Medical Surgical Transes

College of Nursing-Medical Surgery Lecture 1
Care of Clients with Problems in

Oxygenation, Fluid, Electrolyte and
Acid – Base Balance, Infectious,
Inflammatory and Immunologic and
Cellular Aberrations (Acute and
Chronic)
(NCM 112 – A/Lecture Course)
Unit 1 Nursing Care of At Risk and

Sick Adult Clients with Alterations/
Functional Anatomy of the Upper
(The Upper Respiratory System and
Respiratory System
its Disorders)
A. Nose
Lesson 1: Overview of the
Respiratory System B. Paranasal sinuses
THE RESPIRATORY SYSTEM -They lighten the skull, and they act as
resonance chambers for speech. We
Along with the cardiovascular system,
don’t really appreciate the weight of our
the respiratory system share
head.
responsibility for supplying the body with
oxygen and disposing of carbon dioxide. -They equalize pressure inside and
The organs of the respiratory system outside of our head
include the nose, pharynx, larynx,
trachea, bronchi, and their smaller Classifications:
branches, and the lungs, which contain 1. Frontal
the alveoli, or terminal air sacs. (Marieb,
2018) 2. Sphenoid
3. Ethmoid
4. Maxillary bones
C. Pharynx
- It serves as a passageway for food and
air. For digestive and respiratory
system.
Subdivided into three portion:
Nasopharynx (nasal cavity),
oropharynx (oral cavity) and
laryngopharynx (lowermost portion of
MERCURIO, Toni Ysabel R.

our pharynx that is connected to our
larynx)
• Vocal folds or true vocal cords
• Auditory tubes- which drain the
– it vibrates with expelled air
middle ear, open into the
which allows us to speak
nasopharynx. Connecting our oral
cavity to our middle ear. Also
• Glottis – slitlike passageway
responsible for equalizing
between the vocal folds
pressure in our middle ear.
E. Trachea
(Kapag ngumanga, beside uvula may two
holes connected sa middle ear; Kapg -Also called “windpipe”, has a length of
umakyat sa mataas na lugar, parang 10-12 cm or about 4in, is lined with a
nabibingi dahil nagaadjust at sa pressure na ciliated mucosa.
need maequalize sa middle ear)
• Cilia- function to propel mucus.
• Tonsils – found also in the
Loaded with dust particles and
pharynx; the pharyngeal tonsils
other debris, away from the lungs
(adenoid), palatine tonsils, and
to the throat, where it can be
lingual tonsils. Part of our
swallowed or spat out.
lymphatic system to collect debris
that needs to be disposed from
- Given the capability,
our body.
propelling or moving out
D. Larynx certain debris that should not
be entering our airway tract.
-Voicebox; routes air and food into the - Protective propellers force
proper channels and plays a role in debris, things that shouldn’t
speech be entering our airway tract.
• Thyroid cartilage – common Functional Anatomy of the Lower
called the “adam’s apple” is the Respiratory System
largest hyaline cartilage which
protrudes anteriorly A. Primary Bronchi
-The right and left primary bronchi are
• Epiglottis – “guardian of the formed by the division of the trachea
airways”; protects superior
opening of the larynx. Protective -The right primary bronchus is wider,
structure for entry of any solid shorter and straighter than the left; also
particles into the airway tract more prone to some lodging of foreign
particularly to trachea and below object
trachea.
-It warm, cleanse and humidify air that
enters the lungs
(para maiwasan ang unwanted entry
of solid particles from mouth of
patient to airway tract)

(Ang ating mga hininga, you try to exhale in • Pleura – visceral serosa that
front of a mirror, nagpproduce ito ng moist, covers the surface of each lung; it
humidification of airway tract. has 2 forms: the parietal pleura
Without proper humidification of air, it would (outside layer) and the visceral
be very difficult for us to collect 02 and be pleura, pleural fluid yung tubig sa
transported freely and easily to our airway loob ng pleura minimal volume
tracts. only.
H2O- O2 loves to attach with our H- ions. (Hindi pwedeng masyadong Malaki ang
pleura it will cause too much pressure to our
Kapag ang panahon ay maalinsangan, may
lungs it will not allow our lungs to fully
patients who hardly breathe, it don’t easily
expand mahihirapan magexhale; it is serous
humidify their air pag mainit and
membrane and fluid filled membrane
temperature.)
If you try to do forceful inhalation, hindi natin
B. Lungs kelan naramdaman na ang lungs natin ay
-contains the terminal portion of our tumama sa ating ribs, para silang balloon na
airway tracts particularly the alveoli pumipigil na dumikit ang lungs natin sa solid
structures like ribs)
-They occupy the entire thoracic cavity
• Bronchioles – subdivisions of
except for the most central area
the primary bronchi inside the
(mediastinum)
lungs before it terminate in alveoli
• Apex – the narrow superior • Alveoli – air sacs; the only site of
portion of each lung, located gas exchange
just deep to the clavicle or
Respiratory Physiology
collar bone
• Base – broad lung area 4 Distinct Events during Respiration:
resting on the diaphragm
1.Pulmonary ventilation (inhaling and
Each lung is divided into lobes by exhaling)
fissures; the left lung has 2 lobes and
2.External respiration (gas exchange
the right lung has 3 lobes.
occurring at the level of your alveoli)
(INTERGUMENTARY SYSTEM- cutaneous
membrane or skin, mucous membrane are 3.Respiratory gas transport
all linings of the body found inside of our (transportation of gases oxygen and
body having connection with the outside CO2 to diff blood vessels in our body or
world, serous membrane ay walang all over the body; artery, veins and
connection sa labas ng skin, nasa heart din capillaries as they commonly carry our
siya (pericardium), abdominal organ life gases)
(peritoneum), sa lungs natin meron ding
serous membrane which surrounds, 4.Internal respiration (also known as
protects, cushion, prevents our lung cellular respiration or cellular breathing
structure from physical injuries and we call it that we all know that the oxygen and
pleura, self-enclosing) carbon dioxide that we keep on
exchanging in the level and inside of our

lungs must reach all cells in our body to •Total Lung Capacity – the total
continue living) volume of the lungs at maximum
inflation; sum of TV, IRV, ERV and RV
(6,000ml or air)
Mechanics of Breathing
Respiratory Sounds
1.Inspiration
• Bronchial sounds (bronchial
2.Expiration tree) air through the level of
bronchi
3.Nonrespiratory Air Movements
(Coughing, hiccups, yawning, sneezing), • Vesicular breathing sounds
allows air to move like crying, laughing (vesicles, alveoli) air through the
level of alveoli
Respiratory Volumes and Capacities
Factors Influencing Respiratory Rate
•Tidal volume – the volume of air
and Depth:
inhaled and exhaled with normal quiet
breathing (500ml), exchange of air
around 500mL
1. Physical factors (running)
•Inspiratory reserve volume – the
2. Volition (Conscious Control)
maximum volume that can be inhaled
following a normal quiet exhalation 3. Emotional factors (kapag galit
(2100-3200ml), forceful inhalation nag alit ka ang bilis mo huminga, kapag
tinakot ka hingal na hingal)
•Expiratory reserve volume - the
maximum volume that can be exhaled 4. Chemical factors (Respiratory
following a normal quiet inhalation gases such as oxygen and carbon
(1200ml), living fact the no person will dioxide)
both empty all air whether you like it or
not may matitira sa ating lungs na air Neurologic Control of the Respiratory
System (w/o nervous system, all
•Residual volume – the volume of air systems of your body will not
that remains in the lungs after forceful function)
exhalation
1.Medulla oblongata – center for
•Vital capacity – the maximum volume respiration, main source of commands
of air that can be exhaled after a for our breathing
maximum inhalation; the sum of the TV,
IRV, and ERV (4800ml) 2.Pons – control rate (speed) and depth
of respiration
•Inspiratory Capacity – total amount of
air that can be inhaled following normal 3.Phrenic Nerve – controls
quiet exhalation; the sum of VC and IRV diaphragmatic movement, would be
(3,600ml) found in the spinal structure, one of our
spinal nerve, without this, you wouldn’t

able to expand your lungs, because you -Also referred to as difficulty of breathing
need diaphragmatic movements, kasi (DOB) or shortness of breathing (SOB)
siya nagpapagalaw neto
-Ask the time it started and how it
4.Pneumotaxic center – controls started
pattern of respiration (E.g. Kussmaul’s,
2.Cough
type of hyperventilation related to
acidoses) -protective mechanism
5.Apneustic center – stimulate medulla -A reflex that protects the lungs from
to create prolonged and deep respiration accumulation of secretions or inhalation
of foreign bodies
Care of the Clients with Respiratory
Disorders -It results from irritation of the mucous
membranes anywhere in the respiratory
Lesson 2: Assessment of the
tract
Respiratory Functions
-Described as dry, hacking/barking,
brassy, wheezing, loose or severe
Risk Factors for Respiratory
-productive or non-productive (may
Diseases
plema or wala)
(interview the patient for risk factors)
-Ask the time it started, how it started,
1.Smoking (the single most important the frequency and characteristics
contributor to lung disease)
3.Sputum production (plema)
2.Exposure to secondhand smoke
-The reaction of the lungs to any
3.Personal or family history of lung constantly recurring irritant and may also
disease (asthma, COPD) be associated with nasal discharge
(plema)
4.Genetic makeup (cancer)
-Assess for color, odor, quality and
5.Allergens and environmental
quantity of sputum
pollutants (Exposure to them may
predispose the patients to respiratory Common characteristics of sputum with
illnesses) its associated condition:
6.Recreational and occupational i.Purulent sputum (pus-filled or may
exposure (workers in factory) nana) (thick and yellow, green or rust-
colored): bacterial infection of many
Physical Examination (IPA method)
kinds (pneumonia, TB)
(inspect, percuss, auscultate)
ii.Thin, mucoid sputum: chronic
1.Dyspnea (nea-breathig)
bronchitis or bronchiectasis (watery lang
-Most common manifestations of all yung plema)
respiratory problems

iii.Pink-tinged mucoid sputum (very -Strong gush of air; a turbulent gas flow
alarming): lung tumor from the upper respiratory airway
iv.Profuse, frothy, pink-tinged (tinubig -E.g. obstruction of epiglottis, laryngeal
ang loob ng baga): pulmonary edema tumor
v.Foul smelling sputum: lung abscess, https://www.youtube.com/watch?v=0fEy
bronchiectasis or any associated -EDHP5Q
infection
6.Clubbing of Fingers
4.Chest Pain
-Hypertrophy of tissues in nail beds
-(pulmonary in origin) May be caused by prolonged hypoxia due to a
associated with pulmonary or cardiac lung disease, (yung dulo ng nails
disease nangangapal)
-May be described as sharp, stabbing or 7.Cyanosis
intermittent, or it may be dull, aching and
-Bluish coloring of the skin indicative of
persistent, ccheck mo muna yung pain
hypoxia or due to deoxygenation of
scale
hemoglobin
-Assess for scale of pain (COLDSPA or
oCentral cyanosis – inside of the
0-10), location and intensity
mouth, tongue and lips
-sharp, stabbing, intermittent
oPeripheral / acrocyanosis –
-pain if it is subjective or objective extremities
(Review)
8.Chest Inspection / Configuration
-(Kapag di continuous baka pulmonary
a.Barrel chest
inorigin)
-Observed as a rounded, over-inflated
5.Adventitious Breath Sounds
lungs common among emphysema
a.Crackles patients, widening or the chest of the
patient becomes more round than
-Soft, high-pitched, popping sounds may
normal, common with patients COPD
indicate fluids in the lungs
particularly emphysema, because of
b.Wheezing overinflation of lungs leads to
hyperinflation of the entire lungs or the
-High – pitched; continuous; hoarse; thoracic cage
whistling
b.Pigeon chest (Bowed chest or Pectus
-Indicates obstruction or narrowing carinatum)
common among asthma and COPD
patients -common with patients Vit D deficiency
c.Stridor -It results from sternal displacement and
observed as protrusion over the
sternum, there is a protrusion of the

sternum, forward protrusion disfunction with increasing ICT),
displacement of sternum WHAXING AND WHANING, breathing
go fast and go slow, presenting irregular
c.Funnel chest (Pectus excavatum)
pattern of breathing
-Sunken appearance of the sternum
oBiot’s respiration (irregular pattern of
which may be congenital, excavation or
breathing but it will be best observed na
sternum or breastbone looks depressed
may periods of apnea, like
d.Thoracic Kyphoscoliosis maghyperventilating tas may periods na
hihinto)
-Combination of kyphosis and scoliosis
oKussmauls respiration (if there is
9.Chest Palpation hyperventilation), if the cause of
-Palpation of masses hyperventilation is respiratory acidosis
like diabetes mellitus, that will be
-Palpation of tactile fremitus (vibration kausmauls respiration (kapag related sa
made by sounds produced by lungs) acidosis)
-Palpation of thoracic excursion (flaring Diagnostic Evaluation
of thoracic cage when you ask the
patient to inhale or exhale) 1.Chest X-ray
10.Chest Percussion (we need to elicit -It can reveal an extensive pathologic
sounds and judge from that sound if its process in the lungs in the absence of
normal or not) symptoms
oResonance – low pitched hollow -Normal pulmonary tissue is radiolucent

sound heard over the lung tissue, (ang baga natin ay being passed
normal sound na dapat marinig through by radiation lumulusot ang
radiation sa ating lung fields; therefore,
oHypperesonance – very loud lower- densities produced by fluid, tumors,
pitched sound; normally not present; foreign bodies and other pathologic
presence may indicate emphysema conditions can be detected
11.Rates and Depth of Respiration -walang laman ang lungs natin dapat
oEupnea kaya madedetect ng xray kung meron
man.
oBradypnea (rate and speed)
Nursing Responsibility:
oTachypnea
i.Instruct the client on how to hold his
oHypoventilation (rate and depth) breath and to do deep breathing when
oHyperventilation procedure is being performed
oApnea (Cessation of breathing) ii.Instruct the client to remove metals

from the chest this would act as
oCheyne’s Stokes respiration distraction
(common with patients with neurologic

2.Bronchoscopy ii.Atropine and valium pre-procedure;
topical anesthesia is sprayed followed
-insertion of a rigid bronchoscope in the
by local anesthesia injected into larynx,
patient’s nose or mouth
or IM
-The direct inspection and examination
Atropine sulfate- medication given
of the larynx, trachea, and bronchi
parenterally or intravenously via spray
through a flexible or rigid bronchoscope
para maghypersalivate na yung patient
-Diagnostic use: (a) to collect secretions bago pa man yung procedure kasi baka
and (b) to determine location of magaspirate siya sa time mismo ng
pathologic process and collect specimen procedure, example of anticholinergic (a
for biopsy, to detect and identify the drug class that is against
problem parasympathetic)
-Therapeutic use: its not only to detect Hyperactive ang patient- sympathetic
the problem but also to treat the problem
-pampawala ng hypersalivation
right away
-kapag nagbigay ka ng anticholinergic,
nagbibigay ka ng kontra
parasympathetic,
Valium- Muscle relaxant- depressed the
gag reflex
Example:
iii.NPO for 6 to 8 hours
iv.Remove dentures, prostheses,
contact lenses (assignment)
Nursing interventions (After the
procedure):
i.Side – lying position
ii.Check for the return of cough and gag
reflexes before giving fluid per orem
(a) to remove foreign object and
(kung di pa nagagag bawal pa uminom
secretions, (b) treat postoperative
kasi baka masamid yan)
atelectasis, and (c) to destroy and
excise lesions iii.Watch for cyanosis, hypotension,
tachycardia, arrhythmias, hemoptysis,
Nursing interventions (Before the
dyspnea. These signs and symptoms
Procedure):
indicate perforation of bronchial tree
i.Secure consent before the procedure
3.Thoracoscopy

