain
W—Where is the pain?
H—How does it feel?
A—Do certain positions or activities alleviate or aggravate the pain?
T—Is there a correlation between time and pain?
S—Which is the most painful, the spine or the extremity?
U—Ask the patient to identify associated symptoms.
P—What is the patient’s perception of the pain?
Medical Managements:
▪ A trans-cutaneous electrical nerve /noninvasive pain-relief technique. Small
electrodes are placed on the skin around the area of the pain, then transmits a
low-voltage through the skin.
▪ Cervical traction for patients with herniated cervical disks.
▪ Traction is discontinued immediately if it increases pain.
▪ Lumbar traction is not effective , lumbar muscles are very large and strong.
▪ Medication. Muscle relaxants decrease pain , spasm, increase range of
motion and activity. Patients warned that drowsiness is a common side effect
▪ Inflammation of the nerve manage by NSAIDs
Surgical Management
❖ A laminectomy removes one of the lamina, the flat pieces of bone on each
side of a vertebra.
❖ A discectomy removes the entire disk
Complications After Surgery
- Hemorrhage.
- Nerve Root Damage, loss of motor and sensory functions
- Re-herniation / recurrence .
- Herniation Of Another Disk
Head Injury
A term that encompasses several types of injuries.
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It Includes any trauma to the scalp, skull, or brain. A serious form of head
injury is traumatic brain injury (TBI)
It classified :
Based skin integrity to
o Open or penetrating trauma : skull integrity compromised, high risk for
infection
o Closed or blunt trauma : skull integrity maintained
Based on severity( depending upon Glasgow Coma Scale) ratings
Mild(13–15) Moderate (9–12) Severe (<9)
Based on the length of time the client was unconscious
Concussions Contusions
Based on Tissues includes : Scalp Skull Brain
Head injuries may be associated with hemorrhage (epidural, subdural, and
intra-cerebral) or cerebrospinal fluid leakage
Etiology:
Motor vehicle accidents Falls Guns assaults,
Sports-related trauma War related injuries
Concussion
Concussion is a minor, sudden, transient, and diffuse head injury associated
with a disruption in neural activity and a change in the level of consciousness
Etiology
✓ A concussion results from a blow to the head that jars the brain.
✓ It usually is a consequence of falling, striking the head against a hard
surface
✓ There is generally complete recovery within a short time.
Clinical manifestations: generally of short duration

- A brief disruption of consciousness
- Amnesia for the event (retrograde amnesia)
- Headache, blurred or double vision
- Emotional Irritability, and Dizziness.
Post-concussion syndrome:
Develop 2 weeks to 2 months after the injury
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Symptoms :
➢ persistent headache,
➢ lethargy,
➢ behavior changes,
➢ decreased short-term memory,
➢ changes in intellectual ability
Contusion
• A contusion is the bruising of brain tissue within a focal area
• Associated with a closed head injury
• A contusion contain areas of hemorrhage, infarction, necrosis, and edema
✓ vary depending on the severity of the shock and the degree of head
velocity.
✓ Hypotension
✓ Rapid and weak pulse
✓ Shallow respirations
✓ Loss of consciousness
✓ Pale, clammy skin.
✓ Permanent brain damage impair gait and cause speech difficulty,
seizures, and paralysis
Scalp wounds confirm that there has been an injury to the head, and may
indicate underlying bone or brain tissue damage.
Because the scalp contains many blood vessels with poor constrictive abilities,
even relatively small wounds can bleed profusely
Cerebral Hematomas
It is bleeding within the skull
Risk for cerebral hematomas + Head Trauma
• anticoagulant therapy
• bleeding disorder
• thrombocytopenia
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Types : epidural , subdural , and intra-cerebral hematoma
Type Location Signs And Symptoms

Epidural Arterial blood Client may be alert after initial
collects unconsciousness, increasingly lethargic
between the before lapsing into coma.
skull and dura Common symptoms are headache, ipsalateral
(same side as injury) pupil changes, and
contralateral (opposite side to injury)
hemiparesis (weakness or paralysis).
Subdural Venous blood Deterioration in LOC is progressive. There
collects are ipsalateral pupil changes, decreased extra
between the ocular muscle movement, and contralateral
dura and hemiparesis, with periodic episodes of
subarachnoid memory lapse, confusion, drowsiness, and
layers personality changes.
Intra- Blood collects Client shows classic signs of increased ICP:
cerebral within the headache, vomiting, seizures, posturing,
brain hyperthermia, irregular breathing.
Skull Fractures
A skull fracture is a break in the continuity of the cranium.
The most common types are simple, depressed, or comminuted Fractures
Skull fractures are classified as linear, depressed, or basilar
Linear skull fractures resemble a line or single crack in the skull.
Depressed skull fractures are characterized by an inward depression of bone
fragments. Depressed skull fractures require surgery to elevate
Basilar skull fractures involve the base of the skull, including the anterior,
middle, or posterior fossa
Basilar fractures is often clinical:
• CSF leaking from the nose (rhinorrhea) or ear (otorrhea)
• Periorbital ecchymosis (raccoon eyes).
• Ecchymosis behind the ear (Battle's sign).
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Detecting Cerebrospinal Fluid in Drainage

