MEDICAL SURGICAL NURSING - Albumin is the protein we see in blood.

It is responsible for maintaining the

oncotic pressure.
- To simplify oncotic pressure, it is the
ADRENAL GLAND albumin that holds the water in the
blood vessels. But because of increase
capillary permeability, the albumin
goes out and makes the interstitial
compartment hypertonic. That will now
tell you what’s the movement of water.
- Osmosis is flow of fluid from lesser
which is inside capillary now. Because
the albumin went out, it accumulates
outside the capillary (interstitial
Questions: How come body produces histamine? compartment). Because the water outside
capillary is Hypertonic (concentration
Answer: is high), it will pull water from
intravascular to interstitial. If fluid
 There is injury, so the injured tissue goes out it will cause Swelling or
produces chemical mediators. The most Edema. So that will explain what tumor
abundant is Histamine. Then because of is.
injury, it will release histamine that - Pain: because of swelling it will push
causes vasodilation. Then it will enter the nerve ending underneath the skin,
blood vessels and blood will go to injured and will cause pain. The patient will
area (because of vasodilation). not be able to move (loss of function).
- Vasodilation is the reason there is warm That is why patient who undergo surgery
to touch and redness. are bed ridden.
- Assessing warm to touch is through
palpation.
BLOOD VESSEL DYSFUNCTION
 Then histamine will increase capillary
permeability and this is because of the
histamine released by the injured tissue,  Permeability
blood vessels specifically Capillaries is - Capillaries leak fluid
affected. out their walls
- Capillaries connect the veins and - Cause by severe
arteries. There is also an exchange of infection (sepsis) and
nutrients, gases and substances in certain diseases
capillaries. Why? Because the membrane
is made up of a single layer, so that
exchange of substances can easily take
place. Also, inside there is WBC, RBC
and platelets. INFLAMMATORY RESPONSE
 Histamine will cause the pores to be
bigger. Albumin is the blood protein. This
is one of the end products if it takes in
protein. And that albumin stays in
intravascular, because it such a big
molecule that it will not be allowed to be
in another compartment.
 Swelling: Because of the injury the
histamine will be produced, it will
increase the force of the capillary, and
this big molecule which is supposed to be
FLUID COMPARTMENT
inside will now have chance to go out and
that is albumin. So it will make
interstitial compartment Hypertonic whereas
inside the capillary is Hypotonic.

What is the mechanism involved?

- Osmosis is flow of fluid from lesser to

greater concentrated solution.

What is inside and in the outside?

- The histamine produced by the injured

issues is going to make the pores in - Intravascular compartment - inside the
the capillary bigger and that will give blood vessels
chance for albumin to go out.
 - Interstitial compartment - space
outside cell and blood vessels. The  Capillary permeability (2nd picture) – the
fluid will go out here which will cause pores became bigger; it should be tight.
swelling. It allows the water, albumin to go out
- Cytoplasm - is the fluid inside the which cause swelling.
cell and have the biggest amount of RAAS in SURGERY
fluid in the body. When there is loss of blood in the body, the
INFLAMMATION body compensates through releasing the 2
catecholamines norepinephrine and epinephrine.
Inflammation is good (Increase cardiac rate + vasoconstriction) and
sends the blood to the primary organ which is
1.) If there is inflammation the WBC will the brain.
show like monocytes and neutrophils.
Immediately it will embrace the bacteria, The kidney will detect that there is less
so that the injury is localized. It will blood flowing to the secondary organ so the
not allow bacteria to spread. If it kidney will release the hormone renin which
spreads it is already the generalized converts angiotensinogen that is found in the
manifestation of inflammation like fever, liver into angiotensin I (a mild
no appetite to eat and body weakness. vasoconstrictor) angiotensin I will then be
Inflammation will limit the injury or converted by Angiotensin converting enzyme
infection. that is found in the lungs into angiotensin II
2.) It prevents spread of damaging agent a potent vasoconstrictor which also stimulates
because of plenty WBC, it will the release of aldosterone in the adrenal
phagocytize (ingest) bacteria. cortex. The aldosterone reabsorbs sodium:
3.) It is going to digest cell debris and where sodium goes water follows. To retain
bacteria fluids in the body. The brain will also
4.) It will Repair the injured area to compensate and the posterior pituitary gland
recover. How? Because of histamine will release the hormone ADH which retains the
produced. Histamine will cause water in the kidney and decreases the
vasodilation, there will be rush of blood production of urine in the body which causes
in operated area. You will see redness, oliguria.
palpate (warm to touch).
- Repair because of the gush of blood in o 1000-1500mL for 24 hours
the injured area. The blood will o 30-50cc for an hour
contain nutrients, oxygen, antibodies, o Decrease urinary output – d/t loss of
and WBC which will help wound recovery. blood during surgery -> hypothalamus
can feel that -Posterior Pituitary
 Function of the inflammatory Response Gland will release ADH – orders kidney
- Prevents spread of damaging agents to reabsorb fluids – Aldosterone is
- Disposes of cell debris & pathogens secondary to retain sodium =
- Set the stage for repair PHYSIOLOGIC OLIGURIA.
o 4th Post-Operative day will give a
CAPILLARY PERMEABILITY Normal I&O
o 2-3 days of Post-Operative will give
you normal bowel sounds
o Dull if you percuss an organ and fluid
o 6 to 8 hours is the expected for the
patient to void after removal of Foley
Catheter.

To prevent constipation
o Early Ambulation
o Increase Fluid Intake
o Fibers in Diet

 Oncotic pressure – fluid is retained in

the blood vessel. Remove the protein and PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENTS
it will cause edematous.
(pp. 418-476 14th Edition)
Ex. Just like babies. Last privilege of
PURPOSE OF SURGERY
Filipinos is not able to get good milk to
children. Hence, usage of condense milk. It 1. Diagnostic -confirmation of suspected
has zero nutrients. The baby will have edema diagnosis
since there is no protein and albumin. It will (ex. Biopsy, Endoscopy, Culture)
result to Anasarca (general swelling of whole - Assessment is needed, also a first step
body). in nursing process.

(ex. Your father says he has a black stool.

Assess, so ask if he ate food or take medicine
which will cause the problem. Medicine like
PRE-OPERATIVE INTERVIEW
ferrous sulfate (iron prep.) will make stool
dark or there might be intestinal bleeding,
peptic ulcer or cancer in the rectum. These  Meet the patient at eye level & introduce
might give blood in stool.) yourself by name first & role
- The nurse should ask the patient to
2. Explorative – confirms the type and tell her full name rather than asking
extent of a disease process. Use what is is she is Mrs. Cruz there might be
inside that can’t be seen by diagnostic another patient by that name on the
test. (ex. Laparotomy, Joint Exploration) schedule
3. Reconstructive – repairs physical
deformities, improves appearance (ex.
 Nurses should not start the physical
assessment or ask the patient’s name
Rhinoplasty, Mammoplasty, Skin grafting)
without first identifying themselves and
4. Curative – diseased, or damaged body
their role
organ, or structure is removed or
repaired (ex. Appendectomy, Hysterectomy, - To relieve the patient’s anxiety in
Fixation of fractures) the new environment of the surgical
5. Palliative – alleviates pain, discomfort experience
or other disease symptoms; Slow PRE-OPERATIVE ASSESSMET
progression of disease but does not cure
(ex. Nerve blocks, Placement of feeding  History of Previous Surgery
tubes)
- To avoid problems previously
(ex. The patient cannot eat because of many encountered (ex. Pneumonectomy;
lesions in mouth or unconscious. IV will respiratory complication will be
not be enough. On the 3rd hospitalization day, possible. Because of anesthesia, it
patient need to eat or else it will destroy will temporarily collapse lung. Also,
the permeability of colon. In the large colon bed ridden patient mucus doesn’t move,
there is microorganism like E. Coli. It should so mucus might block the airway and
only stay in colon. Or the patient might die might cause accumulation.)
due to septic shock)  History of Allergies
 Chronic Disease History (Need to ask:
URGENCY OF SURGERY Diabetes Mellitus, Hypertension, Cancer
or Asthma)
1. Emergent
- Diabetic patient needs to be noted
- Preserves function of body parts or because of hyperglycemia. Wound will
life of the patient
not be able to heal properly. Px need
- The procedure will be carried out to stay longer.
within 1-2 hours from admission (ex.
Repair of major vessels to stop (Note: Be alert about Aspirin medication.
bleeding; like appendectomy, vehicular Because the side effect of Aspirin is
accident) bleeding. The patient will undergo surgery. If
2. Urgent not noted, possible to bleed profusely. Need
- Requires prompt attention within 24-48 to stop 5 – 7 days prior surgery. Other drugs
hours (ex. Repair of fracture Incision to stop are anti-coagulate drugs like
and drainage of wound infection.) Enoxaparin, Coumadin which might cause more
3. Elective bleeding.)
- Patient is in optimal health
- It can wait for days, months or year  Smoking History
- Doe before the disease affect or - Increase risk for postoperative
threatens the quality of life (ex. complications
Inguinal Surgery) - Smoking needs to stop 1-month prior
- Satisfies patient’s desires but not surgery
needed to preserve life or function
Smoking 3 effects:
(ex. Cosmetic Surgery)
1.) It decreases contraction of Cilia.
SURGICAL PROCEDURES CAN BE BROADLY CATEGORIZED
Cilia are hair like structures in upper
AS:
respiratory system. The environment is
- Elective – which is planned not sterile like COVID. So, the Cilia
contracts 1000times/min upwards to
- Emergency – which is unplanned
bring foreign bodies inhaled out to not
reach lungs. Remove by sneezing or
PHASES OF PERIOPERATIVE NURSING cough. Smoking paralyzes Cilia, so when
foreign bodies enter, it easily goes to
I. PRE-OPERATIVE PHASE lungs which might cause Pneumonia.
- Begins when the decision for surgery 2.) You are creating another gas Carbon
is made, and ends when the patient is Monoxide. There are 2 gases in body
transferred to the operating room. Oxygen and Co2. However, smoking
accumulates huge amount of carbon
 monoxide. Hemoglobin which is in RBC When immediate medical treatment is
and carrier of Oxy. & CO2 will be 200x needed to preserve life and the patient
attracted to carbon monoxide. is incapable of giving consent,
3.) Cause Vasoconstriction. It will
THE NEXT OF KIN may give consent
increase the pressure in periphery.
Hence, heart will increase workload. IF REACHING THE NEXT OF KIN IS NOT
 Current Height and Weight POSSIBLE,
- Determine drug dosage calculations THE PHYSICIAN MAY INSTITUTE TREATMENT
 Vital Signs WITHOUT WRITTEN CONSENT
- To detect abnormalities However, healthcare personnel must make
- Provide baseline data every effort to obtain consent by:
Telephone.
(High temp. & High BP like for anxiety = Stop
Surgery)  If it is a true lifesaving emergency,
consent may be obtained over the
 Current Medications telephone from the patient’s next of
- Medications that can affect kin or guardian
coagulation status  The surgeon must obtain the telephone
consent
INFORMED CONSENT  If it is a true lifesaving emergency,
the surgeon often is already in
 An active, share decision-making process surgery, the nurse makes the telephone
between the provider and the recipient of call & another nurse witnesses the call
care
 Consent can be waived in situations in
 It protects the patient, the surgeon and which no family is available
the hospital and its employees
PREOPERATIVE PROCEDURES and EXERCISES
When is it Necessary? 4 Reasons:
Teaching is needed for pre-op than post-op.
1. When it is invasive  Breathing exercises
2. When it requires anesthesia  Coughing and Splinting
3. When it involves radiation  Incentive Spirometry
4. When there is a risk of potential harm  Leg exercises
 Early Ambulation
The operative consent must be signed
before any preoperative medication is  Range-of-Motion Exercises
given.
DEEP BREATHING EXERCISES
- Medications can make you sleepy like
Demerol, Valium. Signing of consent  Dilates the airways
must be prior pre-operative  It expands lung tissue. It will improve
medication. exchange of Oxygen and CO2
The surgeon is legally responsible for  Stimulates surfactant production
obtaining the patient’s informed  Expands the lung tissue surface THUS
consent. Nurse are only witness. IMPROVING RESPIRATORY GAS EXCHANGE
 It is the surgeon's responsibility  Dilated airways → increased lumen of
 to discuss the planned procedure bronchi → better passing of oxygen and
 review the risks, benefits, &
alternatives to the planned carbon dioxide → stimulates surfactant
procedure production → decreasing surface tension
 If the patient verbalizes that he or → decreased attraction of water
she does not understand the molecules
procedure that is planned, it is the  Surfactants: a phospholipid substance
nurse’s responsibility to notify the found only in alveoli. Alveoli has
surgeon of this lack of many water molecules. This has
understanding right away tendency to attracts towards each
 The nurse should not teach about the other. If surface tension is high, can
procedure; the surgeon needs to do cause collapse of alveoli. Surfactants
this. are produced by alveolar type 2 cells.
If the patient is a o Surfactant is present as early as 8
 MINOR months of pregnancy
 UNCONSCIOUS o If the surface tension is increased,
 MENTALLY INCOMPETENT it results to the collapse of the
 The written permission may be alveoli
given by a REPONSIBLE FAMILY o Surfactants decrease surface tension
MEMBER (water molecules). Meaning it will
decrease attraction of water
molecules.
 o Alveoli: 3 Million of alveoli, 150
million in each lung; comparable to seal with the lips → breathe deeply
a tennis court. through the mouth → hold for
- Pain after surgery → shallow 3 seconds → remove mouthpiece → exhale
breathing (inhaling deeply = pain) normally through the mouth
- Immobilized (bed ridden because of LEG EXERCISES
pain): tendency of accumulation of
goblet cells causing mucus to - Prevent venous stasis and help push blood
partially obstruct airways to the right side of the heart. Venous
stasis promotes blood to clot.
 DIAPHRAGM - Muscle is surrounding the vein. Veins
have valve, moving the legs will squeeze
- The diaphragm is the major muscle of
veins and that will push blood to the
respiration.
right side of the heart.
- Inhale = diaphragm descends
- More than 3 Days bed ridden Px: prone to
- Located under the lung clotted blood. One of the complications
- Deep breathing causes it to descend, is Thrombus, once dislodge can lead to
thereby increasing the ventilating pulmonary embolism or to the brain and
surface cause cerebrovascular accident.
COUGHING EXERCISES EARLY AMBULATION
 Loosens mucus secretions and forces them  Ambulation will move secretions,
up into the BRONCHUS to be expectorated increase peristalsis, prevent venous
or suctioned. stasis (accumulation of blood in the
 SITTING UPRIGHT shifts abdominal organs lower extremities) that can develop
away from the lungs, enabling greater venous thrombosis, DVT.
expansion.
 Mucus accumulates and can partially RANGE-of-MOTION EXERCISES
obstruct flow of oxygen and carbon  To prevent joint rigidity and muscle
dioxide contractures
 Patients should be asked to perform deep  Done 3 – 4 times a day
breathing & incentive spirometry 10
times every hour holding each breath for PREOPERATIVE TEACHING
three seconds during waking hours to o Reduces anxiety
prevent: o The timing of pre-op teaching is highly
 Atelectasis (Anesthesia will individualized.
temporarily collapse lung. o Ideally there will be enough time for
Surgical pain causes shallow the nurse to give instructions and
breathing, that will not expand answer questions
lungs.) o Often the client is admitted on the day
 Pneumonia (anesthesia may paralyze of surgery. It is imperative that the
Cilia. Foreign bodies will easily client receives instructions before
enter your lung) this time so that the nurse can simply
 Contraindications reinforce instructions and answer
 Cranial surgeries because of questions
increased Intracranial pressure o But if the teaching is done too far in
(ICP) advance, the client will forget the
 Eye surgeries because of increased information
intraocular pressure
CLIENT PREPARATION
SPLINTING
NPO STATUS
- Small pillow/rolled blanket or
towel/hands (middle fingers should be  To prevent aspiration
touching)  8-10 or 10-12 hours before surgery.
- For the suture not to break Anesthesia → Decrease peristalsis →
- If patient has muscle weakness, use Increase secretions → accumulation of
nurse’s hand gastric secretions in the stomach →
gag reflex not active → No epiglottis
→ substances can regurgitate → Food
INCENTIVE SPIROMETRY
may enter lungs → Thus aspiration and
- Promotes lung expansion & increases
respiratory function Pneumonia
- Causes maximal inspiration & increased
Adults are advised to fast for:
cardiac output
 8 hours after eating fatty food
- Patient is at sitting position → exhale
 4 hours after ingesting milk products
normally → put mouthpiece to lips →
 Clear liquids up to 2 hours before an
elective procedure
INTRAVENOUS ACCESS o For surgery, appropriate preoperative
o For fluid and replacement skin preparation is key step to
o Administering IV medications preventing SSIs.
o Providing a route for emergency o Research studies show shaving cause
medication multiple skin abrasions that later may
o Act as nutrition become infected.
o Administering blood products
o Removing hair at the surgical site
 Profuse bleeding: route to give BT abrades the skin surface and enhances
microbial growth.
OXYGEN
o Cannula  Destroy dermal layer of skin →
o Mask opening pores → injury to the skin
 Minimum of 5L → possible for microorganisms to
 Whenever a patient exhales, he/she enter → infection to set in
is giving out carbon dioxide. The o Hair at the surgical site should be left
pressure inside is going to push the in place, whenever possible. When hair
carbon dioxide out of the pores so removal is required, hair should be
that that patient won’t inhale it clipped with an electric clipper.
again  Ex: cranial surgeries
o Venturi
o Rebreather
o A common adverse effect of sedatives is BOWEL PREPARATION
respiratory depression  For patients undergoing elective GIT
o If alveoli is collapsed, exchange of surgery to ensure that the contents of
gases will not be good and also the bowel are cleared. (Risk for
decreases hemoglobin Peritonitis)
o For the wound to recover, there must be
 Enemas are not commonly prescribed
plenty of blood to the area (WBC,
preoperatively unless the patient is
nutrients, antibodies)
undergoing abdominal or pelvic surgery.
FOLEY CATHETER  At 24-48 hours prior to surgery, the
patient may be allowed CLEAR LIQUIDS (no
o Muscle contract → Increase Urine → milk):
Bladder enlarge. → Catheter Inserted.  Water
o Prevent distention of urinary bladder  black tea
especially if the operation is quite  coffee no cream
long  meat extracts
o Inserted at intraoperative phase  consommé
o An invasive procedure (any tube
inserted) which is a good medium for  glucose drinks
*Full liquids contain milk like sherbet,
growth of bacteria
ice cream, creamy soup*
o 90% prone to UTI
o Should not last inside for two days.  Less food intake
Removed on second postoperative day  Laxatives/Enema: Used the evening before
preventing UTI surgery to clear the bowel of fecal
o Maintain close system of Foley catheter matter. (Induce to move bowel)
o Empty bag regularly Examples:
o Prone to infection – Aseptic insertion  Bisacodyl (Dulcolax)
–Perineal care  Na Picosufate (Laxoberal)
o Meperidine  Klean-Prep (Picolax)
 Food and water are usually withheld at
ORAL AIRWAY MIDNIGHT (no midnight snacks) of the
o Gag reflex not good, insert surgical day.
 Water may be given up to 4 hours before
HAIR REMOVAL surgery. (Depends on type of surgery)
o The main purpose is to ease visualization  Aspirin is withheld 7-10 days before
of the surgical site and to provide a surgery.
better skin surface for wound closure.
o Shaving is done as close to the time of PURPOSES OF PREANESTHETIC MEDICATIONS
incision as possible to avoid o Facilitation of anesthesia induction
contaminating the shave wound. o Lowering of the dose of the anesthetic
 If the wound occurred within 30 agent used.
minutes before incision time, it o Reduction of pain and anxiety
is considered a clean wound.
 5 – 8 hrs negative tayo dyan boss PREOPERATIVE MEDICATIONS
baka ma-squeeze ang ating fucking 1. To reduce anxiety and induce sedation
neck. (strong sedatives)
o Diazepam (Valium)
o Lorazepam (Ativan)
 o Midazolam (Versed, Dormicum)
Note: MIDAZOLAM HYDROCHLORIDE
Causes antegrade amnesia or decreased
ability to remember events that occurred
around the time of sedation.
The patient should be encouraged to take
slow, deep breaths because midazolam is a
respiratory depressant.
2. To reduce/relieve discomfort during
preoperative procedure
o Meperidine (Demerol)
o Morphine
3. Anticholinergics to decrease the risk of
bradycardia during surgery
o Atropine + Demerol is always given
 Risk of Bradycardia – Common
adverse effect of anesthesia
 Atropine counteracts
bradycardia
 Atropine also decreases
mucus secretion and saliva
o Scopolamine
o Glycopyyrolate (Robinul)
NOTE: GLYCOPYRROLATE an anticholinergic
given for its ability to reduce oral and
respiratory secretions before general
anesthesia.
Adverse Effects: Increased CR and RR
4. To increase gastric pH and decrease gastric
volume
o Cimetidine (Tagamet)
o Famotidine (Pepcid)
o Ranitidine (Zantac)
NOTE:
 H2 BLOCKER: Hydrochloric Acid 60%;
increase gastric PH, gastric volume ↓
 PPI: Gastric PH 90-95; potent but
expensive
 Not always given
 Gastric PH: hydrogen content low in the
stomach for it to be acidic needed for
digestion of food. Acidity can kill
microorganisms found in food
 Reason for increasing gastric PH or
decrease gastric volume in surgery:
 The stomach has three types of cells:
mucous mast cells, parietal cells
(production of hydrochloric acid), chief
cells (pepsinogen = neutralize acidity)
→ 2400 gastric secretions in 24 hours →
production of acid is continuous but
protected by mucous mast cells or eating
on time is another → patient is going to
bleed decreasing circulation → stomach
is a secondary organ and is receiving
less blood → mucous mast cells won’t be
able to produce enough mucus to
neutralize acid → plenty of acid → acid
can eat mucosa of stomach → Gastric
ulcers
 Drugs can diminish acidity of gastric
secretions (Gastric PH of 3.5 or 4 ↑)
 Less acid for not cause auto digestion
5. Anti-Emetics
 Metoclopramide
 Droperidol
 Stop nausea
 Can open wound when vomiting causing
dehiscence
NOTE: Eye/brain surgery. Vomiting increase
pressure. Anti-Emetics given preop (Depends on
anesthesia, if major adverse effect is vomiting)
or postoperatively.
PREOPERATIVE MEDICATIONS
o Oral medications should be given 60-90
minutes before the patient goes to the
OR. (Esophagus-stomach-intestine-absorbed
blood-taken to liver-etc.)
 The patient should swallow these
meds with minimal amount of water.
o IM and SC injections should be given 30-
60 minutes before arrival at the OR
o “On Call” from operating room
 OR nurse call when to give meds
o The patient is kept in bed with the side
rails raised.
o Identify yourself.
o Ask the patient to void before pre-op
meds
o Inform patient of the effects of the drug
to avoid anxiousness because it can
increase BP
o Do not let patient to get out of the bed
once given with pre-op meds (tendency to
fall)
o The immediate surroundings are kept quiet
to promote relaxation. (no visitors)
o Cover the head completely with disposable
paper cap
o All patients should void immediately
before going to the OR
o The nurse should have the patient empty
the bladder BEFORE the premedication is
administered.
RATIONALE FOR WEARING A SURGICAL CAP
o To prevent dissemination of microorganism
o To protect it from being soiled.
o To prevent hair from falling into the
sterile field.
o To prevent a static spark near the
anesthesia machine.
PREOPERATIVE CHECKLIST
(NIGHT BEFORE THE SURGERY)
 Allergies
 Consent
 History/PE
 Weight
 NPO
 Pre anesthetic evaluation
 Exercises Performed
 PM Care
 Polish/Denture/Make up removed
 Sedatives as ordered. If not, ordered
call the physician
 Signature of RN
 Lab/Diagnostic
  BT/Consent for BT. Ask religion
 Jewelry, dental prosthesis and contact
lenses removed
 Voided on call
 Indwelling catheter if ordered
 Tampon Removed
 ID Checked
 Vital Signs
 Preoperative medications
 Side rails up
 Instruct the patient not to get out of
the bed
 Vital signs 30 minutes after pre-op
 Old chart sent to OR
 Time sent to surgery
NOTE: The patient must have identification
bracelet properly secured on the wrist before
being transported to the operating room to
ensure correct identification.
II. INTRAOPERATIVE PHASE
 Includes all those that occur from the time
the patient is transferred to the OR until
he or she is transferred to the RECOVERY
FACILITY.
NURSING INTERVENTIONS
1. PROVIDE EMOTIONAL SUPPORT
o Introduce yourself, addressing the
patient by name warmly and frequently
o Providing appropriate information and
explanation, answering questions to
help the patient feel secure
o Providing emotional support for the
client’s family is equally important
o The purpose of separating the public
from the restricted attire are is to:
 Provide an aseptic environment
 Prevent contamination of the
environment by organisms
o THE MAIN PURPOSE IS INFECTION CONTROL.
o LET THE FAMILY KNOW when the procedure
is completed.
o How long the client will be in the OR
o Where the client will go after
discharge from the recovery room.
2. ENSURING A SAFE ENVIRONMENT
o Proper positioning of the patient
(Circulating Nurse)
o Using safety straps, bed rails
o Not leaving the sedated patient
unattended.
COMMON SURGICAL POSITIONS
SUPINE: abdomen, thorax, face, orthopedic,
vascular surgeries
TRENDELENBURG: allows greater access to the
lower abdominal cavity and pelvic structures by
allowing gravity to retract organs
REVERSE TRENDELENBURG: surgeon requires
unobstructed access to the upper peritoneal
cavity and lower esophagus, allows clear view of
the diaphragm, cardiac sphincter and esophagus
LITHOTOMY: gynecological, obstetrical,
genitourinary procedures
SITTING (FOWLER’S): facial, cranial,
reconstructive breast surgery
LATERAL (SIMS): renal and cardiothoracic surgery
PRONE: spine, cranium, perianal region; pressure
on the abdomen restricts normal ventilation
JACKKINFE OR KRASKEE: anorectal surgery
Contraindicated: ages 60 and above. Lithotomy,
sims and lateral positions instead
URINARY CATHETERIZATION
o To prevent bladder distention during a
long procedure or after the surgical
procedure.
o For bladder decompression to avoid trauma
during a lower abdominal or pelvic
procedure.
o To facilitate output and healing after a
surgical procedure on GUT structures
o Catheterization is performed after
anesthesia is administered
o Before the patient is positioned for the
surgical procedure.
o It should be inserted before the vaginal
or abdominal skin preparation to prevent
perineal splash to the surgical site.
o Sterile technique must be maintained.
ANESTHESIA
STAGE I Analgesia Stage
STAGE II Excitement Stage
STAGE III Surgical Anesthesia
STAGE IV Medullary Paralysis
STAGE I: ANALGESIA STAGE
o Loss of pain sensation with the patient
still conscious and able to communicate
o Warmth, dizziness and feeling of
detachment
o May feel or have RINGING, ROARING,
BUZZING
o Noises are exaggerated; even low voices
or minor sounds seem loud or unreal.
STAGE II: EXCITEMENT STAGE
o Period of excitement and often combative
behavior
o Characterized by struggling, shouting,
talking, laughing, crying
o Signs of sympathetic stimulation such as
tachycardia, Increase RR and BP
o Uncontrolled movements: RESTRAIN PATIENT
STAGE III: SURGICAL ANESTHESIA
o Involves relaxation or skeletal muscles
and return of regular respiration
o Patient is unconscious
o Progressive loss of eye reflexes and
pupil dilation
o Surgery can be safely performed in Stage
III.
STAGE IV: MEDULLARY PARALYSIS ADVERSE EFFECTS
o Very deep CNS depression with loss of
o Respiratory depression
respiratory and vasomotor center stimuli
o Hypotension
to which, death can occur rapidly
o Expensive
o Happens when too much anesthesia has been It is not associated with renal or
administered. hepatic toxicity
o Cyanosis develops and death may follow
ENFLURANE (ENDURANCE, ETHRANE)
Anesthesia may be produced in a number of ways
o Induction of anesthesia is smooth and
rapid
GENERAL ANESTHESIA o Salivation is not stimulated
o Drugs that produce UNCONSCIOUSNESS and o Muscle relaxation is greater than with
lack of responsiveness to all PAINFUL halothane. However, despite the action, a
STIMULATION Neuromuscular Blocker is employed to
o Basic elements include: permit a reduction of Enflurane dosage
 Loss of consciousness o Suppress uterine contraction
 Analgesia
 Muscle relaxation ADVERSE EFFECTS
 Interference with undesirable o High dosage can induce SEIZURE
reflexes o SUBSTANTIAL DEPRESSION OF RESPIRATION
 Amnesia: inability to recall what
took place. NITROUS OXIDE (BLUE CYLINDER)
o “Laughing Gas”
TWO METHODS OF ADMINISTERING GENERAL ANESTHESIA o It has a VERY HIGH ANALGESIC POTENCY and
o Inhalation a VERY LOW ANESTHETIC POTENCY
o Intravenous
Analgesia: Loss of sensibility to pain
INHALATION ANESTHETICS Anesthesia: refers not only to loss of pain but
o Halothane to loss of all other sensations as well. Touch,
o Isoflurane Temperature, Taste
o Enlurane
o Nitrous Oxide o Never employed as a primary anesthesia.
o Cyclopropane It is frequently combined w/other
o Ethylene inhalational agents to enhance ANALGESIA
o Most widely used inhalation agent
HALOTHANE (FLUOTHANE) o Almost all patients undergoing general
o Induction of anesthesia is smooth and anesthesia receive nitrous oxide to
rapid supplement the analgesic effect of the
o WEAK ANALGESIC. Co-administration of a primary anesthetic
STRONG ANALGESIC (morphine, nitrous o Major concern is postop Nausea and
oxide) is usually required. Vomiting
 Counteract with atropine sulfate o Can cause bowel distention
o RELAXATION OF SKELETAL MUSCLE is only o There is no muscle relaxation
moderate. Concurrent use of neuromuscular
blocking agent is required (Pancuronium) CYCLOPROPANE (ORANGE) and ETHYLENE (RED
o Promote significant RELAXATION OF THE CYLINDER)
UTERINE SMOOTH MUSCLE → inhibit uterine o Obsolete inhalational anesthetics
contractions → DELAYING DELIVERY because:
 They are explosives
ADVERSE EFFECTS  They offer no advantage over newer
o HYPOTENSION: less hazardous anesthetics
 Dec myocardial contractility ->
dec. CO by 20%- 50%. INTRAVENOUS ANESTHETICS
 Stimulate vagal tone -> dec. HR -> o Injected directly into the circulation
dec. CO usually via a PERIPHERAL VEIN in the arm.
o RESIRATORY DEDPRESSION o May be used alone or to supplement the
o VOMITING effects of INHALATIONAL AGENTS.

