Communicable Disease Nursing Guide

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCH*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM

NCLEX*DHA*HAAD*PROMTERIC*UK-CBT
COMMUNICABLE
DISEASE NURSING
 Infection
 Implantation and success replication of an organism in the tissue of the
host resulting to signs and symptoms as well as immunologic response.
 Carrier
 An individual who harbors the organism and is capable of transmitting it to a
susceptible host without showing manifestations of the disease.
 Communicable Disease
 It is an illness caused by an infectious agent or its toxic products that are
transmitted directly or indirectly to a well person through an agency, and a
vector or an inanimate object.
 Contact
 It is any person or animal who is in close association with an infected
person, animal or freshly soiled materials.
 Contagious Disease
 It is a term given to a disease that is easily transmitted from one person to
another through direct or indirect means.
 Disinfection
 It is the destruction of pathogenic microorganism on inanimate objects by
directly applying physical or chemical means.
 Concurrent
 it is a method of disinfection done immediately after the infected
individual discharges infectious material/secretions.
 Method of disinfection when the patient is still the source of infection.
 Terminal
 It is applied when the patient is no longer the source of infection
 This is done after patient is discharged from the hospital to prepare the room for the
next patient.
 Habitat
 It is a place where an organism lives or where an organism is usually found.
 Host
 It is a person, animal or plant on which a parasite depends for its survival.
 Infectious Disease
 It is transmitted not only by ordinary contact but requires direct inoculation of
the organism through a break on the skin or mucous membrane.
 Isolation
 it is the separation from other persons of an individual suffering from a
communicable disease during the period of communicability.
 Quarantine
 It is the limitation of freedom of movement of persons or animals which have
been exposed to communicable disease/s for a period of time equivalent to
the longest incubation period of that disease.
 Reservoir
 It is composed of one of more species of animal or plant in which an infectious
TOPRANK REVIEW ACADEMY | 1

agent lives and multiplies for survival and reproduces itself in such a manner
that it can be transmitted to man.
EPIDEMIOLOGY
 It is study of occurrences and disturbance of diseases as well as the distribution
and determinants of health states of events in specified population and
application of this study to the control of health problems.
 Foundation of preventing disease
Uses
 Study the history of the health population and the rise and fall of disease and changes
in their character.
 Diagnose the health of the community
 Study the work of health services with a view of improving them
 Estimate the risk of disease, accident, defects and the chances of avoiding them.
 Complete the clinical picture of chronic disease and describe their history
Epidemiologic Triangle
 Consists of three components – host, environment and agent.
Host
 Any organism that harbors and provides nourishment for another organism
Agent
 Intrinsic property of microorganism to survive and multiply in the environment to
produce disease.
Environment
 It is the sum total of all external conditions and influences that affect the
development of an organism which can be:
 Biological
 Social
 Physical
Patterns of Occurrence and Distribution
 Sporadic
 Intermittent occurrence of a few isolated and unrelated cases in a given locality.
 Cases are few and scattered
 E.G. Rabies
 Endemic
 Continuous occurrence throughout a period of time, of the usual number of case in
a given locality.
 The disease is therefore always occurring in the locality and the level of
occurrence is more or less constant through a period of time.
 Examples:
 Schistosomiasis (Leyte & Samar)
 Filariasis (Sorsogon)
 Malaria (Palawan)
 Epidemic (Outbreak)
 Unusually large number of cases in a relatively short period of time.
 Pandemic
 The simultaneous occurrence of epidemic of the same disease in several countries.
 E.G. HIV/AIDS and SARS

CHAIN OF INFECTION
1. Causative Agent
 Any microbe capable of producing a disease
 Bacteria, spirochete, virus, ricketssia, chlamydiae, fungi, protozoa and parasites
2. Reservoir of Infection
 Refers to the environment and objects on which an organism survives and multiples
3. Portal of Exit
 It is the path or way in which the organism leaves the reservoir.
 Common portals of exit:
 Respiratory System
 Genitourinary Tract
 Gastrointestinal Tract
 Skin and Mucous Membrane
 Placenta
4. Mode of Transmission
 It is the means by which the infectious agent passes through from the portal of exit
of the reservoir to the susceptible host.
 Easiest link to break the chain of infection
Contact Transmission
 Most common mode of transmission.
Direct Contact
 Refers to a person to person transfer of organism.
Indirect Contact
 Occurs when the susceptible person comes in contact with a contaminated object.
Droplet Spread
 It is the transmission through contact with respiratory secretions when the
infected person coughs, sneezes or talks.
 Transmission is limited within 3 feet.
Airborne Transmission
 Occurs when fine microbial particles or dust particles containing microbes
remain suspended in the air for a prolonged period.
 Transmission can be more than 3 feet.
Vehicle Transmission
 It is the transmission of infectious disease through articles or substance that
harbor the organism until it is ingested or inoculated into the host.
Vector-borne Transmission
 Occurs when intermediate carriers, such as fleas, flies and mosquitoes transfer
the microbes to another living organism.
5. Portal of Entry
 It is the venue the organism gains entrance into the susceptible host.
 The infective microbes use the same avenues when they exit from the reservoir.
6. Susceptible Host
 When the defenses are good, no infection will take place.
 However, in weakened host, microbes will launch an infectious disease.
IMMUNITY
 Natural

 Active
 Acquired through recovery from a certain disease
 Passive
 Acquired through placental transfer
 Artificial
 Active
 Acquired through the administration of vaccine and toxoid
 Passive
 Acquired through the administration of antitoxin, antiserum, convalescent
serum, and immunoglobulins
Type of Antigen
 Inactivated (killed organism)
 Not long lasting
 Multiple doses needed
 Booster dose needed
 Attenuated (live, weakened organism)
 Single dose needed
 Long lasting immunity
ISOLATION
 Separation of patients with communicable disease from other so as to prevent or
reduce transmission or infectious agent directly or indirectly.
Categories Recommended in Isolation

 Strict Isolation
 Prevents highly contagious or virulent infections
 Contact Isolation
 Prevents the spread of infection primarily by close or direct contact
 Respiratory Isolation
 Prevents the transmission of infectious diseases over short distance through the air
 TB Isolation
 For TB patients with positive smear or with chest X-ray which strongly suggests
active tuberculosis.
 Enteric Isolation
 For infection with direct contact with feces
 Reverse/Neutropenic Isolation
 An immunocompromised client is separated to prevent contracting infection from
environment.
 Standard Precaution
 To prevent infections that are transmitted by direct or indirect contact with
secretions or drainage (except sweat) from another person.
 Universal Precaution + Body Substance Isolation (BSI)
 Universal Precaution
 Intended to prevent parenteral mucous membrane and non-intact skin
exposure of health care workers to blood borne pathogens
 Transmission Based Precaution

 Second Tier of precaution

 Applicable to patient who are highly contagious
 Three types: Contact, Airborne, Droplet
CHICKEN POX
Other Term: Varicella zoster
Description: Acute infectious disease of sudden onset with slight fever, mild constitutional
symptoms and eruptions which are maculopapular for a few hours, vesicular for 3-4 days
and leaves granular scabs.
Etiologic Agent: Human (alpha) herpes virus 3 (Varicella-zoster virus)
Sources of Infection:
 Secretions of respiratory tract of infected persons
 Lesions (little consequence)
 Scabs are not infective
Mode of Transmission
 Direct contact
 Contact with contaminated linen and fomites
 Airborne
Incubation Period
 2 to 3 weeks
Period of Communicability
 Cases are infectious for up to 2 days before the onset of the rash until 5 days after the first
crop of vesicles.
Diagnostic Test
 Isolation of the virus from the vesicular fluid within the first 3 to 4 days of the rash
 Serum antibodies is present in 7 days after onset
Congenital Varicella results in:

 Hypoplastic, deformities and scarring of limb
 Retarded growth
 CNS and ophthalmic manifestation
Nursing Considerations
 Strict Isolation
 Exclusion from school for 1 week after eruption first appears and avoid contact with
susceptible
 Concurrent disinfection if throat and nose discharge
 Tell the patient not to scratch the lesions
 Teach the child and the family how to apply topical antipruritic medication correctly
Susceptibility, Resistance & Occurrence

 Universal among those not previously attacked
 Severe in adults

 An attack confers long immunity

 Second attacks are rare
Prevention
 Vaccine
 Varicella – zoster Immune Globulin (VZIG)
 It should be given within 10 days of exposure
MEASLES
Other Terms: Rubeola / Morbili / 7 – day Measles
Description: it is an acute contagious and exanthematous disease that usually affects

children who are susceptible to Upper Respiratory Tract Infection (URTI)
Etiologic Agent
 Filterable virus of Measles (Paramyxoviridae)
Source of infection
 Secretions of nose and throat of infected persons
 Droplet Spread / Direct Contact with Infected person
 Indirect Contact (articles with secretions)
 Airborne
Incubation Period
 1-2 weeks
 Starts just before the prodrome and lasts until 4 days after the rash appears.
Clinical Manifestations
Koplik spots – pathognomonic sign
1. Pre-eruptive Stage
 Fever
 Catarrhal Symptoms (cough, conjunctivitis, coryza)
 Photophobia
 Stimson’s line (red line on the lower conjunctiva)
2. Eruptive Stage
 Maculo-papular rash
 High grade fever
 Anorexia and irritability
 Throat is red and extremely sore
3. Convalescence Stage
 Rashes fade away
 Fever subsides
 Desquamation begins
 Symptoms subside and appetite is restored

Diagnostic Procedures
 Nose and Throat Swab
 Urinalysis
 Blood exams (Single raised IgM or rise on IgG)
Treatment Modalities
 Anti-viral drug (Isoprenosine)
 Antibiotics
 Oxygen Inhalation
 IV fluids
Complications
 Bronchopneumonia
 Otitis Media
 Pneumonia
 Nephritis
 Encephalitis
Nursing Management
 Isolation
 Maintain standard and airborne precautions.
 Place the patient on a negative pressure room
 Tepid Sponge Bath (TSB)
 Skin care
 Oral and nasal hygiene
 Eye care (photosensitivity)
 Ear care
 Daily elimination (Mild laxative)
 During febrile stage, limit the diet to fruit juices, milk, and water.
 Give medication as ordered by the physician (Penicillin)
Preventive Measures
 Immunization with:
 Anti-measles at the age of 9 months as a single dose
 MMR vaccine (15 mos.); 2nd dose (11 to 12 years old)
 Measles vaccine should not be given to pregnant women, or to persons with active
tuberculosis, leukemia, lymphoma or depressed immune system.
LEPROSY
Other Terms: Hansen’s Disease / Hansenosis
Description: It is a chronic systematic infection characterized by progressive cutaneous

lesions
Three distinct forms

 Lepromatous (Multibacillary) leprosy
 Most serious type
 Not infectious

 Causes damage to the respiratory tract, eyes and testes and well as the nerves and
the skin.
 Lepromin test is negative, but the skin lesion contains large amount of Hansen’s
bacillus
 Slow involvement of the peripheral nerves, with some degree of anesthesia and
loss of sensation and gradual destruction of the nerves.
 Tuberculoid (Paucibacillary) Leprosy
 Affects the peripheral nerves and sometimes the surrounding skin, especially on
the face, eyes and testes as well as the nerves and the skin.
 Lepromin Test is positive, but the organism is rarely isolated from the lesions
 Macules are elevated with clearing at the center and more clearly defined than the
lepromatous form
 Borderline (dimorphous)
 Has the characteristics of both lepromatous and tuberculoid leprosy.
Etiological Agent: Mycobacterium leprae
Incubation Period:
 The incubation period varies from a few months to many years. Lepromatous patients
may be infectious for several years.
 Airborne
 Prolonged skin-to-skin contact
Clinical Manifestation
 Early
 Changes in skin color (reddish/white)
 Loss of sensation on the skin/Anesthesia
 Decrease/loss of sweating and hair growth over the lesion
 Thickened/painful nerves
 Muscle weakness
 Redness of the eye
 Nasal Obstruction
 Ulcers that do not heal
 Late
 Madarosis (Loss of eyebrow and eyelashes)
 Lagopthalmos (inability to close eyelids)
 Clawing of fingers and toes
 Contractures
 Sinking of the nose bridge
 Gynecomastia
Diagnostic Tests
 Slit skin Smear
 Blood Test (Inc. RBC & ESR; Dec, Ca, albumin & Cholesterol level)

 Sulfone Therapy
 Rehabilitation, Recreational and Occupational Therapy
 Multiple Drug Therapy
 Multibacillary (Rifampicin, Clofazimine, Dapsone)
 Infectious Type
 Duration of treatment (12 months)
 Paucibacillary (Rifampicin and Dapsone)
 Tuberculoid & indeterminate
 Non-infectious types
 Duration of treatment (6-9 months)
Nursing Management
 Isolation and Medical Asepsis should be carried out
 Diet: Full, nutritious diet
 Give antipyretic, analgesics and sedative as needed.
 Provide emotional support throughout treatment and rehabilitation of affected extremities
 Patients with eye dryness need to use a tear substitute daily and protect their eyes to
prevent corneal irritation and ulceration.
 Tell the patient with an anesthetized leg to avoid injury by not putting to much
weight on the leg, testing water before entering to prevent scalding, and wearing
appropriate footwear.
Prevention
 Report all cases and suspect of leprosy
 BCG vaccine
 Health education
SCABIES
Description: It is a highly transmissible skin, infection that is characterized by burrows,
pruritus, and excoriations with secondary bacterial infection.
Etiologic Agent: Sarcoptes scabei var. homonis
Source of Infection
 Human skin
 Skin to skin contact
 Direct contact with fomites
Incubation Period
 The itch mite may burrow under the skin and lay ova within 24 hours of an original contact
 This disease is communicable for the entire period that the host is infected.
 Intense itching that becomes more severe at night
 Burrows (lesions) seen in webs of the fingers, wrists and elbows
 Burrows in immunocompromised, infants, young children and elderly appears in face,
neck, scalp and ears

Complications
 Persistent pruritus
 Intense scratching can lead to excoriation, tissue trauma and secondary bacterial infection
Diagnostic Procedure
 Superficial scraping and examination under a low-power microscope of material from a
burrow
Treatment
 Aqueous Malathion lotion
 Permethrin derma cream left on the skin for 8-12 hours
 Benzyl Benzoate
 Sulfur in petrolatum
 Ivermectin – Anti-helminthic drug is effective in resistant cases
 Antipruritic emollient or topical steroid for itching
Nursing Intervention
 Have the patient’s fingernails cut short to minimize skin breaks from scratching
 Instruct patient on proper application of the drugs
 Contaminated clothing or beddings should be dry-cleaned or boiled
 Advise patient to report any skin irritation
 Advise family member and other people who had close contact with the patient be
checked for possible symptoms and be treated if necessary
 Practice contact precaution
 Terminal disinfection should be carried out
 Encourage the patient to verbalize his/her feelings
Prevention and Control
 Good personal hygiene
 Avoid contact with infected persons
 All members of the household, including close contact should be treated
GERMAN MEASLES
Other Terms: Rubella / Three-day Measles
Description
 It is a mild viral illness caused by rubella virus
 It causes mild feverish illness associated with rashes and aches in joints.
 It has a teratogenic effect on the fetus.
Etiologic Agent: Rubella virus

 Droplet transmission
 Transplacental transmission in congenital rubella
Incubation Period
 2 to 3 weeks
 Prodromal Period
 Low grade fever
 Headache
 Malaise
 Mild coryza
 Conjunctivitis

 Post-auricular, sub-occipital and posterior cervical lymphadenopathy which

occurs on the 3rd to the 5th day after onset
 Eruptive Period
 Forchheimer’s spot (pinkish rash on the soft palate)
 Eruption appears after the onset of adenopathy
 Children usually present less or no constitutional symptoms
 The rash may last for one to five days and leaves no pigmentation nor
desquamation
 Testicular pain in young adults
 Transients polyarthralgia and polyarthritis may occur in adults and occasionally in
children.
 Congenital Rubella
 Classic Congenital Rubella Syndrome
 Intrauterine growth retardation
 Infant has low birth weight
 Thrombocytopenic purpura known as “blueberry muffin” skin
 Intrauterine Infection
 May result in spontaneous abortion
 Birth result in spontaneous abortion one or multiple birth anomalies such as:
 Cleft palate, talipes and eruption of teeth
 Cardiac defects (patent ductus arteriosus, atrial septal defect)
 Eye defects (glaucoma, retinopathy, micropthalmia)
 Neurologic (Microcephaly, mental retardation, psychomotor
retardation, vasomotor instability)
Diagnostic Tests
 Clinical observation
 Cell cultures of the throat, blood, urine and cerebrospinal fluid confirm the presence of the
virus
 Convalescent serum that shows a fourfold rise antibody titer supports that the diagnosis
 Acetaminophen for fever and joint pain.
 Isolation
Complications
 Encephalitis
 Neuritis
 Arthritis
 Arthralgias
 Rubella syndrome manifested by:
 Microcephaly
 Mental retardation
 Cataract
 Deaf-mutism
 Heart Disease
Nursing Consideration
 Provide comfort
 Make sure female patients understand how important it is to avoid exposure to this

disease when pregnant.

 Report confirmed cases of rubella to local public health officials
 Warn the patient about possible mild fever, slight rash, transient arthralgia, and arthritis.
 If lymphadenopathy persists after the initial 24 hours, suggest a cold compress to
promote vasoconstriction and prevent antigenic cyst formation.
 Patient’s room must be darkened to avoid photophobia
 Patient’s eyes should be irrigated with warm saline to relieve irritation
 Good ventilation is necessary.
Prevention
 Administration of live attenuated vaccine (MMR)
 Pregnant women should avoid exposure to patients infected with rubella virus
 Administration of Immune Serum Globulin one week after exposure to rubella
PEDICULOSIS
Description
 Any human infestation of lice
 May occur anywhere on the body
Types:
 Pediculosis capitis
 Lice feed on the scalp and rarely, on the skin under the eyebrows, eyelashes and
beard
 Pediculosis Corporis
 Lice live next to the skin in clothing seams.
 Pediculosis pubis
 Lice are found primarily in pubic hairs but may extend to the eyebrows, eyelashes
and axillary or body hair.
 Head-to-head contact
 Fomites
 Sexual activity
Incubation Period
 3 to 7 days
 Pruritis (most common symptom of infestation)
 Tickling sensation of something moving in the hair may be noticed
 Head lice and their nits are most commonly found behind the ears and on the hairs of the
neck and occiput.
 Body lice are found on clothing seams
 Pubic lice will be found attached to the base of the pubic hair and the infestation generally
results in severe itching.
Diagnostic Tests
 Wood’s light examination (fluorescence of the adult lice)
 Microscopic examination (presence of nits on the hair shaft)
 Permethrin (Eliminate) / Pyrethin (Rid Mousse)
 Initial treatment of choice
 Topical insecticide
 For Pediculosis capitis & Pediculosis pubis

 Fine-tooth comb dipped in vinegar

 Washing hair with ordinary shampoo
 Oral Anti- elminthics (Ivermectin, Levamisole, Albendazole) are effective against head lice
infestation
 Prevention of head re-infestation
 Clothes and bed linens must be washed in hot water, ironed or dry cleaned.
 Storing clothes or linens for more than 30 days or placing them in dry heat of 140 F
(60 C)
Complications
 Excoriation
 Secondary bacterial infections
 If left untreated, pediculosis may result in dry, hyperpigmented, thickly encrusted, scaly
skin, with residual scarring
 Contact precautions should be maintained until treatment is complete to prevent spreading
the infection
 Have the patient’s fingernails cut short to prevent skin breaks and secondary
bacterial infections caused by scratching.
 Be alert for possible adverse reactions to treatment with an antiparasitic, including
sensitivity reactions and in some cases, central nervous system (CNS) toxicity.
 To prevent self-infestation, avoid direct contact with the patient’s hair, clothing and
bedsheets.
 Use gloves, a gown, and a protective head covering when administering delousing
treatment.
 After each treatment, inspect the patient for remaining lice and eggs.
 Teach the patient and family how to inspect and identify lice, eggs and related lesions
 Instruct the patient and family about the use of the creams, lotions, powders and
shampoos that eliminate lice.
 Instruct the patient in the proper application of lindane, which can be absorbed
by the skin and cause CNS complications.
HERPES ZOSTER
Other Term: Shingles
Description
 It is acute unilateral and segmented inflammation of the dorsal root ganglia caused
by reactivation of the herpes varicella-zoster virus, which also causes chickenpox
 Usually occur in adults
Causative Agent
 Varicella virus
Incubation Period
 Unknown, but it is believed to be 13-17 days
 Communicable a day before the appearance of the first rash until 5-6 days after the last
crust
 Airborne
 Droplet
 Direct contact

 Begins with fever and malaise
 Severe deep pain, pruritus, and paresthesia and hyperesthesia, usually on the trunk and
occasionally on the arms and legs
 Small, red, nodular skin lesions (Unilateral) erupt on the painful areas up to 2 weeks after
first symptoms
 Vesicles filled with fluid or pus
 Cranial nerve involvement
Complications
 Generalized central nervous system infection
 Acute transverse and ascending myelitis
 Intractable neurologic pain
 Differentiation of herpes zoster from herpes simplex virus through fluorescent light
 Tissue culture technique
 Smear of vesicle fluid
 Microscopy
Management
 Antiviral therapy – Acyclovir
 Analgesics to control pain
 Anti-inflammatory
Nursing Interventions
 Airborne and contact precautions
 If vesicles rupture, apply a cold compress as ordered
 To minimize neuralgic pain, administer analgesics as ordered and evaluate their effects
 Instruct the patients to avoid scratching the lesions
 Keep the patient comfortable and maintain meticulous hygiene
 Encourage sufficient bed rest and give supportive care
Prevention
 Vaccination against varicella
 Avoid exposure to patients with varicella infection
DIPHTHERIA
Description: Acute febrile infection of the tonsil, throat, nose, larynx or wound marked by
patches of grayish membrane from which the diphtheria bacillus is readily cultured.
Etiologic Agents: Corynebacterium, diphtheria (Klebs-Loeffier bacillus)
Sources of Infection
 Discharges and secretion from mucus surface of nose and nasopharynx and from skin and
other lesions
 Reservoir = Man
 Contact with a patient or carrier or with articles soiled with discharges of infected persons.
 Milk (vehicle)
Incubation Period
 2 to 5 days

 2 weeks to more than 4 weeks

 Variable until virulent bacilli has disappeared from secretions and lesions
Types
 Nasal
 with foul – smelling serosanguinous secretions from the nose
 Tonsillar
 Low fatality rate
 Lesions are confined to the tonsils only but tend to spread over the pillars, into the
soft palate and uvula.
 Nasopharyngeal
 Cervical lymph nodes are swollen
 Neck tissues are edematous
 Laryngeal
 Most commonly found in children ages 2 to 5 years old
 It is considered as most severe and more fatal type due to anatomical reason
 There is moderate hoarseness; voice is diminished until it is finally absent.
 Most fatal
 Wound / Cutaneous
 Affects to mucous membrane and any break in the skin.
 Bull neck formation (swelling of the soft tissues of the neck)
 Exudates forming the membrane are grayish in appearance (Pseudomembrane)
 Fatigue / malaise
 Slight sore throat
 Breathing difficulty
 Husky voice
 Swelling of the palate
 Low-grade fever
Methods of Prevention and Control
 Active immunization of all infants and children with 3 doses of DPT
 Pasteurization of milk
 Education of parents
 Reporting of case to the Health Officer of proper medical care
Diagnostic Tests
 Swab from the nose and throat
 Schick Test
 Involves giving an injection of 0.1 mL of dilute diphtheria toxin intradermally.
 Area is checked in 3-4 days and the reaction is documented
 Positive Test is indicated by inflammation or induration at the point of injection.
This indicates that the client lacks antibodies to diphtheria.
 Virulence Test
 Moloney Test
 A test to detect a high degree of sensitivity to diphtheria toxoid is given
intradermally.
 Penicillin
 Anti-toxin
 Erythromycin

Nursing Care
 Follow prescribed dosage and correct technique in administering anti toxin
 Provide comfort
 Absolute bed rest for at least two weeks
 Soft-food diet; small frequent feedings
 Ice collar applied to the neck
 Visiting bag should be set up outside the room of the patient of should be far from
the bedside of the patient
 Watch for signs of shock, which can develop suddenly as a result of systematic vascular
collapse, airway obstruction, or anaphylaxis.
 If neuritis develops, tell the patient it’s usually transient. Be aware that peripheral
neuritis may not develop until 2 to 3 months after the onset of illness.
 Explain how to properly dispose of nasopharyngeal secretion and teach proper infection
precautions
PERTUSSIS
Other Term: Whooping Cough
Description: Acute infection of the respiratory tract characterized by repeated attacks of
spasmodic coughing which consists of a series of explosive expirations, producing a crowing
sound, “the whoop”, and usually followed by vomiting.
Etiologic Agents
 Haemophilus pertussis
 Bordet Gengou bacillus
 Bordetella pertussis
Source of Infection
 Discharges from laryngeal and bronchial mucous membrane of infected persons.
Incubation Period: 7-10 days but may occasionally be up to 3 weeks

 Seven days after exposure to three weeks after typical paroxysms
 Direct spread through respiratory and salivary contacts
 Violent coughing
 Nose bleeding
 Distended neck veins
 Periorbital edema
 Conjunctival hemorrhage
Complications
Most dangerous: bronchopneumonia
 Convulsion
 Umbilical hernia
 Otitis media
 Severe malnutrition and starvation
Diagnostic Tests

 Nasopharyngeal swabs (Positive for B. pertussis)

 Sputum culture
 CBC (leukocytosis)
 Chest Radiography may reveal infiltrates or pulmonary edema with atelectasis
 Supportive Therapy
 Fluid & electrolyte replacement
 Adequate nutrition
 Oxygen therapy
 Antibiotics
 Erythromycin
 Ampicillin
 Post Exposure Treatment: Hyperimmune convalescent serum / gamma-globulin
Nursing Management
 Isolation and medical asepsis
 Suction Equipment should be present at bedside
 Provide warm baths
 Keep the bed dry and free from soiled linens
 I & O should be closely monitored
 General care of nose and throat discharges
 Instruct patients to cover their mouths when they cough or sneeze and to wash their hands
immediately afterwards.
Prevention
 Any case of pertussis should be reported
 Patient should be isolated for 4 to 6 weeks
 Previously immunized children should be given reinforcing injection
INFLUENZA
Other Term: La Grippe
Description: It is an acute infectious disease affecting the respiratory system
Etiologic Agents
 Influenza virus A, B, C
Source of Infection: Discharges from the mouth and nose of infected persons
 Droplet
 Direct contact through droplet infection
 Indirect contact (fomites)
Incubation Period
 1 to 3 days, occasionally up to 5 days

 Infectious period lasts from 1 day before until 3-5 days after onset of symptoms in adults.
 Chilly sensation
 Hyperpyrexia
 Severe aches and pain usually at the back associated with severe sweating
 Vomiting
 Sore throat
 Coryza and cough
Complications
 Hemorrhagic pneumonia
 Encephalitis
 Myocarditis
 Sudden Infant Death Syndrome
 Myoglobinuria
 Blood examinations
 Usually normal but leukopenia has been noted
 Viral Culture (oropharyngeal washing or swabbing during the first few days of illness)
 Viral Serology
 Complement Fixation Test
 It is an immunological medical test that can be used to detect the presence
of either specific antibody or specific antigen in a patient’s serum
 Chest Radiography may reveal bilateral symmetrical interstitial infiltrates indicative of
pneumonia
 Arterial Blood Gas Testing may reveal hypoxemia in severe cases
 Laboratory Tests may reveal leukopenia, lymphopenia, and/or thrombocytopenia.
Management
 Stay at home
 Teach the patient about proper disposal of tissues and good handwashing technique
 Drink plenty of fluids
 Fever Management
 Paracetamol
 Ibuprofen
 Maintain contact and droplet precautions
 Limit strenuous activities
 Watch for signs and symptoms of developing pneumonia such as crackles,
another temperature increase , or coughing accompanied by purulent or bloody
sputum

 Instruct patients who are sick with flu-like symptoms to avoid contact with others for at
least 24 hours.
Preventive Measures
 Active immunization with influenza vaccine
 Education of the public as to sanitary hazard from spitting, sneezing and coughing
 Avoid crowded places
 Avoid use of common towels, glasses and eating utensils.
ANTHRAX
Other Terms: Wool-sorter’s Disease / Ragpicker’s Disease
Description: An acute bacterial disease usually affecting the skin but which may very rarely
involve the oropharynx, lower respiratory tract, mediastinum or intestinal tract.
Etiologic Agent: Bacillus anthracis
 Cutaneous infection is by contact with:
 Tissues of animals (cattle, sheep, goats, horses, pigs and others) dying of the
disease
 Contaminated hair, wool, or products made from them such as drums or brushes
 Soil associated with infected animals or contaminated bone meal used in gardening.
Incubation Period
 Inhalation Anthrax (1 to 7 days) usually within 48 hours
 Cutaneous anthrax (1 to 7 days rarely up to 7 weeks
 Ingestion (1 to 7 days)
 Cutaneous Anthrax
 Most common (over 90% of cases)
 Infection is through the skin
 Over a few days a sore, which begins as a pimple, grows, ulcerates and forms a
black scab, around which are purplish vesicles
 Systemic symptoms may include rigors’ headache and vomiting
 The sore is usually diagnostic: 20% cases are fatal.
 Inhalational Anthrax
 Spores are inhaled with subsequent invasion of mediastinal lymph nodes.
 Abrupt onset of flu-like illness, rigors, dyspnea and cyanosis followed by shock
and usually death over the next 2-6 days.
 Most Fatal
 Intestinal Anthrax
 Occurs following ingestion of meat from infected animals and is manifested as
violent gastroenteritis with fever, vomiting, bloody stools and then septicemia
 Poor prognosis
Diagnostic Tests

 Polymerase Chain
Reaction (PCR)
 Definitive test for B. anthracis
 Swabs from cutaneous lesions
 Blood cultures
 Lymph node or spleen aspirates
 CSF shows characteristic bacilli on staining with polychrome methylene blue.
 Chest radiology may show fluid surrounding the lungs or widening of the mediastinum
 Antibiotics
 Penicillin
 Ciprofloxacin (DOC)
 Doxycycline
 Treatment of cutaneous anthrax is oral antibiotic for 7 to 10 days
 Length of treatment for GI anthrax is 60 days, but safety has not been evaluated beyond14
days
Complications
 Cutaneous
Anthrax
 Septicemia
 Inhalational Anthrax
 Hemorrhagic meningitis
 Pleural Effusions
 Mediastinitis
 Shock
 Acute Respiratory Distress Syndrome
 GI Anthrax
 Hemorrhage
 Shock
 Obtain culture specimens before starting antibiotic therapy
 Supportive measures are geared toward the type of anthrax exposure
 Teach the patient and family that anyone who has been exposed to anthrax must see a
doctor immediately.
 Instruct the patient to take antibiotics as prescribed and until completed.
 Instruct the patient with cutaneous anthrax not to scratch at the lesions.
 Alcohol-based hand sanitizers do not kill anthrax spores; wash hands with soap and water.
Prevention
 Pretreatment of animal product and good occupational health cover are the mainstays of
control

 Animals believed to have died of anthrax should be disposed of under supervision.

 Mass vaccination of animals may reduce disease spread
 Non-cellular vaccines for human use are available for individuals at risk from occupational
exposure
 Workers handling potentially infectious raw materials should be aware of the risks.
PNEUMONIA
Description: An acute infectious disease of the lungs usually caused by the pneumococcus
resulting in the consolidation of one or more lobes of either one or both lungs.
Etiologic Agents
 Streptococcus pneumonia
 Staphylococcus aureus
 Haemophilus influenzae
 Pneumococcus of Friedlander
Incubation Period
 2 to 3 days
 Droplet infection
 Rhinitis
 Chest indrawing
 Rusty sputum
 Productive cough
 High fever
 Vomiting
 Convulsions
 Flushed face
 Dilated pupils
 Pain over the affected lung
 Highly colored urine with reduced chlorides and increased urates
Complications
 Emphysema
 Endocarditis
 Pneumococcal meningitis
 Otitis Media
 Jaundice
Diagnostic Test
 Chest X-ray
 Sputum Analysis
 Blood/Serologic Exam
 Dull percussion note on affected side

Management
 Bed Rest
 Adequate salt, fluid, calorie, and vitamin intake
 TSB
 Frequent turning from side to side
 Prevent common colds, influenza and other upper respiratory infections
 Immunization with pneumonia vaccine
 Eliminate contributory factors such as exposure to cod, pollution, and physical conditions
of fatigue and alcoholism.
TUBERCULOSIS
Other Terms: Koch’s Disease / Phthisis / Galloping Consumption Disease
 TOP 8 highest cases of TB in the world (Philippines)
Description
 It is a chronic sub –acute or acute respiratory disease commonly affecting the lungs
 Characterized by the formation of tubercles in the tissue which tend to undergo ceseation
necrosis and calcification
Etiologic Agents
 Mycobacterium tuberculosis
 M. africanum
 M. bovis
Source of Infection
 Sputum
 Blood from Hemoptysis
 Nasal discharge
 Saliva
 Airborne
 Direct / Indirect contact with infected persons
Incubation Period
 3 to 8 weeks (occasionally up to 12 weeks)
Period of communicability
 As long as the tubercle bacilli are being discharged in the sputum
 Cough of two weeks or more
 Afternoon rise of temperature
 Chest or back pains
 Hemoptysis
 Significant weight loss
 Fatigue

 Body malaise
 Shortness of breath
 Night sweating
 Sputum positive for AFB
Diagnostic Tests
 Sputum Analysis for AFB
 Confirmatory
 Chest X-ray
 Tuberculin Testing (for TB exposure)

 Mantoux Test (PPD)
 Tine Test
 Heaf Test
 Short – course chemotherapy
 Six-month treatment (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol)
Rifampicin
 Empty stomach
 Body fluid discoloration (red-orange)
 Hepatotoxic (metabolism)
 Nephrotoxic (elimination)
 Permanent discoloration of contact lenses
Isoniazid
 Empty stomach
 Peripheral Neuropathy
 Avoid alcohol
 Hepatotoxic
 Nephrotoxic
 Increase intake of Vitamin B6
Pyrazinamide
 Before meals
 Monitor s/sx of liver impairment
 Anorexia
 Fatigue
 Dark urine
 Photosensitivity
 Liver Function Studies
 Causes hyperuricemia
Ethambutol
 Not affected by food
 Report visual disturbances

 Hepatotoxic
 Not recommended for children (below 6 years old); can cause optic neuritis
Streptomycin
 After meals
 Report Oliguria – nephrotoxic
 Ototoxic
 Neurotoxic
Direct Observation Treatment Short Course

 Strategy to prevent non-compliance
Nursing Management
 Maintain respiratory isolation
 Administer medicines as ordered
 Educate patient all about PTB
 Stop smoking
 Cough or sneeze into tissue paper and dispose secretion properly
 Provide the patient with a well-balanced, high-calorie diet, preferably in small, frequent
meals to conserve energy.
 Allow ret periods
 Caution the patient who is taking an oral contraceptive that the contraceptive may be
less effective while she’s taking rifampin.

 Submit all babies for BCG (Bacille Calmette-Guerin) immunization
 Avoid overcrowding
 Improve nutritional and health status
 Persons who have been exposed (Receive Tuberculin Test)
BIRD FLU
Other Term: Avian Influenza
Description: It is an infectious disease of birds ranging from mild to severe form of illness.
Source of Infection
 Viruses that normally infect only birds and less commonly pigs
Incubation Period
 3 to 5 days
 Fever
 Body weakness / muscle pain
 Cough
 Sore throat
 May have difficulty of breathing in severe cases
 Sore eyes

Susceptibility, Resistance & Occurrence

 All birds are susceptible to infection but domestic poultry flocks are especially
vulnerable to infection that can rapidly reach epidemic proportion.
Control Measures
 Rapid destruction, proper disposal of carcasses and quarantining and rigorous disinfection
of farms
 Restrictions on the movement of live poultry
Nursing Care
 Isolation precaution
 Infected Control
 Early recognition of cases of highly pathogenic Avian Influenza during outbreak among
poultry
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
 Earliest known case (Guangdong Province, China, November, 2002)
 Outbreak and Worldwide Surveillance (March 12, 2003)
 First case in the Philippines (April 11, 2003)
Etiologic Agent
 Human coronavirus
Mode of Transmission:
 Droplet Contact
Incubation Period
 Mean incubation period is 5 days (range 2-10 days) and may reach up to 14 days
 Prodromal Phase
 Fever > 38oC (Initial Sign)
 Chills
 Malaise
 Myalgia
 Headache
 Respiratory Phase
 Dry, non-productive cough with or without respiratory distress
 Hypoxia
 Crackles
 Dullness on percussion
 Decreased breath sounds on physical examination
Preventive Measures and Control

 Screen patents for travel hx, symptoms and/or close contact ith cases
 Isolation of suspected probable case
 Barrier nursing technique for suspected and probable cases

Nursing Care
 Maintain Isolation Measures
 Utilize Personal Protective Equipment (PPE)
 Apply principle of hand washing
CHOLERA
Other Term: El Tor
Description: It is an acute bacterial enteric disease characterized by profuse diarrhea,
vomiting, massive loss of fluid and electrolytes that can result to hypovolemic shock,
acidosis and death.
Etiologic Agent: Vibrio El Tor
Source of Infection
 Vomitus and feces of infected persons
 Food and water contaminated with vomitus and stools of patients and carriers
Incubation Period
 6 to 48 hours
 Cases are infectious during the period of diarrhea and up to 7 days after
 Rice-watery stool
 Washer-woman’s hands
 Vomiting
 Diarrhea
 Deep, rapid breathing
 Oliguria
Diagnostic Tests
 Rectal swab
 Darkfield or phase microscopy
 Stool exam
 Blood test
 Elevated BUN & Creatinine Levels
 Increase in serum lactate, protein and phosphate levels
 IV treatment
 Oral Therapy Rehydration
 Coconut water
 Give ORESOL
 Antibiotics
 Tetracycline
 Furazolidone
 Chloramphenicol

 Cotrimoxazole
Nursing Management
 Medical Aseptic protective Care (Hand washing)
 Enteric Isolation
 VS
 I & O monitored accurately
 Psersonal hygiene
 Proper excreta disposal
 Environmental sanitation
Prevention
 Food and water supply must be protected from fecal contamination
 Water should be boiled and chlorinated
 Milk should be pasteurized
 Sanitary disposal of human excreta is a must
TYPHOID FEVER
Description: It is a systemic infection characterized by continued fever, anorexia,
involvement of lymphoid tissue, especially ulceration of Peyer’s patches.
Etiologic Agents
 Salmonella typhi or Typhoid bacillus
Sources of Infection
 Feces and urine of infected persons
 Fecal-oral Transmission
 Contaminated Urine
 Direct/indirect contact with infected person
 Ingestion of contaminated food, water and milk
Incubation Period
 1 to 3 weeks; average (2 weeks)
 As long as typhoid bacilli appears in excreta
 Onset
 Headache
 N/V
 Ladder-like fever
 Rose spots on the abdomen
 Typhoid State
 Coma vigil
 Subsultus tendinum
 Carphologia

 Delirium
Complications
 Hemorrhage/Perforation (most dreaded complications)
 Peritonitis
 Bronchitis and Pneumonia
 Typhoid spine
 Septicemia
 Reiter’s syndrome – joint pain, eye irritation
Diagnostic Tests
 Typhidot – confirmatory
 ELISA
 Widal
 Rectal swab
 Bone Marrow Aspiration (identifies S. typhi)
 Chloramphenicol – drug of choice
 Ampicillin
 Co-trimoxazole
 Ciprofloxacin
 Cefixime / Azithromycin
 Ceftriaxone (recommended for complicated cases)
Nursing Management
 Isolation
 Maintain standard precautions unless the patient is incontinent or in diapers or if
an outbreak develops in an institution.
 Give nourishment fluids in small quantities at frequent intervals
 Monitor VS
 Prevent further injury
 WOF: intestinal bleeding / bowel perforation, including sudden pain in the lower
right side of the abdomen and abdominal rigidity.
 Provide good skin and mouth care
 Turn the patient frequently and perform mild passive exercises, as indicated.
 Apply mild heat to the abdomen to relieve cramps.
 Sanitary and proper disposal of excreta
 Proper supervision of food handlers
 Enteric isolation
 Provision of safe drinking water supply
 Detection and supervision of typhoid carriers
BACILLARY DYSENTERY
Other Terms: Shigellosis / Bloody Flux
Description: It is an acute bacterial infection of the intestine characterized by diarrhea, fever,

tenesmus and in severe cases, bloody and mucoid stools.