1. Collect droplets of drainage on a white absorbent pad.
2. Observe the wet area after a few minutes for a halo sign.
3. Note if a pale yellow or clear ring encircles a central ring that is red: the red
ring indicates blood; the pale yellow ring suggests CSF.
Traumatic Brain Injury (TBI)

Brain damage is classified into:
1. Primary brain damage. It occurs at the time of injury and is irreversible
(i.e. lacerations, contusions, axonal injuries of the white matter due to shearing
forces).
2. Secondary brain damage. It occurs at a later stage due to tissue hypo
perfusion and may be preventable and reversible.
Cause of secondary brain damage:
Extra-cranial causes: shock, hypoxia, and electrolyte abnormalities
hypotension, hyperglycemia, hypoglycemia, acidosis, and hypercapnia.
Intracranial causes: hematoma, brain edema, infection, and hydrocephalus
Cerebral Perfusion Pressure (CPP)
CPP = mean arterial pressure (MAP) - intracranial pressure (ICP).
Normal ICP is 1-15 cmH20
MAP is calculated by taking one-third of the difference between the systolic
and diastolic blood pressure and adding it to the diastolic
A minimum CPP of 70 mm Hg for adult (or >50 mmHg in young children)
A CPP of <50 mmHg is associated with ischemic brain injury
Health teams are responsible to maintaining adequate brain perfusion and
minimizing secondary brain damage
For a patient with a BP of 110/80 , has normal ICP
MAP = ({sys. – diay.} ÷ 3) ({110-80}÷ 3)+80=90
CPP= MAP – ICP = 90-({normal range: 1=15}÷ 2) = 90-8=82 mmHg within
normal
✓ Loss or decrease in level of consciousness,
depending on severity and type of injury
✓ Loss of memory before or after the injury
✓ Increased ICP
✓ Headache, dizziness
✓ Nausea and vomiting
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✓ Unequal pupils
✓ Tachycardia, tachypnea
✓ Diaphoresis
✓ Hemiparesis
Inside the cranium, there is : brain tissue 84%, blood 4%, and cerebrospinal
fluid 12%
Increase any one significantly without a decrease in either of the other two,
intracranial pressure
Etiology increases of ICP:

o head trauma
o brain tumors
o bleeding within the brain
o meningitis
ICP remains at 15 mm Hg or below to ensure normal cerebral perfusion
pressure (CPP) of 70 to 100 mm Hg
Signs of Increased Intracranial Pressure
Early Late
• Drowsiness; difficult to awaken • Glasgow Coma Scale <12
• Restlessness • Decreased response to painful
• Confusion stimuli
• Irritability • Decorticate or decerebrate
• Glasgow Coma Scale =13 posturing
• Personality changes • Increased weakness or
• Sluggish or unequal pupil hemiparesis
response • Dilated pupil(s)
• Weakness in arms or legs • Seizures
• Slow or slurred speech • Cushing’s triad: bradycardia ,
• Dull headache, especially upon elevated systolic blood
awakening pressure with wide pulse
• Vomiting without nausea pressure, irregular breathing
• Loss of gag and corneal
reflexes
• Periods of apnea
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Diagnostic tests for head trauma:

1. MRI and CT scan show densities that indicate the location of the
hematoma and shifts in cerebral tissue.
2. ICP monitoring provides direct and continuous data for evaluating the
extent to which the lesion is expanding or responding to treatment
3. Skull X ray, CT scan, and MRI rule out a more serious head injury
(e.g., skull fracture, intracranial bleeding).