ISOFLURANE (FORANE) THIOPENTAL (PENTOTHAL)

o Most widely used inhalational anesthetic
o A POTENT MUSCLE RELAXANT and protects the
HEART against cathecolamine-induced
dysrhythmias -> CO is not decreased
o It depresses BRONCHOCONSTRICTION. May be
used in Asthma and COPD.
o Acts rapidly to produce UNCONSCIOUSNESS
in 10-20 seconds after IV injection
o ANALGESIC and MUSCLE RELAXANT EFFECTS are
weak.
o Supplement to regional anesthesia
o Used as a safe adjunct for intubation in
HEAD INJURIES
ADVERSE EFFECTS o Anesthesia is produced by injection into
o CARDIOVASCULAR and RESPIRATORY DEPRESSION the DISTAL VEIN of an arm or leg
o APNEA, if given rapidly
TOPICAL ANESTHETICS
PROPOFOL (DIPRIVAN, DIPRIFOL)
o Used for rapid induction and maintenance BENZOCANE (Auralgan)
of anesthesia for non-invasive procedures o For ear pain
 Endoscopy
 MRI LIDOCAINE (XYLOCAINE, EPICAINE, ENDUCAINE, EMLA,
 Radiation Therapy EMLOCAINE)
o UNCONSCIOUSNESS develops w/in 60 secs and o For dermatological procedures
lasts for 3-5mins following a single o For painless IV insertion
injection. o Most widely used local anesthetics
o Causes death rapidly o Preparations: Cream ointment jelly patch
o MODERATE TO SEVERE PAIN may be felt at soln aerosol
the injection site
 Larger antecubital vein should be TATRACAINE (PONTOCAINE, NIPHANOID)
use o For surgical, dental and obstetric
 Site should be injected with procedures.
LIDOCAINE o Eye drop to numb the eye for various
ophthalmic procedures.
ADVERSE EFFECTS
o Profound respiratory depression Avoid application to skin that is abraded or
o Bradycardia injured. TO PREVENT SYSTEMIC TOXICITY,
BRADYCARDIA, CONVULSIONS
KETAMINE (KETAMAX, KETAZOL) ADVERSE EFFECTS Wear gloves when applying the anesthetic
o Hallucinations
o Disturbing dreams SPINAL ANESTHESIA (LUMBAR)
o Injecting local anesthetic into the
BALANCED ANESTHESIA SUBARACHNOID SPACE (Intrathecal)
Use of a COMBINATION OF DRUGS each with a o To create sensory, motor and autonomic
specific effect to achieve blockage of the nerve roots and spinal
o Analgesia cord.
o Muscle relaxation o Indicated for surgical procedures below
o Unconsciousness the diaphragm such as:
o Amnesia  Prostectomy
 Knee Arthoscopy
The agents most commonly used to achieve these  Total Joint Replacement
agents are:  Urologic Procedures
SHORT ACTING NEUROMUSCULAR BLOCKING
BARBITURATES AGENTS ANESHETICS MOST COMMONLY EMPLOYED
For induction of For muscle relaxation o Bupivacaine
anesthesia o Lidocaine
o Thiopental o Vecuronium o Tetracaine
o Methohexital (Norcuron)
o Rocuronium COMPLICATIONS AND INTERVENTIONS
(Dameron) o HYPOTENSION
o SPINAL HEADACHE
OPIODS AND NITROUS PREOPERATIVE MEDICATIONS o URINARY RETENTION
OXIDE
The patient will feel sensation to the toes
For Induction of Use of ANTICHLONERGICS that before the perineal area
Analgesia decrease secretions to A spinal headache due to the loss of fluid is a
facilitate intubation and severe headache that occurs while in the upright
prevent bradycardia position but is relieved in the lying position.
o Morphine
o Demerol HYPOTENSION
o BP is decreased by venous dilation
NERVE BLOCK secondary to blockade of sympathetic
o Injecting the anesthetic at some point nerves.
along the nerve/nerves that run to and o Loss of venous tone decreases the rerun
from the region in which the loss of pain of blood to the heart casing a reduction
sensation or muscle paralysis is desired in cardiac output and corresponding fall
in BP
INTRAVENOUS REGIONAL ANESTHESIA
o Employed to the anesthesia the INTERVENTION
extremities o Elevate legs.
o Closely Monitor BP
 o IV fluids and EPHEDRINE, alpha 1 agonist o Contains nasal and oral droplets, which
that increases BP by stimulating are easily transmitted to the hands as
norepinephrine release. the mask dangles when left hanging around
the neck.
SPINAL HEADACHE o When a face mask is not worn over the
o Indicating leak of CSF thru the opening mouth and nose, it should be discarded
in the Dural sheath.
o Injected lumbar area → leak of CSF SURGICAL SCRUB
(shock absorber) → increasing pressure o A study revealed that microorganisms
o May occur from6-12hrs after spinal decrease to an estimated 50% with each
anesthesia to the 2nd postop day SIX-MINUTE SCRUB
o Signs and symptoms: o Other studies have shown that a VIGOROUS
 Frontal/occipital headache FIVE-MINUTE scrub with a reliable
 Tinnitus antiseptic agent is as effective as a
 Double vision TEN-MINUTE SCRUB.
 Nausea o During and after scrubbing KEEP THE HANDS
 Photophobia HIGHER THAN THE ELBOWS to allow water
flow from the cleanest area the HANDS, to
INTERVENTION the marginal areas of the UPPER ARMS
o Supine position (6-8 hours): good DRYING OF HANDS AND ARMS
distribution of CSF o Hold the towel away from the body, dry
o Large amount of IV fluids. (Well- only scrubbed areas, starting with the
regulated to replace lost CSF) HANDS.
o Systemic ANALGESIA o Avoid contaminating the hands or areas
distal to the ELBOWS
STERILE TECHNIQUE
o STERILE means absence of all HAND RUB
microorganisms o CHLORHEXIDINE GLUCONATE or
o BETADINE SOAP 7%
MAINTAINING SURGICAL ASEPSIS ∞ RUB 3-5 MINS
o Maintaining ASEPSIS to avoid o STERILEUM
contamination of the surgical site by ∞ CONTINUOUS RUBBING 2-5MINS, AIR
microorganisms is the responsibility of DRY
ALL OTHER MEMBERS OF THE SURGICAL TEAM.
o All materials in contact with the MAINTAINING SURGICAL SEPSIS
surgical wound and used w/in the sterile o The STERILE GOWN is worn immediately
field must be STERILE. AFTER THE SURGICAL SCRUB.
o The STERILE GLOVES are worn immediately
PRINCIPLES OF STERILE TECHNIQUE AFTER GOWNING
o The edge of a sterile field and 1-2 o Sterile drapes to create sterile field
inches inward is unsterile. o The MOVEMENTS of the surgical team are
o Sterile packages are labelled as sterile. from are from STERILE to STERILE AREAS
If a package is not labelled sterile, it and from unsterile to unsterile areas
should be considered an unsterile item o Have unscrubbed personnel stay at least
o Sterile objects that comes in contact ONE FOOT AWAY from the sterile field
with unsterile objects are considered o Whenever a STERILE BARRIER is breached,
contaminated the area must be considered CONTAMINATED.
o Any part of sterile field that falls of
hands below the top of the table is SCRUB NURSE AND CIRCULATING NURSE
unsterile. SCRUB NURSE CIRCULATING NURSE
o A sterile field that becomes WET will PREOPERATIVE
draw microorganisms from the surface The SCRUB NURSE performs SPONGE COUNTS with
underneath and contaminate the field. the CIRCULATING NURSE
o Items in a sterile package must be used READ CARD FILE TO HELP IN PREPARING
immediately once it has been opened or it VERIFY SURGEONS NEEDED SUPPLIES
considered contaminated SPECIAL REQUIREMENTS
o GOWNS of the surgical team are considered HELP SCRUB NURSE AND
sterile IN FRONT FROM THE CHEST TO THE ASSEMBLE ALL STERILE SURGEON IN GOWNINH
LEVEL OF THE STERILE FIELD. SUPPLIES NEEDED IN
o The SLEEVES are considered sterile form PROCEDURE OPENS STERILE PACKS
TWO INCHES ABOVE THE ELBOW TO THE
STOCKINETTE CUFF. WEAR MASK AND SCRUB PERFORM AND RECORD
HANDS COUNTS
SURGICAL MASK PUT GOWN AND GLOVES ADMIT PATIENT TOP
o Remove all jewelry, hair covered by IN PREPARATION FOR OPERATIVE SUITE
headgear THE PROCEDURE
o Disposable mask must fit snugly and
comfortable over the nose and mouth PREPARE STERILE
FIELD  Because if the patient vomits and is
performing Valsalva maneuver, that
MAKE SURE ALL will increase pressure in brain or
INSTRUMENTS ARE eyes can give complication bleeding.
WORKING PROPERLY In abdomen, wound might open due to
increase pressure.)
 If px is unconscious vomits while in
bed/ lying down: turn the patient’s
head to one side for them not to
swallow the vomit.
 If px is conscious while vomiting:
Semi Fowler position; 45-degree angle.
 Don’t give anything by the mouth if px
PRE INCISIONAL is vomiting.
Assist surgeon in Anticipate
DRAPING the ANESTHESIOLOGIST’S needs (Ex. Scenario: Nurse making round 3rd post-
patient during induction of operative day, and the patient says “I’m so
anesthesia hungry. Can I eat the oatmeal that was
Pass off suction prepared by my wife?”. The doctor’s order is
cautery lines Assist with drapes; NPO.)
connect suction and
cautery Answer: Nurse can independently decide. Assess
CLOSING PHASE patient first: 3 to look for
Count with Make a tally of SPONGES
CIRCULATING NURSE counted together with 1. If patient can already swallow or has
at frequent SCRUB NURSE gag reflex. Just feeling it in neck and
intervals the pharynx goes up and down while
Assist surgeon in Apply tape to secure patient swallow. It is okay.
SUTURES and TUBINGS and other 2. Use stethoscope to assess abdomen.
DRESSING attachments There are 4 quadrants, if not heard in
one quadrant go to another. If
TIME-OUT peristalsis is good it is okay.
When a “time-out” is called prior to surgery,  Normal Bowel Sound: 5 – 25 Bowel
the surgical team must: sounds/min
o Read back all prescriptions 3. Flatus is the most reliable
o Verify the correct site Note: Assessment is always first before making
o Identify the patient again an action. In nursing process first is
o Double check the echocardiogram
assessment, second diagnosis, 3rd is planning,
4th implement and 5th/last evaluate
III. POST-OPERATIVE PHASE  Peristalsis is movement. It is seen in
esophagus, stomach, small & large
Involves the period after the client is
intestines.
discharged from the recovery room and ends with
the resolution of all surgical consequences. o Normal: 3-5 days
3.) Deep vein thrombosis (DVT). Px is immobile
4.) Infection. Temperature is taken q4 even in
Complications:
1st day. To look for infection (ex. UTI,
1.) Respiratory Complication is number one respiratory infection, wound infection)
because: (Ex. Scenario: 1st operative day px tempt. is
a. Adverse effect of anesthesia 38.7 C.)
b. Pain causes shallow breathing. Not
expanding alveoli. Exchange of gas Answer: Not normal. If it is elevated in 1 st
will not be good day it is respiratory complication.
c. Immobility because px in bed for  It would take 3-5 days post op for wound
several days. Solution: Early infection to develop. You can have high
ambulate helps prevent constipation, temperature. If wound is assessed, there
DVT will be calor, dolor, rubor and tumor.
2.) Nausea and Vomiting. Surgical pain
 UTI develops 2nd post op day. That is why
triggers vomiting center in brain. If
catheter is removed in 2nd day to prevent
patient is nauseated, immediately give
UTI. If needed longer, it is a must to
anti-emetic drug like Metoclopramide.
keep perineal care.
 If no order, immediately refer to
 Respiratory complication like Atelectasis
doctor. Not allowed to vomit if the
or pneumonia develops 1st post op day
patient will undergo cosmetic surgery,
1st post-op day:
cranial surgery, abdominal surgery.
 ∞ Temp. should be lower than 38 C,
expected because there is
surgical incision.
∞ Higher than 38 C, there is
complication.
∞ Temp. is assessed every 4 hours,
after the first 24 hours of
surgery.
 To prevent UTI, doctors usually orders
to pull catheter in 2nd post op day.
Steps to pull:
a. Wash hands
b. With the syringe put in balloon
part, then aspirate 5-10 cc
c. After aspiration, gently pull out
catheter.
∞ Expect patient to void normally 6-
8 hours after removal.
(Ex. Scenario: Nurse entered the room at 8 or
9 pm. Nurse asks patient Ms. Cruz if she
voided already. The answer is no, not urinated
yet. What is the nursing intervention?)
Answer:
1. Percuss and the sound is Dull, because
it is filled with water
2. There is urinary distension. You should
not let the urinary bladder to be
distended with so much urine. You
should motivate patient to void.
Motivations that help are:
o Water sound
o Pouring perineum with tap/warm
water
o Best: Provide bedside commode, if
px can’t go to the restroom yet
(Ex. Scenario: You were making rounds 2 nd post
op. Px still have foley catheter, the shift is
6 am to 2pm. As you were making rounds, px
urinary output in whole shift is 100 cc. What
will be your reaction?)
Answer: Normal because px body is
compensating. Expect physiologic oliguria the
px bled in surgery therefore body has to do
something. Hypothalamus will alert posterior
pituitary gland and will release hormone
Oxytocin & anti-diuretic hormone. Because
there is decrease in circulating blood volume,
ADH will be release. Then will be absorbed by
the blood and this will order renal tubules to
reabsorb water. So, it will order kidneys, the
body loss a lot of blood so don’t make so much
urine reabsorb water that is why urine is
less. Another hormone to release as
compensatory mechanism by adrenal cortex and
adrenal gland is Aldosterone. It compensates
and will order again renal tubules to reabsorb
because of loss of blood and where sodium is,
water follow.
 Intake & Output = equal in 4th day post
op.
 Maximum: 50 cc/hr multiply by 8 = 400c
in 8 hours.
 Minimum: 30 cc/hr multiply by 8 = 240
cc in 8 hours
ACID BASE BALANCES
Body’s line of defense in maintaining normal
pH are:
1.) Respiratory System (Lungs) - controls
acid like CO2. Responds within minutes
2.) Renal System (Kidneys) - reabsorbs or
excrete bicarbonate (HCO3). Bicarbonates
are base. Kidneys will take time to
act. 1 or 2 days to make changes. Only
system that can put pH in normal level.
3.) Buffer System
 Proteins
 Bicarbonate buffer system
 Transcellular hydrogen potassium
exchange system.
 Buffer system and respiratory
system almost the same. Quickly
responds. However, cannot bring
pH in normal level. This is where
kidneys come in. 2 kidneys will
control base in form of
bicarbonates.
 If the pH is BELOW 7.40 and PaCO2 is
GREATER than 45 mmHg = RESPIRATORY
ACIDOSIS
 If the pH is LEESS THAN 7.40 and HCO3 is
BELOW 22mEq/L = METABOLIC ACIDOSIS
 Respiratory acidosis – accumulated CO2
in lungs probably pneumonia, asthma
where bronchi is partially obstructed.
It can be in COPD.
 Metabolic acidosis – immediately lungs
will compensate. Kidneys & lungs help
each other. But lung can’t bring pH to
normal, and kidneys are broken. Plenty
of acid due to renal failure like urea,
uric acid accumulate toxins, cannot
excrete it there is accumulation and
you can be in state of metabolic
acidosis. Px will be hyperventilating
due to so much acids in form of
Hydrogen Ions and CO2. So, lungs are
compensating, it increases RR. You are
blowing some form of acids in form of
CO2.
 Cerebrovascular vasodilation happens
when CO2 is elevated because CO2 will
elevate arteries. CO2 is not only in
lungs, there is also metabolism in
 brain and end product is CO2. Since brainstem
airway is partially obstructed not all
CO2 can be eliminated. So possible
headache, because too much CO2 can
dilate arteries in brain.

ABG IN ADULTS: NORMAL

VALUES
pH 7.35 – 7.45
PaCO2 35 – 45 mm Hg
PaO2 80 – 100 mm Hg
HCO3 22 – 26 mEq
SaO2 95 – 100 %

RESPIRATORY ACIDOSIS

1. Depressed central respiratory centers

 Over sedated
 Head trauma
 General Anesthesia

Respiratory acidosis results from

HYPOVENTILATION

2. Compromised respiratory apparatus

 COPD
 Guillain-Barre’
 Asthma
 Pneumonia

Patent airways is essential.

There is depress CNS

Note: Respiratory center is in pons, medulla

oblongata. Above pons is Midbrain. All part of
RESPIRATORY ALKALOSIS

3. Results from HYPERVENTILATION

1. Fever
2. Hyperthyroidism
3. Shock
4. Pulmonary embolism
5. Over ingestion of salicylate

METABOLIC ACIDOSIS

1. Bodily gain of a strong acid

 Diabetic ketoacidosis
 Prolonged starvation
2. Loss of Bicarbonates
 Chronic diarrhea
3. Decreased acid excretion
 Renal Failure

METABOLIC ALKALOSIS

1. Loss of acid from the plasma

 Vomiting
 Gastric Suctioning
2. Large intake of antacid

 7.40 above ALKALOSIS

 7.36 below ACIDOSIS

COMPENSATED

- pH within normal level. Examples:

7.38, 7.42, 7.44 (It is compensated)

UNCOMPENSATED STATUS

- Indicates that one of the body systems

Respiratory or Kidneys. Has made no
attempt to change pH
 PARTIALLY COMPENSATED
HCO3 19 Low
- It can be below or higher than 7.45 mm
Hg. But if you look at other figures, one
of figures is compensating. However, 5.) A: Uncompensated Respiratory Acidosis
failed to put pH within normal level.
pH 7.43 Normal
Sample Problems:
PaCO2 58 High
1.) A: Uncompensated Metabolic Acidosis
HCO3 25 Normal
pH 7.30 Acidosis
PaCO2 38 Normal Interpretation:

HCO3 16 Low - PaCO2 is 58 because there is plenty of CO2

Interpretation:
- Since lungs is damage, kidneys will
- pH is not normal. Lungs is not doing compensate by releasing bicarbonate. Since
anything there is plenty of acid it will neutralize it.

2.) A: Uncompensated Metabolic Alkalosis - 25 HCO3 is normal so it doesn’t compensate.

- It is uncompensated and not partially 6.) A: Partially Compensated Respiratory
because the lungs are normal and didn’t Acidosis
compensate.
- Uncompensated because CO2 is normal pH 7.10 Acidosis
level.
PaCO2 50 High
- Lung didn’t do anything maybe aged/have
problem with lungs. Lungs react in HCO3 24 Normal
minutes but it didn’t react here.
- Lungs are normal so it is not the
problem, so it is metabolic.
7.) A: Partially Compensated Respiratory
- Alkalotic happens if vomiting → it
Acidosis
lets gastric juices (hydrochloric acid
produce by parietal cell) & chief cell pH 7.32 Acidosis
produces acid Pepsinogen → active
form pepsin. PaCO2 48 High
- So, for gastric juices to be potent it
HCO3 30 High
should be acidic for it to kill
microorganism in the food. While Interpretation:
vomiting, it releases great amount of
acids which will cause the Alkalotic - PaCO2 is damage.
state.
-HCO3 is compensating. However, it didn’t
pH 7.56 Alkalosis bring the pH in normal level. So partially
compensated respiratory acidosis. Bicarbonate
PaCO2 41 Normal increased to compensate due to many acids, but
HCO3 failed to normalize pH.
40 High
8.) A: Partially Compensated Metabolic
Acidosis
3.) A: Uncompensated Metabolic Acidosis Normal;
pH 7.38
acidosis
pH 7.27 Alkalosis
PaCO2 28 Low
PaCO2 38 High
HCO3 18 Low
HCO3 14 Low
- Partially compensated because its pH is
normal. But still considered acidotic because
4.) A: Compensated Respiratory Alkalosis it is below 7.40.
pH 7.45 Normal;
Alkalosis

PaCO2 25 Low
 9.) A: Uncompensated Respiratory Alkalosis A: uncompensated metabolic acidosis
pH 7.50 Alkalosis pH 7.27 Acidosis
PaCO2 30 Low PaCO2 38 High
HCO3 25 Normal HCO3 14 Low
Interpretation:

- Low PaCO2 will cause high respiratory rate A: compensated respiratory acidosis
(RR). Maybe px is in severe pain, fear,
anger, anxious pH 7.39 Normal
- Bicarbonate takes days to react
PaCO2 60 High
- Fast breathing, release too much CO2
- Tachypnea is shallow breathing. While, HCO3 34 High
Hyperventilation is deep

10.) A: Combined Acidosis

A: uncompensated metabolic alkalosis
pH 7.32 Acidosis
pH 7.56 High
PaCO2 52 High
PaCO2 42 Normal
HCO3 18 Low
HCO3 40 High
Interpretation:

- Plenty of CO2. (pneumonia, asthma, COPD)

- 18 Bicarbonate didn’t compensate so it A: compensated metabolic acidosis
may be broken (COPD, renal failure,
pH 7.36 Normal
probable Diabetes)
- Diabetes & Hypertension destroy kidneys PaCO2 29 Low
11.) A: Uncompensated Metabolic Acidosis HCO3 20 Low

pH 7.27 Acidosis
A: partially compensated respiratory acidosis
PaCO2 38 Normal

HCO3 pH 7.34 Low

14 Low
Interpretation: PaCO2 52 High

- Uncompensated metabolic acidosis because HCO3 30 High

the CO2 didn’t do anything.

◆ Wrong or Not Possible Case:


↑ CO2 = not excreted well
A: 
↑ HCO3 = kidneys are compensating
because we have plenty of carbon
pH 7.38 Normal dioxide in the body. Kidneys will
produce plenty of bicarb and able to
PaCO2 43 Normal bring pH within the normal level

Tachypnea = cause of too much acid. To
HCO3 18 Abnormal be able to blow off some acid in the
Interpretation form of CO2 (carbonic acid + water)

- Bicarbonates are low. So PaCO2 needs to

compensate, it should be low.
- Many acids → High RR to remove CO2
→
PaCO2 is low.
- PaCO2 is 43 so it didn’t do anything. Not
probable.
 PULMONARY EMBOLISM
RIGHT VENTRICULAR HYPERTROPHY
Blood cannot pass through because of
obstruction → high afterload (right ventricle)
→ right ventricle having a hard time pushing
blood against the pressure → increasing the
work load → muscles will enlarge

Less blood supply to the lungs → less cardiac

output (amount of blood ejected by the heart
in 1 minute) → anaerobic metabolism → plenty
of lactic acid → metabolic acidosis

With hypertension/COPD (viscous blood)

Bronchoconstriction (diminishing lumen of the
blood) → high pressure in the lungs (pulmonary
hypertension) = increasing workload of right
ventricle

Cardiac muscle: less space for blood to enter

→ less blood in the lungs for oxygenation →
less blood going to the left side of the heart
→ less cardiac output → metabolic acidosis
o 90% come from lower extremities
o Blood stopping lower extremities = Cannot accumulate blood in the right → blood
blood can be viscous → forming a clot will regurgitate → going to right atrium →
To prevent: blood from superior vena cava cannot be
 Contract muscles → squeeze veins accommodated by the right side of the heart →
→ causing valves to push blood flow of blood in superior and inferior vena
back from the heart cava → Neck Vein Engorgement (vein will be
o Thrombus: attached to the wall of the distended)
vein
o Embolus: detached ATRIAL FIBRILLATION
o Can also be a fat embolism Heart is beating too fast. Atrium is
o Decrease oxygen in the lungs (alveolar contracting 200-400 times per minute → SA node
hypoxia) damaged (right atrium) → tricuspid and
 Lessen blood supply to the lungs bicuspid valves will open when atrium
→ bronchoconstriction (smaller contracts pouring blood into the ventricles
lumen of bronchi) → increased for about 2-3 seconds only (because of 200-400
pressure → pulmonary hypertension beats per minute = ↑ cardiac rate) → 80-120 cc
o Obstruction (clotted blood/lipids) → of blood did not enter ventricles → blood
obstructed airways → alveolar hypoxia accumulating in the atrium → blood becoming
viscous → opportunity to clot → clotted blood
in the atrium → ventricles → obstructing
pulmonary artery → less oxygenated blood going
through the different systems of the body →
anaerobic metabolism (mitochondria cannot
produce a good amount of ATP needed by the
cell) → body will produce lactic acid
*normal: AV valves open for about 5 seconds
for 80-120cc of blood to enter ventricles
 CHRONIC ONSTRUCTIVE PULMONARY DISEASE
It is a disorder wherein the protein alpha-1
antitrypsin is defective or absent. This
protein is a protease which inactivate
elastase that breaks down elastin. But since
there is a deficiency, the elastase cannot be
prevented from breaking down too much elastin.
This primarily affects the lungs. If there are
bacteria or foreign matter that has entered
particularly in the alveoli, the Neutrophils
usually arrive to release Neutrophil Elastase.
This elastase is going to break down the
proteins of the bacteria and as well as the
elastin - which gives the lung tissues
elasticity and strength. But before this
elastase could break down the elastin in our
lung tissue surface, the liver will release
the alpha-1 antitrypsin to inhibit
elastase. Without this alpha-1 antitrypsin
protein, the neutrophil elastase
unchecked causing further breakdown of the
elastin in the alveolar walls therefore also
resulting in the alveoli to lose
structural integrity and elasticity. If this
happens, there would be loss of elastic recoil
resulting in decrease in ventilation and
destruction of the alveolar wall and capillary
bed would result in decreased perfusion.
HYPOXIC DRIVE
Normal (Central Chemoreceptor)
The stimulus for respiratory center is found
in medulla oblongata and pons. (inhalation and
exhalation). The presence of carbon dioxide
(end product of metabolism = waste product)
drives us to breathe
In COPD, Peripheral Chemoreceptor
o Stimulated with low oxygen (hypoxic
drive)
o Because of destroyed airways and
damaged alveoli, it damages elastin and
collagen and it will not be elastic
anymore. It completely distends alveoli
and carbon dioxide will accumulate in
the alveoli
o There is bronchoconstriction,
inflammation, and accumulation of
carbon dioxide in the lungs = barrel
chest
o If 6-8L of oxygen, patient may develop
respiratory distress because it would
not stimulate hypoxic drive
o 1-2L of oxygen only because of the
damaged airways and alveoli, there is a
high level of carbon dioxide which is
not good. This will stimulate
peripheral chemoreceptors (carotid
arteries) for the stimulating hypoxic
drive (low flow of oxygen)
o Venturi mask is used to give a precise
level of oxygen
POLYCYTHEMIA = destroyed alveoli → less oxygen
in blood → kidneys being the secondary organs
will be affected → release erythropoietin →
stimulate bone marrow to produce red blood
cells.
Compensatory mechanism that makes blood
viscous. The hematocrit can be evaluated.
COR PULMONALE
According to WHO, enlargement of the right
ventricle due to respiratory disorder (but not
if pulmonary edema)
1. Kidneys compensated, releasing
erythropoietin = producing RBC = high
hematocrit (blood viscous). Muscle of
the right ventricle having a hard time
pushing a viscous blood
2. Chronic bronchitis is an inflammation,
alveoli damaged, oxygen content of
lungs diminished, less oxygen in lungs
because of damages airways and alveoli.
= bronchoconstriction. Smooth muscle
the surrounding airways will contract and
construct airway, decreasing lumen =
goes pulmonary hypertension (high pressure
in the lungs). High pressure in the
pulmonary arteries. Viscous blood =
its enlarge the heart
NURSING INTERVENTION
o Backslapping
o Vibration
o Postural drainage
Rebamipide (Mucosta)- Antacid
o Because of steroids (intravenously can
cause gastric ulcer)
o It is given to counteract solu-medrol
o A cytoprotective agent (protect mucosa
of stomach because patient is receiving
medication that can cause gastric
ulcer)
ASTHMA
o Hereditary, inflammatory disorder
o Swelling in airways
o Psychological stressors (asthmatic
attack)
RISK FACTORS
o Dust (rich in cockroaches, becoming
part of the dust) = acts as an irritant
o Foods (seafoods) oyster, shrimp,
mussels, eggs, chocolate
o Soap (ariel or tide)
o Smoke
o Weather
o Perfumes
PATHOPHYSIOLOGY
Obstruction
Airways are affected (bronchi), there are
goblet cells stimulating mucus, obstructing
the airways (complete/partial).
Passage of oxygen and carbon dioxide will not
be good. Carbon dioxide will be in the airways
and won’t be eliminated
Obstruction
Plenty of mucus
Edema
Because of inflammatory disorder
Less oxygen in lungs = bronchoconstriction
 DRUGS USED TO TREAT ASTHMA

SHORT- ACTING BRONCHODILATORS

Short – Acting beta – 2 agonists
o SALBUTAMOL – Ventolin/Asmalin
o TERBUTALINE SULFATE – Bricanyl (can
also be used in delivery room)
Bronchodilators to dilate airways (for easy
breathing; mucus will move)
Expectorant (let patient expectorate mucus)

MDI
o Put patient in sitting or semi fowlers
o Place it in front of the mouth
o Seal it with lips
o Let patient inhale exhale then push
hold breath for 10 sec (for the
Smooth muscle is going to contract, squeezing medicine to reach the deepest part of
the lumen = high pressure lungs)

If there is airway obstruction in bronchi

There will be atelectasis (collapse of part of
the lung) = ventilation/perfusion mismatch
The ventilation is affected because airways
are obstructed. Perfusion is flow of blood
that enters the right ventricle (unoxygenated)
pulmonary trunk entering the lungs for
oxygenation
If collapsed, not all blood will be oxygenated
Blood with less oxygen = quality of blood
ejected by the left ventricle to the different
systems of the body

SINGS AND SYMPTOMS

o Irritable (brain cells not oxygenated)
o Restlessness (less oxygen)
o Hypoxemia (blood going to descending BRONCHODILATORS
aorta to different systems of the body Beta-Adrenergic Drugs
= less oxygen o Albuterol – Ventolin
o Easy Fatiguability (cells not receiving o Metaproterenol – Alupent
sufficient amount of oxygen) Bronchodilators with long duration of action
o Pallor (less oxygen) Frequently administered by metered-dose
o Increased cardiac rate (because heart inhaler
has to compensate)
o Increased respiratory rate METAPROTERENOL
o Tachypnea (respiratory acidosis, lungs o Metaproterenol (Alupent)is a
compensate increasing respiratory rate) sympathetic bronchodilator
o The client should take the last dose a
UPON AUSCULTATION few hours before bedtime so that the
o Plenty of mucus = crackles medication does not produce insomnia
o Obstructed airways = reduced breath
sounds (dangerous signs) ALBUTEROL
o Rales/crackles (partially obstructed) o Albuterol (Proventil) is a
bronchodilator
HYPERINFLATION (plenty of carbon dioxide in o The patient should avoid drinking large
the lungs) obstructed airways = hypercapnia. amounts of caffeine-containing drinks
Can develop respiratory acidosis such as tea, coca and cola drinks
 Make brain cells alert
EX: o Sprite and 7-Up do not contain caffeine
65 years old, with pneumonia and hypertension
(less blood going to kidneys = reabsorbing ANTICHOLINERGICS
bicarbonates) = Diarrhea o Ipratropium Bromide – Atrovent/Duavent
o pH: 7.29 = decreased (acidosis) o Used to treat asthmatic conditions by
o PCO2: 48 = high(respiratory) dilating the bronchioles
o HCO3: 20 = low (combined respiratory o stopping action of parasympathetic =
and metabolic acidosis) because bicarb bronchodilator
went down
Low=compensating
Ipratropium Side Effects o If patient receiving for 3 months, it
Atrovent softens bones developing fractures
o Dryness of mouth (resulting to o Weight gain = because it causes
halitosis)
reabsorption of sodium attracting
o Cough
water, increased appetite, BP also
increases
Duavent
 Lessen sodium in diet
o Dyspnea
o Cough  Give food that has less
carbohydrates
o HPN
o Tremor, nervousness
o Insomnia HEALING FOODS FOR ASTHMA
FOODS HIGH IN VITAMIN C
COMBIVENT o Papaya
o Guava
o The combination of ipratropium bromide
with albuterol o Oranges
o Kalamansi
o Used to treat chronic bronchitis
o For patients who require more than a o Strawberry
single bronchodilator o Datiles
o Melons
MDI TEACHING POINTS
o Wait 30 seconds between inhalation of
same medication NURSING INTERVENTIONS
o Wait 5-10 minutes between inhalations o Loosens mucus secretion
of different medications o Backslapping
o Inform the patient to start breathe in o Postural depression
slowly for 3 to 5 seconds, to draw in o Increase fluid
medication o Perform coughing exercises
o Instruct patient to hold his breath for o Try to know the cause that triggers
10 seconds, to allow medicine to go asthma
deeply into his lungs. o Don’t put patient in a room with
carpet, heavy curtains (it collects
o Use BRONCHODILATOR before
dust) or many books, newspapers,
CORTICOSTEROIDS (for better absorption
stuffed toys
GLUCOCORTICOIDS o Wear masks if travelling publicly /
handkerchief or face towel, wet it and
o Beclomethasone (Foster) – MDI
o Dexamethasone (Prednisone) – Tablet; squeeze water as a mask
(Decadron) (IV & Tablet) o Expose pillows and mattresses once a
month
INHALED CORTICOSTEROIDS o Hypoallergenic pillows or mattresses
o Tonsillectomy: cold foods
o First line therapy for Asthma
o Used for clients with moderate to
severe Asthma CARDIOVASCULAR

Most Common Adverse Effects CIRCULATION OF THE HEART

o Oropharyngeal Candidiasis The unoxygenated blood coming from the upper
extremities will go to the superior vena cava,
 Steroids can still be in the
mouth killing lysosomes prone to while the unoxygenated blood coming from the
mouth infection lower extremities will go to the inferior vena
cava → right atrium → tricuspid valve → right
 To minimize this effect, clients
ventricle → pulmonary valve → pulmonary trunk
should GARGLE after each
administration → pulmonary artery, going to the lungs for
oxygenation then it will go to the four
 Nurse will let px perform mouth pulmonary veins → left atrium → bicuspid valve
wash to remove remaining steroids
→ left ventricle → aortic valve → ascending
o Dysphonia (voice hoarseness)
and descending aorta → different parts of the
o Inflammation (-it is_
body
o Gastric ulcer
o If taking more than 2 weeks, it o 70 cc (lub-dub)
diminishes immune system (activity of o Cardiac Output – 5-8 liters
WBC = prone to infection
CONDUCTION SYSTEM
o If patient has catheter, asepsis
Superior and inferior vena cava → SA node
technique
(contract 60-100 bpm) → right atrium
o Good personal hygiene if patient is
(contracting) → Bachman’s bundle → left atrium
advised to take prednisone for 3
→ AV node (open valves and semilunar valves
months (hand washing, bath, changing
close) → bundle of his (atrioventricular
underwear)
valves close, ventricles contract) → purkinje
o Take after a meal because it can cause
fibers (AV valves close, SV valves open) → the
gastric pain
right ventricle pushes unoxygenated blood
against the pulmonary valve going to the lungs
→ then the left ventricle pushes oxygenated
blood against the aortic valve → aorta →
different systems of the body
o 8 seconds – cardiac cycle

STROKE VOLUME: amount of blood ejected per

contraction (lub-dub)

CARDIAC OUTPUT: blood ejected by the heart in

one minute (5-8L)

DIASTOLE
Opening of the atrioventricular valves which
are the tricuspid and bicuspid valves and the
closing of the semilunar valves which are the
pulmonic and aortic valves. The ventricles are
in a relaxed state and the atrium contracts
filling ventricles with blood; s2 sound is
The medium and big arteries are affected
produced
(coronary arteries) arteries that supply blood
with oxygenated blood for the heart to
SYSTOLE function as a pumping organ
Closing of the atrioventricular valves which
Affected with lipids/plaques, obstructing
are the tricuspid and bicuspid valves and the artery
opening of the semilunar valves which are the Carotid arteries (vertebral arteries) = supply
pulmonic and aortic valves. The right the brain with oxygenated blood
ventricle pushes unoxygenated blood to the
Young people (as early as 2 years old) can
pulmonic valve going to the lungs for
develop lipids in arteries especially if fat
oxygenation and at the same time, the left
Progressive: will take years to be big in size
ventricle contracts and pushes oxygenated
and will later cause complete obstruction
blood to aortic valve to ascending and
descending aorta to be distributed to the ARTERIOSCLEROSIS
different systems of the body
Small arteries are affected
PRELOAD: when chambers of the heart (atrium
DEVELOPMENTAL STAGES OF CAD
ventricles) filling with blood, during
diastole, atrioventricular open, giving blood
to ventricles = distend
Place px in a semi fowler to decrease preload,
giving rest to the heart, diminishing blood
going back to the heart

AFTERLOAD: pressure that the heart must

overcome to eject the blood
Ex: BP-160/100; 60-80 in left ventricle, it
cannot eject blood = generating higher
pressure so that it can push blood towards the
different systems of the human body,
increasing workload and muscle will enlarge
(left)

Risk factors: Obesity

ATHEROSCLEROSIS Complications
o Peripheral arterial disorder
o Myocardial infarction
o CVA

Myocardium will die = less contractility;

blood remains at heart
COLLATERAL CIRCULATION ECG INTERPRETATION
o Compensatory mechanism P wave – the atrioventricular (bicuspid and
o More blood vessels formed tricuspid valve) are open during the p wave,
o Disadvantage: weak and new blood the atriums are contracting and filling the
vessels = can rupture and have bleeding ventricles with blood.