-right through the thoracic wall with an i.Check for iodine-allergy if with contrast
endoscope (kapag may allery sa seafoods) (may
iodine kasi yung contrast material)
-A procedure in which the pleural cavity
is examined with an endoscope wherein ii.Instruct the client to remain still
a small incisions are made into the
iii.Assess for claustrophobia
pleural cavity in an intercostals space
5.Magnetic Resonance Imaging (MRI)
-Indicated in the diagnosis of pleural
effusion (presence of many watery -hindi radiation ang ginagamit niya kundi
discharges presence of blood, pus in the magnetic field
pleura, pleural disease and tumour
staging. -A non-invasive diagnostic tool that uses
a powerful magnetic field and computer-
-Nursing Responsibility: generated pictures to image the lungs
and its associated diseases
i.Assess for shortness of breath after the
procedure which might indicate Nursing intervention:
pneumothorax (presence of air in the
pleural space, dahil sa incision) i.The patient is instructed to remove any
jewelries, watches or any metal items
4.Computed Tomography (CT) Scan
and Fluoroscopy ii.Interview if the patient has
pacemakers, metal plates, prosthetic
-provides us images in our body joints or any metallic implants
multidimensional ang xray kasi harap at
likod lang iii.The patient is instructed to be
motionless during the procedure
-production of xray films if the patient is
lying still, patient is motionless iv.Know if the patient has claustrophobia
(ano kaya ang alternate)
-kapag nagrequire ito ng movement sa
patient, it is not ct scan anymore, 6.Lung Scan
fluoroscopy na yun -pet scan
-Studies the lungs and chest via series -Following injection of a radioisotope
of x-ray in different dimensions or in given intravenously, scans are taken
motion like in fluoroscopy with a scintillation camera. Measure
-Used to assist with invasive blood perfusion through the lungs.
procedures, such as a chest needle Confirm pulmonary embolism or other
biopsy or transbronchial biopsy blood-flow abnormalities
Nursing Responsibility: -Instruct the client to remain still during

the procedure
(be watchful kasi may mga ct scan na
nagbibigay ng contrast material, iniiject it -Nagbibigay ng pic ng structure, saka
make the body structures be more yung processes
visible,)

-Di na masyado ginagamit dahil marami
na adv na procedure na hindi naman
7.Sputum examination
invasive
-Obtained for analysis to identify
Nursing Responsibility Before the
pathogenic organisms and to determine
Procedure:
whether malignant cells are present
i.Secure written consent
-used to look for microbials and cancer
malignancy ii.Check for allergies to iodine or
seafoods
MRA- kung ag MRI ay for organ and
tissues, ang MRA looks for blood iii.NPO for 6 to 8 hours
vessels
iv.Pre – op meds: atropine S04 and
-Forms of examination: (a) gross valium, topical anesthesia sprayed,
appearance, (b) sputum C&S (Culture followed by local anesthetic injected into
and Sensitivity) to help the doctor decide larynx
for the best treatment for the patient, (c)
v.Have oxygen and antispasmodic
AFB staining (acid fast baccili staining),
agents ready
(d) Cytologic examination / Papanicolau
examination when dealing with 9.Pulmonary Function Studies
malignancy testing
a.Vital Capacity
-The maximum volume of air that can be
i.Early morning sputum specimen is to exhaled after a maximum inhalation
be collected (early in the morning only)
b.Tidal Volume
ii.Rinse mouth with plain water
-The volume of air inhaled and exhaled
iii.Use sterile container with normal quiet breathing
iv.Sputum specimen for C and S is c.Inspiratory Reserve Volume
collected before the first dose of
antimicrobial (dat di muna nabigyan ng -The maximum volume that can be
antibiotic) inhaled following a normal quiet
exhalation
8.Bronchography
d.Expiratory Reserve Volume
Graphy- study, or radiopaque medium,
contrast material to visualize the body -The maximum volume that can be
exhaled following a normal quiet
-A radiopaque medium is instilled inhalation
directly into the trachea and bronchi and
the entire bronchial tree or selected e.Functional Residual Capacity
areas may be visualized through x-ray, -The volume of air that remains in the
gumagamit ng contrast lungs after normal, quiet exhalation

f.Residual volume i.Transbronchoscopic biopsy – done
during bronchoscopy
-The volume of air that remains in the
lungs after forceful exhalation ii.Percutaneous needle biopsy
10.Thoracentesis -can be done with thoracentesis, pwede
ka na magaspirate ng specimen mo na
-Aspiration of fluid or air from the pleural
pwede mong gamitin for a lung biopsy
space
iii.Open lung biopsy- open operation, the
Centesis- act of aspiration
doctor may obtain a specimen
Nursing Responsibility (Before
12.Pulse Oximetry
Procedure):
-measures oxygen saturation how much
i.Secure consent
oxygen attached to your hemoglobin
ii.Take initial VS
-A non-invasive method of continuously
iii.Orthopneic position monitoring the oxygen saturation of
hemoglobin (SaO2).
iv.Instruct to remain still, avoid coughing
during insertion of needle to avoid -Normal value: 95 to 100% (below 85%
trauma in the pleural space indicate hypoxia)
v.Pressure sensation is felt on insertion 13.Arterial Blood Gas

of needle
-Performed to assess ventilation and
Nursing Responsibility (After acid-base balance
Procedure)
-Radial artery is the common site for
i.Turn on the unaffected side to prevent withdrawal of blood specimen, sa thumb
leakage of fluid in the thoracic cavity site.
ii.Bed rest until VS is stable -halos lahat ng blood test kinukuha ang
specimen sa vein except sa ABG, kasi
iii.Check for the expectoration of blood. ieexamine din natin yung level ng
Notify the physician as it could be a sign oxygen, kasi artery carries o2
of lung trauma
-nurses must know the proper execution
iv.Monitor VS of ABG
11.Lung Biopsy -Allen’s test is done to assess for
Biopsy- testing a certain specimen of the adequacy of collateral circulation of the
body for malignancy hand, search a video, test na tinitingnan
kung ang radial artery together with
-Performed to obtain lung tissue for ulnar artery ay both patent and intact
examination to identify the nature of the because the moment that we puncture
lesion our radial artery for blood extraction, we
-Different techniques of biopsy: must have the ulnar artery beside the

radial artery still intact, dahil baka may Bicarbonate is best regulated by our
some kind of occlusion with the blood kidneys through urination.
flow
-Kapag piniga mo yung radial and ulnar
Carbon Dioxide mostly is acidic in
artery tas binitawan mo, it must return to
composition
the normal color of your palm means na
ang ABG can be safely performed Kung lungs ang may problem it could be
respiratory in nature
-10ml pre-heparinized syringe to prevent
clotting of specimen Kung kidney ang may problem it could
be metabolic in nature
-Container with ice to prevent hemolysis
of the specimen
We, nurses and medtech must know EXAMPLE: Kapag ang patient mo
that there are balance between carbon nagaacidic or nagaalkalosis e we just
dioxide, and bicarbonate know that this patient is COPD pala,
most likely the problem is respiratory in
Analysis of ABG values:
nature.
a.Ph level
Kapag naman nagaacidic or alaklinic
Normal value: 7.35 – 7.45 kasi siya ay may RSID (renal failure),
metabolic in nature
Acidosis: <7.35
Alkalosis: >7.45
Finding Solution 1.1 The Confusing
b.PaCO2 (arterial pressure of carbon
ABG
dioxide)
Most nursing students often have
Normal value: 35-45 mm Hg
difficulty interpreting arterial blood gases
Acidosis: >45 (ABGs). Puzzling often begins with
trying to remember many random rules
Alkalosis: <35 and lacking a standardized approach to
c.HCO3 (Bicarbonate) ABGs. In addition, nurses often attempt
to analyze too many components of the
Normal value: 22-26 ABG at the same time. The
Acidosis: <22 consequence is often confusion and an
incorrect interpretation leading to
Alkalosis: >26 misdiagnosis.
Two organs that balance the ph: lungs Wise and Easy Tips 1.1 Shortcuts to
and kidneys ABG Analysis
Carbon Dioxide is best regulated by the
lungs

Since you’ve known already the ABG Step 2: Remember a helpful shortcut
basic components (pH, pCO2 and reminder – Always remember the
HCO3) and their normal ranges for mnemonic ROME!
interpretation, let’s further your
Respiratory Opposite
knowledge and find answers on the
following: The CO2 is the respiratory component
of the ABG, and if it is low and the pH is
How do we identify the acid-base
high the client would experience
imbalance
respiratory alkalosis. Similar condition
(i.e. when it is a respiratory disorder or a applies to respiratory acidosis.
metabolic)?
Example:
Is there a shortcut or mnemonic to
If pH – 7.15 (↓); PaCO2 – 54 (↑); HCO3
easily remember?
– 25 (Normal);
What does it mean when our body
Therefore, relationship of alterations as
does compensation to the acid-base
supported by arrows would denote a
imbalance?
“respiratory acidosis”.
Step 1: Matching pH with CO2 or
Metabolic Equal
HCO3
The HCO3 is the metabolic component
If both pH and pCO2 values show
of the ABG. If the HCO3 is low and the
similar acid-base imbalance (i.e. both
ph is low the the client would experience
acidic or alkalinic), respiratory acid-base
metabolic acidosis. Similar condition
imbalance will result; vice versa, if both
applies to metabolic alkalosis.
pH and HCO3 values show similar acid-
base imbalance (i.e. both acidic or Example:
alkalinic), metabolic acid-base
imbalance will result. If pH – 7.58 (↑); PaCO2 – 38 (Normal);
HCO3 – 28 (↑);
Example:
Therefore, relationship of alterations as
pH – 7.30 (acidic) ║ pCO2 – 55 mm Hg supported by arrows would denote a
(acidic) ║ HCO3 – 30 mƐq/L (alkalinic) “metabolic alkalosis”.
Per condition, if both pH and pCO2 Step 3: Compensation to Acid-Base
becomes acidic therefore we say it is a Imbalance
“respiratory acidosis” The body regulates pH by using the
opposing system to balance pH. So if
Wise and Easy Tips 1.1 Shortcuts to
the pH is out of balance because of a
ABG Analysis
respiratory disorder, it will be the renal
(continuation) system that makes the corrections to
balance the pH. Conversely, if the renal
system is to blame for the pH disorder,
the respiratory system will have to

compensate. This process is called ay continuously na nagkakaroon ng
compensation. (Woodruff, 2011) problema sa aspect na yon and you
have your kidneys doing nothing at all to
Compensation may not always be
counteract the problem
complete. Complete compensation
returns the pH balance to normal. There 14.Skin Test: Mantoux Test
are times when the imbalance is too
-PPD (Purified Protein Derivative)
large for compensation to restore the pH
to normal. This is called partial -the wheal you created must be red in
compensation. terms of reaction after 48-72
More examples, including the -Intradermal : 4inches below the elbow
compensation conditions, can be found
in a pdf file entitled “6 Easy Steps to -Read after 48-72 hours after injection
ABG Analysis” that you will provided in for skin reaction
the course. -(+) Mantoux Test is induration of 10mm
DETERMINING COMPENSATION or more; but HIV positive patients, an
BETWEEN ACID-BASE IMBALANCES induration of 5mm is considered positive
already;
-(+) Mantoux test reading signifies
FULL COMPENSATION- when exposure to Koch’s bacilli, pulmonary
balancing between CO2 and HCO3 tuberculosis agent
results to normal pH levels (kapag yung
pagtatalo ng kidney at lungs at With complete and thorough execution
pagbabalanse nung dalawa ay of these assessment modalities,
nagresulta sa normal blood pH identification of the client’s illness or
sickness up to implementation of
nursing care becomes appropriate, safe
and successful. The next lesson gives
PARTIAL COMPENSATION- when
readers an overall familiarity to common
balancing between CO2 and HCO3
respiratory interventions.
results to near-to-normal pH levels
(kapag yung pagbabalanse ay If there is problem with respiratory
nagreresulta sa malapit na maging system regarding acid-base imbalance,
normal na blood pH) your kidneys must do something to
counteract or reciprocate to reverse the
problem (homeostasis), kailangan
NO COMPENSATION/ mabalanse
UNCOMPENSATED- when either CO2
Kung nagaacidosis si respiratory
or HCO3 remains normal despite the
system, your kidney must do alkalosis to
presence of an abnormal pH level
balance the issue (Compensation)
(kapag yung pasyente mo na
nagrerespiratory acidosis or alkalosis
because of a some respiratory disorder,

Self-Check 1.2 ABG Analysis and B. Face masks
Interpretation
Simple face mask
Identify the acid-base imbalance
-delivers 40-60 percent of Oxygen
(including the compensation status) of
the ABG values in each box. -regulations: 5-8 lpm
Partial rebreather mask

-delivers 60-90 percent of Oxygen
-regulations: 6-10 lpm
-rebreathes 1/3 of exhaled air
-it gives patient an opportunity to inhale
portion of air that the patient already
exhaled, pwede pa malanghap ng
pasyente yung nabuga niyang hangin,
Carbon Dioxide ang real reason kung
bakit tayo humihinga, dahil there will be
Lesson 3:Common Respiratory a rising of carbon dioxide that will
Interventions sensitized your brain to resume your
1.Oxygen Therapy (As a nurse, you breathing
must be watchful, you must be keen -May mga patient na maensure na need
observer on what are the exact oxygen nila continuous breathing kaya
concentration that must be given with binibreathe nila ang cabon dioxide
the patient, you must be knowledgeable instead
on how oxygen must be delivered to the
patient, and knowledgeable with -Carbon dioxide ang nagreresume ng
common liter flow per minute of the breathing natin and it is our Oxygen that
patient will slow down our breathing or worse
will stop your breathing
The maximum oxygen that we can
deliver to the patient is 100 percent and
10 liters per minute
Nonrebreather mask
Ambu bag- yung di talaga makakaalis
-delivers 95-100 percent Oxygen
oxygen sa patient
-regulations: 10-15 lpm
TYPES: A. Nasal Cannula
-with one-way valve entry so that no
-delivers 24 to 45 percent of Oxygen
room air or exhaled air will be
-regulations is at 2-6 lpm rebreathed

-mga patients na may hyperventilation - Auscultate breath sounds after
kasi may px na kaya naghhyperventilate the procedure
kasi marami silang CO2 sa body at
3.Chest Physiotherapy
kailangan maalis yun
-kind of technique very necessary if u
want to help the patient breathe easier
Venturi Mask like tapik tapik sa likod
-delivers 40-50 percent Oxygen -It includes three techniques: (a)
Postural drainage, (b) Percussion and
-regulations 4-10 lpm
(c) Vibration
Nursing Intervention:
d. Face tent
i.Verify the doctor’s order
-delivers 30-40 percent Oxygen
ii.Assess areas for accumulation of
-regulations 4-8 lpm mucus secretions
iii.Position to allow expectoration of
mucus secretions by gravity
e. Transtracheal Oxygen delivery
iv.Reposition the patient every 10 to 15
- delivers 30-40 percent Oxygen minutes
-regulations 4-8 lpm v.Percussion and vibration done to
Mercurial ball- indicates lpm that you loosen mucus secretions
need to deliver to the patient vi.Change position gradually to prevent
2.Tracheobronchial Suctioning postural hypotension
-Client should be in semi or high vii.Procedure is best done 60 to 90