Medications
Mannitol is an osmotic diuretic used to treat cerebral edema
Pentobarbital is used to induce a barbiturate coma to decrease cerebral
metabolic demands
Phenytoin prophylactically to prevent or treat seizures
Morphine sulfate analgesics used to control pain and restlessness
Antibiotics : prophylaxis’s to infection
Craniotomy
A craniotomy is the removal of nonviable brain tissue that allows for
expansion and/or removal of epidural or subdural hematomas, through creating
a bone flap to permit
access to the affected area
➢ Supine position with the head slightly elevated or a side-lying position on
the unaffected side.
➢ Neurologic assessments & VS every 15 to 30 minutes until the patient’s
condition is stable to detect increased ICP
➢ Maintains a neurologic flow sheet to compare trends in assessment findings.
➢ Assess edema around the eyes (Periorbital edema)
➢ Removes antiembolism stockings briefly every 8 hours and reapplies them
to reduce the risk of thrombus or embolus.
➢ Monitor the client’s body temperature closely, because hyperthermia
increases brain metabolism, increasing the potential for brain damage.
➢ Closely observe for increased ICP ( Projectile Vomiting ).
➢ Restricts fluids to control cerebral edema and to increase cerebral perfusion.
➢ Administers corticosteroids when prescribed.
➢ Test mobility and strength in all four extremities.
191
➢ Monitor for seizure & provide safety measures

➢ Initiate I.V. therapy while strictly monitoring intake and output to maintain
hydration and prevent cerebral edema
➢ Provide respiratory care to maintain a patent airway and adequate
ventilation; turn and encourage
➢ frequent deep breathing in a nonintubated patient, suction an intubated
patient, remember that hypoxemia and Hypercapnia increase ICP
➢ Avoid factors that increase ICP
o Hypercarbia, which leads to cerebral vasodilation
o Endotracheal or oral tracheal suctioning
o Coughing
o Blowing the nose forcefully
o Extreme neck or hip flexion/extension
o Maintaining the head of the bed at an angle less than 30°
o Increasing intra-abdominal pressure (restrictive clothing, Valsalva maneuver)
➢ Implement actions that will decrease ICP.

• Elevate head at least 30° to reduce ICP and to promote venous drainage.
• Avoid extreme flexion, extension, or rotation of the head, and maintain the
body in a midline neutral position.
• Maintain a patent airway. Provide mechanical ventilation as indicated.
• Administer oxygen as indicated to maintain an oxygen saturation level of
greater than 92%.
• Hyperventilate clients on mechanical ventilation to keep the PaCO2
between 35 to 38 mm Hg. This reduces cerebral blood flow.
• Maintain cervical spine stability until cleared by an x-ray.
• Report presence of cerebrospinal fluid (CSF) from nose or ears to the
provider.
• Provide a calm, restful environment (limit visitors, minimize noise).
• Implement measures to prevent complications of immobility (turn every 2
hr, footboard, and splints). Specialty beds can be used.
• Monitor fluid and electrolyte values and osmolality to detect changes in
sodium regulation, the onset of diabetes insipidus, or severe hypovolemia.
• Provide adequate fluids to maintain cerebral perfusion and to minimize
cerebral edema.
• When a large amount of IV fluids are prescribed, monitor for excess fluid
192
volume which could increase ICP.

• Maintain safety and seizure precautions (side rails up, padded side rails, call
light within the client’s reach).
• Even if the level of consciousness is decreased, explain to the client the
actions being taken and why.
• Hearing is the last sense affected by a head injury
Pupil size and reaction
Pupils should be assessed for size and reaction to light. Altered pupil size and
reaction is a later sign than reduction in level of consciousness
• Patients with a GCS of 8 or less must be intubated and ventilated
indications
o Hypoxia
o Hypercarbia
o Significantly deteriorating conscious level
o Facial fractures/copious facial bleeding
o Seizures
Spinal Cord Injury(SCI)

✓ Spinal cord injuries (SCIs) involve the
loss of Motor function, sensory function,
reflexes, and control of elimination.
✓ Injuries in the cervical region result in
quadriplegia
✓ Injuries below T1 result in paraplegia
Mechanism Of Spinal Cord Injury :

• Falls
• Road traffic accidents
• Sporting injuries – rugby, horse riding
• Diving – especially into shallow water
• Self harm (hanging)
• Disease (metastatic cancer spine)
• Fractures of the vertebral column
• Penetrating trauma (gunshot and knife wounds)
❖ Cervical and lumbar injuries are the most common because these levels
are associated with the greatest flexibility and movement
193
SCI can be divided into :

Primary injury refers to the injury that has occurred at the time of the
incident.
Secondary injury occurs minutes or hours after the primary injury and it is
the health care professional’s role to minimize the risk of this by avoiding
ischemia, hypoxia, hemorrhage, and edema.
✓ Fractures , Dislocation & Hematoma can damage spinal cord, by reducing
blood supply to the cord or affecting the structure of the cord
Common factors that worsened secondary SCI