PR – the stimulus is already received by the

AV node, trying to open the valves a longer
time so that more blood will go to the
ventricles

QRS – the ventricular contraction, systole,

the stimulus is already received by the bundle
of his and purkinje fibers, the
atrioventricular valves will close (bicuspid
and tricuspid) and the semilunar valves are
open, and the right ventricle will eject the
unoxygenated blood towards the lungs for
oxygenation, and the left ventricle will also
contract pushing the oxygenated blood to the
RISK FACTORS FOR CAD aortic valve to the aorta, to the different
A. NONMODIFIABLE RISK FACTORS systems of the body
o Age: arteries not elastic, sudden
change of position causes dizziness and
ST – the ventricles has ejected all the blood
fall (should be gradual and walk
and is starting now to relax
slowly)
o Gender: males (stressors in life e.g.,
T – ventricles are contracting
fight in a family, bad relationship
with coworkers, death of a family
CASE STUDY PRINCIPLES
member, jobless) = they handle it by
COPD
usually smoke and drink liquor
 Nicotine causes vasoconstriction, DRUGS (fucking reason muna bakit ibibigay sa
increasing blood pressure, patient bago ka maglagay ng fucking mechanism
destroying intimal layer of of action)
artery = no supply of the nitric
Examples:
oxide (produced by intimal o Ampicillin was ordered because cilia
layer). It dilates artery. If was paralyzed making the patient
pressure is always high, it susceptible to infection, etc.
destroys it. Artery won’t be able o Steroid is given because of chronic
to dilate bronchitis there is inflammation in
o Ethnicity: African-Americans because of order to stop the migration of WBC,
high salt intake; Koreans and etc.
Filipinos; 1 in every 4 Filipinos are o Rebamipide is given because patient is
hypertensive taking ampicillin and steroids, both
o Family history: genes; hereditary are GI irritants, a cytoprotective
agent, etc.
B. MODIFIABLE RISK FACTORS
o Elevated serum lipids: do not eat red HEALTH TEACHING (i-relate sa case ng patient;
meat (beef)/ limit (bad cholesterol) common sense)
 Should be lower than 200mg Examples:
o Hypertension: 140/90 1. Cessation of smoking (patient might
 Can be prevented by limiting food smoke again, importance of reducing
intake and exercise regularly, number of cigarette)
lessen stressors in life a. Avoid friends who are smoking
o Diabetes – high glucose levels may b. Let patient put all cigarette box
irritate the endothelial layer of the in a transparent container so
blood vessel, leading to that patient can realize just how
atherosclerosis many cigarettes did he already
stopped taking
ANGINA c. If there is an urge to smoke,
Chest pain - can be obstructed with lipids; chew bubblegum as substitute
blood cannot flow into the heart. Continuously 2. Good hydration (increase fluid intake)
beat but activity will be converted to 3. Pursed lip breathing (include how)
anaerobic metabolism (less oxygen) because of 4. Avoidance of infection
clotted blood (less blood) → body is producing a. not going to crowded places
lactic acid stimulating nerve endings at the b. avoiding people with respiratory
heart → angina or chest pain infection
c. vaccines
5. Dietary
  Decrease Carbohydrate Content: o Spasm – less blood (ischemia)triggered
The end product is CO2 by smoking or cocaine causing chest
 Avoid gas forming foods = pain
bloating push diaphragm o Unlike typical angina-which is often
triggered by exertion or emotional
MYOCARDIAL INFARCTION stress
o Almost always occurs when a person is
DRUGS at rest, usually between midnight and
NITROGLYCERIN – dilates coronary artery early morning
There is pain when there is less blood supply. o These attacks can be very painful
With MI, there is lipid meaning there is less o Can be severe but pain can respond to
blood supply going to the heart → aerobic medications like NTG.
changed to anaerobic → lactic acid produced → o Can occur even at rest
pain
Relieves pain by dilating coronary artery: ANGINA COMPLAINTS
pain will subside, giving plenty of blood = no o Heaviness
lactic acid produced o Pressure
o Squeezing
MORPHINE SULFATE (opiate) – for chest pain o Burning sensation/tenderness (For
Drug for chest pain (primary), relieves pain women)
and anxiety (not stimulating norepinephrine,
there will be no vasoconstriction that lessens
blood supply) and also a dilator

INTERVENTIONS IN PTCA
Stent inserted at femoral artery
Once the catheter is removed, there is wound,
and there will be clotted blood (normal
reaction) *platelets will be attracted to that
area*
1. Keep patient on bed rest and keep legs
straight for 4-6 hours (can be
dislodged and go to the lungs)
2. Put sand bag over the area to prevent
bleeding

PAIN radiates because of presence of the

nerves

Coronary artery is blocked with lipids = less

blood supply going to heart = aerobic will be
changed to anaerobic and it will be producing
lactic acid (Krebs cycle) = irritate nerve
endings at the heart = ANGINA

ANGINA PRECIPITATING FACTORS

4 E’s
o Exertion
o Eating (after heavy meal) food remain
at stomach – stomach needs a lot of
blood to digest food but if there’s
blockage, possible for patient to have
chest pain
o Emotional distress (catecholamines
cause vasoconstriction) STABLE UNSTABLE MYOCARDIAL
o Extreme temperatures (cold causes ANGINA ANGINA ANGNA INFARCTION
vasoconstriction = less blood) Blockage 50% More than 50% Complete
- 90% obstruction
Prinzmetal Angina Less than More than
Duration 15-20 minutes
o Vasospasm occurs 10 minutes 30 minutes
 Narrowing of the coronaries Immediately Morphine
 No buildup of fatty deposits in Relief by resting NTG IV only Sulfate
the artery walls or NTG SL only
o Experienced at night, which can be Predictable
Unpredictable
disruptive to sleep (doing
(can occur
o It is a medical condition in which something
Onset while working
there is temporary spasm of the heavy →
or even
coronary arteries causing pain and inadequate
resting)
discomfort blood
 supply →
chest pain)
NITROGLYCERIN SUBLINGUAL HEALTH TEACHING
1. Take the drug sublingually (under tongue) up
to 3 doses at 5 minutes interval
o Ex: Patient is given at 8:00,
then go back at 8:05 and ask if
the patient still has pain. If
so, give the second dose. Ask
patient again at 8:10 and if so,
give the third dose. If pain
persists, don’t give the fourth
dose and bring patient to the
hospital – possible Myocardial
Infarction
2. Once buying NTG, store it in original
container, should be colored because it
is sensitive to light
3. Store in a cool, dry place (not in the
refrigerator, because it will cause
moisture)
4. Bring NTG whether in school or office,
but do not put in pocket or glove
compartment, because it can destroy
potency of drug
5. If there is discoloration upon opening
the container, discard
NITROGLYCERIN PATCH HEALTH TEACHING
1. Apply it anywhere in the chest (no
lesion, sweat, hair)
o Do not shave if there is hair
because purpose of the drug is
slower absorption
2. Not to apply patch in the same area
everyday (cause contact dermatitis);
rotate it
3. Common side effect: headache (call
physician for medication of headache,
probably acetaminophen)
4. Wash hands after applying patch. Can
cause vasodilation of the arteries
5. Before sleeping at night, tell patient
to remove patch
Additional:
 The nurse should remove the old patch,
wash the client’s skin
 Note the date and time the new patch is
applied
 Apply it in a new area that is not
hairy
 The NTG patch should be held if the
client’s blood pressure is less than
90/60
ECG
P WAVE – atrium (left & right) are contracting
and AV (tricuspid & bicuspid) valves are open.
Atrium giving blood to ventricles (diastole)
PR INTERVAL
QRS – ventricles are contracting so that AV
valves should close and semilunar valves open.
Right ventricle is contracting unoxygenated
blood. Entering pulmonic valve → pulmonary
trunk → pulmonary arteries → lungs for
oxygenation. Left ventricle also contracting
giving out oxygenated blood entering aortic
valve to ascending aorta to different systems
of the body (occupies 1 small box)
ST SEGMENT – early ventricular
repolarization/depolarization
T WAVE – complete ventricular repolarization
o PR and ST segment should be at the same
level (normal)
o Depression of ST segment – indication
of myocardial ischemia
COMPONENTS OF A NORMAL ECG
PWAVE: <0.11 SECONDS
QRS: 0.06-0.1O SECONDS
TWAVE: 0.16 SECONDS
PR INTERVAL: 0.12-0.20 SECONDS
NON-ST-SEGMENT ELEVATION MI
o Same signs and symptoms with unstable
angina
o Occurs at rest or with exertion; limits
activity
o LONGER IN DURATION and MORE SEVERE than
in UNSTABLE ANGINA
o Cardiac Catheterization and
Percutaneous Coronary Intervention
DIAGNOSTIC FINDINGS
o ST-segment depression or T-wave
inversion on ECG
o Cardiac biomarkers are elevated
o There may be less damage to the
myocardium
ST-SEGMENT ELEVATION MI
o Thrombus fully occludes the coronary
artery
o Same signs and symptoms with ANGINA and
NSTEMI
o Occurs at rest or with exertion
o LONGER IN DURATION and MORE SEVERE than
in UNSTABLE ANGINA

DIAGNOSTIC FINDINGS
o ST-segment depression or T-wave
inversion on ECG
o Cardiac biomarkers are elevated
o There is significant damage to the
myocardium
 PHASES OF MYOCARDIAL INFARCTION
CLINICAL MANIFESTATIONS
o Chest pain
Myocardial Ischemia o Vomiting (can trigger vomiting center,
o less blood supply because coronary but not all patient will vomit)
artery is with lipids/plaques
o Tachycardia
o depressed ST segment o increased blood pressure
o Causes ST segment Depression with or
o cold, clammy, pale skin
without T wave inversion as result of
o decreased cardiac output
altered repolarization.
o increased respiratory rate
o hypoxemia
Myocardial Injury o body weakness
o ST elevation o low grade fever
o Causes ST segment elevation with or o leukocytosis
without loss of R wave
o can also mean other diseases like *stimulates cathecholamines epinephrine
pericarditis
causing tachycardia and norepinephrine that
o inverted T wave
causes vasoconstriction therefore increasing
blood pressure and giving patient cold,
Myocardial Infarction clammy, pale skin (SNS stimulation) *
o ST elevated,
o T wave inverted
Interventional laboratory
o Q is deep and wide
o Where angioplasty is done
o Causes deep Q waves as result of
o Guided by fluoroscopes
absence of depolarization current from
dead tissue and receding current from
Before PTCA:
opposite side of heart
o IV line
o Death of one part of heart usually
o Heart monitor
myocardium
o Oral or IV sedative
*No death of tissue in ischemia and injury
After PTCA
CARDIAC ENZYMES o Apply pressure bandage
o released by heart whenever injured o Lie on back for several hours
CK-MB o Check for bleeding or chest pain
CARDIAC TROPONIN o Discharged same day or stay overnight
TROPONIN I (CREATININE
BIOMARKERS T
KINASE-MB)
PERICARDITIS
Exclusively
Seen in *itis-inflammation
seen in
cardiac Most
cardiac
and reliable PERICARDIUM
muscle
skeletal before outer layer of the heart; followed by
(most
muscle myocardium (muscle responsible in contracting
reliable)
heart); then inner endocardium
3-6 hours 3-6 4-6 hours o Provides lubrication to decrease
hours
Release after after friction during systolic and diastolic
after
injury injury heart movements
injury
o Normally it contains 10 to 15 mL serous
5-10 days 5-14 2-3 days fluid
days
Elevation after after o Assist in preventing in excessive
after
injury injury dilation of the heart during diastole
injury
Sac contains fluid so that parietal will not
PTCA INDICATION: for patients with coronary come in contact with visceral. If parietal and
arteries that have at least 70% narrowing visceral touch, it causes friction and will
give severe chest pain
ANGIOPLASTY CABG
4 arteries 5-7 arteries

STENT
o a foreign body
o 2 complications
 Blood clots (can go to the brain
= CVA)
 infection
o Tissue will grow over it becoming a
part of artery holding it in place
o Can still be blocked with lipids and
undergo PTCA again
 *Sharp, stabbing chest pain is a common
symptom of pericarditis*

PERICARDIUM PALAPTION
o Apex beat (5th
intercostal
space/mid-
clavicular line)
o to feel
pulsation
o to evaluate
apical pulse
o to assess
dilation and
dynamics of RV, aorta and pulmonary
artery
Pericardial Cavity o If obese, place patient at left lateral
o 10-15 ml of water acts as a lubricant decubitus position to put heart
o Parietal layer contains plenty of nerve anteriorly for you to feel it
endings. If it comes in contact with
visceral = chest pain Can anemia give you chest pain?
o Protect heart: pericardium = parietal & - Yes, because lack RBCs → less oxygen →
visceral = pericardial sac (act as aerobic-anaerobic → lactic acid → chest
lubricant) pain

AUSCULTATION
o The most characteristic clinical
manifestation is CREAKY, or SCRTACHY,
GRATING in quality friction rub
o Heard in both the inspiratory and
expiratory phases of the respiratory
cycle

ECG

ETIOLOGY
VIRAL
o Echo virus
o Mumps
o HIV
o Hepatitis
BACTERIAL
o Pneumococci
o Streptococci
NONINFECTIOUS o T wave initially upright and elevated
but then during recovery phase it
o Uremia
inverts
 Renal failure = toxins: uric
o ST segment elevated and usually flat or
acid, urea, creatinine
concave
 Can also be azotemia
 Results to inflammation of the PAIN
heart
o The pain is generally worse with deep
o Acute MI (because of blood) INSPIRATION and when lying supine or
o Cancer, radiation turning
o Trauma: thoracic surgery, pacemaker
 when lying down, parietal by
insertion
gravity comes in contact with
o Dissecting aortic aneurysm
visceral = chest pain
CLASSIC TRIAD OF SYMPTOMS  pain on inspiration associated
1. CHEST PAIN: with fluids, decreased with pericarditis is due to
contractility of heart → less stroke contact between the inflamed
volume and cardiac output → less blood pericardium, which is adjacent to
going to coronary artery → aerobic- the diaphragm, and the trachea
anerobic = chest pain o It is relieved by sitting up and
2. FEVER: general manifestation of patient leaning forward
with inflammation  Sitting up and leaning forward
3. PERICARDIAL FRICTION RUB: heard through positions the stretched
stethoscope pericardium away from the pleura,
which relieves comfort
  Sitting up: allow CARDIAC TAMPONADE
pericardium to
o If accumulation is rapid, as little as
hung 100 to 150 mL of blood in the
 Leaning forward: pericardial sac can adversely affect
to keep parietal cardiac output
layer away from o The leading cause of cardiac tamponade
the visceral is penetrating chest injuries (80% to
layer 90%) such as stab wounds
o DYSPNEA o Develops as the pericardial effusion
 Pain on inspiration associated increases in volume, → compression of
with pericarditis is due to the heart → restricts diastolic
contact between the inflamed ventricular filling → cardiac output
pericardium, which is adjacent to drops
the diaphragm and the trachea. o Results from a stab or gunshot wound or
 Sitting up and learning forward surgery = plenty of blood in
positions the stretched pericardial sac → limit contraction of
pericardium away from the pleura the heart → less cardiac output →
which relieves discomfort. hypoxemia, renin released
 The parietal (fibrous) o Develops as the pericardial effusion
pericardium is innervated with increases in volume → compression of
pain nerve fibers responsible for the heart → restricts diastolic volume
producing the pain experienced in
pericarditis.

MANIFESTATIONS
o PERICARDIAL FRICTION RUB at the left
sternal of the chest
o Fear and ANXIETY
o INCREASED WBC COUNT
 given with steroids (anti-
inflammatory) to prevent of WBC
to injured site (causes edema and
sever pain)
o ELEVATED ESR and C-REACTIVE PROTEIN
(dangerous)
o NONPRODUCTIVE COUGH or HICCUP

TWO MAJOR COMPLICATIONS

PERICARDIAL EFFUSION PATHOPHYSIOLOGY

Less than 100cc → because of inflammation
there will be exudates → increase fluid in
pericardium (can have blood, if stabbed,
gunshot wound, or surgery entering
pericardium) → limiting space of ventricles →
less contractility (less space because of
fluid) → less stroke volume and less cardiac
output → SVC: neck vein engorgement; IVC:
hepatomegaly

SIGNS AND SYMPTOMS

o Confused, anxious, and restless
 More than 2L → compress heart →
plenty of fluids → hard time
contracting → cardiac output less
→ brain cells depend on blood →
less cardiac output → less oxygen
and nutrient in the brain →
confused, irritable restless
 o Tachypnea and tachycardia
 Decrease migration of WBC in
 Decreased cardiac output → injured site and decreases immune
stimulate SNS → triggering system
adrenal medulla → producing
o PERICARDIOCENTESIS – performed only
catecholamines epinephrine causes for:
tachycardia (trying to
 Pericardial effusion with cardiac
compensate) & norepinephrine tamponade
cause vasoconstriction to
 Purulent pericarditis
increase blood pressure because
 Neoplasm
it is one way in putting more
blood to the brain
o Distended neck veins HEALTH TEACHING FOR ASPIRIN
o Instruct patient to take it after a
 Plenty of fluids in pericardial
meal because it causes gastric
sac that it is compressing the
irritation that can cause ulcer
heart → unoxygenated blood from
superior and inferior vena cava
HEALTH TEACHING FOR COLCHICINE/PREDNISONDE
cannot enter atrium → back flow
Decreases immunity (usually after 2 weeks of
of blood taking it)
o Muffled heart sounds
o Tell patient to not expose himself to
 S1 cannot be differentiated with crowded places and people with
S2 respiratory infections
o Advise patient to have good hygiene
 Although muffled heart sounds indicate (good hand washing technique)
accumulation of fluid around the heart Can cause osteoporosis if taking for more than
 Narrowing pulse pressure signals 3 months
cardiac tamponade o Protect patient from falls because it
 Pulse pressure (difference can cause fracture of bones
between systolic and diastolic For side effects, it causes weight gain due to
pressure) sodium retention. Patient becomes a voracious
 normal: 30-40mmHg eater and mooning of the face. Advise patient
 tells you pressure inside to avoid:
arteries o Salt and caloric intake
 Ex: 90/70 = 20 (narrowed pulse  Junk foods
pressure)  Cured meats (bacon, ham)
 Cold cuts (sweet ham, Canadian
PERICARDIOCENTESIS ham)
 Canned goods
 Boxed foods
 Condiments high in salt
 Chicken nuggets
 Milk and milk products (cheese,
butter, ice cream, cottage
cheese, queso de bola)

NURSING CARE
o Bed rest until fever, chest pain, and
friction rub have subsided
o Pain may be relieved with a FORWARD
LEANING or SITTING POSITION
o Providing simple, complete explanations
of all procedures and possible causes
DIAGNOSTIC STUDIES of the pain
o Widespread ST segment elevations  The goal of nursing management is PAIN
o Elevated CRP and ESR RELIEF
o CT imaging – best diagnostic tool to o Reassure patient that the pericardial
determine size, shape, location pain does not indicate an MI
o MRI for visualization of the o Six meals a day; avoid gas-forming
pericardium and pericardial space foods
-Produces plenty of flatus → abdominal
MEDICAL MANAGEMENT distention → pushing diaphragm up →
o ASPIRIN, IBUPOROFEN (anti-inflammatory chest pain
 Given because it lessens  Eggs
inflammation and therefore lessen  Soft drinks
the swelling. Inhibits migration  Broccoli
of WBC in the injured area  Eggplants
o COLCHICINE or PREDNISONE for severe  Beans (chili con carne)
pericarditis
 Kamote (sweet potatoes)
 *know certain dishes for beans and vulnerable in having frequent
sweet potatoes* grrr upper respiratory infection
 Tonsillectomy is done to prevent
VALVULAR DISORDERS
rheumatic heart disease
o Congenital
CHORDAE TENDINEAE
o Calcification-elderly
Valves are connected to chordae tendineae so
o Ineffective endocarditis
that it will be closed then connected to
MITRAL VALVE STENOSIS DEVELOPS SLOWLY OVER 10
papillary muscles
to 20 YEARS
During Systole SIGNS AND SYMPTOMS
Will pull chordae tendineae to close
o The first symptom is DYSPNEA ON
atrioventricular valves so that blood in the
EXERTION as a result of pulmonary
ventricle will not go up (regurgitation)
venous hypertension
o CLINICAL MANIFESTATIONS
INTRODUCTION
 Fatigue
Mitral Stenosis
o narrowing  Palpitations
o can also be because of aging because of  Orthopnea
calcium deposits  Paroxysmal nocturnal dyspnea
o genetics
During Diastole (should be open to deliver DYSPNEA
100-120 cc of blood to ventricles) not all Exertional Dyspnea: whenever you increase
blood will go to ventricles → less blood → activity
less cardiac output → less glucose and oxygen
to different systems of the body = body Orthopnea: dyspnea in a lying position
weakness and easy fatigability o can I have a pillow? (patient’s
request)
Regurgitation o If patient requests for 2 pillows = 2
o valves cannot close completely and pillow orthopnea
blood returns o Depends on the number of pillow kung
san comfortable to breathe
Mitral Insufficiency
o valves cannot close completely Paroxysmal Nocturnal Dyspnea: is a sensation
of SHORTNESS OF BREATH that awakens the
MITRAL STENOSIS patient, often after 1 to 2 hours of sleep,
The heart valves can be inflamed and become and is usually relieved in the upright
scarred over time. This can result in position
narrowing or leaking of the heart valve making
it harder for the heart to function normally. DRUG TREATMENT
This may take years to develop and can result DIURETIC
in heart failure. o Ex: Furosemide (Lasix): removes excess
water from the body.
ETIOLOGY o If there is water in pulmonary bed, the
o Rheumatic fever – most common cause amount of blood that goes to ventricles
 Since there is bacteria are less. Blood will accumulate in left
(Streptococci) the body will atrium (enlarge) → cannot accommodate
compensate, antibodies will be oxygenated blood entering pulmonic
produced (immunoglobulins), then valves → lungs → backflow of blood in
antigen and antibody will react pulmonary bed → pulmonary congestion →
and it will produce antigen- pulmonary edema
antibody complexes which is a o Used to remove excess water because it
protein then after 15-20 years it causes dyspnea
can destroy the valves and you
can have Rheumatic Heart Disease DIURETIC HEALTH TEACHING
Ex: Taken for 1-month for twice a day
 The rheumatic fever can result to
o Give in the morning 8:00 because it
rheumatic heart disease if there
increases urinary excretion
is damage in the valves of the
o 2nd dose will be given at 18:00 and not
heart like mitral valve stenosis
near at retiring time of the patient.
- aortic valve is the most common
Patient’s sleeping pattern will be
valve that is affected
disturbed (sleep pattern dysfunction)
 Prevalent in congested/crowded
places
o If once a day, give it at morning
 Ex: a one room house with five o Take weight to see effect of medication
members; if a family member is
having productive cough or
DIGOXIN (LANOXIN)
sneezing without covering, o Positive inotropic: increase
children and elderly are contractility
 o Negative chronotropic: decrease cardiac
rate to open atrioventricular valves
for a longer time for more blood to go
to the ventricles to improve cardiac
output
BETA BLOCKERS/CALCIUM-CHANNEL BLOCKERS
(Metoprolol/Verapamil)
o have the same action with digoxin but
not a positive inotropic
o Good in decreasing cardiac rate
o Also, a dilator
ANTICOAGULANTS for AF (Warfarin (Coumadin))
o less blood going to the ventricle → blood
will accumulate in left atrium → tendency to
clot
HEPARIN WARFARIN
IV
SQ
Route Oral
IM (should be avoided for
this case)
SURGICAL TREATMENTS
o Mitral Balloon Valvuloplasty
o Open Valvotomy
NURSING INTERVENTION FOR DYSPNEA
o Position
o Alternate rest and activity
MITRAL REGURGITATION
In regurgitation, ventricles are contracted,
left with oxygenated blood. Push blood toward
aortic valve. Some went to descending aorta,
some went back → less cardiac output →
enlarging left atrium → backflow of blood to
the lungs → pulmonary congestion/edema →
dyspnea
Backflow of blood to the right atrium → enlarge
RA → chambers of the heart enlarge because it
cannot accommodate blood coming from the superior
and inferior vena cava → backflow again (blood
goes back) → ascites and pitting edema
MOST COMMON SYMPTOMS
o Dyspnea/shortness of breath
o Fatigue
o Weakness
DRUG TREATMENT
ACUTE MR
o Nitroglycerin/Nitroprusside IV – to
reduce afterload (given first)
o Dobutamine – to increase force of
myocardial contraction (patient might
die from cardiogenic shock); (given
last)
o Diuretics
o ACE inhibitors – decrease afterloads
SURGICAL TREATMENTS
o Mitral Valve Annuloplasty
AORTIC STENOSIS
o Most common cardiac valve dysfunction
o More common in MEN than in women
o Patients with AS can be ASYMPTOMATIC
for years
o HEART MURMUR is the most common early
sign
ETIOLOGY
o Age-related degenerative calcific AS
most common cause in adults
o Rheumatic disease
o Congenital

ETIOLOGY Without treatment, the patient is at risk for:

o Rheumatic heart fever o Heart failure
o Coronary artery disease o Dilated cardiomyopathy
o Cardiomyopathy  muscles of the heart are
o Congenital affected; accumulated blood at
o Ineffective endocarditis the left ventricle → enlarge
PATIENTS WITH CHRONIC MR MAY NOT EXPERIENCE muscle
ANY SYMPTOMS UNTIL 20 YEARS AFTER EPISODE OF o Sudden cardiac death
RF.
o In ACUTE MR, the patient may develop THREE CARDINAL SYMPTOMS
PULMONARY HYPERTENSION and RIGHT-SIDED 1. Angina
HEART FAILURE with EDEMA and ASCITES 2. Syncope
3. Exertional Dyspnea
During Systole, left ventricle should eject
blood into descending aorta but mitral valve
is open, causing the blood to go back → left
atrium enlarges because valve cannot close
completely → left atrium accumulate blood
because it is receiving blood coming from
pulmonic veins and left ventricle → cannot
accommodate blood coming from the lungs →
pulmonary bed → pulmonary congestion → lots of
fluids in the lungs → pulmonary hypertension →
pressure in pulmonary trunk increase → right
ventricle having a hard time pushing
unoxygenated blood towards a high pressure →
increasing workload → enlarge RV muscle
 HYPERTENSION CLASSIFICATION OF HYPERTENSION
Hypertension is consistently high blood
pressure of at least 140 (systolic) over 90 PRIMARY HYPERTENSION (ESSENTGIAL/IDIOPATHIC)
(diastolic) o Affects 90% of people with hypertension
CAUSES
o Hereditary
o Increased salt intake
o Stressors in life
o African-Americans due to increased salt
intake
o Asians: Koreans and Filipinos due to
increased salt intake like kimchi which
is preserved using salt
o Abnormal arteries
o Increased blood volume
o Genetic disorders

SECONDARY HYPERTENSION
o A direct result of another problem or
Lumen of artery is small compared to vein condition
because media is thick in artery making CAUSES
pressure in artery higher than the vein o Health conditions
o Thyroid gland is firing out/plenty of
Effects of Hypertension T3 an\d T4 that increases metabolism
Sluggish flow of blood → viscous → formation and therefore increases blood pressure
of clots → embolus → can go to lungs/brain  Medicine that lower T3 and T4
resulting to CVA → half of body paralyzed bring blood pressure to a normal
level
o PHEOCROMOCYTOMA: Tumor in adrenal
medulla that releases catecholamines:
norepinephrine and epinephrine.
Norepinephrine causes vasoconstriction
that increases blood pressure
 Removing tumor lowers blood
pressure
o Hyperthyroidism
o Neurologic disorders that increase ICP
o High dose estrogen use
o Renal artery stenosis
o Pregnant (Preeclampsia)
o Certain medicines
Pressure is high in the artery → destroying o Recreational drugs
intimal layer of blood vessel → less nitric o Hormonal therapy
oxide (dilates arteries) → artery will not
dilate anymore → plaque can start forming