Etiologic Agents
 Shigella sonnei (most common species in Western Europe)
 Shigella flexneri
 Shigella boydii
 Shigella dysenteriae
Incubation Period
 12 to 96 hours, but may be up to 1 week
 The patient can transmit the microorganism during the acute infection until the feces are
negative of the organism.
 Ingestion of contaminated food
 Drinking contaminated water / milk
 Feco-oral transmission
 Fever
 Tenesmus
 N/V
 Headache
 Colicky or cramping abdominal pain associated with anorexia and body weakness
 Bloody-mucoid stool
 Rapid dehydration
Diagnostic Tests
 Microscopic examination of a fresh stool specimen may reveal mucus, red blood
cells, and polymorphonuclear leukocytes.
 Direct immunofluorescence with specific antisera will demonstrate Shigella.
 Sigmoidoscopy or proctoscopy may reveal typical superficial ulcerations
 Stool culture must rule out other causes of diarrhea, such as enteropathogenic
Escherichia coli infection, malabsorption disease, and amebic or viral
diseases.
 Antibiotics
 Ampicillin
 Ceftriaxone
 Trimethoprim-sulfamethoxazole
 Ciprofloxacin
 IV Therapy
 Low Residue Diet
 Contraindicated: Anti-diarrheal drugs (they delay fecal excretion that can lead to prolong
fever)


 Sanitary disposal of human feces
 Adequate personal hygiene, particularly handwashing after defecation.
 Sanitary supervision of processing, preparation and serving of food (raw)
 Fly control and protection against fly contamination
 Isolation (Acute Stage)
 Protection and purification of public water supply
 Routine cooking kills shigella
PARAGONIMIASIS
Etiologic Agents:
 Lung Fluke
 Paragonimus westermani
 Paragonimus siamenses
 Ingestion of raw / uncooked crabs/crayfish
 Contamination of Food
 Using meat / juice of infected animals
Reservoir of Hosts
 Cats
 Dogs
 Rats
 Pigs
 Cough of long duration
 Recurrent blood-streaked sputum
 Chest/back pain
 PTB – like signs/symptoms not responding to anti-TB medication
Diagnostic Test
 Sputum Microscopy
 Immunology
 Cerebral Paragonimiasis
Treatment
 Praziquantel (Billtrizide)

 Treatment of infected person
 Anti-mollusk campaigns
 Educated of the population
 Avoid eating infected foods
MUMPS
Other Terms: Infectious Parotitis / Epidemic Parotitis

Description: It is a acute viral disease manifested by swelling of one or both parotid glands,
with occasional involvement of other glandular structures, particularly the testes in male.
Etiologic Agent: Paramyxoviridae
Source of infection: Secretion of the mouth and nose
 Direct contact
 Indirect contact with the articles freshly soiled with secretion from the nasopharynx.
 Cases are infectious for up to a week (normally 2 days) before parotid swelling until 9 days
after.
 48 – hours period immediately preceding onset of swelling is considered the time of
highest communicability.
 Sudden headache
 Earache
 Loss of appetite
 Fever
 Swelling of the parotid gland (between the earlobe and angle of the mandible)
Complications
 Orchitis
 Oophoritis
 Mastitis
 Nuchal rigidity
 Deafness
 Meningoencephalitis
 Pancreatitis
 Myocarditis
 Nephritis
Diagnostic Tests
 Serum amylase Determination (most useful test in making early presumptive diagnosis
of mumps); elevated amylase level
 Complement Fixation Test
 Hemo-agglutination Inhibition Test
 Used to determine the immune status
 Neutralization Test
 Determines immunity to mumps
 Viral Culture
 Analgesics for pain
 Antipyretics for fever
 IV Fluid Replacement

 Hot and Cold Application
Nursing Management
 Medical Aseptic Protective Care
 Single-occupancy room
 Oral Care and Personal Hygiene (warm salt-water gargles)
 General Management of the disease

 Bed rest
 Diversional Activities
 Eye care
 Provide extra fluids
 Diet
 No restriction of food
 Soft bland and semi-solid is easily managed
 Acid foods (fruit juices) increases discomfort

 Active Immunization (MMR)
 Reporting of cases to health authorities
 Isolation
of patient
BOTULISM
Description
 Rare but severe form of poisoning caused by a gram-positive, anaerobic bacteria.
 It is an illness of descending paralysis and autonomic dysfunction due to a neurotoxin
Causative Agent: Clostridium Botulinum

 Foodborne Botulism
 Wound Botulism
 Infant Botulism
Source of Infection
 Untreated water
 Undercooked and improperly preserved canned foods, especially those with a low acid
content
 Home-canned vegetables
 Cured pork and ham
 Smoked or raw fish
 Honey and corn syrup
 Ingestion (or injection) of preformed toxin
 Spores may resist 100 degree Celsius for many hours
 Inhalation of toxin may also cause disease
 Introduction of spores into the wound

Incubation Period: 12 to 72 hours but extremes of 2 hours to 10 days are reported.
Clinical Manifestations:
 Double or blurred vision
 Droopy eyelids
 Dry mouth
 Difficulty swallowing and talking
 Difficulty breathing
 Flaccid paralysis (descending)
 Deep tendon reflexes are decreased or absent
 Initial vomiting or diarrhea followed by constipation
Diagnostic Tests:
 A toxicity screen may identify C. botulinum.
 Stool culture may identify C. botulinum.
 The suspected food may also be cultured to isolate C. botulinum.
 Electromyography will show little response to nerve stimulation in the presence of
botulism.
 Diagnostic tests should be conducted as needed to rule out diseases that may be
confused with botulism, such as myasthenia gravis and Guillain-Barre syndrome.
 A mouse-inoculation test will be positive and is the most direct way to confirm a diagnosis
of botulism.
Complications
 Aspiration
 Weakness and nervous system problems can be permanent
 Death
 Botulinus antitoxin- IV, IM
 Infants – inducing vomiting or giving an enema
 IV fluid can be administered
 Nasogastric tube
 Endotracheal intubation – respiratory distress
Nursing Consideration
 Obtain a careful history of foods eaten in the past several days.
 Monitor respiratory and cardiac function carefully
 Perform frequent neurologic checks
 Purge the GI tract as ordered
 If giving the botulinus antitoxin, check the patient’s allergies, perform a skin test first.
 Educate the patient and family about the importance of proper hand hygiene
 Teach the patient and family to cook food thoroughly before ingesting.
 Instruct the patient who eats home canned food to boil the food for 10 minutes before
eating to ensure that it is safe to consume.
 Teach patient and families to see their doctors promptly for infected wounds and to avoid
injectable street drugs.

Suggested on-call action

 Ensure that the case is admitted to hospital
 Obtain food history as a matter of urgency
 Obtain suspect foods
 Identify others at risk
 Inform appropriate local and national authorities
AMOEBIASIS
Description: Protozoal infection that initially involves the colon but may spread into the liver
and lungs by lymphatic dissemination
Etiologic Agent
 Entamoeba Histolytica
 2 stages
 Cyst – considered to be the infective stage and the resistance to
environmental conditions and can survive for few days outside the body
 Trophozoites / vegetative form – Facultative parasites that invades the
tissue
Source of Infection
 Contaminated food and water
 Flies
 Fecal-oral
 Oral-anal
Incubation Period
 Severe infections: 3days
 Average 2-4 weeks
 Communicable for the entire duration of the illness or until cysts are present in the stool
 Acute Amoebic Dysentery
 Slight attack of diarrhea altered with PD of constipation
 Watery foul-smelling stools containing blood streaked mucus
 Gaseous distension of the lower abdomen

 Nausea, flatulence
 Tenderness in the right iliac region
 Chronic Amoebic Dysentery

 Diarrhea for several days, succeeded by constipation
 Anorexia, weight loss, weakness, fatigue
 Watery, bloody mucoid stool
 Flatulence and irregular bowel movement

 Abdomen loses its elasticity

 Severe cases – scattered ulceration is seen through sigmoidoscopy
 Stool exams – cyst (plenty of amoeba on the stool)
 Blood exams – leukocytosis
 Sigmoidoscopy
Management
 Metronidazole (Flagyl) 800mg TID x 5 days
 Tetracycline, Ampicillin, Streptomycin, Chloramphenicol
 Observe isolation and enteric precautions
 Proper collection of stool specimen
 No oil prep for 48 hours
 Large portion of stools containing blood mucus
 Label specimen properly
 Send specimen immediately to the laboratory
 Provide skin care and hygiene
 Provide optimum comfort dysenteric patient should never be allowed to feel cold
 Diet fluid should be forced
 Cereals and strained meat broths without fats
 Bland diet without cellulose or bulk producing foods
 Chicken and fish may be added when convalescence is established
Prevention
 Health education and Fly control
 Sanitary disposal of feces
 Safe drinking water
 Proper food preparation and food handling
 Detection and treatment of carriers
SCHISTOSOMIASIS
Other Terms: Bilharziasis / Snail Fever
Description: Slowly progressive disease caused by blood flukes
Causative Agent
 Schistosoma japonicum – endemic in the Philippines and China
 Schistosoma mansoni – South America, the Caribbean, Africa and countries of the Arab
Middle East
 Schistosoma haematobium – Africa and the Middle East
Source of Infection
 Stool and urine of infected persons or animals
 Ingestion of contaminated water
 Penetration through the skin pores
 *Oncomelania hupensis quadrasi is the intermediary host

Incubation Period
 At least 2 months
 1st stage
 Pruritic rash known as “swimmers itch” occurs 24 hours after penetration of
cercariae in the skin
 nd
2 Stage
 Bloody mucoid stools (on and off for weeks)
 Katayama Fever – clinical constellation of the following:
 Fever, headache
 Cough, chills and sweating
 Lymphadenopathy and hepatosplenomegaly
 3rd (Chronic) Stage
 Granulomatous reactions to egg deposition in the intestine, liver, bladder
 Inflammation of
the liver Icteric
and jaundice
 Bulging of the Abdomen
 Enlargement of the Spleen
 Sometimes the brain is affected that caused epilepsy
 Eggs are deposited in the bladder wall, leading to hematuria, bladder obstruction
 Hydronephrosis and recurrent urinary tract infection
 Pale and marked muscle wasting
Complications
 Liver cirrhosis and portal hypertension
 Bleeding esophageal varices
 Bladder cancer
 Pulmonary hypertension
 Heart failure
 Ascites
 Renal failure
 Cerebral schistosomiasis
 Fecalysis
 Liver and rectal biopsy
 ELISA
 Circumoval precipitation test (COPT) – confirmatory test
Management
 Drug of choice: PRAZIQUANTEL for 6 months
 1 tab 2x a day for 1st 3 mos
 1 tab a day for next 3 mos
 Alternative: Ovamniquine

 TSB
 Skin care
 Provide comfort
 Proper nutrition

 Reduce snail
density
 Molluscicides
 Stream Cleaning Vegetation (expose the snails to sunlight)
 Proper waste disposal
 Control of stray animals
 Safe and adequate water supply for bathing, laundering and drinking
 Foot bridges over snail-infested streams
 Health education about mode of transmission and prevention
SYPHILIS
Other Terms: Sy, Bad blood, The Pox, Lues Venereal, Morbus Gallicus
Description: it is an acute, chronic infectious disease caused by spirochete and is acquired

through sexual contact
Etiologic Agent: Treponema pallidum
Source of Infection
 Discharges from obvious or concealed lesions of the skin or mucous membrane
 Semen
 Blood
 Tears
 Urine
 Mucous discharge from the nose, eyes, genital tract
 Surface lesions
Incubation Period
 Varies, but typically lasts about 3 weeks
 Variable and indefinite
 Sexual Contact
 Indirect contact with the articles freshly soiled with discharges or blood
 Transmission via placenta
 Primary
 Painless chancre (sore) at site of entry of germs, swollen glands
 Chancres disappears after three to six weeks even without treatment

 Secondary
 Rash can be macular, papular, pustular or nodular
 Macules often erupt between rolls of fat on the trunk and on the arms, palm, sole
face and scalp
 Alopecia (temporary)
 Nail become brittle and pitted
 Latent
 Patient is asymptomatic for a few months
 Dormancy stage of bacteria
 Late
 Varies from no symptoms to indication of damage to body organs such as brain and
heart and liver
Diagnostic Tests
 Dark Field Illumination Test identifies T. pallidum from lesion exudates and provides an
immediate diagnosis
 Fluorescent treponemal antibody absorption test
 Venereal Disease Research Laboratory (VDRL) test detects nonspecific antibodies that
become reactive within 1 to 2 weeks after the primary syphilis lesion appears or 4 to 5
weeks after the infection begins
 CSF analysis, identifies neurosyphilis when the total protein level is higher than 40 mg/dL
 IM Penicillin G benzathine
 Tetracycline
 Doxycycline
 Stress the importance of completing the treatment even after the symptoms subside
 Practice universal precaution
 In secondary syphilis, keep the lesions dry as much as possible
 Report cases to the Department of Health
 Control prostitution
 Require sex worker to have check up
 Proper sex education
TRICHOMONIASIS
Other Term: Trich
Etiologic Agent: Trichomonas vaginalis
 Direct sexual contact
 Indirect contact (towels, wash clothes, douching equipment)
Incubation Period
 5 to 21 days

Females: White or greenish – yellow odorous discharge; vaginal itching and soreness, painful
urination.
Males: Slight itching of penis, painful urination, clear discharge from penis
Diagnosis:
 Microscopic slide of discharge
 Culture of urethral tissue, urine or semen
 Physical Examination
 The OSOM Trichomonas Rapid Test identifies infection within 10 to 45 minutes, but it
is less sensitive and specific than culture.
Treatment
 Metronidazole (Flagyl) – treatment of choice
 Tinidazole (Tindamax)
Complication
 Cervical cancer
 Follow standard precautions
 Assist with obtaining appropriate specimen for culture or testing
 Tell the patient to avoid ingesting alcohol while taking metronidazole (and for 48 hours
after completing the prescription), as the combination may cause severe nausea and
vomiting, abdominal pain, headaches, and flushing.
CHLAMYDIA
Etiologic Agent
 Chlamydia trachomatis
 Vaginal / Rectal intercourse
 Oral-genital contact
Incubation Period
 7 to 14 days
 Case will remain infectious until treated
 Cervical erosion
 Mucopurulent discharges
 Dyspareunia
 Pain and tenderness of the abdomen
 Chills
 Fever
 Dysuria
 Urinary frequency

 Painful scrotal swelling

 Diarrhea
 Tenesmus
Diagnostic Test
 Culture of the site of infection will reveal C. trachomatis
 Nucleic acid probe will be positive for C. trachomatis
Treatment
 Tetracycline
 Erythromycin
 Azithromycin
Complications
 Sterility
 Prematurity
 Stillbirths
 Infant pneumonia
 Eye Infections (infants)
Nursing Management
 Observe standard precautions
 HIV testing for both partners
 Assess newborn for signs of chlamydial infection
 Urge the patient to inform sexual contacts of his or her infection so they can receive
appropriate treatment.
 Stress the importance of completing the course of antibiotics even after symptoms
subside.
 Teach the patient to follow meticulous personal hygiene measures
 Instruct the patient to avoid touching any discharge and to wash and dry the hands
thoroughly before touching the eyes to prevent eye contamination.
GONORRHEA
Other Terms: Clap / Flores Blancas / Gleet / Drip
Description: It is a sexually transmitted bacterial disease involving the mucosal lining of the
genitor-urinary tract, the rectum, and pharynx
Etiologic Agent
 Neisseria gonorrhoeae
Incubation Period
 2 to 5 days
 Direct contact through sexual intercourse
 Direct contact with contaminated secretions of the mother during vaginal delivery

 Females
 80% are aysmptomatic
 Burning sensation and frequent urination
 Yellowish purulent vaginal discharge
 Redness and swelling of the genitals
 Males
 Dysuria with purulent discharge
 Rectal infection
 Inflammation of the urethra
 Prostatitis
 Pelvic Pain
Complications
 Sterility
 Pelvic Infection
 Epididymitis
 Arthritis
 Endocarditis
 Conjunctivitis
 Meningitis
Diagnostic Tests
 Gram staining
 Culture of cervical & urethral smear
Treatment
 Ceftriaxone (IM)
 Azithromycin or Doxycycline (po)
 Standard precautions
 Sexual abstinence until he/she recovers from the disease
 For gonococcal arthritis (apply moist heat to relieve pain)

 Sex education
 Case finding
 Report cases of gonorrhea
CANDIDIASIS
Other Term: Candidosis / Moniliasis
Description: Superficial fungal infection that usually infects the skin, nails, mucous
membrane, vagina, esophagus and GI tract
Etiologic Agent: Candida albicans

Sources of infection
 Candida are part of the normal flora of the GI tract, mouth vagina and skin, They cause
infection when some changes in the body (such as increased blood glucose or
immunocompromised) occurs
 Skin
 Scaly, erythematous, popular rash, sometimes covered with exudates, appearing
below the breast, between the fingers, and the axillae, groin, and umbilicus
 Nails
 Red, swollen, darkened nail bed
 Occasionally, purulent discharge and the separation of a pruritic nail from the nail
bed
 Oropharyngeal mucosa (thrush)
 Cream-colored or bluish white curd-like patches of exudates on the tongue,
mouth, or pharynx that reveal bloody engorgement when scraped
 Esophageal mucosa
 Dysphagia
 Retrosternal pain, regurgitation
 Occasionally, scales in the mouth and throat
 Vaginal mucosa
 White or yellow discharge, with pruritus and local excoriation
 White or gray raised patches on vaginal walls, with local inflammation
 Dyspareunia
 Lungs – hemoptysis, cough, fever

 Kidney – fever, flank pain, dysuria, hematuria, pyuria, cloudy urine
 Brain – headache, nuchal rigidity, seizures, focal neurologic deficits
 Endocardium – systolic or diastolic murmur, fever, chest pain, embolic phenomena
 Eye – Endophthalmitis, blurred vision, orbital or periorbital pain, scotoma, exudates
 Blood Culture
 Culture of vaginal scraping
 Echocardiography if here is cardiac involvement
 Fundoscopy for patients with endophthalmitis
Management
 Antifungal: Nystatin, Clotrimazole, Miconazole
 Mutism
 Coma
Diagnostic Tests
 Enzyme linked Immuno-Sorbent Assay (ELISA) – presumptive test
 Western Blot – confirmatory test
 Particle agglutination (PA)
 Immunofluorescent Test

 Reverse transcriptase inhibitors (Zidovudine)
 Protease inhibitors (Ritonavir)
Nursing Management
 Avoid accidental wounds from infectious materials used in HIV patients
 Avoid contact of open skin lesions
 Gloves should be worn when handling blood specimens
 Handwashing
 Blood and other specimens should be labelled prominently
 Instruments with lenses should be sterilized after use on AIDS patient
 Needles should not be bent after use, placed it under puncture – resistant
 Patients with active Aids should be isolated
 Care of thermometer – wash with warm soapy water, Soak in 70% alcohol for 10 minutes,
dry and store.
DENGUE FEVER
Other Terms: Break bone Fever / Hemorrhagic Fever / Dandy Fever / Infectious
Thrombocytopenic Purpura
Description: It is an acute febrile disease caused by infection with one of the serotypes of
dengue virus.
Etiologic Agents
 Dengue Virus Types 1, 2, 3, & 4
 Chikungunya Virus
 Bite of female infected mosquito (Aedes aegypti)
Incubation Period
 3 to 15 days
 Unknown
 Presumed to be on the 1st week of illness (when the virus is still present in the blood)
 Human-to0human spread of dengue has not been recorded, but people are
infectious to mosquitoes during the febrile period
Herman’s sign (maculopapular rash with patches of normal skin) – pathognomonic sign
 Febrile / Invasive Stage

 First 4 days
 High fever (39 – 40 C)
 Abnormal pain
 Headache
 Later flushing

 Toxic / Hemorrhagic Stage

 Lowering of temperature
 Severe abdominal pain
 Vomiting
 Melena
 Hematemesis
 Convalescent / Recovery Stage
 Generalized flushing with areas of blanching appetite
 BP stable
Diagnostic Tests
 Tourniquet test (Rumpel – Leede Test)
 Platelet count (decreased)
 Hemoconcentration (increased of at least 20%)
 Occult blood
 Hemoglobin determination
 Dengue NS1 Test (confirmatory)
 Give analgesic (Don’t give Aspirin)
 Rapid replacement of body fluids
 Oxygen Therapy
 Oral Rehydration Solution
 Blood Transfusion (for severe bleeding)
 Sedatives
Nursing Management
 Patient should be kept in mosquito-free environment
 Monitor VS
 Provide periods
 Nose bleeding (apply ice bag on the forehead and at the bridge of the nose)
 Watch out for: signs of shock
 Diet: Low fat, low fiber, non-irritating, non-carbonated
Prevention & Control

 Health education
 Early detection and treatment of cases
 Treat mosquito nets with insecticides
 House spraying
 Avoid too many hanging clothes
 Case finding
MALARIA
Other Term: Ague and Marsh Fever
Description: It is an acute and chronic parasitic disease transmitted by bite of infected

mosquitoes and it is confined mainly to tropical and subtropical areas.
Etiologic Agents

 Plasmodium falciparum (most common)

 Plasmodium vivax
 Plasmodium malariae
 Plasmodium ovale
Incubation Period
 P. falciparum (5 to 7 days)
 P. vivax (6 to 8 days)
 P. ovale (8 to 9 days)
 P. malariae (12 to 16 days)
 Transmitted mechanically through bite of an infected female Anopheles mosquito
 Blood transfusion
 Transplacental transmission
Clinical Manifestation:
 Paxoysms with shaking chills
 Rapid rising fever with severe headache
 Profuse sweating
 Myalgia
 Splenomegaly
 Hepatomegaly
Chemoprophylaxis
 Chloroquine
 This must be taken at weekly intervals, starting from 1-2 weeks before entering
endemic areas.
Preventive and Vector Control Measures

 Insecticide – treatment of mosquito nets
 House Spraying
 On-stream seeding
 On-stream clearing
 Wearing of clothes that covers arms and legs in the evening
 Avoiding outdoor night activities (9PM to 3AM)
 Planting of Neem tree
 Zooprophylaxis
FILIRIASIS
Other Term: Elephantiasis
Description
 It is a parasitic disease caused by an African eye worm, microscopic thread-like worm
 Extremely debilitating and stigmatizing disease
Etiologic Agents
 Wuchereria bancrofti

 Brugia malayi
 Brugia timori
 Loa loa
 Mosquito bite (Aedes poecilius)
Incubation Period
 8 to 16 months
 Asymptomatic Stage
 No clinical signs and symptoms of the disease
 Acute Stage
 Lymphadenitis
 Lymphangitis
 Epididymitis
 Orchitis
 Chronic Stage
 Develop 10 to 15 years from the onset of the first attack
Chronic Signs and Symptoms
 Hydrocele
 Lymphedema
 Elephantiasis
Diagnosis
 Physical examination
 History taking
Laboratory Examinations
 Nocturnal Blood Examination (NBE)
 Blood are taken from the patient’s residence (8pm)
 Immunochromatographic Test (ICT)
 Rapid Assessment Method
 Antigen test can be done at daytime
treatment
 Diethylcarbamazine citrate (Hetrazan)
Nursing Management
 Health Education
 Environmental Sanitation
 Psychological and emotional support
 Personal hygiene

 Mosquito net
 Mosquito repellent
 Yearly dose of medicine

LEPTOSPIROSIS
Other Terms: Canicola Fever / Hemorrhagic Jaundice / Mud Fever / Swine Herd Disease /
Flood Fever / Trench Fever / Spirochetal Jaundice / Japanese Seven Days Fever
Description: It is a zoonotic infectious bacterial disease carried by animals, both domestic

and wild, whose urine contaminates water or food which is ingested or inoculated through the
skin.
Etiologic Agent: Leptospira interrogans
Incubation Period
 7 to 13 days (range 4 to 19 days)
 Direct contact on the skin through open wounds
 Leptospiremic Phase (4 to 7 days)
 Nausea
 Vomiting
 Fever
 Headache
 Myalgia
 Chest pain
 Immune Phase (4 to 30 days)
 Meningeal irritation
 Oliguria
 Anuria
 Severe cases (shock, coma, congestive, heart failure)
 Convalescence Phase
 Relapse may occur during the 4th to 5th week
Laboratory Tests
 ELISA
 Liver Function Tests
 Leptospira Antigen-antibody test
 Leptospira Antibody Test
Complications
 Meningitis
 Respiratory distress
 Renal interstitial tubular necrosis
 Cardiovascular problems
Treatment
 Doxycycline (Prophylactic)
 Penicillin

 Tetracycline
 Erythromycin
 Administration of Fluid and Electrolyte and Blood
Nursing Management
 Isolate patient
 Darken patient’s room
 Observe meticulous skin care
 Wide Rat Eradication Program
 Encourage Oral fluid intake
Prevention & Control

 Environment Sanitation
 Proper Drainage System and Control of Rodents
 Information - dissemination campaign
RABIES
Other Terms: Hydrophobia / Lyssa
Description: It is a specific, acute, viral infection communicated to man by saliva of an

infected animal.
Etiologic Agent
 Rhabdovirus (Bullet Shape Virus)
Incubation Period
 3 to 8 weeks, but may be as short as 9 days or as long as 7 years, depending on the
amount of virus introduced, the severity of the wound and its proximity to the brain
Susceptibility and Resistance

 All warm-blooded mammals are susceptible
 Prodromal / Invasion Phase
 Fever
 Malaise
 Irritability
 Restlessness
 Apprehensiveness
 Melancholia
 Sensitive to light and sound
 Excitement / Neurological Phase
 Marked excitation and apprehension
 Nuchal rigidity
 Involuntary twitching
 Severe and painful spasm of the muscles of the mouth, pharynx and larynx
 Hydrophobia
 Aerophobia

 Profuse drooling of saliva
 Terminal / Paralytic
Phase
 Quiet and unconscious
 Loss of bowel and urinary control
 Cessation of spasms and progressive paralysis
 Tachycardia; respiratory paralysis, heart failure
Diagnostic Tests
 Virus isolation from the patient’s saliva / throat
 Fluorescent rabies antibody (RFA) – most definitive diagnosis
 Presence of negri bodies in the dog’s brain
 Wash with soap and water
 Application of antiseptics such as povidone iodine may be done
 Patients should not be bathed and there should not be any running water in the room
 Concurrent and terminal disinfection should be carried

 Vaccination of all dogs (immunized 3 months of age and every year thereafter)
 Confinement of any dog that has bitten a person for 10 to 14 days
 Provide public education
TETANUS
Other Term: Lock Jaw
Description: It is an acute illness caused by toxin of the tetanus bacillus. This infection is
usually systemic; less commonly, it is localized.
Etiologic Agent: Clostridium tetani
Source of Infection:
 Soil
 Feces
 Transmission occurs when spores are introduced in the body through
 Dirty wound
 Injecting drug use and occasionally during abdominal surgery
Incubation Period
 3 to 21 days depending on the site of the wound and the extent of contamination
 Localized
 Spasm

 Increased muscle tone in the wound

 Generalized
 Marked muscles hypertonicity
 Hyperactive deep tendon reflexes
 Tachycardia
 Profuse sweating
 Low-grade fever
 Painful, involuntary muscle contractions:
 Neck and facial muscles
 Lockjaw (trismus)
 Painful spasms of masticatory muscles
 Difficulty opening the mouth

 Risus sardonicus
 Somatic Muscles
 Arched-back rigidity and board-like abdominal rigidity
 Intermittent tonic seizures lasting several minutes, which may result in
cyanosis and sudden death by asphyxiation
Diagnostic Tests
 Clinical features
 Blood cultures and tetanus antibody tests are often negative, only a third patients have a
positive wound culture
 Cerebrospinal fluid pressure may rise above normal
 Drainage of ski abscesses
 Administration of antibodies
 Metronidazole (first-line agent)
 Pen G
 Administration of tetanus immunoglobulin (TIG)
 Sedatives
 Patients with severe, generalized or rapidly progressing muscle spasm should be
intubated sedated and paralyzed if necessary
 Manage autonomic instability
 Labetalol
Complications
 Atelectasis
 Pneumonia
 Pulmonary emboli
 Acute gastric ulcers
 Seizures
 Flexion contractures
 Cardiac Arrhythmias
Nursing Management
 Maintain an adequate airway and ventilation to prevent pneumonia and atelectasis

 Suction often and watch for signs of respiratory distress

 Maintain an IV line for medications and emergency care, if necessary
 Monitor for arrhythmias
 Record intake and output accurately and check vital signs often
 Keep the patient’s room quiet and dimply & Warn visitors not to upset or overly stimulate
the patient
 Give muscle relaxants
 Perform passive-range-of-motion
 Provide adequate nutrition to meet the patient’s increased metabolic needs.
 Stress the importance of maintaining active immunization with a booster dose of tetanus
toxoid every 10 years
 Teach the patient or family about proper wound care.
POLIOMYELITIS
Other Terms: Polio / Infantile Paralysis
Description: It is an acute communication disease caused by the poliovirus
Etiologic Agent: Poliovirus Types 1, 2 and 3
 Direct contact with infected oropharynges secretions or feces
Incubation Period
 7 to 14 days
 Fever
 Headache
 Vomiting
 Lethargy
 Irritability
 Pains in the neck, back, arms, legs and abdomen
 Muscle tenderness, weakness an spasms in the extensors of the neck, back,
hamstring and other muscles during range-of-motion exercises
 Loss of superficial and deep reflexes
 Positive Kernig’s and Brudzinski’s signs
 Hypersensitivity to touch
 Urinary retention
 Tripod (arms extended behind for support when sitting up)
 Hoyne sign (head falls back when surprise and shoulders are elevated)
 Inability to raise the legs a full 90 degrees from a supine position.
 Diplopia
 Dysphasia
 Difficulty chewing
 Inability to swallow or expel saliva
Diagnostic Tests

 Viral culture = Stool sample

 Convalescent serum antibody titers four times greater than acute titers support the
diagnosis
 CSF pressure and protein levels may be slightly increased, and the white blood cell
count elevated initially, thereafter mononuclear cells constitute most of the diminished
number of cells.
 Electromyographic findings in early poliomyelitis show a reduction in the
recruitment pattern and a diminished interference pattern due to acute motor axon
fiber involvement.
 Fibrillations develops in 2 to 4 weeks, and fasciculations also may be observed
 Analgesics (No Morphine)
 Moist heat application
 Bed rest is necessary only until extreme discomfort subsides
 Physical therapy
 Braces
 Corrective shoes
Complications
 Respiratory failure
 Pulmonary edema
 Pulmonary embolism
 Urinary Tract Infection
 Urolithiasis
 Atelectasis
 Pneumonia
 Cor Pulmonale
 Paralytic shock
 Observe the patient for paralysis and other neurologic damage
 Maintain patent airway
 Check blood pressure frequently
 Provide an adequate, well-balanced diet
 Good skin care and frequent repositioning

 Inform ambulatory patients about the needs for careful handwashing.
 Instruct the patient or caregivers about measures need to manage symptoms and prevent
complications.
Prevention
 Administration of Oral Polio Vaccine
 Boosters are required at 10-years intervals for travel to endemic areas.


COMMUNITY HEALTH NURSING

Definition:
 Focus of the community health nursing is the community as a whole, with nursing care
of individuals, families and groups being provided within the context of promoting and
preserving the health of the community (Association of Community Health Nursing
Educators, 1990)
 According to Ruth B. Freeman, it refers to a service rendered by a professional nurse
with communities, group, families, individuals at home, in health centers, in clinics,
in schools, in places of work for the:
 Promotion of health
 Prevention of illness
 Care of the sick at home and rehabilitation
Four Levels of Clientele:
 Individuals
 Family
 Population
 Community
Subspecialties:
 School Nursing
 Occupational Health Nursing
 Community Mental Health Nursing
 Public Health Nursing
COMMUNITY – BASED NURSING

 It is a philosophy of care in which the care is provided as clients and their families
move among various service outside of hospitals.
PUBLIC HEALTH NURSING

 It is a special field of nursing that combines the skills of nursing, public health and some
phases of social assistance (World Health Organization)
 Functions as part of the total public health programme for the promotion of health, the
improvement of the conditions, in the social and physical environment, rehabilitation of
illness and disability
 According to Dr. C.E Winslow, public health is the science and art of:
 Preventing diseases
 Prolonging life
 Promoting health and efficiency
 Refers to the nurses in the local/national health departments or public schools
whether their official position title is public Health Nurse or Nurse school nurse
 Starts with a Salary Grade 15
Roles & Functions
 Planner/Programmer
 Identifies the health needs, priorities and problems of individuals, families, and
community

 Nursing Care Provider

 Provides nursing care to the sick, disabled in the home, clinic, school, or place of
work
 Manager/Supervisor
 Formulates and implements nursing plan for individual, family, group, community
 Leads and encourages them to address their health needs and solve their health
problems
 Community Organizer
 Motivates and enhances community participation
 Initiates and participates in community development activities
 Service Coordinator
 Collaborates with individuals, families, and groups for health and health services
 Health Educator/Counselor/Trainer
 Conducts health teaching, training and counseling
 Trains and educates rural health midwives Acts as a resource speaker on health and
health related services
 Health Monitor
 Monitors the status of the individuals, families and groups through various contacts
 Role Model
 Sets as good example of healthful, living to the individuals, families, and community
 Change Agent
 Motivates changes in the health behavior of individual, families and community
 Reported/ Recorder/Statistician
 Records every nursing interventions
 Updates existing data base
 Makes statistical analysis of data for interpretation
 Researcher
 Uses observation, interview, survey questionnaire, physical exam, and other
methods in the assessment of individuals, families, and community
Qualifications of Public Health Nurses

 Graduate of Bachelor of Science in Nursing and a Registered Nurse
 Good physical and mental health
 Interest and willingness to work in the community
 Capacity and ability to:
 Relate the practice with on-going community health and health related activities
 Work cooperatively with other disciplines and members of the community
 Accept and take actions needed to improve self and service
 Analyze combination of factors and conditions that influence health of populations
 Apply nursing process in meeting the health and nursing needs of the community
 Mobilize resources in the community
 With leadership potential
 Resourcefulness and creativity
 Active membership to professional nursing organizations
PHILIPPINE HEALTH CARE DELIVERY SYSTEM

DEPARTMENT OF HEALTH (PUBLIC SECTOR)

Leadership  Serve as national policy and regulatory institution.
in Health  Provide leadership in formulation, monitoring, and evaluation of national
policies, plans and programs.
 Serve as advocate in the adoption of health policies, plans and programs
Enabler  Innovate new strategies in health
and  Exercise oversight functions and monitoring and evaluation of
Capacity national health plans, programs, and policies
 Ensure the highest achievable standards of quality health care, health
promotion, and
health protection
Administrator  Manage selected national health facilities and hospitals with modern and
of specific advanced facilities
Services  Administer direct services for emergent health concerns that
require new complicated technologies
 Administer health emergency response
VISION
 Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040
MISSION
 To lead the country in the development of a productive, resilient, equitable and people-
centered health system
GOAL
 Health Sector Reform Agenda (HSRA)
 Health Sector reform is the overriding goal of DOH
FRAMEWORK FOR THE IMPLEMENTATION OF HSRA

 FOURmula ONE for Health (2005-2010)
 Goals of the FOURmula One of Health
 Better Health Outcomes
 More responsive health systems
 Equitable health care financing
 Four Elements of the Strategy
1. Health Financing
 To foster greater, better and sustained investments in health (PHILHEALTH)
2. Health Regulation
 To ensure the quality and affordability of health goods and services
3. Health Service Delivery
 To improve and ensure the accessibility and availability of basic and essential
health care
4. Good Governance
 To enhance health system performance at the national and local levels.
LOCAL HEALTH SYSTEM

 RA 7160 – Local Government Code
 All structures, personnel, and budgetary allocations from the provincial health level
down to the barangays were
 Devolved to the Local Government Units to facilitate health service delivery

 Objectives of Local Health System
 Establish local health system
 Upgrade the health care management and service capabilities of local health facilities
 Promote inter-LGU linkages and cost sharing schemes
 Foster participation of the private sector, non-government organizations and community
 Inter Local Health System
 It is a system of health care similar to a district health system
 System that is being espoused by the DOH in order to ensure quality of health care
service
Composition of Inter-Local Health Zone
1. People
 Ideal health district would have a population size between 100,000 to 500,000
for optimum efficiency and effectiveness
2. Boundaries
 Clear boundaries between inter Local Health Zones determine the accountability
and responsibility of health service providers
3. Health Facilities
 District or provincial hospital and other health services deciding to work together as an
integrated health system
4. Health Workers
 Right unit of health providers is needed to deliver comprehensive health services.
PRIMARY HEALTH CARE

1. Adopted in the Philippines through:
 Letter of instruction (LOI) 949
 Signed by President Marcos on October 19, 1979
 Underlying theme: “Health in the Hands of the People by 2020”
2. Characterized by partnership and empowerment of the people that shall permeate as
the core strategy in the effective provision of essential health services that are
community- based, accessible, acceptable, and sustainable at a cost, which the
community and the government can afford.
Elements/Components of PHC
Education for health
Locally Endemic and Communicable Disease Control and Treatment
Expanded Program on Immunization
Maternal and Child Health and Family Planning
Essential Drugs
Nutrition
Treatment (Medical and Emergency Care, Non Communicable Diseases and Mental Health)
Sanitation of the Environment
Four Cornerstones/Pillars in Primary Health Care
 Active community participation
 Intra and inter-sectoral linkages
 Use of appropriate technology
 Support mechanism made available

Levels of Primary Health Care Worker

1. Village/Barangay Health Workers
 Refers to trained community health workers or health auxiliary volunteer or a
traditional birth attendant or healer
2. Intermediate Level Health Workers
 General medical practitioners or their assistants.
 E.g. Public Health Nurse, Rural Sanitary Inspectors and Midwiwes, Rural Health
Physician
Levels of Health Care and Health Referral System

1. Primary Level of care
 Devolved to the cities and municipalities
 Health care provided by center physicians, public health nurses, rural health
midwiwes, barangay health workers, traditional healers
Example:
 Barangay Health Station
 Rural Health Unit
 Community Hospital
 Health Centers
 Puericulture Center
2. Secondary Level of Care
 Secondary care is given by physicians with basic health training
 Serves as a referral center for the primary health facilities
 Capable of performing minor surgeries and perform some simple laboratory
examinations
Example:
 Emergency/ District Hospitals
 Provincial/City Health Services
 Provincial/City Hospital
3. Tertiary Level of Care
 Tertiary care is rendered by specialists in health facilities
 Referral center for the secondary care facilities
 Complicated cases and intensive care requires tertiary care
Example:
 Regional Health Services
 Regional Medical Centers and Training Hospitals
 National Health Services
 Medical Centers
 Teaching and Training Hospitals
Levels of Prevention
1. Primary Prevention
 Focuses on health promotion and disease prevention
Examples: Immunization and Promotion of Healthy Lifestyle (Proper Diet and
Exercise)
2. Secondary Prevention
 Focuses on early detection of disease and prompt treatment for individual
experiencing health problems
Examples: Breast- Self Examination, Diagnostic Test (AFB Test), Cancer Sign and
Symptoms (Caution us)
3. Tertiary Prevention
 Rehabilitation (prevent further disability)
 Restore client’s optimum level of functioning
Examples: Mental Health, Crutch Walking and Physical Therapy
COMMUNITY HEALTH NURSING PROCESS

1. Assessment
 This provides:
 An estimate of the degree to which a family, group or community is achieving the
level of health possible for them
 Identifies specific deficiencies or guidance needed
 Estimates the possible effects of nursing interventions
 Health Deficit
 A gap between actual and achievable health status
 Failure in health maintenance
 Already developed the disease or disability, developmental lag.
 Health Threat
 Condition that promote disease or injury and prevent people from realizing their
health potential
 Foreseeable Crisis
 Anticipated periods of unusual demand on the individual/family in terms of resources
and adjustment
 Wellness Potential
 This refers to states of wellness and the likelihood for health maintenance
or improvement to occur depending on the desire of the family
2. Planning
 Goal Setting
 Initial step
 Declaration of purpose/ intent that gives essential direction to action
 Constructing a Plan of Action
 Choosing from among the possible courses of action
 Selecting the appropriate types of nursing intervention
 Identifying appropriate and available resources
 Developing an Operational Plan
 Establish priorities, phase, and coordinate activities
 Development of evaluation parameters is done in the planning stage
3. Implementation
 Involves various nursing interventions which have been determined by the
goals/objectives that have been previously set
 Carrying out of nursing procedures
 Documentation is done at this phase
4. Evaluation
 Three Classic Frameworks
 Structural elements
 Process elements
 Outcome elements

MANAGEMENT FUNCTIONS OF COMMUNITY HEALTH NURSE

 Planning
 Includes assisting the organization in establishing a vision for the future
 Deciding what must be done and what the organization wants to achieve
 Organizing
 Helps to determine how a manager implements planning to achieve the stated goals
 Major concerns:
 Analysis of the systems
 Analysis of functions
 Assigning job responsibilities
 Implementation
 Directing
 Includes conveying to the workers what has occurred in the planning and organizing
phases
 Coordinating
 Linking people on the health care team together to function in such a way that objectives
are achieved
 Controlling
 Process that measures and corrects the activities of the people and establishes
standards so that objectives are met
 Step:
 Establishing standards
 Measuring performance criteria
 Correcting deviations from normal
 Evaluating
 Involves upon actions to determine their effectiveness in order to make decisions
regarding future action
 Documenting the progress by comparing achievements against a performance standard
CLINIC VISIT
NURSING PROCEDURES
 Standard Procedures
1. Registration/Admission
 Greet the client and establish rapport
 Prepare family record (New Client)
 Retrieve record (Old Client)
 Elicit and record the client’s chief complaint and clinical history
 Perform physical exam on the client
2. Waiting time
 Give Priority numbers to clients
 Implement “first come, first served” policy except for emergency cases
3. Triaging
 Manage program-based cases
 Manage according to Protocols
 Refer all non-program based cases to the physician
 Provide first-aid treatment to emergency cases
4. Clinical Evaluation