1. Mechanical instability (carefully handled and positioned) .
When being moved for examination of the back, placement of sliding sheets ,
relief of pressure areas, the patient should be log rolled using four people
2. Hypoxia, Injuries to the cervical spine at C3–C4 can cause damage to the
phrenic nerve causing paralysis of the diaphragm. breathing become labored,
with paradoxical movement ( chest and abdomen appear to move at different
times), and be more shallow, require mechanical ventilation
3. Hypoperfusion:
Caused by direct vessel injury in the spinal column or hypovolemia due to
bleeding problem.
Function be reduced and eventually cell death, treatment of hypovolemia is
essential.
Spinal shock is a loss of sympathetic reflex activity below the level of injury
within 30 to 60 minutes of a spinal injury. In addition to paralysis, manifestations
include:
hypotension, bradycardia, and warm, dry skin. If injury is in the cervical or
upper thoracic region, respiratory failure ,Bowel and bladder distention
develops
Autonomic Dysreflexia (Hyperreflexia)
✓ It is an exaggerated sympathetic nervous system response in people with
spinal cord injuries above T6., is a life-threatening situation that requires
immediate resolution
✓ It can occur suddenly at any time after spinal shock subsides
Common Causes of Autonomic Dysreflexia
• Full bladder
• Abdominal distention
• Impacted feces
194
• Skin pressure or breakdown

• Overstretched muscles
• Sexual intercourse
• Labor and delivery
• Sunburn below the cord injury
• Infected ingrown toenail
• Exposure to hot or cold environmental temperature
• Taking over-the-counter decongestants
Clinical Manifestations include :

- hypertension (up to 300 mm Hg systolic)
- blurred vision, throbbing headache, marked diaphoresis above the level of
the lesion
- bradycardia (30 to 40 beats per minute), nasal congestion , and nausea.
- It is important to measure BP when a patient with headache
Neurogenic shock is caused by damage to the sympathetic pathways in the

spinal cord, exit the thoracic spine at the level of T6, therefore, usually does
not occur in injuries below T6.
Cause alteration to normal autonomic function

➢ Vasomotor tone is lost because of sympathetic pathway damage, the blood
vessels in lower extremities and abdominal will not be able to constrict,
vasodilation occur, caused pooling of the blood in the vessels and consequently
hypotension.
Hypovolemic shock is much more common that neurogenic shock

o Ongoing care of patient with a spinal injury depends on the injury sustained,
treatment needed and resources available : neurosurgeon , orthopedic surgeon,
ICU
o Cervical cord injuries can affect all four extremities, causing paralysis and
paresthesia, impaired respiration, and loss of bowel and bladder control
o Tetraplegia a term that replaces (quadriplegia), refers to weakness,
paralysis and sensory impairment of all extremities and the trunk when there is
a spinal injury at or above the first thoracic (T1) vertebrae.
o If the injury is at C3 or above, the injury is usually fatal because muscles
used for breathing are paralyzed. An injury at the fourth or fifth cervical
195
vertebra affects breathing and may necessitate some type of ventilatory support
o Paraplegia, weakness or paralysis and compromised sensory functions of
both legs and lower pelvis, occurs with spinal injuries below the T1 level
o Complete cord involvement results in total loss of sensory and motor
function below the level of the injury.
o The degree of sensory and motor loss varies depending on the level of
injury
Cascade of metabolic and cellular events that leads to spinal cord ischemia and
hypoxia of secondary injury. SCBF, spinal cord blood flow.
- Inability to feel light touch when touched by a cotton ball, inability to
discriminate between sharp and dull when touched with a safety pin or other sharp
objects, and an inability to discriminate between hot and cold when touched with
containers of hot and cold water.
- Absent deep tendon reflexes.
- Flaccidity of muscles.
- Hypotension that is more severe when the client is in sitting in an upright
position.
- Shallow respirations.
196
- Dependent edema.
- Neurogenic shock, which accompanies spinal trauma, causes a total loss of
all reflexive
- decreased reflexes, loss of sensation, and flaccid paralysis below the level of
the injury.
Complications:
✓ Infection
✓ Deep Vein Thrombosis
✓ Orthostatic Hypotension
✓ Skin Breakdown
✓ Autonomic dysreflexia
✓ Neurogenic shock
Diagnostic Tests
o Plain radiographs are done to identify fractures or displacement of vertebrae.
o A CT scan is also useful for identifying fractures.
o MRI may demonstrate lesions within the cord
o Urinalysis, hemoglobin, ABGs, CBCs (for evaluation of platelets and WBCs)
Used to monitor for undiagnosed internal bleeding