Fowler’s position minutes before meals or in the morning
upon awakening and at bedtime
-Use sterile gloves, sterile suction
catheter viii.Provide oral car after the procedure
-Hyperventilate client with 100% oxygen 4.Incentive Spirometry

before and after the procedure -Performed to enhance deep inhalation,
-Insert 3-5” length of catheter only for especially for post-operative clients; to
suctioning prevent atelectasis
-Apply suction only during the 5.Closed Chest Drainage

withdrawal of catheter in a rotating (Thoracostomy Tube)
motion -kind of intervention that free the pleural
-Suctioning should take only 10 seconds space from accumulation of fluids like so
(maximum of 15 seconds) much watery discharges, blood, pus,

and even the presence of air, siya yung na bumula its normal. Pag bula ng bula
nagreremove non di rin pwede dahil it may mean air leak.
Kaya siya on and off dahil sa breathing
ng ptient dahil kapag umiinhale
-Performed to remove air and/or fluids nageexpand ang ating lungs,
from the pleural space nagaattempt na magpush ng secretion
down into the bottle kapag napush sa
-To re-establish negative pressure and bote syempre bubula yun
reexpand the lungs
2.If not fluctuating, consider lung re-
Types: expansion as validated by x-ray
i.One – bottle system ii.Two – bottle system
1 bottle serves as drainage and water- 1st bottle – serves as drainage
seal bottle
2nd bottle – serves as water-seal or
Sisipsip ng mga secretions coming both water-seal and suction control
from the patient’s chest particularly in (prevent entry of air in the patients
the pleural space (PLEURAL SPACE thorax) (pwede iconnect sa suction
LANG HINDI LUNGS) machine)
PLAIN NSS NILALAGAY SA BOTE B.1 Not Connected to Suction;
We make sure na yung dulo ng tube -Observe for fluctuation/intermittent
ay nasa ilalim ng tubig dahil baka bubbling in the water-seal or 2nd bottle
pumasok yung hangin sa pleural space (normal finding)
ng pasyente
B.2 Connected to Suction;
Dahil ang negative pressure they have
tendency to suck -Expect a continuous bubbling in the
suction bottle (2nd bottle)
Tip of the tube immersed 2-3cm below
NSS level -Immerse tip of CTT in the drainage
bottle (1st bottle) 2-3 cm below the NSS
Bottle kept 2-3 ft below the chest level level
so that there will be pull of gravity and
the pul of gravity would aid in the -Immerse tip of CTT in the suction (2nd
suctioning of secretions that are overly bottle) 10-20 centimer below the NSS
accumulating in the patients pleural level
space
iii.Three – bottle system
Assess for patency of the tube:
1st bottle – drainage the patient from
1.Observe for fluctuation/ intermittent abnormal secretions or discharges from
bubbling of the bottle (normal finding); pleural cavity
continuous bubbling means air leak
2nd bottle – water-seal preventing
(abnormal finding) pero okay lang kung
entry of air in the pleural space
nagkafull expansion of the lungs kaya di

3rd bottle – suction control blood vessels and there can be a certain
parts in our body that blood vessels can
Observe for fluctuation/ intermittent
be so fragile and can be ruptured if put
bubbling in the water-seal during
so much tension, RHD, cancer
respiratopm
Observe for continuous bubbling in the
suction control bottle Nursing Management
Figure 1.4 Types of a Thoracostomy 1.Sit-up, lean forward, head tilted then
Tube/ Drainage pinch soft tissues (nosebridge or
Kiesselbach’s plexus) of the nose for 5-
10minutes.
(Kapag gaya nung sa movies na
tingalang tingala, you might cause
aspiration of the blood)
2.Cold compress / ice pack
(Vasoconstricting effect of bleeding)
3.Cotton pledgets soaked in
vasoconstricting solution most of the
time is an epinephrine which is a
vasoconstricting drug
B. Rhinitis
-A group of disorders characterized by
inflammation and irritation of the mucous
membrane of the nose; may be
infectious, allergic, or inflammatory in
origin
-rhino- nose
-it is- infection
Lesson 4: Management of Patients Types of Rhinitis
with Upper Respiratory Tract
Disorders 1.Hay Fever (Seasonal or Allergic
Rhinitis)
A. Epistaxis
-It occurs during pollen seasons,
-Hemorrhage from the nose; nose panahon ng tag-lamig
bleeding
2.Perennial Rhinitis
-Caused by trauma, hpn (hypertension)
because it could be traumatic for our - It occurs throughout the year

-It is triggered by animal’s dust, feather, Pathophysiology
dander
3.Non-allergic rhinitis (Vasomotor
Rhinitis)
-Unknown etiology characterized by
abnormal vasodilation in the nasal cavity
-vasodilation cause release of many
fluids kaya nagkakasipon
-It may be due to sexual arousal due to
hormonal changes kapag heightened
libido, smoking, emotions
Causes of Rhinitis
1.Vasomotor (idiopathic, anger, sexual
arousal, smoking)
2.Mechanical (foreign body like NGT,
CSF leaks, deviated septum)
3.Chronic Inflammation (polyps,
sarcoidosis, Wegener’s granulomatosis)
4.Infection (Acute viral infection,
sinusitis, tuberculosis)
5.Hormonal (pregnancy, use of oral
contraceptives, hypothyroidism)
Inflammation ay second defense natin
Signs and Symptoms for healing, nagpproduce siya ng
histamine na galing sa WBC natin na
-Rhinorrhea (Excessive nasal discharge, nagcacause na magvasodilation kaya
runny nose) nagkakasipon. Since we call blood as
-Nasal congestion (because of the the river of life, all fluids in the body
swelling in nasal cavity) would come from nowhere but the
blood. From your plasma specifically.
-Sneezing (protective mechanism to
blow off any infectious agent) Search for the cardinal signs. (redness,
cessation of pain, warm to touch,
-Nasal pruritus (itchiness in the nose) swelling)
-Headache (if sever nasal congestion) Medical Management
(walang panggagalingan ang sipon kung 1.Pharmacologic Treatment
di dugo lang din natin)
a. Antihistamine

-block the over releasing of histamine viruses like rhinovirus, adenovirus,
from our inflammatory agents coronavirus and influenza virus
-E.g. diphenhydramine (Benadryl), Signs and Symptoms
Loratidine (Claritin), Dimetapp
-Nasal congestion
-Treats symptoms of allergic and non-
-Rhinorrhea
allergic rhinitis
-Sneezing
-Kapag may fever, give paracetamol
-Sore throat
b. Decongestants
-General malaise
-Intranasal ipatropium (Atrovent) per
nostril -Watery eyes
- de: removal -Cold sores (herpes simplex or singaw)
it would be a viral type
-free patient from congestion
Medical Management
c. Nasal (saline) spray
1.Symptomatic treatment (only for
-H20 + 1tsp or med drop of salt =
signs and symptoms, palliative
8ounces
treatment only)
d. Antimicrobial
DUE TO LACK OF CELL MEMBRANE
-If bacterial in origin; if viral just consider VIRUSES ARE HARD TO KILL. Without
bed rest, increase fluid intake and cell membrane, how do medications can
symptomatic treatment take effect?
Nursing Management a. NSAIDS (analgesics)
1. Avoid exposure to known allergens -E.g. Aspirin (antipyretic, analgesic, and
and irritants anti-inflammatory), Ibuprofen
2. Saline spray to loosen and remove -Relieves aches, general body malaise,
irritants and secretions; instruct the pains and fever in adults
client to blow the nose first before
b. Antihistamine
spraying and keep the head upright
during administration (for full absorption -Relieves form allergic reaction,
of medication) sneezing, rhinorrhea, nasal congestion
(Benadryl)
3. If infectious rhinitis is suspected,
always practice hand hygiene c. Topical (nasal) decongestants
C.Viral Rhinitis (Common Cold) d. Antimicrobial should not be used
(antibiotics or antibacterial)
-A viral infection of the nasal mucosa
caused by more than 200 different e. Vitamin C (lets help the patient boost
up their immunity)

Nursing Management ng specific time na kalian mo need
inumin, tapusin mo)
1. Instruct bed rest (conserve energy)
3. Chronic – episodes of prolonged
2. Break the chain of infection, do hand
inflammation lasting >3mos of therapy
washing (many infection can only be
transferred by certain modes of 4. Allergic – requires a known allergen
transmission)
5. Hyperplastic – can cause
Weakest link in the chain of infection to malformation of the nasal mucosa;
prevent spread of infection- MODE OF presence of polyps
TRANSMISSION
*hyperplasia- one of the many
3. Increase fluid intake classifications of cell mutations in the
body
4. Warm salt-water gargles to soothe
sore throat
5. Chicken soup may be given, if not
allergic
D. Sinusitis
- An infection of the mucous membrane
that line the paranasal sinuses which
may be bacterial, fungal, or viral in
origin; could also be an autoimmune
(self-destroying, self-infecting, it is our
immune system that attack itself) issue
5 Subtypes of Sinusitis
1. Acute – rapid-onset of infection URTI- Upper Respiratory Tract Infection
(suddenly occurring to an individual)
Swelling one of the cardinal signs in
2. Subacute – with persistent purulent or inflammatory response can cause
pus filled nasal discharge despite of edema when untreated. Kapag naipon
<3mos of therapy ang pressure sa ulo ng patient due to
sinusitis nagkakaheadache siya).
(Maraming factors kung bakit hindi Hypersecretion of mucuous membrane.
gumagaling ang patient kahit ginagamot The more that the patient experience
naman. One example is aging, baka inflammatory response. Hindi naman
tumatanda na siya kaya di ganon nagkakaron ng swelling kung walang
kalakas na immune system niya to exudation. The more na nageexudates,
combat the disorder, baka naman may the more nagkakasipon.
drug tolerance. Kaya kapag binigyan ka
Signs and Symptoms

1. Facial fullness or pressure over the 1. Meningitis
affected sinuses
2. Brain Abscess
2. Purulent nasal discharge
3. Ischemic Brain Infarction
3. Fever (Kapag may something na
4. Osteomyelitis
masakit sa katawan mo, yung pyrogens
mo ay nagooverstimulated yung body Medical Management
temperature mo)
1. Antimicrobial
4. Headache
- E.g. Amoxicillin, Ampicillin, Cefuroxime
5. Otalgia
- Used to eradicate infecting organisms
Oto- ear if bacterial in origin
Algia- pain 2. Oral decongestants or nasal saline
spray
Ear pain as our nasal cavity have
connection with our middle ear -Diphenhydramine (Benadryl)
6. Dental pain (radiating pain) 3. Heated Mist and saline irrigation
7. Periorbital edema (eye socket, a 4. NSAIDs except aspirin because it
hollow space that house our eyeballs) increases risk of developing nasal
(Kung namamaga continuously ang polyps
ating sinuses na usually sa mukha natin,
theres no way na maaapektuhan ang A. Drug Actions:
ating eyeballs) i. Bacteriostatic (to slow down the
8. Cough that worsens when in supine synthesis or production, the
manufacturing of cell membranes or cell
9. Other manifestations same with wall. Antibiotics can attack these types
rhinitis by attaching to the cell wall of your
bacteria and the synthesis of cell wall
Diagnostic Test
will be slowed down. by slowing down
1. Sinus aspirates (confirmatory for your the cell wall, para di na dumami pa. It is
sinusitis and identify the pathogen) the cell wall the protects all the
organelles in the cell) vs Bactericidal (
2. Sinus x-ray and CT scan
this kills the bacteria)
3. Sinus swab for C & S (Culture and
ii. Narrow and Broad Spectrum (they
Sensitivity)
rely to gram negative or gram positive
Sinus/ Nasal/ THROAT Swabbing measure of a particular bacteria) (who
confirms URTI while sputum exam would be more threatening between
confirms LRTI (pneumonia, pulmonary gram negative and gram positive)
tb, level of your trachea and below) Narrow (either choose who to attack
whether gram negative or gram positive)
Complications

vs. Broad Spectrum (it can attack the (maraming possibility na kaya
two) niyang iattack yung gram-positive
bacteria, pero minsan
Kapag ang bacteria walang cell wall,
hinahanarap niya parin ang gram-
mahirap patayin yan. Our medication is
negative bacteria)
made to be cell wall specific. Hindi
c. Third: less gram (+); more gram
gagana ang gamot kung hindi mahanap
(-) coverage (e.g. Ceftriaxone)
ang cell membrane nila. Kilala ng mga
gamot ang jojowain nila. Kung gram- (they have more power to attack the
negative ang napili nila, yun ay Narrow- gram-negative bacteria)
spectrum drug/antibiotic. Kung parehong
d. Fourth: good gram (-) coverage
kaya ikill, broad spectrum antibiotics
(Cefepime)
yun.
(bakit mas mahirap kill yung gram-
B. Antibacterial Classes
negative bacteria?)
i. Sulfonamide
iv. Tetracyclne
-Bacteriostatic/ broad- spectrum
-Bacteriostatic/ broad spectrum
(they can both attack both gram-positive
-Eg. Doxycycline
and gram-negative bacteria)
-Watch out: can cause permanent
- e.g. Bactrim, Cotrimoxasole
teeth discoloration from fetal
ii. Penicillins development to 8 years of age
-Bacteriostatic/ narrow-spectrum v. Macrolide
(they will be choosing with gram-positive -Bacteriostatic/ broad- spectrum
or gram- negative only)
-E.g. Erythromycin (mycin drugs)
-e.g. Co- Amoxiclav (combined
vi. Aminoglycoside
amoxicillin and clavsearch mo),
Amoxicillin -Bactericidal/ narrow- spectrum
iii. Cephalosporins (usually starts with - E.g. Gentamicin, Amikacin
letter C)
vii. Fluoroquinolones (floxacin)
-Bactericidal/ bacteriostatic
-Bactericidal/ broad- spectrum
Generations: (The higher the
generation, the more potent) -E.g. Ciprofloxacin, Levofloxacin
a. First: good gram (+) coverage viii. Carbapenems

(e.g. Cefazolin, Cefalexin) -Bacteriostatic/ broad- spectrum
(have a great capacity to kill the
gram-positive bacteria) ix. Ketolide
b. Second: good gram (+); some -A macrolide-derivative
gram (-) coverage (e.g. Cefaclor)