 Validate clinical history and physical exam

 Nurse arrives at the evidence-based diagnosis and provides rational treatment based
on DOH programs
 Inform the client on the nature of the illness, appropriate treatment and prevention
and control measures
5. Laboratory and other Diagnostic Examinations
 Identify a designated referral laboratory when needed
6. Referral System
 Refer the patient if he needs further management following the two-way referral
system
 Accompany the patient when an emergency referral is needed
7. Prescription/Dispensing
 Give proper instruction on drug intake
8. Health Education
 Conduct one-on-one counseling with the patient
 Reinforce health education and counseling messages
 Give appointments for the next visit
HOME VISIT
 Allow the health worker to assess the home and family situations in order to provide the
necessary nursing care and health related activities
 Principles
 Home visit must have a purpose or objective
 Planning should:
 Make use of all available information
 Involve the individual and family
 Give priority to the essential needs
 Purposes
 To give nursing care to the clients
 To assess living conditions of the patient and his family
 To give health teaching regarding the prevention and control of diseases
 To establish close relationship between health agencies and public
 To make use of inter referral system
 Factors influencing Frequency of Home Visits

 Needs of the (most important)
 Acceptance of the family 2nd most important
 Policy of a Specific agency
 Other health agencies involved
 Past services given to family
 Ability to recognize own needs
 Steps in conducting Home Visits
1. Greet the patient and introduce self
2. State the purpose of visit
3. Observe the patient and determine health needs
4. Put the bag in a convenient place then proceed to perform the bag technique
5. Perform the nursing care needed and give health teachings
6. Record all important data, observation, and care rendered

7. Make appointment for a return visit
BAG TECHNIQUE
 A tool by which the nurse will enable her to:
 Perform a nursing procedure with ease and deftness
 Save time and effort
 Public Health Bag
 An essential and indispensable equipment of a public health nurse which she has to
carry along during her home visits
 Principles of bag Technique
 Minimize if not prevent the spread of any infection
 Saves time and effort
 This should show the effectiveness of total care given to an individual or family
 Can be performed in a variety of ways depending on the agency’s policy or home
situation or as long as principles of avoiding transfer of infection is always observed
 Important Points to Consider in the Use of the Bag
 The bag should:
 Contain all the necessary articles, supplies, and
 Equipment that will be used to answer emergency needs
 Be cleaned very often, the supplies replaced, and ready for use any time
 Be well protected from contact with any article
 Arrangement of contents should be the one most convenient to the user
Epidemiology
 Study of the occurrence and distribution of health conditions such as disease, death,
deformities or disabilities on human populations.
 The nurse measures the frequency and distribution of health conditions using Vital
statistics.
Important Concepts related to Epidemiology:

1. The Multiple Causation Theory (the wheel, the web, the ecologic triad)
2. Natural History of Disease
A. Pre-pathogenesis or susceptibility
B. Pathogenesis which has 3 substages:
a. Pre-symptomatic
b. Discernible lesions
c. Advanced Disease
3. Level of Prevention of Health Problems
4. Concept of Causality and Association
The Epidemiological Approach

1. Descriptive Epidemiology
 Concerned with disease distribution and frequency
2. Analytical Epidemiology
 Attempts to analyze causes or determinants of disease through hypothesis
testing
3. Intervention or Experimental Epidemiology

 Answers questions about the effectiveness of new methods for controlling

diseases or for improving underling conditions
4. Evaluation Epidemiology
 Attempts to measure the effectiveness of different health services and programs
VITAL STATISTICS
 Refers to the systematic study of vital events such as births, illnesses, marriages, divorces,
separation and deaths
 Morbidity (Disease) and Mortality (Death)
 Indicate the state of health of a community and the success of failure og health work
 Uses of Vital Statistics
 Indices of the health and illness status of a community
 Serves as bases for planning, implementing, monitoring and evaluating CHN programs
and services
 Sources of Data
 Population census
 Registration of Vital Data
 Health survey
 Studies and researches
 Comparison between Rates and Rations
 Rate - Shown the relationship between vital event and those persons exposed to
the occurrence of said event within a given area and during a specified unit of time
 Ratio – is used to describe the relationship between two numerical quantities or
measure of events without taking particular considerations to the time or place
 Infant Mortality Rate
 Good index of the general health condition of a community
 Crude Birth Rate
 A measure of one characteristic of the natural growth or increase of population
 Crude Death Rate
 A measure of one mortality from all causes which may result in a decrease of
population
 Maternal Mortality Rate
 Measures the risk of dying from causes related to pregnancy, childbirth and
puerperium
 Index of the obstetrical care needed and received by women in a community
 Fetal Death Rate
 Measures pregnancy wastage
 Death of the product of conception occurs prior to its complete expulsion,
irrespective of duration of pregnancy
 Neonatal Death Rate
 Measures the risk of dying 1st month
 Attack Rate
 More accurate measure of the risk of exposure
 Case Fatality Ratio
 Index of a killing power of a disease and is influenced by incomplete reporting and
poor morbidity data
 Incidence Rate
 Measures the frequency of occurrence of the phenomenon during a given period of

time
 New cases
 Prevalence Rate
 Measures the proportion of population which exhibits a particular disease at a
particular time
 New and old cases
FIELD HEALTH SERVICES AND INFORMATION SYSTEM (FHSIS)

 Objectives
 To provide summary of data on health services delivery
 To provide data that can be used for program monitoring and evaluation purposes
 To provide a standardized, facility level database which can be accessed for more in-
depth studies
 To ensure that the data are useful and accurate
 To minimize the recording and reporting burden at the service delivery level
 Components
 Family Treatment Record
 Fundamental building block of FHSIS
 Target Client List
 Second building block of FHSIS
 Reporting Forms
 Only mechanism through which data are routinely transmitted from one facility to
another
 Prepared and submitted either monthly or quarterly
 Output Reports
 Objective in designing the output formats: Make the reports useful for monitoring or
management purposes
PUBLIC HEALTH PROGRAMS (Maternal Health Program)

1. Antenatal Registration
PRENATAL VISITS PERIOD OF PREGNANCY
1ST Visit As early in pregnancy as possible
2nd Visit During 2nd trimester
rd
3 Visit During 3rd trimester
Every 2 weeks After 8th month of pregnancy until delivery
2. Tetenus Toxoid Immunization

VACCINE INTERVAL PROTECTION DURATION
TT 1 As early as possible during ----------- ---------
pregnancy
TT 2 After 4 weeks 80% 3 years
TT 3 After 6 months 95% 5 years
TT 4 After 1 year 99% 10 years
TT 5 After 1 year 99% Lifetime
3. Micronutrient Supplementation

VITAMINS DOSE SCHEDULE

Vitamins A 10,000 IU Twice a week starting on the 4th month of pregnancy
Iron/Folic 60mg/400ug Daily (Starting 5th month of pregnancy up 2 months
acid tablet postpartum)
4. Treatment of Diseases and Other Conditions
5. Clean and Safe Delivery
6. Health Teachings:
 Birth registration
 Importance of breastfeeding
 Newborn screening between 48 hours up 2 weeks after birth
 Schedule when to return for consultation for post-partum visits
 1st Visit – 1st week postpartum preferably 3-5 days
 2nd Visit – 6 weeks postpartum
7. Support to Breastfeeding
8. Family Planning Counseling
 Proper spacing of birth (3 to 5 years interval)
FAMILY PLANNING
 Overall Goal: To provide universal access to family planning information and services
wherever and whenever these are needed
Aims to reduce:
 Infant deaths
 Neonatal deaths
 Under-five deaths
 Maternal deaths
Objectives
 Addresses the need to help couples and individuals achieved their desired
family size within context of responsible parenthood
 Ensure that quality FP services are available in DOH retained hospitals, LGU
managed health facilities, NGOs and private sector
Family Planning Methods
1. Female Sterilization
 Also known as Bilateral Tubal Ligation
 Safe and simple surgical procedure which provides permanent contraception for
women who do not want more children
 Involves cutting or blocking of two fallopian tubes.
Advantages
 Permanent method of contraception
 Does not interfere with sex
 Results in increased sexual enjoyment
 No effect on breastfeeding
 No known long term side effects or health risks
Disadvantages
Uncommon complications of surgery:
 Infection or bleeding
 Increase risk for ectopic pregnancy

 Requires physical examination

 Reversal surgery is difficult
 Do not protect against sexually transmitted diseases
2. Male Sterilization
 Also known as Vasectomy
 Permanent method wherein the vas deferens is tied and cut or blocked through a
small opening in the scrotal skin
Advantages
 Very effective in 3 months after the procedure
 Permanent, safe, simple and easy to perform
 Can be performed in a clinic
 Person will not lose his sexual ability and ejaculation
Disadvantages
 May be uncomfortable due to slight pain and swelling 2-3 days after the
procedure
 Reversibility is difficult and expensive
 Bleeding may result in hematoma formation
3.Pill
 Contains hormones – estrogen and progesterone
Advantages
 Safe as proven through extensive studies
 Convenient and easy to use
 Reduces gynecologic symptoms such as painful menses and endometriosis
 Does not interfere with sexual intercourse
Disadvantages
 Often not used correctly and consistently, lowering its effectiveness
 Has side effects such as nausea, dizziness or breast tenderness
 Can suppress lactation
4.Male Condom
 Thin sheath of latex rubber made to fit on a man’s erect penis to prevent the passage
of sperm cells and sexually transmitted disease into the vagina
Advantages
 Safe and has no hormonal effect
 Protects against microorganisms during intercourse
 Encourages male participation in family planning
Disadvantages
 May cause allergy for people who are sensitive to latex or lubricant
 May decrease sensation, making sex less enjoyable
5. Injectables
 Contain synthetic hormone, progestin that suppresses ovulation, thickens cervical
mucus and changes uterine lining.

Advantages
 Reversible
 No need for daily intake
 Does not interfere with sexual intercourse
 Has no estrogen-related side effects
6. Lactating Amenorrhea Method/LAM

 Temporary introductory postpartum method of postponing pregnancy based
on physiological infertility experienced by Breastfeeding women
Advantages
 LAM is universally available to all postpartum breastfeeding women
 No other FP commodities are required
 It contributes to improve maternal and child health and nutrition
Disadvantages
 Short term FP method which is effective only for a maximum of 6 months
 The effectiveness of LAM may decrease if a mother and child are separated for
extended periods
 Full or nearly full BF may be difficult to maintain up to 6 months
7. Mucus/Billing Methods
 Abstaining from sexual intercourse during fertile days prevents pregnancy
Advantages
 Can be used by any woman of reproductive age as long as she is not suffering
from an unusual disease or condition that results in extraordinary vaginal
discharge
Disadvantages
 Cannot be used by woman with medical conditions that would make pregnancy
dangerous
8. Basal Body Temperature

 Identifies the fertile and infertile period of a woman’s cycle by daily taking and
recording of the rise in body temperature during and after ovulation.
 Before Ovulation: Temperature decreases 0.5 °F
 During Ovulation: Temperature increases 1.0°F
9. Sympto-thermal Method
 Identifies the fertile and infertile days of the menstrual cycle as determined
through a combination of observations made on the cervical mucus, basal
body temperature recording and other signs of ovulation
10. Two Day Method
 Simple fertility awareness based method of FP that involves:
 Cervical secretions as an indicator of fertility
 Women checking the presence of secretions everyday
Advantages
 Can be used by women with any cycle length
 No health related side effects associated
 Incurs very little or no cost
 Immediately reversible

Promote male partner involvement in FP


Disadvantages
 Needs cooperation of the husband
 Can become unreliable for women who have conditions that cause abnormal cervical
secretions
Standard Days Method

11.
 Couples use color coded cycle beads to mark the fertile and infertile days of the
menstrual cycle
Advantages
 No health related side effects associated with its use
 Increases self-awareness and knowledge of human reproduction
 Can be used either to avoid or achieve pregnancy
 Enhances self-discipline, mutual respect
 Can be integrated in health and family planning services
Disadvantage
 Cannot be used by women who usually have menstrual cycle between 26 and 32
days long
 Misconceptions about Family Planning

 Causes abortion
 Will render couples sterile
 Will result to loss of sexual desire
 Roles of Public Health Nurse on FP Program
 Provide counseling
 Provide packages of health services
 Ensure the availability of FP supplies and logistics
CHILD HEALTH PROGRAMS

 Goal: To reduce morbidity and mortality rates (for children 0-9yrs)
 Programs:
 Infant and Young Child Feeding
 Newborn Screening
 Expanded Program on Immunization
 Management of Childhood illnesses
 Micronutrient Supplementation
 Dental health
 Early Child Development
 Child Health Injuries
INFANT AND YOUNG CHILD FEEDING

 Goal: Reduce child mortality rate by 2/3 by 2015
 Objective: To improve health and nutrition status of infants and young children
 Outcome: To improve exclusive and extended breastfeeding and complementary feeding
 Key Messages on Infant and Young Child Feeding
 Initiate breastfeeding within 1hour after birth
 Exclusive for the first 6 months of life

 Complemented at 6 months with appropriate food

 Extend Breastfeeding up to 2 years and beyond
 Exclusive breastfeeding means giving a baby only breast milk, and no other liquids or
solids, not even water.
 Complementary feeding- after six months of age all babies require other foods to
complement breast milk.
 Complementary foods should be:
 Timely
 Adequate
 Safe
 Properly fed
 When not to breastfeed:
 AIDS
LAWS THAT PROTECT INFANT AND YOUNG CHILD FEEDING

1. Milk Code (EO 51)
 Products covered by Milk Code consist of breast milk substitutes, including
infant formula; other milk products, food and beverages, including bottle-
fed complementary foods.
2. Rooming-In and Breastfeeding Act of 1992 (RA 7600)
 To promote room-in and to encourage. Protect and support the practice of
breastfeeding.
 Compliance to the law is ensured through one of the 10 steps to Mother Baby
Friendly Hospitals wherein the mother and the baby should be together for 24
hours.
3. Food Fortification Law (RA 8976)
 The law requires a mandatory food fortification of staple foods – rice, flour,
edible oil and sugar and voluntary food fortification of processed food or
food products
4. Expanded Breastfeeding Act of 2010 (RA 10028)
 Exclusive breastfeeding for the first 6 months.
PD 996 (EPI LAW)

 Principles:
 It is safe and immunologically effective to administer all EPI vaccines on the same
day at different sites of the body
 Measles Vaccine should be given as soon as the child is 9 months old. If the child
is living in an endemic area, give the vaccine as early as 6 months. If given at 9
months = 85% protection; if given at one year and older = 95%
 Vaccine schedule should not be restated
 Giving doses less than the recommended interval may lessen the antibody response
 No extra must be given to children/ mother who missed a dose of DPT/Hepa-B/OPV/TT
 Strictly follow the principle of never, ever reconstituting the freeze dried vaccines
other than the diluents supplied with the
 One Syringe, One Needle per child during vaccination
RA 10152 (2011)
 An act providing for mandatory basic immunization services for infants and children.

False Contraindications:
 Malnutrition
 Low Grade Fever
 Mild Respiratory Infections
 Cough
 Diarrhea
 Vomiting
Absolute Contraindications:
 DPT 2 or DPT 3 to a child who has had convulsions or shock within 3 days the
previous dose.
 Patients with neurologic disease should not be given vaccines containing whole cell
pertussis
 Live vaccines like BCG vaccine must not be given to individuals who are
immunosuppressed due to a malignant disease.
VACCINE MINIMUM AGE AT 1ST DOSES INTERVAL

DOSE
BCG At birth 1
Pentavalent 6 weeks 3 4 weeks
OPV 6 weeks 3 4 weeks
HEPA B At birth 1 6 weeks from 1st dose
MEASLES 9 months 1
MMR 12 months 1
IPV 14 weeks 1
VACCINE DOSAGE ROUTE SITE

BCG 0.05 mL ID Right deltoid region
DPT 0.5 mL IM Upper outer portion of thigh (Vastus
lateralis)
OPV 2-3 drops Oral Mouth
HEPA B 0.5 mL IM Upper outer portion of thigh (Vastus
lateralis)
MEASLES 0.5 mL SQ Outer portion of upper arm
NUTRITION PROGRAM
Goal: improve quality of life of Filipinos through better nutrition, improved health, and increased
productivity
Common Nutritional Deficiencies

 Vitamin A
 Iron
 Iodine
Programs and Projects:
 Micronutrient Supplementation
 Food Fortification

 Essential maternal and Child Health Service Package

 Nutrition Information, Communication, and Education
 Home, School and Community Food Production
 Food Assistance
 Livelihood Assistance
ORAL HEALTH PROGRAMS

Goal: Reduce the prevalence rate of dental caries and periodontal diseases from 92% in
1998 to 85% and from 78% in 1998 to 60% by 2010 among general population
Objectives:
 To increase the proportion of orally fit children under 6 years old 80% by 2010
 To control oral health risk among the young people
 To improve the oral health conditions of pregnant women by 20% and older
persons by 10% every year until 2010
CLASSIFIACTION OF ORAL INTERVENTIONS
Promotive  Health education
Service
Preventive  Oral examination
Treatment  Oral hygiene
 Pit & Fissure Sealant Program
 Fluoride Utilization Program
Curative  Permanent Filling Gum Treatment
Treatment  Atraumatic Restorative Treatment
 Temporary Filling
 Extraction
 Treatment Post Extraction
 Drainage of Localized Oral abscesses
PHILIPPINE REPRODUCTIVE HEALTH

Overall Goal: Better Quality Life among Filipinos
Main Objectives
 Reducing Maternal Mortality Rate
 Reducing Child Mortality
 Reversing spread of HIV/AIDS
 Increasing access to reproductive health information and services
Elements
 Family Planning
 Maternal and Child Health Nutrition Prevention and Management of Reproductive Tract
Infection
 Adolescent Reproductive Health
 Prevention and Management of Abortion and its Complications
 Prevention and Management of Breast and Reproductive Tract Cancers and other
Gynecological Conditions
 Education and Counselling on Sexuality and Sexual Health
 Men’s Reproductive Health and Involvement
 Violence against Women and Children

 Prevention and Management of Infertility and Sexual Dysfunction
Environmental Health
 It is a branch of public health that deals with the study of preventing illness by
managing the environment and changing people’s behavior to reduce exposure to
biological and non-biological agents of disease or injury
Health and Sanitation Laws
 PD 856 – Sanitation Code of the Philippines
 RA 6969- toxic Substances and hazardous and Nuclear Waste Control Act of 1990
 RA 8749- Clean Air Act of 1999
 RA 9003- Ecological Solid Waste Management Act of 2000
 RA 9275- Clean Water Act 2004
Environmental Sanitation
 Study of all factors in man’s physical environment, which may exercise a
deleterious effect on his health well- being and survival
The Development of Health through the Environment and Occupation Health Office (EOHO)
has set some policies on the following areas:
1. Approved Types of Water Supply Facilities
 LEVEL 1 (Point Source)
 Protect well or developed spring with an outlet but without a distribution system
 Serves around 15 to 25 households
 Outreach must not be more than 250 meters from the farthest user
 Yield or discharge is generally from 40 to 140 liters per minute
 Generally adaptable for rural areas where the houses are thinly scattered
 LEVEL II (Communal Faucet System or Stand –posts)
 System composed of a source of reservoir, a piped distribution network and
communal faucets
 Located not more than 25 meters from the farthest house
 Designed to deliver 40-80 liters of water per capital per day
 Average households: 100
 One faucet per 4 to 6 households
 Suitable for rural areas where houses are clustered densely to justify a simple-piped
system
 LEVEL III (Waterworks System or Individual House Connections)
 NAWASA, Maynilad
2. Unapproved type of water facility
 Open drug wells
 Unimproved springs
 Wells that need priming
3. Access to sage and potable drinking water

4. Water quality and monitoring surveillance
 Disinfection of water supply sources is required on the following:
 Newly constructed water supply facilities
 Water supply facility that has been repaired/improved
5. Waterworks/water system and well construction

 Well sites shall require the prior approval of the Secretary of Health or his duly
authorized representative
 Well construction shall comply with sanitary requirements of the Department of Health
 Water supply system shall supply safe and potable water in adequate quantity
APPROVED TYPE OF TOILET FACILITY

Level I Non-water Carriage Toilet Facility
 Pit Latrines
 Reed Oderless Earth Closet
Toilet Facilities requiring small amount of water
 Poor Flush Toilet
 Aqua Privies
LEVEL II Water carriage type with Water Flush type with septic vault/tank
disposal facilities
LEVEL III Water carriage types of toilet facilities connected to septic tanks
and/or sewerage system to treatment plant
FOOD SANITATION PROGRAM

 Food Establishments shall be appraised as to the following sanitary conditions:
 Inspection/approval of all food source, containers, transport vehicles
 Compliance to sanitary permit requirements for all food establishment
 Provision of updated Health certificate for food handlers, cooks and cook helpers
 DOH’s Administrative Order no.1 – 2006 requires all laboratories to use

Formalin Ether Concentration Technique (FECT) instead of the direct fecal
smear in the analysis of stools of food handlers.
Food Establishment shall be rated as follows:

 CLASS A – Excellent
 CLASS B – Very Satisfactory
 CLASS C – Satisfactory
Four Rights in Food Safety

 Right Source
 Always buy fresh meat, fish fruits & vegetables
 Look at the expiry dates of processed food
 Avoid buying canned goods with dents, bulges, deformation, broken seals and
improper seams
 Boil water for at least 2 minutes (running boiling)
 Right Preparation
 Avoid contact between raw food and cooked food
 Always buy pasteurized mild and fruit juices
 Wash vegetables well if to be eaten raw such as lettuce, cucumber, tomatoes &
carrots
 Wash hands kitchen utensils before and after preparing foods
 Sweep kitchen floors to remove food droppings
 Right Cooking

 Cook food thoroughly (temperature on all parts of the food should reach 70 degrees
centigrade
 Eat cooked food immediately
 Wash hands thoroughly before and after eating
 Right Storage
 All cooked food should be left at room temperature for not more than two hours
 Use tightly sealed containers for storing food
 Store food under hot conditions (at least or above 60°C) or in cold conditions
(below or equal to 10°C) if you can plan to store it for more than 4 to 5 hours
 Do not overburden the refrigerator by filing it with too large quantities of warm food
 Food should be reheated to at least 70 degrees centigrade
 Rule in Food Safety: “When in doubt, throw it out!”
PRIORITY HEALTH PROGRAMS

SENTRONG SIGLA (SS) CERTIFICATION
Goal: Quality Health Care, Services, and Facilities
Level and Scope of Certification

1. Basic SS Certification
 Minimum input, process and output standards for integrated public health
services for 4 core programs, facility system, regulatory functions and basic
curative services
2. Specialty Awards
 Second level quality standards for selected 4 core public health programs
3. Awards for Excellence
 Highest level quality standards for maintaining Level 2 standards for the 4 core
public health programs and level 2-facility system for at least 3 consecutive
years.
 The SS Certification validity of certification is every two years.
 Facilities which did not progress to a level of certification but maintained current certification
are:
 Given stickers to confirm the renewal of the validity of seal
 No other incentives given for mere renewal of SS status
 Facilities that slide back; seal will not be removed but not issued an SS sticker
 Scope and structure of the SS Quality Standards (Level I)

 Primary Function: Provide basic public health services
 Facility and System Standards

 Ensure that the health facility is appropriately equipped with sufficient
manpower, adequate logistics and organized procedures to efficiently and
effectively promote core public health programs
 Integrated Public Health Function Standards

 Ensure that the health facility and staff promote public health programs and
prevent and control public health problems through direct patient/client care

 Basic Curative Function Standards

 Ensure that the health facility and staff provide basic curative services that consist
of primary level outpatient and emergency care
 Regulatory Function Standards

 Ensure that the health facility and staff support and provide an environment to
prevent, reduce and control risks and hazards to the community
 Scope and Structure of SS Quality Standards (Level II)

1. Local Health System Development
Goal: To strengthen local health system development
2. Integrated Public Health Functions covering 5 core public health programs:
 Integrated Women’s Health
 Child Care
 Prevention and Control of Infectious Disease
 Integrated Prevention and Control of Lifestyle Related Diseases
 Environmental Health
HERBAL MEDICINE
 General guidelines for the use of medicinal plants
 Be sure that the right king of plant is used according to the intended purpose
 Use the plant part suggested
 Use according to the dosage and direction recommended
 Use only one kind of medicinal plant at a time
 Stop the use of the plant if there is any untoward reaction or if side effects occur
 If there are no signs of improvement after two or three administration of the drug,
consult a physician
 In boiling the plants, use enamel were or clay pots, not aluminum ware. Clean the
pots very well before and after boiling the plant
 Use only the prescribed part of the plant
 Avoid the use of insecticides
 Herbal Plants
1. Lagundi (Vitex negundo)
 For cough and asthma
 Preparations
 Clean the leaves thoroughly and chop
 Measure two cups of water and boil on a low fire for 15 minutes
 Use the table on the amount of leaves to be used
LEAVES
AGE FRESH DRIED
Adult 6 tbsp. 4 tbsp.
7- 12 y/o 3 tbsp. 2 tbsp.
2 – 6 y/o 1 ½ tbsp. 1 tbsp.

 Dosage
 Divide the solution into three parts. Drink one part each in the morning, noon
and night For fever, drink each part every four hours
2. Yerba Buena (Mentha cordifolia Opiz ex Fresen)

 For pains of the body
 Preparations
 Cleanse thoroughly and chop the leaves, then boil in two glasses of water for 15
minutes.
 Do not cover the pot; allow to cool and strain
 For adults, six tbsp. of fresh leaves or four tbsp. of dried leaves should be used
 For patients 7-12 years old, use half the adult dose
 Dosage
 Divide the boiled solution into three parts and drink on part each in the
morning, afternoon and evening, Squeeze the fresh leaves and place on the
painful part
3. Sambong (Blumea balsamifera)

 For swelling. Diuresis, anti-urolithiasis
 Preparations
 Cleanse thoroughly and chop leaves, boil in two glasses of water for 15 minutes
 Do not cover the pot; keep boiling and strain
 For adults, use six tbsp. fresh leaves or four tbsp. dried leaves
 Dosage
 Divide the boiled solution into three parts and drink one part each in the
morning, afternoon and evening, Squeeze the fresh leaves and place
on the painful part.
4. Tsaang Gubat (Ehretia microphylla Lam)

 For stomachache
 Preparations
 Cleanse thoroughly and chop leaves and boil in two glasses of water for 15
minutes
 Do not cover the pot; keep cooking and strain
 For adults, six tbsp. of fresh leaves or four tbsp. of dried leaves should be used
 For patients 7-12 years old, use half the adult dose
 Dosage
 Divide in two parts and drink one part every four hours
5. Niyug-niyugan (Quisqualis indica)

 For ascaris
 Preparation
 Use newly-opened, mature and dried nuts
 Administration
 Eat the seeds two hours after supper
 Dosage
Adult 8-10 seeds
7-12 y/o 6-7 seeds

6-8 y/o 5-6 seeds

4-5 y/o 4-5 seeds
6. Bayabas (Psidium guajava)

 For cleansing or wounds, mouth infections and swollen gums
 Preparations
 Clean thoroughly and chop leaves
 Boil two glasses of leaves in four glasses of water on a low fire
 Administration
 Clean wounds with the solution two times a day. To use as a mouthwash, use a
lukewarm solution
7. Akapulko (Cassia alata)

 Infected skin, skin irritation and scabies
 Preparation
 Squeeze enough leaves
 Administration
 Apply the juice of the leaves on affected parts twice a day
8. Ulasimang bato (Peperomia pellucida)

 Lower uric skin; for arthritis or gout
 Preparations
 Salad: Clean leaves thoroughly, Eat three times a day with meals
 Decoction: Clean leaves thoroughly and boil 1 ½ glasses of leaves in two glasses
of water for 15 minutes. Divide into three parts and take three times a day.
9. Bawang (Allium sativum)

 To lower cholesterol level
 Preparation
 Saute or boil; may be infused (five minutes); be mixed with vinegar
 Administration and Dosage
 Eat two clove of garlic with meals three times a day
10. Ampalaya (Momordica charantia)

 For diabetes mellitus (mild-insulin dependent)
 Preparation
 Clean the leaves thoroughly and chop. Measure two cups of leaves in two
glasses of water, Boil for 15 minutes on low fire. Drink ½ glass three times a day
before eating
HEALTH EMERGENCY PREPAREDNESS AND RESPONSE PROGRAM

Goal: Promoting health emergency preparedness among the general public and strengthening
the health sector capability and response to emergencies disaster.
 Legal Mandate
 Presidential Decree No 1566 (1978) – Strengthening the Philippine Disaster
Control Capability and Establishing the National Program on Community Disaster
Preparedness
 Republic Act No 7160 (Local Gov’t Code of 1991)

 Transfer of responsibilities from the national to the local government units (LGUs)
 Disaster and Health Emergency Management
 Disaster
 It a serious disruption of the functioning of a society, causing widespread human,
material or environmental losses which exceed the ability of the affected society
to cope, using only its own resources.
Classification of Disaster according to its cause
1. Natural Disaster
2. Human generated/Man-made
 Emergency
 Requires an immediate response
 It is the responsibility of all
 It should be woven into the community and administrative levels
 It should concentrate on process and people rather than documentation
Main objective: Decrease mortality, morbidity and prevent disability
 Hazards
 Any phenomenon, which has the potential to cause disruption or damage to humans
and their environment
 General Principles
 First priority: protection of the people who are at risk
 Second priority: protection of critical resources and systems on which communities
depend
 Disaster management must be an integral function of national development plans and
objectives
 Disaster management relies upon an understanding of hazard risks
 Capabilities must be developed prior to the impact of a hazard
 Disaster Management must be based upon interdisciplinary collaboration
 Major Risks to be Considered

1. Natural risks
E.g. flood, earthquake, cyclones
2. Technological risks
 Chemical, radiological, other events caused by the failure of the socio-technical
systems
3. Epidemics
4. Societal risks
 Caused by social exclusion, extreme poverty and group violence.
NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM

(RA 7719 – Blood Services Act 1994)
 Objectives
 To promote and encourage voluntary blood donation by the citizenry and to instill public
consciousness of the principle that blood donation is a humanitarian act.
 To provide adequate, safe, affordable and equitable distribution of supply of blood and
blood products
 To mobilize all sectors of the community to participate in mechanisms for voluntary and
non-profit collection of blood
 Vision
 Envision a network of modernized national and regional blood centers operating on a
fully voluntary, non- remunerated blood donation system
 Mission
 Ensure adequate, safe and accessible blood supply by:
 Promoting voluntary blood donation
 Establishing new blood service facilities
 Organizing association of blood donors and training medical practitioners on national
blood use
 Requirements before donating:

 Weigh more than 45 kg (100 lbs) for 250 ml of donated blood; 50kg (110 lbs) for 450 ml
of donated blood
 Be in good health
 Be aged 16-65 years (for ages 16 & 17, parental consent is need)
 Systolic BP =90-160 mm Hg
 Diastolic =60-100 mm Hg
 Hemoglobin at least 12.5g/dL
 Contraindications
 Diabetes
 Cancer
 Hyperthyroidism
 Cardiovascular disease
 Severe psychiatric disorder
 Epilepsy/convulsions
 Severe bronchitis
 AIDS/ Syphilis and other STI (past & present)
 Malaria
 Kidney and Liver disease
 Prolonged bleeding
 Use of prohibited drugs
 Blood extracted for Donation

 Whole blood and red cell concentrates
 Shelf-life to 5 weeks
 Plasma
 Can be stored frozen for 12 months
 Considerations after blood donation:
 Leave the adhesive dressing on your arm for at least 3 hours but not more than
twelve (12) hours.
 Bruising or discoloration may occur and will disappear in a few days
 Avoid carrying heavy objects with your donating arm
 Do not smoke for the next 2 hours
 Avoid alcohol intake for the next 12 hours
 Eat regular meals and increase fluid intake following your donation

BOTIKA NG BARANGAY
Goal: To promote equity in health by ensuring the availability and accessibility of affordable
safe and effective quality essential drugs to all, with priority for marginalized, underserved,
critical and hard to reach areas.
 Objective:
 To rationalize the distribution of common drugs and medicines among intended
beneficiaries
 To serve as mechanism for the DOH to establish partnership with Local Government
Units (LGUs)
 To optimize involvement of the Barangay Health Workers addressing the health need of
the community
 Criteria for Establishing a Botika ng Barangay

 Managed or operated by an established community organization or cooperative
which is duly recognized as a judicial body
 Service or coverage area a barangay that is far flung, depressed, and hard to
reach area as defined in the Magna Carta for public Health Workers
implementing Rules and Regulations
 Community-sourced funds at least 1/3 of the initial capital requirements
 Local government unit/other government officials-sourced funds at least 1/3 of the
initial capital requirement
 Submission of a barangay socio-economic profile and health profile including
a master list of indigents, if available
 Commitment form a licensed pharmacist to supervise Botika ng Barangay operations
 Identification and selection of at least 2 accredited Barangay Health Workers or
Community Volunteer Health workers trained as botika ng barangay Aides
 Availability of a botika ng barangay space
COMMUNITY ORGANIZING PARTICIPATORY ACTION RESEARCH (COPAR)

DEFINITION
 The strategy used by the health Resource Development Program (HRDP) III in
implementing primary health care delivery in depressed and undeserved
communities for them to become self-reliant
 It is collective, participatory, transformative, liberate, sustained & systematic process of
building people’s organizations by mobilizing and enhancing the capabilities and
resources of the people for the resolution of their issues and concerns towards
effecting change in their existing oppressive and exploitative conditions (National Rural
CO conference, 1994)
 Importance:
 Tool for community development & people empowerment
 Prepares people/clients to eventually take over the management of a development
programs in the future
 Maximizes community participation and involvement

PRINCIPLES
People, especially the most oppressed, exploited and deprived sectors are open to
change, have the capacity to change, and are able to bring about change
Based on the interests of the poorest sectors of society
Should lead to self-reliant community and society
 Process/Methods used in COPAR

 Progressive Cycle of Action Reflection Action
 Begins with small, local and concrete issues identified by the people and the
evaluation and reflection of and on the action taken by them
 Consciousness Raising
 Emphasis on learning that emerges from concrete action and which enriches
succeeding action
 COPAR is participatory and mass-based
 Primarily towards and biased in favor of the poor, the powerless and the oppressed
 COPAR is group-oriented not leader-oriented
 Leaders are identified, emerge and are tested through action
 Rather than appointed or selected by some external force or entity
COMMUNITY ORGANIZING
 Continuous and sustained process of educating the people let them understand and
develop their critical awareness of the existing conditions
Objectives
 To make the people aware of social realities towards the development of local
initiative, optimal use of human, technical and material resources
 To form structures that uphold the people’s basic interests as oppressed and
deprived sections of the community and as people bound by the interest to serve the
people
 To initiate responsible actions intended to address holistically the various community
health and social problems
Emphasis
 Members of the community work to solve their own problems
 Direction is internal rather than external
 Development of the capacity to establish a project is more important than the project
 There is consciousness-raising with regard to the situation of health care delivery
within the total structure of society.
PROCESS
1. Pre – Entry Phase
 Done before going to the community
 Activities
 Community consultations/dialogues related to site selection
 Setting of issues/considerations related to site selection
 Development of criteria for site selection
 Socio-economically depressed and underserved community with majority of the
population belonging to the poor sector

 Health services are inaccessible

 Community is in poor health status
 The area must have relative peace and order
 Acceptance of the program by the community
 Site selection
 Preliminary Social Investigation (PSI)
 Use of secondary data from various government offices, particularly the
Provincial Health Office and / or RHU
 Use of secondary data from other community based health programs
 Coordination with extension workers form both GO and NGO
 Conduct ocular observations, noting the accessibility, geography ,
terrain, settlement patterns and available physical resources
 Networking with local government units (LGUs) NGO and other departments
2. Entry phase
 Integration with community residents
 Deepening Social Investigation
 Information Dissemination
 Core Group (CG) Formation
 Development of criteria for the selection of CG members
 Respected member of the community
 Belongs to the poor sector of society
 Must be responsible, committed and willing to work for social change and social
transformation
 Must be willing to learn
 Must be able to communicate; can express oneself in a group
 Defining the roles/functions/tasks of the CG
 Delivery of basic health services
 Coordination/dialogue/consultation with other community organizations
 Self-Awareness and Leadership Training (SALT)
 This will help each one discover his/her potentials and talents and discover
opportunities for growth and development of the entire community
3. Community Study/Diagnosis phase/Research phase

 Selection of the research team
 Training on data collection methods and techniques
 Planning for the actual data gathering
 Data Gathering
 Community Validation
 Presentation of Community Diagnosis and recommendation
 Prioritization of Community Needs/Problems for action
4. Community Organization & Capacity Building Phase

 Community Meetings
 Election and induction of CHO officers

 Development of management systems and procedures

 Team building Activities /Action-Reflection- Action Session (ARAS)
 Organization of the Working Committees
 Training of CHO officers/ Community Leaders
5. Community Action Phase

 Organization and training of Community Health Workers (CHW)
 Development of criteria for the selection of CHWs
 Selection of CHWs
 Training of CHWs
 Setting up linkages, networks, and referral systems
 Project implementation, Monitoring, and Evaluation (PIME) of health services
intervention schemes and community development projects
 Initial identification and implementation of resource mobilization schemes
6. Sustenance & Strengthening Phase

 Formulation and ratification of constitution and by-laws
 Identification and development of secondary leaders
 Formalizing and institutionalizing of linkages, networks, and referral system
 Setting up and institutionalizing financing scheme for the community health
program/activities
 Development and implementation of viable committees, management system and
procedures
 Continuing Education of community leaders, CHWs and CHO members and community
residents
 Develop medium and long-term community and development plans
CRITICAL ACTIVITIES IN COPAR

1. Integration
 Establishing rapport with the people in a continuing effort to imbibe community life
and undergoing the same experience as the people and sharing their hopes,
aspirations and hardships towards building mutual trust and cooperation
2. Social Investigation
 Process of systematically learning and analyzing the various structures and forces in
the community
 Objectives
 Gather data on the geographic, economic, political and socio-cultural situation of
the community
 Identify the classes and sectors present in the community
 Determine the correct approach and method of organizing
 Provide a basis of planning and programming of organizing activities
3. Planning
 Process of formulating specific activities to attain the goals of meeting
community needs solving community problems
4. Ground Working
 Also termed as Agitation

 This entails going around and motivating people on a one-to-one basis to do

something about community issues.
5. Community Meeting
 Ratification of what has been already decided
 The meeting gives a sense of collective power and confidence
6. Role play
 This is means of acting out the meeting or the activity that will take place between
the people and the group targeted by the mobilization
7. Social Mobilization
 This refers to the activities undertaken by the community through the people’s
organization to solve problems confronting the community
8. Evaluation
 The process of discovering by the people the way something has been
accomplished, what has been left out and what remains to be done.
9. Reflection
 Analyzing the finished mass action, its good and weak points identified
10. Organization
 This facilitates wider participation and collective action on community problems
PARTICIPATORY ACTION RESEARCH

 Active process where the expected beneficiaries of research are the main actors in the
entire research process
 It is combination of education, research and action
 Purpose is the empowerment of the people
 Characteristics of Traditional and Participatory Action Research

TRADITIONAL PARTICIPATORY
Research has the purpose of identifying Research seeks social transformation
and meeting individual needs within
existing social system
Community problems or needs are defined Research problems are defined by the
by experts or researchers external to the community members themselves who are viewed
community group and as experts of their own reality
considered neutral or non-biased
Research problem is studied by the Community group undertakes the investigation on
researchers who control the research research process from data collection to analysis.
process External researcher
work alongside the community group
Recommendations for the community are Community formulates recommendations and an
based on researcher’s findings and action plan based on research outcome
analysis

FUNDAMENTALS OF NURSING
NURSING PROCESS - is a systematic, rational, cyclical method of planning and providing care
STEPS OF THE NURSING PROCESS:

• ASSESSMENT
Purpose: To establish a data base about the client’s perceived needs, health problems and risks, related
experiences, health practices, goals, values, and lifestyle.
Stages of Interview:
 Opening (establish rapport - self introduction, non-verbal gestures)
 Body (open and close-ended questions)
 Closing
 DIAGNOSING
Purpose: To identify and develop a list of nursing and collaborative problems
Types of Nursing Diagnoses:

 Actual: the client shows manifestations of a health problem or condition.
 High-Risk: A health problem or condition is likely to develop as a result of risk factors being assessed
unless the nurse intervenes.
 Wellness: The client is healthy as assessed but he wishes to achieve a higher level of functioning.
 Possible: a nursing diagnosis is which evidence is unclear unless further provided, but existing condition
may predict a possible health problem
 Syndrome: a clustered nursing diagnosis.
 PLANNING
Purpose: To develop an individualized, goal oriented and therapeutic care plan
SPECIFIC How the nurse will know the client’s response has changed.
MEASURABLE What the client will do, when it will be done, and to what extent.
ATTAINABLE Relate with the client in formulating expected outcomes
REALISTIC Includes client’s health capabilities
TIMELY Time estimate for outcome attainment.
 IMPLEMENTATION
Purpose: To assist client meet desired goals/outcomes and promote maximum level of functioning
Types:
1. Independent: nurses are licensed to act related to their knowledge and skills.
2. Interdependent/ Collaborative: carried out by a nurse with collaboration of other healthcare team.
3. Dependent: carried out by a nurse in collaboration with the physician.
 EVALUATION
Purpose: To determine the effectiveness of the care plan and its corresponding actions whether to continue,
terminate, or modify the care plan.
Evaluation may be:
 Ongoing: done while or immediately after implementing the nursing intervention.
 Intermittent: performed at specified intervals, such as thrice a week.
 Terminal: performed to indicate the client’s condition at the time of discharge.
PHYSICAL ASSESSMENT
Technique: Inspection, Palpation, Percussion, Auscultation
1.Inspection
 Use of sense of sight
 Visual inspection/examination
2.Palpation
▪ Use of sense of touch
NOTE: Finger pads and the back of the hand are the most sensitive body parts used for palpation.
Types of palpation:
Light palpation - detects superficial mass (1 “depth)
Deep palpation - palpates organ enlargement like liver, mass and pulsations (3 - 4” in depth)
3. Percussion
▪ Assess for vibration with the use of fingers
▪ The finger of one hand taps the finger of the other hand to generate vibration which can be used to
determine a diagnostic sound.
TONE QUALITY PITCH EXAMPLE
Resonance Hollow Low Healthy Lungs
Hyperresonance Booming Very Loud Emphysema
Tympany Drum - like High GI Bubbling, empty stomach or large intestine
Dullness Thud - like High Kidney, full bladder, feces, filled intestine
Flatness Very Dull Soft - moderate Bones and muscles (very dense tissues), heart,
spleen, liver
4. Auscultation
• use of sense of hearing with the use of the unaided ear or a stethoscope
• frequently assessed organs: heart, lungs, abdomen, and blood vessels
VITAL SIGNS
TEMPERATURE
ALTERATIONS IN BODY TEMPERATURE:
1.Pyrexia - (hyperthermia) Above 40°C - hyperpyrexia
2.Fever
Intermittent - fluctuation of body temp. at regular intervals between periods of fever and periods of normal or
subnormal Temperature
Remittent- fluctuations above Normal of more than 2 °C
Relapsing - a fever that subsides and after few days returns.
Constant - a fever with minimal temperature fluctuations

3. Hypothermia - a body temperature of 35 degrees Celsius or lower resulting from cold weather exposure or
artificial induction
PULSE RATE - number of beats per minute; assess this by compressing an artery with the pads of three
fingers.
 Bradycardia: a pulse that is below normal rate.