Medications
Glucocorticoids Vasopressors
Plasma expanders Vasodilators
Muscle relaxants Cholinergics
Analgesics Anticoagulants
❖ Spinal fusion is commonly done when a spinal fracture creates an area of
instability of the spine
❖ A decompressive laminectomy is done by removing a section of lamina,
accessing the spinal canal, and removing bone fragments, foreign bodies, or
hematomas that may be placing pressure on the spinal cord
❖ Application of paravertebral rods can be used to mechanically immobilize
several vertebral levels
197
Nursing interventions
Respiratory status
- Monitoring the client’s respiratory status is the first priority
- Provide the client with oxygen and suction as needed.
- Assist with intubation and mechanical ventilation if necessary.
- Assist the client to cough by applying abdominal pressure when attempting
to cough.
- Teach client about use of incentive spirometer, and encourage client to
perform coughing and deep breathing regularly.
Tissue perfusion
o Neurogenic shock occurs after a SCI and can cause total loss of voluntary
and autonomic function for several days to weeks
o When in an upright position, clients who are in neurogenic shock will
experience postural hypotension. Transferring the client to a wheelchair
o Raise the client’s head of the bed and be ready to lower the angle if the client
reports dizziness
o Monitor the client for signs of thrombophlebitis, bleeding, infection , skin
breakdown(complications)
o Maintain an adequate fluid intake for the client; fluid will aid in preventing
urinary
calculi and bladder infections, and maintain soft stools
o Determining the baseline data: LOC, VS, I& O, Bowel Function, Reflexes,
movement, sensations , edema and muscle strength and tone
o Mobility with various types of braces
Stroke
o Known as cerebrovascular accidents (CVAs) or brain attacks
o It is a disruption in the cerebral blood flow secondary to ischemia,
hemorrhage, brain attack, or embolism.
There are 2causes & types of strokes:
- Hemorrhagic – These occur secondary to a ruptured artery or aneurysm ,
blood is released in brain tissue
- Ischemic strokes :
thrombus or embolus obstructs an artery carrying blood to the brain
o Thrombotic – These occur secondary to the development of a blood clot
in a cerebral artery, and causes ischemia distal to the occlusion.
o Embolic – These occur secondary to an embolus traveling from another
198
part of the body to a cerebral artery

When ischemic strokes occur, glucose and oxygen to brain cells are reduced
✓ When a hemorrhagic stroke occurs, blood leaks from intracerebral arteries.
✓ The collection of blood adds volume to the intracranial contents, resulting in
elevated pressure
✓ Atherosclerosis and arteriosclerosis are major contributors to the formation
of thromboemboli and subsequent CVAs
✓ Common causes of cerebral hemorrhage are rupture of cerebral vessels ,
hemorrhagic disorders such as leukemia and aplastic anemia, severe
hypertension,and brain tumors
❖ Brain and cerebral nerve cells are extremely sensitive to a lack of oxygen; if
the brain is deprived of oxygenated blood for 3 to 7 minutes during stroke, both
the brain and nerve cells begin to die
Risk Factors
Uncontrollable Controllable
• Age: Risk of • Hypertension: 40% to 90% of clients with CVA have
CVA increases previous hypertension.
with each decade • Atrial fibrillation: 15% of those with atrial fibrillation,
beyond age 55 dysrhythmia associated with thromboembolic complications
years. develop a CVA.
• Sex: Men have • Hyperlipidemia: High blood cholesterol and low-density
a slightly higher lipoprotein (LDL) levels increase the risk for atherosclerosis
risk than women. and CVA.
• Genetics: Those • Diabetes: Elevated blood glucose level increases
whose blood triglycerides and accelerates their conversion to LDLs.
relatives have had • Smoking: Nicotine is a vasoconstrictor.
a CVA are at • Obesity: It contributes to hypertension, hyperlipidemia, and
increased risk. diabetes.
• Thrombogenic substances: Stimulants such as herbal
products derived from ephedra plants, estrogens, and oral
contraceptive increase risk.
• Valvular disease or replacement: Thrombi and emboli
form and break free from vegetation or valve replacements.
Signs of an impending stroke include the following:
199
• Numbness or weakness of one side of the face, an arm, or leg