CAUSES
1. Hyperactivity of the sympathetic
nervous system
o Obstruction → bigger in size → causes
narrow lumen of the artery → sluggish
Plaque → left ventricle generates higher flow of blood → viscous → heart is
pressure than 160 → increasing workload of the trying to push against a high pressure
heart → contracting against pressure → bigger → less cardiac output → stimulate SNS →
in size = left ventricular hypertrophy trigger the adrenal glands above the
kidneys → adrenal medulla release
norepinephrine (vasoconstriction) and
epinephrine (tachycardia) → increased
 cardiac rate → atrioventricular
MEDICAL MANAGEMENT
(bicuspid and tricuspid) valves close o All studies have shown that the
immediately (should be open for .5 majority of hypertensive patients will
seconds) → less amount of blood need two to three drugs to control
delivered in the ventricles their BP
 Combined 2-3 drugs are better
2. Hyperactivity of the renin-angiotensin-
because complications will not
system
develop and that is if patient is
o Hypertension → increased cardiac rate →
taking the drugs religiously.
increased blood pressure → less stroke
o Sticking to monotherapy will only delay
volume and cardiac output → kidneys are
control and may cause serious
secondary organ receiving less blood →
complications
will compensate → renin → angiotensin
o The absence of symptoms which is
one → liver → lung converting it to
usually the case in most hypertensive
angiotensin two which is a potent
patients, does not mean that one is low-
vasoconstrictor
risk
3. Endothelial dysfunction  The BP should be brought down to 120/70
mmHg to less than 140/80 mmHg
o High blood pressure → destroying
intimal layer → less production of
DIURETICS
nitric oxide → arteries will not dilate
o First-line therapy for hypertension
o Eliminating excess salt and water from
Enlarged left ventricle → limiting space of
the body
blood that will be sent by the atrium to the
o To remove excess body fluids
ventricles → increase cardiac output
o Hydrochlorothiazide (Betazide, Diuzid)
o Furosemide (Lasix, Pharmix)
Hypertension is asymptomatic, slowly
destroying the eyes, heart, kidneys and brain
NURSING MANAGEMENT
o Take diuretics in the morning
NOSE BLEEDING (late manifestation of HTN) o Caution patients to stand up slowly to
1. Help the patient to sit, leaning
minimize the risk of orthostatic
forward, with the head tilted forward
hypotension
o This position keeps the blood
o Monitor the patient for signs of
from dripping down the throat, or
hypokalemia such as:
being aspirated into the lungs;
 Muscle weakness
prevent entering pharynx
2. Apply DIRECT PRESSURE at least 15  Confusion and irritability
minutes by PINCHING THE NOSTRILS o Weigh patients daily
together (might re-bleed if less than  Weigh before breakfast and let
15 minutes) patient void first
3. Apply COLD COMPRESS to the bridge of o Report a significant weight gain such
the nose as 3 pounds in 3 days
4. Keep the patient CALM and QUIET o Increase potassium intake because
especially if he has HIGH BP potassium can be removed
o Anxiety tends to increase BP
which could worsen the nosebleed ACE INHIBITORS (PRIL)
o Enalapril (Renitec, Hypace)
 Stimulate SNS =
o Imidapril (Norten, Vascor)
increasing BP
o Cilazapril (Vascase)
o Ramipril (Ramipro, Tritace)
o Prevent conversion of angiotensin one
to angiotensin two (vasoconstriction),
preventing release of aldosterone and
reabsorption of sodium

NURSING MANAGEMENT
o Risk for hyperkalemia
*do not tilt head back*  Do not give potassium
o The patient may experience persistent
dry, irritating, non-productive cough
TO PREVENT RE-BLEEDING after the bleeding has  Report because it can disturb the
stopped: sleep pattern of the patient
o Don’t pick or blow your nose o Infrequent but dangerous adverse
o Don’t bend down until several hours effects are agranulocytosis,
after the bleeding episode proteinuria, acute kidney failure,
o Keep your head higher than the level of glomerulonephritis
your heart
BETA BLOCKERS (OLOL) EXERCISE REGULARLY
o Atenolol (Cardioten, Tenormin) Brisk walking for 30mins drops your systolic
o Metoprolol (Betaloc, Neobloc) BP by 4-9 points
ALPHA BLOCKERS LIMIT YOUR SODIUM INTAKE
o Doxazocin (Alfadil XL) Eating no more than 2,400mg a day of sodium
brings down your systolic pressure by 2-8
COMMON ADVERSE EFFECTS points
o Dizziness
o Bradycardia While all the above measures are important for
o Hypotension health promotion, weight reduction measures
o Fatigue will have to most immediate impact
CALCIUM CHANNEL BLOCKERS (PINE) 30 minutes of Brisk Walking benefits health
o Depresses myocardial contractility o Regulate blood pressure
o Should not be given with heart failure o Lower body fat levels
o Relaxes and dilates arteries causing a
o Protection from arthritis
fall in BP and decrease in venous o Lowers stress levels
return o Weight loss
o Diltiazem (Dilzem, Filazem)
o Verapamil (Isoptin) EXERCISE
o Amlodipine (Amlodine, Amlocor) 1. Exercise helps make BV more flexible
o Nifedipine (Adalat, Calcibloc) and increases their diameter by
 Gel-like increasing NITRIC OXIDE levels
 Can be placed under the tongue 2. Forty-five minutes of moderate-
(SL) intensity exercise will raise HDL
 For faster absorption cholesterol level
: with a sterile needle, prick o HDL (good cholesterol) → going to
and then squeeze under the remove bad cholesterol that
tongue) = lower BP immediately obstructs artery
o SE: 2-3% edema at lower extremities o Eating peanuts, legumes, beans
increases HDL
AMLODIPINE BESYLATE (NORVASC) o High in sodium: soy sauce, patis,
o Dilate the peripheral vessels to lower ketchup
BP (results to dizziness and swelling) 3. Exercise increases an enzyme that
o Used primarily in patients with breaks down TRIGLYCERIDES so it can be
hypertension processed by the liver
o Reduce visceral fat (deep fat
NURSING MANAGEMENT that is hart to remove)
o Instruct patient to report dizziness 4. Regular exercise has an ANTI-CLOTTING
and irregular heart rate EFFECT similar to aspirin therapy
o Avoid grapefruit juice because it o Can send fats in blood that
inhibits the hepatic metabolism of CCB causes obstruction
that may lead to pharmacologic effects
o All CCBs should be used cautiously in SODIUM LANDMINES
patients with heart failure o WHOOPER with CHEESE-------------1450 mg
o PASTA SAUCE, canned, 1 cup------1025 mg
COMPLICATIONS OF HYPERTENSION o BROTH/BOUILLON, 1 packet--------1020 mg
o Aneurysm: ballooning of the artery in o SOY SAUCE, 1 tablespoon---------900 mg
the brain → ruptured → blood in the o COTTAGE CHEESE, 1 cup-----------800 mg
brain → increased ICP (80% brain o CHICKEN McNUGGETS, 6------------600 mg
tissue, 10& cerebrospinal fluid, 10% o BEEF/PORK HOTDOG----------------500 mg
blood only). Edema will also cause high o BACON, 3 strips-----------------550 mg
ICP, diminishing blood o MILK and MILK PRODUCTS (cheese, butter,
o Destroy the kidneys resulting to renal ice cream)
failure as evidenced by less urine
excretion and plenty of bubbles in the LDL: <100 mg/dL
urine which indicates protein HDL: >60 mg/dL
o Blurred vision: arteries in the eyes
are dilated CARDIOVASCULAR DISEASE
o Enlargement of the heart o Others, however, have no such innate
capability, and the excess sodium gets
LIFESTYLE MODIFICATIONS stored in the body and attracts water
causing:
LOSING EXCESS WEIGHT  Edema
For every 20lbs you lose, you drop your  Weight gain
systolic BP 5-20 points o The greatest amount of salt we ingest
does not come from the condiments we
use.
 o The biggest source is processed foods,
o Obesity
which include:
o Diabetes
 canned goods
o Metabolic syndrome
 instant noodles o Physiologic states
 salty snacks o Homocysteine level
 margarine
 frozen meals CENTRAL OR ABDOMINAL OBESITY
 ketchup o Men – waist circumference is greater
 Dried fruits than 40 inches
o Salt reduction in all processed foods o Women – wait measures more than 35
is doable and can have a tremendous inches
impact on hypertension control, since o A healthy waist circumference is less
around 80% of salt intake really comes than 35 inches (87.5 cm) in women and
from them less than 40 inches (100 cm) in men
o Too much salt retained in the body may o The desired BMI is 18.5 to 24.9 kg/m2
lead to: for both sexes
 High blood pressure
 Heart failure SATURATED FATS
 Stroke Typically come from ANIMAL SOURCES such as:
 Premature death  Meats
o CVD and stroke have remained the top  Cheese
two killers in the country for the last  Egg yolks
30 years  Ice cream
o Around 200,000 Filipinos dying yearly  Cream
o Increased salt intake is particularly  Butter
related to the risk of developing  Whole milk
stroke  Lard
 Bacon drippings
LIFESTYLE MODIFICATION
o The primary dietary culprit in raising
FOLLOWING A DASH DIET (DIETARY APPROACHES TO blood levels of LDL CHOLESTEROL
STOP HYPERTENSION) o Saturated fats increase the risk of
Low fat diet, rich in vegetables, fruits and HEART DISEASE
low-fat dairy foods lower your SBP by 8-14 o An optimal level of LDL is <100 mg/dL
points
HIGH-DENSITY LIPOPROTEIN
STOP SMOKING o HDL leave the LIVER with very little
cholesterol, PICK UP EXCESS CHOLESTEROL
LIMIT YOUR ALCOHOL INTAKE on their route through the bloodstream
No more than 2 drinks a day for men, one for and take it back to the LIVER
women o The LIVER EXCRETES this cholesterol
into the bile and out of the body
SMOKING through the BOWELS
o TOBACCO use is the leading risk factor o Higher levels of HDL, ideally 60 mg/dL
for coronary artery disease and a OR GREATER
POTENT VASOCONSTRICTOR leading to o You get HDL from:
hypertension  Nuts
 Beans
COMPLIANCE
 Legumes (green peas, garbanzos,
o Long-term compliance and adherence have monggo)
emerged as the most essential element
*garbanzos with the skin has good
in reducing morbidity associated woth fiber content*
hypertension
 High-fiber fruits and vegetables
o Taking medications consistently and as
directed by the doctor  Virgin olive oil
 Exercising regularly and being
BREAKFAST more physically active
o According to research skipping
breakfast increases platelet stickiness TRANS FAT
which in turn can promote clotting, o A specific type of fat formed when
eventually leading to a heart attack liquid fats are made into solid fats by
the addition of HYDROGEN atoms
RISK FACTORS FOR CAD o The HYDROGEN makes the fat harder which
is why it sticks to the arteries
Modifiable Risk Factors
o gives the food a good form
o Elevated serum lipids
o Hypertension
EXERCISE
o Tobacco use
o Physical inactivity o Walking, jogging, bike riding that
raises your heart rate for 20 to 30
 minutes at a time maybe the most THROMBOANGIITIS OBLITERANS
effective way to increase HDL levels BUERGER'S DISEASE
o Mainly seen in young men between ages
LOSE WEIGHT
20 and 35 years.
OMEGA-3 FATTY ACIDS (salmon, mackerel, trout)
o Tends to occur in young men and women
who are heavy cigarette smokers.
PERIPHERAL ARTERY DISEASE o Affects the small and medium sized
o PVD usually affects people in their arteries and medium- sized, mostly
60’s and 70’s superficial, veins of the extremities.
o Men are more affected than women
PATHOPYSIOLOGY
o Having PAD puts a person 2 to 6 times
greater risk of dying of a Heart Attack Prolonged periods of Tissue Hypoxia increase
or Brain Attack the risk for:
o Risk Factors for PAD are similar to o Tissue Ulceration
those for Atherosclerosis and CHD o Gangrene
 HTN
INTERMITTENT CLAUDICATION
 DM: ↓ insulin produced → glucose
o The most common symptom is intermittent
cannot enter the cell and stays claudication
in the blood → viscous → high
o The leg cramping that occurs during
pressure in arteries walking or exercise and disappears with
 Cigarette smoking rest.
 High homocysteine levels (from  It results from inadequate blood
meat) flow to the legs.
o PAD interferes with Arterial Blood Flow o Example Scenario: in the mall with
to the lower extremities, the risk for: parents, father will stop and complain
 Neuropathy and Paresthesias pain in the right lower leg. When he
 Ulcers that do not heal sat down, the pain subsided. Because of
 Necrosis, Gangrene: decrease obstruction, there is less blood supply
blood supply that damages the in the lower leg, converting aerobic to
nerves that results on wounds anaerobic producing lactic acid that
taking time to heal = gangrene will stimulate nerve endings in the leg
= pain. When the father stopped
 Amputation
o Sudden pain, numbness or tingling walking, sit and took a rest, there is
sensation in one leg indicates possible no anaerobic metabolism and no lactic
arterial occlusion from an embolus acid is produced = pain will subside
o The patient’s leg becomes cold and
pale, and pain will ensue
 Obstruction → less blood supply →
pale in color and cold to touch,
numbness
 The pain is caused by lactic acid
buildup secondary to anaerobic
metabolism in the affected leg
o The absence of pulses distal to the
occlusion is an ominous sign that the
artery has been completely occluded
o Absent or diminished distal pulses
indicate that the ulcers in the
patient’s leg are due to an arterial
problem
o A patient with arterial insufficiency
will have hairless shiny skin on their
legs
 This is due to the lack of blood
supply that brings oxygen and
nutrients to nourish the skin and
the roots of the hair CLINICAL MANIFESTATIONS
o Peripheral arterial diseases have many
skin manifestations Pain
o A patient with a peripheral arterial o Elevation of the extremity may
disease would have: aggravate rest pain; dependency may
 Dystrophic brittle toenails relieve it.
 Bluish or pale extremities Coldness
 Hairless skin o The temperature of the feet is colder
to touch than the rest of the body.
Impaired Arterial Pulsation Pentoxifylline (Trental)
o Pulsation may improve on rest, which
o ↓ Blood viscosity & ↑ Blood flow to the
indicates that some alterations in
lower extremities.
blood flow may be due to Arterial o The patient should have improved
Spasm. circulation in the legs as evident by
Rubor / Cyanosis/ Pallor less pain
o Visible particularly when the extremity
is in Dependent Position NURSING INTERVENTIONS
o Pallor with extremity elevation Smoking cessation is vital.
Paresthesia
o Thin, shiny, hairless skin, thick, HEALING FOODS FOR INTERMITTENT CLAUDICATION
brittle and slow growing nails.
o A blood thinning compound in ginger is
GINGEROL.
THE PAIN AND OTHER SYMPTOMS OF ARTERIAL
o It slows the production of THROMBOXANE,
DISEASE CAN BE CHARACTERIZED AS THE "FIVE Ps":
a compound that causes blood platelets
o PAIN to clump together and clot. (anti-
o PALLOR inflammatory)
o PULSELESSNESS
o Also, pineapple
o PARESTHESIA
o PARALYSIS NURSING INTERVENTIONS
*Paresthesia and Paralysis indicate ACUTE LIMB 1. INEFFECTIVE PERIPHERAL TISSUE PERFUSION
ISCHEMIA*
Positioning:
POIKILOTHERMIA o Maintain the legs in a position of
o Ischemic tissue is pale in appearance
slight dependency, so that the gravity
and cool to touch compared to other
enhances tissue perfusion.
areas of the body.
o If the patient experiences rest pain at
night, the head of the bed is elevated
CAPILLARY REFILL OF THE TOE PADS
4 to 6 inches.
o Return of color after more than 3
o The legs are not elevated above the
seconds indicates a slow arterial
level of the heart, Impede Arterial
inflow.
Flow.
o Press the distal part of a toe until it
 Put legs down, increased blood
blanches and then release.
supply and giving oxygen and
o Normal reperfusion takes 0-5 seconds
nutrients relieving pain.
o Delayed refill is an indicator of
arterial ischemia.  Never elevate (arterial) because
o Prolonged capillary refill time it diminishes blood supply
indicates compromised arterial  Elevate (vein)
perfusion, a problem associated with
cardiogenic shock and heart failure. AVOID THE FOLLOWING:
o Crossing the legs at the knees
MEDICATIONS  Places pressure on the arteries
o Sitting in a slumped or slouched
Aspirin or Clopidogrel posture
o To inhibit platelet aggregation, to  Acute constriction of the
reduce the risk of arterial thrombosis arteries in the pelvis
o AE: bleeding o Massage of the extremities
Cilostazol (Pletal)  Promote embolus formation
o Platelet inhibitor with vasodilator  Can detach clotted blood going to
properties, improves claudication. brain/lungs
o Exposure to cold. (vasoconstriction)
Clopidogrel (Plavix) is an antiplatelet o Constrictive or restrictive clothing.
medication.
ELIMINATE SMOKING
Ginkgo, an herb, can increase bleeding when o Smoking is a major risk factor for PAD
taken with an antiplatelet medication such as
aspirin or Plavix. Use of elastic stockings (support hose) to
o The nurse should encourage the client promote circulation by preventing pooling of
to quit taking ginkgo. blood in the feet and legs.
o Ginkgo has been shown to have a o The stocking should be applied in the
beneficial effect of increasing blood morning before the patient gets out of
flow to the brain, but in this case, bed
the risk of bleeding warrants the o The stockings should be applied
nurse's intervention. smoothly to avoid wrinkles, but the top
should not be rolled down to avoid
constriction of circulation
o The stocking should be removed every 8
hours and the patient should elevate
 the legs for 15 minutes and reapply
o Indwelling w/ Catheters
stockings
o Injection of irritating catheters
substances
2. RISK FOR IMPAIRED SKIN INTEGRITY
*give antibiotics via vein in a slow manner to
Because of decrease tissue oxygenation. prevent inflammation*
o Inspect the skin daily for:
 Dryness Venous Stasis
 Redness o Immobilization for more than 3 days
 Injury (bedridden)
o Clean feet daily using a mild soap o Obstruction or compression of the iliac
o Skin is gently dried & moisturizing or femoral veins from
lotion to counteract dryness.  Abdominal or pelvic tumors
o Properly fitted shoes, soft leather.  Obesity
o Toenails are trimmed straight across  Lengthy surgery more than 30
using nail clippers minutes
 Congestive heart failure
3. RISK FOR ACTIVITY INTOLERANCE
 Shock
o Encourage the patient to exercise
frequently  Varicose veins
 Walking
Hypercoagulability
 Swimming
o Pregnancy
 Use of stationary bicycle
o Malignancy
o Exercise should be slow & and
o Polycythemia vera
progressive
o Dehydration
o Walking 30 to 45 minutes twice a day.
o Estrogen Therapy
o Exercise is halted immediately when o Sickle cell disease
pain occurs.
o The nurse should suggest that the
As people age, the valves inside leg veins
patient enroll in a supervised exercise
commonly weaken, which can lead to pooling of
training program that will assist the
blood in the periphery and may further
patient to gradually increase walking
contribute to orthostatic hypotension.
distances without pain.
o The patient is instructed to avoid bed
SIGNS & SYMPTOMS OF DVT
rest as much as possible.
o More than 50% of the DVT's don't cause
o Buerger - Allen exercises for patients symptoms initially.
with advanced disease with minimal
o Most reliable physical findings in DVT
exercise tolerance. is
 Unilateral edema of the affected
4. STRESS REDUCTION leg.
5. DIET o Abnormal findings that are unilateral
o Adequate amounts of protein; Vitamins are more indicative of an acute problem
A, C & E and minerals zinc for wound that may be developing, and such
healing. findings require immediate attention.
o Homans' sign: Pain that occurs in the
STENT is longer and more expensive calf on forced dorsiflexion of the foot
GREENFIELD FILTER is inserted into inferior is an unreliable diagnostic sign.
vena cava to catch blood clots (150-200,000) o Dull ache in the calf that intensifies
during walking or their leg feels heavy
DEEP VEIN THROMBOSIS (DVT) or tight.
DEEP VEIN THROMBOPHLEBITIS o The affected limb becomes painful, warm
and reddish.
o DVT Usually occurs in the lower leg o Cyanosis and Mottling of the skin due
o Nearly 70% of the venous ulcers recur. to stagnant blood flow.
o DVT is a common complication among
Asians who underwent major orthopedic COMPLICATIONS OF DVT
surgery of the lower limb
o Women are three times more likely than PULMONARY EMBOLISM
men to have venous ulcer. o Most serious complication of DVT
 Varicosity due to estrogen that o PE can be life-threatening and may
weakens wall of the veins require mechanical ventilation
RISK FACTORS FOR DVT POSTTHROMBOTIC SYNDROME
Collectively known as Virchow's Triad o Caused by back flow of blood related to
faulty valves and blockage that remains
Vascular Wall Injury in the vessel.
o Surgery Signs and Symptoms
o Infection o Pain increased swelling
o Trauma - burns o Skin ulcers
o W/ drug abuse
 o Hyperpigmentation
Compression Therapy
Treatment
o Intermittent pneumatic compression
o Anticoagulation device work by repeatedly squeezing the
o Elevating the affected extremity to
legs which help empty the leg veins.
decrease Swelling and pain.
o The use of elastic compression
stockings (3 to 6 months) to support
HEMOSIDEROSIS the vein walls & valves & decreasing
Fibrinogen builds up around the capillaries swelling & pain on ambulation
↓ o Remove for 30 minutes every 8 hours &
The fibrin formed interferes with the
inspect the skin for irritation &
transport of OXYGEN and NUTRIENTS to
breakdown.
capillaries and surrounding tissues
Elastic Compression Stockings
DRUGS USED TO TREAT DVT FALL INTO 3 GENERAL
o Support hose apply external pressure on
CLASSES
the veins, preventing the retrograde
Anticoagulants pressure or flow that may occur in the
o Inhibit blood coagulation and serve to
standing or sitting positions
weaken already formed clots, preventing
o Application before arising, prevents
further expansion.
the veins from having the opportunity
o Heparin with to become engorged.
 low - molecular - weight heparins
 Enoxaparine - Clexane S.C. Perform deep breathing exercises
 Oral warfarin - Coumadin (3 to 6 o Help the large veins in the legs and
months) elsewhere in the body to empty by
increasing negative pressure in the
Thrombolytic Agents thorax
o Help dissolve clots
 For patients with hemodynamically When in bed active/passive leg exercises
unstable PE or Massive o Done after S/S have subsided.
iliofemoral thrombosis
ND: PAIN > INFLAMMATION> EDEMA
Antiplatelet Agents o Asses pain as to:
o To decrease activation of platelets &  Onset
prevent new clots from being formed.  Quality
o Assess a patient who's receiving  Intensity
anticoagulant therapy for signs &
 Location
symptoms of bleeding.
 Duration
 Bleeding Gums
 Nose Bleeds
Apply warm, moist heat at least 4x/daily as
 Unusual Bruising ordered.
 Bloody urine o warmth promotes vasodilation, allowing
 Black, tarry stools reabsorption of excess fluids into the
o Advise the patient not to take any circulation.
medication containing aspirin or non-
steroidal anti-inflammatory drugs. Bed Rest
o Instruct a patient on warfarin therapy o Using leg muscles during walking
to maintain a consistent intake of exacerbates the inflammatory process &
foods with high Vitamin K. increases Edema → increase pain

NURSING MANAGEMENT Caution the patient not to massage the leg or

arm.
ND: Ineffective Peripheral Tissue Perfusion o This maneuver could dislodge the clot
and cause more pain
GOAL: To reduce venous stasis
PREVENTION OF DVT
Bed Rest for 5 to 7 days thrombus formation o The simplest way to prevent DVT is
o Indicated initially to allow time for encouraging early ambulation.
clot organization or until the Thrombus  Exercising the legs & engaging in
is stable and has adhered to the early ambulation activates the
intraluminal wall. calf muscle pump which can
o Bed rest is continued until S/S decrease venous stasis & increase
particularly Edema subside. venous return.
 if edema subsided, patient can
To reduce Edema, elevate the legs 18 cm (7 ambulate
inches) above the heart for 2 to 4 hours o Monitor for adequate fluid intake to
during the day & at night. prevent dehydration & changes in the
blood flow.
 o Avoid sitting with knees bent or
SIGNS AND SYMPTOMS
crossed, and standing for long periods.
o Pallor: skin, mucous membranes,
o Avoid sitting for more than 2 hours at conjunctiva and nails beds
a time. The patient should walk at o Tachycardia An attempt to increase
least 10 minutes every 1 to 2 hours if o Tachypnea CO and tissue perfusion
possible, to help prevent venous o Fatigue
stasis. o Dyspnea Due to tissue hypoxia
o Prolonged standing increase venous o Angina
pressure causes venous distention & o Headache, dizziness, dim vision due to
decrease venous return. cerebral hypoxia
o Quit SMOKING, nicotine increases o Bone pain – increase erythropoietin
viscosity of the blood.  Activity → stimulates RBC
o NO SMOKING production in the bone marrow
o Weight loss can lower venous pressure Significant Blood Loss:
o Hypotension
PAD DVT o Tachycardia
Antiplatelets Anticoagulants o Decrease LOC
Never elevate Elevate o Oliguria: because of hypotension, low
BP

ANEMIA Less oxygen in the red blood cells → the heart

o An abnormally low number of circulating has to work harder to get enough oxygen
RBC’s, low hemoglobin concentration or circulating in the body → this can cause
both serious HEART PROBLEMS
o Regardless of the cause, every type of
anemia reduces oxygen–carrying of the
blood → TISSUE HYPOXIA

HEMOGLOBIN

RBC 80-130 days

RBC 4.5-5 million
Hemoglobin 12-17 g/dL
Hematocrit 38-54% IRON-DEFICIENCY ANEMIA
WBC 5,000-10,000 o Insufficient intake of iron
Platelets 300,000-400,000 o Excessive blood loss
o Pregnancy (diverts maternal iron to
fetus for erythropoiesis)
o Malabsorption

Iron-Rich Foods
o Beef liver
o Pork
o Chicken
o Fish
o Oyster
o Clams
o Green leafy veggies (kangkong, kamote
leaves)
o Potatoes with skin
o Beans
o Peas
o Dried fruits like prunes and raisins
 o Iron-fortified breads and cereals o Aging (progressive loss of vitamin B12
absorption usually beginning after age
Ferrous Sulfate 50)
o Should be taken with vitamin c  Vitamin B12 is absorbed in ileum
and aging results on less
PERNICIOUS ANEMIA
absorption of vitamin B12
Characterized by decreased production of HCL
o Strict vegetarian diet
acid in the stomach and deficiency of
INTRINSIC FACTOR
SIGNS AND SYMPTOMS
↓
o Glossitis: a smooth beefy-red tongue,
Essential for vitamin B12 absorption in the due to atrophy of papillae
ILEUM
 Approximately 50% of patients
↓
have a smooth tongue with loss of
Inhibits RBC cell growth deformed RBCs
papillae
↓
 The tongue may be painful and
POOR OXYGEN-CARRYING CAPACITY
beefy red
o CNS involvement = ataxic gait, urinary  It may be associated with changes
incontinence in taste and loss of appetite
o No intrinsic factor o Neurologic abnormalities
o Parietal cells produce HCL and  Paresthesias of the hands and
intrinsic factor which is needed by the feet
extrinsic factor (vitamin B12) to be  Ataxia
absorbed  Loss of bowel and bladder control
o Deficiency of vitamin B12, autoimmune o Primary symptoms include: neuropathy
disorder with paresthesias of hands and feet

o A megaloblastic anemia, is lack of SCHILLING’S TEST

intrinsic factor, which results from o A normal result shows at least 10% of
atrophy of the stomach wall the radiolabeled vitamin B12 in the
 Large RBCs decrease intrinsic urine over the first 24 hours
factor which causes inflammation o In patients with impaired absorption,
in the stomach less than 10% of the radiolabeled
 Gastritis (not eating on time) / vitamin B12 is detected
drinking liquor increases gastric
juice TREATMENT
 Infection in the stomach if not o Lifetime vitamin B12 via IM
produced
APLASTIC ANEMIA
 Undergone partial gastrectomy
o Inhalation of chemicals like benzene
 Strict vegetarian (3-5 years
o Adverse effect of chloramphenicol which
before signs and symptoms will
is an antibiotic
manifest)
 Vitamin B12 is stored in
the liver for 3-5 years CAUSES
o Congenital
o Without the intrinsic factor, vitamin
o Exposure to TOXIC SUNSTANCES
B12 cannot be absorbed in the small
intestine, and folic acid needs vitamin  INDUSTRIAL CHEMICAL – BENZENES,
INSECTICIDES
B12 for deoxyribonucleic acid synthesis
of RBCs  CHEMOTHERAPY medications
VITAMIN B12 FOOD SOURCES:  Antibiotics
o Eggs o Bacterial and viral infections
o Poultry  Tuberculosis
o Shellfish  Hepatitis
o Milk and milk products
o Pork SIGNS AND SYMPTOMS
o Chicken Ecchymosis
o Beef Nose bleeds
Bleeding gums
Vitamin B12 is important for the metabolism, Petechiae
the formation of red blood cells, and the
maintenance of the central nervous system, ANEMIA OF CHRONIC DISEASE
which includes the brain and spinal cord o Chronic kidney disease
(development of spinal cord) o Inflammatory diseases
 Rheumatoid Arthritis reduce the
RISK FACTORS bone marrow’s response to
o Genetic predisposition erythropoietin leading to a
o Partial gastrectomy decrease in RBC
o HIV, Cancer, Cirrhosis
 MEDICAL SURGICAL NURSING Renin, Angiotensin 2 will stimulate the
MIDTERMS thirst center.

FLUID AND ELECTROLYTES ATRIAL NATRIURETIC PEPTIDE (ANP)

o A cardiac hormone, stored in the cells
or the atria
INTRACELLULAR (40%)
o ANP is released when atrial pressure
Cytoplasm (organelles flow)
increases
o The hormone opposes the RAAM by
EXTRACELLULAR (20%) decreasing BP and reducing intravascular
Outside the cell blood volume
o Released whenever there is increase
INTERSTITIAL COMPARTMENT (15%) 11-12L of fluids
pressure in the atrium, plenty of blood
in the atrium. ANP will oppose RAAM by
INTRAVASCULAR (5%)
decreasing BP
Blood and plasma
OSMOLARITY
MECHANISMS OF FLUID BALANCE
o Sodium is the largest contributor of
particles to osmolality
Fetus: 100%
o More sodium outside than inside
Baby: 80%
o Potassium inside
Adult: 70% o Normal Serum Osmolality – 280 – 295
Elderly: 50%
mOsm/kg (milliosmole)
o Swell - <280 – hypo-osmolar
The amount of water taken in must equal the o Shrink - >295 – hyperosmolar – more
amount of water lost solutes than water
o When Serum osmolality is increased (more
WATER OUTPUT
solutes than water), the fluid in the
Kidneys---1,500 mL intracellular (cells) is greatly
Skin------600 mL
decreased
Lungs-----300 mL
o Hyper-osmolality pulls the water out of
GI tract--100 mL
the cells to maintain homeostasis of the
Total-----2,500 mL
body fluid and cellular dehydration
(lesser to greater; the cell will
MECHANISMS OF FLUID BALANCE
shrink)
ANTI-DIURETIC HORMONE (ADH)
HYPOVOLEMIA (FLUID VOLUME DEFICIT)
o Posterior pituitary gland will secrete
o severe diuresis
ADH if you have less body fluids like
o abnormality (SIADH, Diabetes insipidus)
vomiting or severe diarrhea.
o UO: 3L in one day instead of 1.5L per day
o Order renal tubules to reabsorb water
= dehydrated
for compensation.
o suctioning gastric area
o Decreasing circulating blood volume.
o sweating
o Body is compensating
o diuretics
ALDOSTERONE HYPERVOLEMIA (plenty of water fluid overload)
RAAM
o SIADH: over secretion of ADH
o Compensatory
o water retention = water intoxication
o released whenever there is less blood
o liver disorder
circulating (stab or car accident
o heart failure
decreasing amount of blood)
o destroyed kidneys = edematous in the
o the brain, heart and lungs will be lower extremities
perfused with blood.
o Kidneys are secondary organs only and
DIFFUSION – movement of solutes from greater to
whenever there is less blood supply, lesser concentrated solution (osmolarity)
there is a release of hormone called
renin converted to angiotensin 1 to OSMOSIS – fluid moving from lesser to greater
angiotensin 2. concentrated solution (edema)
o ADH is water, where sodium is, water
follows.