-Treats macrolide-resistant strep
infections
Surgical Management
1. Functional Endoscopic Sinus Surgery
2. Caldwell – Luc Surgery
-Do not chew on the affected side
-Do not wear dentures for 10 days
-So not blow the nose for 2 weeks after
removal or packing
-Avoid sneezing for 2 weeks after
surgery
3. Ethmoidectomy / Sphenoidectomy
Nursing Management
1. Stress rest periods
3 Types of Chronic Pharyngitis
2. Steam inhalation and warm compress
to relieve pressure 1. Hypertrophic – thickening and
congestion of the pharynx
3. Stop smoking
2. Atrophic – late stage of the 1st type;
4. Positioning (Semi-Fowler’s) thin, whitish and wrinkled pharyngeal
5. Nasal spray membrane
6. Explain signs of complications of 3. Chronic granular – also called

sinusitis (fever, severe headache, “clergyman’s sore throat”; characterized
nuchal rigidity by numerous swollen lymph follicles
Figure 1.5 Caldwell – Luc Procedure Diagnostic Test
E. Pharyngitis 1. Rapid Strep Test (RST)
- Inflammation of the pharynx caused by -Done by throat swabbing

either bacterial or viral infection - Do not include the tongue when
- Commonly referred to as “Sore Throat” swabbing
- Classified as either acute or chronic 2. Nasal swabs and blood cultures

pharyngitis Medical Management
Table 1.1 Common Causative Agents 1. Pharmacologic Treatment

a. Antibacterial - Can lead to RH fever, AGN, if recurrent
and untreated during childhood (Sakit sa
- E.g. Penicillin, Cephalosporin,
puso, sakit sa bato, kasi may chance na
Macrolides
mapunta sa bloodsteam)
- Administered at least 10 days to
- Viral : gradual onset, low grade fever,
eradicate infection of the oropharynx
reddened and swollen tonsils
b. Analgesics
- Bacterial : sudden onset, high fever,
- E.g. aspirin, acetaminophen with vomiting, whitish spot on throat,
gray furry tongue
- First line of intervention is to alleviate
pain (sore throat) Signs and Symptoms
c. Antitussives -Sore throat

-uncontrollable coughing - Fever
-cough suppresant -Snoring / bruxism (teeth grinding)
- Codeine, dextromethorphan -Dysphagia

(Robitussin DM)
-Mouth – breathing
2. Nutritional Therapy
-Otalgia
- Liquid or soft diet
-Bronchitis
- Cool beverages, warm liquids,
-Halitosis
flavoured frozen desserts(popsicles) to
soothe sore throat -Voice impairment
Nursing Intervention -Draining ears (luga)
1. Symptomatic management ** Peritonsillar Abscess (PTA)
2. Ice collar for sore throat AKA “Quinsy”
3. Provide rest periods s/sx: trismus (inability to open mouth);
hot potato voice (muffled voice); drooling
4. Warm saline gargles to relieve sore
saliva; odynophagia (burning, squeezing
throat
pain when swallowing)
5. Compliance on pharmacologic
Diagnostic Test
treatment especially when on antibiotic
1. Throat swab for C & S
F. Tonsillitis and Adenoiditis (what
are the difference) Medical Management
- Usually caused by Group A beta 1.Pharmacologic Treatment
hemolytic streptococci
a. Analgesics

-Advil, Acetaminophen (Tylenol) 5. Report signs and symptoms of
bleeding (frequent swallowing, or kung
b. Antimicrobial
mabago yung dumi ng pasyente)
-Penicillin, Amoxicillin, Erythromycin
6. Plenty of rest for 2 weeks
usually for 7-10 days
7. Avoid cold exposure and
Surgical Management
overcrowded places which may cause
1.Tonsillectomy / Adenoidectomy URTI
-Indicated if tonsillitis recurs 5 to 6 times G. Laryngitis

a year despite of antibiotic therapy
- Inflammation of the larynx often due to
Preop care: voice abuse, dust, chemicals, smoke or
as part of URTI
i.Assess for URTI (hindi na pwede
magsurgery baka kumalat lang yung -pinakamahirap gamutin
infection). Coughing and sneezing
- Always viral in origin
postop may cause bleeding
Signs and Symptoms
ii. Check Prothrombin time. Bleeding is a
common postop complication (more -Hoarseness or aphonia
than 15 sec, hindi maooperahan)
-Severe dry cough
Postop care:
-Painful phonation
i. Prone, head turn to side or lateral
-Husky sounds
position
-“Tickle” in the throat
ii.Oral airway until swallowing reflex
returns Medical Management
iii.Monitor for hemorrhage 1. Topical corticosteroid
iv.Promote comfort (ice collar, avoid - E.g. beclomethasone
ASA for pain)
- Reduces local inflammatory process
v.Diet (ice-cold fluids, bland foods)
2. Symptomatic treatment
Nursing management
Surgical Management
1. Avoid clearing of throat. This may
cause bleeding 1. Subtotal / Total Laryngectomy
2. Avoid coughing, sneezing, blowing of Preop care:

nose for 1-2 weeks i. Psychosocial support on the effects of
3. Increase fluid intake @ 2-3L/day procedure: loss of voice, permanent
tracheostomy, loss of sense of smell,
4. Avoid hard, scratchy foods inability to blow the nose, whistle,
gargle, etc.

ii.Establish means of communication to
be used postop
Postop care:
i.Care of tracheostomy
ii.Establish patent airway (suction as
necessary)
iii.Prevent infection (care of dressing)
Figure 1.6 Tracheostomy Set and
Placement
iv. Establish means of communication

Nursing Management
1. Rest the voice and maintain well
humidified environment
2. Increase fluid intake to liquefy and
easily expectorate secretions
3. Treat symptoms

Unit 2 Title Nursing Care of At Risk 4. Internal respiration
and Sick Adult Clients with
The diffusion of gases between the
Alterations/ Problems in Oxygenation
blood of the systemic capillaries and
(The Lower Respiratory System and
cells.
its Disorders
Lesson 1: The Respiratory
Physiology:
The upper and lower respiratory tract

system function together in transporting
vital gases in the body except in actual
gas exchange which only occurs in the
lower respiratory system, particularly in
the alveoli. This lesson will cover a more
in-depth discussion of the respiratory
physiology in which the lower respiratory
parts, specifically the primary bronchi, A. Mechanics of Breathing
left and right bronchus, bronchioles and
the lungs fields, play a major role. 1. Inspiration
THE RESPIRATORY PHYSIOLOGY 2. Expiration
A. 4 Distinct Events during 4. Nonrespiratory Air Movements

Respiration: B. Respiratory Volumes and
1. Pulmonary ventilation Capacities
The movement of air into and out of • Tidal volume – the volume of air
the lungs. inhaled and exhaled with normal quiet
breathing (500ml)
The diaphragm and intercostals
muscles promote lung expansion for • Inspiratory reserve volume –
ventilation the maximum volume that can be
inhaled following a normal quiet
2. External respiration exhalation (2100-3200ml)
The diffusion of gases between lung • Expiratory reserve volume - the
fields, particularly the alveoli and the maximum volume that can be exhaled
blood of the pulmonary capillaries. following a normal quiet inhalation
3. Respiratory gas transport (1200ml)
The transportation or exchange of • Residual volume – the volume

oxygen and carbon dioxide between the of air that remains in the lungs after
lungs and tissues. forceful exhalation

• Vital capacity – the maximum 4. Chemical factors
volume of air that can be exhaled after a
5. Aging
maximum inhalation; the sum of the TV,
IRV, and ERV (4800ml)
• Inspiratory Capacity – total
amount of air that can be inhaled
following normal quiet exhalation; the
sum of VC and IRV (3,600ml)
• Total Lung Capacity – the total
volume of the lungs at maximum
inflation; sum of TV, IRV, ERV and RV
(6,000ml)
F.Neurologic Control of the

Respiratory System
1.Medulla oblongata– center for
respiration
2.Pons – control rate and depth of
respiration
3.Phrenic Nerve – controls
diaphragmatic movement
4.Pneumotaxic center – controls
pattern of respiration (E.g. Kussmaul’s)
D. Respiratory Sounds 5.Apneustic center – stimulate medulla

o create prolonged and deep respiration
1. Bronchial sounds
2. Vesicular breathing sounds
E. Factors Influencing
Respiratory Rate and Depth:
1. Physical factors
2. Volition (Conscious Control)
3. Emotional factors

1.COPD
2.Lung distention/compressing forces
(pleural effusion or presence of fluids in
the pleural space, pneumothorax or
presence of air, hemothorax or form of
pleurisy, ascites or third spacing over
accumulation of fluids in the peritoneal
cavity or abdominal wall)
3.Chest wall disorder (Scoliosis)
4.Immobility (if you are confirmed or
diagnosed to have a lung problem, all
the more that you need to move and do
ROM)
5.Pain (Chronic and Excruciating)
(kapag may sobrang pain na unbearable
to the pain, all the vital signs ay for sure
na maaapektuhan)
6.Trauma and Surgical Procedure in the
Lungs (the patient should move and do
ROM so that it cant lead to immobility)
7.CNS dysfunction/coma (passive
exercises)
8.Duration of Anesthesia (it is very
Lesson 2: Management of Patients important to encourage the patient to
with Lower Respiratory Tract deep breathing exercises)
A. Atelectasis Signs and Symptoms (Alarming)
-Refers to closure or collapse of the -Fever : 1st clinical
alveoli; or simple “lung collapse” manifestation/universal sign
-most common complication -Cough
-it usually is a secondary problem, like -Diminished breath sounds and crackles
pneumonia or respiratory infection if not
treated -Sputum production
Causes: (their aim is to compress or -Dyspnea

to hinder our lungs from its full -Tachycardia as a compensatory
expansion w/c is dangerous for our mechanism of the heart since dapat
heart also) bilisan niya yung tibok to be able na
magfunction ang lungs well

-Pleural pain 2.Pulse oximetry
-Central cyanosis (mouth, lips, eyelids) (low oxygen saturation, <90%)
-Anxiety Medical Management
PATHOPHYSIOLOGY 1.First Line Measures
-Frequent turning on bed
-Early ambulation (esp. patients who
have surgery)
-DBE (Deep breathing exercises)
-Incentive spirometry it would exercise
full expansion of lungs)
-Coughing exercise
2.Positive – end expiratory pressure
(PEEP)
-“Pressure in the lungs above
atmospheric pressure that exists at the
end of expiration”
-(Yung pasyente pag huminga, kahit
(Lahat ng causes, pinapahirapan nila anong buga niya, may natitira pa ring
ang ating lungs sa paglabas at pressure because of residual volume)
pagpasok ng air.) -A simple mask and 1-way valve system
(Tidal volume- normal quiet breathing, that provides varying amounts expiratory
Kapag mababa ang diaphragm function, resistance, usually 5-15cm H20
theres no way that your lungs will fully -ensure that the patient will prevent the
expand or recoil) total exit of air, making all your alveoli
(If the task of your alveoli is to give O2 totally collapse, binibigay sa kanya yung
to different parts of the body, at ang aparato na yan)
sarili rin niya, kaso nahihirapan siya -hindi dapat magcollapse ang alveoli,
hence, nagkakaroon ng low alveolar kailangan may matira at matirang air
ventilation, tapos nagkakaroon ng and pressure sa patient
atelectasis)
3.Intermittent Positive Pressure
Diagnostic Test Breathing (IPPB)
1.Chest X-ray (It reveals patchy “an apparatus-controlled delivery of
infiltrates or consolidated area, or liquid positive pressure into the airway until a
forms that are visible in xray, mamuti- preset pressure is achieved”
muti yon)

-it is necessary that the inside of our (The inflammatory chemicals are
lungs is a positive pressure bradykinin, histamine, prostaglandin.
Hindi naman mangyayari yung
-It improves lung volume expansion
inflammation kung walang vasodilation.
4. CPAP Each time na ang blood vessels natin ay
nagvavasodilation, mabilis lumalabas
5. BiPAP din ang mga fluid from the inside of our
Nursing Management blood vessels, increasing capillary
permeability. Increase of fluid from the
1.Preventive Measures is the Focus blood stream into the airway tracts will
2.Review and reinforce First Line eventually become airway secretions,
Measures to prevent atelectasis kaya inuubo patient, kaya may crackles.
B. Acute Tracheobronchitis Signs and Symptoms
-infection of your trachea, going down to -Dry, irritating cough

the level of your bronchi, pwede kumalat -Scanty mucoid sputum
sa bronchioles
-Sternal soreness from coughing
-A sequel of URTI (upper respi tract
infections) that causes inflammation of -Fever
the trachea and bronchial tree -Night sweating
Causes -Headache
1.Smoking -General malaise
2.Environmental pollutants -DOB
3.Bacterial infection (S. pneumoniae, H. -Purulent (pus-filled) sputum (maputi-
influenzae, M. pneumoniae) puti yung plema)
4.Fungal infection (Aspergillus) -Blood-streaked sputum (hemophysis)
5.Viral infection (Adenovirus) Medical Management
1.Pharmacologic treatment
a. Antibiotic (if the cause is bacteria)
b. Antihistamine, usually not prescribed
(because they tend to dry the secretions
of the patient). Instead, you can give
mucolytic drugs
c. Expectorants (Robitussin)
d. Analgesics and antipyretics

2. Suctioning and bronchoscopy 3.Pneumonia in the
Immunocompromised Host
(excessive secretions and further rule
out the disease process of patient) -It occurs with the use of
immunosuppressive agents and
Nursing management
conditions like use of corticosteroids,
1. Increase fluid intake to liquefy broad-spectrum antibiotic or all of the
secretions and easily expectorate kinds of bacteria that could be killed
because of this broad spectrum (pati
2. Positioning techniques (Fowler’s good bacteria napapatay nila),
position) (allow full expansion of lungs) chemotherapy because it has the power
3. DBE and coughing exercises (if the to kill good and bad cells in the body,
patient is showing not good breathing AIDS, etc (it suppresses full functionality
rates or ventilatory pattern) of our immune system)
4. Advise adequate rest periods (to 4.Aspiration Pneumonia

conserve energy) -It refers to the pulmonary
C.Pneumonia consequences resulting from entry of
endogenous (Airway secretions), or
- An inflammation of the lung exogenous substances (contrast
parenchyma caused by infectious materials) into the lower airway tract.
agents (mycobacteria, chlamydiae,
mycoplasma, fungi, parasites, and -If the patient accidentally aspirate
viruses) and non-infectious agents (toxic secretions
gases, chemicals, foreign matter,etc.) Know your common medical
-the patient is still immune-compromised adjectives for disease causations:
Classification According to Congenital- means “at birth”

Etiology Juvenile- means “young-age onset” or
1.Community-Acquired Pneumonia “youthful”
(CAP) Nosocomial- means “hospital-acquired”
-It occurs either in community setting or Iatrogenic- means “acquired from or
within the first 48 hours of hospitalization associated with medical- surgical
-you acquired in your home procedures”, due sometimes to
negligence
2.Hospital-Acquired Pneumonia
(HAP) Autoimmune- means “Self-destructing”
-aka “nosocomial pneumonia”, occurs Idiopathic- means “unknown causation”

more than 48 hours after admission in Classification According to Degree
patients with no evidence of infection at and Site of Affectation
the time of admission
1.Lobar Pneumonia