• Mental confusion
• Difficulty speaking or understanding
• Impaired walking or coordination
• Severe headache
Immediately after a large cerebral hemorrhage,

o The client is unconscious
o Breathing is noisy and labored.
o The cheek on the side of the CVA blows out on exhalation
o The eyes deviate toward the affected side of the brain.
o The pulse is slow, full, and bounding. Initially, BP is elevated.
o Temperature is elevated during the acute phase and persists for several days.
o The level of consciousness (LOC) ranges from lethargy to deep coma,
whichcan persist for days or even weeks.
➢ Clinical manifestations, are highly variable and depend on

▪ the area of the cerebral cortex and the affected hemisphere
▪ the degree of blockage (total, partial
▪ the presence or absence of adequate collateral circulation( circulation
formed by smaller blood vessels branching off from or near larger occluded
vessels.
➢ A common neurologic result of a CVA in the motor area of the cerebrum is
hemiplegia on the side opposite the area of the brain (paralysis on one side of the
body).
➢ Expressive aphasia, the inability to speak, or receptive aphasia, the
inability to understand spoken and written language, can result, depending on
where the client’s speech center is located in the brain.
➢ Confusion and emotional liability are characteristic symptoms of a CVA.
➢ Hemianopia is the ability to see only half of the normal visual field
➢ When looking straight ahead, the client cannot see to the right (in left-sided
stroke) or left (in right-sided stroke) with either eye
➢ Motor deficits with CVA include impairment of (1) mobility, (2) respiratory
function, (3) swallowing and speech, (4) gag reflex, and (5) self-care abilities
Diagnostic Tests:
CT or MRI rapidly distinguish between ischemic and hemorrhagic stroke and
200
help determine the size and location of the stroke.

CT angiography (CTA) provides visualization of cerebral blood vessels and
an estimate of perfusion, detects filling defects in the cerebral arteries.
Magnetic resonance angiography (MRA) can detect vascular lesions and
blockages
Angiography can identify cervical and cerebrovascular occlusion,
atherosclerotic plaques, and malformation of vessels.
Transcranial Doppler (TCD) ultrasonography has been effective in
detecting microemboli and vasospasm in the major cerebral arteries
Stroke prevention include: management of modifiable risk factors

(1) healthy diet,
(2) weight control,
(3) regular exercise,
(4) no smoking,
(5) limiting alcohol consumption,
(6) routine health assessments
Close management of patients with known risk factors such as diabetes
mellitus, hypertension, obesity, high serum lipids, or cardiac dysfunction
Ischemic Stroke.
Drug Therapy:
✓ Recombinant tissue plasminogen activator (tPA) is administered IV to
reestablish blood flow and prevent cell death for patients with acute onset of
✓ This drug must be administered within 3 to 4.5 hours of the onset of clinical
signs.
✓ Patients are screened carefully before tPA can be given, including a CT or
MRI scan to rule out hemorrhagic stroke, blood tests for coagulation disorders,
and screening for recent history of GI bleeding, head trauma, or major surgery
✓ Aspirin may be initiated within 24 to 48 hours of an ischemic stroke
Surgical :
❖ Carotid artery angioplasty with stenting (CAS)
❖ Carotid endarterectomy is performed to open the artery by removing
atherosclerotic plaque
❖ Corkscrew-like device that is twisted into the clot, after which the clot is
gently pulled out.
❖ The mechanical embolus removal in cerebral ischemia (MERCI) retriever (a
201
corkscrew-like device) allows physicians to go inside the blocked artery of

patients who are experiencing ischemic stroke
Acute Care: Hemorrhagic Stroke
Drug Therapy:
✓ Anticoagulants and platelet inhibitors are contraindicated in patients with
hemorrhagic strokes.
✓ The main drug therapy for patients with hemorrhagic stroke is the
management of hypertension.
✓ Oral and IV agents may be used to maintain BP within a normal to high-
normal range
✓ Seizure prophylaxis in the acute period after intracerebral and subarachnoid
hemorrhages
✓ The calcium channel blocker is given to with subarachnoid hemorrhage to
decrease the effects of vasospasm and minimize cerebral damage
Surgical :
• Immediate evacuation of aneurysm-induced hematomas or cerebellar
hematomas larger than 3 cm
• Following aneurysmal occlusion via clipping or coiling, hyper dynamic
therapy
• Subarachnoid and intracerebral hemorrhage: Insertion of a ventriculostomy
for cerebrospinal fluid drainage can dramatically improve these situations
Goals Of Nursing Care