THIRST MECHANISM
o Sweating a lot due to exercise or
climate
o Drinking a lot of water
o Compensatory mechanism
o Decrease blood volume because of
vomiting and diarrhea, gastroenteritis,
it will decrease BP, if decrease BP
there will be less blood going to the
kidneys and kidneys will compensate, it
will release
 RENAL CALCULI o Weight-bearing activities produce
o No exact etiology biomechanical stresses on the bone,
o Runs in the family initiating a cascade of events to cause
o Masses of crystals and protein bone remodeling
o Most common: calcium oxalate (70% of o Bone resorption is the process by which
people) osteoclasts break down bone and release
o Men are more affected than women the minerals, resulting in a transfer of
o Age: 40 - 50 calcium from bone fluid to the blood
o The osteoclasts are multi-nucleated
FUNCTIONS OF KIDNEYS cells that contain numerous mitochondria
and lysosomes. These are the cells
Forms urine. removing waste products of the responsible for resorption of bone
body (urea from protein, uric acid, creatinine
(muscle metabolism)) UTIs
o Ex.: inflammation in the urinary bladder
Responsible in maintaining acid base balance. > urethra becomes edematous > no good
Primarily control base in the form of flow urine because there is partial
bicarbonates. Example is with COPD and there obstruction > urine becomes stagnant >
is a destruction in alveoli, exchange of gases urine becomes super concentrated >
affected. CO2 will not be excreted and develop formation of crystals > stones
respiratory acidosis. Since there is o Urinate 2-3 hours
accumulation of CO2, the kidneys can feel this
and it will produce more bicarbonates and it FAMILY HISTORY OF STONE FORMATION
will lessen the production of hydrogen ions.
Remove excess water and electrolytes and NEUROGENIC BLADDER
urinate if kidneys are working. o cannot feel the urge to void
*Potassium can cause dysrhythmia if excessive o Destroyed spinal cord: sacral 1 – 5
(where urge to void & defecate is
Erythropoietin production. It will stimulate seen/being felt) is destroyed → leads to
bone marrow to produce red blood cells. incontinence (urge to void cannot be
controlled)
Vitamin D production. The vitamin D is taken
from early morning sunlight and food. However, A DIET HIGH IN:
the vitamin D form external environment is o PURINES
still inactive. Kidneys are responsible in  Beer
activating the vitamin D from the environment.  Sardines
Vitamin D is responsible in absorption of  Seafoods (tahong, shrimp)
calcium in small intestine (gut)
 Vegetable oil
Stones are masses of crystals and proteins  Peanuts and legumes (monggo)
that form when the urine becomes o OXALATES
supersaturated with a salt capable of forming  asparagus
solid crystals  cabbage
 tomatoes
Hydronephrosis urine formed by the kidney  nuts
cannot flow and enter urinary bladder  celery
 parsley
RISK FACTORS FOR STONE FORMATION  cola drinks
 instant coffee
INCLUDE ANYTHING THAT CAUSES WHETHER STASIS OR  ovaltine
SUPERSATURATION  tea
o Ex.: person on a diet doesn’t eat on  Worcestershire sauce
time  Beans
→ bile stored in the gall bladder is not  Grapes, apples
used → bile becomes super
 Peanuts and peanut butter
saturated/concentrated → becomes
o ANIMAL PROTEINS
crystals → stone gall bladder calculi
 meat
o Ex.: not voiding → urine becomes super
saturated/concentrated
AGE AND GENDER
GENETIC o Stones are more common in men than women
o The risk peaks between the ages of 40 or
early 50s
DEHYDRATION, WHICH LEADS TO SUPERSATURATION
o Estrogen helps kidneys remove stones
o Ex.: d/t not drinking enough water,
sweating, vomiting, diarrhea
OVERWEIGHT
o Researches show that overweight people
IMMOBILITY AND A SEDENTARY LIFESTYLE/OCCUPATION
excrete more calcium and oxalate in
o Releasing calcium and go to blood going
their urine, which increases the risk of
to kidneys
stones
o Lack of physical activity increases BONE
RESORPTION (releasing calcium in blood)
STONE TYPE o URINARY TRACT OBSTRUCTION is an
emergency and must be treated
CALCIUM OXALATE immediately to preserve kidney function
o most common type of stone o NAUSEA, VOMITING: Pain will stimulate
o small, rough, and hard the vomiting center in the brain
o grayish-whitish in color o PALLOR: Pain will stimulate SNS, trigger
adrenal Medulla will release
HYPERCALCIURIA – high calcium in the urine NOREPINEPHRINE will cause
vasoconstriction, arteries will
1. A high rate of BONE RESORPTION which constrict to increase BP in order to
liberates calcium → goes to blood → blood is give lots of blood to the no. 1 organ
being filtered in the kidneys → Calcium will (it will take the blood away from the
be part of the urine secondary organ to give blood to the
o Hyperparathyroidism → overuse of primary organ) [Norepi – will redirect
parathyroid gland → release parathormone the blood from the skin to the brain].
→ Calcium is released from bone and goes o ELEVATED BP AND PR: Epinephrine – tachy
to blood o DIAPHORESIS AND ANXIETY (less blood to
o Immobility → bone resorption the brain)
- In an immobilized patient, calcium o ELEVATED WBC COUNT AND TEMPERATURE (due
leaves the bone and concentrates in the to inflammation)
extracellular fluid o BLOOD IN THE URINE, WHICH OFTEN MAKES IT
- When large amount of calcium passes LOOK PINK
through the kidneys, calcium can o PERSISTENT URGE TO URINATE
precipitate and form calculi o PAIN WITH URINATION (DYSURIA)

2. Gut absorption of abnormally large amounts HEMATURIA

of calcium According to the amount of RBC in the urine,
o Excessive intake of vitamin D hematuria can be classified as:

3. Renal leak of calcium resulting to Gross Hematuria (visible)

hypocalcemia o Tea-colored, cola-colored, pink or even
o Ex.: low Ca → stimulate PTH → PTH will red
release Parathyroid hormone Microscopic Hematuria
(parathormone) → bone resorption AND ᛏ o Normal color with eyes
intestinal absorption of calcium
o Ex.: destroyed kidneys (basement PREVENTIVE MEASURES
membrane) → electrolytes (Ca+) leaks out
and goes to the urine DRINKING ENOUGH FLUID
o 12 glasses of fluid, preferably WATER a
STRUVITE day
o Made of magnesium ammonium phosphate o Most basic kidney stone prevention step
o Second most common type of stone o This dilutes urine and decreases the
o Calculi crumble easily risk of crystal formation
o Stones have a yellow color
LIMITING MEAT INTAKE
URIC ACID STONES o Consuming more than 6 to 8 ounces of
o due to high uric acid levels meat daily can increase CALCIUM and URIC
o high purine food ACID in the urine
 seafoods o Increase the acidity of urine
 beer o Reduce chemicals that inhibit crystal
 meat formation

CYSTINE STONES o A diet rich in acid should be provided

o caused by genetic defects in the renal to keep the urine acidic, which
reabsorption of amino acids increases the solubility of calcium
o stones form at LOW UIRINARY pH o Limiting foods rich in calcium, such as
o small, smooth, waxy stones dairy products will help prevent renal
calculi
CLINICAL MANIFESTATION o A liberal fluid intake
o RENAL COLIC – lumbar region and radiates o Decrease intake of highly acid-ash food
down toward the TESTICLE in the male and o Foods to avoid include:
BLADDER in the female  Meat
o PAIN – severe, colicky, dull, or aching  Fish
o FLANK PAIN  Poultry
o FREQUENCY and DYSURIA occur when a stone  Eggs
reaches the bladder  Cheese
o OLIGURIA or ANURIA suggest obstruction  All breads
possibly at the bladder neck  Crackers
 Macaroni/Spaghetti
 Nuts
GETTING CALCIUM IN THE DIET OTHER MEASURES
o The calcium in food may lower the risk
of stones by binding oxalate in the GIT
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)
o The bound oxalate is excreted in the o Uses high-energy shock waves to break
stool, which leaves less oxalate to be the stone into tiny pieces that can be
absorbed into the blood and later more easily passed
excreted in the urine
o Sedation or anesthesia is required
o Dairy products and supplements o Large stone require repeated treatments
containing calcium citrate are the (up to 5 treatments)
preferred way of getting calcium
PATIENT EDUCATION AFTER ESWL
LIMITING INTAKE OF OXALATE-CONTAINING FOODS o PAIN may be experienced as the stone
SUCH AS: fragments pass down the ureter.
ANTISPASMODICS are given
 Mebeverine HCL---Duspatalin
100 mg tab
 Pinaverium Br Eldicet
50 mg tab
o Advised to drink 2-3L in 24 hours to
help flush out stone fragments and clear
any blood in the urine
 The fragments may be passed for
up to 3 months after the
procedure
o Early ambulation

PERCUTANEOUS NEPHROLITHOTOMY
DON’T OVERDO VITAMIN C
o Some of the vitamin is metabolized to
oxalic acid in the body ‘
o In three studies done, those taking
2,000 mg had a higher oxalate level in
their urine

MEDICATION FOR STONES

THIAZIDE DIURETICS (HYDROCHLOROTHIAZIDE)

o Promotes calcium resorption from the
renal tubules, thereby preventing excess
calcium loads in the urine
o Thiazide diuretics are prescribed
because they decrease the amount of
calcium released by the kidneys into the
urine by favoring calcium retention in
the bone
o Most kidney stones (75% to 80%) are
calcium stones, composed of calcium
o This medication will decrease calcium
levels in the bloodstream by increasing
calcium excretion in the urine

POTASSIUM CITRATE (ACALKA)

o Inhibits calcium oxalate and calcium
phosphate crystal formation in urine
o Lowers the acidity, to increase the pH
of urine to 6-7 NEPHROSTOMY TUBE
o Uric acid stones form in ACIDIC URINE

ALLOPURINOL (ZYLOPRIM)
o To lower uric acid concentration
o Prescribed only if a reduced purine diet
fails and stones persist

TIOPRONIN (THILA)
o For cystine stones, which make cystine
more soluble for excretion
o Long-term ANTIBIOTICS are used to
control the infection
POSTOPERATIVE CARE
o Secure the tube to the patient’s flank to
ensure that it does not become dislodged
 o Check that the nephrostomy and drainage
tubing are not KINKED or that the
patient is not compressing the tubing
o Assess the tube insertion for BLEEDING
and DRAINAGE
o Notify the physician immediately if
there is an ABSENCE of urinary drainage
o Encourage FLUID INTAKE of 2-3 L in 24
hours (intravenous and oral fluids
initially
 To flush out any blood or stone
fragments that might be present
PATIENT EDUCATION
ELIMINATION
o There may still be blood present in the
urine in the initial days following
surgery. THIS IS NORMAL, but it should
decrease in the first 3-5 days
TEACH THE PATIENT SIGNS AND SYMPTOMS OF UTI:
o Urgency
o Frequency
o Dysuria
HIV – HUMAN IMMUNODEFICIENCY VIRUS
AIDS – ACQUIRED IMMUNODEFICIENCY
SYNDROME
GENDER/AGE GROUP
o Most of the cases were males (96%)
o Almost half (49%) of the cases were from
25-34 year of age
HIV RISE IN THE PHILIPPINES
o Sexual contact remains the main mode of
transmission with 863 cases
o 90% of which are from the male-having-
sex-with-male population
o Injecting drugs accounted for 16 new
cases
o 4 cases of mother-to-child transmission
o The country has the fastest growing HIV
epidemic in the Asia and the Pacific
region
o A total of 72 overseas Filipino workers
were also found to have acquired HIV/AIDS
IMMUNE SYSTEM
CD4
o
CD4 + T helper cells are white blood
cells that are an essential part of the
human immune system
o
There is a protein molecule on the
surface of the T-helper cells known as
CD4 hence the T-helper cells are also
known as CD4
o CD4 cell count is a key measure of the
health of the immune system
o Anyone who has less than 200 CD4 cells
is considered to have AIDS
HIV INFECTION-AIDS
o AIDS is a group of serious illnesses and
opportunistic infection that develop
after a person is infected with HIV for
a long period of time
o Even if the symptoms of AIDS develop and
then subside for a while, that virus is
still present, and the infected person
can still transmit the disease
HOW IS HIV/AIDS CONTRACTED?
The BIG Three: Exchange of Bodily Fluids
1. Sexual Contact (vaginal, oral, anal); does
not include casual kissing (unless open mouth
sores are present)
2. Sharing hypodermic needles/syringes through o Viral load: the risk of contracting HIV
IV drug use, tattooing, and body piercing is higher if the person with HIV has a
high viral load
3. Mother to infant transmission: in utero
 Higher viral loads increase
exchange, during birth, or through
infectivity
breastfeeding after birth
VAGINA
ALSO, less commonly (and now very rarely in
o Is a thin-walled tube 8 to 10 cm (3 to 4
countries where blood is screened for HIV
inches)
antibodies), through transfusions of infected
o Three main functions:
blood or blood cutting factors
 To accommodate the penis during
coitus
 To channel blood discharged from
the uterus during menstruation
 To serve as the birth canal
during child birth

HIV-MOTHER TO FETUS
An HIV+ pregnant woman can transmit HIV to her
baby 3 WAYS:
o During pregnancy
o During vaginal childbirth
o Through breastfeeding

Sharing IV drug needles of HIV positive people

ANAL SEX HIV infected blood
o Unprotected anal sex is considered to be
a HIGH-risk factor
o HIV is present in blood, semen, pre-
seminal fluid, or vaginal fluid of a
person infected with the virus
o The individual receiving the semen has a
higher risk of contracting HIV since the
virus can penetrate the thin lining of
the rectum during anal sex
o A person who inserts his penis into an
infected partner is also at risk because
HIV can enter through the urethra or
through small cuts, abrasions, or open
sores in the penis

ORAL SEX
o Fellatio (oral-penile sex) carries some
risk, but it’s low
o Cunnilingus (oral-vaginal sex)
o Anilingus (oral-anal sex)
o If you’re giving a blowjob. Receptive
oral sex with a male partner who has HIV
is considered exceptionally low-risk
 A 2002 study found that the risk HIV-AIDS
for HIV transmission through o A recent CDC study found that 1 in 5 gay
receptive oral sex was and bisexual men are in 21 major US
statistically zero cities were infected with HIV, and
o If you’re receiving a blowjob. Insertive nearly half were unaware of their
oral sex is an unlikely method of infection
transmission too o Gay and bisexual guys have much more
anal sex than straight guys
 Enzymes in the saliva neutralize
viral particles. This may be true o It has been scientifically proven that
even if the saliva contains blood anal sex is riskier than vaginal sex
when it comes to HIV. Eighteen times
o Risk varies based on whether the person
with HIV is giving or receiving oral sex riskier to be exact. There are two
reasons for this
 If the person with HIV is
receiving oral sex, the person o First, the cells in the anus are much
giving it may have a higher risk more susceptible to HIV than cells in
o Mouths may have more openings in the the vagina
skin or lesions o Second, both semen and rectal mucosa
(the lining of the anus) carry more HIV
o Saliva, on the other hand, is not a
carrier of the virus than vaginal fluid
 Vagina is acidic because the
urethra of female is short, a
protective mechanism
 o Combine this with the fact that gay and
bi guys have much more anal sex than
straight guys

HIV IN BODY FLUIDS

ELISA TEST
o A human immunodeficiency virus (HIV)
test detects antibodies to HIV or the
genetic material (DNA or RNA) of HIV in
the blood
o After the original infection, it takes
between 2 weeks and 6 months for
antibodies to HIV to appear in the blood
o If antibodies to HIV are present
(positive), the test is usually repeated
to conform the diagnosis. If ELISA is
BODY FLUIDS NOT INFECTIOUS negative, other tests are not usually
The following body fluids are NOT infectious needed
o Saliva o ELISA, like the Western blot test,
o Tears detects HIV antibodies in your blood
o Sweat o Antibodies are proteins your immune
o Feces system produces in response to the
o Urine presence of foreign substances, such as
viruses
STAGES OF HIV INFECTION o if you test positive for HIV on the
ELISA test, your provider will order the
Western blot test to confirm HIV
infection

WINDOW PERIOD
o Occurs between the time of HIV infection
and the time when diagnostic tests can
detect HIV
o The length of the window period varies
depending on the type of diagnostic test
used and the method the test employs to
detect the virus

HIV TESTS
STAGE 1 PRIMARY INFECTION o HIV tests after the 3-month window are
o infected with HIV until development of more than 99.97% accurate. They work for
antibodies (6-12 weeks to develop all types and subtypes of HIV
antibodies) o If the result is negative three months
o no signs and symptoms (asymptomatic) for after exposure your result is
years, maximum of 15 years before interpreted as negative. This assumes
developing you have had no further risks
STAGE 2 SYMPTOMATIC SYMPTOMS OF HIV/AIDS INFECTION
o signs and symptoms appear
o CD4 less than 200
o persistent fever
o loss of appetite
o diarrhea
o infection

STAGE 3 AIDS
o no cure
o drugs control replication of virus but
no treatment
o prone to opportunistic infection (immune
system is down)
 o Facial Lipoatrophy (diarrhea and loss of
appetite)
o Swelling of lymph nodes
o Dry cough
o Night sweats
o Fatigue
o Rashes
o Thickening of nails (CD4 is down, fungi
growing)
o Clubbing and curving of the nails
o Wasting syndrome (protein catabolism)
HIV-CANDIDIASIS
o Candidiasis is a fungal infection due to
any type of Candida (a type of yeast).
When it affects the mouth, it is
commonly called thrush
o Signs and symptoms include white patches
on the tongue or other areas of the
mouth and throat
o CD4 count less than 50
KAPOSI’S SARCOMA
o Most common HIV-related malignancy
o Most often seen among men who have sex
with men
o It involves the endothelial layer of
blood and lymphatic vessels
PNEUMOCYSTIS CARINII/JIROVECI
o This pneumonia occurs in more than 80%
of AIDS patient
o Most opportunistic infection in persons
affected with HIV
HIV TREATMENT
ART – ANTIRETROVIRAL THERAPY
o NRTIs – Nucleoside Reverse Transcriptase
Inhibitors
 Emtriva------Emtricitabine
 Epivir-------3TC, Lamivudine
 Retrovir-----AZT, Zidovudine
 Videx-EC-----Didanosine
 Viread-------Tenofovir
 Zerit--------Stavudine
 Ziagen-------Abacavir
o PIs – Protease Inhibitors
o Fusion Inhibitor
HIV
o
The DOH data showed that as of May 2019,
38,279 Filipinos with HIV were
undergoing the therapy
o
As of May 2019, 3,357 patients listed in
the registry had already died
PREVENTION
o Abstain from sex before marriage
o Be faithful to your husband or wife
o Condoms are a protective barrier
 When used consistently and
correctly, condoms are highly
effective in preventing HIV
 Condom use remains inexpensive,
cost effective first line of
defense against HIV
o Avoid drugs and excess alcohol
o Early detection and treatment of STIs
o No to alcohol and drugs because it can
impair your judgement and affect your
ability to make safe choices, putting
you at greater risk for HIV
o No anal sex
o A new pill known as Truvada or pre-
exposure prophylaxis (PrEP), can reduce
the risk of transmission by more than
90%
 PrEP is a new HIV prevention
method in which people who do not
have HIV infection take a pill
daily to reduce their risk of
becoming infected
o Promoting sex-education among teenagers
o Safe injections: using unused syringes
will help to prevent HIV infections
o Male circumcision: it is the surgical
removal of the foreskin (prepuce) from
the human penis
 Removal of the inner foreskin
removes the main site of HIV
entry into the penis, resulting
in a sevenfold reduction in
susceptibility to infection
o Strict examination for blood, blood
products, organ donation for HIV before
administration
o No sharing of needles, brushes, or razors
o Proper sterilization of dental and
surgical instrument
REPUBLIC ACT NO. 8504
A.K.A. “Philippine AIDS Prevention and Control
Act of 1996”
An act promulgating policies and prescribing
measures for the prevention and control of
HIV/AIDS in the Philippines, instituting a
nationwide HIV/AIDS information and
educational program, establishing a
comprehensive HIV/AIDS monitoring system,
strengthening the Philippine National AIDS
Council and for other purposes
HIV does not make people dangerous to know, so
you can shake their hands and give them a hug.
Heaven knows they need it. -Princess Diana
 PNEUMONIA
CHEMOTHERAPY cause pneumonia because of the
drug. It can destroy bone marrow – anemic and
white blood cells will be decreased in number:
leukopenic.
STEROIDS is an anti-inflammatory and if given
more than 2 weeks, it decreases the immune
system and infection can set in. Environment
is not sterile and microorganisms can enter
the lungs and cause inflammation
COMMUNITY ACQUIRED PNEUMONIA (CAP) – from
environment that can affect especially aged
and children. Patient can have pneumonia
Mechanical Ventilator – help patient breathe.
Taking in oxygen and taking out carbon
dioxide. Endotracheal tube is a tube inserted
and microorganism can easily enter.
INFECTION SEPSIS-HYPOVOLEMIC SHOCK (nawalan ng
dugo): If there are microorganisms that
entered the body (sepsis) it will cause an
inflammatory response and that will release
chemical mediators like histamine and
cytokines. And this will increase the
permeability which means it will allow the
free passage of molecules or substances in the
capillary. The plasma leak in the capillary
and may enter the alveoli and cause pulmonary
edema or congestive pneumonia and some fluids
will go the interstitial space causing
hypovolemic shock (Rabino, 2020)
LUNG CONSOLIDATION: nag heal, maraming peklat
PRECAUTIONS TO IMPLEMENT INFECTIOUS PNEUMONIA
STANDARD PRECAUTION
o Private room
 If the patient can’t afford a
private room, place the patient
in the ward but see to it that
there is spatial separation (3-6
ft away from another bed of
patient)
o Doctors, nurses, janitors should wear
mask
o Have patient wear mask if frequently
coughing
o Handwashing technique
o Gowning, if highly infectious
DROPLET PRECAUTION
o Donning and doffing technique
NURSING MANAGEMENT
o Move patient from side to side
o Physiotherapy (vibration, backslapping)
 In order to move that mucoid
secretion so that patient
o Increase fluid intake if patient is
negative of pleural effusion. If
positive, no intake because it adds
edema to the patient
o IV fluid well-regulated because this is
going to thin the mucoid secretion
o Put humidifiers in the room
o Boil water and inhale the steam
CHICKEN POX/VARICELLA
The Plucky Little Virus You Ought to Know
About
CHICKENPOX/VARICELLA
 A highly contagious viral illness that
causes an itchy rash & is followed by a
vesicular eruption on the skin
 Usually occurs during childhood
(normally 5-9), but you can get it at
any time in your life
 Within 1 or 2 days, the rash appears,
begins as red spots which then forms
blisters & spreads to the rest of the
body
Varicella (Chicken Pox)
 Mild, highly contagious disease chiefly
affecting children
 Mode of transmission:
o airborne droplets and direct
contact from varicella patients
o Vesicular fluid of Zoster
patients can be the source of
Varicella in susceptible children
CHICKENPOX/VARICELLA
 INFECTIOUS AGENT: Varicella Zoster Virus
 INCUBATION PERIOD: 10 to 21 days or may
be prolonged after passive immunization
against chicken pox
 Varicella zoster virus, a DNA virus and
is a member of the herpes virus group
 Primary infection causes chicken pox.
 Recurrent infection results in herpes
zoster (shingles).
INCUBATION PERIOD
 The host may become infectious (i.e.
able to transmit the pathogen to other
hosts) at any moment of the infection.
This moment will vary per pathogen.
 The starting point is the moment when a
pathogen enters the host this moment is
often referred to as blabla moment
 Immediately after this moment, the
pathogen usually will move to the blabla
tissue or target organ
 This will be the place within the host
where the pathogen can effectively
multiply
 Different pathogens may have different
target organs. Hepatitis virus will
target the liver for multiplication, for
example.
MODE OF TRANSMISSION
 AIRBORNE or spread by aerosolized
droplets from the nasopharynx of ill
individuals
 Direct contact with a patient who sheds
the virus from the vesicles
 Indirect contact, through linens or
fomites
AIRBORNE TRANSMISSION
 Small droplet nuclei, <5 microns
diameter
 Stay suspended in air
 When inhaled, can reach the alveoli and
cause infection
DROPLET TRANSMISSION
 Large droplets >5 microns in diameter
 Do not remain suspended in the air, so
no special air handling or ventilation
is required
 if inhaled, do not reach alveoli
PERIOD OF COMMUNICABILITY
 The patient is capable of transmitting
the disease about a day before the
eruption of the first lesion up to about
5 days after the appearance of the last
crop.
 Following primary infection there is
usually lifelong protective immunity
from further episodes of chickenpox
SIGNS & SYMPTOMS
 Very itchy rashes
o Trunk - Neck, Face, Limbs (Rashes
in Crops)
 Red bumps
o Blisters, filled with clear fluid
(1-5mm or more in size) → drain
→ scab
 Fever with body ache
o On the day or 1st day before rash
appears
 MOUTH, SCALP, AROUND EYES, GENITALS →
Painful
 Cycle repeats in crops
ERUPTIVE STAGE
 The rash is most dense on the trunk and
head
 Macules → Papules → Vesicles → Pustules
 PUSTULE- is a vesicle that is infected or
filled with pus.
 CRUST- is a scab or eschar. A secondary
lesion caused by the secretion of
vesicle drying on the skin.
o The scars are superficial,
depigmented, & take time to fade
out
VESICLE
 Blister: Filled with clear liquid
containing the virus.
 Skin lesions caused by chicken pox
appear in the form of red papule several
millimeters wide, with a blister in the
middle. The blister dries out and forms
a scab which falls off after about a
week without leaving any marks, except
in the case of secondary infections
TREATMENTS
 Chickenpox is a virus, so the physician
will not prescribe an antibiotic
 Virus has self-limiting disorder.
No medication can kill the virus,
only prevent multiplication of
the virus.
 Over time, the body's immune system will
clear out the virus
 Usually, those infected are instructed
to:
o Rest (to prevent skin abrasion)
o Cut their nails
o Depending on the severity of the
rash, wear gloves to prevent
further infections.
 Acyclovir, an antiviral medication, is
licensed for treatment of chickenpox.
 Reduce fever, body weakness,
lesion
 The medication works best if it is given
within the first 24 hours after the rash
starts.
 Other antiviral medications that may
also work against chickenpox include
valacyclovir and famciclovir.
 Acyclovir is the generic name for
Zovirax, a prescription medication used
to treat certain virus infections
 The drug works by preventing viruses from
dividing and multiplying.
  If you are taking ACYCLOVIR to treat
chickenpox, the drug can reduce the
severity of the infection
 It's important to know that treatment
with acyclovir works best when you start
taking it as soon as possible after a
rash appears.
 This means within three days of a
shingles rash and within 24 hours of a
chicken pox rash.
VACCINATION
 MEASLES, MUMPs, RUBELLA, VARICELLA
(MMRV)
o 1st dose: 12 months 12 y/o
o 2nd dose: 4-6 y/o
 2nd dose may be administered at an
earlier age provided the interval
between the first and the second dose is
at least 3 months
AIRBORNE PRECAUTIONS
 Used when patient has a known or
suspected disease that can be spread
through the air. (TB, Measles,
Chickenpox, disseminated herpes zoster,
and SARS)
 Properly fitted N95 respirators (high
filtration masks) required for people
entering room
 Room engineered with special airflow
criteria is required
 Door must remain closed
 Patients must wear a surgical mask when
outside the airborne isolation room
(e.g. for testing)
CALAMINE LOTION/CALADRYL
OATMEAL BATH to relieve itchiness
ICE CAP numbs the nerves and won’t feel pain
CARROT AND GINGER
 A soup made of carrots and coriander is
highly beneficial in the treatment of
chickenpox. It is rich in antioxidants
that help in the healing Process.
 Afritada
 Macaroni soup with plenty of
diced celery or finely chopped
carrots
 Ginger can reduce the itching as they
have the anti-bacterial property.
 Pineapple can be also due to its anti-
inflammatory effects
HERPES ZOSTER/SHINGLES
 Stored at dorsal root (posterior, back)
of spinal cord and remains dormant. If
immune system went down because of
infection, surgery/transplant, cancer,
immunosuppressants, that virus will be
reactivated and result to shingles or
herpes zoster. Shingles are highly
infectious.
 ls caused by the same virus responsible
for chickenpox, the varicella zoster
virus
 It occurs in people who have had
chickenpox after several years
 After the initial exposure, herpes
zoster lies dormant in certain nerve
fibers.
 Approximately 80% of cases occur in
persons older than 20 years
 Although it is most common in people
over age 50
 Anyone who has had chickenpox is at risk
for developing shingles
 Lesion will appear at the back because
virus is stored at dorsal root of spinal
cord (afferent nerves, responsible for
sensory) that’s why there is pain
 Ventral root – efferent nerves,
(front/anterior) supplying skin and
muscles in front/anteriorly
Herpes zoster may become active as a result of:
 Aging (50 and above)
 Stress
 Suppression of the immune system
o HIV-infection
o Cancer
 Certain medications
o Corticoid steroid use
o Radiation therapy
PERIOD OF COMMUNICABILITY
 A day before the appearance of the first
rash until five to six days after the
last crust disappears.
 The virus that causes shingles, VZV, can
be spread from a person with active
shingles to a person who has never had
chickenpox through direct contact with
the rash
 The person exposed would develop
chickenpox, not shingles
HERPES ZOSTER/SHINGLES
 Reactivation of latent VZV
 Uncommon in childhood
 Zoster is not caused by exposure to a
patient with varicella
 The lifetime risk for herpes zoster for
individuals with a history of varicella
is 10-20%
 75% of cases occurring after 45 years of
age.
 Herpes zoster is very rare in healthy
children <10 year of age
PATHOPHYSIOLOGY
 After the primary infection, the
varicella zoster virus may persist in a
dormant state in the dorsal nerve root
ganglia
 The virus remains latent for decades
because of varicella-zoster virus
specific cell-mediated immunity acquired
during the primary infection.
  The virus may later emerge from the site  Pain Control: Narcotics, gabapentin,
following a decrease in cell-mediated pregabalin, amitriptyline
immunity
 It produces localized vesicular skin
NURSING MANAGEMENT
lesions, usually in a single dermatome &
pain along the involved dermatome  Keep the patient in strict contact
precaution
SIGNS & SYMPTOMS
 Apply cool, wet dressings with NSS to
pruritic lesions
 Pain occurs from one to five days prior
to the development of rash  Do not puncture & open the blisters
o burning or stabbing  Avoid contact with the skin lesions of
o extreme pain persons with known herpes zoster
infection
o pain is usually worse at night &
is intensified by movement.  Encourage adequate rest (increases
 Rash starts off as red spots, which activity of cell due to infection, to
quickly turn into blisters promote healing)
o They affect only one side of the  Provide the patient with a diversionary
body & never cross the midline activity to take his mind off the pain &
o This is because they come out on the pruritus
the area of skin which is  Prevent entrance of microorganisms into
supplied by one particular nerve the lesions, especially if they are
o Lesions may last for one to two broken
weeks
 Pruritus
 Fever, malaise, headache
 Paralysis of the facial nerve & vesicles
in the external auditory canal affects
the 7th CN. This condition is called
Ramsay-Hunt Syndrome

RAMSAY-HUNT SYNDROME
 Vesicular rash on external ear
 Lower motor neuron paralysis of facial
nerve
 Loss of taste sensation over anterior
2/3 of tongue
 Other manifestation
o Ramsay Hunt syndrome is an
otologic manifestation of herpes
zoster infection that results
from a reactivation of the
geniculate ganglion of CN VII.
The triad of symptoms include
 Ipsilateral facial
paralysis
 Ear pain
 Vesicles in the auditory
canal and auricle

HERPES ZOSTER OPTHALMICUS

ZOSTER TREATMENT
 Antivirals: Acyclovir, valacyclovir,
famciclovir
 Prednisone in certain cases
 MEASLES
Signs and Symptoms
o Fever of 38.3◦ C or greater
o Cough, runny nose and red, watery eyes
o Red blotchy itch
GERMAN MEASLES/RUBELLA
o There was a pandemic of rubella between
1962 and 1965, starting in Europe and
spreading to the United States
o In the years 1964-65, the United States
had an estimated 12.5 million rubella
cases. This led to 11,000 miscarriages
or therapeutic abortions and 20,000
cases of congenital rubella syndrome. Of
these, 2,100 died as neonates, 12,000
were deaf, 3,580 were blind, and 1,800
were mentally retarded
o Three-day Measles
o Rubella is a contagious disease caused
by a virus
o Most people who get rubella usually have
a mild illness, with symptoms that can
include a low-grade fever, sore throat,
and a rash that starts on the face and
spreads to the rest of the body
o 79% of all cases of rubella occurred
among people ages 15 and older
o Rubella is rare to catch, unless you are
unvaccinated
o A mild self-limiting illness with rare
sequelae
INFECTIOUS AGENT: Rubella virus
INCUBATION PERIOD: from exposure to the
appearance of the rash, usually 14 to 21 days
MODE OF TRANSMISSION
o Direct contact with nasopharyngeal
secretions
o Air droplets
o Transplacental transmission in
congenital rubella
PERIOD OF COMMUNICABILITY
o Approximately one week before and 4 days
after the onset of rashes, but is at its
worst when the rash is as its peak
o Highly communicable infants with
congenital rubella may shed virus for
more than a year after birth
CLINICAL MANIFESTATIONS
PRODROMAL PERIOD
o Low-grade fever
o Headache
o Malaise
o Mild coryza
o Conjunctivitis
o Cervical lymphadenopathy
ERUPTIVE PERIOD
o Maculopapular rash that appears first on
the face, spreading on the neck, the
arms, trunk and legs
o The rash involves the entire body during
the first 24 hour → fades on the face
during the 2nd day → rashes disappear on
the 3rd day
o The rash is typically pink or light red
o RASH spreads in a cephalocaudal direction
to involve the entire body over the next
24 hours, and fades during the ensuring
2 or 3 days, also in a cephalocaudal
direction
o Duration changes from < 1 day to > 5 days
o Clears with minimal desquamation
o A pinkish rash on the soft palate,
Forchheimer’s spot
FORCHHEIMER SPOT
o Forchheimer spots are a fleeting
enanthem seen as small, red spots
(petechiae) on the soft palate in 20% of
patients with rubella
o They precede or accompany the skin rash
of rubella. They are not diagnostic of
rubella, as similar spots can be seen in
measles and scarlet fever
GERMAN MEASLES/MEASLES
o Once recovered, people are immune to
future infections
LABORATORY FINDINGS
Rubella-specific IgM
o Diagnostic of acute infection
o Usually appears within four days after
onset of the rash
o Can persist up to 4-12 weeks
Rubella-specific IgG
o Long-term marker of previous rubella
infection
o Begins to rise after the onset of the
rash, peaks about four weeks later, and
generally lasts for life
CONGENITAL RUBELLA
o Result of in utero fetal infection
o Occurs during 1st 12 weeks of pregnancy
o Fetal infection may be subacute or
chronic
o May result in abortion, stillbirth,
congenital malformation
RISK OF CONGENITAL MALFORMATION
o 100% when maternal infection occurs on
the first trimester of pregnancy
o 4% in the second and third trimesters of
pregnancy
o 90% of congenital rubella cases excrete
the virus at birth and are therefore
infectious
o 10% of the virus remains contagious
until the first year of age of the
infected child
PATHOLOGY
o Maternal viremia → transplacental
infection → embolization of necrotic
placental vascular endothelium → fetal
infection
 Placental infection does not
always result in fetal infection
particularly after the 1st
trimester
 o The virus crosses the placenta. Rubella
infections of pregnant women during the
first month results in birth defects:
 Deafness
 Blindness
 Mental retardation
Infants with congenital rubella syndrome
o Contagious
o Maintain contact precautions until they
are at least 1 year old, unless repeated
nasopharyngeal and urine cultures after
3 months old are (-) for rubella