-Infection of a substantial portion of one
or more lobes of the lungs
-Common among adults, middle age
(20-50 yrs. Old)
-Primary disease
-Common in males
-95% caused by Kleibsiella
-Entire lobe consolidation or diffue
-Limited by anatomic boundaries
-Unilateral affectation (just one like Stages of Pneumonia
would be observed having pneumonia) 1.Congestion – 1 day with marked
2.Bronchopneumonia vasodilation leading to congestion of the
lungs, airway tract will thicken thus can
-Infection distributed in a patchy fashion have heavily breathing.
or consolidation in the lung parenchyma
2.Red Hepatization – 2 days with
-Common among extreme ages (too marked exudation (coughing) or cause
young /too old) of increasing permeability wherein the
blood vessels allow a too much escape
-Usually bilateral
of the plasma from the blood stream into
-secondary disease the interstitial spaces, or open spaces,
or extracellular space and presence of
-both genders are affected
RBCs (redness)
-Caused by staph, strep, and H.
3.Grey Hepatization – 4 days with
influenzae
engulfment of bacteria by WBCs
-Scatters around small airways (wherein our WBCs will be in
hyperactivity) (e.g. macrophages,
-Not limited by anatomic boundaries
search granulocytes and agranulocytes)
Figure 2.3 Comparing Lobar and Kapag namatay ang mga WBC,
Bronchopneumonia
nagiging nana. Your pus is a collection
of your dead bacteria, and dead cells
4.Resolution – 8 days with few WBCs
on site of infection; near-to-normal lung
structures onX-rays
Manifestations
-Fever with chills

-SOB and chest pain Pathophysiology
-Signs of respiratory distress
-Cyanosis (mas maraming consolidated,
mas no gas exchange)
-Fatigability (lack of O2)
-WBC level (more than 10,000 cells,
may infection kaya tumataas)
-Cough with greenish/yellowish sputum
(discoloration in sputum is an indication
that the patient is harboring
microorganisms)
-Cough with rusty sputum (common
board exam question) (one late sign of
pneumonia) (pathopeumonic (unique)
sign)
Diagnostic Test
1.Chest x-ray
(Complication of untreated infection na
2.Sputum exam laging nagiiflammatory process,
3.CBC (reveals high WBC level) nagccause ng hypersecretions of
mucus, etc)
Kung hindi nagfafunction si alveoli due
to consolidation, the patient might suffer
from alveolar hypoventilation. Alveoli
themselves will suffer from hypoxia.
Medical Management
1.Pharmacologic treatment
a. Antibiotics
-Amoxicillin, Clarithromycin (CAP
(community-acquired pneumonia
treatment) nababago depende sa
sputum exam
-Vancomycin, 3rd and 4th
generation of Cephalosporins(HAP
hospital-acquired pneumonia treatment)

- Rimantidine, Amantidine (Viral -Overcrowding
treatment)
-Being a healthcare worker
b. Antipyretics
Signs and Symptoms
c. Antihistamine (controlling allergic
-Fever (low-grade,late afternoon)
reactions)
-Loss of appetite
-Reduces sneezing and rhinorrhea
-Easy fatigability
2. Supportive treatment
-Night sweating
a. Oxygen therapy
-Dry cough, later productive with
b. Mechanical ventilation – if more
hemoptysis
aggressive support is required
-Weight loss
Nursing Management
-Chest pain
1. Maintain patent airway
Diagnostic Test
2. Teach DBE
1. Mantoux test (Pirquet Test or PPD or
3. Proper disposal of secretions
Tuberculin Test)
4. Reinforce compliance of therapeutic
2. Sputum examination
regimen
-(+) acid fast smear
D. Pulmonary Tuberculosis
-more definitive of PTB
-Common in Ph
-3 different sputum specimen should be
-An infectious disease that affects the
collected in 3 consecutive mornings
lung parenchyma caused by
M.tuberculosis and other gram (+) acid 3. Chest x-ray
fast bacilli
Classification of PTB
- Can be transmitted via airborne droplet
a. Class 0 – no exposure; no infection
-Associated with poverty, malnutrition,
and inadequate health care b. Class 1 – with exposure; no infection
(no active infection, just exposure)
Risk Factors
c. Class 2 – latent infection ; no
-Close contact with active PTB patient infection; no s/sx; (+) PPD
-Immunocompromised status d. Class 3 – with infection; clinically
active; (+) all tests, highly communicable
-Substance abuse
e. Class 4 – with infection; not clinically
-Environment (immigration in area with
active; (+) all tests
high prevalence)

f. Class 5 – suspected disease; pending SE: side effects
diagnosis
i. Rifampicin:
SE: red orange color of body secretions,
hepatotoxicity (overmedication,
therefore your liver is in danger,
thrombocytopenia or low level of
platelets)
-Urine is observed to be in red orange
color
ii. Isoniazid (INH):
SE: peripheral neuritis or inflammation
with our peripheral nerves,
hepatotoxicity Administer Vit B6 to
prevent peripheral neuritis
iii. Pyrazinamide (PZA)
(check messenger)
SE: hepatotoxicity
(If the patient is immune-suppressed,
the M. tuberculosis is sufficient enough iv. Ethambutol
to cause an infection, kaya nagkakaron SE: optic neuritis, skin rash
ng inflammatory response, part of
inflammatory response, is phagocytes v. Streptomycin
will kill the bacteria ( yun ang work ng SE: ototoxicity, nephrotoxicity
WBC).
- Anti-TB drugs must be taken in
(Liquefaction- like exudation) combination to avoid bacterial
(Ghon tubercle- encapsulated pus resistance
formation, end products of phagocytosis - Drugs to be taken on empty stomach
Kapag may hx of PTB, meron at merong for maximum absorption
consolidated area, nana na nabulok ay 2. Oxygen therapy
titigas, nagiging peklat sab aga ng
pasyente) 3. Isolation techniques
Medical Management 4. BCG vaccination of newborn infants
- Treated primarily with 6-12 months Nursing Management
1. Pharmacologic treatment 1. Maintain airway patency
a. Anti-TB drugs (Remember mnemonic 2. Educate proper nutrition

RIPES): QUADTAB PWERA
3. Break the mode of transmission
streptomycin dahil injectible to

4. Reinforce preventive measures – Pleural Effusion – accumulation of
wear face mask, hand hygiene fluids in the pleural space
E. Pleurisy Pneumothorax – accumulation of air
in the pleural space
- Inflammation of the pleural space by
air, fluid, bacteria, or associated Types of Pleural Effusion
diseases resulting in a severe sharp,
1. Hemothorax- presence of blood in
knifelike pain. Not inside the lungs.
pleural space
-classified either pleural effusion or
2. Pyothorax / Empyema- presence of
pneumothorax
pus or purulent discharge in pleural
Signs and Symptoms space
- Pleuritic pain, usually occurring in one 3. Hydrothorax- fluid of patient is overly
side only accumulating in the pleural space
- Pleural friction rub Causes
Diagnostic Finding 1. Trauma
1. Chest x-ray 2. Thoracic surgery
2. Sputum exam 3. Positive pressure ventilation
3. Thoracentesis 4. Thoracentesis (puncturing of
thoracic well to reach pleural space and
4. Pleural Biopsy
aspirate something in it)
Medical Management
5. CVP line insertion (Central Venous
1. Analgesics (NSAIDs) Pressure, catheter inserted in our vein
most of the time the vein that we see in
2. Corticosteroids our clavicular area, until it reaches the
3. Warm or cold pack on the affected right atrium of the heart)- measures the
side RA of your heart it will reflect the overall
fluid volume status in our body.
Nursing Management
6. Emphysema
1. Turn frequently on the affected side to
splint chest wall and reduce stretching of -problem of our alveoli wherein they are
the pleura overly distended or overly inflated, kaya
nila uminhale pero nahihirapan sila
2. Splint the rib cage while coughing magexhale
3. Warm and cold application Signs and Symptoms
F. Pleural Effusion and - Sudden, sharp chest pain
Pneumothorax
- SOB

- Anxiety / restlessness of the patient will be placed with a tube
that will transfer the excessive fluid from
- Tachycardia
the pleural space into the peritoneal
- Diminished / absent breath sounds (the cavity. Once the pleural fluid reaches
more na lumalaki yung tubig, the more the peritoneal cavity, immediately it will
na lumiliit yung lungs ng pasyente, be replenished. Yung mga natapon, ay
hence, mas mahirap idetect yung mapupunta ng kidney and it will form
sounds sa ating stethoscope, mas urine.
lumalayo siya sa thoracic wall)
5. Oxygen therapy
- Increased RR (because the patient is
6. Analgesics
having hypoxia), there will be an attempt
of body to breathe in more kaya Nursing Management
nagiincrease to
1. Positioning technique – High Fowler’s
- Chest tightness position
- Chest asymmetry 2. Record thoracentesis output
- Cyanosis 3. Monitor and report ABG results (with
hyperventilation of the lungs)
- Tympanic sound on chest percussion
4. Kink tube of drainage bottle of CTT
Medical Management
when transporting patient (e.g. going to
1. Chest Tube Thoracostomy (CTT) x-ray)
(evacuate the fluid from the space , if
G. Pulmonary Edema
the patient in need of longer staying of a
tube that will evacuate the drainage, - Abnormal accumulation of fluid in the
kapag matagal gumaling ang pasyente) lung tissue, alveolar space, or both. A
severe, life-threatening condition
2. Thoracentesis- immediate
intervention -the inside of our alveoli is being filled
with fluid
3. Surgical pleurectomy- removal of
the infected parts of the pleura -“pagkakaroon ng tubig sa loob ng baga”
4. Pleuroperitoneal shunt- rerouting or -your alveoli are the actual site for gas
change the route of a fluid to one exchange
compartment to another compartment.
-problem of left-side of the heart
Pleural and peritoneum are both serous
membrane. Peritoneal fluid is -will only be showing central
continuously produced and at the same manifestations such as central
time, we still replenished them. There is respiratory signs and symptoms and
no chance that the pleura will replenish central cyanosis
as fast as peritoneal fluid. Pwedeng
tulungan ni peritoneum si pleura by Causes
lalagyan ng shunt wherein pleural space

1. CHF (Congestive Heart Failure) -Abnormal breath sounds
2. Left ventricular failure (heart failure -Central cyanosis
usually happens in the ventricles)
-Productive cough, frothy and blood-
3.Arrhythmias tinged
4. HPN (hypertension) -Confused and stuporous
5. Pericardial effusion (problem of PATHOPHYSIOLOGY
serous membrane that enclosed or
protected your heart, abnormal
accumulation of fluid in the inside of
your pericardium)
6. Fluid overload (e.g. poor monitoring of
patient in IV)
7. Multiple blood transfusion (strictly
monitored whenever they’re performed)
*They all would be caused to weaken
your heart particularly the left side
because of its work overload due to
compressing factors
*Your right side receives deoxygenated
blood, the left side engage the delivery
of oxygenated blood in our body, cells,
organs, tissues. The left side receives
blood from the lungs through pulmonary
vein
The left atrium function is to travel or to
transport or push down the blood in LA , Medical Management
the Aorta then deoxygenated blood.
1.Vasodilators and inotropic drugs
Kapag masyado ito nawork overload,
mahihirapan siya magpump ng blood - Given to improve cardiac function if the
kay aorta. Babalik at babalik siya sa LA cause is cardiac in origin
to the pulmonary vein to the lungs
-Kung nagvavaso constrict yung mga
Bear in mind: A weak left side of the arteries, dahil nagccarry sila ng
heart leads to reflux of blood into the oxygenated blood, you cannot expect
lung fields hence pulmonary edema good oxygenation to your heart
becomes imminent
-Inotropic drugs are set of medications
Signs and Symptoms that improve the strength or the pumping
-DOB

ability of our heart. Pampalakas ng tibok H. Acute Respiratory Failure
ng puso
- A sudden and life-threatening
2. Diuretics (review) deterioration of gas exchange function
of the lungs
-Given if fluid overload is the cause
Causes
-initiate an improve urination
1. Alveolar hypoventilation
Most Common Classifications
2. Diffusion abnormalities
1.) Loop Diuretics
2.) Potassium-wasting Diuretics 3. Ventilation-perfusion mismatching
3.) Potassium-sparing Diuretics
4. Shunting
4.) Thiazide Diuretics
5.) Osmotic Diuretics 4 Categories of ARF Causes
Without Potassium, you’ll lose the 1. respiratory drive
normal rhythm of our heartbeats. Kapag
naman sumobra rin ng taas yung 2. Dysfunction of the chest wall
potassium, kawawa rin yung patient 3. Dysfunction of the lung parenchyma
because it will abnormally pump fast, to
the magnitude that eventually, your 4. Other causes (post-surgical
heart will stop pumping. procedure)
3.Morphine (Opioid) Signs and Symptoms
-To reduce anxiety and control pain - Restlessness
4. Oxygen therapy - Fatigability
5. Intubation and mechanical - Headache

ventilation, in severe cases - DOB
Nursing Management - Tachycardia
1. Oxygen administration - Increased BP
2.Assisting in intubation and mechanical - Confusion
ventilation, if respiratory failure occurs
- Lethargy
3.Monitor VS especially RR when
administering Morphine (Kapag ang - Central cyanosis
pasyente nagoopioids, tingnan mo parati - Diaphoresis
ang RR, kasi SE neto ay respiratory
depression, pinapabagal ang trabaho) - Respiratory arrest
4.Restrict fluid intake if hypervolemia is Medical Management

the cause 1. Intubation and mechanical
ventilation

- To maintain adequate ventilation 4. oxygen inhalation
and oxygenation while correcting the
5. Infection
underlying cause
6. Shock
Figure 2.4 Endotracheal tube and
7. Trauma
8. Fat or air embolism
9. Systemic Sepsis
Signs and Symptoms
- Tachypnea
- DOB
- Retractions
- Central cyanosis
Laryngoscope
- Dry cough
- Crackles
Nursing Management
- Fever
1. Assisting in intubation and
- Altered LOC
mechanical ventilation
- ABGs: PaO2, PaCO2
2. Monitor level of responsiveness,
ABGs, pulse oximetry and VS Medical Management
3. Frequent turning, mouth care, skin 1. Intubation and mechanical ventilation
care and ROM exercises
2. Pharmacologic treatment
I. Acute Respiratory Distress
Syndrome (Adult RDS) a. Human recombinant interleukin – 1
receptor antagonist
- It occurs as a result of an inflammatory
trigger that initiates the release of b. Neutrophil inhibitor
cellular and chemical mediators, causing c. Vasodilators
injury to the alveolar capillary membrane
which leads to impaired gas exchange d. corticosteroids
Causes 3. Surfactant replacement therapy
1. Aspiration Nursing Management
2. Drug overdose 1. Maintain patency of airway (Oxygen

therapy, Chest physiotherapy,
3. Hematologic disorder Endotracheal intubation or tracheostomy
care, Suctioning )