▪ maintain a stable or improved level of consciousness
▪ attain maximum physical functioning,
▪ attain maximum self-care abilities and skills,
▪ maintain stable body functions (e.g., bladder control),
▪ maximize communication abilities,
▪ maintain adequate nutrition,
▪ avoid complications of stroke,
▪ maintain effective personal and family coping
Client and family educations:

• Administer medications as directed
• Implement eating and swallowing techniques that reduce the potential for
aspiration
202
• Perform the Heimlich maneuver to clear the airway if the client cannot speak
or breathe after swallowing food
• Continue follow-up care with the speech pathologist and dietitian.
• Remove throw rugs, clutter, and electrical cords from the client’s home
environment to reduce the potential for falls.
• Perform regular exercises, change the client’s position frequently, and apply
braces or splints designed to maintain extremities in proper anatomic position.
Respiratory System:
➢ An oropharyngeal airway may be used in comatose patients to prevent
the tongue from falling back and obstructing the airway and to provide access
for suctioning
➢ Provide airway protection include :
• frequently assessing airway patency and function,
• providing oxygenation
• suctioning
• promoting patient mobility
• positioning the patient to prevent aspiration
• encouraging deep breathing.
Neurologic System
❖ The primary clinical assessment tool to evaluate and document neurologic
status in acute stroke patients is the NIH Stroke Scale (NIHSS) that measures
stroke severity
❖ Monitor for changes in the client’s level of consciousness
❖ Applying measures of reducing increase ICP
❖ Institute seizure precautions
Cardiovascular System :aimed at maintaining homeostasis, include

o monitoring vital signs frequently
o monitoring cardiac rhythms
o calculating intake and output, noting imbalances;
o regulating IV infusions;
o adjusting fluid intake to the individual needs of the patient;
o monitoring lung sounds for crackles & rhonchi indicating pulmonary
203
congestion
o monitoring heart sounds for murmurs
o teach active range-of-motion
Musculoskeletal System:
Interventions to optimize musculoskeletal function are
• range-of-motion ROM exercises and positioning are important interventions
• trochanter roll at the hip to prevent external rotation
• hand cones (not rolled washcloths) to prevent hand contractures
• arm supports with slings and lap boards to prevent shoulder displacement;
• avoidance of pulling the patient by the arm to avoid shoulder displacement
• posterior leg splints, footboards, or high-top tennis
• shoes to prevent foot drop
• hand splints to reduce spasticity
Integumentary System: Interventions for prevention of skin breakdown

✓ pressure relief by position changes, special mattresses
✓ good skin hygiene, dry skin
✓ early mobility, maximum duration of 2 hours for any position, paralyzed
side for only 30 minutes, & 15 minutes of pressure relief (area of redness)
✓ do not massage the damaged area
Gastrointestinal System
Common bowel problem is constipation.
o Physical activity promotes bowel function
o Laxatives, suppositories, stool softeners
Urinary System
Common problem is poor bladder control, resulting in incontinence
• Take steps to promote normal bladder function (manual evacuation of
bladder)
• Avoid the use of an indwelling catheter that associated with UTI
• An intermittent catheterization can be used
Assist with the client’s communication :

- Assess the ability to understand speech by asking the client to follow simple
commands.
- Observe for consistently affirmative answers
204
- Assess accuracy of yes/no responses in relation to closed-ended questions.

- Supply the client with a picture board of commonly requested items/needs
Assist with safe feeding

✓ Assess swallowing and gag reflexes before feeding.
✓ If a swallowing deficit is identified, the client’s liquids may need to avoid
aspiration.
✓ Have the client eat in an upright position and swallow with the head and
neck flexed slightly forward.
✓ Place food in the back of the mouth on the unaffected side.
✓ Have suction on standby.
✓ Maintain a distraction-free environment during meals
General Nursing Interventions

➢ Measures to prevent the development of a thrombus or embolus are used
➢ Monitor the client’s vital signs every l to 2 hr
➢ Prevent complications of immobility, such as atelectasis, pneumonia,
pressure sores, and DVTs
➢ Maintain a safe environment to reduce the risk of falls
➢ Provide assistance with ADLs as needed
➢ Acute care begins with managing the airway, breathing, and circulation.
➢ Oxygen administration, artificial airway insertion, intubation, and
mechanical ventilation and baseline neurologic assessment is carried out
➢ Fluid and electrolyte balance must be controlled carefully
➢ Management of increased intracranial pressure
➢ Management of hyperthermia drug therapy, pain, constipation and
avoidance of hypervolemia
➢ Apply rehabilitation and coping mechanism
Bell's Palsy
Inflammation of CN -7
Resulting in weakness or paralysis of one side of the face
Usually resolve in 2-8 weeks
Etiology
Unknown
Clinical Manifestations
Facial pain that radiates to the eye & ear
205
Eye tearing
Speech difficulties
Distortion of the face
Diminished blink reflex
Teaching Eye Care