 Tachycardia: a pulse that is above normal rate.
NURSING ALERT: Pulse Force/ Pulse Volume

Grading:
+3: bounding pulse
+2: normal
+1: thready pulse, weak or difficult to feel
0: absent pulse
• Cardiac Output - 5-6 L of blood is forced out of the left ventricle per minute
RESPIRATORY RATE
Breathing Pattern/ Sounds Characteristics

A. Kussmaul’s - Faster and deeper respiration without pauses in between panting
- Prolonged grasping breathing followed by extremely short inefficient
B. Apneustic
exhalation
C. Dyspnea - difficulty of breathing
D. Orthopnea -DOB unless patient is sitting; can breathe only when in an upright position.
- is the term for cycles of breathing characterized by deep, rapid breaths for
E. Cheyne-Stokes about 30
seconds, followed by absence of respirations for 10 to 30 seconds.
F. Wheezing - narrowing of airways, causing whistling or sighing sounds
G. Stridor - high-pitched sounds on inspiration with laryngeal obstruction
- sound caused by air passing thru fluid or mucus in the airways usually heard
H. Crackles/Rales
on inhalation
- sound caused by air passing thru airways narrowed by fluids, edema,
I. Gurgles/ Rhonchi muscle spasm
usually heard during exhalation ;course ,dry, wheezy or whistling sound
BLOOD PRESSURE - Pressure exerted by blood to the blood vessel wall
TECHNIQUES
• The direct method (CVP)
• The indirect method (sphygmomanometer and stethoscope)
• Common site: brachial artery
Contraindications for brachial artery:

Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis. Surgery
involving the breast, axilla, shoulder, arm, or hand. Injury or disease to the shoulder, arm, or hand, such
as trauma, burns, or application of a cast or bandage
GENERAL MEDICAL AND NURSING PROCEDURES
GASTRIC TUBE INSERTION

Purposes:
 Administer tube feedings and medications to clients who cannot take in food per orem (Gavage)
 Prevent gastric distention, nausea and vomiting
 To remove stomach contents for laboratory analysis
 To lavage / wash stomach in case of poisoning or over dose of medication
Procedure:
1. Gather the necessary equipment.
2. Explain procedure to the patient
3. Position the patient in a sitting position
4. Check nostrils for patency by asking the patient to breathe through one nares while occluding the
other.
5. Measure length of NG tubing.
6. Don gloves and lubricate tube in water or a water soluble lubricant.
(Never use petroleum jelly.)
7. Ask the patient to tilt his or her head backward, and gently advance the NG tube into an
unobstructed nostril; direct tube toward back of throat and down.
8. As the tube approaches the nasopharynx, ask the patient to flex head toward chest (to close the
trachea) and allow him or her to swallow sips of water or ice chips as the tube is advanced
into the esophagus (about 3 to 5 inches each time the patient swallows).
NOTE: If the patient coughs or gags, check the mouth and oropharynx. If the tube is
curled in the mouth or throat, withdraw the tube to the pharynx and repeat attempt
to insert the tube.
9. Check for proper tube placement in the stomach by aspirating with a syringe for gastric
drainage or by instilling about 20 mL of air into the NG tube while listening with a
stethoscope for a gurgling sound over the stomach.
10. Secure the tube after checking for proper placement by cutting a 3-inch strip of 1-inch tape
and then splitting the tape lengthwise at one end, leaving 1 inch intact at the opposite end
11. Place the intact end of the tape on top of the patient’s nose, and wrap one side of the split
tape end around the tube and secure on a nostril. Repeat with the other split tape end.
12. Document the size and type of tube inserted. Note the nostril used and the patient’s tolerance
of the procedure. Document how placement was validated and whether tubing was left clamped
or attached to other equipment.
 Total parenteral nutrition (TPN)

- is delivered via a central venous catheter to reverse starvation and promote tissue synthesis, wound
healing, and normal metabolic function.
 Central Venous Tunneled Catheters (CVT)

- Are catheters with single, double, or triple lumens and can be used for administering drugs, blood
products, and total parenteral nutrition as well as for obtaining blood samples for lab tests.
- CVTCs can be used for months or years if infection does not occur
- Dressing changes are made on all catheters using sterile technique. (Both nurse and patient should
wear a mask during the procedure.)
COMPLICATIONS:
 hyperglycemia- hyperosmolar (HA, Nausea and Vomiting, fever, chills, malaise)
 Infection (fever, redness and swelling on site )
 Pneumothorax (dyspnea , ecchymosis, diminished/absent lung sound)
GUIDELINES:
1. Verify central line placement after initial insertion via chest (radiograph) prior to beginning
(pneumothorax or hemothorax is a risk with central line placement.)
2. Check vital signs (including blood pressure) at least every 6 hours after initiating infusion.
3. Check central line insertion site frequently for signs of infection (which may lead to sepsis)
4. Follow agency policy regarding frequency of dressing changes and procedure.
5. Change IV line setup every 24 hours.
6. (TPN fluids are an excellent medium for bacterial growth.)
7. Do not administer IV piggyback or direct IV push medications through or draw blood samples from
the TPN line. Only lipids may be a “piggybacked” carefully through the TPN line beyond the in-line
filter.
8. Monitor blood glucose every 6 hours; administer sliding scale insulin as ordered.
9. Weigh patient daily. (High glucose content of TPN can cause an osmotic diuresis and lead to
dehydration.)
10. Order TPN solutions from the pharmacy in a timely manner; remove the next container from
the refrigerator an hour before needed to prevent central infusion of cold solutions.
11. When a new container of TPN is needed, but is not available, follow agency policy to maintain
the ordered fluid delivery rate with D10W until the TPN is available. (High glucose content of
fluid stimulates release of insulin, which may cause hypoglycemia if fluids are discontinued
abruptly.)
12. Do not attempt to “catch up” on fluids if rate inadvertently slows.
13. Discontinue TPN solution gradually at the end of therapy to prevent hypoglycemia.
14. Monitor lab values. (Liver complications, electrolyte imbalances, and pH changes are possible.)
ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS

Guidelines in Administering Blood and Blood Products:
1. Verify physician’s order.
2. Check expiration date on product.
3. Verify accuracy of component with another licensed nurse or physician.
Types of Blood Products:

1. Fresh Whole Blood- complete components
2. Red Blood Cells- used to replace erythrocytes, 1 unit increases hgb by 1g/dl and hct by 2 – 3 % after
transfusion
3. White Blood Cells / Granulocyte Concentrate- Rarely used
4. Platelets- used to treat thrombocytopenia. Administered rapidly over 15 to 30 minutes
5. Fresh Frozen Plasma- used to provide clotting factors or for volume expanders Albumin- to
maintain colloid osmotic pressure
6. Check baseline vital signs (VS) and report any abnormal findings to the physician before beginning
infusion of component.
7. Warm blood in approved blood warmer for use in rapid transfusions or for neonatal exchange
transfusions.
8. Ascertain that the IV line is present and not infiltrated before beginning infusion.
9. Flush any solution from present IV line with 0.9% normal saline. (Flush again with saline after
completion of product.)
10. Check manufacturer’s information before using any pump to administer product. (Some pumps may
cause hemolysis of red cells.)
11. Initiate infusion within 30 minutes from the time the product is released from the blood bank.
12. Remain with the patient for at least 5 minutes after transfusion has begun.
13. Check VS 15 minutes after product infusion has begun, then 15 minutes later, and at
least every 30 minutes until the infusion is completed.
14. Administer a maximum of 50 mL of product over the first 15 minutes of transfusion.
15. Complete the infusion within 4 hours.
16. Validate teaching, assessment (including VS), product ID check, procedure (including time infusion
begun and completed), and reaction in the patient’s record.
17. Stop infusion of blood product, maintain IV access with 0.9% normal saline, and notify
the physician, send blood and blood set to the lab and reassess intensive monitoring.
Oxygen Therapy
 Indicated to clients who need additional oxygen, those clients who have reduced lung diffusion of
oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.
 “NO SMOKING” sign on the door/head of bed area
 Avoid use of volatile and flammable materials such as alcohol, oils, greases, ether and acetone
O2 Delivery System:
1. Cannula
Delivers low concentration of oxygen (24% to 45%) at flow rates of 2 - 6 LPM
2.Facemask
Covers mouth and nose
3.Simple Face mask

40% - 60% at liters flow of 5 -8 LPM
4. Partial Rebreather Mask

60% - 90% at liters flow of 6 - 10 LPM
The o2 reservoir bag allows the client to re-breathe about third of the exhaled air in conjunction with oxygen. It
increases FiO2 by recycling expired oxygen
5. Non - rebreather Mask

Highest oxygen concentration possible 95% - 100% at 10 - 15 LPM
6. Venturi Mask
Oxygen concentrations vary from 24% - 40% - 50% at 4 - 10 LPM
Has wide bore tubing and color coded jet adapters that corresponds to the exact oxygen concentration and flow
liters to be delivered
7.Face Tents:
Used when O2 masks are not tolerated
Note: check facial skin frequently for dampness and chaffing
Nursing Care: Keep the catheter patent by cleaning the catheter with Normal Saline
CARING FOR CLIENTS WITH CHEST TUBES

Types of Chest Tube Drainage System:
Simple drainage system

a simple drainage system that can be connected to
suction or to a Heimlich valve. The fluid-
collection bottle would have measurement
markings on it to help clinicians track the
amount of fluid collected.
Water Seal Drainage System

addition of a water-sealed bottle to the simple
drainage system. This helps to stop the problem
of air moving back into the chest, and it also
provides greater capacity for the collection of
blood or body fluids without any clogging of the
suction outlet/connection.
Three-bottle drainage system

the system has a fluid-collection bottle and a
water-sealed bottle, along with a pressure-
regulating bottle. This bottle helps the system
maintain a measured, constant negative
pressure and negative flow.
1. Note accumulated drainage in the collection chamber at the start of each shift or more frequently if
warranted by patient condition, and mark the date and time of observation on the collection chamber.
2. Check the water-seal and suction-control fluid levels at the start of each shift and replace water as
necessary; water will evaporate from the suction-control chamber, especially with vigorous bubbling.
To check fluid levels, temporarily turn off the wall suction.
3. Observe the water-seal chamber for fluctuations (tidaling) that occur with the patient’s ventilations;
unless the patient is on a ventilator, the column of fluid rises with inhalation and falls with exhalation.
4. Observe the water-seal chamber for bubbling. Bubbling is normal on exhalation when the patient has a
pneumothorax; continuous bubbling indicates an (abnormal) air leak in the system.
5. Maintain extra lengths of tubing by coiling it on the bed in order to prevent dependent loops that may
slow/stop drainage.
6. If drainage slows or stops, gently “milk” the chest tube from proximity to the patient toward the collection
chamber: to milk the tube, grasp and squeeze it between the fingers and palm of one hand; release and
repeat with the other hand on the next lower portion of the tube; continue toward the Collection chamber,
squeezing the tube with only one hand at a time.
7. Do NOT strip the tube; stripping involves both hands with one holding the tube while the other squeezes
and pulls toward the drainage chamber. (Stripping greatly increases the negative pressure applied to the
pleural space and can cause tissue damage, bleeding, and pain.)
8. Document system function, including time initiated/discontinued, type and amount of drainage, patient
respiratory status, details related to chest dressing, and appearance of the tube insertion site.
CARING FOR CLIENTS WITH TRACHEOSTOMY

 Air is not filtered and humidified therefore, a mist collar or a 4 x 4 gauze may be held in place with
a cotton tie over the stoma to filter the air as it enters.
 soak inner cannula in antiseptic soak with hydrogen peroxide, rinse well
 tie new tie before removing the old tie to prevent accidental dislodgement
 use precut gauze and perform care once a day at least.
 suction as needed and do oral care frequently
SUCTIONING
 Aspiration of secretions through a catheter that is connected to a suction machine or wall suction outlet
Catheters:
1. Open tipped: Most effective in aspirating secretions
2. Whistle tipped: Less irritating
3. Oral suctioning: Yankauer device / oral suction tube
4. Catheter has a thumb port which serves as a controller when suctioning
 Points to remember:
 NEVER suction more 10 - 15 seconds
 Use aseptic technique when suctioning
 HYPEROXYGENATE prior to suctioning
 Do oral care after suctioning
 DO NOT suction while inserting the catheter
 When you close the thumb port with your finger the suctioning is done
 Open thumb port (no suction is done)
 Suction in a circular manner/ by rotating catheter (ensures all surfaces are reached and prevents
trauma)
 Apply intermittent suction on withdrawal of the catheter
Urinary Catheterization
Procedure
1. Explain procedure to the patient.
2. Wash hands.
3. Position.
A. female patient supine with knees flexed;
B. male patient supine with legs slightly spread.
4. Place waterproof pad under buttocks.
5. Drape patient, diamond fashion, with sheet.
6. Arrange for adequate lighting.
7. Wash perineum with soap and water if soiled.

8. Open kit using sterile technique.

9. Don sterile gloves.
10. Set up sterile field (off bed if the patient may contaminate).
11. Test balloon if catheter will be indwelling.
12. With nondominant hand, spread labia (female) or retract foreskin (male). This hand is no longer sterile.
Using provided antiseptic solution and cotton balls or swabs, cleanse perineum (female) from clitoris
toward anus with top-to-bottom motion or retract foreskin (male) and use circular motion from meatus
outward. Repeat this step at least three times.
13. Slowly insert catheter until urine is noted (2 to 3 inches for female or 7to 8 inches for male) For male patient,
hold penis perpendicular to body and pull up gently during insertion.
14. Collect specimen if needed.
15. Remove catheter if it is not indwelling.
IF INDWELLING:
1. Inflate balloon. If patient has sudden pain, deflate balloon, advance catheter slightly and re-inflate.
2. Pull catheter gently to check adequacy of balloon.
3. Attach catheter to collection tubing if not already connected by manufacturer.
4. Tape catheter to patient’s inner thigh. Allow slack for patient movement.
5. Discard gloves and equipment.
6. Wash hands.
7. Document size and type of catheter inserted, amount and appearance of urine, and patient’s tolerance of
procedure.
CARING FOR CLIENTS WITH COLOSTOMY

OSTOMIES - divert and drain fecal material/ bowel resection
Stoma - red, initial slight bleeding - normal, no redness or irritation 2 to 5 inches surrounding the area, no
burning sensation.
Colostomy Ileostomy
 Can irrigate, can be bowel trained, pouch may not be  no irrigation , wet fecal material , appliance all the time
worn and emptied after every defecation , meticulous skin care, prevent skin breakdown,
 Ascending colon colostomy: liquid stool constant flow not regulated, bag emptied half full
Transverse Colon Colostomy: loose to
semi formed
 Descending Colon Colostomy: close to normal Stool
Monitor color changes in the stoma: Healthy stoma is red: a color change (dark black to blue
Normal color : pink or red is noticeable)
Pale pink : low hgb/hct Stool is liquid
Purple black: compromised circulation Post op drainage is dark green then yellow as the client
begins to eat
What to Remember in Colostomy Care
 Avoid gas forming foods and nuts, but can have any food at tolerated after 6 weeks
 Dry skin before applying appliance
 Karaya powder - barrier to prevent contamination with excreta
 Appliance can be up to 2 weeks; 24-48 hours if eroded or ulcerated

 With deodorant (Charcoal filter Disk, Bismuth)
ENEMA ADMINISTRATION
 Enema is a solution introduced into the rectum and large intestines.
 Its aim is to distend the intestine and irritate the intestinal mucosa; stimulates peristalsis and excretion of
feces
 Position: Left Lateral ( adult) dorsal recumbent ( child)
 After administering the solutions, press buttocks together to prevent feces from expelling
 For abdominal cramps: stop temporarily

Types of Enemas:
1. Carminative Enema- Aims to expel flatus. About 60mL to 180 mL of solution is administered
2. Cleansing Enema- It irritates the colon producing peristalsis by distending the colon with volume fluid
A. High enema
Target: colon
1L of solution is introduced
B. Low enema
Target: rectum and sigmoid process
½ L is administered
3. Retention enema- Uses oil based solution (which acts as stool softeners and facilitates passage of
feces). Administer oil into the rectum and sigmoid colon, then the oil is retained for 1 - 3 hours
4. Return flow / colonic Irrigation- Aims to expel flatus. Uses an inflow - outflow process that is
repeated 5 - 6 times. Solution container is lowered so that the fluid backs out through the rectal
tube into the container.
Intravenous Therapy
Purposes:
 used to replace fluids and electrolytes
 provides vascular access for immediate or rapid delivery of substances or medications especially
in emergency situation
Isotonic
 Isotonic fluids have an osmolality the same as that of blood; about 310 mEq/L of electrolytes.
Hypotonic
 Hypotonic fluids have an electrolyte content below 250 mEq/L.
 Lower osmolality than the body thus causing movement of solutes into the cells by osmosis. Used
to prevent cellular edema
Hypertonic
 Hypertonic fluids have an electrolyte content above 375 mEq/L. Higher osmolality than the body
 Movement is from cell to extracellular compartment Crystalloids
 Used for fluid volume replacement Contains mostly of electrolytes
Colloids
 Or plasma expander
 Used in cases such as severe hemorrhage and hypovolemia
Type of Solution Fluid Uses

Isotonic Solutions · 0.9% saline ( NS ) Supplies calories as
· 5% dextrose in water ( D5W) carbohydrates; prevents
· 5% dextrose in 0.255% saline (5% D ¼ NS) dehydration; maintains water
· Lactated Ringers solution ( LR) balance; promotes sodium
diuresis
Hypotonic · 0.45 Saline (½ NS) Replaces fluid and
· 0.25% Saline (¼ NS) electrolyte loss
· 0.33 % Saline (1/3 NS)
Hypertonic · 3% Saline ( 3% NS) Replaces fluid and
· 5% Saline ( 5% NS) electrolyte loss
· 10% Dextrose in water ( D10 W)
· 5% dextrose in 0.9% saline ( 5% D/NS)
· 5% Dextrose in 0.45% saline ( 5% D/1/2
Solution
Colloid · Dextran Maintains colloid osmotic
· Albumin pressure
Flow rate: amount of fluid - drop factor on tubing box ÷ running time stated in total number of minutes.
COMPLICATIONS OF IV THERAPY
1. Local/Phlebitis - involves only the insertion site and manifest as peri-catheter inflammation;
Warm erythematous skin over an indurated or tender vein an often precedes or is associated
with more severe infections.
2. Cellulitis - Warm erythematous and often tender skin surrounding the site of cannula insertion, pus is rarely
detectable.
3. Infiltration - Edema, pain, and coolness at the site ( may not have back flow)
4. Circulatory Overload - distended jugular vein, high Blood Pressure, dyspnea, moist cough and crackles
5. Hematoma - ecchymosis, immediate swelling and leakage of blood at the site of insertion and painful lumps
6. Air embolism - tachycardia, dyspnea, hypotension, cyanosis, decreased LOC
Wound Dressings
Types of dressing:
1. Dry to Dry
 Trap necrotic debris and exudate
2. Wet to Dry
 Uses saline and anti-microbial solution
 this softens debris as it dries and dilute exudate
3. Wet to damp
 Wound debrided if gauze is removed Variation at drying
 WOUND DEBRIDED IF GAUZE REMOVED (VARIATION at DRYING)
4. Wet to Wet
 Keeps wound moist (wound is bathed) Moisture dilutes viscous exudate


Notes:
 Use sterile gloves or clean gloves
 Use gauze pads (which may be lifted with sterile forceps) to cleanse the wound with prescribed antiseptic
solution. Cleanse the wound from the center outward, using a new gauze pad for each outward motion.
 Iodine solutions may cause skin irritation if they are left on the skin between dressing changes
 “Wet-to-dry dressing change” describes the technique of applying several layers (the number of layers
depends on the size of the wound area and the patient) of saline-soaked dressings next to the wound and
covering these with dry dressings.
GRIEF, LOSS, DEATH AND DYING

LOSS
 Actual or potential situation where in something valued is changed/lost/gone
 Actual
 Perceived
 Can be recognized by others
 Only the “self” can experience
 Cannot be verified by others
GRIEF
 Anticipatory
 Experienced before the actual loss
 Loss can be situational or developmental
 Response or reaction to loss
 Bereavement
▪ Subjective Response
▪ Mourning
Types of Grief Responses:

 Abbreviated Grief
o Genuinely felt grief but brief
 Anticipatory Grief
o Grieving in advance
 Disenfranchised Grief
o Unable to acknowledge the loss to other people
o Examples are unacceptable loss that cannot be spoken about like suicide, abortion
 Dysfunctional Grief
o Pathologic grieving
 Unresolved Grief
o Extended / lengthy and severe grieving
o May deny loss or grieve beyond expected time
 Inhibited Grief
o Suppressed grieving

Stages of Grieving
Kübler Engel Sander
Ross
Denial Shock and Disbelief (accepts Shock
“No! not me” situation but denies emotionally)
Anger “why me?” Awareness Awareness of Loss
Bargaining Restitution Conservation/Withdrawal
“if only I could live a lil longer.” ( do rituals of mourning) (social withdrawal/ needs to be alone)
Depression - silence Resolving Loss Healing: The turning point (acceptance)
Acceptance Idealization Renewal
“I’m ready” (new self - awareness
Legal Aspects Related to Death

 Advance Health Care Directives Variety of legal and lay documents that allow persons to specify aspects of
care they wish to receive should they become incapable of verbalizing their care preference
2 TYPES:
 Living Will - Provides specific instructions about what medical treatments the client choose to refuse in the
event that the client is incapable of making decisions
 Health Care Proxy

 Durable Power of Attorney for Health Care -Notarized/witnessed statement appointing SOMEONE ELSE
(relative or friend) to manage health care treatment and decisions.
Do - Not - Resuscitate Orders
 DNR/no Code
 Ordered by physician when the client/ health care proxy has verbalized the wish for no
resuscitation when the client will have respiratory or cardiac arrest
 DNR indicates that the goal of treatment is a comfortable dignified death and further life
sustaining interventions will not be done to patients any longer.
Nursing Responsibility in Dying Patients

 Assisting the Client to a peaceful death
 Maintaining humanity, consistent with the client’s values, beliefs and culture
 Providing spiritual support
 Facilitating expressions of feelings and emotions about death
 Arranging an appointment with a clergy or a spiritual adviser.
 Use of therapeutic communication for the family to be able to express feelings
Post Mortem Care

 Do post mortem care according to hospital policy
 All equipment, tubes, supplies must be removed
 A pillow is placed under the head and shoulders to prevent discoloration in the face
 A complete bath is not necessary ( the mortician will do the bathing
 Identification band should be attached before the body is taken to the morgue
 A shroud is used to wrap the body

Intervention
Rigor Mortis  Position the body naturally (in natural/neutral
(stiffening of the body; starts in the involuntary muscles manner)
like the heart etc.)  Place dentures (if there is)
Algor Mortis  Close eyes and mouth
(gradual decrease of temperature)
Livor Mortis
( discoloration of the body)

MEDICAL SURGICAL NURSING:

CARDIOVASCULARY SYSTEM
CORONARY ARTERY DISEASE (CAD)
• Ischemic Heart Disease/ Atherosclerotic Heart Disease
• CAD results from the focal narrowing of the large and medium-sized coronary arteries due to
deposition of atheromatous plaque in the vessel wall.
ANGINA PECTORIS MYOCARDIAL INFARCTION

It is a myocardial ischemia without cell death. Death of myocardial tissue in regions of the heart
Caused by vasospasm, decrease blood flow due to with abrupt interruption of coronary blood supply
atherosclerosis of coronary arteries and increasing
workload.
S/SX: S/SX:
✓ Substernal, anterior chest pain that radiates ✓ Chest pain is described as severe,
to the shoulders, arms, neck and jaw. persistent, crushing substernal discomfort
✓ Burning like/and squeezing pain, indigestion, ✓ Radiates to the neck, arm, jaw and back
tightness, SOB Increased heart rate, Occurs without cause, primarily early morning
diaphoresis, pallor, nausea. NOT relieved by rest or nitroglycerin
✓ (for STABLE ANGINA) ✓ Lasts 30 minutes or longer
✓ S- ubsternal pain A-nterior chest ✓ Dyspnea Diaphoresis, cold clammy skin N/V,
✓ V- ague (radiates) E-xertion related R- elieve restlessness, sense of doom Tachycardia or
by rest bradycardia , hypotension dysrhythmias
✓ S-hort Duration (commonly 5-15 mins) (most fatal complication)
Levine’s sign (chest hand clutching) universal Levine’s sign (chest hand clutching) universal
symptom of distress of both angina and MI symptom of distress of both angina and MI
Types: Laboratory findings:
✓ Stable Angina: chest pain last for 15 mins with ECG:
predictable severity, pattern and duration. ✓ ST segment elevation; results from the
✓ Unstable Angina: (Preinfarction Angina) area of injury (early sign)
✓ Chestpain last for 15 mins and more but less ✓ T wave inversion; originates from the area
than 30 mins of ischemias (Angina Pectoris)
✓ More frequent recurrence ✓ Pathologic Q wave; developed from the
✓ Occurs with minimal rest and area of infarction (late sign)
exertion Prinzemetal Angina: Myocardial enzymes
(Variant Angina) ✓ Elevated CK-MB: most reliable cardiac
✓ Caused by a coronary artery spasm specific enzyme
✓ Angina at rest after a long exertions exercises ✓ Elevated, LDH: increase only with cardiac
and even sleep damage 3-6 hrs after onset of MI
✓ Nocturnal Angina: occurs only at night ✓ Elevated Troponin levels: most
associated with REM Angina Decubitus: definitive CBC- may show
paroxysmal chest pain that occurs during sitting elevated WBC count
and standing ✓ Test after the acute stage: Exercise
✓ Intractable Angina: chronic and severe tolerance test, thallium scans, and cardiac
1
incapacitating chest pain with no response to catheterization.

intervention.
✓ Post Infarction Angina: occurs after MI when
residual ischemia may cause episodes of
angina
Treatment and Medical Management: Treatment and Medical Management:

✓ Nitroglycerin ✓ M-orphine MSO4 specific to MI
✓ Tablet (recommended) ✓ Administer via IV not IM (can increase
✓ Stored in dark container- photosensitive troponin levels due to sympathetic effect
✓ Take tablet maximum of 3x with 15 mins ✓ O-xygen 2lpm,
interval, pain last for 3 mins/subside, bring promote rest N- ot
the drug at all times!! relieved by NTG or
✓ Inform patient that stinging / burning sensation rest
and lightheadedness is expected , S.E shows ✓ nticoagulant (heparin/ aspirin) prevents
potency of drug clot formation T-rombolytics
✓ Patch/paste (maintenance) (streptokinase) dissolves clots
✓ Apply on non hairy areas ✓ S- tool Softeners, soft diet, prevents straining
proximal to chest Rotate site of
application ✓ Points to remember
✓ Remove old before applying new patch ✓ Advise patient taking nitroglycerine not to take
sildenafil (viagra) because both drugs are
vasodilators
❖ CONGESTIVE HEART FAILURE (CHF)

• Inability of the heart to pump sufficiently
• The heart is unable to maintain adequate circulation to meet the metabolic needs of the
body
• Classified according to the major ventricular dysfunction- Left or Right
Left Sided Heart Failure Right Sided Heart Failure

✓ Origin: Cardiac Problem Manifestation: ✓ Origin: Pulmonary Problem Manifestation:
Pulmonary (Primary) Systemic
✓ Signs and Symptoms are due to pulmonary ✓ Results from increase venous pressure - initially
edema, cellular hypoxia and activation of seen as bipedal edema
RAAS
2
Sign and Symptoms: Sign and Symptoms:

✓ Dyspnea on exertion PND ✓ Peripheral dependent, pitting edema Weight gain
✓ Orthopnea ✓ Distended neck vein Hepatomegaly Ascites
✓ Pulmonary crackles/rales ✓ Body weakness Anorexia, nausea Pulsus
✓ Cough with Pinkish, frothy sputum alternans
✓ Tachycardia
✓ Cool extremities Cyanosis Nursing Management
✓ Decreased peripheral pulses Fatigue ✓ Position on semi-fowler’s to high fowler’s for
✓ Oliguria adequate chest
✓ Signs of cerebral anoxia ✓ expansion
✓ Weigh patient daily to monitor fluid retention
Diagnostic test ✓ Administer medications- usually cardiac
✓ CXR- may reveal cardiomegaly glycosides are given- DIGOXIN or DIGITOXIN,
✓ ECG -may identify Cardiac hypertrophy Diuretics, vasodilators and hypolipidemics are
✓ Echocardiogram - hypokinetic heart prescribed
✓ ABG and Pulse oximetry- may show decreased O2 ✓ Provide a LOW sodium diet
saturation ✓ Limit fluid intake as necessary
✓ PCWP is increased in LEFT sided CHF and CVP ✓ Provide adequate rest periods to prevent fatigue
is increased in RIGHT sided CHF ✓ Prevent complications of immobility
❖ CARDIAC TAMPONADE
• A condition where the heart is unable to pump blood due to accumulation of fluid in the
pericardial sac
• This condition restricts ventricular filling resulting to decreased cardiac output.
• Acute tamponade may happen when there is a sudden accumulation of about 50ml in the
pericardial sac
✓ BECK’s Triad
o Jugular vein distention,
o hypotension and
o distant/muffled heart sound
o Pulsus paradoxus
o Increased CVP
o Decreased cardiac output
Nursing Management
• Assist in pericardiocentesis
• Administer IVF
• Monitor ECG, urine output and BP
• Monitor for recurrence of tamponade
❖ HYPERTENSION
• A systolic BP greater than 140 mmHg and a diastolic pressure greater than 90
mmHg over a sustained period based on two or more BP measurements.
Types of Hypertension:
✓ Primary or ESSENTIAL—Most common type
✓ Secondary—Due to other conditions like Pheochromocytoma, renovascular hypertension,
Cushing’s, Crohn’s, SIADH
3
• Occipital headache (most common complaint)
• Visual changes
• Chest pain
• Dizziness
• N/V
• Fatigue
• Palpitations
• Epistaxis
Medical Management
• Lifestyle modification
• Diuretics- 1st line of drugs for treatment of mild hypertension
• Loop- furosemide
• Osmotic – Mannitol
• Thiazide - Diuril Spirinolactone - aldactone
• ACE inhibitors- inhibits vasoconstriction, suppressed conversion of Angiotensin I to Angiotensin
II
• Beta Blockers- PNS, decreases heart rate may lead to bradycardia (count HR before administering the
drug)
• Calcium Channel Blockers- blocks entry of calcium into smooth muscle cells causing a decrease in
contractility and arteriolar constriction
❖ PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (PAOD)

• Refers to arterial insufficiency of the extremities usually secondary to peripheral
atherosclerosis.
• Usually found in males age 50 and above
• The legs are most often affected
• Intermittent Claudication- the hallmark of PAOD
• This is PAIN described as aching, cramping or fatiguing discomfort consistently
reproduced with the same degree of exercise or activity
• This pain is RELIEVED by REST
• This commonly affects the muscle group below the arterial occlusion
• Progressive pain on the extremity as the disease advances
• Sensation of cold and numbness of the extremities
• Skin is pale when elevated and ruddy/rubor when placed on a dependent position
• Muscle atrophy, leg ulceration and gangrene
Diagnostic Test
• Duplex ultrasonography
Medical Management
• Pentoxyfylline (Trental) reduces blood viscosity and improves supply of O2 blood to muscles
• Cilostazol (Pletal) inhibits platelet aggregation and increases vasodilatation
• Surgery- Bypass graft and anastomoses
Nursing Managements:
• Evaluate pulses, temperature, sensation, motor function and capillary refill time
• Note for bleeding, hematoma, decreased urine output
4
• Elevate the legs to diminish edema

• Encourage exercise of the extremity while on bed
• Teach patient to avoid leg-crossing
• Instruct to AVOID smoking
• Instruct to avoid leg crossing
❖ BUERGER’S DISEASE
• A.k.a. Thromboangitis obliterans
• A disease characterized by recurring inflammation of the medium and small arteries and veins
of the lower extremities
• Occurs in MEN ages 20-35
• RISK FACTOR: SMOKING!
• Leg pain
• Foot cramps in the arch (instep claudication) after exercise
• Relieved by rest
• Aggravated by smoking, emotional disturbance and cold chilling
• Digital rest pain not changed by activity or rest
Nursing Management
• Strongly advise to AVOID smoking
• Post-operative care (AMPUTATION)
• Elevate stump for the FIRST 24 HOURS to minimize edema and promote venous return
• Place patient on PRONE position after 24 hours - to prevent hip flexion fracture
• Assess skin for bleeding and hematoma
• Wrap the extremity with elastic bandage
❖ REYNAUD’S DISEASE (Blue - White - Red Disease)

• A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and
pallor of the fingertips or toes
• Cause: UNKNOWN
• Most commonly affects WOMEN, 16- 40 y/o
o Raynaud’s phenomenon:
• A localized episode of vasoconstriction of the small arteries of the hands and feet that
causes color and temperature change
• Pallor- due to vasoconstriction, then
• Blue- due to pooling of Deoxygenated blood
• White - from severe vasospasm
• Red- due to exaggerated reflow/hyperemia
• Tingling sensation
• Burning pain on the hands and feet
Drug therapy - Calcium channel blockers (DOC), Vasodilators, Anti Inflammatory, Analgesics
Nursing Management
• Instruct to avoid exposure to cold and remain indoors when the climate is cold
• Instruct to avoid all kinds of nicotine
5
• Instruct about safety. Careful handling of sharp objects
❖ ANEURYSM
• A sac formed by dilation of an artery secondary to weakness and stretching of an arterial
wall. The dilation may involve one or all layers of the arterial wall.
• usually occurs in men ages 50-70; caused by arteriosclerosis, infection, syphilis, hypertension
Classification
• Fusiform: both sides of arterial wall dilates
• Saccular: outpouching on one side only, affecting part of the arterial circumference
• Dissecting: separation of the arterial wall layers to form a cavity that fills with blood
• False: the vessel wall is disrupted, blood escapes into surrounding area but is held in
place by surrounding tissue an aneurysm, usually fusiform or dissecting, in the
descending, ascending, or transverse section of the thoracic aorta
• Often asymptomatic; deep, diffuse chest pain; hoarseness; dysphagia ; dyspnea
• Pallor, diaphoresis, distended neck veins
Diagnostic tests:
1. Aortography shows exact location of the aneurysm
2. X-rays: chest film reveals abnormal widening of aorta
Medical Management:
• control of underlying hypertension
• Surgery: resection of the aneurysm and replacement with a Teflon/Dacron graft; client will
need extracorporeal circulation
6

EMERENCY AND DISASTER NURSING
PROVISION OF SAFETY
SAFETY IN EMERGENCY
Fire:
R - Rescue (remove clients from the utility)
A - Alarm (activate Fire alarm. Then report fire) C - Confine (close doors to confine fire)
E - Extinguish (use extinguisher if available)
• Do not use elevator
• Turn of oxygen and appliances
• For patients with mechanical ventilation, do ambubagging
• Observe proper transfer techniques for non-ambulatory patients
ELECTRICAL
• Avoid overloading any circuit
• Read warning labels on all equipment
RADIATION
• Label potentially radioactive material
Principles:
o Distance: keep distance of at least 6 feet
o Time: limit time when doing nursing procedures and communicating with patient ( 5
minutes per contact; total of 30 minute per shift)
o Shield : use LEAD apron
• Never touch radiation implants with bare hands (use forceps and put in a lead container)
RESTRAINTS
• A protective device used to limit physical activity of a client or a body part Used to immobilize an
extremity or extremities
Types:
✓ Physical - involves manual or physical or mechanical device, material or equipment
✓ Chemical - use of medications (e. g. Nueroleptics, sedatives, anxiolytics)
Legal Implication:
2 standards for applying restraints:
Behavior management standard: if client is a danger to self or others Medical Surgical
Care Standard: if it is related to any procedure
CLIENTS IN BIOLOGIC CRISIS AND FIRST AID

Emergency Triage
PURPOSE: to classify severity of illness or injury and determine priority needs for efficient use of
health care providers and resources.
CATEGORY:
1. Emergent: Conditions that are life threatening and require immediate attention.
Examples: Cardiopulmonary arrest, pulmonary edema, chest pain of cardiac origin, and multisystem
trauma. These patients frequently arrive by ambulance.
*Treatment must be immediate.
1
2. Urgent: Conditions that are significant medical problems and require treatment as soon as
possible. Vital signs are stable. Examples: fever, simple lacerations, uncomplicated extremity fractures,
significant pain, and chronic illnesses such as cancer or sickle cell disease.
*Treatment may be delayed for several hours if necessary.
3. Nonurgent: Minor illnesses or injuries such as rashes, sore throat, or chronic low back pain.
*Treatment can be delayed indefinitely.
CPR GUIDELINES:
Age Cardiac Method Depth (inches) Ventilation: Cycles /

Compression Location Compression minute
Ratio
Neonate Simplified approach- 2 fingers 1/2-1
center of the chest
Infant <1 yr Simplified approach- 2 fingers At least 1.5 2:30 5
center of the chest in
Child 1-8 yr Simplified approach- 1 hand About 1-2 in 2:30 5
center of the chest (heel)
Adult Simplified approach- 2 hands At least 2 in 2:30 5
center of the chest
DEFIBRILLATION:
• To terminate ventricular fibrillation by electric countershock.
METHOD
1. Place two gel pads on the patient’s bare chest or apply gel to entire surface of paddles. (To
prevent burns and improper conduction, remove gel from your hands and the sides of the
paddles, and remove any gel that may have fallen on the patient’s chest.)
2. Temporarily discontinue oxygen (if applicable).
3. Apply one electrode below right clavicle just to the side of the upper sternum. Apply second
electrode just below and lateral to left nipple.
4. Set defibrillator at 200 joules (J)
5. Grasp paddles by insulated handles only.
6. Give “Stand Clear” command, and ascertain that no one is touching patient or bed.
7. Push discharge buttons in both paddles simultaneously, using pressure to ensure firm
contact with the patient’s skin.
8. Remove paddles and assess patient and ECG pattern.
AHA recommends that, if three rapidly administered shocks fail to defibrillate, CPR should be continued, IV
access accomplished, epinephrine given, and then shocks repeated
Automatic External Defibrillator - used in pre-hospital setting

Cardioversion:
✓ Treatment for arrhythmias
2
✓ The procedure restores the normal heart rate and rhythm, allowing the heart to pump more
effectively.
✓ Synchronized counter shock
✓ The defibrillator is synchronized to the client’s R wave
✓ Oxygen should be stopped during the procedure
Pacemakers:
✓ Temporary or permanent device that provides electrical stimulation and maintains heart rate
when the intrinsic pacemaker fails
TRAUMA IN EMERGENCY SETTING