2. Proper positioning technique – - Distended neck veins
Fowler’s position
- Hepatomegaly (connected and heart
3. Frequent turning to improve and liver)
ventilation and perfusion in the lungs
- Ascites
J. Pulmonary Heart Disease
- Heart murmurs
- A condition in which the right ventricle
of the heart enlarges as result of
diseases that affects lung functions and
vasculature
- Also called “Cor Pulmonale”, “Right
Heart Failure”
-peripheral manifestations or lateral
aspects of the body
- Common with COPD
-Right ventricle is very thickened, and
tend to enlarge, it will make the space of
RV less spacious, would not
accommodate sufficient amount of blood
to be pumped in the pulmonary artery
that would required oxygenation kasi
deoxygenated yan. Konti lang nakabalik Ang trabaho ni lungs ay magoxygenated
sa lungs para maoxygenate, konti lang ng blood na galling sa right side ng
din yung marereceive ni left side of the heart. If your lungs would not be
heart na oxygenated blood, kasi konti receiving sufficient amount of blood from
lang naman yung nagtravel na dugo the right side of your heart, wala tayong
from the right side magagawang maraming oxygenated
Causes blood. How would your lungs and all its
cells be expecting sufficient amount of
1. COPD oxygenated blood also. Hindi
2. Chest wall deformities masusuplyan ng baga ang sarili niya ng
oxygenated blood kasi wala siya
3. Obesity (too much fat, can put so narereceive na dugo para ioxygenate
much pressure on your heart) which will lead to lung tissue hypoxia.
4. HPN Hence, wala rin madedeliver na
sufficient amount of oxygen sa mga
5. Pulmonary embolism blood vessels, kaya nagkakaroon ng
hypoxemia. Simultaneously the pt will
Signs and symptoms
have an opposite effect which is sudden
- Edema of the lower extremities rise of the counterpart of the oxygen in

our body and that is the CO2, which we - To relieve pulmonary hypertension if
called as hypercapnia. One problem that caused by ventricular failure and
may happen is that many of your arrhythmias
arteries particularly the PA would go
b. Diuretics
vasoconstriction because of too much
CO2 in the body. Eventually, the patient - To reduce peripheral edema
would not enjoy sufficient amount of
blood flow. So much pressure and 2. Oxygen therapy
workload for the right ventricle. Kung 3. CPT (Chest physiotherapy)
laging lalakasan ni RV ang pagtibok
para mapush ang blood sa heart, 4. ET intubation and mechanical
maghahyperthrophy si RV particularly ventilation
myocardium. Kapag masyado kumapal, - If respiratory failure occurs
the space in the ventricle will lessen.
Parang exercise na kapag laging 5. Continuous pulse oximetry and ECG
nageeffort, lumalaki ang muscles or monitoring
myocardium. - To watch out for further progression
Kaya sila nagkakaedema, dahil napagod and complications of the disease
ang RV sa kakapump ng blood, Nursing Management
nagkakaroon ng returning of blood.
From the RV to the RA to the SVC or 1. Maintain airway patency
IVC. 2. Sodium and fluid restriction (All the
Pulmonary Hypertension more na magkakaroon ng fluid overload)
-Narrowed pulmonary artery, hindi 3. Provide skin care for edematous

makakapasok dugo sa PA, the blood extremities
would just stay in the RV, either they 4. Encourage compliance on the
stay or regurgitate or reflux therapeutic regimen
Medical Management K. Pulmonary Embolism
1. Pharmacologic treatment - Obstruction of the pulmonary artery or
a. Digitalis glycosides one of its branches by a thrombus (or
emboli) that originates somewhere in the
digitalis are known as positive inotropic venous system.
drug which are capable of strengthening
or increasing the strength the power of -Nabubuo ang mga blood clot kapag
the heart but they are also said to be mabagal ang agos ng dugo kaya aprati
negative chronotropic (yung gamot has ito sa veins kesa sa artery. Too much
the ability to slow down the HR), immobility may promote blood clot
improves the right side of the heeat formation.
-embolus: blood clot that has been
dislodged to one specific portion of our

blood vessels. Because usually the Medical management
blood clot is attached in the lining of our
1. Oxygen therapy
blood vessel and if its attached, we call
it thrombus, it has been detached from 2. Pharmacologic treatment
the lining of the blood vessel and freely
flows in the blood vessels, we call them a. Anticoagulant
embolus. There is a tendency that it - Heparin (2weeks) then Coumadin (3-
reaches your heart, if this reaches your 6mos)
heart, enters the right atrium, then
enters the right ventricle, and go up in b. Thrombolytics (thrombus- blood clot,
the pulmonary artery. As it branches out, lytics- dissolving of something) (-kinase)
the diameter of the arteries will be (usually via IV)
smaller, the higher the tendency that the - Urokinase, streptokinase
blood clot will get dislodged or clog, As
soon as it dislodges and cause a 3. Surgical treatment
blockage in a normal flow in your a. Surgical embolectomy (surgical
circulation in the pulmonary arteries or in removal of embolus where it is detected)
your entire body. Sa pulmonary artery
nangyayari ang pulmonary embolism b. Transvenous catheter embolectomy
Causes Nursing Management
1. Fat embolism (fatty particles may 1. Instruct early ambulation postop if

dislodged in diff arteries in the body) surgical procedure is done (promote
circulation preventing embolism)
2. Multiple trauma
2. Oxygen therapy
3. PVDs (varicose veins, DVT)
3. Do not massage the legs
4. Abdominal surgery
4. Patient teaching when on
5. Immobility anticoagulant: when heparin or
Signs and Symptoms coumadin
- Restlessness-cardinal / initial sign i. Observe for bleeding
- Dyspnea ii. Use soft toothbrush, electric razor
- Stabbing chest pain iii. Do not take aspirin with Coumadin

(Aspirin has side effect of anti-platelet
- Cyanosis effect, dinoudouble mo danger na
- Tachycardia magbleeding tendency)
- Anxiety
- Diaphoresis iv. Avoid prolonged sitting or standing
(promote blood stasis)
- Dysrhythmia

v. Stop smoking
L. Chronic Obstructive Pulmonary
Disease
- A disease state characterized by
airflow limitation that is not fully
reversible associated with abnormal
inflammatory response of the lungs to
noxious stimuli
-collective term for a long term
respiratory illness
Classification of COPD
1. Chronic Bronchitis
- Disease of the airway defined as the
presence of cough and sputum for at
least a combined total of 3mos in each
of 2 consecutive years (ikaw ay paulit
ulit na may ubo at sipon na 3 months)
2. Emphysema
- A disease of the airways characterized
by destruction of the walls of over-
distended alveo\li (normally inhaling,
abnormally exhaling)
-can be hereditary if with a1-antitrypsin
deficiency
Causes of COPD
1. Smoking
2. Passive smoking
3. Occupational exposure
(production of exudates, together with
4. RTI
mucosal edema or congestion or
5. Genetic abnormalities (chestwall narrowing of airways is filled with
deformities) secretions will put the patient to be
unable to breathe. Nagkakaron ng
hypoxia and hypercapnia. Too much
level of CO2 in the body, may lead to
pulmonary arterial hypertension)

1. Risk reduction
- STOP smoking
a. Bronchodilators
- To relieve bronchospasm and reduce
airway obstruction
- E.g. Salbutamol (Ventolin),
Aminophylline (Theophylline), Bricanyl
(Terbutaline)
b. Expectorants
Bronchial irritation- due to airway c. Antitussives (cough-suppressant)

congestion, too much production of - E.g. Codeine
airway secretions which became mucus
sputum d. Antihistamine
Disequilbrium of elastase and e. Corticosteroids

antielastase f. Antibacterial
Elastin- protein responsible for allowing 3. Oxygen therapy
our alveoli to fully inflate and recoil
-For clients with emphysema: do not
(Si alveoli kaya maginflate pero dahil sa give high 02 concentration. The drive for
destruction ng elastin, hirap na sila breathing will be depressed.
magrecoil. Nagkakaroon ng air trapping)
4. Diet : calorie, CHON, CHO
Hindi rin mapapakinabangan ang
bronchioles sa pagblow off ng CO2 kasi 5. CPT – percussion, vibration and
it has been filled with mucus, at dahil sa postural drainage (to release secretions
bronchial irriatation, it became and be easily expectorated)
congested. Surgical Management
Diagnostic Test 1.Bullectomy
1. Pulmonary Function Test -Surgical excision of bullae in a patient
2. ABGs with bullous emphysema
3. X-ray and CT scan may be performed Bullae- are enlarged airspaces that do
but rarely done not contribute to ventilation but occupy
space in the lungs (para silang
4. Screening for alpha1 – antitripsyn consolidated area)
deficiency
2.Lung Transplantation
Medical Management

Nursing Management Causes
1. Instruct pursed lip breathing (promote 1. Allergens
bronchodilation, higher the chance that
2. RTI
CO2 can be blown off)
3. Air pollution
2. Oxygen therapy
4. Active / passive smoking
3. Plan and implement adequate rest
periods Signs and Symptoms
4. Increase fluid intake - Wheezing
5. CPT as necessary - Cough
6. Avoid SMOKING - DOB
7. Proper positioning – semi or high - Chest tightness
Fowler’s position
- Tachypnea
J. Bronchogenic Carcinoma and all
Ca issues - Nasal flaring
C- hange in bowel/ bladder habits - Restlessness
A-sore that does not heal - Diaphoresis
U-nusual bleeding or discharge - Cold, clammy skin
T-hickening or lump in the breast or - Pallor, cyanosis

elsewere - Exhaustion
I-ndigestion or difficulty swallowing Diagnostic Test
O-bvious change in warts or moles 1. ABGs and pulse oxymetry
N-agging cough or hoarseness 2. Physical examination
U-nexplained anemia Medical Management
S-udden unexplained weight loss 1. Pharmacologic treatment
M. Asthma a. Long – acting medications
- A chronic inflammatory disease of the - Corticosteroids (Prednisone)
airways that causes airway hyper-
responsiveness, mucosal edema and - Bronchodilator (Theophylline)
mucus production. - Antileukotriene (Montelukast)
- It is largely reversible, either b. Short – acting medications
spontaneously or with treatment
compare to obstructive lung diseases - Bronchodilatoor (Salbutamol)

2. Nebulization - Regional lymph nodes
3. Oxygen therapy - Hoarseness
Nursing Management - Dysphagia
1. Remove, avoid, and prevent known - Neck edema
allergens that causes acute attacks
- hemoptysis
2. Oxygen therapy
Classification
3. Nebulize, as ordered
1. Squamous cell carcinoma – with good
4. Increase fluid intake once stable prognosis
5. Proper positioning 2. Adenocarcinoma – with good
prognosis
6. Advise adequate rest periods
3. Oat cell carcinoma – with poor
N. Bronchogenic Carcinoma (Lung
prognosis
Cancer)
4. Undifferentiated – with poor prognosis
- It arise from a single transformed lung
epithelial cells where in which Diagnostic Test
carcinogens binds to and damages it
1. Chest x-ray
resulting to cellular changes, abnormal
cell growth and eventually a malignant 2. CT scan
cells
3. Bronchoscopy
Causes
4. Fine needle aspiration biopsy
1. Smoking
Medical Management
2. Asbestosis
1. Surgery
3. COPD
a. Pneumonectomy
4. PTB
b. Lobectomy
5. heredity
c. Segmentectomy
Signs and Symptoms
d. Wedge resection
- Cough : hacking, non-productive, thick,
purulent, blood-tinged 2. Radiation therapy
- Wheezing 3. Chemotherapy
- Dyspnea 4. Palliative therapy
- Recurring fever Nursing Management
- Chest and shoulder pain 1. Maintain airway patency

2. Oxygen therapy - Headache
3. DBE - Conjunctivitis
4. Protection from infection - Sore throat
5. Adequate nutrition - Diarrhea
6. Quit SMOKING - Loss of taste or smell
7. Early detection and screening - Skin rashes or discoloration
8. Psychological Support Special Consideration
O. COVID-19 People of all ages who experience fever
and/or cough associated with difficulty
COVID-19 is the infectious disease
breathing/shortness of breath, chest
caused by the most recently discovered
pain/pressure, or loss of speech or
coronavirus. This new virus and disease
movement should seek medical
were unknown before the outbreak
attention immediately. If possible, it is
began in Wuhan, China, in December
recommended to call the health care
2019. COVID- 19 is now a pandemic
provider or facility first, so the patient
affecting many countries globally.
can be directed to the right clinic.
(WHO, 2020)
Diagnostic Test
A person-to-person kind of disease
spreading through acquisition of infected 1. Nasal swabbing
small droplets via coughs, sneezes and
2. Chest radiologic examination
speeches. It was claimed that the
droplets are relatively heavy hence Medical Management
settling of viruses on air is not expected
or more likely come to the ground upon 1. No specific pharmacologic treatment
release from an infected person. yet. Researchers, currently run tests for
variety of possible treatments.
The time between exposure to
COVID-19 and the moment when a. Remdesivir – an FDA-granted
symptoms start is commonly around five antiviral for emergency use as to treat or
to six days but can range from 1 palliate severe symptoms of COVID-19.
– 14 days. (WHO, 2020) b. Dexamethasone – aids in

supplemental oxygen support or
Signs and Symptoms mechanical ventilation.
- Flu-like initial symptoms, chiefly fever, 2. Palliative-Supportive Care
cough and tiredness
a. Pain relievers (ibuprofen or
- Body pain acetaminophen)
- Nasal congestion b. Cough syrup (mucolytic and/or
antitussives)

c. Rest
d. Increase fluid intake
Note: no evidence yet that ibuprofen or
other nonsteroidal anti- inflammatory
drugs (NSAIDs) need to be avoided
Nursing Management
1. Early detection and screening
(including travel history-taking)
2. Wash hands regularly and maintain
social distancing.
3. Monitor vital signs particularly body
temperature and respiratory rate.
4. Ensure adequate oxygen saturation
as to avoid risks of hypoxia.
5. Institute respiratory isolation such as
proper disposal of patient’s airway
secretions and use of protective masks.
6. Maintain adequate nutrition and
exercise.
7. Supportive psychological support and
health education.