RUBELLA SYNDROME MEASLES, MUMPS, RUBELLA (MMR) VACCINE

o Microcephaly o 1st dose: 12 months
o PDA o 2nd dose: 4-6 years old
 Blood was oxygenated blood and o Those who have not received the 2 nd dose
goes through the four pulmonic should complete the schedule during the
veins to enter the left atrium 11-12-year-old visit
and passes the bicuspid valve, o The WHO recommends the first dose be
then left ventricle, then aortic given at 12 to 18 months of age with a
valve and enters the ascending second dose at 36 months
aorta and there is a connection: o Pregnant women are usually tested for
the pulmonary artery and immunity to rubella early on. Women
descending aorta. Unoxygenated found to be susceptible are not
blood in the descending aorta and vaccinated until after the baby is born
higher pressure in artery. because the vaccine contains live virus
There’s mixing of unoxygenated o It is recommended that all susceptible
blood and oxygenated blood. Blood non-pregnant women of childbearing age
with less oxygen sent to should be offered rubella vaccination
descending aorta, affecting o Due to concerns about possible
growth of child due to less teratogenicity, use of MMR vaccine is
oxygen not recommended during pregnancy
o Cataracts o Instead, susceptible pregnant women
should be vaccinated as soon as possible
CONGENTIAL RUBELLA in the postpartum period
o All non-immune women should be
HEARING LOSS vaccinated during the immediate
o WHO definition (Smith, 1999): permanent postpartum period and before discharge
unaided hearing threshold level for the  Breastfeeding is not a C/I to
netter ear of 26 dB or greater postpartum immunization
o Most common manifestation of congenital
rubella CENTER FOR DISEASE CONTROL AND PREVENTION
o Occurs in 70-90% of CRS cases PREVENTION OF INFECTIOUS DISEASES 2005-2006
o In 50% of these children it is the only o Immunization contraindicated during
sign of CRS pregnancy
o Most important cause of non-genetic o Do not conceive 28 days after vaccination
congenital hearing loss o Can cross placenta, infect fetus but do
o Average age of identification: 2 years not produced defects
o Inadvertent administration of vaccine
GENERALIZED GROWTH RETARDATION during 1st trimester is not an indication
o Most common manifestation of congenital for termination of pregnancy
rubella readily apparent at birth  3% rate of viral isolation
o Each patient should be counseled to
EYE FINDINGS avoid pregnancy for 28 days after
o Cataracts vaccination because of the theoretical
o Congenital glaucoma risk for vaccine virus affecting the
fetus
NEUROLOGIC o If vaccination of an unknowingly
o Meningoencephalitis – 10 to 20% of pregnant woman occurs or if she becomes
infants pregnant within 4 weeks after MMR, she
should be counseled about the
CARDIOVASCULAR theoretical basis of concern for the
o PDA, Pulmonary Artery Stenosis fetus
o Myocarditis – most common cause of death o MMR vaccination during pregnancy should
not be regarded as a reason to terminate
ISOLATION pregnancy
o Gamma-globulin to pregnant women
Infants with congenital rubella
 Reduce frequency of symptomatic
o Infected actively at the time of birth disease in the mother
o Contagious  Little effect on
o Placed in isolation frequency/severity of fetal and
neonatal disease
Room isolation and urine precautions
o Should be continued for the duration
unless repeated viral culture are
negative
 RABIES ACUTE KIDNEY INJURY
o an abrupt decrease (within 48 hours) in
DOG BITES kidney function that includes:
o Stay still when an unfamiliar dog comes  increase in serum creatinine,
up to you greater than 0.3 mg/dL (reliable)
o If knocked over by a dog, roll into a  decrease in urine output (less
ball and lie still; do not look a dog in than 0.5 mL/kg/hour) for more
the eye than
o Vital areas on your torso, head, and 6 hours
neck are also now vulnerable to attack.
These are the most important spots on RISK FACTORS
your body to protect because bites in o Age 75 or older
these places will inflict the most  less blood supply to the brain,
damage and will have the greatest chance heart, kidneys
of killing you. Protect your vitals by o Diabetes
rolling onto your stomach, tucking your  glucose will stay in blood and
knees in, and bringing your hands makes blood viscous increasing
(balled in fists) up to your ears blood pressure
o Hypertension
FIRST AID TREATMENT  viscous and slow movement of
o Wash the wound with ANTIBACTERIAL soap blood decreasing blood supply to
for 5 full minutes kidneys
 This is a vital step to combat o CKD
wound infection o Heart or liver failure
 Flush the wound for additional 5  heart is unable to eject a good
full minutes allowing water to supply of blood due to damage:
run into the dog bite wound less cardiac output
o Sepsis
 decreased blood supply
 there is severe infection causing
injury to the tissues. Injured
tissues will release cytokines,
histamine, bradykinin, increasing
capillary permeability. Plasma
including albumin goes out from
intravascular going to
interstitial compartment,
decreasing circulating blood.
Kidneys being a secondary organ,
will receive less blood supply
and lead to AKI
o Use of intravascular radiocontrast agent
 Should increase fluid intake
o Cardiac surgery after use of
radiocontrast agent

AKI
o
Approximately 70% of patients who
develop AKI are age 70 or older
o
Renal function may decline by 50% or more
by age 70

3 MAJOR MECHANISMS

PRE-RENAL - HYPOPERFUSION
o Decreased blood supply → decreased blood
supply to kidneys → kidneys will be
damaged
o Bleeding d/t vehicular accident, stab or
gunshot wound
o Hypertension
o Diabetes mellitus

HYPOTENSION
o Hypotension decreasing blood supply to
the brain and kidneys.
o For each hour of hypotension, the risk
of kidney injury more than doubled with
each 10 mmHg drop in MAP below 80
o Report if BP goes down (drop in mean
arterial pressure)
 o Formula: systolic + diastolic x2 /3 o Urine output at 30mL or less per hour
(only 50% of patients are oliguric)
INTRARENAL - DIRECT TISSUE INJURY o The remainder excreting 600ml/8hours
Directly destroying the kidneys by: o Urinary sodium excretion greater than 40
o Microorganisms: Streptococci (acute mEq/L
glomerulonephritis, nephrotic syndrome)
o Drugs: aminoglycosides because they are II. OLIGURIC-ANURIC PHASE
nephrotoxic; NSAIDs like Alaxan,
o Lasts 5 to 8 days in NONOLIGURIC patient
Ibuprofen, Voltaren o 10 to 16 days in OLIGURIC patient
o Chemicals (take years before kidneys
o Below 400 mL/day
will be damaged)
 Oliguric: less urine formed in 24
o Nephrotoxic drugs hours (less than 300 per hour or
 Amphotericin B 600 cc or below for 24 hours)
 Aminoglycosides  Anuric (50 cc in 24 hours)
 Neomycin, Gentamycin, o GFR is greatly reduced → AZOTEMIA
Amikacin  Toxins: Should not accumulate in
 Vancomycin the body and must be removed by
o Rhabdomyolysis is a life-threatening urinating creatinine, uric acid,
condition in which skeletal muscle urea
tissue breaks down and releases the
 Uremia – toxins accumulating in
oxygen- carrying muscle protein the body (urinary output is less,
myoglobin into the blood not all toxins will be excreted)
o Rhabdomyolysis may result from
 Azotemia – big amount of toxins
 Traumatic muscle injury in the body and can destroy the
 Heat-related hyperthermia heart and the brain, patient will
 High-voltage electrical or become confused and disoriented
extensive third-degree burns o ↑ serum CREATININE
 Pressure injuries related to o Electrolyte abnormalities
immobility  Hyperkalemia
 Toxins (snake venom, black widow  Hyponatremia
spider venom, carbon monoxide)  Hyperphosphatemia
o Hypersensitivity  Hypocalcemia
 It causes renal inflammation; o Metabolic acidosis
kidney dysfunction occurs within
7-14 days of drug administration
HYPERKALEMIA
 This type of AKI is usually o Due to tissue trauma, bleeding, or blood
reversible, but recovery may take transfusion because K is released from
several months and in rare cases damaged cells
dialysis may be necessary o In metabolic acidosis, the K levels
 Hypersensitivity reactions: rash, increase as hydrogen ions enter the
hives, eosinophilia, fever cells and force K out of the cells
o lead to cardiac dysrhythmia and then
POSTRENAL AKI lead to cardiac arrest
o obstruction (calculi in the ureter-tube o 98% of potassium are removed by kidneys
where urine will pass going to urinary o Due to toxins, it shortens the life span
bladder) of RBC, releasing potassium leading to
o urine formed by the kidneys cannot pass hyperkalemia.
and goes up to the kidneys, destroying o Potassium goes out because of the acids.
it Hydrogen ions will go inside the cell,
o Results from obstruction of urine potassium will go out in exchange of
outflow by: hydrogen ions.
 Tumors
 Calculi HYPONATREMIA
 Prostate gland enlargement o Sodium normal value: 135-145
 BPH o body is compensating
 Prostate gland nourishes o ADH and aldosterone will be released
the sperm for motility because there is decreased circulating
 Due to diet, obesity, blood volume. Will reabsorb plenty of
hormone (testosterone) water
 Prone to UTI o dilutional hyponatremia (plenty of water
in the body)
PHASES OF ACUTE KIDNEY INJURY
HYPERPHOSPHATEMIA
I. ONSET PHASE o foods rich in protein are also rich in
o Time when an insult occurs until cell phosphates
injury
o Last from hours to days HYPOCALCEMIA
o The GFR is decreased because of impaired o low calcium because kidneys are
blood flow to the kidney responsible in activating vitamin D.
 o calcium will not be absorbed by vitamin
D if kidneys are damaged in the small
intestine. Have a high phosphate
Causes
Phosphate and Calcium should be balanced
o controlled by parathyroid gland,
posteriorly of the thyroid gland.
o Since kidneys are destroyed, phosphates
will not be eliminated, thereby
increasing it. Calcium will not be
absorbed from the food that we eat in
TWENTY-FOUR-HOUR URINE COLLECTION
the small intestine.
o Doctors will give medicines that lower
phosphate so that calcium will be
absorbed
o Vitamin D from early exposure to sunlight
(6-7 am), egg yolk, butter, milk.
Inactive once taken in and kidneys
activate it. If kidneys are damaged,
calcium won’t be absorbed in the small
intestine
METABOLIC ACIDOSIS
o so much hydrogen ions in the body
(acids).
o Because kidneys are damaged/destroyed
and it cannot produce adequate amount of
bicarbonates, cannot remove toxins
(urea, creatinine, uric acid)
o Pyelonephritis
o Edema from brain injury/surgery
of increased USG
o DM
o Syndrome of Inappropriate
o Secretion of Antidiuretic Hormone
o over secretion of ADH
o CHF
o All urine voided during a 24-hour period
is collected
o Urine is kept chilled (on ice)
o May need preservative added
o Void to begin test – discard this urine
o Collect for next 24 hours
o The patient is instructed to void and
discard the first specimen (8AM day 1)
o The patient collects all urine voided up
to and including that at 8
AM the following morning (day 2)
o If any urine is removed or discarded
during a timed collection, the entire
time collection is invalid
o A 24-hour creatine clearance test is
necessary to detect changes in renal
reserve

III. DIURETIC PHASE

o May last 7 to 14 days
o The tubular obstruction has passed but
EDEMA and SCARRING remain
o The urine is able to flow through the
tubular space, but the cells cannot
concentrate the urine
o When the client moves from the oliguric
to the diuretic phase, hypovolemia and
electrolyte losses are the primary
problems
o In the oliguric phase, fluid and
electrolytes are retained
o Because of fluid loss the patient
experiences:
 Hypovolemia
 Hypotension
 Hyponatremia
 Hypokalemia

IV. RECOVERY PHASE

o Kidney function may return to normal or
near normal or near normal
o Edema diminishes and the tubular cells
begin to slowly resume normal
functioning Nurse fills up the data
o GFR that is 70% to 80% normal within 1
to 2 years CREATININE

URINE SPECIFIC GRAVITY

o Measures the concentration of particles Proteins (bubbles
in urine in the urine)
o To gauge the patient’s hydration status
as well as the functional ability to the Proteins should
kidneys not be present in
o Normal Value: 1.010 – 1.020 the urine

Causes of decreased USG

o Excessive fluid intake
o Diabetes insipidus
o Glomerulonephritis
URINALYSIS  Example: 75kg should have a fluid
o Protein or cells in the urine may intake of 2,250 mL/day
indicate intrarenal damage, such as
glomerulonephritis or kidney infection
Xerostomia (dry mouth)
o Hematuria, pyuria, or urinary crystals o A metallic taste
may indicate a postrenal cause o An unusual breath odor from bacterial
interaction with urea in the saliva
 Provide foods soft to masticate and
nutritious
 Prepare solutions
 Frequent oral hygiene
 Moisturize the lips every 2 to 4 hours
to prevent breakdown

 Caution patients using NSAIDs to be

mindful of potential adverse effects
such as hypersensitivity
 Drink plenty of water when taking
Pyuria (milky) these medications
 Instruct patients to discontinue any
DIAGNOSTIC STUDIES medication to which they have a
o Renal ultrasound may show renal tissue hypersensitivity reaction
damage or urinary tract obstruction  A repeat serum creatinine level should
o Renal biopsy to investigate possible be obtained 7 to 10 days after any
intrarenal disorders: (7-10k) hypersensitivity reaction
 Glomerulonephritis  Clean all equipment used between
 Nephritis patients, practice SCRUPULOUS HAND
HYGIENE
MEDICAL MANAGEMENT  Ensure that everyone on the unit
does so as well
For volume overload  Instruct patient on infection
Volume overload (cannot form urine, fluid is prevention
accumulating in the body → edematous d/t  Manage peripheral and central venous
protein na lumabas. Has albumin that maintain access devices as well as dialysis
osmotic pressure (holds water in the blood access catheters with STRICT STERILE
vessel) TECHNIQUE
o Furosemide  Administer prescribed antibiotics
o Dialysis – machine, cleaning blood (5k) strictly on time to prevent any drop in
therapeutic drug levels
For hyperkalemia  If patient needs a urinary catheter,
o Kayexalate maintain a
o Furosemide  Closed drainage system
o Glucose-insulin  Unobstructed urine flow
 Insulin will be given to carry  Perform meatal care with soap and
glucose bringing it inside the water
cell, including the potassium.  Discontinuing it as soon as
Diminishing potassium in the possible
blood to not develop dysrhythmia  Patient is not lying over it
 Use clean gloves when measuring
Avoid magnesium-containing antacids, salt I&O
substitutes, NSAIDs and other nephrotoxins  Teach patients-before surgery, after
o Pantoprazole-----------Pantoloc surgery and at discharge to report any
o Aluminum Hydroxide-----Alu-tab reduction in urine output or voiding
frequency
NURSING INTERVENTIONS
 Surgery
 Accurately document intake and output  Injury
and daily weight
 Medications
 Low blood volume or cardiac output
 In postoperative patients report any:
 0.9% sodium chloride
 Urine output less than 0.5 mL/kg
 Urine: 30-50 cc/hour. If
per hour, assess vital signs and
less, report
urine output every 15 to 30
 For hypervolemia minutes until VS are stable
 Restrict sodium intake
 Report any hypotension or
 Early identification and prevention of tachycardia
dehydration, especially in older
patients
 Older adults should have 30mL of
daily fluid intake per kg of body
weight
 TYPHOID FEVER

o Small intestine is affected INFECTIOUS AGENT: Salmonella typhosa

o Once the bacteria enter the bloodstream,
it can affect the pancreas, heart, brain
etc.
o Bacteria can grow inside the macrophages
DEFINITION
Typhoid fever is an acute bacterial infection
characterized by constitutional symptoms like
prolonged pyrexia, prostration and involvement
of spleen and lymph nodes. It does not cause
lifelong or sufficiently prolonged immunity,
second attack often occurs
TYPHOID FEVER-OTHER NAMES
o Enteric fever
o Bilious fever
o Yellow Jack
TYPHOID FEVER
o Typhoid spreads when people consume food
or water, which is contaminated by the
feces of another infected person
o People with a poor immune system are
more prone to the disease and are more
likely to be severely affected
BACTERIOLOGY-TYPHOID FEVER
o The Genus Salmonella belong to
Enterobacteriaceae
o Facultative anaerobe
o Gram negative bacilli
o Distinguished from other bacteria by
biochemical and antigen structure
INCUBATION PERIOD: 5 to 45 days
MODE OF TRASNMISSION
o The disease can be passed from one
person to another through fecal-oral
transmission
o Through the ingestion of contaminated
food, water and milk
o Contamination is usually by hands of
carrier
SOURCES OF INFECTION:
o A person who has just recovered from the
disease or has recently taken care of a
patient with typhoid
o Ingestion of shellfish (oyster) taken
from waters contaminated with sewage
disposal
o The stools and vomitus of an infected
individual
PERIOD OF COMMUNICABILITY
o As long as the patient is excreting the
microorganisms, he is capable of
infecting others
CAUSES
o Poor sanitation
o Contaminated or infected water
o Food: contaminated with germs by flies
(attracted to yellow color)
o People who have the disease if they
prepare or serve the food
o Unhealthy diet faulty style of livings

TYPHOID MARY PATHOPHYSIOLOGY

o The most notorious carrier of typhoid Salmonella typhi
fever – but by no means the most ↓
destructive – was Mary Mallon, also Survives the acidity of the stomach
known as Typhoid Mary. In 1907, she ↓
became the first American carrier to be Invades the Peyer’s patches of the intestinal
identified and traced. She was a cook in wall (tonsils of small intestine)
New York; some believe she was the ↓
source of infection for several hundred Macrophages (Peyer’s patches)
people ↓
o Mary Mallon was a cook in Oyster Bay, The bacteria are within the macrophages and
New York in early 1900s survives
o Gave rise to more than 1300 cases in her ↓
lifetime Bacteria spreads via the lymphatics while
o She died of pneumonia after 26 years in inside the macrophages
quarantine
o Natural infection is by ingestion
followed by either direct invasion of
the
 mucosa of small intestine or
multiplication for several days before
invasion
o The Peyer’s patches are potential sites
where S. typhi is internalized and
transported to the underlying lymphoid
tissues
o From the submucosa, the organism travel
to the mesenteric lymph nodes, multiply
and then enter the bloodstream
 Mesenteric (hold organs in place)
o During the bacteremia phase, the
organism may invade any organ but most
commonly are found in the liver, spleen,
bone marrow, gallbladder, and Peyer’s
patches in the terminal ileum
o The Peyer’s patches become hyperplasic
with infiltration of inflamed cells DIAGNOSIS
o Hemorrhage and perforation may occur due Physician still plays the key role
to the growth of the lesion and the o Because there is no definitive rest for
continuous erosion of the epithelial typhoid or parathyroid fever, the
lining of the small intestines diagnosis often has to be made
o Since the toxins are absorbed into the clinically. The combination of a history
bloodstream, almost all organs of the of being at risk for infection and a
body are affected gradual onset of fever that increases in
o The mesenteric lymph glands are red and severity over several days should raise
swollen suspicion of typhoid or parathyroid
fever
SOURCES o An elevated WBC
o Food handlers o Blood culture during first week of the
o Flies fever can show S. typhi bacteria
o Street foods/vendors o A stool culture
o Taho vendors o A platelet count (decreased platelets)
o Jollijeep in Makati
PREVENTION
SIGNS AND SYMPTOMS o Clean water
o High fever o Sanitation
o Headache o Hygienic handling of foodstuffs
o Diarrhea o Typhoid fever vaccine-give protection
o Constipation o Good hygiene
o Weakness o Avoid raw vegetable that cannot be peeled
o Dry cough o Avoid foods and beverages from street
o Rashes vendors
o Rose Spots o Wash hand with soap and water
 Occurs in up to 20-30% of people o Sanitary and proper disposal of excreta
infected with Salmonella typhi o Proper supervision of food handlers
 Characteristically, rose spots o Provision of adequate amounts of safe
are seen in untreated typhoid drinking water supply
fever o Education of the general public on the
 Usually occur between the second mode of transmission
and fourth week of illness o Food inspection
 They are usually distributed
between the level of the nipples NURSING CARE
and umbilicus, but can also be o Increase fluid intake and stay on a
found on proximal extremities and liquid diet until the diarrhea stops
back o Isolate the patient or have him use a
 Each lasts 3 to 5 days separate bathroom
 are thought to be bacterial o Rest in bed until symptoms subside (to
emboli to the skin, i.e. clumps slow metabolism; lessen workload)
of bacteria have spread through o Wash hands thoroughly and frequently
the bloodstream o High caloric diet after the diarrhea
stops

TREATMENT
o In most cases typhoid fever is not fatal
o Antibiotics such as ampicillin,
chloramphenicol, trimethethoprim-
sulfamethoxazole, and ciprofloxacin
o These antibiotics have been used in most
developed countries
Fluids in the form of:
o Tender coconut water
LEPTOSPIROSIS
o Also known as canicola fever,
o Electrolyte fortified water (gatorade)
hemorrhagic jaundice, infectious
o Fresh fruit juice
o Vegetable soup (chicken macaroni soup jaundice, mud fever, spirochetal
with finely chopped carrots; pumpkin jaundice, swamp fever, swineherd’s
soup) disease, caver’s flu or sewerman’s flu,
is a bacterial infection resulting from
o Water
exposure to the Leptospira interrogans
Should be consumed until body temperature
comes back to normal bacterium
o Infectious disease caused by spirochete
Consume liquid diet for a few days and then bacteria (Leptospira interrogans)
gradually take fruits like: o Acquired when coming in contact with
o Bananas flood water contaminated by urine of
o Cantaloupe (high in potassium) animals such as rats, dogs, goats, and
o Watermelon swine
o Grapes o Common in tropical countries with heavy
o Peaches rainfall
o Apricot
INFECTIOUS AGENT: Leptospira interrogans
As the person’s appetite gets better, semi- INCUBATION PERIOD: 6 to 15 days
solid foods can be given
o Found in river and lake waters, sewage,
o Boiled rice (lugaw)
o Baked potato and in the sea
o Soft boiled or poached eggs o Spread mainly by the urine of infected
animals
o Yoghurt
o Not transmitted from person to person
o Vegetable soup

o Avoid high fiber foods: intake of whole MODE OF TRANSMISSION

grain cereals and their products like o Ingestion or contact with the skin or
oatmeal, whole wheat bread, and raw mucous membranes
vegetables in the form of salads, are o Mucous membranes of the yes, nose, and
rich in fiber mouth and through breaks in the skin
o Common among watersport enthusiast,
 It can add on the stress on your
prolonged immersion in water is known to
digestive system
promote the entry of bacteria

o Avoid vegetables like cabbage, capsicum

and sweet potato, as these can cause
bloating and gas
o Stay away from oily foods, spices and
seasonings like pepper, cayenne and
chili powder to make sure that the
digestive tract dies not inflame all the
more
 Spicy foods: Decrease absorption
of small intestine
 TREATMENTS
o Penicillin G- drug of choice
o Ampicillin, Amoxicillin, Doxycycline
o In more severe cases, Cefotaxime or
Ceftriaxone
o Glucose and salt solution infusions
o Dialysis in serious cases
o AMPICILLIN – broad-spectrum penicillin,
weaken the bacterial cell wall, causing
lysis and death
o CEFTRIAXONE – bactericidal
o DOXYCYCLINE – suppress bacteria growth
by inhibiting protein synthesis

PREVENTION
o The risk of acquiring leptospirosis can
be greatly reduced by not swimming or
wading in water that might be
contaminated with animal urine, or
eliminating contact with potentially
infected animals
SIGNS AND SYMPTOMS o Wear boots
o Diarrhea o Boil water for cooking
o Vomiting o Immerse vegetables in water with
o Eye redness vinegar/salt/baking powder and rinse
o Headache thoroughly before cooking
o High fever o Cover trash bins
o Conjunctival suffusion (dilated o Vaccinate dogs
conjunctival blood vessels in the o Cover foods
absence of discharge) o Rat killers
o Pharyngeal erythema without exudate
o Muscle tenderness
o Rales on lung auscultation or dullness
on chest percussion over areas of
pleural hemorrhage
o Rash (macular, maculopapular,
erythematous, petechial, or ecchymotic)
o Jaundice
o Meningismus
o Hypo- or areflexia, particularly in the
legs

SYMPTOMS-MILD FORM
o Leptospirosis is a BIPHASIC DISEASE
begins with flu like syndrome (fever,
chills, intense headache, myalgia)
o First phase resolves, and the patient is
briefly asymptomatic until the second
phase begins
o Red eyes, diarrhea, rash
o Jaundice
o Pulmonary symptoms
 MEDICAL SURGICAL NURSING  Red blood cells
FINALS o When this DNA is gone, the cell
responds to signals for
CANCER programmed cell death, apoptosis
o The purpose of apoptosis is to
ensure each organ has adequate
number of cells at their
functional peak

Chemotherapy AE: alopecia because

these drugs are very effective in
cells that are growing rapidly and
hair follicles are one

Some cells will not leave G0 (resting

phase) and most of the cells come from
CNS and it would not regenerate
(permanently damaged)

CHARACTERISTICS BENIGN MALIGNANT

o Persistent Proliferation Dangerous, can
Localized
o Cancer cells undergo UNRESTRAINED spread
GORWTH and DIVISION Slow growing Fast growing
o Cancer cells are able to Capsulated Non capsulated
continue multiplying under Non-invasive Invasive and
conditions that would suppress infiltrate
further growth and division of Do not Metastasize
normal cells metastasize
o INVASIVE GROWTH Well Poorly
o Malignant cells can penetrate differentiated differentiated
adjacent tissues, thereby Suffix “oma” Suffix “carcinoma”
allowing the cancer to spread e.g. Fibroma or “sarcoma”
o The various type of cells that
compose a tissue remain WELL-DIFFERENTIATED CANCER
segregated from one another Well-differentiated cancer cells
o Cells of one type do not invade o Looks more like normal cells
territory that belong to cells o Tend to grow and spread more
of a different type slowly than poorly
o Malignant cells are free of the differentiated or
constraints that inhibit undifferentiated cancer cells
invasive growth
 It goes everywhere else to POORLY DIFFERENTIATED CANCER
metastasize because they go o The cells of poorly
with blood. Through also differentiated or
the lymphatic system undifferentiated cancers
o FORMATION OF METASTASIS (carcinomas) looks very
o Ability of malignant cells to different from normal cells
break away from their site of under the microscope
origin
o Migrate to other parts of the Metastasis can occur by the following
body and then re-implant to form mechanisms
a new tumor o Direct spread of tumor cells by
o IMMORTALITY diffusion to other body cavities
o Unlike normal cells, which o Circulation by way of blood and
eventually die, cancer cells lymphatic channels
undergo endless divisions o Transplantation or direct
o Normal cells have a finite life transport of tumor cells from
span one site to another
  Abdominal surgery, the Pain is a late manifestation of cancer
surgical instrument (stage 3 or 4)
touching the tissue can
spread to cells RISK FACTORS ON CANCER
o Of all cancer cases, 77% occur
Lymph Nodes in people older than 55 years of
o 600-700 age (American Cancer Society,
o most abundant in the head and 2005). This higher incidence
neck reflects a lifelong accumulation
of DNA mutations that result in
STAGING IN CANCER cell changes and cancer.
Reasons o Older adults may not be able to
1. To know the treatment repair these mutations as they
 Stage 1 & 2: surgery once did. Immune function,
 Stage 3 & 4: radiation and especially cell-mediated
chemotherapy; will only immunity (WBC, macrophages), is
prolong life also reduced in the older adult.
2. To know the prognosis
 Stage 1: 90% chances of BREAST CANCER
living o Pectoral muscle: tumor can
 Stage 4: 10-15% chances of adhere inside minor outside
living major
3. To know the extent of tumor o Modified: minor pectoral removed
o Total: minor and major pectoral
1. A way in which the removed
characteristics of CANCER can be
described 2 MAIN KINDS OF BREAST CANCER
2. Classifying the EXTEND and o Ductal: Meaning it starts in the
SPREAD of Cancer. tubes, or milk ducts
3. Allows decisions to be made o Lobular: Meaning it starts in
about the management of the the milk-producing glands
CANCER patient; identifying
appropriate treatments DUCTAL CARCINOMA IN SITU (Inside)
4. A way of estimating the o Most common non-invasive cancer
PROGNOSIS of a case. (localized)
o Cancerous cells are confined to
STAGE I: Malignant cells are confined the duct
to the tissue of origin, no signs of o It has an excellent prognosis
metastasis with treatment
STAGE II: Spread of cancer is limited o Unchecked it could turn into
to the local area, usually to area invasive cancer
lymph nodes
STAGE III: Tumor is larger, probably INFILTRATING DUCTAL CARCINOMA (Going
has invaded surrounding tissues or out)
both STAGE IV: Cancer has invaded or o Most common type of breast cancer,
metastasized to other parts of the making 75% of all invasive cancers
body o Cancerous cells break through
the duct wall and invade the
7 WARNING SIGNS breast tissue
1. A change in bowel habits or o Most common sites for metastasis
bladder function are the bones, lungs, liver and
2. Sores that do not heal brain
3. Unusual bleeding or discharge
4. Thickening or lump in breast or LOBULAR CARCINOMA IN SITU
other body parts o Collection of abnormal cells is
5. Indigestion or difficulty present, but doesn’t extend
swallowing beyond the affected lobule
6. A recent change in a wart or mole
7. A nagging cough or hoarseness
 o Women with lobular carcinoma in o Ionizing radiation
situ have an increased risk of o High fat diet
developing invasive breast
cancer in either breast later in
life

INFLAMMATORY BREAST CANCER

o An aggressive cancer in which
the affected beast looks
inflamed, red and feels warm
o The skin has the appearance of an
orange peel, with an engorged look
 Edema: late manifestation
o Sometimes, there’s also lump in
the breast
o Symptoms begin to appear when
lymph vessels become blocked
o Death occurs within 18 to 24
months of diagnosis
o The classic sign of this cancer
is the peau d’orange of the
breast skin accompanied by
erythema.