PRIMARY SURVEY
1. Airway maintenance with cervical spine immobilization:
• Use jaw thrust, clear secretions, and insert artificial airway as needed.
2. Breathing:
• Intubate if needed. Administer high-flow oxygen.
3. Circulation with hemorrhage control:
• Use pressure as needed, Establish two large-bore IVs, and draw blood for
cross-match.
4. Neurologic status:
• Assess and document LOC, assess pupil reaction to light, and assess for
head and neck injuries.
5. Injuries:
• Expose patient to completely assess for injuries.
***As life-threatening problems are identified, each must be dealt with immediately.
SECONDARY SURVEY
• consists of a history and a complete head-to-toe assessment.
PURPOSE: to identify problems that may not have been identified as life threatening.
If, at any time during the secondary survey, the patient’s condition worsens, return to the steps in the
primary survey.
1. Take history and complete head-to-toe assessment.
2. Splint fractures.
3. Insert urinary catheter unless there is gross blood at meatus.
4. Assess urinary output and check urine for blood. Insert NG tube (OG if facial fractures are
involved).
5. Obtain Chest X - ray
6. Administer tetanus prophylaxis and antibiotics (question regarding allergies first) if
indicated.
7. Continue to monitor components under primary survey as well as adequacy of urine output,
and document findings.
3
Shock
Type Description Causes Signs and Symptoms Treatment
Anaphylactic Dilation of blood Allergic reaction Respiratory distress O2
shock vessels, fluid Hypotension Edema Epinephrine
shifts, edema, Rash Corticosteroids
and spasms of Pale, cool skin Antihistamine IV fluids
respiratory tract. Convulsions possible Aminophylline
Cardiogenic Failure to Acute left or right Increased pulse rate IV fluids

shock maintain blood ventricular failure Weak pulses O2
supply to Acute mitral Cardiac dysrhythmias Dopamine
circulatory regurgitation Prolonged capillary fill Norepinephrine
system and Acute ventricular time Nitroprusside if BP
tissues septal Cool, clammy skin adequate
because of defect Cyanosis Dobutamine
inadequate Acute pericardial Altered mental ability
cardiac output. tamponade
Acute pulmonary
embolism
Acute myocardial
Infarction
Hypovolemic Decrease in Hemorrhage Hypotension Control bleeding
shock intravascular Vomiting Decreased pulse IV fluids
volume Diarrhea pressure O2
relative to Any excess loss Tachycardia Elevate legs
vascular of body Rapid respiratory rate Volume expanders
capacity. Results fluids Pale, cool skin
from Anxiety
blood volume
deficit of
at least 25% and
larger
interstitial fluid
deficit.
Neurogenic Increase in Anesthesia Spinal Hypotension Supine position O2
shock vascular capacity cord injury Bradycardia Bounding IV fluids Possibly
and subsequent pulse Vasopressors
decrease in blood Pale, warm, and dry
volume: space skin
ratio resulting
from profound
vasodilation.
4
Septic shock Circulatory failure Endotoxins Elevated temperature O2

and released Flushed, warm skin IV fluids
impaired cell most commonly Vasodilation (early) Culture, e.g., blood,
metabolism by Vasoconstriction (late) urine,
associated gram-negative Decreased WBC at sputum, wounds.
with septicemia. organism first Antibiotics
Divided Normal urinary output Possibly
into “early warm” (early) Vasopressors
(increased Decreased urinary
cardiac output (late)
output) and “later
cold”
(decreased
cardiac
output).
BURNS
Classification Description
1st Degree Burn > Involves epidermis only
> Looks like sunburn
2nd Degree Burn a. Superficial partial thickness

>Extends beyond epidermis superficially into dermis
>Red and weepy appearance
>Very painful
>Formation of blisters
b. Deep partial thickness
> May appear mottled
> Dry and pale appearance
3rd Degree ( Full Thickness ) >Extends through epidermis, dermis, and into subcutaneous
tissues
• Dry, leathery appearance
• May be charred, mottled, or white
Estimation of Burned Body Surface
• Rule’s of Nine ( adult )
• Body surface Area Proportions (Children)
American Burn Association’s Classification of Burns: BSA % Estimation
Minor Second-degree burns over _15% BSA (body surface area) for adult or < 10% BSA for
child
• Third-degree burns of 2%
Moderate Second-degree burns over 15 to 25% BSA for adult or 10 to 20% BSA for child
• Third-degree burns of 2% to 5% BSA
• Burns not involving eyes, ears, face, hands, feet, or perineum
5
Major Second-degree burns >25% BSA for adult or > 20% BSA for child
• Third-degree burns ≥ 10% BSA
• All burns of hands, face, eyes, ears, feet, or perineum
• All inhalation injuries
• Electric burns
• All burns with associated complications of fractures or other trauma
• All high-risk patients (with such conditions as diabetes, COPD, or heart disease)
First Aid Management
• Fluid resuscitation with Ringer’s lactate or Hartmann’s solution for the first 24 hours as follows:
4 mL fluid x kilograms of body weight x percent of burned BSA
Administer 1/2 of fluid in first 8 hours.
Administer 1/4 of fluid in second 8 hours. Administer 1/4 of fluid in third 8 hours.
POISONING
1. Focus initially on the ABCs of life support.
2. Attempt to identify poison.
3. Contact poison control center for directions
4. Vomiting is not to be induced - whether corrosive or non-corrosive agents - because of risk of
aspiration.
5. Gastric lavage with NG tube can be used to remove poison but must not be attempted if corrosive
has been ingested. Corrosives include strong acids and alkalines such as drain cleaners,
detergents, and many household cleaners as well as strong antiseptics such as bichloride of
mercury, phenol, Lysol, cresol compounds, tincture of iodine, and arsenic compounds.
6. Corrosives should be diluted with water and the poison control center contacted immediately.
Activated charcoal may be given via NG tube. Destruction and/or swelling of esophageal and
airway tissue is likely with corrosive ingestion. Monitor respiratory status closely.
7. If several hours have passed since poison ingestion, large quantities of IV fluids are given to
promote diuresis. Peritoneal dialysis or hemodialysis may be required.
6
7

ENDOCRINE SYSTEM
❖ DIABETES INSIPIDUS
• a syndrome characterized by the production of abnormally large volumes of dilute urine and
water imbalance characterized by polydipsia secondary to deficiency of Anti diuretic
Hormone ( Vasopressin).
• Large urine output (Polyuria) up to 20 Liters/day
• Decrease urine concentration / diluted urine
• Polydipsia - increase craving of cold water
Diagnostic test
❖ Fluid Deprivation Test
✓ withhold the fluid 8-12 hours
✓ Water balance should be monitored closely with hourly measurements of body
weight, plasma osmolarity and/or sodium concentration, and urine volume
and osmolarity.
Medical Management
✓ Vasopressin replacement (Desmopressin acetate or DDAVP,Stimate). It can be given IV,
SC, nasal inhalation or oral tablet.
❖ SYNDROME OF INAPPROPRIATE ANTI DIURETIC HORMONE (SIADH)

• excessive production of ADH that leads to excessive retention of water by the renal tubules
• Highly concentrated urine ( Increased urine specific gravity)
• Reduced urine output
• Dilution of most body fluids 2º to fluid retention (Dilutional hyponatremia)
• Edema
• Weight gain
Nursing Management:
• Restriction fluid intake is used commonly.
• Lasix (Furosemide) diuretic therapy to excrete excess water and to treat hyponatremia.
DISORDERS OF THYROID GLAND

❖ HYPOTHYROIDISM
• Deficiency of circulating thyroid hormones that leads to decrease
basal metabolic rate and heat production Myxedema Coma
Clinical Manifestations of Hypothyroidism
Tiredness, weakness Dry coarse skin; cool peripheral extremities

Dry skin Puffy face, hands, and feet (myxedema)
Feeling cold Diffuse alopecia
Hair loss Bradycardia
Difficulty concentrating and poor memory Peripheral edema
Constipation Delayed tendon reflex relaxation
Weight gain with poor appetite Serous cavity effusions
Dyspnea
1 Hoarse voice
Menorrhagia (later oligomenorrhea or amenorrhea)
Paresthesia
• Rare but serious d/o which result from persistently low thyroid hormone precipitated by
acute illness, rapid withdrawal of thyroid meds, use of sedatives & narcotics.
• Hypotension
• Bradycardia
• Hypothermia
• Hyponatremia
Nursing Management:
• Prevent immobility. Provide activities within tolerance level.
• Provide warm environment and extra clothing and blanket to combat the effect of cold
intolerance.
• Increase fiber in the diet to
prevent constipation.
Medical Management:
• Synthetic Levothyroxine (Synthroid), liothyronine (cytomel)
• May increase blood glucose level; insulin and oral hypoglycemic agents must be
adjusted for clients with DM during stress and illness.
HYPERTHYROIDISM
• Excessive secretion of thyroid gland or hyperactivity of the thyroid gland.
• Metabolism of all the tissues of the body becomes greatly increased.
Clinical Manifestations Of
Hyperthyroidism
✓ Hyperactivity, irritability, ✓ Tachycardia; atrial
dysphoria Heat fibrillation in the elderly
intolerance and sweating Tremor
Palpitations ✓ Goiter Warm,
✓ Fatigue and weakness moist skin
✓ Weight loss with ✓ Muscle weakness,
increased appetite proximal myopathy Lid
✓ Diarrhea Polyuria retraction or lag
✓ Oligomenorrhea, loss of ✓ Gynecomastia
libido
Nursing Management:
✓ Provide High calorie, high protein food to compensate the hypermetabolic requirement.
✓ Stimulants such as coffee, tea and colas are generally discouraged
Medical Management:
✓ Commonly used: Propylthiouracil (Propacil, PTU), Methimazole (Tapazole)
✓ Side effects: Fever, rash, urticaria
✓ Agranulocytosis- report s/s of infection
o Saturated Solution of Potassium Iodide (SSKI)
o Lugol’s Solution
❖ PHEOCHROMOTCYTOMA
✓ a tumor usually benign that arise from chromaffin cells of adrenal medulla which produces
2
catecholamines that stimulate SNS (dangerous effects are peripheral vasoconstriction and
increased CR and contractility with resultant paroxysmal HPN)
✓ Hypertension
✓ Headache
✓ Hyperhidrosis (Excessive sweating)
✓ Hypermetabolism
✓ Hyperglycemia
Vanillylmandelic Acid Test (VMA)
• most direct and conclusive test for overactivity of adrenal medulla
• Instruct the patient to avoid coffee, tea or substance contains caffeine
Nursing Management:
✓ Monitor ECG changes during client’s admission.
✓ Replacement therapy compliance. Steroids usually given after meals to prevent stomach upset.
✓ During attack of hypertension patient is placed on bed rest with head of bed elevated to
promote orthostatic decrease in BP
Treatment of choice: “Adrenalectomy”
❖ ADDISON’S DISEASE
▪ adrenal cortex function is inadequate to meet body’s demand for cortical hormone
M - Muscle weakness and fatigue There is a decrease in:
A - Anorexia S-alt (mineralocorticoids)
D - dark pigmentation S-ugar (glucocorticoids)
H - hypotension S-ex (androgen)
E - emaciation
G - GI symptoms
Nursing Management:
• Administer IV fluids, salt replacement, glucose and corticosteroid during Addisonian crisis.
• Instruct patient to avoid unnecessary activities.
• Provide calm, quiet and non-stressful environment.
Medical Management:
• IV fluids, hydrocortisone corticosteroid
• Recumbent position with legs elevated
❖ CUSHING’S DISEASE
• due to excessive adrenocortical activity
• due to excessive administration of corticosteroid Clinical Manifestations
A - arrest of growth
M - musculoskeletal change due to overproduction of ACTH
O - obesity
B - buffalo hump T - thin fragile skin and easily traumatized
T - truncal obesity S - striae and ecchymoses
T - thin extremities W - weakness and lassitude
A - amenorrhea
B - breast atrophy
C - clitoral enlargement
3
D - deepening of voice
E - excessive body hairs (hirsutism)
Assessment and Diagnostic Findings
• Dexamethasone Suppression Test
• Dexamethasone given at 11pm
• Plasma cortisol level taken at 8 am. > (< 5mg/dl) - Good function
Nursing Management
• Promote safety: prevent falls, fractures and other injuries
• Increase protein, calcium and Vitamin D in diet.
• Instruct patient to avoid crowded areas and
exposure to others with infection
Medical Management:
• Transphenoidal hypophysectomy ( TOC for pituitary tumor as cause)
• Adrenalectomy ( TOC for Adrenal hypertrophy)
❖ DIABETES MELLITUS
• A chronic disorder of impaired glucose intolerance and carbohydrate, protein &
lipid metabolism; caused by a deficiency of insulin
Clinical manifestations
• Hyperglycemia
• Weight loss
• Blurred vision
• Slow wound healing
• Vaginal infections
• Weakness & paresthesias
CLASSIC P’s
• Polyuria
• Polydipsia
• Polyphagia
Test blood—Inject insulin— Eat food
4
TYPE 1- Diabetes Mellitus TYPE 2- Diabetes Mellitus

This type of DM is characterized by the destruction of A type of DM characterized by insulin resistance
the pancreatic beta cells and impaired insulin production
Destruction of BETA cells; decreased insulin Decreased sensitivity of insulin receptor to

production; uncontrolled glucose production by the insulin ; less uptake of glucose ;
liver; hyperglycemia; signs and symptoms HYPERGLYCEMIA
Decreased insulin production; diminished
Because the patient with TYPE 1 DM cannot produce insulin action
insulin, exogenous insulin must be administered for
life. TYPE 2 DM may have decreased insulin
ONLY Regular insulin can be used production; ORAL agents that stimulate
INTRAVENOUSLY! insulin production are usually employed.
INSULIN GLUCAGON
*Insulin increases glucose transport into cells & *Increase blood glucose by stimulating
promotes glycogenolysis in the liver
conversion of glucose to glycogen, decreasing given SC, IM or IV routes
serum
glucose levels *Used to treat when
semiconscious/unconscious
COMPLICATIONS OF INSULIN THERAPY

o Insulin dystrophy
o insulin resistance
o morning hyperglycemia
DAWN PHENOMENON SOMOGYI EFFECT INSULIN WANING
✓ Relatively normal blood ✓ Normal or elevated blood ✓ Progressive rise in blood
glucose until about 3 am, glucose at bedtime, glucose from bedtime to
when the glucose level decrease blood glucose at 2- morning
begins to RISE 3 am due to hypoglycemic ✓ Seen when the NPH
✓ Results from the nightly levels and a subsequent evening dose is
surges of GROWTH increase in blood glucose administered before
HORMONE secretion (rebound hyperglycemia) dinner
Management: Bedtime ✓ Due to the production of ✓ Management: Move the
injection of NPH counter regulatory insulin injection to bedtime
hormones- glucagon.
cortisol and epinephrine
✓ Management- decrease
evening dose of
✓ NPH or increase bedtime
snack
❖ ORAL HYPOGLYCEMIC AGENTS

• These may be effective when used in TYPE 2 DM that cannot be treated with
diet and exercise. These are NEVER used in pregnancy!
5
Sulfonylureas Non-sulfonylureas
• Biguanides - Metformin (Glucophage)
• Alpha-glucosidase inhibitors - Precose (Acarbose)
• Thiazolidinediones - Rosiglitazone (Avandia)
• Meglitinides
• Chlorpropamide (Diabinase)
• Tolbutamide (Orinase)
• Glimepinide (Solosa)
• Acetohexamide (Dymelor)
• Prandial Glucose Regulator
• Repaglinide (Novonorm)
Diagnostic Criteria:
1. FBS equal to or greater than 126 mg/dL (7.0mmol/L) (Normal 8 hour FBS- 80-109 mg/dL)
2. OGTT value 1 and 2 hours post-prandial equal to or greater than 200 mg/dL Normal OGTT 1
and 2 hours post-prandial is 140 mg/dL
3. RBS of equal to or greater than 200 mg/dL PLUS the 3 P’s
The main goal is to NORMALIZE insulin activity and blood glucose level by: Nursing Management
1. Nutritional modification
2. Regular Exercise
3. Regular Glucose Monitoring
4. Drug therapy
5. Client Education
Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS)

➢ Coma
➢ Similar to DKA but without Kussmaul Respirations and acetone breath.
DKA - Diabetic Ketoacidosis HHNS/ HHNK

Nursing Management Nursing Management Approach
✓ Assist in the correction of dehydration is similar to the DKA
✓ Up to 6 liters of fluid may be ordered for ✓ Correction of Dehydration by IVF
infusion, initially NSS then D5W ✓ Correction of electrolyte imbalance by
✓ Assist in restoring Electrolytes replacement therapy
✓ Kidney function is FIRST determined ✓ Administration of insulin injection and drips
before giving potassium supplements! ✓ Continuous monitoring of urine output
✓ REGULAR insulin injection is ordered IV
bolus 5-10 units
✓ BICARBONATE is not used
Client Education During Illness - Sick Day Rules

*Take insulin or oral hypoglycemic agents as prescribed.
*Test blood glucose & test the urine for ketones every 3-4 hours
*If meal plan cannot be followed, substitute with soft food 6-8 x per day
*If vomiting, diarrhea or fever occurs, consume liquids every ½ to hour to prevent dehydration &
to provide calories
6

GASTRO INTESTINAL SYSTEM
 Hiatal Hernia
 Herniation of part of the stomach into the thoracic cavity through the esophageal hiatus in the
diaphragm.
 Heartburn
 Regurgitation and dysphagia
 sense of fullness after eating
 chest pain or maybe asymptomatic
 obstruction
 hemorrhage
 strangulation
Diagnostic Test
 X-ray studies
 Barium Swallow Nursing Management
 Small frequent feedings
 Advise the patient not to recline 1 hour after meals to prevent reflux
 Elevate HOB 4-8 inches to prevent hernia from sliding upward
 Avoid straining, coughing , bending Medical Management
 Antacid- neutralizes acid - Maalox
 Proton pump inhibitors - Omeprazole
 H2 Receptor Antagonist - Ranitidine (Zantac)
 Gastroesophageal Reflux Disease (GERD)

 Backflow of gastric acid and other gastric contents into the esophagus due to incompetent
barriers at the gastroesophageal junction (lower esophageal sphincter), or motility disorder.
 Heartburn or pyrosis ( burning sensation in the esophagus)
 regurgitation of sour material into the mouth
 dysphagia and odynophagia
Diagnostic Test
 Barium swallow
 Esophagoscopy to assess mucosal damage
Nursing Management
 Instruct patient to sleep with the head of the bed elevated by about 4-6 inches
 Maintain ideal body weight or weight reduction
 Instruct patient to avoid caffeine, tobacco, alcohol and foods that contain mints and carbonated
drinks.
 Low fat diet, Instruct patient to avoid eating and drinking too much 2 hours before bedtime to
prevent nocturnal reflux
 Surgery of Choice: Fundoplication- “Gastric Wrap” gastric fundus is wrapped around the
esophagus to create anti reflux barrier

 GASTRITIS
 Acute Gastritis - short term inflammatory process that may cause mucosal reddening, edema,
hemorrhage and erosion
 Chronic Gastritis - common among elderly and people with pernicious anemia. All mucosal
layers are inflamed
Type A -Autoimmune in nature (Atrophic gastritis, pernicious anemia)
Type B - Associated with Helicobacter pylori infection
 Anorexia; Nausea
 Hiccupping ; Heart burn
 Hematemesis ; Indigestion
Nursing Management
 Instruct client to avoid alcohol, irritating and spicy foods
 Bland diet is indicated
 Small but frequent meals
Medical Management
 Gastric resection (gastroduodenostomy), partial or total gastrectomy, vagotomy and
pyloroplasty (if all conservative treatment failed)
 PEPTIC ULCER DISEASE

 Break in the continuity of the esophageal, gastric and duodenal mucosa or in any
part of GI that comes in contact with hydrochloric acid and pepsin.
 HCL+ Pepsinogen+ intrinsic factor+ mucus =gastric acid
Types
 Esophageal
 Gastric
 Duodenal
GASTRIC DUODENAL
 Stomach  Duodenum
 Left side  Right
 Burning, gnawing pain  Burning, gnawing pain
 Food causes pain during eating- hitting the  Food after digestion including chime
scar/ injury/ ulcer goes to the duodenum causing pain
 Pain not relieve by pain  No pain during eating
 Hematemesis- vomits blood (nearer to  Melena - blood on the stool (nearer
stomach) to duodenum)
Diagnostic Test
 Barium swallow - show ulcerations
 Upper GI endoscopy shows ulceration of the mucosa
 Fecal occult blood test
 Test for H-pylori confirmation
 H- pylori antigen
 Urea breath test

Nursing Management
 Assess GI status to monitor signs of bleeding
 Relieve of pain by adherence to medications and avoid foods that could cause
mucosal irritation (spicy foods, caffeine, alcohol etc)
Surgical Management
 Billroth1 ( Gastroduodenostomy)
 Billroth2 (Gastojejunostomy)
 Vagotomy - to control HCl secretion
 APPENDICITIS
 Periumbilical pain progress to right lower quadrant/ McBurney’s point ( halfway between the
umbilicus and anterior spine of the ileum)
 (+) Rebound tenderness (Blumberg sign)
 (+) Rovsing’s sign ( LLQ is palpated pain is felt in the RLQ)
 Hematology shows increase WBC count
 Psoas sign (lateral position with right hip flexion)
 Constipation
 Sudden cessation of pain ( indicates rupture)
Nursing Management
 Monitor GI status and pain. Sudden cessation of pain indicates rupture of appendix.
 If surgery done by spinal anesthesia put the client flat in bed 6-8 hours post op.
 Maintain on NPO status until
bowel sounds return.
Medical Management
 Appendectomy to decrease the risk of complications (peritonitis, abscess formation and
portal pyephlebitis
 No enema and laxative, may lead to perforation
 Analgesic; meperidine (Demerol) or morphine. Analgesic is only administered once
the diagnosis is confirmed and the client is ready for surgery.
INFLAMMATORY BOWEL DISEASE

A. Regional Enteritis (Crohn’s Disease)
B. Ulcerative colitis
 REGIONAL ENTERITIS (CROHN’S DISEASE)
 A non-specific chronic inflammatory disease of small intestine usually affecting the terminal
ileum. It may also affect large intestine, usually the ascending colon. It’s slowly progressive
with exacerbation and remission.
 Right Lower Quadrant pain and spasms after eating
 Chronic Diarrhea
 Steatorrhea ; Flatulence
Diagnostic Tests
 Proctosigmoidoscopy - reveals inflammation of mucosal layer
 Barium study of Upper GI - most conclusive diagnostic exam. Reveals “string sign” segment

of stricture separated by normal bowel. It also show cluster of ulcers with “Cobble stone”
appearance
Nursing Management
 If client can tolerate oral feedings; small frequent meals diet high in protein,
high calories. Low in fat, fiber and residue with bland foods. Intake of milk
and gas forming foods is restricted.
 Provide skin and perianal care to prevent skin breakdown.
 Pharmacologic Management:
 Analgesic: Morphine or Demerol
 ULCERATIVE COLITIS
 Is a specific, recurrent ulcerative and inflammation of the
mucosal and submucosal layer of the colon
 Left lower quadrant pain
 Bloody, purulent, mucoid watery stools (15-20 times per day)
 Hyperactive bowel sounds
 Intermittent tenesmus
 Rectal bleeding
 Weight loss
 Hypocalcemia and anemia frequently develop
Diagnostic Test
 Hematology: ↓Hgb, ↓ Hct 2º to bleeding
 Barium enema - shows ulceration, mucosal irregularities, focal strictures or
fistulas, shortening of the colon and dilation of bowel loops.
 Colonoscopy and sigmoidoscopy - reveals hyperemia,
ulceration and inflamed mucosa with exudates
Nursing Management
 Administer IV fluids and TPN as ordered to rest the bowel and promote nutrition.
 If client can tolerate oral feedings; small frequent meals diet high in protein, high
calories. Low in fat, fiber and residue with bland foods. Intake of milk and gas
forming foods is restricted.
 Semi - fowlers position to promote comfort
 PANCREATITIS
 is an acute / chronic inflammation of the pancreas
Collaborative Management
 Avoid excessive food intake to prevent autodigestion.
 During Acute stage : NPO, IVF / TPN, NGT - dec. autodigestion
 Pain management - Morphine ( current recommendation - Reddy & Long,
2004; Swaroop et al , 2004 ; Brunner and Suddarth 2008 ); Demerol may
cause CNS irritation and possibly seizures
 H2 blockers / Proton pump inhibitors
 CHOLELITHIASIS/ CHOLECYSTITIS

 is stone formation andan inflammation in the GB Clinical Manifestations

 Decreased fat emulsification
o Fat intolerance anorexia, N/V, flatulence steatorrhea
 Inflammation
o Pain (RUQ), fever, leukocytosis
 Decreased bile flow in colon
o Acholic stool, poor absorption of fat soluble vitamin
 Increased serum bilirubin
o jaundice, pruritus, tea-colored urine
Collaborative Management
 Meperidine HCL (demerol)
 Diet: low fat diet
 Bile salts: chenodeoxycholic acid, ursodioxycholic acid given after meals
 Surgery:
cholecystectomy,
choledochotomy
Postop Care
o Low or semi-fowler’s position
o Diet: low fat for 2-3 months
o T tube if with CBD exploration
 -Purpose is to drain bile Drainage:
o Brownish red for 1st 24 hrs
o 300-500 ml of bile drainage for 1st 24 hrs
 LIVER CIRRHOSIS
 Irreversible chronic inflammatory disease characterized by massive degeneration and destruction of
hepatocytes.
Complications
1.Ascites
Relieve breathing difficulty.
Paracentesis and Diuretics to dec. ascites and edema
2. Bleeding Esophageal Varices
 Assess for signs of bleeding
 Sengstaken Blakemore Tube & Vasopressin to control bleeding
3. Hepatic Encephalopathy
 Observe for signs of encephalopathy (lethargy, confusion, personality changes, motor
changes, depression, irritability).
 Lactulose - Dec . Ammonia
 Neomycin SO4 - Dec Int. production of Ammonia


NERVOUS SYSTEM
❖ INTRACRANIAL PRESSURE
• Intracranial pressure more than 15 mmHg
Causes:
• Head injury
• Stroke
• Inflammatory lesions
• Brain tumor
• Surgical complications
MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the
volume of the other. Any increase or alteration in these structures will cause increased ICP
Early manifestations: Late manifestations
Changes in the LOC- usually the earliest Changes in VS
Other early indicator: slow speech Cushing reflex- systolic hypertension, bradycardia
and wide
Pupillary changes- fixed, slowed response pulse pressure
Headache Bradypnea
Vomiting Hyperthermia
SHOCK ICP
Decreased BP Increased BP-systolic
Inc HR Dec HR
PP narrow PP wide
Inc RR Dec RR
Nursing Management
• Elevate the head of the bed 15-30 degrees- to promote venous drainage
• Assists in administering 100% oxygen or controlled hyperventilation- to reduce the
CO2 blood level; constricts blood vessels; reduces edema
• Administer prescribed medications- usually Mannitol, corticosteroid and anticonvulsants,
stool softeners
• Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous
suctioning, bending, lifting heavy objects
TRAUMATIC BRAIN INJURY

CONCUSSION
• Involves jarring of head without tissue injury
• Temporary loss of neurologic function lasting for a few minutes to hours
CONTUSION
• Involves structural damage
• The patient becomes unconscious for hours
1
Diffuse Axonal injury

• Involves widespread damage to the neurons
• Patient has decerebrate and decorticate posture
Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually
due to laceration of the middle meningeal artery
Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by
trauma. This is usually due to tear of dural sinuses or dural venous vessels
Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from
trauma, hypertensive rupture of aneurysm, coagulopathies, vascular abnormalities
• Altered LOC
• CSF otorrhea
• CSF rhinorrhea
• Racoon eyes and battle sign
• HALO SIGN- blood stain surrounded by a yellowish stain
NURSING MANAGEMENT
• Monitor for declining LOC- use of Glasgow
• Elevate bed, suction prn, monitor ABG
• Use padded side rails
• Minimize environmental stimuli
• Turn patient every 2 hours
❖ SPINAL CORD INJURY

• The most frequent vertebrae - C5-C7, T12 and L1
• Paraplegia
• quadriplegia
• spinal shock
Diagnostic Test
• Spinal x-ray
• CT scan
• MRI
Nursing Management
• Promote adequate breathing and airway clearance
• Improve mobility and proper body alignment
• Improve bowel and bladder function
• Assists with surgical reduction and stabilization of cervical vertebral column
❖ AUTONOMIC DYSREFLEXIA/ HYPER REFLEXIA

• An exaggerated response by the autonomic system resulting from various stimuli most commonly
distended bladder, impacted feces, pain, skin irritation
• Hypertension
• Bradycardia
• Severe pounding headache
2
• Diaphoresis - above the lesion

• Pilmotor spasm “goose flesh” - below the lesion
• Nausea and nasal congestion
• Blurring of vision
Nursing Management
• Elevate the head of the bed immediately. To lower BP by gravity
• Check for bladder distention and empty bladder with urinary catheter
• Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer
Medical Management
• Administer antihypertensive medications- hydralazine
• Administer Hexamethonium Chloride (a ganglionic blocking agent)
❖ SPINAL SHOCK
• The sudden depression of reflex activity in the spinal cord below the level of injury
• The muscles below the lesion are flaccid, the skin without sensation and
the reflexes are absent including bowel and bladder functions
• Absence of sweating above the level of the lesion
• Bowel and bladder retention
• Hypotension, bradycardia
Nursing Management
• Assist in chest physiotherapy
• Manage potential complication- DVT, skin breakdown, injury, hypotension
❖ CEREBROVASCULAR ACCIDENT / “Apoplexy” “stroke”

• Caused by disruption of blood supply to the brain, causing neurologic deficit
• The middle cerebral artery is the most common affected in CVA
1. Ischemic stroke- caused by thrombus and embolus
2. Hemorrhagic stroke- caused commonly by hypertensive bleeding
Ischemic Stroke Hemorrhagic Stroke

Clinical Manifestations: Clinical Manifestations:
Numbness or weakness Sudden and severe headache
Confusion or change of LOC Same neurologic deficits as ischemic stroke
Motor and speech difficulties Loss of consciousness
Visual disturbance Meningeal irritation
Severe headache Visual disturbances
Diagnostic Test Diagnostic Test
1. CT scan 1. CT scan
2. MRI 2. MRI
3. Angiography 3. Lumbar puncture (only if w/o increased ICP)
Nursing Management Nursing Management
1. Improve Mobility and prevent joint deformities 1. Optimize cerebral tissue perfusion
2. Enhance self-care 2. Relieve Sensory deprivation and anxiety
3. Manage sensory-perceptual difficulties 3. Monitor and manage potential complications
3
4. Manage dysphagia
5. Help patient attain bowel and bladder control
Degenerative Disorders- Demyelinating

❖ MULTIPLE SCLEROSIS
• An auto-immune mediated progressive demyelinating disease of the CNS
• The myelin sheath is destroyed and replaced by sclerotic tissue (sclerosis)
Charcot’s triad
S -canning of speech loss of coordination
I -ntentional tremors
N -ystagmus (upward rolling of eyes)
Diagnostic Tests
• MRI- primary diagnostic study
• CSF Immunoglobulin G
Nursing Management
• Schedule activity and rest periods
• Wide stance walking
• Use of walking aids
• Set a voiding schedule
• Careful feeding, proper positioning, suction machine availability
• Speech therapist
• Improve Sensory and Cognitive function
• Vision- use eye patch for diplopia
Medical Management
• Corticosteroids
• Immunosuppressant
• Plasmapheresis - method of removing a quantity of plasma from the blood
❖ GULLAIN BARRE’ SYNDROME

• An auto-immune attack of the peripheral nerve myelin
• Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves
• Ascending weakness and paralysis (symmetrical)
• diminished reflexes of the lower extremities
• potential respiratory failure - diaphragm
• paralytic ileus - paralyze GIT
Degenerative disorders- NON-demyelinating

❖ ALZHEIMER’S DISEASE
• A progressive neurologic disorder that affects the brain resulting in cognitive
impairments
• Decreased Acetylcholine and Neurofibrillary tangles
• Forgetfulness
• Recent memory loss
4
• Difficulty learning
• Deterioration in personal hygiene
• Severe deterioration in memory, language and motor function
Diagnostic Test
• PET scan
• EEG, CT and MRI
• Other tests to rule out Vit B deficiencies and hypothyroidism
• Autopsy is the most definitive test!
Nursing Management
• Establish an effective communication system with the patient and family
• Use short simple sentences, words and gestures
• Maintain a calm and consistent approach
• Protect the patient from injury by providing a
• Safe , Supervised , Simplified and Structured environment
• Keep bed in low position
• Encourage exercise to maintain mobility
❖ PARKINSON’S DISEASE /“Paralysis Agitans”

• The degenerative idiopathic form is the most common form
• It affects the extrapyramidal system (EPS). This causes decreased dopamine production
• Tremors- resting, pill-rolling
• Rigidity- cog-wheel, lead-pipe
• Bradykinesia- abnormally slow movement
• Dementia, depression, sleep disturbances and hallucinations
Nursing Management
• Improve mobility
• Enhance Self- care activities
• Improve nutrition
• Encourage the use of assistive devices
Medical Management
• Anti-parkinsonian drugs- Levodopa, Carbidopa
• Anti-cholinergic therapy
• Dopamine Agonists- bromocriptine and Pergolide, Ropirinole and Pramipexole
Parkinson’s Multiple Myastenia Amyotropic Guillain Bare Huntington’s

Sclerosis Gravis Lateral Syndrome chorea
Sclerosis
Degenerative Autoimmune Autoimmune Degenerative Autoimmune Degenerative
Late elderly- Female young Female young Female young Female young Both sexes middle
males adult adult adult adult adult
Decrease Demyelination Increase Loss of motor Inflammation Defect in a single
dopamine (brain-spinal acetylcholine function gene that is
Increase cord) s- terase inherited as an
acetylcholin Descending Decrease autosomal
e acetylcholine dominant
5
characteristic
Bradykinesi Charcot’s Muscle fatigue Sudden Ascending

a Tremors triad: Ptosis- drooping paralysis paralysis Abnormal
Rigidity Nystagmus of eyes In 2 yrs time movements
Shuffling Scanning of patient dies (chorea) intellectual
gait Mask speech Ascending decline emotional
like face Intentional paralysis disturbance.
Monotonous tremors
slow speech Charcot’s
Resting triad
tremors
Levodopa - Steroids Neostigmine Steroids Steroids
carbidopa Pyridostigmine immunosuppres Haloperidol
(Sinemet Give the drug sants After Diazepam
RTC Prevent meals Antidepressants
myesthenic and Full
cholinergic stomach to
crisis prevent
taken before gastric
meals irritation
Motor dysfunction- CNS

❖ EPILEPSY
• A group of syndromes characterized by recurring seizures
GENERALIZED SEIZURES PARTIAL SEIZURES
Cause a generalized electrical abnormality within the ✓ these seizures arise from a localized part
brain of the brain and cause specific symptoms
✓ General Tonic-Clonic seizure (Grand mal) - ✓ Simple partial seizure- typically limited to
characterized by loss of consciousness and one cerebral hemisphere
alternating movements of the extremities ✓ Complex partial seizure- begins with an
✓ Absence Seizure (Petit mal)- common in children, aura, then with impaired consciousness,
begins with a brief change in the LOC, by blinking, with purposeless behaviors like lip-
rolling of eyes, blank stares smacking, chewing movements
✓ Myoclonic seizure- characterized by brief, involuntary
muscular jerks of body extremities
✓ Akinetic seizure- general loss of postural tone and a
temporary
✓ loss of consciousness- a drop attack
Nursing Management
During seizure
• Remove harmful objects from the patient’s surrounding
• Ease the client to the floor
• Protect the head with pillows
6
• Loosen constrictive clothing

• DO NOT restrain, or attempt to place tongue blade or insert oral airway
POST seizure
• Place patient to the side to drain secretions and prevent aspiration
• Help re-orient the patient if confused
• Provide care if patient became incontinent during the seizure attack
• Stress importance of medication regimen
Motor dysfunction- Cranial Nerve

❖ BELL’S PALSY/“Facial Paralysis”
• Damage in the cranial nerve VII- facial
• Unilateral facial weakness
• Mouth drooping
• Distorted taste perception
• Inability to close eyelid on the affected side
• Inability to raise eyebrows, puff out the cheek
Diagnostic Tests
• EMG
Nursing Management
• Apply moist heat to reduce pain
• Massage the face to maintain muscle tone
• Protect the eye with an eye patch. Eyelid can be taped at night
• Instruct to chew on unaffected side
Medical Management
• Prednisone
• Artificial tears- methylcellulose eyedrops
❖ TRIGEMINAL NEURALGIA/Tic Douloureux

• Painful disorder that affects one or more branches of the fifth cranial nerve
• Pain aggravated by cold, washing of face, chewing, hot or cold foods and fluids, touch of wind
on the face
Assessment
1. Pain history
2. Searing or burning jabs of pain lasting from 1-15 minutes in an
area innervated by the trigeminal nerve
Nursing Management
• Instruct client to avoid hot or cold foods and beverages
• Provide liquid and soft foods
• Instruct client to chew foods on the unaffected side
Medical Management
• Tegretol (carbamazepine)
• Valium (diazepam)
• Dilantin (phenytoin)
Surgery
• Alcohol injection in the nerve
• Neurectomy
7

MUSCOLOSKELETAL SYSTEM
MUSCULOSKELETAL MODALITIES
Cast Traction
Immobilizing tool made of plaster of Paris A method of fracture immobilization by
or fiberglass applying equipment to align bone fragments
Provides immobilization of the fracture Cast Used for immobilization, bone alignment and
application relief of muscle spasm
TO immobilize a body part in a specific TO decrease muscle spasms
position TO exert uniform compression to TO reduce, align and immobilize fractures To
the tissue correct deformities
TO provide early mobilization of Pulling force exerted on bones to reduce or
UNAFFECTED body part TO correct immobilize fractures, reduce muscle spasm,
deformities correct or prevent deformities
TO stabilize and support unstable joints
General Nursing Care Traction: General Nursing Care
P-ETAL the edges of the cast T - rapeze bar overhead
L-IFT with the PALMS R -equires free — hanging weights A -
A-ir dry (usually 24-72 hours) nalgesics is given to relieve pain C - heck
S-kin check-pressure circulation (pulse)
T-urn the extremity for equal drying T - emperature monitoring I -nfection
E-xtremity ELEVATED using a pillow prevention
R-egular Monitoring of 5P’s O -utput and intake monitoring N - utrition(
P-ulses,pain,paresthesias,paralysis,pallor appropriate diet)
A-void placing sticks, small objects inside S -kin must be checked frequently
R-ange of motion exercises,mobility
I-SOMETRICS
S-welling ,Hot spots and sensation LOSS
ASSISTIVE DEVICES
 Crutches
 Standing; 2 -3 (1-2 inches) fingers below axilla or supine; measure from the anterior fold
of the axilla to the heel of the foot and add 2.5 cm
 Measure from anterior fold of axilla to heel, add 6 inches
 Elbows should be flexed 20-30’ and crutches should be kept 6 inches laterally and 6
inches to the front=tripod position (8-10 inches- ok)
 There should be 2 inch space between axillary fold and underarm piece to prevent damage to
brachial plexus (crutch paralysis)
Basic stance
 Crutches should rest in front and lateral of feet
2-Point Gait
 Two point- faster safe-weight bearing allowed for both legs
 Advance right crutch and left foot together
1
 Advance left crutch and right foot together

3-Point Gait
 Used if only one leg is injured
 Three-point-non weight bearing of one leg
 Advance both crutches and involved leg forward
 Advance healthy foot while
keeping body weight on crutches
4-Point Gait
 Similar to 2-point gait, but slower and more stable
 Four point-slow safe-weight bearing allowed for both legs
 Advance right crutch
 Advance left foot
 Advance left crutch
 Advance right foot
Getting into a chair
 Both crutches to the weak side, stronger arm holds the armrest
Going up and down the stairs
 good goes up 1st and bad goes down 1st.
Walker
 Move walker ahead 15 cm (6inches-8-10 inches)while weight is borne by both
legs then alternate weight bearing assisted by the arms
 Elbows should be flexed-20-30’
 If one leg is weaker move that leg together with the walker
Cane
 Hold cane on the stronger side
 Flex elbow 30’ and tip of cane 15 cm lateral to the side of the 5th toe.
 Hand piece should allow 30degree. Flexion at elbow
 Don’t lean body over cane
 Going up and down the stairs -same with crutches
 FRACTURE
 A break in the continuity of the bone and is defined according to its type and extent
Types of Fracture
 Complete fracture
o Involves a break across the entire cross-section
 Incomplete fracture
o The break occurs through only a part of the cross-section
 Closed fracture
o The fracture that does not cause a break in the skin
 Open fracture
o The fracture that involves a break in the skin
 Comminuted fracture
o A fracture that involves production of several bone fragments
 Simple fracture
o A fracture that involves break of bone into two parts or one
Strains Sprains Fracture
2
Excessive stretching of a muscle or Excessive stretching of the A break in the continuity of the
tendon LIGAMENTS bone and is defined according to
its type and extent
P-ain or tenderness over the involved area-sharp
L-oss of function
A-bnormal movements and sensation(paresthesias)
C-repitus / CREPITATION (numbness)
E-dema, - Swelling and discoloration
E-rythema ,
E-cchymosis
D-eformity-obvious, shortening
Medical Management Management: Management: For open

For closed fracture fracture
1. Reduction of fracture 1. Assist in reduction and 1.Prevent wound and bone
either open or closed, immobilization infection Administer
Immobilization and 2. Administer pain medication prescribed antibiotics
Restoration of function and muscle relaxants Administer tetanus
2. Antibiotics, Muscle 3. Teach patient about prophylaxis Assist in
relaxants and Pain potential complication of serial wound
medications fracture and to report debridement
infection, poor alignment 2.Elevate the extremity to
and continuous pain prevent edema formation
3.Administer care of
traction and cast
 FAT EMBOLISM
 Fat globules of the long bones may move into the blood stream because the marrow
pressure is greater than capillary pressure
 Onset is rapid, within 24-72 hours
 Sudden dyspnea and respiratory distress
 Tachycardia
 Chest pain
 Petechial rashes over the chest, axilla and hard palate
Nursing Management
 Administer O2 in high concentration
 Prepare for possible intubation and ventilator support
 Adequate support for fractured bone during turning and positioning
 Maintain adequate hydration and electrolyte balance
 COMPARTMENT SYNDROME
 A complication that develops when tissue perfusion in the muscles is less than required for
tissue viability
3
 Deep, throbbing and UNRELIEVED pain by opiods