Unit 3 Nursing Care of At Risk and •3 layers of the Heart Wall:
Sick Adult Clients with Alterations/
a.Outer epicardium
Problems in Oxygenation
b.Myocardium (only layer of heart
(The Cardiovascular System and its
capable of pumping due to muscles
Assessment)
which is capable of contracting)
Lesson 1 :Overview of the
c.Endocardium (diff chambers of our
Cardiovascular System
<3)
Most simply stated, the major function of
B.4 Hollow Chambers or Cavities:
the cardiovascular system is
transportation. Using blood as the a.Superior atria/ left and right atrium
transport vehicle, the system carries – “receiving chambers”
oxygen, nutrients, cell wastes,
hormones and many other substances Right side of the heart- lacking O2, to
vital for body homeostasis to and from receive O2
the cells. The force to move the blood Left side of the heart- carrying O2 blood
around the body is provided by the
beating of the heart. (Marieb, 2018) b.Inferior ventricles/ left and right
ventricle – “discharging chambers”;
actual pumps of the heart
What we can see in our ventricles is our
myocardium,
C.Great Vessels:
a.Superior and inferior venae cavae –
it delivers oxygen-poor blood into the
right atrium (directly connected to RA)
Vena- vein
b.Pulmonary artery or trunk – it
delivers oxygen-poor blood pumped by
the right ventricle into the lungs.(directly
connected to RV), it is carrying
deoxygenated blood or CO2
c.Four Pulmonary veins (left and
A.Covering and Wall
right) – it delivers blood oxygenated by
•Pericardium – a double sac of serous the lungs into the left atrium
membrane (Self-enclosing) that
d.Aorta – it delivers oxygenated blood
encloses the heart, its job is to protect
pumped by the left side (left ventricle) of
our heart: visceral pericardium or
the heart, largest artery
epicardium (inner side) and the parietal
pericardium (outer side)

D.Four Valves of the Heart (preventing
reflux or regurgitation of the fluids that
has already been transported (they are
assuring one way flow of any fluids of
the body), di na dapat bumalik sa
pinanggalingan
a.Atrioventricular or AV valves –
located between the atria and ventricles
on each side; it prevent backflow into
the atria when the ventricles contract; 2
types of AV valves include:
•Left AV valve or bicuspid valve or mitral
valve
•Right AV valve or tricuspid valve, has
three cusps *depolarization – the exchange of ions
that creates a positively charged
b.Semilunar valve – guards the bases intracellular space and negatively
of the two large arteries leaving the charged extracellular space, purpose to
ventricular chambers. This prevents make cells in the body such as cardiac
arterial blood from reentering the heart. cells highly polarized, theres a tendency
•Pulmonary semilunar valve – it of our heart to do action such as
prevents backflow of blood into the right contract, or pump.
ventricle after it pumps. * repolarization – a state that follow
•Aortic semilunar valve – it prevents depolarization wherein exchange of ions
reentry of blood into the left ventricle reverts back to its resting state
after pumping. Pano nakakapagpapump ang ating
20:57 heart?
E.Cardiac Circulation Our hearts are capable of conducting

electricity. Through diff ion of the body,
•Right and left coronary arteries – it are capable of conducting electricity that
provide oxygenated blood into the heart, makes our heart pump. This is intrinsic
support the entirety of our heart with conduction system. May path yan hindi
oxygenated blood basta bastang tibok lang. There should
LADA- dyan madalas nagkakaheart be a path named electrical impulse. It
attack starts with SA node (pacemaker) which
is an imaginary point wherein it can only
•Coronary sinus – it delivers be found somewhere in the opening of
deoxygenated blood into the right atrium SVC, from the inside of our RA.
to be oxygenated again by the lungs, Mapupunta sa AV node, found between
atrium and ventricular area, tapos

bundle of His, tapos punta naman sa left of the AV valves. The second heart
and right bundle branches, then it will sound (dup) S2 occurs when the
quickly go directly to Purkinje fibers, semilunar valves close at the end of
they are believed to be situated in our systole. Kapag nagsara si S1 open si
entire ventricles. You expect that all S2. Di sila pwede magsabay
sides of ventricles receiving this impulse
Kapag nagpump ang right side, ang left
will surely pump. Pagkareach sa
side ay may action din. Simultaneous
purkinje fiber ay magpump na.
opening and closure of our valves.
Simultaneously ang tricuspid and mitral
valve. Kapag closure kalang ng valves
makakarinig ng sounds. Parang pinto
lang yan.
Cardiac Output – the amount of blood
pumped out by each side of the heart. It
is the product of heart rate (HR) and the
stroke volume (SV). Stroke volume is
the volume of blood pumped out by a
ventricle with each heartbeat. Best
achieve with monitoring devices.
CO (5250 ml/min) = HR (75 beats/min) x
SV (70 ml/beat)
Blood Vessels
•Arteries- deliver oxygenated blood into
different cells and tissues of the body
•Capillaries- directly supply oxygenated
blood into the cells and drains
F.Cardiac Cycle, Heart Sounds and
deoxygenated blood from the cells into
Cardiac Output
the vein.
Cardiac cycle – refers to the events of
•Veins- carries deoxygenated blood
one complete heartbeat, during which
used by the different cells and tissues in
both atria and ventricles contract and
the body
then relax.
Microscopic Anatomy of Blood
•Systole – the contraction phase of heart
Vessels
activity
Tunics- walls of blood vessels; 3 coats
•Diastole – the relaxation phase of heart
or tunics
activity
a. Tunica interna
Heart Sounds – “lub” and “dup”. The first
sound (lub) S1 is caused by the closing b. Tunica media

c. Tunica externa A.Risk Factors
Non – Modifiable Risk Factors
1.Age
2.Gender
3.Race (can be due to foods that they
eat, cultural lifestyle)
4.Family History of CAD
Modifiable Risk Factors

1.Hypertension
2.Hyperlipidemia (hypercholesterolemia)
3.Stress
4.Diet
Lesson 2: Assessing the 5.Cigarette smoking
Cardiovascular Function
6.Alcohol
Lesson Proper
7.Diabetes mellitus (increasing viscosity
Guided by the previous NCM courses on their blood bc of too much blood
and with refreshing of knowledge with glucose, would make our blood flow
Anatomy and Physiology of sluggish, it will be hard to reach the diff
Cardiovascular System, nursing vital signs of body including the heart)
students can be expected to find
rendering of nursing care easier, i.e. 8.Obesity
more prioritized and appropriate. 9.Exercise / Lifestyle
However, prior to discussion of medical
– surgical managements for each B.Physical Examination
cardiovascular disorder, the following 1.General Appearance
needs to be first discussed when
assessing cardiovascular functions: 2.Inspection of the Skin
Nursing Health History (particularly Pallor, peripheral cyanosis, central

the risk/causative factors) cyanosis, xanthelasma (similar to
jaundice), skin turgor (poor O2 and
Physical Examination hydration of skin) , cold and clammy skin
Common Clinical Manifestations (hypoglycemic), ecchymosis, etc.
Diagnostic Procedures / Evaluation 3.Blood Pressure

Pulse pressure – the difference Heart Sounds:
between the systolic and diastolic
1.S1
pressure (just subtract) (normal pulse
pressure 30-40 mmhg) 2.S2
Kapag mataas PP, widened pulse 3.S3 or ventricular diastolic gallop
pressure ang tawag, common sa mga (produced by rapid ventricular filling;
may hypertension normal in children or young adults; may
indicate MI, CHF)
Kapag naman mababa, common sa
mga low blood or hypotensive patients, 4.S4 or atrial diastolic gallop(produced
we call it narrowed pulse pressure by atrial resistance to hyperthrophied
RV or RHF)
Postural (orthostatic) hypotension
(kapag binigla mo ng tayo at nahilo yan 5.Murmurs (sound created by turbulent
flow of blood caused by malfunctioning
4.Arterial Pulses (yung pulso ba
Heart valves having regurgitations)
mahirap kapain..)
6.Friction rub (evident with pericarditis or
Pulse rate
pericardial effusion)
Pulse rhythm
9.Inspection of the extremities
Pulse quality
capillary refill time, pain, paresthesia,
5.Jugular venous pulsation (if it is numbness, hematoma, peripheral
palpable or visible na dapat hindi naman edema, clubbing of the fingers and toes,
coz its not normally pulsating, it can lower extremity ulcers
indicate cardiovascular disorders)
10.Other Systems
6.Heart Inspection and Palpation
Lungs
(Apical pulse- point of maximal impulse
where we usually place the bell of 1.Dyspnea
stethoscope for beating), which is best
assessed in the left side the patient 2.Tachypnea
Aortic area 3.Cheyne – Stokes respirations
Pulmonic area 4.Hemoptysis
Erb’s point 5.Cough
Right ventricular or tricuspid area 6.Crackles
Left ventricular or apical area 7.Wheezes
Epigastric area Abdomen
7.Chest Percussion 1. Hepatojugular reflux
8.Cardiac Auscultation 2. Bladder distention

C. Common Clinical Manifestations of RBCs (4 to 6 M cells/mm3), WBCs (5
Cardiovascular Disorders to 10K cells/mm3), Platelets (140-160
K/mm3), Hgb (12 to 15 g/dL), Hct (49-
1.Chest pain
52%)
2.Dyspnea or shortness of breath
b.Blood Chemistry and Serum
Dyspnea on exertion Electrolytes
Orthopnea Na+, K+, Ca++, Mg++
Paroxysmal Nocturnal Dyspnea Blood Urea Nitrogen

(Sudden sleep apnea)
-End-product of protein metabolism
3.Peripheral Edema or Weight Gain excreted by the kidneys
(there would be a prob with fully
-An indicator of renal function
excreting fluids in body, there is direct
relationship with your heart and kidney; -Elevated BUN reflects reduced renal
that if your heart is not sufficiently perfusion from decreased cardiac output
pumping blood from the inside your or intravascular fluid volume deficit (how
kidneys will not also receiving sufficient good our kidney is excreting body
enough of blood because its dependent waste)
with our heart, without sufficient enough
-Normal range is 10 to 29 mg/dL
of blood, there woudldnt be sufficient
enough of urine, therefore, there would Creatinine
be fluid retention, the more you collect
the more fluid you retain there would be -A more sensitive measure of renal
weight gain) function
4.Palpitations -Normal range is 0.8 to 1.2 mg/dL
5.Dizziness/Syncope/ALOC (your brain -Byproduct of our muscular metabolism

is also dependent with the sufficient particularly from creatine proteins
amount of blood that will be pumped by c.Blood Coagulation Tests
the left side of your heart. Without aorta (Effectiveness of anticoagulants also)
supplying enough blood into your brain,
you wouldn’t have normal neurological hepAPTT
functions Heparin tested by PTT
6.Fatigue Heparin tested by APTT
D.Diagnostic Procedures Related to Prothrombin Time (PT)
Cardiovascular Function
-It valuable in evaluating effectiveness of
1.Laboratory Tests Coumadin
a.Complete Blood Count -Normal range is 11 to 16 seconds
Partial Thromboplastin Time (PTT)

-It is the best single screening test for 2 Types of Serum Aminotransferases:
disorders of coagulation
1.)AST (Sgot) (produced only by cardiac
-It is determined to evaluate the muscle cells)
effectiveness of heparin therapy.
2.)Alt (SGPT)
-Normal range is 60 to 70 seconds
In your minds write SGOT (AST) as SG
Activated Partial Thromboplastin <3T or sa puso yun lagi
Time (APTT)
Remember that “L” in ALT (or SGPT)
-It has the same purpose as PTT. It is points to your liver, nagiincrease pag
most specific test to evaluate may liver disorder
effectiveness of heparin
Aspartate Aminotransferase (AST)
-Normal range is 30 to 45 seconds
-normally not found in the blood but if
d.Blood Lipids this would be rising or elevated value, it
will indicate tissue necrosis in the
Cholesterol
cardiac muscles
-A lipid required for hormone synthesis
-true to patients with heart attacks
and cell membrane formation
-Formerly called SGOT
-The client should be on NPO for 10-12
hours (search why this long) -Elevated level indicates tissue necrosis
-Normal range is 150 to 250 mg/dL 3 CK Isoenzymes
Triglycerides 1.)CK-MB- denoting cardiac problems
-Free fatty acids and glycerol stored in 2.)CK-BB- denoting neurologic problems
the adipose tissues and are a source of (BB, brain problems)
energy
3.)CK-MM- denoting musculoskeletal
-The client should observe fasting for 10 problems (MM, muscles)
to 12 hours
Creatine – Phosphokinase (CK-MB)
-Normal range is 140 to 200 mg/dL
-The most cardiac specific enzyme
Two Major Transporters of
-An accurate indicator of myocardial
Cholesterol and Triglycerides:
damage because it is the first enzyme to
oLow-Density Lipoproteins (LDL) increase
oHigh-Density Lipoproteins -Kapag nagmyocardial infarction yung
patient,yang enzyme ang unang tataas.
e.Enzyme Studies (particularly enzymes
produced by cardiac muscles cells, Lactic Dehydrogenase (LDH)
kapag nagkainjury sa muscles sa heart,
-Most sensitive indicator of myocardial
magpproduce yon ng enzymes)
damage but analyzed only in selected

patients because of its delayed increase -Useful in positioning IV pacing
compare to CK- MB electrodes and for guiding catheter
insertion during cardiac catheterization.
Ase- enzymes yan kapag dyan yung
suffix 4.Echocardiography
-matagal lumabas. Yung CK-MB mabilis -Uses ultrasound to assess cardiac
man makita, mawawala at mawawaa structure and mobility
yan, Si LDH naman kahit delayed man
-No special preparation is required
lumitaw ay it will be long lasting.
-It is painless and takes approximately
Troponin T and I
30 to 60 minutes to complete
-It has the capacity to stay longer than
-The client has to remain still, supine
CK-MB
position slightly turned to the left side
-Proteins found only in the cardiac
5.Electrocardiography (ECG)
muscles
-A graphical recording of the electrical
-It peaks early during myocardial
activity of the heart. It indicates
damage and remains elevated for 1 to 3
alterations in myocardial oxygenation
weeks which allow both early and late
diagnosis of MI -It is the first diagnostic test done when
cardiovascular disorder is suspected
f. Urinalysis
-Part of routine examination
-Assess the effects of cardiovascular
disease on renal function and the Intrinsic Conduction System
existence of concurrent renal or
systemic diseases 2 Distinct Events
Albuminuria – detected with malignant Depolarization- the exchange of ions

hypertension and CHF that creates a positively charged
intracellular space and negatively
Myoglobinuria – supports diagnosis of charged extracellular space (i.e.)
MI “myocardial contraction”)
2.Chest X-ray Repolarization- a state that foow
depolarization wherein exchange of ions
-It determines the size, contour and
reverts back to its resting stage (i.e.
position of the heart.
myocardial relaxation)
-It does not diagnose acute MI but it can
AV node- nagpapadelay sa impulses
help diagnose some complication (e.g.
para maiwasan ang tachycardia, it gives
HF)
enough time for ventricles to be fully
3.Cardiac Fluoroscopy filled with blood to pump well
-Facilitates observation of the heart from
varying views while it is in motion

ECG WAVES AND WHAT THEY a. 12-Lead ECG
REPRESENT
Lead- PQRST
P-WAVE- Depolarization of atria in
Limb leads (sourcing leads from
response to SA node triggering, eto
extremities of the patient) – Lead I, II, III,
yung first impulse, duration is 0.04 to
AVR (augmented vector of the right arm)
0.11 secs
, AVL (augmented vector of the left
PR Interval- Delay of AV node to allow hand), and AVF (augmented vector of
filling of ventricles (eto yung delay ng AV the foot) (traced from limb electrodes)
node), time of impulse transmission SA
Precordial leads – V1,V2,V3,V4,V5,
node to AV NODE; DURATION IS 0.12-
and V6 (traced from chest electrodes)
0.20 SECS
b. ECG electrode placement(6 on
QRS Complex- Depolarization of
the chest and 4 on the limbs)
ventricles, triggers main pumping
contractions (nung nakarating pala RA – right arm (usually red color)
kanina si cardiac impulse kay Bundle of
His up to purkinje fibers and the net RF – right foot (usually black color)
effect is fully ejection of blood because LA – left arm (usually yellow color)
finally the ventricles contract, that is the
QRS Complex, duration is 0.05 to 0.10 LF – left foot (usually green color)
secs, exact moment where your heart is
pumping
Lead I- Left and Right Arm Electrodes
T- Wave- Ventricular repolarization,
duration is 0.16 secs, resting stage of Lead II- Right Arm and Left Leg
our heart Electrodes
ST Segment- Beginning of ventricle Lead III-Left Arm and Left Leg

repolarization, should be flat, plateau Avr- Right arm
place (moment wherein a certain action
in the body is beginning to rest, malapit Avl-Left arm
na magrelax Avf- Left leg or both
COMMON ECG TERMINOLOGIES
Wave- movement away from the V1 to V6- the 6 chest leads
baseline on either (+) or (-) direction
V1 – 4th ICS, right sterna border
Segment- a line between two waveforms (usually red color)
(eg ST segment)
V2 – 4th ICS, left sternal border
Interval- combination of a waveform and (usually yellow color)
a segment (eg PR interval)
V3 – diagonally between V2 and V4
Complex- comprised of several (usually green color)
waveforms (QRS segment)