• Cover the eye with a protective shield at night.
• Apply eye ointment to keep eyelids closed during sleep.
• Close the paralyzed eyelid manually before going to sleep.
• Wear wraparound sunglasses or goggles to decrease normal evaporation
from the eye.
Maintaining Muscle Tone

• perform facial massage with gentle Upward motion several times daily
• Demonstrate facial exercises, such as wrinkling the forehead,
• blowing out the cheeks, and whistling, in an effort to prevent muscle atrophy.
• Instruct patient to avoid exposing the face to cold and drafts.
Diet & Nutrition

• Instruct patient to chew on the unaffected side of his mouth.
• Provide soft and nutritionally balanced diet.
• Eliminate hot fluids and foods.
• Give frequent mouth care, being particularly careful to remove residues of
food that collects between the cheeks and gums.
206

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كتاب التمريض الجديد2022

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Medical Surgical Nursing

Nursing Management for the Common Diagnostic Test

Test Uses of Patient Posttest NI

Angiography ● Identifying ● Instruct the patient to ● Observe the patient

● Assessing blood flow gallbladder,

followed by disease 15-minute intervals radiation precautions

Magnetic ● Detecting ● Have the Pt. remove metal objects, such as

Nursing Care Management of Clients with Cardiovascular Disorders

Physical examination of CVS

Assessing Blood Pressure and Pulse for Postural Changes

• Current health status: - Ask the following questions:

Physical assessment findings:-

Nursing considerations of ECG:

Nursing considerations of Exercise ECG:

raise his heart rate.

Nursing considerations of Cardiac catheterization and coronary

Nursing management pre-posttest

every hour for 4 hours, then once every 4 hours.

Four important parameters are used to asses homodynamic status which

readings on different dates is above pre-hypertensive levels .

Predisposing factors of primary hypertension:

- High dietary intake of sodium or saturated fats.

Signs and symptoms may include:

• Left ventricular hypertrophy • Angina • Stroke • Heart failure

In diabetes, ACE inhibitors delay the progression of renal disease: e.g.

Example of Antihypertensive Agents

1. Monitor blood pressure with multiple readings—lying, sitting, and standing,

What is the Difference between Arteriosclerosis and Atherosclerosis?

Atherosclerosis is a condition in which the lumen of arteries fill with fatty

Signs and Symptoms of Atherosclerosis:

Diagnosing for Atherosclerosis

A. Lifestyle Changes: The changes will focus on weight management,

Signs and Symptoms:-

Treatment:- depends on whether an artery or a vein is occluded and the

2- Results from weakness of valves or loss of elasticity of vessel wall.

Varicose veins can appear in various parts of the body, including:

Signs and Symptoms:-

Nursing Care of Clients with Varicose Veins:

Coronary artery disease (CAD) is a term applied to obstructed blood flow

Risk Factors for Coronary Artery Diseases

Risk factor:- Factors That Increase Cardiac Workload

pressure, with increased oxygen demand?

✓ The diagnosis of angina pectoris depends principally upon the history,

Types, causes, symptoms & treatment

Unstable Progressive ✓ Chest pain of ▪ Sedation, IV

Remember PQRST (A method of pain assessment) as following:

Q Quality of pain What does the pain feel like?

Relieving/ aggravating factors' angina is aggravated by continued activity

2. Administer beta-adrenergic blocker: has a cardio protective effect,

Definition: Myocardial infarction or “heart attack” is an irreversible injury to

Etiology and Risk factors:-

Signs and Symptoms:-

Complications Of Myocardial Infarction

✓ Electrical cardioversion for unstable ventricular tachycardia. In

Nursing Intervention:- Monitor

➢ Laboratory data (cardiac enzymes, electrolytes, ABGs)

Explain to the patient:

Valvular heart disease

● Three types of Acquired Valvular heart disease & causes:

Clinical Manifestations (S & S):

• Radionuclide studies determine ejection fraction during activity and rest.

Therapeutic Interventions for Cardiac Valvular Disorders

Nursing Assessment for Patients with Cardiac Valvular Disorders

✓ Monitor current weight, and note recent changes.