 Paresthesia
 Motor weakness
 Pulselessness, impaired capillary refill time and cyanotic skin
Nursing Management
 Assess frequently the neurovascular status of the casted extremity
 Elevate the extremity above the level of the heart
 Assist in cast removal and FASCIOTOMY
 OSTEOMYELITIS
 Inflammation of the bone due to infection
 Malaise
 Pain, swelling and tenderness over bone
 Fever
Diagnosis Test
 Bone scan or culture from Needle Biopsy
Nursing Management
 Immobilization of affected limb
 No weight-bearing on affected limb
 Explain client need for long-term antibiotics (oral for 6 weeks after fever normalizes)
 Carpal Tunnel Syndrome

 Compression of median nerve at wrist joint
 Pain in wrist or palm or hand
 Paresthesias in radial palmar aspect of hand
 Weakness of thumb
Nursing Management
 Avoid prolonged flexion of wrist
 Teach proper hand position when typing or using computer
 Relief pressure on median nerve:(hand elevation, splinting of hand and forearm)
 Cortisone injections into carpal tunnel
 OSTEOPOROSIS
 A disease of the bone characterized by a decrease in the bone mass and density with a
change in bone structure
Types
 Primary Osteoporosis- advanced age, post-menopausal
 Secondary osteoporosis- Steroid overuse, Renal failure
 Low stature
 Fracture-Femur
 Bone pain
4
 Provide adequate dietary supplement of calcium and vitamin D

 Take alendronate with an EMPTY stomach with water
 Instruct the patient to rest on a firm mattress
 Heat application may provide comfort
 Encourage good posture and body mechanics
 Advise intake of HIGH fiber diet and increased fluids
 Prevent injury
 Instruct to use isometric exercise to strengthen the trunk muscles
 Degenerative Joint Disease/Osteoarthritis

 The most common form of degenerative joint disorder
 Chronic, NON-systemic disorder of joints
 Stimulate the chondrocytes to release chemicals and will cause cartilage degeneration,
reactive inflammation of the synovial lining and bone stiffening
Diagnostic test
 Loss of cartilage
 Osteophytes
 Joint pain
 Inflamed cartilage and synovium
 Commonly occurs in the morning after awakening for less than 30 minutes
 Decreases with movement, but worsens after increased weight bearing activitry
 Crepitation may be elicited
 Functional joint impairment limitation
 The joint involvement is ASYMMETRICAL
 This is not systemic, there is no FEVER, no severe swelling
 Usual joint are the WEIGHT bearing joints
 Rheumatoid Arthritis
 A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting
more women (ages 35-45) than men
 Immune reaction in the synovium attracts and irritates the synovial lining causing synovial
inflammation
Diagnostic test
 Shows bony erosion
 Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and
 Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous
WBC and inflammatory proteins
 Pain
 SYMMETRICAL, Bilateral
 Joint STIFFNESS occurs early morning, lasts MORE than 30 minutes
 Fever, weight loss, anemia, fatigue
5
 Deformities are common in the hands and feet causing misalignment

 Rheumatoid nodules
 Gouty Arthritis
 A systemic disease caused by deposition of uric acid crystals in the joint and body tissues
 Primary gout- disorder of Purine metabolism

 Secondary gout- excessive uric acid in the blood like leukemia
Diagnostic test
 Elevated levels of uric acid in the blood
 Uric stones in the kidney (+) urate crystals in the synovial fluid
 Severe pain in the involved joints, initially the big toe Swelling and inflammation of the joint
 TOPHI
 Yellowish-whitish, irregular deposits in the skin that break open and reveal a gritty
appearance
 PODAGRA
 Renal stones
6

RESPIRATORY SYSTEM
CONDITIONS OF THE UPPER AIRWAY
Rhinitis Sinusitis Pharyngitis
Allergic, non-allergic and infectious Acute and chronic Acute and chronic
S/Sx; S/Sx; S/Sx;
Rhinorrhea Facial pain Fiery-red pharyngeal
membrane
Nasal congestion Tenderness over the White-purple flecked exudates
paranasal sinuses
Nasal itchiness Purulent nasal discharges Enlarged and tender cervical
lymph
Sneezing Ear pain, headache, dental nodes
pain
Headache Decreased sense of smell Fever malaise, sore throat
Difficulty swallowing
Cough may be absent
LABORATORY TESTS
1. CBC- elevated WBC, acts to fight infection
2. Nasal Swab/Throat Culture - to identify the causative organism
Nursing Management
 Maintain Patent Airway
 Positioning: HOB elevated
 Increase fluid intake to loosen secretions
 Utilize room vaporizers or steam inhalation (not more than 15 mins)
 Warm gargles for the relief of sore throat
Medical Management
 Administer medications to relieve nasal congestion
 Decongestant- Phenylpropanolamine (Dimetap, Neozep)
 Administer prescribed analgesics
 DOC: Penicilin (complete dose as prescribed)
 Administer lozenges (to soothe throat): Dequadin, Strepsils
ASTHMA
 The acute episode of airway obstruction is characterized by airway hyperactivity to
various stimuli that results in recurrent wheezing brought about by edema and
bronchospasm.
 Mechanism: Hypersensitivity (allergy)
 Mediator: Histamine (trigger)
 Respiratory distress: slow onset of shortness of breath, expiratory wheeze, prolonged
expiratory phase, air trapping (barrel chest if chronic), diaphoresis, cough, weak pulse,
1
diaphoresis, increase in respiratory rate: acute (alkalosis- initial), (CNS depression- late)
 Cardiovascular symptoms: tachycardia, ECG changes, hypertension, decreased cardiac
contractility, pulsus paradoxus
 CNS manifestations: anxiety, restlessness, fear and disorientation
Nursing Management
 Positioning: HOB elevated/ Orthopneic position (leaning forward)
 Administer O2 to maintain Pa02 at more than 50 mmHg
 Suction airways as required
 Deep Breathing Exercise to divert patient’s attention to illness
Medical Management
 Administer Bronchodilators as prescribed
 B - Agonist (Epinephrine, Albuterol, terbutaline
 Methylxanthines (aminophylline and derivatives)
 Corticosteroid
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Chronic Bronchitis Emphysema
“BLUE BLOATERS” “PINK PUFFERS”
(Cyanosis/ Duskiness + Edema) (Acyanotic/Air trapping+ Pursed- lip breathing)
 Inflammation of the bronchioles characterized  Presence of over distended non-functional alveoli
by the presence of cough and sputum due to Alpha1-Anti Trypsin deficiency (DUE TO
production for at least 3 months in each 2 SMOKING)
consecutive years.  s/sx:
 s/sx:  with cough and sputum production, dyspnea,
 persistent (copius) cough, dyspnea increase rate and depth of breathing, flaring of
on exertion scattered rales and nostrils, decrease expiratory excursion resonance-
ronchi hyperresonance, decrease breath sounds with
 feeling of epigastric fullness, distended neck prolonged expiration, normal/ decrease fremitus
veins, ankle edema (late)
Dx test: Dx test:
PCO2 and PO2 PCO2/ Normal and PO2 slightly / Normal
Nursing Management
 Positioning: HOB elevated -to decrease exertion: in supine
 Rest-To reduce oxygen demands of tissues
 DBE: Pursed lip breathing technique- to increase airway pressure and to allow dilation of
bronchioles and to increase expel of CO2
 Increase fluid intake-To liquefy mucus secretions
 Diet:
 High caloric diet provides source of energy
 High protein diet helps
maintain integrity of
alveolar walls Moderate
fats
 Low carbohydrate diet limits carbon dioxide production (natural end product). The client
has difficulty exhaling carbon dioxide.
 O2 therapy 1 to 3 lpm (2 lpm is safest)
2
 Do not give high concentration of oxygen. The drive for breathing may be depressed.
 CPT -percussion, vibration, postural drainage
Medical Management
 Administer Expectorants
 Guaiafenessin mucolytic
 Administer Mucomyst
 Administer Antitussives as ordered
CHEST AND TRAUMA RELATED DISORDERS

 FLAIL CHEST
 Complication of chest trauma occurring when 3 or more adjacent ribs are fractured at two or
more sites, resulting in free-floating rib segments.
 The flail portion is sucked in on inspiration and bulges out on expiration.
 Severe dyspnea; rapid, shallow, grunty breathing; paradoxical chest motion. The chest will
move INWARDS on inhalation and OUTWARDS on exhalation.
 Cyanosis, possible neck vein distension, tachycardia, hypotension
Nursing Management
 Maintain an open airway
 Suction secretions, blood from nose, throat, mouth, and via endotracheal tube;
 Note changes in amount, color, and characteristics.
 Monitor mechanical ventilation
 Encourage turning, coughing, and deep breathing.
 Monitor for signs of shock: HYPOTENSION, TACHYCARDIA
 PNEUMOTHORAX/HEMOTHORAX
 Partial or complete collapse of the lung due to an accumulation of air or fluid in the pleural
space
Types:
 Spontaneous pneumothorax: air accumulates in the pleural space without cause.
 Open pneumothorax: air enters the pleura through an opening in the chest
 Tension pneumothorax: air enters the pleural space with each inspiration but cannot
escape; causes increased intrathoracic pressure and shifting of the mediastinal
contents to the unaffected side (mediastinal shift).
 Hemothorax: accumulation of blood in the pleural space; frequently found with an
open pneumothorax resulting in a hemopneumothorax.
 Sudden sharp pain in the chest, dyspnea,
 Diminished or absent breath sounds on affected side
 Hyperresonance on percussion,
 Decreased vocal fremitus, tracheal shift to the opposite side (tension pneumothorax
accompanied by mediastinal shift)
Diagnostic tests
1. Chest x-ray reveals area and degree of pneumothorax
2. ABG Analysis
 PCO2 elevated
 pH decreased
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Nursing Management
 Suction secretions, vomitus, blood from nose, mouth, throat, or via endotracheal tube.
 Assist with insertion of a chest tube to water- seal drainage or thoracentesis.
 Positioning: High-Fowler’s position
 Administer narcotics/analgesics/sedatives as ordered and monitor effects.
 PLEURAL EFFUSION
 Accumulation of air, H20, blood in the pleural space
General Classification
 Transudative effusion: accumulation of protein-poor, cell-poor fluid
 HYDROthorax: accumulation of water/serous fluid
 Exudative effusion: accumulation of protein rich fluid
 PYOthorax or Empyema: accumulation of pus
 Hemothorax: accumulation of blood
 Dyspnea, increase respiratory rate dullness over affected area upon percussion
 Absent or decreased breath sounds over affected area,
 Pleural pain, dry cough, pleural friction rub, unequal chest expansion
Diagnostic tests
1. Chest x-ray positive if greater than 250 cc pleural fluid
2. Pleural biopsy may reveal bronchogenic carcinoma
3. Thoracentesis may contain blood if cause is cancer, pulmonary infarction, or tuberculosis;
positive for specific organism in empyema.
Medical Management
 Administer narcotics/sedatives as ordered to decrease pain.
 Assist with instillation of medication into pleural space (reposition client every 15 minutes).
 For tension pneumothorax needle thoracentesis is done if chest tube insertion is not
immediately done
 For open pneumothorax, cover wound with sterile, non-porous dressing and tape on
three sides; one side is left open to vent excess pressure.
 For hemothorax, prepare for blood transfusion. To prevent hypovolemic shock
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* NLE * NCLEX * CGFNS * HAAD * PROMETRICS * DHA * MIDWIFERY * LET * RAD TECH * CRIMINOLOGY * DENTISTRY * PHARMACY *
OBSTETRICS NURSING
The Menstrual Cycle - Cyclic monthly changes in endometrium in preparation for ovulation
 normal cycle is 25-35 days; average of 28 days
 menstruation - monthly shedding off of uterine lining in response to drop in estrogen and
progesterone level Ø average of blood lost: 30-80 ml.
 menarche - onset of menstruation between 12-16 years of age
 ovulation - occurs 14 days before the next menstrual period
 menopause - permanent cessation of menstrual flow between 45-50 years of age.
The Menstrual Cycle is divided into 3 events:

1. The Hormonal Cycle
 Hypothalamus secretes GnRH

 GnRH, in turn, stimulates FSH
 FSH stimulates the ovarian follicle to mature
 The anterior pituitary secretes LH
 LH causes final maturation of the graafian follicle, ovulation and formation of the corpus
luteum
2. The Ovarian Cycle
Phase 1: The Follicular Phase

 graafian follicle matures in response to FSH
 in a 28 day cycle, this phase lasts for 14 days
 ovulation and rupture of the graafian follicle occurs 14 days before the onset of the next
menses
Phase 2: The Luteal Phase
 This phase lasts 14 days regardless of the average length of the cycle
 Begins following ovulation
 Corpus luteum begins to degenerate at 1 week after ovulation
3. The Uterine Cycle
Phase 1: The Menstruation Phase

 Degenerated portion of the endometrium is shed
 Estrogen levels are low
Phase 2: The Proliferative Phase
 Endometrium proliferates under inc. estrogen production
 Endometrium increases in thickness
Glands become larger, long and more tortuous
 Blood vessels dilate and become more prominent
 Lasts 6-14 days
Phase 3: The Secretory Phase
 Begins following ovulation
 Endometrium becomes secretory
 Progesterone is the hormone produced by corpus luteum initiating secretory changes
Phase 4 : The Ischemic Phase
 Occurs 27-28 days into 28 day cycle
 Corpus luteum degenerates
 Estrogen and progesterone secretion falls
 Necrosis of parts of the endometrium
 Menstrual flow begins
Fetal Development
A. Fertilization - union of sperm and ovum 3 Stages of Human Prenatal Development
1. Ovum - period of fertilization until primary villi appears
- 12-14 days of gestation
2.EMBRYO
 54-56 days of gestation
 Period of rapid cell division
 Most critical time for development of individual
 Highly vulnerable to teratogens, virus, radiation
3. Fetus
 From embryonic stage until pregnancy is terminated
Amniotic Fluid
 Clear pale straw fluid in which the fetus floats

 Slightly alkaline with a pH of about 7.2
 Quantity: 800-1200 ml. at term
 Polyhydramnios-fluid more than 2000 ml
Risk factors:
(a) inability of the fetus to swallow normal amounts of amniotic fluid (as in esophageal atresia and
anencephaly);
(b) a mother with diabetes mellitus (hyperglycemia causes excessive fluid shift into the amniotic
space)
 Oligohydramnios- fluid less than 300 ml
Risk factor: abnormalities in fetal urine production
 Green tinged-presence of meconium
Functions of Amniotic Fluid

 Protects fetus from direct trauma
 Separate fetus from fetal membrane
 Allow freedom of fetal movement
 Facilitate growth and development
 Protect fetus from heat loss
 Source of oral fluid
 As excretion or collection system
Umbilical Cord
 extends from fetal umbilicus to the fetal surface of placenta
 cord carries 2 arteries and 1 vein
 Average Length is 56cm
 funic soufflé - synchronous with fetus
 uterine soufflé - synchronous with maternal pulse
 Wharton’s jelly - gelatinous mucopolysaccharide which gives the cord body and prevents pressure
on the vein and arteries
A. Growth and Development of the Fetus

>cephalocaudal development
>1st trimester-period of organogenesis
>2nd trimester-period of rapid increase in length
>3rd trimester-period of continuous growth and rapid growth due to subcutaneous fat deposition
Development of Fetus per Lunar Month
1st Lunar Month

 does not appear human
 heart appears as bulge on anterior surface
2nd Lunar Month

 organogenesis is complete
 heart is beating
 facial features are discernible
 external genitalia present but not distinguishable
3rd Lunar Month

 ossification centers forming at the bones, tooth buds
 male and female distinguishable
4th Lunar Month

 FHT can be heard
 Lanugo is forming
5th Lunar Month

 quickening occurs
6th Lunar Month

 passive antibody transfer occurs
 vernix caseosa forms
 production of lung surfactant begins
7th Lunar Month

 surfactant found in amniotic fluid
8th Lunar Month

 subcutaneous fat begin to deposit
 assumes delivery position
9th Lunar Month

 stores glycogen
 iron deposited
 testes descend
10th Lunar Month

 ready for labor
The Pregnant Patient

LABOR
- Series of events resulting to birth of the fetus and products of conception from the mother’s
womb
Preliminary Signs of Labor
 lightening
 increased vaginal secretions
 weight loss of 1-3 lbs
 sudden burst of energy
 cervix becomes soft and effaced
 membranes may rupture
 frequent Braxton Hicks contractions
 backache may increase
 diarrhea may occur
 bloody show
Stages of Labor
1st stage of labor

 stage of cervical dilatation
 begins with true labor
 ends with complete cervical dilatation
nd
2 stage of labor
 stage of expulsion
 begins with full cervical dilatation
 ends with expulsion of fetus
3rd stage of labor
 placental stage
 begins with expulsion of the fetus
 ends with delivery of the placenta
4th stage of labor
 vigilant stage
 from delivery of placenta to an hour post partum
Phases of Labor
1. Latent Phase
 early phase
 cervix dilates from 0-4cm
 uterine contractions- mild, with a duration of 15-20 seconds duration and frequency of
every 10-20 minutes progressing to a duration of 30-40 seconds with a frequency of
every 5-7 minutes
 patient is excited
 thoughts centered to self, labor and baby
 talkative or mute, calm or tense
 pain controlled fairly well
 the patient is alert and follows directions
2.Active Phase
 accelerated phase
 dilates 4-7cm
 uterine contractions- mild to moderate, with a duration of 40-60 seconds and frequency of
every 2-3 minutes
3.Transition Phase
 declaration phase
 dilates 8-10cm
 uterine contractions- moderate to strong, with a duration of 60-90 seconds and frequency of
every 2 minutes
 hyperventilating
 perspiration on forehead
Breathing Techniques
 used for relaxation in the early phases of labor

 breathing technique depends of degree of cervical dilatation
1. Dilatation to 3cm
 cleansing breath
 keep breathing slow and rhythmic when contraction ends, take one deep breath
2. Dilatation to 4-7cm
 cleansing breath at the beginning of each contraction
 breathing now more shallow
 encourage slow, abdominal breathing
3. Dilatation of 8-10cm
 cleansing breath
 maintain concentration on breathing
 encourage use of 4:1 breathing pattern: breath, breath, breath and puff
 panting breathing is encouraged
Antepartal Nursing Care
A. Terminology
1. Primipara - woman delivered only once of a fetus reaching viability
2. Nullipara - woman who has never completed pregnancy beyond abortion
3. Multipara - woman who has completed 2 or more pregnancies to viability
4. Nulligravida - woman who is not now or has been pregnant
5. Gravida - woman who is or has been pregnant irrespective of outcome
6. Parturient - woman in labor
7. Puerpera - woman who has just given birth
B.Naegele’s Rule
Expected date of confinement EDC Date on the 1 st day of LMP plus 7 days Count back 3
months
C.Diagnosis of Pregnancy
1. Presumptive Symptoms
 Nausea and vomiting Disturbance in urination Fatigue
 Perception of fetal movement Breast symptoms
 Cessation of menstruation
 Anatomical breast changes Chloasma
 Linea nigra
 Striae gravidarum Spider telangiectasia Palmar erythema
2. Probable Evidence
 Abdominal enlargement
 Goodell’s sign - softening of the cervix
 Hegar’s sign - softening of the isthmus of the uterus
 Chadwick’s sign - blue-purple discoloration of vagina
 Braxton Hicks painless irregular contractions
 Ballotement feeling that something is floating or bouncing inside Endocrine test or pregnancy
test
 HCG in the urine is the basis
3. Positive Signs
 Identification of FHT Normal rate: 120-160 bpm
 Distinguished from mother’s own pulse
 Other sounds heard: funic soufflé, uterine soufflé, maternal pulse, gurgling gas Perception of fetal
movement by examiner
Leopold’s Maneuver
- performed during latter parts of pregnancy
1. First Maneuver LM 1
 fundal grip
 what fetal pole occupies the fundus?
 Breech: large nodular body
 Cephalic: hard, round, freely movable
2. Second Maneuver LM 2
 umbilical grip
 which side is the fetal back?
 Back: hard resistant structure
 fetal parts: numerous nodulations
3. Third Maneuver LM 3
 pawlike’s grip
 which fetal part lies above the pelvic inlet?
4. Fourth Maneuver LM 4
 pelvic grip
 which side is the cephalic prominence?
 Confirms findings of third maneuver
Contraindications to progress of labor

 head not engaged
 malpresentation
 premature labor
 placenta or abruptio placenta
Mechanism of placental extrusion

 Schultze’s mechanism- delivery of the placenta with the shiny or fetal surface presenting first
 Duncan’s mechanism- occurs when the maternal surface of the placenta presents upon delivery
rather than the shiny fetal surface.
Complications of Labor
A. Dystocia
 painful, difficult, prolonged labor
 problems with: passenger, passageway, power
B. Assessment
 contractions drop in intensity Ø progress of labor
 vaginal exam
 contractions drop in frequency Ø uterus tense
 fetal position
 abdominal palpation
Most common malposition
- right occipitoposterior, left occipitoposterior
A. Hemorrhage
 blood loss > 500ml
1. Assessment
 uterine atony
 lacerations
 retained placent
 lack of blood coagulation
2. Intervention for uterine atony
 weigh pads
 administer oxygen
 blood typing
 give oxytocin
 massage uterus
 inspect for lacerations
 administer blood products
Complications of Pregnancy
A. Pregnancy induced Hypertension
 most common hypertensive disorder of pregnancy
 character: increase BP, proteinuria, edema
 systolic BP of 30mmHG and diastolic BP of 15mmHg above baseline
 cause: unknown
 only cure: delivery of the fetus
1. Assessment
 increase in BP
 generalized edema
 weight gain: > 1 lb/wk (3rd trimester)
 proteinuria (+1)
2. High risk patients
 black primigravidas
 primi with twins
 adolescents in low socioeconomic status
 women over 35 y/o
 Rh incompatibility
 DM
 History of H. mole
3. Severe preeclampsia
 headache
 blurred vision
 spots before eyes
 pulmonary edema
 dyspnea
4. Eclampsia
 temp 101 F
 facial twitching
 grand mal seizures
 apnea
 staring, dilated pupils Ø coma
Nursing Responsibility in giving MGSO4:

 monitor for signs of toxicity to MgSO4
B- blood pressure decreased
U- urine output less than 30 ml/hr
R- respiratory rate less than 12 cycles/min
D- deep tendon reflexes absent
 prepare an ampule of Calcium gluconate (antidote for MgSO4) at bedside
B. Ectopic Pregnancy
 gestation outside the uterine cavity
 most frequent site: ampullary portion of FT
C. Hydatidiform mole / Gestational trophlobastic disease / Molar Pregnancy
1.Signs and symptoms of H-mole:
 uterine enlargement greater than expected for gestational age
 >markedly elevated serum hCG
 hyperemesis gravidarum- due to abnormally high levels of hCG
 vaginal spotting of dark brown blood accompanied by discharge of clear fluid-filled
vesicles
 low maternal serum alpha feto-protein
 >anemia
2. Nursing intervention
 D&C
 NO oxytocics
D. Hyperemesis Gravidarum
 exaggerated nausea and vomiting in pregnancy that is prolonged past week 12
 fluid and electrolyte imbalance
 cause: unknown but it is related to high levels of HCG
Nursing intervention
 IV Fluids Ø I & O
 Oral intake
 NPO
Placenta Previa
 placenta is improperly implanted in lower uterine segment
 cause: unknown
Degrees of placenta previa:

 low-lying placenta- implantation in the lower rather than in the upper portion of the uterus
 marginal placent previa- the edge of the placenta approaches that of the cervical os
 partial placenta previa- implantation that occludes a portion of the cervical os
 total placenta previa- implantation that totally obstructs the cervical os
1.Assessment
 bright red bleeding Ø fetal distress
 engagement
 hypovolemic shock
2.Nursing action
 bedrest
 prepare for CS
 vital signs
 blood type and Crossmatch
 IV fluids
 no vaginal examination
 monitor blood loss, pain, and uterine contractility
 evaluate FHR with external monitor
E. Abruptio Placenta
 premature separation of placenta
 occurs after 20th weeks gestation
 hemorrhage
 cause: unknown but may be related to the following- short umbilical cord, chronic
hypertensive disease, PIH, direct trauma (as from an automobile accident),
vasoconstriction due to cocaine use.
Assessment
 dark red vaginal bleeding
 severe abdominal pain
 hypovolemic shock
 hypertonic uterus
 portwine amniotic fluid
PROFESSIONAL ADJUSTMENT, LEADERSHIP AND

MANAGEMENT AND RESEARCH
PROFESSIONAL ADJUSTMENT
Profession - an occupation calling; requires advance training & experience in some specific or specific
body of knowledge that provides services to a society in a special field
Qualifications and Abilities of a Nurse

*A professional nurse must possess specific qualifications and abilities:
• have a license to practice nursing in the country
• have a Bachelor of Science degree in Nursing; and
• be physically and mentally fit
Ethics - came from the Greek word ethos which means moral duty; refers to a standard to examine
and understand moral life Respect - recognition for the autonomy of an individual
Autonomy - involves self-determination and freedom to choose, free from deceit, constraint or coercion
Nonmaleficence - requiring to act in such a manner as to avoid causing harm to patients
- “do no harm”
Beneficence - doing acts of mercy and kindness that directly benefit the patient;
- “doing good”
Justice - “fairness”; the right to demand to be treated justly, fairly and equally Fidelity - concept of
faithfulness and the practice of keeping promises Veracity - relates to the practice of telling the truth;
Confidentiality - require non-disclosure of private or secret information in which one is entrusted
Morals - personal standards of right and wrong
Moral Maxims
1. The Golden Rule
2. The Two-fold Effect
3. The Principle of Totality
4. Epikia - exemption to the rule
5. One who acts through an agent is himself responsible.
6. No one is obliged to betray himself.
7. The end does not justify the means.
8. Defects of nature may be corrected.
9. If one is willing to cooperate in the act, no injustice is done to him/her.
10. A little more or less does not change the substance of an act.
11. The greatest good for the greatest number.
12. No one is held to the impossible.
13. The morality of cooperation.
14. Principle relating to the origin and destruction of life.
15. When in doubt, one may do what is generally done.
1
16. No one can give what he does not have.

17. No one is a judge in his own case.
18. An object cries out for his owner.
19. A doubtful law does not bind.
20. Passion does not usually arise from things to which we are accustomed.
What is a Law?
Law is defined as the “sum total of rules and regulations by which society is governed.
It is man-made and regulates social conduct in a formal and binding way. It reflects society’s needs,
attitudes and morals.”
It commands what is right and prohibits what is wrong
Professional Negligence
The term “negligence” refers to the commission or omission of an act, pursuant to a duty, that a
reasonably person in the same or similar circumstance would or would not do, and acting or the non-
acting of which is the proximate cause of injury to another person or his property.
a. Doctrine of Res Ipsa Loquitur (common knowledge doctrine)
- Literally translated “the thing speaks for itself”. It means that the nature of the wrongful act or
injury is suggestive of negligence. (a nurse giving the wrong medicine)
b. Doctrine of Respondeat Superior
The term means “let the master answer for the acts of the subordinate.” Under this doctrine, the
liability is expanded to include the master as well as the employee and not a shift of liability from
the subordinate to the master the Clinical instructor’s involvement and liability)
-“Let the superior answer; let the principal answer for the acts of his agent”.
- both employee and superior are liable; liability is expanded to the superior
Captain-of-the-ship doctrine - primarily applied in the operating room and imposes liability
on the surgeon for the acts of the people working in the room.
c. Doctrine of Force Majeure
The term means an irresistible force, one that is unforeseen or inevitable.
Incompetence- is the lack of ability, legal qualifications or fitness to discharge the required duty.
Although a nurse is registered, if in the performance of her duty she manifests incompetency, there is
ground for revocation or suspension of her certificate of registration.
Torts - a legal wrong, committed against a person or property independent of a contract that renders the
person who commits it liable for damages in a civil action. The person who has been wronged seeks
compensation for the injury or wrong he has suffered from the wrong doer.
Assault - the imminent threat of harmful or offensive bodily contact. It is unjustifiable to

touch another person, or to threaten to do in such circumstances as to cause the other to
reasonably believe that it will be carried out.
Battery - an intentional, unconsented touching of another person.
False imprisonment or Illegal Detention - means the unjustifiable detention of a person

without a legal warrant within boundaries fixed by the defendant.
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Invasion of Right to Privacy - committed when the nurse divulge information from a patient’s
chart to improper sources or unauthorized persons.
Breach of Confidentiality - committed through publication of any picture of a patient e.g. a

malformed baby, without the consent of the parents, or revelation of the contents of the
records of the patient.
Defamation - Character assassination, be it written or spoken, constitutes defamation.
*Slander - oral defamation; speaking unprivileged or false words by which a reputation is damaged
*Libel - defamation by written words, cartoons such as representations that cause a person
to be avoided, ridiculed or held in contempt or tend to injure him in his work
NURSES AND CRIMINAL LIABILITIES

Crime is defined as an act committed or omitted in violation of the law. Criminal offenses are
composed of two elements: (1) criminal act and (2) evil/criminal intent. In criminal action, the state
seeks the punishment of the wrongdoers.
Misdemeanor is a general name for a criminal offense that does not in law amount to felony.
Felony is a public offense from which a convicted person is liable to be sentenced to death
or to be imprisoned in a penitentiary or prison; - acts or omissions punishable by law.
Classes of Crimes according to the degree of execution

a. Attempted - offender commences the commission by open acts but not able to
perform all the acts which shall produce the felony by some reason other than his
own spontaneous desistance
b. Frustrated - offender performs all the acts which shall produce the felony but do
not produce the act by reason independent of the will of the perpetrator
c. Consummated - when all the elements necessary for the accomplishment and the execution of
the crime are present
Conspiracy to commit a crime

It happens when two or more persons agree to commit a felony and decide to do it. Persons who
commit felonies are principals, accomplices, or accessories.
a. Principals - who take a direct part in the execution of the act, or those who directly force or
induce others to commit it.
b. Accomplice - persons who cooperate in the execution of the offense by previous or
simultaneous act that contribute to the commission of the crime
c. Accessories - those who having knowledge of the commission of the crime and
without having participated therein either as accomplice or principals, take part
subsequently to its commission by:
Circumstances affecting Criminal Liability

a. Justifying Circumstances
*defense of self or spouse
*fulfillment of duty
*refusing orders unlawful orders
b. Exempting Circumstances
- These are certain circumstances under which the law exempts a person from criminal liability for
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the commission of the crime

*imbecile/insane persons
*under 9 yrs. of age
*over 9 & under 15 yrs., acted without discernment
*performance of lawful act with due care, causes injury which is merely accident without
fault
*acting under compulsion of an irresistible force
*acting on impulse or uncontrollable force
c. Mitigating Circumstances
- Are those that do not constitute justification or excuse of the offense in question,
but which, in fairness and mercy, may be considered as extenuating or reducing the
degree of moral culpability.
d. Aggravating Circumstances
- Are those attending the commission of a crime and which increase the criminal liability of the
offender or make his guilt more severe
e. Alternative Circumstances
- Are those that must be taken into consideration as aggravating or mitigating according
to the nature and effects of the crime and other conditions attending its commission.
Crimes which Concern Nurses: those crimes against persons and community at large which a
nurse may commit or encounter in the practice of her profession. Among these crimes are the
following:
a. Parricide - crime committed by one who kills his father, mother, or child, whether legitimate
or illegitimate, or any of his ascendants or descendants, or his spouse.
b. Murder - committed by killing another person, other than those mentioned in parricide, with
evident premeditation and criminal intent. Homicide - killing of another person; it may be
committed without criminal intent or any circumstance attending the commission of a
murder.
c. Infanticide - killing of a child less than 3 days of age
d. Abortion - expulsion of the fetus at a period of uterogestation so early that it has not
acquired the power if sustaining an independent life.
e. Illegal detention - any private individual who shall detain another or, in any other manner,
deprive him of his liberty.
f. Simulation of births - a crime against the civil status committed by substituting one child for
another or who shall conceal or abandon any legitimate child with intent to cause such
child to lose civil status.
Consent, Contracts & Wills Contract

• meeting of minds between 2 persons whereby one binds himself, with respect to the other, to
render service
• a legally binding exchange of promises or agreement (meeting of minds) between
parties that creates and obligation and which the law will enforce
Requisites:
a. 2 or more parties
b. both must give consent
c. subject must be specified
d. obligation is established
e. legal capacity to enter
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Kinds of Contracts
1. Formal - required to be in writing by some special law
2. Informal - oral or written where the law does not require the same to be in writing
3. Express - condition & term are given orally or written
4. Implied - one that is concluded as a result of acts of conduct of the parties
5. Void - inexistent from the very beginning
6. Illegal - one that is expressly prohibited by law
Consent
- granting permission to perform a procedure
- means approval of what is proposed by another
2 Types:
1. Informed- written, sufficient information has been given to give consent.
2. Implied- when consent can’t be obtained through writing
Who can give consent?

1. 18 yrs old & above, conscious & coherent, competent
2. Below 18 yrs provided that he/she is an emancipated minor
Who can’t give consent?

1. Minors
2. Unconscious
3. Mentally ill persons
Wills
- “testament”; legal declaration of a person’s intention upon death
- a document by which a person (the testator) regulates the rights of others over his or
✓ Decedent – a person whose property is transmitted through succession whether or not he left a
will also called Testator/Testatrix if he left a will
✓ Heir – person called to succession either by provision of a will or by operation of the law
✓ Testate – a person who died leaving a will
✓ Intestate – a person who died without leaving a will
✓ Probate – validation of a will in court
✓ Holographic Will – a will that is written, dated & signed by the testator
✓ Noncupative Will - a will that is made orally
Note:
Witnesses to wills must be of sound mind, at least 18 years old, not deaf, blind or dumb.
Allowance and disallowance of wills necessary - meaning it should be proved and allowed in the
probate court.
Basic Legal Terminologies

✓ Affidavit - a sworn statement of facts that a person swears to be true before an official
authorized to administer an oath. Civil Law - the law which has the dual purpose of
organizing family and regulating property.
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✓ Complaint - a formal charge against a person or persons.

✓ Criminal Law - the division of the law dealing with crime and punishment.
✓ Day in court - The right of a person to appear in court and be heard concerning his
complaint/defense. Due process of law - legal means by which judgment is given only
after a fair trial
✓ Dying declaration/Ante mortem statement - verbal or written statements made by one
who believes he is dying. This is admissible in court when made by a victim of a crime
✓ Expert witness - one who has special training, experience, skill, and knowledge in relevant area, and
who is allowed to offer an opinion as testimony in court.
✓ False testimony is punishable both in civil and criminal law Gross negligence - flagrant disregard for
duty
✓ Hearsay rule - a rule of evidence that restricts the admissibility of evidence which is not personal
knowledge of the witness Moral turpitude - an act of baseness, vileness or depravity in social or
private duties
✓ Quasi-judicial - of a judicial nature. Action or discretion of public administrative officials to investigate
facts and draw conclusion from them as a basis for their legal action.
✓ Quasi-legislative - action or discretion of public administrative officers to formulate the implementing
rules and regulations of a law. Reckless imprudence - willful lack of prudence
✓ Res gestae - all of the surrounding events which become part of an incident.
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LEADERSHIP AND MANAGEMENT

LEADERSHIP
• the process of influence in which the leader influences others toward goal achievement
• is the effort to envision and inspire change
TYPES OF LEADERS:
✓ Informal leader - Does not have official sanction to direct activities of others; chosen by the group
itself; Usually become leaders because of age, seniority, especial competencies, an inviting
personality or ability to communicate with and counsel others
✓ Formal or appointed - Chosen by administration, and given official or legitimate authority to act
STYLES OF LEADERSHIP
1. AUTHORITARIAN/AUTOCRATIC
- Strong control over the group or directive approach
- Concern with task accomplishments
Autocratic involves centralized decision making, with the leader making the decision & using
power to command & control others
2. DEMOCRATIC OR PARTICIPATIVE
- Leaders focuses on involving subordinates in decision making
- People-oriented
Democratic is participatory, with the authority delegated to others, influential by having close and
personal relationship with the subordinates
3. LAISSEZ - FAIRE OR PERMISSIVE
- Delegating approach
- Little or no direction is provided to subordinates
Laissez-Faire Is passive & permissive, nondirective, inactive. Chaos is most likely to develop
because members may work independently
Authority - Legitimate power to direct others

Power - It is one’s capacity to influence others
Sources of power:
✓ Expert power - it is derived from the knowledge & skills one possess
✓ Legitimate power - is derived from the position one holds in a group & indicates authority but not
sufficient as one’s only source of power
✓ Referent power - derived from respect & trust coming from any individual group or organization
✓ Reward power - it comes from the ability to recognize others for complying
✓ Coercive power - is based on fear of punishment if one fails to conform
✓ Connection power - it comes from coalition & interpersonal relationship
✓ Informational power - it comes from knowledge & access to information
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MANAGEMENT
✓ Process that involves guidance, direction of a group of people toward organizational goals or
objectives
✓ the act of planning, organizing, directing (leading), controlling (evaluating).
✓ is a process of coordinating and allocating resources to achieve organizational goal
✓ MANAGEMENT LEVELS
✓ FIRST LEVEL - Supervises the operative employee
✓ MIDDLE LEVEL - plan and coordinate activities of the organization.
✓ TOP LEVEL - manages the organization as a whole.
STEPS IN MANAGEMENT
1. PLANNING
- Forecasting or setting the broad outline of work to be done CHARACTERISITCS OF
GOOD PLAN
✓ Based on clearly defined objectives
✓ It should be simple
✓ It should provide for the proper analysis and classification of action
✓ It should be flexible
✓ It should be balance
✓ It should make use of all available resources
Mission - purpose of existence and reason behind organizational structure Philosophy -

statements of shared values and beliefs
Goals - statement of intent derived from the purposes of the organization, usually stated broadly
and generally Objectives - specific aims, purposes or targets that will have to be accomplished
2. ORGANIZING
Grouping of activities, providing assignments, supervising, defining means of coordinating
activities to accomplish goals and objectives
CHARACTERISTICS OF ORGANIZATIONAL STRUCTURE

- Division of work in which each boxes represent an individual responsible for a given part of
the organization’s workload
- Chain of command, with lines indicating who reports to whom and why what authority
- The type of work performed, indicated by the labels or description for each boxes
- The grouping of work segments shown by the cluster of work groups
- The level of management, which indicate individual and entire management hierarchy BASIC
TYPES
A. Informal - consists of the personal and social relationship of the members in the organization
B. Formal - describes the positions, responsibilities and those occupying the positions and their
relationships
ORGANIZATIONAL CHART
- Diagrammatic representation of the organizational structure
1. Line Organization- Is the simplest and most direct type of organization in which position has
general authority over the lower position in the hierarchy
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2. Functional Organization- Is one where each unit is responsible for a given part of the organization’s
workload. There is a clear delineation of roles and responsibilities which are actually interrelated
3. Staff Organization- Is purely advisory to the line structure w/ no authority to put recommendations
into action.
FORMS OF ORGANIZATIONAL CHART

1. Vertical or Tall Chart - Depicts the Chief Executive at the top with line of authority flowing down
2. Horizontal or Flat Chart - Depicts the manager at the top w/ a wide span of control.
3. Concentric or Circular Chart - Shows outward flows of communication from center.
a. STAFFING
Is the process of determining and providing the acceptable number and mix of nursing
personnel to produce a desired level of care to meet the patient’s demand.
Patient Classification System

- quantify the quality of nursing care by matching patients’ needs to numbers and kinds of nursing
personnel using time as the unit of measure.
SCHEDULE
✓ It is a timetable showing planned work days and shift for nursing personnel.
✓ Is to assign working days and days off to the nursing personnel so that adequate patient care is
assured.
❖ Cyclic staffing- sets a basic time pattern that is repeated in cycles.
❖ Modified workweeks- include systems of scheduling personnel such as 10-hour and 12-hour shifts,
weekend alternative, team rotation, and flexible hours.
❖ Self-scheduling- is a method of scheduling in which the nurse manager determines the needs per
day and shift and the nursing staff schedule themselves to meet these needs.
b. DIRECTING
Issuance of assignments, orders and instructions that permits the worker what is expected of the
to achieve organizational goals and objectives
Delegating
✓ Is the process by which a manager assigns specific task/duties to workers with commensurate
authority to perform the task.
✓ The worker in return assumes responsibility & is held accountable for its result. 2 Important
Criteria in Delegation
✓ Ability of the worker to carry out the task.
✓ Fairness not only to the employee but to the team as a whole.
C. CONTROLLING
✓ The process by which managers attempt to measure if actual activities conform to planned
activities
✓ A process wherein the performance is measured and corrective action is taken to ensure the
accomplishment of organization goal
PERFORMANCE APPRAISAL/EVALUATION SYSTEM

✓ Process of evaluating employee’s performance against standards
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✓ To determine job competence

✓ Enhance staff development and motivate employee
QUALITY ASSURANCE PROGRAM

✓ Process of establishing a standards of excellence of intervention and taking steps to ensure
that each patient receives the expected level of care
✓ Fulfillment of social contract between society and professions
FRAMEWORK OF QUALITY ASSURANCE

1. Structure - instrumentalities in the delivery of care (personnel, supplies etc)
2. Process - how the service was delivered
3. Outcome - results expected of the service
NURSING AUDIT
✓ Official examination of: nursing records, physical facilities, personnel involved in patient
care
✓ Serves as a means of improving nursing care by revealing existing deficiencies
NURSING RESEARCH
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✓ A systematic search for and validation of knowledge about issues of nursing profession
Types of Nursing Research According to Purpose