PAGET’S DISEASE
o This cancer is associated with
nipple changes
 Eczema
 Itching
 Thickening of the areola
o Can be invasive or non-invasive

RISK FACTORS FOR BREAST CANCER

o Age >50 years old
 About 78% of breast cancers
occur among women over 50
years of age
o Family History
o Female Gender
 Estrogen is the food of
cancer cells
o History of previous breast CA
o Menstrual History
 Menarche prior to age 12
 Menopause after age 55
 menopause at 58 exposure to
estrogen high risk of
cancer
o Estrogen Exposure
 Nulliparity
 First born child after 30
y/o
 Breast feeding of at least
one-year duration
o Researchers have found out that
the more years a body is exposed
to estrogen, the greater risk of
developing breast cancer
 o Obesity o Distant metastases evident
 Decreasing immune
system- responsible in
killing carcinogen
o Exogenous hormones
o Benign breast disease
o Oral contraceptives
o Alcohol
 Suppresses the ability
of WBC to multiply and
inhibit the action of
killer WBC on cancer
cells
 Lessen the ability of
macrophages to produce
TUMOR NECROSIS FACTORS

CLINICAL MANIFESTATIONS
o Single lump, painless, non-
tender and fixed
o Lump
 Firm to hard in consistency
 Irregularly shaped
 Fixed, not mobile
 Often attached to the
chest wall (minor or
major pectoralis) upper
outer quadrant of the
breast
o Upper outer quadrant
o Dimpling and retraction of the
skin and nipple
o Peau D’orange: Late manifestation
o Nipple discharge that is
unilateral
 Serosanguineous
 Bloody
 Watery
o Breast distortion
o Pain: Late manifestation of
any cancer
o Axillary adenopathy

STAGES OF BREAST CANCER

Stage I
o Tumor smaller than 2cm
o No node involvement
Stage II
o Tumor more than 2 cm but less
than
5 cm.
o Possible axillary
node involvement
Stage III
o tumor greater than 5 cm.
o axillary lymph (+) for
cancer cells
Stage IV
o Tumor any size.
SCREENING TESTS BREAST ULTRASONOGRAPHY
PREPARATION:
MAMMOGRAM o No fasting or sedation is required
o The BEST IMAGING TOOL for o Instruct the patient not to
detecting breast CA apply any lotions or powders to
o Yearly screening between the the breast.
ages 40-50 o Supine position, a conductive
o BEST TIME: 1 week after paste is applied.
menstrual period or 1-2 weeks o Duration: 15 minutes
after the onset of menses.
 Before menstruation, breast SENTINEL LYMPH NODE BIOPSY
is dense and hard because o To map the lymphatic drainage of
of the presence of a primary cancer so that surgery
progesterone can be directed:
o MAMMOGRAPHY + MRI 1. For diagnostic
o Done for women with a high risk 2. Possibly therapeutic
for breast CA resection of lymph nodes
o 2 techniques when combined,
detects 94% of tumors THREE REASONS
o Detection of breast cancers, 1. To stage the patient
benign tumors, and cyst before appropriately
they are even palpable. 2. To determine treatment based on
o Inform the patient that some stage
discomfort may be experienced 3. Remove cancer cells and decrease
during breast compression. amount of tumor
o Compression allows better
visualization of the breast Functions of the Lymphatic System
tissue. o Filtration of foreign objects
o Talcum powder can give the o Fluid transport
impression of calcifications o Initiation of immune responses
within the breast
o Tell the patient that NO FASTING Side Effects of SLNB
is required o Tenderness around the area of
o Explain to the patient that a surgery
minimal radiation dose will be o Numbness
used during the test. o Limited range of motion
o Jewelry worn around the neck can o Infection
preclude total visualization of o Lymphedema
the breast
o Breast augmentation implants Techniques
prevent total visualization of Injecting a dye (radioactive or blue
the breast. dye)
DIGITAL MAMMOGRAPHY SLNB
o On the day of your mammogram, o With the use of SLNB, the first
please DO NOT USE deodorant, lymph node in the chain of lymph
powder, perfume or lotion under nodes can be identified and
your arms or near or your breast biopsied
area. These products may show up
on your mammogram images. CLINICAL BREAST EXAM (Physician)
o Caffeine should be eliminated o YEARLY if 40 y/o or older
one week prior to your exam. o EVERY 3 YEARS if 20-39 y/o
This is for your comfort, as
caffeine can sometimes cause BREAST SELF- EXAM (Patient)
breast tenderness o MONTHLY for all, beginning at
o Wear a two-piece outfit so you age 20
only need to remove your top.
 o Done 5-7 days after the onset of your breast cells susceptible to
menstruation the growth of cancer.
*The latter half of menstrual cycle o BRCA2 is a gene that, when
is influenced by the secretion of healthy, prevents breast tumors
progesterone, which causes the from forming
breast vasculature and ductal o BRCA2 makes a protein that is
structures to dilate with resultant involved in DNA repair and
tissue engorgement. genetic stability.
o If BRCA2 is broken (mutated),
o Put a small pillow underneath to the protein that it makes is
distribute equal fat unable to repair broken DNA,
o Elevate arm if you are palpating leaving your breast cells
that side of the breast being susceptible to the growth of
cancer.
o The BRCA gene test is offered
only to people who are likely to
have an inherited mutation,
based on personal or family
history, or who have specific
types of breast cancer. The BRCA
gene test isn't routinely
performed on women at average
risk of breast and ovarian
cancers.

COST OF BRCA
o The BRCA test in St. Luke’s
Quezon City and Global, costs
PHP170,000.00. They start with
GENETIC SCREENING testing your blood for
o Done if a family member dies of infection. If you don’t have the
cancer infection, then it’s a go for
o Normally, the BRC1 and BRCA2 the BRCA gene test.
genes protect you from getting o BRCA Testing is expensive. In
certain cancers. (chromosome 17 the US, it may cost from
and 13, respectively) hundreds to thousands.
o But some mutations in BRCA1 and o According to the Texas Medical
BRCA2 genes prevent them from Association, the cost of BRCA
working properly gene testing can range from
o If you inherit one of these US$385 for a single site
mutations, you are more likely analysis to US$3,120 for full
to get breast, ovarian and other sequencing of both genes.
cancers o According to the National Cancer
o Their function is to produce Institute, women with an
proteins that prevent abnormal abnormal BRCA1 or BRCA2 gene
cell growth and, therefore, have about a 60% risk of being
CANCER diagnosed with breast cancer
o However, if a person inherits a during their lifetimes.
BRCA gene mutation from either o Does inheriting the BRCA gene
parent, the risk of developing mutation mean that cancer
cancer is greater inevitably will develop?
o BRCA1 is a gene that when  The answer is NO
healthy, prevents breast tumors o Those who don't have genetic
from forming mutations also may develop
o If BRCA1 is mutated, the protein cancer from other known and
that is makes is unable to unknown causes.
regulate cell division, leaving
GENETIC SCREENING
o In a retrospective study of 639
women with a family history
of
 breast cancer who had bilateral
mastectomy between 1960 and 1993
at the Mayo clinic
o Researchers concluded that
PROPHYLACTIC SURGERY reduced the
risk of developing breast cancer
by at least 90%.
o A mutation in the BRCA1 gene-
indicating a lifetime risk of
ovarian cancer as high as 60%
and a lifetime risk of breast
cancer as high as 85%.
o In hormone-related cancers,
these prophylactic operations
stop the flow of estrogen and
the growth of tumors
BREAST ULTRASONOGRAPHY
o a supplemental tool to further
investigate an abnormality found
on mammography.
o It reveals whether a lump is a
fluid-filled cyst that is likely
to be harmless or a solid tumor
which could be cancerous.
 Pectoralis muscles are left
intact
2. Lumpectomy or Tylectomy
 Only the tumor is removed
 Some AXILLARY LYMPH NODES
may be excised at the dame
time for microscopic
examination
Other Types of Breast-Conserving
Surgery
The Breast-Conserving results in 5-
and 10-year survival.
1. Partial or Segmental Mastectomy
 The tumor and some breast
tissue and some lymph nodes
are removed
2. Simple of Total Mastectomy
 All breast tissue is removed
 No lymph node dissection is
performed
Typically, radiation therapy follows
to eradicate residual tumor cells

o Researchers concluded that STAGES III and IV

bilateral prophylactic o Mastectomy in combination with
oophorectomy reduces the risk of SYSTEMIC CHEMOTHERAPY or
developing either coelomic HORMONAL THERAPY
epithelial cancer or breast o Patients who were initially
cancer in women carrying either treated by breast-conserving
a BRCA1 or BRCA2 mutation. therapy and develop recurrence
undergo TOTAL MASTECTOMY
PREOPERATIVE
o Shower with an antibacterial soap POST OP INTERVENTIONS: MASTECTOMY
o Teaching topics include: Prepare the client what to expect
 Expected length of stay immediately following surgery
 Routine postoperative o One or two drains inserted round
the incision site COVERED BY A
monitoring
BANDAGE
 Caring for a drainage tube
JACKSON-PRATT DRAINS
 ROM
 Usually in place for 2-4
 Pain management days
 Drainage should not exceed
SURGICAL MANAGEMENT
200ml in 8 hours
DRAIN
STAGES I and II
o Excessive BRIGHT RED DRAINAGE
o Surgery is the initial treatment
may indicate HEMORRHAGE
of early-stage breast cancer
o Little or no return may indicate
o For PRIMARY LOCALIZED BREAST (<2-
OBSTRUCTION of the drainage
4 CM and no metastasize)
apparatus
o Drains are generally removed
2 Surgical Options may be offered
when drainage is about 30 mL/24
1. Modified Radical Mastectomy
Hours (3rd or 4th postop day)
 Breast tissue, nipple and
lymph nodes are removed
POST OP INTERVENTIONS: MASTECTOMY
 Her arm ELEVATED
o Shoulder positioned at
appropriate angles:
 No greater than 65 degrees
of FLEXION
 45 degrees to 65 degrees of
ABDUCTION
 45 degrees to 65 degrees of
INTERNAL ROTATION
o Forearm resting on a pillow to
facilitate DRAINAGE & ADEQUATE
CIRCULATION
 Continue to elevate her affected
arm at home for 4 to 6 weeks
after surgery to help reduce
initial swelling and discomfort
 Give the patient a small foam
ball and tell her to squeeze it
with the hand on her surgical
side to help circulate lymph
fluid. (20 times)
 PAIN MANAGEMENT – Prime concern
(Demerol)
o Patient-controlled analgesia
o Medicating the patient before
activities such as:
 Turning
 Getting out of bed for the
first time is ADVISABLE
 The affected arm is kept
IMMOBILE FOR 24 HOURS to
decrease any strain on the
incision line
 HAND EXERCISES to facilitate
lymphatic flow may be started
good lymphatic flow (24 hours
after surgery)
 Squeezing a ball (rubbery)
 Opening closing fist
 Flexing and extending the
wrist and elbow
*May be done several times at
each hour*
 Instruct the patient to get out
of bed form the UNAFFECTED SIDE:
 This lessens the pain and
tension on the operative
site.
 The patient should sit with the
head of the bed at least 30
degrees
 Do not use the affected arm for:
 Venipuncture
 BP reading
 Blood sampling
 Injections
 Encourage your patient to look
at her incision
 So, she can see what’s
normal
 To monitor for signs and
symptoms of infection
 The nurse should be beside in
her first look for reassurance
and comfort
 Infection and wound problems are
rare. They’re most likely to
occur in first 2 weeks after
surgery
 Mastectomy patients SHOULD NOT
WEAR ANYTHING THAT MIGHT
IRRITATE THE INCISION UNTIL
AFTER THE WOUND HAS HEALED,
GENERALLY in 6-10 weeks.
 A patient who has undergone
axillary node dissection should
not shave the affected underarm
or apply depilatory creams or
strong deodorants to it for at
least 2 weeks postop
LYMPHEDEMA
o Results from inadequate lymph
flow with tissue swelling due to
interstitial accumulations of
plasma proteins and fluid
o RADIATION THERAPY can damage
healthy lymph nodes and vessels
→ scar → tissue → obstruction →
lymphedema
o When lymphatic system suffers
from trauma, the ability to
remove excess fluid is
compromised
o Lymphedema can develop weeks,
months or years after breast
cancer surgery
o Weeks, months, or years
LYMPHEDEMA S/S
o Swelling of the fingers or arm
o Limb heaviness and skin tightness
o “Heat” or burning or “pins and
needles” to numbness
o Less flexibility in the hands,
wrist or ankle
o Jewelry feels tight even though
they haven’t gained weight
o Feelings of tiredness, aching,
weakness
PREVENTING/MINIMIZING LYMPHEDEMA o Teach them to use the affected
Once lymphedema is established it limb for normal everyday
cannot be cured activities such as hair
o Wear no constricting or jewelry brushing, bathing
including wristwatch on affected o Avoid prolonged exposure to heat
arm (wear jewelry at the non- such as hot tubs and sauna
affected arm) (cause vasodilation)
o Place the arm in sling when the o Avoid immersing the affected arm
client ambulates initially; in hot water
Eventually, the arm can be o Sleep on her back or her
positioned at the client’s side. nonsurgical side
o Use protective hand and finger o Carry luggage or her handbag on
covering when washing dishes, her nonsurgical side
cooking, sewing o AFTER 6 WEEKS OR WHEN ARM FUNCTION
o Avoid lifting or moving heavy IS RESTORED post-operative arm
objects (6-8 weeks) and shoulder exercise are
o Avoid using bags with shoulder instituted gradually (pic mo to)
straps on the affected side  No discomfort (do arm
o The client is vulnerable to exercises). Allow edema to
secondary edema in the arm on subside first
the operated side for life.
o Heavy lifting could lead to RADIOTHERAPY
edema in the arm and trauma in o Lumpectomy or modified radical
the arm may lead to edema and mastectomy will be followed by
infection radiation
o AFTER 6 WEEKS OR WHEN ARM o It’s usually started 2-3 weeks
FUNCTION after surgery, when the wound is
IS RESTORED post-operative arm completely healed and the
and shoulder exercise are patient can comfortably raise
institute gradually her arms over her head.
 Head wall climbing o The treatments are usually done
 Rope turning 5 days a week for a total of 5-6
 Broomstick lifting weeks.
 Towel stretch o ADVERSE EFFECTS:
 Fatigue
 Skin Reactions: Redness,
burning, itching, and
dryness
 Pain

ANTI ESTROGENS

TAMOXIFEN (Novaldex, Fenahex, Gyraxen)

20 mg PO DAILY FOR 5/10 YEARS
o Tamoxifen will not allow the
estrogen to enter the cancer
cell.
The cell will feel hungry and die
o GOLD STANDARD OF BREAST CANCER
TREATMENT
o Tumor cell proliferation
declines. Tumor regress in size
and cell death
o To suppress the growth of
residual cancer cells following
TOTAL MASECTOMY, LUMPECTOMY &
IRRITATION
Adverse Effects o Nicotine can persist on INDOOR
o Hot flushes SURFACES such as:
o Fluid retention  Walls
o Vaginal discharge  Floors
o Nausea and vomiting
 Carpeting, drapes
ENDOMETRIAL CANCER THE BIGGEST
 Furniture
CONCERN:
tamoxifen acts as estrogen agonist at for days, weeks and even months.
receptors in the uterus – endometrial o Studies have revealed that
hyperplasia tobacco residue that lingers on
surfaces can react with other
chemicals in the air to form
LUNG CANCER
POTENT CARCINOGENS
RISK FACTORS
WARNING SIGNS OF LUNG CANCER
1. Cigarette smoking – 85-90%
o Any pattern in respiratory
2. Genetic patterns
3. Inhaled toxins o Persistent cough
 Tragically, SMOKING kills 10 o Sputum streaked with blood
Filipinos every hour and o Frank hemoptysis
hundreds of teenagers take up o Purulent sputum
smoking every day
o Chest, shoulder or arm pain
o Recurring episodes of:
o Lung cancer remains the
 Pleural effusion
deadliest type of cancer
 Pneumonia
globally accounting for 1.18
million people dying each year  Bronchitis
or two deaths per minute o Dyspnea, unexplained
o The top cause of cancer-related  Because of tumor, WBC are
deaths for MALES not growing normally, and
o Lung cancer is detected inly can cause infection like
during ADVANCED STAGES pneumonia
o More and more women are dying of
cancer, 2043 patients have died, Protective Mechanism of Respiratory
(Philippine Cancer Society, System
2010) o Cilia is found in the trachea
o Research has shown that WOMEN and it will contract in an
are approximately 1.5 times more upward motion a thousand times
likely to develop LUNG CANCER per minute because of the
than men unsterile environment and cause
the person to cough or sneeze
o Tobacco contains hundreds of o The vibrissae and mucus produced
carcinogens and other toxic by sinuses which is something
chemicals such as: sticky can trap foreign body
thereby stopping it from
 Nicotine
entering the lower part of the
 Benzene
respiratory system (lungs)
 Formaldehyde o If smoking, it can paralyze the
 Arsenic cilia and it will not contract
 Toluene and when you inhale the air from
the environment, it can easily
o FIRST-HAND smoke is inhaled enter the lungs and there will
directly by the smoker be plenty of WBC to phagocytize
o SECOND-HAND is the smoke exhaled it, but when you have lung
(and inhaled by others) cancer, it cannot give space for
o THIRD-HAND smoke is the residue other cells to do its action.
from second-hand smoke (can
adhere to curtains, walls,
carpet, furniture for days,
weeks, or months. Carcinogenic
when suspended in the air)
2 CATEGORIES OF LUNG CANCER impaired. Not all blood

1. SMALL-CELL LUNG CANCER (SCLC)

o Prognosis is poor (not good;
give complications)
 Prognosis: outcome or
result of the disorder
o Accounts for 18-20% of all
primary lung tumors
o Very aggressive and always
considered systemic
o Tends to spread bilaterally
o Always considered MESTATIC
 Bones
 Liver
 Brain
o Patients have POOR PROGNOSIS

2. NON-SMALL-CELL LUNG CANCER

(NSCLC)
o Represents 80% of lung cancers

NSCLC 3 MAIN HISTOLOGIC GROUPINGS

1. ADENOCARCINOMA
o Accounts for 40% of all cases of
lung cancer
o A significant number of NON-
SMOKERS develop this malignancy
o Grows in the LUNG PERIPHERY and
metastasizes widely to other
parts of the body
 Brain
 Liver
 Other lung
o The predominant type on
NONSMOKERS and the most frequent
type of lung cancer found in
WOMEN

2. SQUAMOUS CELL CARCINOMA

o Accounts for 30% of all cases of
all lung cancers
o Occurs most frequently in the
CENTRAL ZONE OF THE LUNG
o Closely linked to SMOKING
o Tends to grow locally and cause
ATELECTASIS
o Grows more SLOWLY and easier to
resect, may have BETTER
PROGNOSIS

Atelectasis-collapse of the lung

Consequence: the tumor is growing in
one part of the lung and growing in
size and it compresses the bronchi, as
well as the alveoli. The air cannot
pass by that airway making oxygen
exchange in the alveoli
will be oxygenated because part of visceral pleura
the lung has collapsed. The blood  Prevent lungs to expand
that will enter the heart has less because space was taken by
oxygen and there will be hypoxemia water and when the lungs
and lessening the amount of oxygen
in different cells of the body and
result to dyspnea and easy
fatiguability.

3. LARGE-CELL CARCINOMA
o Least common of all NSCLC
o Accounts for about 15% of all
lung cancers
o Peripheral lung tumor that is:
 Poorly differentiated
 Aggressive
 Quick to metastasize
o Survival rate: POOR

DIAGNOSTIC ASSESSMENT
Currently, no effective screening
test exist to detect LUNG CANCER
early enough to cure it

CHEST X-RAY
o To identify a lung mass or
infiltrate

SPUTUM CYTOLOGY
o Useful when the tumor is
located in the CENTRAL PART
of the lung
o 3 early-morning sputum
specimen for microscopic
examination

PERCUTANEOUS FINE-NEEDLE ASPIRATION

o When lesion sits on the
LUNG PERIPHERY
o If the mass is well
visualized on CT Scan and is
accessible

COMPUTED TOMOGRAPHY (CT SCAN)

 Can detect small-size tumors
in early stages of
development

THORACENTESIS
o Patient is with pleural
effusion (fluid in the
pleural space between the
parietal and visceral pleura)
 Pleural space has a
minimal amount of fluid
about 20 cc and the
purpose is for the
parietal pleura not to
come in contact with
 cannot expand well, less o The needle is positioned in the
blood will go the affected PLEURAL SPACE and fluid is
lung and not all blood will withdrawn with a syringe and a
be oxygenated – less oxygen THREE-WAY STOPCOCK
in the blood and that blood o Once the needle is inserted,
will be distributed to the tell patient not to move or
body (hypoxemia). The cough because it can puncture
patient cannot breathe and the pleura and air can enter and
there is shortness of have pneumothorax
breath
o Performed by a physician at the: AFTER THORACENTESIS
 Patient’s bedside o Small bandage over the needle
 Procedure room site (to prevent bleeding)
 Physician’s office o POSITION: turn the patient on the
o DURATION: less than 30 minutes UNAFFECTED SIFE FOR 1 HOUR to
o Extract pleural fluid and check allow the pleural puncture to heal
for cancer cells o CHEST X-RAY examinations are
done after the procedure to
BEFORE THORACENTESIS check for PNEUMOTHORAX
o Explain the procedure and obtain  To see if they have
informed consent punctured the pleura
o NO FASTING OR SEDATION necessary o Monitor the patient’s vital signs
o Inform the patient that movement (bleeding or dyspnea)
or coughing should be minimized
to avoid INADVERTENT NEEDLE GEFITINIB
DAMAGE to the lung or pleura IRESSA (250mg tablet)
o Most commonly used for locally
DURING THORACENTESIS or advanced metastatic non-
POSITION: small- cell lung cancer
o UPRIGHT POSITION with the arms o Suppression of cell
and shoulders raised and proliferation and promotion of
supported in an overhead table apoptosis (programmed cell
death)
o A cancer medication that
interferes with the growth and
spread of cancer cells in the
body
o Used to treat non-small cell
lung cancer

ADVERSE EFFECTS
o Diarrhea Most frequent
o Acne-like rash reactions
o Dry skin
o Nausea
o SIDE-LYING POSITION on the o Vomiting
unaffected side with the side to under STRICT STERILE TECHNIQUE
be trapped UPPERMOST
 If a patient cannot assume
sitting position, place the
patient on a side-lying
position. If right lung,
left lateral position so
that the left lung is at
the bottom and the right
lung which will be tested,
is uppermost
o The thoracentesis is performed
o INTERSTITIAL LUNG DISEASE is the
most serious adverse effect
 Acute-onset dyspnea
 Cough
 Fever
 the drug should be discontinued

o Avoid taking an antacid or

stomach acid reducer (Nexium,
Pepcid, Prevacid, Prilosec,
Zantac, and others) within 6
hours before or 6 hours after
you take Iressa
LUNG SURGERY o Remove if output is less than 50
cc

POSITIONING
o After LOBECTOMY, the patient
should be turned onto the
NONOPERATIVE SIDE to promote V/Q
matching
o When ventilation is compromised
in one lung, the patient should
be positioned with that lung in
o Wedge resection: small section DEPENDENT POSITION (bottom) to
of lung facilitate ventilation in the
o Lobectomy: one lobe other lung (has complication)
o Pneumonectomy: entire lung  Right pulmonary lobectomy
place patient in ride side-
LOBECTOMY lying position, turn
o Lesion confirmed to a single lobe patient at his back then
o PTB side-lying
o Lung abscesses or cysts o Avoid positioning patient on
o Bronchiectasis operative side if a WEDGE
RESECTION or SEGMENTECTOMY has
WEDGE RESECTION been performed
o Small, peripheral lesions  It impedes expansion of
without lymph node involvement remaining lung tissue and
o Peripheral granulomas may impede normal gas
o Pulmonary bled (air at the upper exchange
part)
POST OPERATIVE CARE: PNEUMONECTOMY
PNEUMONECTOMY o The patient may lie on the BACK
o Malignant lesion OR OPERATED SIDE ONLY
o Unilateral TB o Avoid COMPLETE LATERAL
o Multiple lung abscesses
POSITIONING after pneumonectomy
o Massive hemoptysis o Help the patient cough as soon
as he/she is CONSCIOUS and
THORACIC SURGERIES EXTUBATED
o Chest tubes are placed after
 If BP IS STABLE, help
most thoracic surgery procedures
patient to a sitting
to remove air or fluid
position
o The drainage will initially
 Use surgical pillows TO
appear BLOODY becoming
SUPPORT THE INCISION
SEROSANGUINEOUS and then SEROUS
over the first 2 or 3 days
BREATHING EXERCISES
postoperatively
The recommended procedure is
 Serosanguineous drainage:
o Contracting (pulling in) the
thin watery that is blood
abdominal muscles
tinged
o Take a slow, deep breath through
 Purulent drainage: thick the nose; this breath is held 3-
green, yellow, or brown 5 seconds
drainage o Exhaling slowly as if trying to
o Approximately 100 to 300 ml of blow out a candle
drainage will occur during first
2 hours postoperatively, which POST OPERATIVE CARE: PNEUMONECTOMY
will decrease to less then 50 o Closely monitor the amount of
ml/hour over the next several fluids and blood given to
hours prevent fluid overload
 The remaining lung needs 2-
4 days to adjust to the
increase in blood flow
 o Passive ROM arm exercises begins operatively
the evening of surgery to
prevent restriction of motion, 4
hours after recovery from
anesthesia
o POSITION: UPRIGHT OR LYING ON
THE ABDOMEN
 Elevating the scapula and
clavicle (prevent frozen
shoulder and contractures)
 Bringing the scapula as
close together as possible
 Hyperextending the arm
o Proper pain control (Demerol:
50mg/1cc)
o Passive ROM 2x every 4 to 6 hours
o 10 to 20 times every 2 hours
o Use the arm of the affected side
in daily activities
o Keep bedside table on the
operative side to encourage
reaching

SHOULDER ANKYLOSIS
o A stiffness of a joint due to
abnormal adhesion and rigidity
of the bones of the joint, which
may be the result of injury or
disease
o Teach the patient to raise the
arm on the affected side over
the head
o This exercise will:
 Restore normal shoulder
movement
 Prevent stiffening of the
shoulder joint

PNEUMONECTOMY CARE
o ROM exercises prevent adhesions
of the incised muscles
o Prevent “frozen shoulder”
o Regular use of the affected arm
and shoulder reduces the
possibility of contractures
o Medication for pain every 1-4
hours during the 1st 48-72 hours
o BLEEDING into the space occurs
within the first 36 hours
following surgery
 The volume of fluid
accumulating within the
space may be regulated for
the 1st 24 hours with a
CHEST DRAIN
 The chest drain is kept
clamped but released for 1
minute every hour
o Return to work, 6-8 weeks post
 o Advice about smoking cessation o Environmental exposure to
carcinogens
CHEMOTHERAPY
o Chemotherapy, alone or
combined with radiation, may
be used before, after or
instead of surgery in
treating lung cancer

COLORECTAL CANCER

Large Intestine (Colon) Function

o Formation of feces
o Reabsorption of water (body
gets water from the large
intestine)

PERCENTAGE DISTRIBUTION OF CANCER

SITES IN THE COLON AND RECTUM

RISK FACTORS
o High-fat diet, low fiber
 From animal fat (red
meat) increases bile
acid secretion and
anaerobic bacteria →
carcinogenic within the
bowel
 Processed meat – bacon,
ham, hotdogs, sausage,
and so on
o Inflammatory bowel disease
o Obesity
 A high body mass index
(BMI) increases the risk
of developing colorectal
cancer
 Normal BMI is 18.5 to
24.9 in men
o Sedentary lifestyle
o Alcohol use
 Consuming more than four
alcoholic drinks per
week increases the risk
o Genetic factors
 o COLON CANCER ranks fourth in 2. If you have hemorrhoids, wait
incidence and mortality among until they stop bleeding before
all cancers in the country doing the test
(Phil. Cancer Society) 3. Women shouldn’t collect stool
o It is the third most malignant samples near the time of
neoplasm in the world menstruation
o The risk of colorectal increases 4. Foods to avoid include red meat
at age 40, rising sharply (the blood it contains can turn
between ages 50 to 55 you positive)
o Those with symptoms related to COLONOSCOPY
the colon including:
 Rectal bleeding
 Anemia
 Constipation
 Abdominal pain
o Should seek medical consult
without delay

SIGNS AND SYMPTOMS

ASCENDING PORTION
o Crampy or achy abdominal pain
o Dark reddish-brown stools/black
tarry tools
o Weakness and weight loss RECOMMENDATIONS FOR EARLY DETECTION OF
o No change in bowel habits COLORECTAL CANCER
People should begin colorectal
TRANSVERSE PORTION screening earlier if they have any of
o Diarrhea or constipation the following risk factors:
o Bloody stools o Personal history of colorectal CA
o Feeling of fullness in the o Strong family history of
abdomen COLORECTAL CA or POLYPS
o Abdominal pain with cramping o Personal history of CHRONIC
INFLAMMATORY BOWEL DISEASE
DESCENDING COLON
o Sense of fullness COLOSTOMY
o Constipation/diarrhea
o Ribbonlike stool
o Bright red stools
o Fever
o Weight loss

FECAL OCCULT BLOOD TEST

o Often, this small amount of
blood is the first and sometimes
the only sign of early colon
cancer, making the fecal occult
blood test a valuable screening
tool for colorectal (colon and
rectal) cancer
1. Avoid medicines that can PREOPERATIVE CARE
interfere with the results. o Oral administration of
These include NSAIDs and blood CATHARTICS or Fleet enema
thinners which can cause minor started at least 12-24 hours
stomach bleeding, thereby giving before surgery
an abnormal test result o ANTIBIOTICS: Sulfonamides,
Neomycin or Cephalexin 12 to 48
 hours prior to surgery to
decrease bowel bacteria and
postoperative wound infection
POSTOPERATIVE CARE
o Monitoring of vital signs for
manifestations of INFECTIONS AND
SHOCK
o An NGT tube is usually in place
until peristalsis returns (to
prevent bloating); removed if
peristalsis returns
(2nd or 3rd postoperative day)
o Insertion of RECTAL TUBE for 20-
30 minutes per physician’s order
if the rectum contains gas
o EARLY AMBULATION to relieve
distention and promote
peristalsis (prevent respiratory
complications, bedsores, DVT)
 Ensure that you have given
opioids (Demerol) for pain
o PETROLATUM GAUZE over the stoma
to keep it moist followed by a
dry sterile dressing
o Monitor for color changes in the
stoma (reddish in color)
 NORMAL stoma color is PINK
to BRIGHT RED and SHINY
indicating high vascularity
 PALE PINK STOMA – low
hemoglobin and hematocrit
 PURPLE-BLACK STOMA
compromised circulation,
NOTIFY PHYSICIAN
COLOSTOMY STOMA
o A small amount of BLEEDING at
the stoma is normal
o The ideal stoma PROTRUDES
slightly to allow stool to drain
into the pouch
o Stomas SHRINK w/in 6-8 WEEKS
o COMPLETE HEALING of the wound
may take 6-8 months
o Measure the stoma once weekly
for the first 6 to 8 weeks to
ensure proper fit of the
appliance
o Swelling of the stoma is normal
for 2 to 3 weeks after surgery
COLOSTOMY OUTPUT
o Ascending colon - liquid; stool
is looser
o Transverse colon - semi-liquid;
very soft stool; pasty
o Descending colon - semi-solid
stool; solid stool
POSTOPERATIVE CARE
o Monitor the POUCH SYSTEM for
proper fit and signs of LEAKAGE
o Expect the stool is LIQUID in
the immediate posy operative
period
o Empty the pouch when it is one-
third to half full
o The colostomy begins to function
3-6 days after surgery
 A stoma does not have
voluntary muscular control
and may empty at irregular
intervals
COLOSTOMY IRRIGATION
o To regulate bowel movements at a
regular time
o To empty the colon of gas,
mucus, and feces
o Done according to the bowel
movements of the patient (ask
the patient about their bowel
movement)
o BEST TIME: the client’s former
schedule of bowel movement
 Because the bowel is ready
“trained” to evacuate at
this time
–  After breakfast,
GASTROCOLIC REFLEX occurs
 Perform irrigation
preferably 2 hours after a
meal
o Water should flow in over 5-to-
10-minute period
o 300 ml of fluid (1-liter max)
may be all that is needed to
stimulate evacuation
o Most of the water feces, and
flatus will be expelled in 10 to
15 minutes
o Schedule of irrigations
gradually progress to every
other day, every third day or
even twice a week
o Begins on the FOURTH or FIFTH
post-operative day
o AMOUNT: 500-1000ml TEPID water or
LUKEWARM water
o POSITION: sit on a toilet seat
or chair near the toilet
o Remove air by flushing it with
fluid
o Hang the container of irrigant
so that the bottom of the
solution bag is about:
 12 inches above the stoma
 18-20 inches
o Lubricate the distal end of
catheter and gently insert the
catheter into the stoma 2-3
inches
o Hang the irrigation bag so that
the bottom of the bag is at the
level of the patient’s shoulder
or slightly higher
o If CRAMPING occurs, STOP the
flow of solution and ask the
patient to take few deep breaths
o Allow 30-45 minutes for the
solution and feces to be
expelled
o If irrigant fails to return
properly
 Gently massage lower abdomen
 Take several deep breaths
 Drink some warm water
o If there is STILL NO RETURN
 Try irrigation again the
next day
o If there is NO RETURN THE 2ND DAY,
NOTIFY THE PHYSICIAN
o The client should never:
 Use more than 1000ml
 Irrigate the colostomy more
than once a day
 Irrigate the colostomy if
diarrhea is present
OSTOMY CARE  Carbohydrate beverage
o The peritoneal area should be
cleaned well with mild soap and
water
o Dry the skin well before the
skin barrier and a new pouch is
applied
o The skin should be treated with
a SKIN BARRIER to prevent skin
contact with stool
o Empty the pouch when it is about
one-third to half full