✓ Basic Research - to generate new knowledge, to test or generate new theories
✓ Applied Research - to use knowledge/research findings to solve immediate problems
Classification of Nursing Research According to Design:

i. Quantitative - objective, has tight controls, can generalize findings
ii. Qualitative - studies the subjective meaning of an experience to a person
QUANTITATIVE QUALITATIVE
✓ hard, replicable, reliable ✓ rich, real, deep, valid
✓ manipulation and control of phenomena ✓ in-depth description of people or events-
verification of results using empirical data data gathered thru unstructured interviews
✓ testing of hypothesis Deductive and participant observation concerned with
✓ Limited by existing theories patterns and themes
✓ Inductive
✓ Must be open to new theories
Qualitative Research- Focuses on gaining insights and understanding of events.
A. Phenomenological Studies
✓ “Lived experiences”.
✓ Examines human experiences through descriptions provided by the people involved.
✓ Bracketing - the researcher releases expectations and biases prior to doing the research
B. Ethnographic Studies
✓ Collection and analysis of data about cultural groups
C. Case Study
✓ In-depth examination of people or institutions
D. Grounded Theory Studies
✓ Data are collected and analyzed and then a theory is developed that is grounded on the data.
E. Historical studies
✓ Identification, location, evaluation, &synthesis of data from the past
Classification of sources can be:

✓ Primary - an account of the event from the person himself
✓ Secondary - summarized or retold by another
Evaluation of data source:

✓ External Criticism – authenticity or genuineness of the source
✓ Internal Criticism - accuracy of the data in the source
Quantitative Research
Step 1: Identify the Problem
A. Correlational Statement
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B. Comparative Statement
Step 2: Determine the purpose of the study

A. Defines why the study is being made (often mistakenly interchanged with problem statement)
B. Must state the significance and use of the study results in order to get approval
Step 3: Review of Related Literature

✓ To determine what knowledge already exists on the topic to be studied
✓ To develop a conceptual and theoretical framework for the study
✓ To help the researcher plan the study methods (eg. Instruments or tools)
Step 4: Develop a Theoretical or Conceptual Framework

To assist in the selection of the study variables and in defining them
✓ Theory - set of related statements that describes or explains phenomena in a systematic way
✓ Concept - a word picture or mental idea of a phenomenon. The building blocks of a theory.
✓ Construct - highly abstract, complex phenomenon.
✓ Proposition - statement or assertion of the relationship between concepts.
✓ Hypothesis - predicts the relationship between two variables.
✓ Deductive reasoning - proceeds from general to specific.
✓ Inductive reasoning - proceeds from specific to general.
Step 5: Identify the Study Assumptions

✓ Assumptions - beliefs that are held to be true but have not necessarily been proven.
Step 6: Acknowledge the Limitations of the Study

A. Limitations - uncontrolled variables that may affect the study results and limit the
generalizability of the findings. Perceived weaknesses of the study findings.
B. Delimitations - limitations placed on the research by the researcher himself.
C. Scope - the extent to which the study will be made.
Step 7: Formulate the Hypothesis

✓ Hypothesis - predicts the relationship between two or more
✓ Classifications of Hypotheses
Simple vs. Complex
1. Simple - relationship between one independent and one dependent variable
2. Complex - relationship between two or more independent or dependent variables.
Null vs. Research

1. Null - no relationship exists between two variables
2. Research - there is a relationship; states the expected relationship
Nondirectional vs. Directional

1. Nondirectional - mere prediction that a relationship exists
2. Directional - researcher further predicts the type of relationship; direct or inverse
Step 8: Define Study Variables and Terms

1. Operational definition - indicates how a variable will be observed or measured.
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2. Dictionary definition/Theoretical definition - obtained from literature sources
Step 9: Select the Research Design

Research design - the PLAN for how the study will be conducted
✓ Exploratory - conducted when little is known about the topic of interest
✓ Descriptive - phenomena is described or the relationship between variables is examined
✓ Explanatory - searches for causal relationships
Types of Experimental Designs

✓ True Experimental - researcher has great deal of control over the research situation.
✓ Quasiexperimental - missing one criteria for true experimental design.
✓ Pre-experimental design - weak design, researcher has little control over the research
Types of Non-experimental Research design

✓ Correlational Studies - researches extent to which one variable (X) is related to another variable.
✓ Survey studies - self report data are collected from samples with the purpose of describing
populations on some variable/s of interest
✓ Comparative Studies - Examines the differences between intact groups on some dependent
variable of interest.
❖ *Retrospective studies - dependent variable identified in the present, and the independent
variable that occurred in the past is determined
❖ *Prospective studies - independent variable is identified at the present time, and the subjects
are followed in the future to observe the dependent variable
❖ *Ex post facto studies - data are collected “after the fact” variations in the independent
variable are studied after the variations have
❖ occurred, rather than at the time of occurrence.
Step 10: Identify the population

o Population - complete set of individuals or objects that possess some common characteristic that is
of interest to the researcher
o Target population (aka Universe) the group of people or objects to which the researcher wishes to
generalize the findings of a study.
o Accessible population - that group which is actually available for the study.
Step 11: Select the sample

o Sample - a subgroup chosen to represent the population and used to make generalizations about
the population.
o Sampling frame - a listing of all elements of a population Two major types of sampling
Probability Sampling Methods

✓ Simple Random Sampling - ensures that each element of the population has an equal and
independent chance of being chosen.
✓ Stratified Random Sampling - population is divided into subgroups or strata, according to some
variable/s of importance.
✓ Cluster Random Sampling - large groups or samples become the sampling units.
✓ Systematic Random Sampling - sample is taken from every kth element of the population.
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Non-probability Sampling Methods

✓ Convenience sampling (accidental or incidental) - choosing readily available people or objects for a
study.
✓ Snowball sampling - study subjects help refer additional subjects
✓ Quota sampling - similar to stratified random but selection not random.
✓ Purposive/Judgmental sampling - based on a set of criteria Time frame for studying the sample
✓ Longitudinal study - follows the subject over a period of time (6 months or more). More accurate
study of changes that occur over time.
✓ Cross-sectional study - examines the subjects at one point in time. Less expensive and easier to
conduct.
Step 12: Conduct a pilot study

✓ Pilot study: Miniature, trial version of the planned study. Can prevent a researcher from
conducting a large-scale study that might be an expensive disaster.
Step 13: Collect the data

Data collection methods:
Questionnaires - paper and pencil, self-report instrument.
Types of questions:
1. Demographic - data on the characteristics of the subjects. Age, educational background, religion
2. Open-ended questions - essay, fill-in-the blank
3. Closed-ended questions - respondent is asked to choose from given alternatives.
Interviews - interviewer obtains responses from a subject in a face-to-face encounter or via a call.
1. Unstructured interview - interviewer given a great deal of freedom to direct the course
2. Structured interviews - asking the same questions in the same order and in the same manner of all
respondents in the study. Even subtle changes in the wording of the interview may not be permitted.
3. Semi-structured interview - interviewers are generally required to ask a certain number of specific
questions but additional probing questions are allowed or even encouraged.
Observation Method - gathering data through visual observation.

1. Structured - carried out when the researcher has prior knowledge about the phenomenon of interest.
Uses a checklist.
2. Unstructured - researcher attempts to describe events or behaviors as they occur, with no
preconceived idea of what will be seen.
A. Physiological Measures - involve the collection of physical data from the subjects. Generally more
objective and accurate than many of the other data collection methods.
B. Attitude Scales - self-report, data-collection instruments that ask respondents to report their
attitudes or feelings on a continuum
C. Delphi Technique - uses several rounds of questions to seek a consensus on a particular topic
from a group of experts. To obtain group consensus without a face-to-face meeting.
Step 14: Organize the Data for Analysis Level of Measurement of Data
1. Nominal - objects or events are named or categorized
2. Ordinal - data that can be arranged by rank
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3. Interval - “real” numbers

4. Ratio - a true or natural zero can be specified
Step 15: Analyze the data

Measures of Central Tendency
1. Mode - category or value that occurs most often in a set of data under consideration.
2. Median - middle score or value in a group of data.
3. Mean - the average sum of a set of values found by adding all values and dividing by the total
number of values.
Measures of Variability- measures how spread out values are in a distribution of values.
✓ Range - distance between the highest and lowest value in a group of values or scores.
✓ Percentile - a datum point below which lies a certain percentage of the values in a frequency
distribution.
✓ Standard Deviation - Indicates the average deviation or variation of all values in a set of values from
the mean value of those data.
Step 16: Interpret the findings

✓ Made in light of the study hypothesis or research question and the theoretical framework
Step 17: Communicate the findings

✓ The final step in the research process and yet the most important one for nursing. No matter
how significant the findings may be, they are of little value to the nursing profession if not
communicated to other colleagues.
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PEDIATRIC NURSING
PIAGET’S COGNITIVE THEORY
1. SENSORIMOTOR STAGE (0-2 years)
Mainly by reflexes Repetition of acts
2. PRE - CONCEPTUAL OPERATIONS (2-4 years)

No cause and effect reasoning; egocentrism; use of symbols; magical thinking
3. CONCRETE OPERATIONS (7-11 years)

Uses memory to learn Aware of reversibility Inductive reasoning
4. FORMAL OPERATIONS (11-15 years)

Reality, abstract thought
Can deal with past, present and future Deductive reasoning
Theories PSYCHOSEXUAL PSYCHOSOCIAL INTERPERSONAL

MODEL (Freud) MODEL (Erikson) MODEL (Sullivan)
0 -18 ORAL: Pleasure TRUST vs. MISTRUST 1. INFANCY
months gratification through Significant relations: - others will satisfy the
mouth MOTHER needs
Dependency, eating, -NEED FOR SECURITY:
crying, biting aggressive develops a sense of trust,
drives
18 mo. - 3 ANAL: Pleasure through AUTONOMY vs. SHAME 2. CHILDHOOD
years elimination or retention of and DOUBT - Learns to delay need
feces Significant relations: gratification Toddler-
Control of holding on or PARENTS communicate needs
letting go Develops through words
concept of power, Pre-school -Begins using
punishment ambivalence, selective inattention and
concern with cleanliness dissociates those that
or being dirty cause physical or
emotional discomfort
3 - 6 years Phallic / Oedipal: INITIATIVE vs. GUILT 3. JUVENILE
Pleasure through Significant relations: - Learns to relate to peers
genitals Touching of FAMILY - Competition and,
genitals cooperation
Erotic attachment to 4. PRE - ADOLESCENCE
parent of opposite sex - Learns to relate to friends
(Oedipus/ Electra of same sex
Complex)
Fear of punishment
6 - 12 Latency: Energy used to INDUSTRY vs. 5. EARLY
years gain new skills in social INFERIORITY ADOLESCENCE
relationships and Significant relations: - Learns independence

knowledge Sense of NEIGHBORHOOD and and how to relate to

industry and mastery SCHOOL opposite sex
Learns control over
aggressive
destructive impulses
12 - 18 Genital: Sexual IDENTITY vs. ROLE 6. LATE ADOLESCENCE /
years pleasure through genitals CONFUSION YOUNG ADULT
Becomes independent of Significant relations: - Develops intimate
parents PEER GROUPS and relationship with person of
Develops sexual identity, ROLE MODEL the opposite sex
ability to love and work - Becomes economically,
intellectually
and emotionally self-
sufficient
AGE GROSS MOTOR FINE MOTOR LANGUAGE and PLAY

SOCIALIZATION
INFANT 2- Holds head up 1 - follows object 2 - makes cooing SOLITARY PLAY
3- Holds head & to midline sounds 2- enjoys bright
chest up 3 - follows object 3 - laughs out loud colored mobiles
5 - Turns front to past midline 6 - says vowel 3- hand regard
back 6- palmar grasp sounds 4- handles rattles
6- Turns both 7- transfer 7 - stranger anxiety 10 - plays pat-a-
ways (Roll- over) objects between 9 - first cake & peek-a-
7- Sits with support hands words (da- boo
8- Sits without 10 - pincer grasp da) 12 - plays pots and
support 12 - holds cup and 12 - says two pans; Pull toys
9- Creeps or spoon well words plus ma-ma
Crawl & da-da
10- Pulls self to
standing
11- Cruises;
stands with
support
12 - Stands Alone
TODDLER 15 - Walks alone; 15 - scribbles 18 - begins to use PARALLEL PLAY
seats self to chair; voluntarily short sentences Push toys
creeps upstairs 24 - can unscrew 24 - gives first name Riding toys
18 - can run and lids and turn 3 yrs - gives full Puzzles, blocks,
jump into place doorknobs name; repeats 3 finger, paints,
24 - walks upstairs 30 - draws numbers; vocabulary crayons
alone with both feet simple lines or increases to 900
on the same step at crosses with words
a time pencil
30 - jumps down
from stairs

PRE- 3- walks 3- copies circles, Understands COOPERATIVE

SCHOOL upstairs Stands may add facial concept of PLAY
on ONE FOOT features cooperation and Rules and ritual
Jumps off 1 4- copies a compromise dominate play
STEP Rides square; traces Enjoys family Board games,
Bicycle diamond activities Masters painting
4- walks down 5- hand arithmetic and
stair, Hops on 1 dominance reading
foot Ties shoes
5- skips and
hops on
alternate feet
Balances on ONE
FOOT, Throws and
catches ball
SCHOOL- Jumps, tumbles, can tie shoelaces talks in full COMPETITIVE
AGE skips and hops draw a person in sentences can PLAY
Can walk a straight good detail tell time in hours Collects items
line use of swear such as cards,
words dolls, rocks and
marbles
GROWTH AND DEVELOPMENTAL MILESTONES
NEONATAL CARE
A. Immediate Care
 Nursing Prevention of Heat Loss
 Place the newborn near the mother’s skin
 Dry the newborn immediately
 Wrap him with warm and dry sheets Put him under a droplight
 Close windows and door
B. Initial Assessment APGAR Scoring

- A system of assessing the general physical condition of a newborn infant.
SIGN SCORE: 0 SCORE: 1 SCORE: 2
A - Appearance Pale / Blue Blue Extremities Completely Pink
P - Pulse (Heart Rate) Absent < 100 bpm > 100bpm
G - Grimace (Response No Response Grimace Cough / Sneeze
to
Stimuli)
A - Activity Flaccid Some Flexion Well Flexed
R - respiration Absent Weak Good Cry
Score:
8 – 10 Indicates Good Extra-uterine Adaptation
4 – 7 Indicates a Guarded Condition: Needs Airway Clearance and O2 Supplementation
<4 Serious Danger: Needs RESUSCITATION
C. Assessment

NORMAL DEVIATIONS FROM NORMAL

SKIN Pink all over the body Central Cyanosis -decreased
Acrocyanosis - blue extremities; due oxygenation or airway obstruction
to immature peripheral circulation Pallor - indicative of anemia due to
Physiologic Jaundice - occurs within excessive blood loss
48-72 hours caused by immature liver. Gray Skin - indicative of Infection.
 Expose to morning sunlight / Pathologic Jaundice - occurs within the
droplight. 1st 24 hours
Vernix Caseosa - Cheesy-like - indicative of Rh/ ABO Incompatibility,
substance. Hemolysis Hemangiomas - vascular
* Allow it to remain to provide insulation. tumors of the skin
Milia - Immature sebaceous gland 3 types:
usually seen in cheek, chin and nose. Nevus Flammeus - (port wine stain)
Disappear by 2-4 weeks. Do not prick macular purple or dark red lesion usually
or remove, it could be an entry for found in the face and buttocks.
microorganism Strawberry hemangiomas - elevated
Lanugo - fine downy hair usually areas formed by immature capillaries
found in shoulders, back, and upper and endothelial cells associated with
arm. high level of estrogen in uteru.
Erythema Toxicum - (flea bite rash) * It may disappear within 1 year.
appears in 1st to 4th day caused by Cavernous hemangiomas - dilated
eosinophils reacting to the vascular spaces.
environment. - It may or may not disappear.
Mongolian Spots - deep blue
pigmentation appears on the buttocks.
HEAD Fontanel’s - flat, soft and firm Bulging fontanels indicates presence of
Anterior - diamond - shaped. Closes fluid and increased ICP
by 12 - 18 mo. Depressed fontanels indicates
Posterior - triangle - shaped. Closes dehydration Widely separated sutures
by 2-3 mo. Cranial Sutures may indicates fluid accumulation, abnormal
override at birth brain development & increased ICP.
Caput succedanum - edema of the Cephalhematoma - collection of blood
scalp crossing the suture lines. within the periosteum of skull bone due
* disappears within 1 week to rupture of blood vessel during vaginal
Craniotabes - localized softening of delivery. Self-resolving and does not cross
the cranial bone due to pressure of the suture line.
fetal skull against the pelvic bone.
EYES Color gray Large cornea - congenital glaucoma
Absence of tears Purulent discharge - eye infection,
Searching nystagmus Gonorrheal conjunctivitis
Cornea round and adult White Pupil - congenital
size cataract
Pupil should be dark Yellow Sclera - Increased
bilirubin
EARS Pinna top is horizontal line with outer Low set ears- indicates chromosomal
cantus of the eye abnormalities e.g Down Syndrome (

Flexible cartilage Trisomy 21), Patau Syndrome (Trisomy

13)
MOUTH Epstein Pearl - caused by excessive Oral Thrush - candida infection, must be
AND load of calcium in utero. reported immediately
THROAT Inability to pass NGT - may indicate
tracheoesophageal atresia and fistula
NORMAL DEVIATIONS FROM NORMAL

High-pitched cry - Increased ICP
NECK Short, thick, usually surrounded Resistance to flexion - congenital torticollis;
by skin folds Fractured clavicle
CHEST Witch Milk - thin watery fluid from Asymmetry of the chest
the breast of newborn due to Depressed sternum
withdrawal to maternal
hormones. Slight sternal
retractions evident
during inspiration
ABDOMEN Slightly protuberant Scaphoid or Sunken Abdomen - Diaphragmatic
Spleen and liver is palpable Hernia or missing abdominal contents
Umbilical cord: AVA no Bleeding, Malodorous Cord - omphalitis
bleeding, no odor
GENITALIA MALE: MALE:
palpable testes Hypospadias - ventral urethral opening
(+) cremasteric reflex = Epispadias - dorsal urethral opening
intact SN T8-T10 FEMALE: Cryptochirdism - undescended testes
usually edematous labia and FEMALE:
clitoris imperforate hymen: absence of vaginal opening
pseudomenstruation - d/t
withdrawal of maternal
hormones
Age FEARS
Infant  Separation from parents Searches for parents with eyes.
 Develops stranger anxiety around 6 months (peaks at 8 months).
Toddler Potential patterns of response to separation

Pre-school Fear of the dark Fear of mutilation
School-age More realistic fears than younger children; include death, disease or bodily
injury, punishment; school phobia may develop, resulting in psychosomatic
illness
Adolescent Threats to body image: acne, obesity Injury or death
COMMON PEDIATRIC DISORDERS
RESPIRATORY DISORDERS
 EPIGLOTTITIS
 H. influenzae Type b; Strep pneumoniae

 Abrupt onset; winter

 Considered an emergency situation
Assessment:
 Sore, red and inflamed throat
 Drooling, difficulty of swallowing
 Inspiratory stridor
Nursing Intervention
 maintain patent airway
 gag reflex - BQ
 do not force child to lie down
 administer antibiotics; IV fluids
 cool mist oxygen
 LARYNGOTRACHEOBRONCHITIS (LTB)
 Most cparainfluenza virus
 Gradual onset ; preceded by URI
Assessment:
 hoarse voice
 inspiratory stridor and suprasternal retractions
 crackles and wheezing
 cyanosis
Implementation:
 patent airway - elevate HOB humidified oxygen; IVF nebulized epinephrine
 BRONCHIOLITIS/RESPIRATORY SYNCYTIAL VIRUS (RSV)
 production of mucus that occludes bronchiole tubes and small bronchi
 RSV - highly communicable, usually transferred by hands
Assessment:
 Lethargy, poor feeding, tachypnea
 Expiratory wheezes and grunt Diminished breath sounds
The child with RSV:
 Isolate in a single room or place with same patient wear gowns when soiling may
occur
 Ribavirin (antiviral) - may be aerosol
 nurses wearing contact lenses must wear goggles - ribavirin may dissolve contact
lenses
CARDIOVASCULAR DISORDERS
 Cyanotic Congenital Heart Defects
TETRALOGY OF FALLOT
4 Defects:
Ventricular Septal Defect
Overriding of the aorta
Pulmonary valve stenosis
Enlarged right ventricular wall
Assessment:
 Primary sign - cyanosis at birth
 Hypoxic spells - usually initiated by crying

 Fainting - due to cerebral hypoxia

 Squatting position - characteristic position to relieve dyspnea
 Propanolol (Inderal) for vessel dilatation
 Clubbing of fingers
 Blalock-Taussig” palliative repair creating shunt
 between aorta and pulmonary artery
 Polycythemia
Management:
 Place in knee chest position
 Administer O2 as needed
 Morphine sulfate to reduce symptoms
Clinical Findings
 Loud harsh widely transmitted murmur or soft scratchy, localized systolic
murmur in the left
 2nd, 3rd or 4th parasternal interspace
 Echocardiography: Right side heart enlargement
 TRICUSPID ATRESIA
• tricuspid valve did not form an opening between the right atrium and right ventricle
Assessment:
 Profound cyanosis and dyspnea at birth
 Emergency management needed ASAP.
Management:
 IV infusion of prostaglandin
 Surgery: Fontan Procedure (Glenn Shunt Baffle) - venacava-to-pulmonary artery shunt
TRANSPOSITION OF THE GREAT VESSELS

• aorta arises from the right ventricle; pulmonary artery arises from the left ventricle
Assessment:
 cyanotic at birth ( most important clinical sign)
 develop polycythemia thus at risk for emboli and thromboses
Implementation:
 Cardiac catheterization
 Balloon atrial septostomy

 TRUNCUS ARTERIOSUS
• Single vessel arising from the ventricles just above a large VSD
Assessment:
 retarded growth; enlarged liver and heart
 usually infants die within the first year
 Acyanotic Congenital Heart Defects

PATENT DUCTUS ARTERIOSUS
 Most common congenital heart defect
Assessment:
 May have no symptoms; indication may be a “machinery like murmur”
Management:
 Oral of IV Indomethacin (prostaglandin inhibitor) to promote ductus closure
 Surgical closure by ductal ligation
 ATRIAL SEPTAL DEFECTS
 Allows oxygenated blood returning from the lungs to pass into the right atrium
Assessment:
 Harsh systolic murmur in 2nd or 3rd interspace (pulmonic area)
Management:
 Surgical closure of defect by 1- 3 years of age.
 VENTRICULAR SEPTAL DEFECT

 Allows systemic venous and oxygenated arterial blood to mix
Assessment:
 Loud harsh pansystolic murmur at 3rd or 4th interspace, and palpable thrill
Management:
 Large defects can be repair by interventional cardiac catheterization.
 COARCTATION OF THE AORTA

 Narrowing of the lumen of the aorta
Assessment:
 Absent, weak or diminished femoral pulse
 measure BP in both arms and a leg and to assess the pulse in both upper and lower
extremities
Management:
 surgical repair - only permanent treatment; usually deferred until 3 years of age by
interventional angiography
 Acquired Heart Diseases

RHEUMATIC FEVER
 An inflammatory autoimmune disease
 Affects connective tissue of the heart, joints, subcutaneous tissues and blood vessels of the
CNS
 Presents 2-6 weeks following an untreated Group A beta Hemolytic streptococcal infection
Assessment:

Signs of carditis: SOB, edema of the face, abdomen or ankles, precordial pain Erythema
marginatum: macular rash on trunk and extremities
 Subcutaneous nodules
 Elevated ASO ( Anti streptolysin O)
Management:
 Limit physical exercise in child with carditis
 Administer antibiotics (penicillin) as prescribed
 KAWASAKI DISEASE/mucocutaneous lymph node syndrome acute systemic inflammatory illness

Assessment:
 fever
 red, cracked lips; “strawberry tongue”
 Swollen hands, rash, enlargement of the cervical lymph nodes
Implementation:
 assess heart sounds and rhythm
 monitor mucus membrane for inflammation weigh daily
 administer IV immune globulin
HEMATOLOGIC DISORDERS
 LEUKEMIA
 Most common form of childhood cancer
 Proliferation of abnormal wbc that do not mature beyond the blast phase
 Blast cells - infiltrate other organs - liver, spleen, lymph tissue
Types:
1. Acute Lymphocytic leukemia (ALL)
 80-85%
 Acute
2. Acute nonlymphocytic leukemia
 Includes granulocytic and monocytic types
 60-80% will obtain remission
Assessment:
 Anemia, weakness, pallor, dyspnea
 Bleeding, petecchiae, spontaneous bleeding, ecchymoses
 Infection, fever, malaise
Nursing Intervention:
 Provide care for the child receiving chemo and radiotherapy
 Use distraction, guided imagery
 Administer sedation prior to procedure as ordered
 Sickle Cell Disease

 Hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin (HgbS)
 Insufficient oxygen causes the cells to assume a sickle shape and the cells become
rigid and clumped together, obstructing capillary blood flow
Assessment:
Vaso-occlusive crisis
 Most common type of crisis
 Caused by stasis of blood with clumping of the

Splenic sequestration
 Pooling of blood in the spleen. Profound anemia, hypovolemia, and shock
 HEMOPHILIA
 x-linked recessive trait
 Hemophilia A - deficiency of Factor VIII
 Hemophilia B - deficiency of factor IX
 Males inherit hemophilia from their mothers and females inherit the carrier status from their
fathers
Assessment:
 prolonged bleeding after minor injury
 Increase bruising and abnormal bleeding in response to trauma
 Joint bleeding - pain, tenderness, swelling limited range of motion
 Prolonged PTT
Implementation:
 Prepare to administer Factor VIII concentrate /cryoprecipitate
 Monitor urine for hematuria
 Control bleeding by immobilization, elevation, application of ice; apply pressure (15 mins)
 Avoidance of contact sports
GASTROINTESTINAL DISORDERS
 ESOPHAGEAL ATRESIA and TRACHEOESOPHAGEAL FISTULA
Esophageal atresia
 congenital defect; upper segment of the esophagus ends in a blind pouch
Tracheoesophageal Fistula
defect in which embryonic structures fail to divide into a separate esophagus and trachea
Assessment:
 copious oral and nasal secretions -first sign of a defect
 when suctioning or gavage is attempted - catheter cannot pass into stomach
Medical and Surgical intervention
 drainage tube may be placed in the blind pouch - to suction secretions esophageal
atresia - medical emergency (end to end anastomoses)
Nursing intervention:
 Provide gastrostomy tube feeding until anastomosis site has healed Start oral feedings
when infant can swallow well
 PYLORIC STENOSIS
 narrowing of the outlet of the stomach caused by excessive growth of circular muscles of
pylorus hypertrophy develops over 4-6 weeks of life when symptoms begin to appear
Assessment:
 olive size mass or bulge under right rib cage -BQ
 vomiting - projectile; non bilious
 dehydration
 peristaltic waves during and after feeding
 High Fowler’s
 Place on right side after feeding

 INTUSSUSCEPTION
 telescoping of bowel into itself associated with cystic fibrosis
Assessment:
 sausage shape mass in the abdomen upon palpation - BQ
 severe abdominal pain (pulls leg up)
 vomiting of bile stained fluid
 bloody mucus in stool
 “currant jelly” stool - BQ
 HIRSCHSPRUNG’S DISEASE
 absence of autonomic parasympathetic ganglion cells in large intestines results in
decreased motility and signs of functional obstruction
Assessment:
 failure or delay in passing meconium
 ribbon like stools - BQ
 volvulus - bowel twists upon itself
 diagnostic tests: rectal biopsy - confirms presence of aganglionic cells
 Do not use water or soap suds - water intoxication
 Administer TPN as ordered
 Provide low residue diet
 Colostomy care
 CELIAC DISEASE
 malabsorption syndrome characterized by intolerance of gluten, found in rye, oats, wheat and
barley
Assessment:
 chronic diarrhea
 Steatorrhea Distended abdomen
 Symptoms of ADEK deficiency Diagnostic tests:
 pancreatic enzymes
 jejunal or duodenal biopsies
 gluten free diet (BROW - Barley, Rye, Oatmeal, Wheat)
MUSCULOSKELETAL DISORDERS
 CONGENITAL HIP DISLOCATION
 displacement of the head of the femur from the acetabulum acetabulum is shallow and the
head of femur is cartilaginous at birth
Assessment:
 limitation of abduction (cannot spread legs to change diaper)
Ortolani’s click:
 In supine, bend knees and place thumb on bent knees, fingers at hip joint
 Bring femur 90 degrees to hip, then abduct; Audible click - dislocation
Galeazzi’s test:
 With infant on back, bend knees
 Affected knee will be lower because the head of the femur when lying on abdomen,

buttocks of affected side will be flatten

Trendelenburg test - Have child stand on affected leg only, pelvis will dip on normal side
 Maintain proper positioning: keep legs abducted
 Use triple diapering
 Use Frejka pillow splint (jumperlike suit to keep legs abducted)
 Place infant on abdomen with legs in “frog” position
 CLUBFOOT (Talipes)
 Abnormal rotation of foot at ankle
 Most common - talipes equinovarus
o Varus - inward rotation; bottom of feet face each other
o Valgus - outward rotation
o Calcaneous - upward rotation; would walk on heels
o Equinas - downward rotation; would walk on toes
Management:
 Exercises
 Casting
 Denis Browne splint (bar shoe) surgery and casting
 child who is learning to walk must be prevented from trying to stand
 apply restraints if necessary
GENITO-URINARY DISORDERS
 UNDESCENDED TESTES (Cryptorchidism)
 Unilateral or bilateral absence of testes in scrotal sac
 Testes normally descend at 8 months of gestation
Medical Management:
 “Orchipexy”: to retrieve and secure testes placement; performed at ages 1-3 yrs
Nursing Management:
 Avoid contamination of incision
 HYPOSPADIAS
 urethral opening located anywhere along the ventral surface of penis
Assessment:
 Urinary meatus misplaced
 Inability to make straight stream of urine
Management:
 surgery at age 3-9 months
 NEPHROTIC SYNDROME
 alteration of glomerular membrane results in increased permeability to plasma proteins
exacerbations and remissions over months to years commonly affects preschoolers
 boys >girls
Assessment:
 Proteinuria
 Hypoproteinemia
 Dependent edema

 Ascites
Management:
 Corticosteroids, Antibiotics*diuretics are not given because it can lead to hypotension
 Provide high protein, low sodium diet - during edema phase Avoid IM injections - meds not
absorbed in edematous tissue
 ACUTE GLOMERULONEPHRITIS
 immune complex disease 2-3 weeks post streptococcal infection (GAHBS)
 self-limiting : usually resolves in 14 days
Assessment:
 History of strep infection (URTI or impetigo)
 Hematuria or dark colored urine
 Hypertension
Management:
 Antibiotics for prophylaxis
 Antihypertensives
 Digitalis - if with CHF
 Fluid restriction
 Peritoneal dialysis - if severe renal complication occurs
 WILM’S TUMOR (NEPHROBLASTOMA)

 large, encapsulated tumor that develops in the renal parenchyma peak age : 1-3 years
Assessment:
 non tender mass, usually midline near liver Hypertension
 Hematuria
 Test: Intravenous Pyelogram (IVP)
Management:
 Surgery
 NO PALPATION of the abdomen
NEURO-SENSORY DISORDERS
 HYDROCEPHALUS
Imbalance of CSF absorption or production
Types:
 Communicating - impaired absorption within subarachnoid space
 Non-communicating - obstruction of CSF flow within the ventricular system
Assessment:
 Macewen’s sign - cracked-pot sound on percussion of bones of head
 Anterior fontanel tense, bulging
 Frontal bossing, sunsetting eyes
 Headache, nausea and vomiting
Surgical Implementation:
 VP Shunt - CSF drains into the peritoneal cavity from the lateral ventricle
 AV Shunt - CSF drains into the right atrium
Post-Operative Care:
 Keep child flat as prescribed - to avoid rapid reduction of intracranial fluid
 Observe increase ICP - if present, elevate head of the bed no more than 30-45o

 SPINA BIFIDA
 CNS defect that occurs as a result of neural tube failure to close during embryonic
development
Types:
1. Spina Bifida Occulta
• Spinal cord intact; not visible; Meninges not exposed on the skin surfaces
2. Spina Bifida Cystica
A. Meningocele- Protrusion involves meninges and a sac-like cyst
B. Myelomeningocoele- Protrusion of meninges, CSF, nerve roots, portion of spinal cord
Assessment:
 Depends on spinal cord involvement Flaccid paralysis of legs
 Bladder and bowel incontinence
Implementation:
 Monitor for increase ICP
 Cover with sterile, moist (normal saline) non-adherent dressing
 Place prone position
 Diapering may be C/I until defect repaired

PSYCHIATRIC NURSING
SELF-AWARENESS
• The process of recognizing one’s own feelings, beliefs and attitude.
Goal of Self-awareness:
To decrease the size of the blind and private quadrants, thereby enlarging the size of the open
quadrant.
THERAPEUTIC NURSE PATIENT RELATIONSHIP
A. PRE-INTERACTION PHASE
– begins before the nurse’s first contact with the patient
– SELF - AWARENESS
▪ Self-exploration of fears, feelings and fantasies.
▪ Gathering data about the patient if information is available.
▪ Planning for first interaction with patient
B. ORIENTATION OR INITIAL PHASE
– Assessment and Diagnosis Phase.
– DEVELOP A MUTUALLY ACCEPTABLE CONTACT
▪ Explore patient’s thoughts, feelings and actions and encourage him to
share it with the nurse, while the nurse listens attentively.
▪ Identify patient’s problems.
▪ Formulate nursing diagnosis, set priorities, and make plans to achieve the goals.
C. WORKING PHASE
– Resistance behaviours are usually displayed by patient during this phase,
because it contains the greater part of the problem-solving process.
– Identification and resolution of patient’s problems
▪ Explore relevant stressors.
▪ Develop a plan of action, implement the plan and evaluate the results of the plan to
alter the client’s behaviour.
▪ Assist patient to change some maladaptive behaviour to adaptive ones and prepare
him for terminations of relationships.
D. TERMINATION PHASE
– It is assumed that the patient is already with more understanding of reality and
has relearned the needed skills so that he no longer needs one to one
relationship.
– Termination actually has been started in the initial phase/
▪ Establish reality of situation. Review progress of therapy and attainment of goals.
▪ Decreasing number of visits, shortening time, including others in the
meetings or to change venue maybe helpful when termination is near.
▪ Provide necessary referral to others in the health care team.
– Resistance - patient’s attempt to remain unaware of anxiety-producing aspects

within herself.
– Transference - the experiencing of feelings, drives, attitudes, fantasies, and
1
defenses toward a person in the present that do not befit that person but rather
are a repetition of reactions originating with significant others during early
childhood, unconsciously displaced onto figures in the present.
– Counter-transference - involves feelings of the nurse (positive or negative)
toward the patient, such as special concern, sexual attraction, anger,
impatience or resentment.
DEFENSE MECHANISMS
- Unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope with
anxiety automatic; pathology is determined by the frequency of use.
DENIAL - failure to acknowledge an intolerable -A woman denies that her marriage is falling and
thought, feeling, experience or reality verbalizes “ things will be better tomorrow” ,even
though her husband admits he has been sleeping
with another woman
-Upon admission, an anorectic patient says to the
nurse, “Why am I here? I
am not sick and I don’t have any health problem
DISPLACEMENT - redirection of emotions or feelings to The employee who shouts at a subordinate after he
a subject that is more acceptable or less threatening boss reprimanded and humiliated her in front of a
board meeting
PROJECTION - attributing to others one’s feelings, An unfaithful husband thinks of his wife having
impulses , thought affairs with another man.
or wishes
UNDOING - an attempt to erase an act , thought , The mother who batters her child and wounded his
feeling or desire, restitution butt then pampers the child with his favourite ice
-Ritualistic behaviour manifested by anxious patients used cream.
to lessen feeling of guilt
COMPENSATION - an attempt to overcome real An unattractive woman selects an expensive
or imagined shortcoming stylish clothes to draw attention to her
SYMBOLIZATION - a less threatening object or idea is For emotional self-expression the wife of a soldier c
used to her braided hair and gives it to her husband befor
represent another he leaves for a critical assignment.
SUBSTITUTION - replacing desired , impractical , The jilted bride who’s groom did not show up during
unattainable object with one that is acceptable the wedding date
rushes in marrying the brother or the best-frien
of her ex- lover.
INTROJECTION - a form of identification in which The wife of an unfaithful husband repeatedly
there is a taking into oneself the characteristic of commits suicide because of self- hate and self -
another (love object) pity.
REPRESSION - unacceptable thoughts is Inability of the person to recall the feelings of fear
kept from awareness(unconscious after she was raped
forgetting)
2
SUPPRESSION- consciously forgetting; putting a When colleagues ask a fellow employee the reas
disturbing thought or incident out of awareness why the boss fired her ,
she responds ,“I’d rather not talk about it right now
REACTION FORMATION - expressing attitude directly A married woman is attracted to one of her husban
opposite to unconscious wish or fear male friends and
treats him rudely.
REGRESSION - turning back, returning to an earlier A 5 year old toilet trained boy becomes incontine
developmental phase in the face of stress during his father’s
hospitalization
DISSOCIATION - detachment and blocking of painful A student who was a victim of a rape and hold
emotional conflicts from consciousness up incident was seen wandering on a busy
highway in torn, disheveled clothing.
CONVERSION - emotional problems are converted into An applicant for a job develops fever on the day o
symptoms her personal interview
FANTASY - conscious distortion of unconscious The girl daydreams about her crush and imagines
feelings or wishes him dancing with her during the prom.
IDENTIFICATION - conscious patterning of one’s self A child who imitates the gestures of his favourite
from another hero ( Hero Worship )
person
INTELLECTUALIZATION - transferring emotional The father shows no emotional response when
concerns into an intellectual sphere, done by an reading the report card of his son with failing grade
individual to avoid expression of feelings instead he tells his wife, and he is trying to figure ou
why this has happened.
RATIONALIZATION - justifying ones actions which A student says, “I did not get good grades because
are based on other motives the teacher does not like me.”
SUBLIMATION - re- channeling of unacceptable A mother of a child who died because of gang
instinctual drives with one that is acceptable war, joined the “Crusade Against Violence”,
which is an anti - crime organization.
ISOLATION - separation of unacceptable feeling, idea The nurse who was also victim of rape is able to
and impulse care for a sexually abused client by separating
from one’s thoughts personal emotional reactions to the victim’s situatio
DYNAMICS OF BEHAVIOR PATTERNS & SYMPTOMS
(CLINICAL MANIFESTATIONS OF PSYCHIATRIC DISORDERS)
I. Disturbances in PERCEPTION
✓ Illusions - there is perceptual misinterpretation of an existing external stimuli.
✓ Hallucinations - sensory experience of an existing stimulus.
II. Disturbances of SPEECH
✓ Neologism - coining of new words understood only by the speaker.
✓ Word salad - incoherent speech made up from real and imaginary words as a result of
dissociations and pressure of invading thoughts.
✓ Circumstantiality - “beating around the bush”; pattern of speech that involves excessive
details before going to the goal idea.
3
✓ Echolalia - is the pathological repetitive imitation of words spoken by another person.

✓ Verbigeration - the continuous reiteration of a specific phrase. It may also occur in the
form of writing a given word or phrase over and over again, and it is most often seen in
schizophrenia.
✓ Perseveration - obsessive repetition of irrelevant words or phrases.
✓ Clang association - a linkage of similar word sounds, such as seven, heaven, eleven, to
compensate for defects in memory and communication which may be psychic or
organic origin.
✓ Aphasia -all disturbances of language and communication due to brain lesions but not
as the result of faulty innervations of the speech muscles, involvement of the organs of
articulation, or general mental or intellectual deficiency.
✓ Alogia - poverty of speech/lack of speech
III. Disturbances of Thinking
✓ Disturbance of Thought or Association / Looseness of Association - the flow of
thought may become seemingly haphazard, purposeless, illogical, confused,
incorrect, abrupt, & bizarre. This phenomenon is most conspicuous in
schizophrenia. In fact Bleuler regarded disturbance in association as one of the
fundamental symptoms of that disease.
✓ Flight of ideas - a continuous stream of conversation with rapid shifts in topics owing to
pressure of thoughts, sometimes characterized as topic jumping, may be unrelated. An
alert listener can detect connections to the fundamental topic of conversation.
✓ Avolition - lack of ability to exercise willpower, indecision in performing voluntary acts
✓ Fantasy - is a mental representation of a scene or occurrence that is recognized as unreal
but is either expected or hoped for.
✓ Obsession - is the pathological presence of a persistent and irresistible thought, feeling
or impulse that cannot be eliminated from consciousness by any logical effort.
IV. Disturbances in Judgment
Delusion - false belief, not consistent with patient’s intelligence and cultural background, which
cannot be corrected by reasoning.
• Delusion of grandeur - exaggerated perception of one’s importance.
• Delusion of persecution - false belief that one is being persecuted, often
found in litigious patients. (Litigiousness - is a pathological tendency to take
legal action because of suspected and imagined persecution. When these
imagined persecutions reach delusional proportions, we speak of delusion
of persecution.)
• Delusion of reference - false belief that the behaviour of others refers to
oneself; derived from ideas of reference in which patient falsely feels he is
being talked about by others.
• Delusion of self-accusation - false feeling of remorse
• Delusion of control - false feeling that one is being controlled by others
• Delusion of infidelity - false belief derived from pathological jealousy
that one’s lover is unfaithful. (Pathological jealousy - may occur in
marital settings in which a spouse has unconscious extramarital
sexual impulses either heterosexual or homosexual, which are then
projected onto the marital partner and emerge clinically as delusions
of infidelity.)
• Paranoid delusion - over-suspiciousness leading to persecutory delusions
4
V. Disturbances in MEMORY
✓ Amnesia - is the partial or total inability to recall past experiences
✓ Retrograde amnesia - there is amnesia for a distant period - prior to the traumatic event
Anterograde amnesia - loss of memory for recent event
✓ Confabulation - there is an unconscious filling in of gaps in memory by imagined
experience that the patient believes, although they have no basis in fact.
✓ Déjà vu - an illusion of recognition in which a new situation is incorrectly regarded as a
repetition of a previous memory. Jamais vu - there is a false feeling of unfamiliarity with a real
situation that one has experienced.
✓ Anomia - lack of memory of items / inability to name objects or persons
✓ Agraphia- Partial or total loss of the ability to express ones thoughts coherently in writing
✓ Agnosia - inability to recognize certain sensory impressions or name objects,
- Lack of sensory stimuli integration other impressions are normal
VI. Disturbances in AFFECT
✓ Affect is the feeling tone, pleasurable or unpleasurable, that accompanies an idea. Shallow or
inadequate affect - emotional flatness
✓ Inappropriate affect - when the emotion does not correlate with the stimulus Labile - changeable
✓ Blunted affect - severe reduction in emotional reaction
✓ Flat affect - absence or near absence of emotional reaction
✓ Apathy - dulled emotional tone associated with detachment or indifference.
✓ Euphoria - refers to the first, moderate level in the scale of pleasurable affects. It is a feeling of
emotional and physical well-being.
✓ Elation - may be thought of as a second level. It is characterized by a definite affect of gladness
in which there is an air of enjoyment and self- confidence, and motor activity is increased.
✓ Exaltation - extreme elation and is usually associated with delusions of grandeur. Ecstasy -
feeling of intense rapture
✓ Ambivalence - refers to the co-existence of antithetical emotions, attitudes, ideas or wishes
towards a given object or situation at the same time.
✓ Depersonalization - a mental phenomenon characterized by a feeling of unreality and
strangeness about oneself. The patient says, in effect,
✓ “This experience does not hurt me because I am not me.”
✓ Derealization - a mental phenomenon characterized by the loss of the sense of reality concerning
one’s environment/surroundings. The patient says in effect, “This environment is not dangerous
to me because this environment does not really exist”.
PSYCHOPHARMACOLOGY
✓ CONTRAINDICATED TO:
• Patients with Renal and Hepatic Dysfunction
• Elderly
✓ No abrupt discontinuation
✓ Given after meals except anxiolytics (given a.c.)
✓ Adverse Effect: SIMILAR ANTICHOLINERGIC EFFECTS EXCEPT - LITHIUM
• Dizziness
• Dry mouth
• Orthostatic Hypotension
• Blurring of vision – mydriasis
• Constipation
5
• Urine retention
PSYCHOTROPIC INITIAL EFFECT FULL THERAPEUTIC EFFECT
For Immediate Tranquilization Reduction of hallucinations,

Antipsychotic Reduced psychomotor agitation delusions and thought disorder
and insomnia - 1 week Takes 6-8 weeks to achieve full effect
Anticholinergic Reduces tremors and rigidity in 2-3 days
Antidepressants Initial effects will take 2-3

TCA’S weeks to develop Nursing 3 to 6 weeks to achieve full therapeutic
Intervention: response
Emphasize compliance
Avoid citrus juice - decrease
absorption
Antidepressants
SSRI’S 2 weeks to achieve initial effects 3-4 full to notice full therapeutic effects
Antidepressants 3-4 full to notice full therapeutic

MAOI’S 2-3 WEEKS BEFORE INITIAL effects NURSING ALERT: Avoid
THERAPEUTIC EFFECTS foods rich in tyramine -leads to
BECOME NOTICEABLE hypertensive crisis
(processed,preserved and fermented)
Lithium decreased hyperactivity/manic Full therapeutic effect 3-4 weeks

episodes Initial effect - 10-14
days
SOMATIC THERAPY
ELECTROCONVULSIVE THERAPY
• mechanism of action - unclear
o Voltage - 70 - 150 volts
o Duration: about .5 - 2 seconds
o Frequency: 6 - 12 treatments
o Interval: 48 hours
• Indicators of effectiveness - occurence of generalized/ tonic - clonic / brain seizures
• Drugs Administered:
• AT SO4-decrease secretions
• Anectine ( Succinylcholine )- promote muscle relaxation- causes life threatening
apneas
• Methohexital Sodium (Brevital)- serves as an anesthetic agent
• Indication: major depression , bipolar dep. and catatonic schizophrenia
6
• Contraindications: fever , Increases ICP, fracture, retinal deterioration, pregnancy

• Common Complications:
o loss of short- term memory
▪ NI: REORIENT client
o Headache
▪ NI: Administer analgesics as ordered
o apnea, respiratory depression or aspiration
▪ NI: Monitor RR; Side-lying position; Prepare suction and
oxygen equipment at bedside; Administer AtSO4 as ordered.
o Fracture
▪ NI: Administer Anectine as ordered; Restrain Exremities
during ECT; X-ray before and after the procedure
MENTAL HEALTH DISORDERS

Mental Disorder/Illness ; General Criteria for Mental Disorders
COGNITIVE DISORDERS
ALZHEIMERS DISEASE
Cause:
- Degenerative neurological disorder characterized by PRESENCE OF SENILE PLAQUES
THAT DESTROYS NEURONS
- Abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now
called a neurofibrillary tangle which involves the parts of the brain that control
thought, memory, and language.
- AD may impair thinking and memory by disrupting these messages.
- There also are lower levels of some of the chemicals in the brain that carry messages
back and forth between nerve cells LEADING TO DECREASED ACETYLCHOLINE.
DEMENTIA
- Dementia is a brain disorder that seriously affects a person's ability to carry out daily
activities, loss of cognitive function and disturbances in behavior
Phases:
FORGETFULNESS PHASE ADVANCED PHASE TERMINAL PHASE
- Difficulty remembering - Difficulty in remembering - Bed ridden
recent events past events - Death might occur in a year
- Anterogade Amnesia - Retrogade Amnesia
- Agnosia - Wandering
- Apraxia - Incontinence
- Alogia
- Aphasia / Alogia
- Anomia
- Agraphia
NURSING ALERT:
AD begins slowly. At first, the only symptom mild forgetfulness, trouble remembering recent events,
activities, or the names of familiar people or things and difficulty in solving simple mathematical
operations.
SCHIZOPHRENIA
7
- Disturbance in thought and sensory perception accompanied by deterioration in psychosocial

functioning.
- Characterized by a weak ego.
- Etiology:
o Genetic Factors
o Biologic Theory: Increase in dopamine; Metabolic imbalance
o Psychological factors: Disruptions in family interactions; Highly critical, hostile and over-
involved personalities
- Dynamics:
o Individual’s persistent faulty reaction to his environment.
o Withdrawal and regression associated with weak ego.
o Indirect outcome of unhealthy, interpersonal relationships between the child and the parent.
o Fundamental Symptoms (Bleueler)
▪ Associative disturbance (loose association; associative looseness) - the stringing
together of unrelated topics
▪ Autism - a form of thinking in which the major content is largely subjective
or endogenous; preoccupation with self without concern for external
reality
▪ Affective incongruity (lack of affect; affective disturbances) - inappropriate, blunted or
flattened or apathy
▪ Ambivalence - simultaneous opposite feelings
Symptoms & Patho-anatomy of Positive & Negative Schizophrenia
Type I (Positive Symptoms) Type II (Negative Symptoms)
Excess or Distortion Diminution or loss of normal function
Marked positive formal thought disorder emotional withdrawal and dysfunctional
Repeated instances of bizarre or relationships
delusional behavior, Develops over a
short period of time
S’s A’s
Sudden hostility, aggression or excitement anhedonia - inability to experience pleasure
Strange / Bizarre behavior attentional impairment
Sensory and Conceptual disorganization avolition - lack of motivation
Severe hallucinations alogia
Severe delusions anergia - absence of energy
Suspicion and ideas of reference affective flattening
Suicidal tendencies
Speech pressure
Treatment
1. Individual or group psychotherapy, somatic therapy, behavior modifications and chemotherapy.
• Recovery rate is influenced positively when the patient can receive individualized attention.
• PSYCHOANALYSIS
• Electroshock therapy
• Planned recreation and occupational and industrial therapy.
8
2. Selective tranquilizers - ANTI- PSYCHOTICS

• Chlorpromazine (Thorazine)
• Triflouperazine (Stelazine)
• Thioridazine (Mellaril)
• Fluphenazine ( Permitil)
Mood Disorders
• Disturbances in emotional and behavioural response patterns
• Ranges from elation to agitation to severe depression and serious potential suicide.
UNIPOLAR BIPOLAR
Major Depressive Disorder (MDD) -At lease Manic episode - usually begin suddenly,
five of the nine symptoms escalate rapidly, and last from a few days
must be present during that two-week to several months;
period, one of which MUST be depressed
mood or anhedonia.
A-L-O-N-E-S-O-M-E” “M-O-R-B-I-D”
A-GITATION-Increased or decreased M - ore talkative; pressured speech O-
psychomotor activity (psychomotor ver inflated esteem - GRANDEUR
disturbance) R- acing thoughts -FLIGHT OF IDEAS B-
L-OSS OF INTEREST OR PLEASURE- ehavior expansiveness; elation increase
Inability to express pleasure or markedly in activity; agitation
diminished interest in pleasurable activities *excessive involvement in pleasurable
(anhedonia) activities without regard for negative
O-BVIOUS significant WEIGHT CHANGE consequences
with appetite disturbance (>5% of body D- istractability and decreased sleep
weight within one month up or down)
N-IHILISM- Feelings of worthlessness or
excessive or inappropriate guilt
E-MOTIONAL BLUNTING AND SAD
AFFECT - Depressed mood
S-LEEP DISTURBANCE (insomnia or
hypersomnia)
O-VERT SUICIDAL IDEATION , Recurrent
thoughts of death or suicidal ideations
M-EMORY DISTURBANCE -Diminished
ability to concentrate or indecisiveness
E-NERGY LOSS or Fatigue
Specifiers for MDD (DSM-IV): HYPOMANIC - LESS SEVERE
Atypical depression -mood reactivity - An elevated state that is less intense
Melancholic depression -anhedonia and an than full mania.
inability to be cheered up Postpartum
depression -first 30 days or less in the
postpartum period. Psychotic depression -
delusions and hallucinations
Seasonal affective disorder (SAD)
9
DYSTHYMIA- LESS SEVERE 2YEARS OR CYCLOTHYMIA -EPISODES OF

MORE abnormally elevated, expansive or
irritable moods. LAST 2 YEARS
DEPRESSION NOT OTHERWISE BIPOLAR DISORDERS
SPECIFIED- 2 DAYS -2WEEKS Extremes of mood polarity. Manic-
depressive disorder or mood swings.
Bipolar I disorder - there must be current
or past experience of a manic episode,
lasting at least one week,
Bipolar II disorder - presence or history
of one or more major depressive
episodes and at least one hypomanic
episode. There has
never been a manic episode.
Response to real or imagined loss AFFECTIVE DISORDER
Anger and aggression towards self result ELATION AND GRANDIOSITY
from feelings of guilt about negative or DEFENSE AGAINST UNDERLYING
ambivalent feelings DEPRESSION/LOW SELF ESTEEM
INTROJECTION occurs (incorporation of a COMPENSATION, SUPPRESSION and
loved or hated object or REACTION FORMATION. TESTING
person into one’s own ego) AND MANIPULATIVE BEHAVIOR
INDICATIVE OF LOW SELF- ESTEEM
Mania - flight from reality to escape inner
conflict, depression- is the
result of failing to deal adequately with
conflict
Maintain a therapeutically safe environment Provide a safe environment.
Maintain a supportive professional attitude Set limits on patient’s disruptive behaviors
- Encouraging and reassuring Provide a homogenous group if possible
- Show confidence in patient milieu
- Kind firmness approach Administer Communicate with firm, unambivalent
medications as ordered and consistent approach and a
matter-of-fact attitude
ANXIETY DISORDERS
ANXIETY - feeling of dread or fear in the absence of a threat or disproportionate to the nature of
threat present.
• THESE ARE EMOTIONAL ILLNESSES CHARACTERIZED BY FEAR, AUTONOMIC
NERVOUS SYSTEM SYMPTOMS AND AVOIDANCE BEHAVIOR
1. GENERALIZED ANXIETY DISORDERS - a person with this disorder spends his days
experiencing anxiety or worry beyond what would be a normal reaction to daily stresses. The worry or
the anxiety is out of proportion to the original situation.
10
PSYCHOTHERAPEUTIC MANAGEMENT:
✓ Reducing his level of anxiety by developing adaptive coping responses. Support and reassurance;
acknowledgement of his discomfort, promotes trust.
2. PANIC DISORDER - anxiety is the major characteristic. The panic attack is accompanied by
intense fear or discomfort that lasts from minutes to, more rarely, hours. The attacks are spontaneous or
occur “out of the blue” with no apparent cause or stimulus. This panic attack may be severe and
incapacitating to the person and are more frightening than symptoms experienced with the generalized
anxiety disorder.
Psychotherapeutic Management
✓ stay with the patient and acknowledge his discomforts
✓ If the patient is hyperventilating, give him a brown paper bag and focus on breathing with the
patient. If the patient is pacing or crying, allow him to do so to enable him to release tension and
energy.
✓ Communicate to the patient that you are in control
and will not let anything happen to him. Ask the
patient to express his perception or fear about what
is happening to him.
3. OBSESSIVE - COMPULSIVE DISORDER

o Obsession - persistent recurrence of unwanted distressing thoughts or impulses
o Compulsions - illogical, repetitive, and undesired urges to perform acts which are against the
persons ordinary wishes.
o The individual recognizes the unreasonableness and absurdity of the obsessions
and compulsions, but is unable to control them.
✓ Therapeutic work between the patient and the nurse focuses on teaching and
developing adaptive coping behaviors to deal with anxiety. Therapeutic goals are
geared towards increasing the patient’s expression of feelings and increasing his
ability to make decisions concerning conflicts.
✓ Provide the patient with time to perform rituals because he needs to keep anxiety in
check. Later work to decrease the rituals by setting limits, but never take away a
ritual or panic may ensure.
4. PHOBIC DISORDERS - Are intense, irrational fear responses to an external object, activity, or
situation.
It is characterized by a persistent fear of specific places or things; anxiety is displaced or externalized to
a source outside the body.
Types:
✓ Agoraphobia - fear of being in public or open spaces, places, or situations where escape could
be difficult or help might not be available, for example, if the person should faint.
✓ Social Phobia - fear of being humiliated, scrutinized, or embarrassed in public if one should, for
example, choke while eating in front of others or stumble while dancing around others.
✓ Simple Phobia - fear of a specific object or situation that is not either of the above. Examples
are claustrophobia (a fear of closed places and a fear of black cats).
11
Interventions:
✓ Acceptance of the patient and his fears with a non-critical attitude.
✓ Provide and involve the patient in activities that do not increase anxiety but will increase
involvement rather than avoidance of others. Help the patient with physical safety and comfort
needs.
✓ Help the patient recognize that this behavior is a method with coping with anxiety.
5. POSTRAUMATIC STRESS DISORDER

Is a disorder that can develop after experiencing an out of the ordinary life-threatening or
traumatic event or a series of serious circumstances. The traumatic event is persistently re-
experienced in at least one of the following ways:
• Recurrent and intrusive distressing recollections of the event.
• Recurrent distressing dreams of the event.
• Sudden acting or feeling as if the traumatic event were recurring (includes a sense
of reliving the experience, illusions, hallucinations, and dissociative episodes, even
those that occur on awakening or when intoxicated)
• Intense psychological distress at exposure to events that symbolize or resemble
an aspect of the traumatic event, including anniversaries of the trauma.
• Persistent avoidance of the stimuli associated with the trauma of numbing of general
responsiveness (not present before the trauma), as indicated by at least three of
the following:
• efforts to avoid thoughts or feelings associated with the trauma
✓ Treatment must be individualized according to the predominant symptom and the associated
problems, such as depression, suicidal ideation, or substance abuse.
PERSONALITY DISORDERS
- RIGID MALADAPTIVE PATTERNS OF FUNCTIONING AND BEHAVIOR
THAT ARE STABLE THROUGH TIME AND LEAD TO UNHAPPINESS
- Deeply ingrained maladaptive behavioral patterns that are lifelong in duration and often
recognizable at adolescence or earlier.
TYPE CHARACTERISTIC AND PSYCHOTHERAP

CRITERIA EUTIC
MANAGEMENT
PARANOID • suspiciousness and • Psychotherapeut
mistrust o people ic task on dealing
ECCENTR
CLUSTER
A: ODD /
• interprets actions of others with trust issues

as personal threat • Low doses of
• hypertensive and phenothiazines
IC
humourless
• uses PROJECTION
12
SCHIZOID • Shy, Introverted, cold and • focus on

detached building trust
• Little verbal communication • Gradual
• Day dreaming Involvement: Milieu
• Uses and Group
INTELLECTUALIZATION activities that
• Describes emotional improve social
responses as matter of fact skills
SCHIZOTYPAL • sensitive to rejection and • involved with
anger activities in others
• suspicious, blunted or • Low doses of
inappropriate affect neuroleptics may
• eccentric and odd decrease severity of
• vague stereotypical speech symptoms.
• problem in thinking,
perceiving and communicating
ANTI-SOCIAL • immature and irresponsible • firm limit setting
PERSONAL • associated with substance • confront
abuse and dependency behaviours
problems consistently
• lack of guilt and remorse • enforce
• disregards the rights of consequences
CLUSTER B: DRAMATIC / ERRATIC
others • group therapy

• unlawful, reckless and
aggressive behaviours
• smooth talkers
• rationalizes and denies own
behaviour
BORDERLINE • repetitive self- • consistent limit
destructiveness setting
• projective identification • supportive
• splitting behaviours confrontation
• fears of separation • behavioural
• unstable but intense contracts decrease
relationship with others mutilation
• temper tantrums • assist patient in
• impulsive identifying,
• hypochondriac verbalizing and
• labile mood controlling
• blames others for own negative
problem behaviours
• empathy
• group therapy
13
NARCISSISTIC • arrogant • supportive

• grandiosity confrontation
• lack of ability to feel • limit setting and
• shallow relationship with consistent
others approach
• view others as inferior • focus on here
• needs to be admired and now
• uses rationalization to • teach patient
blame others that mistakes are
acceptable and
imperfections do
not decrease worth
HISTRIONIC • overly concerned with • facilitate
physical appearance expression
• attention seeking • positive
behaviours reinforcement for
• extrovert unselfish
• self-cantered behaviour
• excessively impressionistic
and lacking in detail
• cannot deal with feelings
CLU STER C: DEPENDENT • passive • Goal of NPR is
ANXI OUS/ to increase sense
FEAR of responsibility
TYPE CHARACTERISTIC AND CRITERIA PSYCHOTHERAPEUTIC

MANAGEMENT
• icesssant demands for attention of • Promote assertiveness
others
• needs excessive reassurance and
advise
• anxious or helpless when alone
• fear of loss of support and withdrawal
• lacks self confidence
14
PASSIVE / • procrastinator • assertiveness

AGGRESSIVE • argumentative • autonomy
• avoids obligations • relaxationtechniques
• resents opinion of others • proper time management
• unreasonably criticizes
AVOIDANT • hypersensitive to criticism • gradually confront fears
• fears intimacy • discuss feelings before and
• views self as socially inept, inferior, after goal accomplishment
unappealing • teach assertiveness
• withdrawn and timid • increase exposure to small
groups
OBSESSIVE- • Perfectionism interferes task fulfilment • Explore feelings
COMPULSIVE • Preoccupied with rules and details • Help with decision making
• Precise, rigid and stubborn • Teach patient that mistakes
• Punctual and indecisive are acceptable
• Procrastinating
• Pitiless and cold
• Parsimonous
• Reaction Formation, Intellectualization
and displacement
EATING DISORDERS
ANOREXIA NERVOSA BULIMIA NERVOSA
Starvation and Emaciation Binging and Purging
a distortion of body image and Recurrent episodes of overeating
perception, so that the person and self- induced vomiting - AT
perceives herself to be fat when LEAST 2 TIMES / WK
actually she is underweight
INCIDENCE 95% - female, adolescence or early adult life,
12 and 18 years. primarily in females.
May be episodic or persist until Chronic & intermittent -many years.
death,
2 years, dies of complications of
the illness.
15
MANIFESTATIONS L.O.W - F.O.RM Dangerous behaviors - control

Loss Of Weight: shape and weight, that is, extreme
Deliberate Weight Loss; self- dieting, excessive exercising, self-
inflicted weight loss induced vomiting and taking of
2 Groups of Anorectic Patients: laxatives or diuretics. Dental
Dieters -eat less problems usually occur because
- rigid exercise program Vomiters the acidic vomitus decays the
and Purgers - enamel of their teeth.
- Dangerous methods of
weight reduction, such as pre-occupation with thinness
induction of vomiting or excessive Persistent over-concern with body
use of laxative. shape and weight. hiding food -
- commonly deny concern preoccupation with food
about weight Bulimics are torn between two
- Dental problems usually strong conflicting
occur because the acidic vomitus feelings: the fear of being fat and the
decays the enamel of their teeth love of food. The anxiety present
Fear of Obesity before the binge-trigger
pre-occupation with thinness Often replaced with guilt after the
intense fear of becoming fat, even binge. If anxiety is not relieved,
obviously underweight; patient will feel angry and agitated,
rigid structure- fear of spontaneity become depressed.
Fear of loss of control over food Fatigue and headache.
complain of depression 2 Conditions that justify a bulimic
loss of interest in social activities episode: considers excessive
Solitary projects, theme sad or quantity of food
morbid. Involuntary frenzy, gulping & stuffing
Refusal to eat large volume of liquid also may be
preoccupation with food ( loves to consumed, to induce vomiting after
cook and bake ) suppress their eating.
hunger
Miscellaneous
ANOREXIA NERVOSA BULIMIA NERVOSA

Personality changes
Amenorrhea
Constipation
Hypertension Pitting
Edema Lanugo
Hyperactive
Restless
PSYCHOSEXUAL DISORDERS
16
PARAPHILIAS
✓ Exhibitionism - Exposure of one’s body to a stranger or to an unexpecting person, especially
the genitalia, as a means of attracting sexual attention or achieving sexual excitement or
gratification. Usually a perversion of males.
✓ Fetishism - sexual focus is on objects that are intimately associated with the human body.
Common fetish objects are bras, underpants, stockings and shoes. Less common fetish
objects include urine-soaked or feces smeared items. The person often masturbates
while holding or rubbing these items.
✓ Pedophilia - sexual pleasure is derived from sexual activity with (pre-puberty) children
either in fantasy or in actuality. The male pedophile is often said to be masochistic and is
frequently impotent. (The child usually younger than 13 years) (And the Pedophile older
than the victim is usually above 16 years).
✓ Sexual Masochism - excitement is linked with the passive experience of physical or
emotional subjugation, humiliation, discomfort, danger, abuse or tortures any of which
may be simulated or real. Pleasure is derived from being made to suffer.
✓ Sexual Sadism - excitement is linked to the active infliction, in fantasy or in reality, of
humiliation, subjugation, abuses or torture. Pleasure is derived from inflicting
psychological or physical suffering on another.
✓ Transvestic Fetishism - sexual pleasure is derived from cross-dressing. The person may
wear only the underwear of a woman or may completely dress as a woman.
✓ Voyeurism - sexual pleasure is derived from observing unsuspecting persons who are naked
or undressing or who are engaged in sexual activity; “peeping Tom”
MANAGEMENTS:
1. BEHAVIOR MODIFICATION THERAPY
✓ RELEARNING UNCONVENTIONAL SEXUAL BEHAVIORS
✓ Support and Activity Groups Self - Help Group
✓ Cognitive Therapy
✓ Rehabilitation - consistent limit setting and conditioning
✓ PSYCHOANALYSIS
✓ FAMILY THERAPY
SUBSTANCE ABUSE
SUBSTANCE MANIFESTATIONS WITHDRAWAL MANAGEMENT
STIMULANTS
METHAMPHETAMINE Weight Loss
Dexedrine Ecstasy Hyperactivity - Administer anti-
Increased vital signs • Depression hypertensives and anti-
Loss of Appetite • Psychosis anxiety medications as
Euphoria • Psychomotor ordered.
Agitation Irritability Agitation and - IV Barbiturates is
Dilated Pupils seizures given as antidote for
COCAINE perforated nasal overdose
septum
DEPPRESSANTS
17
NARCOTICS Pinpoint pupils • Tremors • Detoxification

MORPHINE HEROINE Drowsiness • Hallucinations • Administer anti-
DEMEROL CODEINE Lack of coordination • Delusions anxiety medication
DILAUDID Respiratory • Seizures as ordered
depression • Coryza • Initiate seizure
• Abdominal precautions
cramps • Limit patient
• Nausea and stimulation
vomiting
HALLUCINOGENS
CANNABIS Fatigue Paranoia • Insomnia -
Psychosis • Hyperactivity
Euphoria • Anorexia
Increases appetite
Disorientation
GENERAL INTERVENTIONS:
BEHAVIOR MODIFICATION (FIRMNESS, MATTER-OF-FACT ATTITUDE)
DETOXIFICATION - first step in rehabilitation
TAPERING down to prevent life threatening withdrawal manifestations
Administer medications as ordered (ANTIDOTES, ANTAGONIST
AND DETOXIFICATION SUBSTANCES) Promote physical
health
Implement measures for personality disorders and manipulative behavior
Alcoholism
State of physical and psychological dependence on alcohol manifested by the individuals
inability to refrain from drinking or control alcohol consumption
Defense CAGE
mechanisms: questionnaire: Phases:
D- enial C- ut down
R- ationalization A- nnoyed Pre alcoholic-social drinking
I - solation G- uilty Prodromal - becomes a need; blackouts occur
P- rojection E- ye- Crucial - loss of control over drinking, cardinal
opener symptoms develops Chronic phase - the person
becomes intoxicated all day
WERNICKE’S ENCEPHALOPATHY BOTH KORSAKOFF’S
PSYCHOSIS
18
CONFUSION AND AMNESIA CONFABULATION

DISORIENTATION MEMORY AND LEARNING
APATHY DISTURBANCE PROBLEMS
ATAXIA AND LACK OF NERVOUSNESS& PSYCHOSIS- LOSS
COORDINATION ATTENTION DIST. OF REALITY
OPTHALMOPLEGIA - irregular EXECUTIVE FUNCTION TESTING
eye movements IMPAIRED SHORT - TERM
LOSS OF TASTE & SMELL SENSORIMOTOR AMNESIA
IMPAIRED THINKING APHASIA INABILITY TO
AGNOSIA LEARN NEW
APRAXIA SKILLS
MANAGEMENT:
✓ IM / IV Thiamine, B12, Folic Acid and Niacin Supplementation Balanced diet and alcohol
abstinence
✓ Behaviour Modification: Consistent limit setting
✓ Group Therapy: Develops insight and personal decision making (to overcome denial)
Detoxification and Aversion Therapy
✓ ANTABUSE - delays alcohol metabolism
✓ Patient MUST BE ALCOHOL FREE FOR 12 HOURS
✓ Avoid food and drinks with alcohol content
✓ DISULFIRAM REACTION: FLUSHING, SWEATING, N & V, SYNCOPE, DIZZINESS,
THROBBING HEADACHE, SEVERE - HYPOTENSION, CONFUSION, COMA, DEATH
SOMATOFORM DISORDERS
✓ PRESENCE OF PHYSICAL SYMPTOMS BUT WITHOUT EVIDENCE OF
PHYSIOLOGIC DISORDER. LINKED TO PSYCHOLOGIC FACTOR OR EMOTIONAL
CONFLICT
✓ Patient has physical symptoms for which there is no known organic cause or physiological
mechanism.
✓ Evidence is present or a presumption exists that the physical symptoms are
connected to psychological factors or conflicts. Unconscious and involuntary;
patient expresses conflicts through bodily symptoms and complaints.
1. SOMATIZATION DISORDER
• The main characteristics of this disorder are that the individual verbalizes recurrent,
frequent, and multiple somatic complaints for several years with no physiological
cause.
• Begins before the age of 30. Complaints in a vague but dramatic fashion.
• Seen many physicians have had exploratory and unnecessary surgical procedures. These
patients may be anxious or depressed.
• Nervous, have sleep disturbances, and experience suicidal ideation because they
experience hopelessness about ever getting better.
• Focuses on symptoms of disease.
• Accompanied by anxiety and depression
2. SOMATOFORM PAIN DISORDER
• THE CHIEF COMPLAINT IS SEVERE PAIN.
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• Is inconsistent. If the pain mimics a physical disorder, it cannot be accounted for by a

physiological reason or cause. Present by 6 months. Location does not change.
• “Doctor Shoppers”, may use analgesics excessively without relief.
3. HYPOCHONDRIASIS
• The hypochondriac is preoccupied or worried about getting a serious disease or fears and
believes that he has a serious disease.
• There is no physiological basis for his fear or belief
• Negative on Physical Evaluation
4. CONVERSION DISORDER
• The major characteristic of the conversion disorder is a loss or alteration of physical
functioning that suggests a physical disorder but instead is an expression of a
psychological need or conflict.
• The most common conversion symptoms suggest neurological disease such as paralysis,
blindness, or seizures.
• PRIMARY GAIN- alleviation of anxiety the in that the conflict is kept out of awareness
• SECONDARY GAIN - AVOID DISTRESSING/UNCOMFORTABLE ACTIVITY WHILE
RECEIVING SUPPORT FROM OTHERS. Refers to the
gratification received as a result of how people in the patient’s environment respond to his
illness.
• CONVERSION HYSTERIA, PHYSICAL SYMPTOMS WITH NO ORGANIC BASIS-
blindness, paralysis, convulsions without LOC, stocking and glove anesthesia, la belle
indifference (unusual lack of concern)
PSYCHOTHERAPEUTIC MANAGEMENT OF SOMATOFORM DISORDERS

• Use a matter-of-fact caring approach when providing care for physical symptoms to
decrease secondary gains and to decrease focusing on physical symptoms.
• Ask the patient how he is feeling and ask him to describe his feelings to increase his
use of verbalization about feelings, especially negative ones, needs, and anxiety rather
than somatization. Assist the patient with developing more appropriate ways to
verbalize feelings and needs.
• Use positive reinforcement to increase non-complaining behavior and set limits by
withdrawing attention from the patient when he focuses on physical complaints or
makes unreasonable demands.
• Be consistent with the patient and have all requests directed to the primary nurse
providing care to decrease attention-seeking or manipulative behaviors.
• Use diversion by including the patient in milieu activities and recreational games to decrease
rumination about physical complaints.
• Do not push awareness or insight about conflicts or problems because anxiety will only
increase, and the need for symptoms will be maintained.
20

PERIOPERATIVE NURSING
Perioperative - refers to the total span of surgical intervention. Surgical intervention is a common
treatment for injury, disease, or disorder and has three phases: preoperative, intraoperative, and
postoperative
CLASSIFICATIONS OF SURGERY
• According to Reason/Purpose:
1. Diagnostic- removal and examination of tissue (e.g., biopsy).
2. Curative/Ablative-removal of a diseased organ or structure (e.g. appendectomy).
3. Restorative - repair a congenitally malformed organ or tissue. (e.g., harelip; cleft palate
repair).
4. Palliative- relief of pain (for example, rhizotomy-interruption of the nerve root between the
ganglion and the spinal cord).
5. Reconstructive- repair or restoration of an organ or structure (e.g., colostomy; rhinoplasty,
cosmetic improvement).
• According to Degree of Urgency

1. Urgent - needs immediate interventions
2. Elective- surgery that can be delayed
3. Optional - Patient may opt to have or not to have surgery 4.
• According to Degree of Risk
1. Major- requires hospitalization, is usually prolonged, carries a higher degree of risk,
involves major body organs or life- threatening situations, and has the potential of
postoperative complications.
2. Minor- brief, carries a low risk, and results in few complications
PRE-OPERATIVE PHASE
Begins when a decision for surgery is made until the client is admitted at the operating room.
• Leg and deep breathing exercises; ROM exercises
• Moving patient ; coughing and splinting
• Preoperative medications : when they are given & their effects
• Postoperative pain control
• Explanation & description of post anesthesia care recovery room
• Discussion of the frequency I assessing V/S & use of monitoring equipment.
INTRA - OPERATIVE PHASE

• The intraoperative phase is the period during which the patient is undergoing surgery in the
operating room. It ends when the patient is transferred to the post-anesthesia recovery room.
A. The Surgeon
✓ the leader of the surgical team.
✓ ultimately responsible for performing the surgery effectively and safely; however, he is
1
dependent upon other members of the team for the patient's emotional well-being and
physiologic monitoring.
B. Anesthesiologist/Anesthetist.
✓ a physician trained in the administration of anesthetics. An anesthetist is a registered
professional nurse trained to administer anesthetics. The responsibilities of the
anesthesiologist or anesthetist include:
1. Providing a smooth induction of the patient's anesthesia in order to prevent pain.
2. Maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical
procedure.
3. Continuous monitoring of the physiologic status of the patient for the duration of the
surgical procedure.
C. Scrub Nurse/Assistant.
✓ is a nurse or surgical technician who prepares the surgical set-up, maintains surgical asepsis
while draping and handling instruments, and assists the surgeon by passing instruments,
sutures, and supplies.
✓ The scrub nurse must have extensive knowledge of all instruments and how they are used.
The scrub nurse or assistant wears sterile gown, cap, mask, and gloves.
D. Circulating Nurse.
✓ is a professional registered nurse who is liaison between scrubbed personnel and those
outside of the operating room.
✓ The circulating nurse is free to respond to request from the surgeon, anesthesiologist or
anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing
care plan.
✓ The circulating nurse does not scrub or wear sterile gloves or a sterile gown. Other
responsibilities include:
1. Initial assessment of the patient on admission to the operating room, helping monitor the
patient’s condition.
2. Assisting the surgeon and scrub nurse to don sterile gowns and gloves.
3. Anticipating the need for equipment, instruments, medications, and blood
components, opening packages so that the scrub nurse can remove the sterile
supplies, preparing labels, and arranging for transfer of specimens to the laboratory
for analysis.
4. Saving all used and discarded gauze sponges, and at the end of the operation,
counting the number of sponges, instruments, and needles used during the
operation.
MAJOR CLASSIFICATIONS OF ANESTHETIC AGENTS

A. General anesthesia is used for major head and neck surgery, intracranial surgery, thoracic surgery,
upper abdominal surgery, and surgery of the upper and lower extremities.
There are three phases of general anesthesia: induction, maintenance, and emergence.
✓ Induction, (rendering the patient unconscious) begins with administration of the anesthetic
agent and continues until the patient is ready for the incision.
✓ Maintenance (surgical anesthesia) begins with the initial incision and continues until near
completion of the procedure.
✓ Emergence begins when the patient starts to come out from under the effects of the
2
anesthesia and usually ends when the patient leaves the operating room.
B. A regional or block anesthetic agent causes loss of sensation in a large region of the body.
✓ The patient remains awake but loses sensation in the specific region anesthetized.
✓ In some instances, reflexes are lost also.
✓ When an anesthetic agent is injected near a nerve or nerve pathway, it is termed regional
anesthesia.
C. Local anesthesia is administration of an anesthetic agent directly into the tissues.
• It may be applied topically to skin surfaces and the mucous membranes in the
nasopharynx, mouth, vagina, or rectum or injected intradermally.
✓ Local infiltration is used in suturing small wounds and in minor surgical procedures such as skin
biopsy.
✓ Topical anesthesia is used on mucous membranes, open skin surfaces, wounds, and burns.
✓ ADVANTAGE of local anesthesia: it acts quickly and has few side-effects.
Recovery Room Care

• The postoperative phase lasts from the patient's admission to the recovery room
through the complete recovery from surgery. THE RECOVERY ROOM
o is defined as a specific nursing unit, which accommodates patients who have undergone
major or minor surgery.
o General nursing goals of care for a patient in the recovery room are:
• Position the unconscious patient with his head to the side and slightly down.
• This position keeps the tongue forward, preventing it from blocking the throat and allows
mucus or vomitus to drain out of the mouth rather than down the respiratory tree.
• Do not place a pillow under the head during the immediate postanesthetic stage. Patients
who have had spinal anesthetics usually lie flat for 8 to 12 hours.
• Call the patient by name in a normal tone of voice and tell him repeatedly that the surgery is
over and that he is in the recovery room.
(2) To relieve the patient's discomfort:
POSTOPERATIVE PATIENT CARE

1. DEEP BREATHING EXERCISES
• Deep breathing exercises hyperventilate the alveoli and prevent their collapse
Ask the patient to:
1. Exhale gently and completely.
2. Inhale through the nose gently and completely.
3. Hold his breath and mentally count to three.
4. Exhale as completely as possible through pursed lips as if to whistle.
5. Repeat these steps three times every hour while awake.
2. COUGHING EXERCISES in conjunction with deep breathing, helps to remove retained mucus from
the respiratory tract.
• Coughing is painful for the postoperative patient. While in a semi-Fowler's position, the
patient should support the incision with a pillow or folded bath blanket and follow these
guidelines for effective coughing:
3
3. INCENTIVE SPIROMETER may be ordered to help increase lung volume, inflation of alveoli, and
facilitate venous return.
A. While in an upright position, the patient should take two or three normal breaths,
then insert the spirometer's mouthpiece into his mouth.
B. Inhale through the mouth and hold the breath for 3 to 5 seconds.
C. Exhale slowly and fully.
D. Repeat this sequence 10 times during each waking hour for the first 5 post-op
days. Do not use the spirometer immediately before or after meals.
4. LEG EXERCISES
To prevent thrombophlebitis: instruct the patient to exercise the legs while on bed rest
o Leg exercises are easier if the patient is in a supine position with the head of
the bed slightly raised to relax abdominal muscles.
- GUIDELINES:
A. Flex and extend the knees, pressing the backs of the knees down toward the mattress
on extension.
B. Alternately, point the toes toward the chin (dorsiflex) and toward the foot of the bed
(plantar flex); then, make a circle with the toes.
C. Raise and lower each leg, keeping the leg straight.
D. Repeat leg exercises every 1 to 2 hours.

Communicable Disease Nursing Guide

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NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH

LET*PSYCH*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM

TOPRANK REVIEW ACADEMY | 1

TOPRANK REVIEW ACADEMY | 2

TOPRANK REVIEW ACADEMY | 3

Categories Recommended in Isolation

TOPRANK REVIEW ACADEMY | 4

 Second Tier of precaution

Congenital Varicella results in:

Susceptibility, Resistance & Occurrence

TOPRANK REVIEW ACADEMY | 5

 An attack confers long immunity

Description: it is an acute contagious and exanthematous disease that usually affects

TOPRANK REVIEW ACADEMY | 6

Description: It is a chronic systematic infection characterized by progressive cutaneous

Three distinct forms

TOPRANK REVIEW ACADEMY | 7

Etiological Agent: Mycobacterium leprae

TOPRANK REVIEW ACADEMY | 8

TOPRANK REVIEW ACADEMY | 9

Etiologic Agent: Rubella virus

TOPRANK REVIEW ACADEMY | 10

 Post-auricular, sub-occipital and posterior cervical lymphadenopathy which

TOPRANK REVIEW ACADEMY | 11

disease when pregnant.

TOPRANK REVIEW ACADEMY | 12

 Fine-tooth comb dipped in vinegar

TOPRANK REVIEW ACADEMY | 13

Etiologic Agents: Corynebacterium, diphtheria (Klebs-Loeffier bacillus)

TOPRANK REVIEW ACADEMY | 14

 2 weeks to more than 4 weeks

TOPRANK REVIEW ACADEMY | 15

Incubation Period: 7-10 days but may occasionally be up to 3 weeks

TOPRANK REVIEW ACADEMY | 16

 Nasopharyngeal swabs (Positive for B. pertussis)

 Post Exposure Treatment: Hyperimmune convalescent serum / gamma-globulin

TOPRANK REVIEW ACADEMY | 17

 Arterial Blood Gas Testing may reveal hypoxemia in severe cases

 Laboratory Tests may reveal leukopenia, lymphopenia, and/or thrombocytopenia.

TOPRANK REVIEW ACADEMY | 18

Etiologic Agent: Bacillus anthracis

TOPRANK REVIEW ACADEMY | 19

 Treatment of cutaneous anthrax is oral antibiotic for 7 to 10 days

TOPRANK REVIEW ACADEMY | 20

 Animals believed to have died of anthrax should be disposed of under supervision.

TOPRANK REVIEW ACADEMY | 21

TOPRANK REVIEW ACADEMY | 22

 Tuberculin Testing (for TB exposure)

TOPRANK REVIEW ACADEMY | 23

Direct Observation Treatment Short Course

Prevention and Control

TOPRANK REVIEW ACADEMY | 24

Susceptibility, Resistance & Occurrence

Preventive Measures and Control

TOPRANK REVIEW ACADEMY | 25

TOPRANK REVIEW ACADEMY | 26

TOPRANK REVIEW ACADEMY | 27

Description: It is an acute bacterial infection of the intestine characterized by diarrhea, fever,

TOPRANK REVIEW ACADEMY | 28

TOPRANK REVIEW ACADEMY | 29

Prevention and Control

Prevention and Control

TOPRANK REVIEW ACADEMY | 30

NURSINGRADTECHDENTISTRYCRIMINOLOGYMIDWIFERY*MEDTECH

LETPSYCHRESPIRATORY THERAPYCIVIL SERVICENAPOLCOM