COLOSTOMY POUCH
o The best time to change the
pouching system is when the
bowel is least active, usually 2
to 4 hours after meals
o Early in the morning, before
eating or drinking, when the
bowel and kidneys will be least
active

DIETARY CONSIDERATION
o Teach patient to chew thoroughly
o Instruct to drink at least 2
quarts of fluid per day,
preferably water
o Control flatus/gas
 Intestinal gas is created
both by swallowed air and
by bacterial action on
undigested carbohydrates
o Avoid the following:
 Drinking with straws
 Chewing gum
 Smoking
 Skipping meals
o Avoid flatus-producing foods
 Beans
 Onions
 Broccoli
 Peas
  Banana SMOKING
 Carrots  Women who smoke have a 50%
 Cauliflower higher risk for developing
 Dairy products
 Eggplant
 Cabbage
o Minimize odor - avoid
odor- producing foods:
 Asparagus
 Broccoli
 Fish
 Garlic
 Eggs
 Highly spiced foods
 Carbonated beverages
 Beer
o Crackers, toast, and yogurt
can help prevent gas
o Cranberry juice, parsley &
yogurt help prevent odor
 Cranberry juice can
prevent urinary tract
infections

CERVICAL CANCER

o Affects the lowest portion of

the uterus
o Second most frequent
malignancy f the female
reproductive system
o Has its peak incidence among
women between the ages of 35
& 50 years
o Approximately 12 FILIPINO
WOMEN die of cervical cancer
every day
o It is the second most common
cancer among women in the
Philippines
o About 6,000 women are
diagnosed with the disease
each year and about 4,349 die
of the disease annually

RISK FACTORS
1. Becoming SEXUALLY ACTIVE at an
early age (before 17 years
old)
2. Having MULTIPLE SEXUAL
PARTNERS or having sexual
intercourse with a high-risk
man
 One who has multiple
partners
 One who has penile
condyloma (warts)
3. Having history of CIGARETTE
 cervical cancer than non- CERVICAL CANCER
smokers o Appears to be related to
repeated injuries to the cervix
o It is not a disease exclusive to o 90% of cervical cancer arises
PROMISCUOUS WOMEN from the SQUAMOUS CELLS
o Even those in a MONOGAMOUS  Squamous cell cancers
RELATIONSHIP have a 46% risk of spread by direct extension
developing cervical cancer to the VAGINAL MUCOSA,
o Any form of sexual intimacy will LOWER UTERINE SEGMENT,
make the person vulnerable to PELVIC WALL BLADDER & BOWEL
the infection:
o The progression occurs SLOWLY
 Kissing over years rather than months
 Necking o It takes 10-15 years from
 Oral sex infection before it develops
 Genital skin-to-skin into full-blown cancer
contact
 Anal sex WHY WOMEN?
Penetration is not a prerequisite o The PENIS is outside. Skin is
shed off regularly
4. Acquiring CHRONIC CERVICITIS o The skin of the penis is the
secondary to uterine prolapse same as the skin elsewhere-it is
5. GENITAL INFECTION caused by KERATINIZED
HUMAN PAPILLOMA VIRUS (HPV) o The cervix’s skin is not
keratinized so there’s less
HUMAN PAPILLOMAVIRUS protection
o About 99.7% of cervical cancer o During sex there are MICRO
cases are caused by HPV, a ABRASIONS
sexually transmitted that is
often without symptoms
o HPV, which causes GENITAL WARTS,
invades both sexual partners
during sexual intercourse
o The virus that lives in the body
permanently, even after
treatment, and can lie dormant
for years, only to become active
when the person’s immune system
is low
o HPV is passed on through genital
contact, most often during:
 Vaginal and anal sex
 Oral sex
 Genital-to-genital contact CLINICAL MANIFESTATIONS
o HPV can be passed on between o It’s a cancer that is hard to
straight and same-sex partners detect at the early stage
even when the infected person o There are almost always NO
has no signs or symptoms SYMPTOMS during stage 1 and
o Health problems that can be stage
caused by HPV: 2 cervical cancer
 Genital warts o Majority of the Filipino women
 Cervical cancer are diagnosed at stage 3 and 4,
 Cancer of the vulva, and when they experience symptoms
vagina such as bleeding, foul smelling
 Cancer of the penis and watery discharge and pelvic pain
anus o Pre-invasive cancer is often
 Oropharyngeal cancer asymptomatic
o Painless vaginal bleeding
  Classic symptom of INVASIVE STAGE IV B
CANCER o The cancer has spread to DISTANT
 Bleeding may start as ORGANS beyond the pelvic area
SPOTTING between MENSTRUAL  Lungs
PERIOD OR AFTER COITUS
o watery blood-tinged vaginal PAPANICOLAOU SMEAR (PAP SMEAR/TEST)
discharge that becomes dark and
foul smelling as the disease
progresses “STRONG FISHY ODOR”
o other signs of
recurrence/metastasis
 flank pain
 dysuria
 hematuria
 rectal bleeding
 unexplained weight loss

STAGING: CERVICAL CA

STAGE 0
o Superficial
o Found only on the layer if cells
lining the cervix o 95% ACCURATE in detecting
o Has not invaded the deeper cervical carcinoma
tissues of the cervix o Routinely performed on women
older than 21 years or on
STAGE I younger women who are sexually
o Has invaded the cervix but has active
NOT spread anywhere else

STAGE II
o The cancer has spread beyond the
cervix to nearby areas
o II A: Still inside the pelvic
area
o II B: Has spread to the upper
part of the vagina

STAGE III A
o Cancer has spread to the LOWER
THIRD OF THE VAGINA but not to
the pelvic wall

STAGE III B
o Cancer extends to the PELVIC
WALL
o Blocks urine flow to the bladder
o Cancer has spread to the LYMPH
NODES IN THE PELVIS
STAGE IV
o The cancer has spread to nearby
organs or other parts of the
body
PREPARATION FOR PAP TEST
o Explain procedure to the patient
o Instruct the patient NOT TO
DOUCHE OR RUB BATH 24 hours
before the pap smear
o Empty her bladder before the
examination
o POSITION: lithotomy position
o A VAGINAL SPECULUM is inserted
to expose the cervix

STAGE IV A CHEMOTHERAPY
o The cancer has spread to the o Chemotherapy is given
 Bladder concurrently with RADIATION-
 Rectum
 primary treatment for localized  For male 13 though 21 years
disease of age who did not get any
or all of the shots when
they were younger
o For gay, bisexual and other men
who have sex with men
 Should receive the vaccine
through age 26 years
BRACHYTHERAPY
 Males 22 to 26 of age may
o Means “NEAR”
also get the vaccine
o RADIOACTIVE SOURCE is embedded
in the tissue cavity or inside
the vagina ACUTE MYELOID LEUKEMIA (AML)
o Adult acute myeloid leukemia
SURGICAL MANAGEMENT (AML) is a type of cancer in
o Surgery is the primary treatment which the bone marrow makes
o Preserve is the OVARIES if abnormal myeloblasts (a type of
necessary white blood cell), red blood
cells or platelets
STAGE I & II
o TOTAL ABDOMINAL HYSTERECTOMY
 Removal of the UTETUS &
CERVIX
o RADICAL HYSTERECTOMY
 The UTERUS, OVARIES,
FALLOPIAN TUBES, ADJACENT
PELVIC TISSUE, LYMPH DUCTS
& UPPER THIRD OF THE VAGINA
are removed

STAGE III & IV

o RADIATION
o PELVIC EXAMINATION
 Considered after
RADIOTHERAPY for RECURRENT
CERVICAL CANCER

PREVENTION
Cervical Cancer Vaccine is now
available
o CERVARIX (3 doses) 0, 1, 6 months
o GARDASIL (3 doses) 0, 2, 6 months

o Human Papillomavirus or HPV

VACCINATIONS are given as early
as possible, ideally, the
vaccine can be given to:
 Girls early as 9 years old
 13 through 26 years of age
who did not get any or all
of the shots when they were BLOOD CELL DEVELOPMENT
younger o A blood stem cell goes through
 Women up to 45 years old several steps to become a red
o Boys and Men blood cell, platelet, or white
 GARDASIL is recommended for blood cell
11- and 12-year-old boys o In AML, the myeloid stem cells
usually become a type of
immature
 white blood cell called 2. Remind the patient to remain
myeloblasts (or myeloid blasts) very still throughout the
o The myeloblasts in AML are procedure
abnormal and do not become 3. The preferred site: posterior
healthy white blood cells. iliac crest
Sometimes in AML, too many stem
cells become abnormal red blood
cells or platelets. These
abnormal white blood cells, red
blood cells, or platelets are
also called leukemia cells or
blasts

RISK FACTORS
o Genetic
o Cigarette smoking
o Exposure to certain chemicals
such as benzene
o Farmers exposed to pesticides 4. Performed at the patient’s
o Exposure to ionizing radiation bedside using local anesthesia
5. One half to 2ml of bone marrow
ACUTE MYELOID LEUKEMIA is aspirated
o AML is the most common form of 6. Duration: 20 minutes
adult-onset leukemia 7. Apply pressure to the puncture
o The incidence rises with age, site-adhesive tape
with the peak incidence at age 8. Ice packs may be used to control
67 years bleeding
o Patients who are older than 60 9. Bed rest for 30 to 60 minutes
years, have a more after the test
undifferentiated form if AML
COMPLICATIONS
o Bleeding
o Infection

CHEMOTHERAPY
o CYTARABINE – continuous
intravenous infusion for 7 days
(antimetabolites)
o DAUNORUBICIN – IV bolus for 3
days (antitumor antibiotic)
o A bone marrow examination is
repeated on day 14 from the
first day of chemotherapy
o If the day 14 bone marrow shows
a persistent leukemia, a second
dose is started despite severe
PANCYTOPENIA
CLINICAL MANIFESTATIONS
o Fever and infection – neutropenia
CHRONIC MYELOID LEUKEMIA
o Weakness and fatigue
o Dyspnea on exertion anemia o The chromosomes in the blood
o Pallor cells swap sections with each
o Petechiae other
o Ecchymoses thrombocytopenia o A section of chromosome 9
o Bleeding tendencies switches places with a section
of chromosome 22
BONE MARROW BIOPSY o Creating an extra-short
chromosome 22 and an extra-long
1. Obtain a written informed consent
 chromosome 9
o BCR GENE – chromosome 22
 o ABL GENE – chromosome 9 PROSTATE CANCER
o When these 2 genes fuse BCR-ABL
gene, they produce an abnormal
protein TYROSINE KINASE PROTEIN PROSTATE GLAND
o Causes leukocytes to divide o Neutralize acidic nature of
rapidly the urethra
o Gives nutrition to the semen
PHILADELPHIA CHROMOSOME for it to be highly motile

o The most common cancer among

U.S. men and the second leading
cause of cancer death in men
older than 55
o The most common cancer in men in
the UK
o ASIAN MEN have the lowest
incidence
o In the Philippines, CANCER of
the PROSTATE is the most common
overall (4.0%) and the fourth
among MALES (8.2%)
o Median survival is 52 months and
a 10-year survival is 30.74%
CML
o Tyrosine kinase promotes cancer RISK FACTORS
by allowing certain blood cells 1. Increasing age
to grow out of control 2. Ethnicity
o The tyrosine kinase caused by 3. Family history
the BCR-ABL gene causes too many 4. High FAT diet and red meat
white blood cells 5. Obesity (decreases function of
o The diseases white blood cells WBC)
build up in huge numbers, 6. Vitamin deficiencies, vit. D and
crowding out healthy blood cells E
and damaging the bone marrow 7. Exposure to ENVIRONMENTAL TOXINS
 Arsenic
RISK FACTORS  Benzene
o Exposure to high-dose radiation
o The incidence increases with AGE
age, mean age is 65 years o Most commonly appears after age
o Patients diagnosed with CML have 50
an overall median life o 64% of all cases occur in men
expectancy of 5 to 6 years over age 65
o While 90% of prostate-related
CLINICAL MANIFESTATIONS cancer deaths occur in men over
Excessive
o Shortness of breath volume of
age 65
o Confused leukocytes
inhibits ETHNICITY
blood flow o The second most common risk factor
through the o BLACK MEN have a threefold risk
capillaries of developing prostate cancer
than white men
o Splenomegaly, left quadrant pain o A study of healthy young men
o Abdominal fullness that circulating testosterone
o Hepatomegaly levels were 15% higher in
o Decreased appetite, weight loss African- Americans than in
whites
  They note that huge amounts coupled with urinary symptoms
of androgens are required may indicate METASTASIS
to induce prostate cancer

FAMILY HISTORY
o FATHER-to-SON is increased 2.5
times
o The relative risk between
BROTHERS is increased to 3.4
times
o There is also risk associated
with the increasing number of
FIRST- DEGREE relatives
diagnosed with prostate cancer

HIGH FAT DIET

o African American men were more
likely to be obese, which is
defined as having a BMI of 30 or DIAGNOSTIC STUDIES
more o DIGITAL RECTAL EXAM (DRE)
o Hypercholesterolemia, o PROSTATE SPECIFIC ANTIGEN (PSA)
hyperlipidemia, have been linked
with an increased risk of PROSTATE SPECIFIC ANTIGEN (PSA)
prostate cancer o The overall aim of PSA testing
is to recognize LOCALIZED
LYCOPENE PROSTATE CANCER when potential
o Consuming a diet high in curative treatment can be
lycopene, especially tomatoes provided
has been shown to be beneficial o The SINGLE MOST POWERFUL BLOOD
o Potent antioxidant that may TEST for identifying the
reduce risk of cancer presence of prostate cancer at a
time when the cancer is curable
CLINICAL MANIFESTATIONS o PSA is not a specific tumor marker
o Prostate cancer is often o Elevated PSA may also be the
asymptomatic result of:
o Back pain  BPH
 Caused by metastatic spread  OLDER AGE
usually to the bones  INFLAMMATION
 First sign of prostate  EJACULATION
cancer o Normal value: 0 and 4 ng/mL
o Weak urinary stream o If PSA is greater than 10ng/ml
o Frequent urination there is about a 50% chance of
o As cancer spreads to the BONES prostate cancer
(a common site of metastasis)
the first sign of prostate DIGITAL RECTAL EXAM (DRE)
cancer before the appearance of o KY jelly as a lubricant
any other local symptoms
o Lateral Decubitus (sims) position
o Pain can become severe, / dogstyle???
especially in the BACK and the (sorry, idfk what
LEGS because of compression of to call this :<)
the SPINAL CORD and the
destruction of bone

o Pain or burning during urination

o Urinary retention
o Inability to urinate
o PAIN in the LUMBOSACRAL area
that radiates down to the HIPS
or LEGS
DIAGNOSTIC STUDIES
o A hard, nodular, irregular
prostate is suggestive of
carcinoma

RADICAL PROSTATECTOMY
o Used when tumor is confined to
the prostate
o Surgical removal of the
prostate, seminal vesicles, tips
of the vans deferens, the
surrounding fat, nerves, and
blood vessels
o ADVERSE REACTIONS
1. Sexual impotence
2. Urinary incontinence
IODINE-125 SEEDS
- Pelvic floor muscle
o Are placed permanently and
training
recommended for patients with a
- Lifestyle changes
life expectancy of at least 10
EXTERNAL BEAM RADIATION years
o Treatment sessions last o Prostate volume of less than 50ml
approximately 15 minutes o No previous prostate surgery
o Performed 5 days a week over 4 o Permanent implants are
to 6 consecutive weeks relatively low-energy sources,
o Impotence in 10%-30% of men and therefore have limited
tissue penetration. A well-done
BRACHYTHERAPY implant will treat the prostate
and the surrounding few
millimeters of adjacent tissue

Special considerations
o Close, prolonged contact
(sitting in the lap) with young
children should be limited to 20
minutes per hour for the first
two months after the procedure
o It is safe to sleep in the same
bed if your partner/spouse is
NOT PREGNANT
o If your partner/spouse is
PREGNANT, separate sleeping
arrangements will be necessary
for 2 months
o The patient should avoid close
contact with pregnant women and
infants for up to 2 months
o Straining urine for seeds
o Use of condom during sexual
intercourse for 2 weeks after
implantation to catch any seeds
that pass through the urethra
GOALS OF RADIATION THERAPY  Rectum
1. CURE for patients with CARCINOMA  Vagina
OF THE:  Brain
 Skin o When the implants are removed,
 Vocal cords no radioactivity is left in the
2. CONTROL of the disease of cancer body
 Given preoperatively to o During the time the implant is
reduce the size of the in place, staff entering the
tumor room are exposed to gamma rays
 Given postoperatively to and must take precautions
destroy any remaining tumor
cells (lumpectomy) SAFETY MEASURES
3. PALLIATION o Client is places in a PRIVATE ROOM
 To control the distressing o STANDARDIZED SIGN is placed on
symptoms of cancer door to designate the room as a
 To relieve symptoms such as RADIATION ROOM
pain and destruction o PREGNANT NURSES should not care
for these clients
RADIATION o Do not allow CHILDREN YOUNGER THAN
o Considered local therapy. Only 16 years of age to visit
the tissues in the radiation o Health care personnel LIMIT TIME
path are affected SPENT in the room and LIMIT
o Therefore, this type of therapy DISTANCE from the source of
is most successful when tumors radiation
have not metastasized beyond a o Limit each visitor to ONE-HALF
local region HOUR PER DAY. Be sure visitors
o Small doses of radiation are are at least SIX FEET from the
given on a daily basis for a set source
period of time o Leave all trash, linens and food
o This method allows multiple trays in the room
opportunities to destroy cancer o Upon living the room, remove
cells while minimizing damage to gloves and place them in the
normal tissues trash receptacles inside the
room
INTERNAL RADIATION THERAPY o Radiation Safety surveys all
o Three key principle for working materials before they leave the
with radiation are distance, room
time, and shielding o After leaving the room, wash
o Exposure time generally should your hands
be limited to 30 minutes of o In the event a source becomes
direct care per 8-hour shift dislodges, notify the Radiation
o Remaining 6 feet from the client Oncology resident on call
would reduce exposure as immediately
compared to standing 3 feet o Do not permit others to enter the
away, but is not the recommended room until the source is secured
course of action o Do not attempt to handle a
dislodged implant or applicator,
SEALED BRACHTHERAPY unless you are trained to do so
o Needles, seeds, wires, or o Never touch the radioactive
catheters containing the source with BARE HANDS. In the
radioactive source are implanted rare instance that it is
directly into the tumor DISLODGED, use a long-handles
o Used in treatment of cancers of FORCEPS to retrieve it
the o Once the treatment is completed
 Tongue and the implant is removed, the
 Cervix patient is no longer radioactive
 Prostate and present no hazard
 Breast
CLIENT EDUCATION FOR EXTERNAL CELL CYCLE
RADIATION
1. Wash the irradiated area GENTLY Go PHASE
each day with MILD SOAP AND o RESTING PHASE
WATER o Cells conduct their everyday
2. Take care not to remove the activities such as:
MARKINGS that indicate exactly
 Metabolism
where the beam of radiation is
 Impulse conduction
to be focused
3. Use your HAND rather than a  Secreting
washcloth to be more gentle o Cells become mitotically DORMANT
4. Dry the irradiated area with o They do not replicate and are
PATTING MOTIONS not active participants in the
5. Use no POWDER, OINTMENTS, cell cycle
LOTION, or CREAMS, on the skin o Cells remain in G0 for days,
at the radiation site, unless weeks, or even years
prescribed by the radiologist
6. Avoid exposure of irradiated G1 PHASE
area to the SUN. avoid HEAT o The cell manufactures the enzyme
EXPOSURE needed for DNA synthesis such
7. Effects of radiation to skin: as:
REDNESS, TANNING, PEELING,  RNA
OTCHING & DECREASED PERSPIRATION  Proteins
o 18 hours
CHEMOTHERAPY
o Considered systemic therapy and S-PHASE
is used as primary therapy or o DNA replication occurs in the
adjuvant therapy for cancers preparation for cell division
that may not be confined to a o Lasts 10 to 20 hours
localized body area
o Because chemotherapy is G2 PHASE
systemic, it circulates through o Specialized DNA proteins and RNA
many body areas and can harm are synthesized needed for
cancer cells that may be some mitosis
distance from the primary o Lasts for 3 hours
treatment
o Usually scheduled every 3 to 4 M-PHASE
weeks o Cell division
o On average, 4 to 12 times o Mitosis
o The IV route is the most o Lasts for 1 hour
preferred route for chemotherapy
CHEMOTHERAPY
NADIR o Chemotherapeutic drugs are much
o The time after chemotherapy more toxic to tissues that have
administration when the white a high growth fraction than
blood cell or platelet count is tissues that have a low growth
at the lowest point fraction
o For most myelosuppressive o Most cytotoxic agents are more
agents, the nadir occurs within active against proliferating
7 days after drug administration cells than against cells in G0
o Knowledge of blood count nadirs o Proliferating cells are
help to predict when the client especially sensitive to
is at greatest risk for chemotherapy because CYTOTOXIC
infection and bleeding drugs usually act by disrupting
either DNA synthesis or mitosis
o These drugs are also toxic to
normal tissues that have a high
growth fraction:
 Bone marrow
 Hair follicles
  GI epithelium ANTIMETABOLITES
 Sperm forming cells o These drugs kill cancer cells
o The goal of cancer chemotherapy blocking synthesis of DNA and RNA
is to decrease the size of the o They’re most effective in the S-
neoplasm so that the human phase of the cell cycle
immune system can deal with it o Cell cycle phase-specific
o Antineoplastic drugs are often o METHOTREXATE (EMTHEXATE, ZEXATE)
given in COMBINATION so that  MYELOSUPPRESSION most
they can affect the cells in severe 7-14 days after dose
various stages of the cell cycle  GI ULCERATION
 KIDNEY IMPAIRMENT
CELL CYCLE-SPECIFIC o FLUOROURACIL (FLUROBLASTIN)
o Drug is selectively toxic when  Bone marrow suppression
the cell in is a specific phase
 Stomatitis
of growth
 Alopecia
o Schedule-dependent drugs
o Malignancies most amenable to o If the total WBC count is <2000,
CCSC are those that proliferate place in PROTECTIVE ISOLATION to
rapidly prevent systemic infection
o Cells that are “RESTING” in G0
will not be harmed ANTITUMOR ANTIBIOTICS
o These drugs interfere with
CELL CYCLE-SPECIFIC ANTINEOPLASTIC cellular DNA, disrupting it and
DRUGS causing cell death
o Antimetabolites o Because of poor GI absorption,
o Mitotic Inhibitors they are all administered
o Antineoplastic Enzymes parenterally, almost always IV
o Topoisomerase I Inhibitors o Classified as CCNS drugs
o DOXORUBIBICIN (ADRIBLASTINA RD,
ADRIMYCIN)
CELL-CYCLE NONSPECIFIC
o Drugs can act during any phase  CARDIOTOXICITY
- Assess cardiac function:
of the cell cycle including G0
ECG, ECHO, palpitations,
o CCNC can increase cell kill when
dyspnea
combined with CELL-CYCLE
SPECIFIC drugs  EMETIGENIC
- Administer antiemetic 30 to
CELL-CYCLE NONSPECIFIC ANTINEOPLASTIC 60 minutes before
DRUGS chemotherapy
o EXTRAVASATION during IV injection
o Alkylating Agents
o Antitumor Antibiotics  Give the drug into the
tubing of a freely flowing
IV infusion
COMBINATION CHEMOTHERAPY
1. Suppression of drug resistance - 0.9% sodium chloride or
2. Increased cancer cell kill - 5% glucose solution
3. Reduced injury to normal cells  For not less than 3 minutes
and not more than 10
minutes
ALKYLATING DRUGS
o These drugs kill cancer cells by
EXTRAVASATION
inhibiting DNA synthesis
o Use a DISTAL VEIN, avoid small
o They are effective in all phases
veins on the wrist
of the cell cycle, including the
o Never use an existing line
RESTING PHASE
unless it is clearly open and
o One or more ALKYLATING AGENT is
running well
included in almost every
o Check site frequently and ask
combination chemotherapy regimen
patient to report any discomfort
in the area
 o Leakage of infused substance 3. Administer drugs in a SAFE,
into the vasculature into the UNHURRIED environment
subcutaneous tissue
o This leakage of chemotherapy can CHEMOTHERAPY SPILLS
result in significant tissue
destruction and complication SPILL ON HARD SURFACE
o Extravasation during IV o Restrict the area of the spill
injection may produce: o Put on a:
 Thrombosis  Protective gown
 Local pain  Gloves
 Sever cellulitis and  Goggles
necrosis
 If POWDER SPILL, a
o Drug infusion should be
RESPIRATOR MASK
immediately stopped
o Place ABSORBENT PADS gently on
o Apply ice cap and notify the
the spill, CAREFUL NOT TO TOUCH
physician
THEM
o Place the saturated absorbent
MITOTIC INHIBITORS pads in the waste bag (double
o Interfere with the ability of a bags)
cell to divide o Clean surface with ABSORBENT
o They block or alter DNA synthesis TOWEL + DETERGENT sol., rinse
o Drugs that kill cells as the with CLEAN TAP WATER
process of MITOSIS o Wipe dry
o They work in the M-phase of the
cell cycle to prevent cell SPILL ON PATIENT/PERSONNEL
division o Immediately remove any
o Cell-cycle-specific agents contaminated protective garments
o VINCRISTINE (ONCOVIN, VINCASAR) or linen
 This drug is BONE MARROW o Wash the affected area of skin
SPARING with soap and water
 It is safely combined with o Notify the physician if the drug
drugs that suppress bone spill on the patient
marrow o Place all contaminated materials
in double-bagged waste disposal
CHEMOTHERAPY bags
o Clinical studies have indicated o Discard the waste bags and
that many chemotherapeutic contents in an approved
agents are: container
 Carcinogenic o Wash hands thoroughly with soap
 Mutagenic and water
 Teratogenic
EYE EXPOSURE
SAFE HANDLING GUIDELINES o Immediately flood the affected
1. Personal Protective Equipment eye with water for at least 5
includes: minutes
 Gloves o Follow-up care with a clinical
- Should be changed every 30 eye exam
minutes during preparation
and administration o All personnel who handle BLOOD,
 Gown – closed front, long VOMITUS, or EXCRETA from
sleeves, knit cuff patients who have received
 Face shield chemotherapy within the previous
2. Place a PLASTIC-BACKED ABSORBENT 48 hours should wear DISPOSABLE
PAD under the tubing during SUGICAL LATEX GLOVES and GOWNS
administration to catch any which are discarded
leakage appropriately after use
o Linen contaminated with
chemotherapeutic drugs, blood,
vomitus, or excreta within
the prior 48 HOURS should be
places
 in a specially MARKED,
IMEPRVIOUS LAUNDRY BAG
SIDE EFFECTS OF CHEMOTHERAPY
o Nausea and vomiting
o Emaciated
o Acute nausea and vomiting occur
within 1 to 2 hours of treatment
and last approximately 24 to 48
hours
o Nausea and vomiting after the
initial 24 hours of treatment is
called DELAYED OR PERSISTENT
NAUSEA AND VOMITING
1. Administer an ANTIEMETIC
least an hour before starting
chemotherapy
 To be effective,
antiemetics must be taken
as prescribed for 72 hours-
even in the absence of
symptoms
2. Patient’s room is pleasant,
odorless, and comfortable
3. Distractions such as music or TV
are available
4. Keep mints, lozenges, and
saltine crackers on hand
5. Avoid CAFFEINE, and AROMATIC,
RICH, SPICY or FATTY foods
6. Six small meals instead of 3
normal meals
7. Brush teeth before and after
meals and at bedtime
8. Don’t eat or prepare food when
nauseated
Bleeding Precautions
o No flossing and use of soft
bristle toothbrush
o Apply pressure for 8-10 minutes
for accidental injuries
o Do not allow patient to fall or
have accidents. Clear the room
or house of clutters (broom,
shoe, rags, slippery floor)
o Do not take NSAIDs like aspirin
(GI irritant)
o Do not use shaver
o Avoid invasive procedures (no
IMs)
o If with IV, always monitor if
there is bleeding at the site of
insertion
NEUTROPENIA
o Normally, the mature segmented
neutrophils (“segs”) are the
major population of circulating
leukocytes, constituting 55% to
70% of the total white blood
cell count
1. Good handwashing before contact
with the patient
2. Use ASEPTIC TECHNIQUE when
performing any invasive
procedure
3. Mouth care and washing of the
axillary and perianal regions at
least every 12 hours
4. Limit the number of health care
at personnel entering the patient’s
room
5. Use of MASK
6. Private room
7. All visitors will have to wear
mask, gown, and gloves
8. SAFE FOOD HANDLING PRACTICES
 Prompt and appropriate food
storage
 Use of LEFTOVERS within 1 to
2 days
 Avoidance of public salad
bars
 Use of safe drinking water
supplies
 Fresh fruits and vegetables
are known to be frequently
contaminated with:
- E. coli
- Klebsiella Species
- Pseudomonas Aeruginosa
- Staphylococcus
LEUKOPOIETIC GROWTH FACTOR
o FILGRASTIM (NEUPOGEN)
 Acts on cell in bone marrow
to increase production of
NEUTROPHILS
 It enhances phagocytic and
cytotoxic actions of mature
neutrophils
o ADVERSE EFFECTS
 Bone pain-acetaminophen
 ↑ of plasma uric acid and
alkaline phosphate
 Long-term therapy →
splenomegaly
o ROUTE: IV or subcutaneous
o Prior to administration,
filgrastim can be kept at room
temperature for up to 6 hours
o Avoid VIGOROUS SHAKING
 o Filgrastim vials are for single
MEDICAL MANAGEMENT
use only
o Isotonic Saline (0.9 Normal
o Neupogen should be stored in a Saline)
refrigerator o Diuretic
o Hemodialysis for renal failure
TUMOR LYSIS SYNDROME o Sodium Bicarbonate
o Occurs when large number of o Allopurinol
NEOPLASTIC CELLS are rapidly o Glucose and Insulin infusions
killed, resulting in the release o Calcium Carbonate
of large amount of: o RASBURICASE (ELITEK)
 Potassium  Converts uric acid to
 Phosphates ALLANTOIN which is much
 Uric acid more soluble urine than
o Destruction of massive numbers uric acid
of malignant cells by  Accelerates uric acid
CHEMOTHERAPY or RADIATION removal
THERAPY
o Unexplained weight gain NURSING CARE
o Diarrhea o I.V. hydration as prescribed and
o Muscle cramps monitor fluid balance by:
o Nausea, vomiting  Weighing the patient daily
o Paresthesia
 Documenting intake and
o Weakness
output accurately
 Urine output should be in
HYPERURICEMIA balance with the intake
o Occurs 48 to 72 hours after the o I.V. hydration should begin as
initiation of anticancer therapy soon as possible, ideally 2 days
o Tumor cell destruction releases before initiating chemotherapy
NUCELIC ACIDS which are o And continue during chemotherapy
metabolized into URIC ACID and for 2 to 3 days afterward
o Needed to excrete excess
HYPERKALEMIA potassium, phosphate and uric
o Occurs within 6 to 72 hours
acid
after the initiation of o Potassium and Phosphorus
chemotherapy
restrictions are necessary
o The most deleterious of all the
 Eggs, fish, meats, poultry,
manifestations of TLS
milk, milk products
o Tumor cell destruction also
o Assess breath sounds, for signs
results in the release of
of fluid overload
POTASSIUM
o Encourage the patient to drink at
o Renal insufficiency related to
least 3L of fluid a day
hyperuricemia prevents adequate
excretion of potassium

HYPERPHOSPHATEMIA and HYPOCALCEMIA

o Occur 24 to 24 hours after the
initiation of therapy
o Phosphorus levels also rise as a
consequence of tumor cell
destruction
o Calcium ions then bind with the
excess phosphorus → calcium
phosphate salts → HYPOCALCEMIA
o The calcium-phosphate complexes
precipitate in soft tissues and
the renal tubules → acute renal
failure