V4 – 5th ICS left MCL (usually brown T wave inversion – MI
color)
Widening QRS – Arrhythmia
V5 – same level as V4, anterior
Tall/Peak T wave – Hyperkalemia
axillary line (usually black color)
Prominent U wave – Hypokalemia
V6 – same level as V4 and V5,
midaxillary line (usually violet color) 6.Holter Monitoring
c.Common ECG terminologies -A continuous (24hr) ECG monitoring
Wave – movement away from the -The portable monitoring unit is called
baseline on either (+) or (-) direction telemetry unit
Segment – a line between two -This attempts to assess the activities
waveforms which precipitate dysrhythmias and time
of the day when the client experiences
Interval – combination of a waveform
dysrhythmias
and a segment
-MakakapagADL parin patient kahit
Complex – comprised of several
nakaholter monitoring
waveforms
7.Stress Testing or Exercise Testing
d.Waves, complexes and interval
-ECG is monitored during the exercise
P wave – atrial duration is 0.04 to
on a treadmill or bicycle-like device
0.11 secs
-The purposes of the test are as follows:
PR interval – time of impulse
a.Identify ischemic heart disease
transmission SA node to AV node;
duration is 0.12- 0.20secs b.Evaluate patient with chest pain
QRS complex – ventricular c.Evaluate effectiveness of therapy
depolarization; duration is 0.05 to
d.Develop individual fitness program
0.10 secs
Nursing Intervention
ST segment – represents the plateau
a.Get adequate sleep the night before
phase of the action potential the test (to avoid false positive)
T wave – ventricular repolarization; b.Avoid tea, coffee, alcohol on the day
duration is 0.16 secs of the test (antistimulants)
U wave – ventricular diastole c.Avoid smoking and taking
nitroglycerine (antichest pain) 2 hours
e.Abnormal ECG changes
before the test (to avoid false negative)
ST segment depression – Angina
d.Eat a light meal at least 2 hours before
ST elevation – MI the test

e.Inform the physician if any unusual
sensations develop during the test
f.Rest after the test
8.Computed Tomography (CT) Scan
-Uses x-ray to provide cross-sectional
images of the chest, including the heart
and great vessels
Nursing intervention:
-Instruct the patient that the procedure is
non-invasive and painless
-Instruct the patient to remain still during
the scanning process
-An IV access line is necessary if
10.Cardiac catheterization
contrast enhancement is to be used.
The purposes of the test are as follows:
-Ask the client if he has allergy on
iodine-rich foods (e.g. seafoods), if a.Assesses oxygen levels, pulmonary
contrast is to be used blood flow, cardiac output, heart
structures
9.Magnetic Resonance Imaging (MRI)
b.Coronary artery visualization
-A non-invasive diagnostic tool that uses
a powerful magnetic field and computer- Nursing Intervention:
generated pictures to image the heart
-Avoint anticoagulants prior the
and great vessels
procedure (With the entry of catheter in
Nursing intervention: pt vasculature, The pt will be very prone
to bleeding)
-The patient is instructed to remove any
jewelries, watches or any other metal -No breastfeeding for 1-2 days after the
items procedure
-Interview if the patient has pacemakers, -Increase fluid intake post-procedure
metal plates, prosthetic joints or any (We want to flush out contrast material
metallic implants
Angiography – a technique that uses
-The patient is instructed to be radiopaque contrast agent injected into
motionless during the procedure the vascular system to outline the heart
and blood vessels
-Know if the patient has claustrophobia
Dye- yun yung magvivisualize

Types or Sites for Angiography -Monitors blood volume, adequacy of
venous return to the heart, pump
a.Aortography
function of the right side of the heart
b.Coronary Arteriography
-It gives full picture of the fluid status in
c.Right Heart Catheterization the body, sensitive indicator
-Done by inserting a catheter with or -The 0 level of the manometer should be

without contrast via a cutdown into a placed at the right, midaxillary, 4th ICS,
large vein, e.g. median cubital or the approximate level of right atrium
brachial vein, through bena cava when in supine position
d.Left Heart Catheterization -Place the client in supine position
-Done by passing a catheter into the -Practice strict asepsis. Cleanse

aorta with or without a contrast via the catheter insertion site and change the
brachial or femoral artery, through vena dressings daily
cava or aorta
-Normal readings:
•Superior Vena Cava: 0-12 cm H20 (0-
-Provide psychosocial support 8mmHg)
-Assess for allergy to iodine/ seafood •Right Atrium: 5-12 cm H20

(because of dye)
-Most common complications of CVP
-Withhold meals before the procedure monitoring are infection, pneumothorax,
and air embolism
-Have the client void
-Insertion sites are External jugular vein,
-Administer sedative as ordered right subclavian vein (upper chest area),
-May experience warm or flushing internal jugular vein (neck area), femoral
sensation as the contrast medium is vein (groin area), brachial vein (arm
injected area)
-“Fluttering” sensation is felt, as the b.Pulmonary Artery Pressure

catheter enters the chambers of the -Swan – Ganz catheter is inserted via
heart antecubital vein into the right side of the
11.Hemodynamic Monitoring heart and is floated into the pulmonary
artery. It reflects pressure in the left
a.Central Venous Pressure (CVP) heart.
Monitoring
-Swan – Ganz catheter is a flow –
-Monitors the pressure within the right directed, balloon – tipped, 4 – lumen
atrium catheter
-The catheter allows continuous
monitoring of the following:

a.Right and left ventricular function
b.Pulmonary artery pressures
(PAP,PCWP)
c.Cardiac output
d.Arterial – venous oxygen difference
-Normal range:
a.PAP : 4 – 12 mmHg
b.PCWP: 4 – 12 mmHg
-PCWP reading above 25 mmHg
suggests impending pulmonary edema
Nursing Interventions:
-Observe catheter insertion site; culture
site every 48 hours
-Assess extremity for color, temperature,
capillary filling and sensation
All these cardiovascular assessment
topics discussed are aimed to help
nursing students identify the most
suitable nursing diagnoses for at risk or
sick adult clients. It is always believed
that rightful nursing problem
identification will lead to appropriate plan
of care, timely and effective nursing
interventions, and immediate revision of
the nursing process employed should
favourable evaluation results will not be
observed. The next units of the course
will tackle cardiovascular disorders and
its medical – surgical managements.

Unit 4 Nursing Care of At Risk and 1.Coronary Atherosclerosis (it can
Sick Adult Clients with Alterations/ happen in other parts of the body, not
Problems in Oxygenation just in the heart)
Lesson 1: Management of the -Abnormal accumulation of lipid, or fatty,
Clients with Coronary Vascular substances and fibrous tissues in the
Disorders lining of arterial blood vessel walls (the
inside of our arteries which are
Cardiovascular diseases (CVDs) locally
supposed to be free from the blockages,
and worldwide are known to be one of
suddenly becomes clog because of fatty
the leading causes of death which
deposits, it may impede the normal
specifically accounts to taking an
circulation of our blood)
estimated 17.9 million lives each year
according to World Health Organization 2.Arteriosclerosis
(WHO), 2019. The identification and
-Loss of elasticity of the arteries;
medical management now includes all
hardening of the arteries, not fully elastic
individuals regardless of age, sex, race,
not fully recoiling. It is alarming because
and cultural diversities. In this lesson
our blood vessels should be capable of
proper, it will discuss few of the most
vasodilation and vasoconstriction,
common CVDs in succession namely
important mechanisms of blood vessels
Coronary Artery Disease, Angina
that maintain blood volume and blood
Pectoris, and Myocardial Infarction.
pressure, etc
A. Coronary Artery Disease
Risk Factors of CAD
- Generic term for condition wherein the
Non-modifiable Risk Factors:
coronary circulation is compromised
leading to imbalance in cardiac oxygen - Familial history of CAD (cholesterol
supply and demand level gets high as their genetic
disposition ages)
-Even though our heart is in the task of
supplying our body with oxygenated - Aging (wear and tear) (blood vessels
blood and draining all the cells and are losing integrity, or hindi nag anon
tissues from the deoxygenated blood, kaelastic, nagiging fragile)
the heart itself is also looking for source
of o2 and branches or vasculature which - Gender (association of gender with the
are responsible for supplying o2 blood, lifestyle, such as the vices)
would be our coronary artery which has - Race (cultures being shared by these
branches as well. When it happens that people, who are engaging with fatty
this coronary artery has imbalance or foods, or so rich with preservatives,
being compromised, CAD. uncooked foods)
Most Common Causes of CAD: Modifiable Risk Factors:
- Hyperlipidemia (associated with the
lifestyle of the person)

- Cigarette smoking Prevention
- Hypertension (tumaas presyon kaya 1. Avoid cigarette smoking (as well as
pumutok yung ugat sa puso or utaak) passive smoking)
- DM (sluggish blood flow because of 2. Drink alcohol moderately
increasing blood viscosity as the bood
3. Daily management of hypertension
sugar increases in level, it will also slow
down the normal supply 02 to other 4. DM control
parts of the body such as the heart)
5. Watch for your diet - fat, salt,
- Lack of estrogen (consistent imbalance dietary fiber (prevent constipation
between estrogen and progesterone because the patient has tendency of
could predispose the patient to fatty Valsalva maneuver, mas lalo tayong iire,
depositions of the body, ano kinalaman may effect din to sa heart natin, its
ni estrogen with CVD) because of vagus nerve stimulation,
there would be direct effect of heart as it
- Obesity
is the longest cranial nerve of all, that
- Physical inactivity (We compromise from the brain steam it will extend to the
ourselves from good circulation) levels of throat to heart to tiyan, the
more you stimulate your vagus nerve, it
Diagnostic Test
will have an effect to your heart, it will
1. ECG slow down the heart rate, kapag tapos
na siya umire, biglang bilis naman dail
- ST depression magcocompensate panandaliang
Figure 4.1 The ECG ST Depression pagbagal ng tibok ng puso), low
cholesterol,
- T wave inversion (goes up
then it goes down) Calorie (the higher blood volume the
patient has in his body, the higher the
Figure 4.2 The ECG T wave inversion bp)
2. Stress Test 6. Regular exercise – 30min daily; 5-
- Positive result (When the patient 6x/week LDL, HDL
during threadmill suddenly complained Medications
for chest pain)
1. Statins
3. Coronary Arteriography
- Block cholesterol synthesis, lower LDL
- It reveals plaque formation and triglyceride and increase HDL levels
4. Lipid Profile (blood extraction) (hindi naman pwedeng mawala ang
cholesterol dahil it is very important in
- LDL, trigyceride cellular formations, with no cholesterol,
5. Cardiac enzyme no cell membranes, with no cell
membranes, no cytoplasmic organelles,
- CK-MB, except CK-BB, CK-MM no cels at all)

- E.g. Simvastatin (Zocor), Lovastatin a. Take with meals to decrease GI
(Mevacor), Atorvastatin (Lipitor) irritation
- Nursing Responsibility: b. Teratogenic effect (Avoid in pregnant
mothers)
a. Watch out for hepatotoxicity (liver life-
threatening complications, e.g. yellowish c. Taper the drug before discontinuing
in color, losing an appetite) (dosage will be cut down to half) (unti
unti pagdiscontinue ng gamot)
b. Report for muscle weakness and pain
B. Angina Pectoris / Myocardial
2. Bile Acid Sequestrants
Ischemia
- Increase cholesterol breakdown and
- Transient (Temporary) chest pain
lower LDL
caused by insufficient blood flow to the
- E.g. Cholestyramine (Questran), myocardium resulting in myocardial
Colestipol HCl (Colestid) ischemia; no apparent myocardial
damages
Ischemia- diminishing level of o2 in a
a. Inform patient that it can cause gastric specific tissue
distention and constipation
b. Increase fluid intake
PATHOPHYSIOLOGY
3. Nicotinic acid
- Lower cholesterol, LDL, and
triglyceride; increases HDL
- E.g. Niacin (Niacor, Niaspan)
a. Take with meals and cold beverages
to decrease GI irritation (because its an
acid, it is a GI irritant)
b. Watch out for hepatotoxicity
c. Avoid alcohol; it can increase uric acid
leading to gout Decreased coronary tissue perfusion.
Pertaining to your heart itself as supply
4. Fibric Acids / Fibrates by coronary artery. Di na sufficient
- Decrease cholesterol, triglyceride supply ng o2 thru CORNARY
levels; increase HDL levels ARTERIES responsible for full
oxygenation of cardiac tissues and
- E.g. Fenofibrate (Tricor) muscles. However, tuloy parin ang
compensation. Magsswitch from aerobic
- Nursing Responsibility:
to anaerobic. Kapag di makagenerate

ng atp or energy from aerobic, seek help Types of Angina
to anaerobic. It is consequential,
1. Stable Angina / Classic Angina
production of waste products not
normally existing. That is lactic acid. -Predictable and consistent chest pain
Kapag muscles ng ating puso ay that occurs on exertion and is relieved
gumamit ng anaerobic instead of an by rest
aerobic, it will produce in its cardiac
muscles and tissues too much lactic -Chest pain last for less than 15 minutes
acid. Too much lactic acid in our -very manageable
muscular tissues can be painful to be
felt. 2. Unstable Angina
Signs / Symptoms: -Also called preinfarction angina,

crescendo, angina, intermittent coronary
1. Chest Pain S – udden syndrome
A – nterior chest (non-radiating; but may - Strikes in unpredictable pattern
radiate to the back) V –ague (hardly
characterized) -Chest pain last more than 15 minutes
but less than 30 minutes
E – xertion-related (extreme emotions)
-May occur at night
R – elieved by rest / nitrate
-Kapag sobrang pagod, kapag sobrang
S – hort in duration (<30 min) init or lamig
2. Pallor
3. Diaphoresis 3. Variant Angina (Prinzmetal’s
4. Dyspnea Angina)
5. Faintness -Pain at rest with reversible ST-

segment elevation; thought to be caused
6. Palpitation by coronary artery vasospasm and not
by atherosclerotic plaques
7. Dizziness
-The attacks tend to occur at the early
8. Anxiety
hours of the day
9. Digestive disturbances
Bronchonstriction and bronchospasm is
Diagnostic Tests same
1.ECG – ST depression, T wave 4. Intractable Angina (Refractory
inversion Angina)
2. Cardiac Stress Test -Severe incapacitating chest pain
unresponsive to intervention
3. Blood Chemistry - LDL, HDL,
(excruciating level of pain)
triglycerides

5. Postinfarction angina hypotensive effect yung vasodilator,
vasocontrict naman sa bp)
-Occurs after MI (myocardial infarction),
when residual ischemia may cause vi. Advise client to always carry three
episodes of angina tablets in his pocket (why?)
b. Beta – adrenergic blocking agent
Olol- beta- blockers (nakakabagal ng
Precipitating Events of Angina
tibok ng puso)
Pectoris
When the patient has pain, vs will all
1. Exertion
increase
2. Emotions
- Propranolol (Inderal), Metoprolol
3. Eating a heavy meal (Lopressor), Nadolol (Corgard)
4. Environment. Exposure to cold - decrease myocardial oxygen demand
by decreasing heart rate, BP,
Medical Management myocardial contractility and calcium
1. Pharmacologic Therapy output (the more you have calcium in
blood, mahyhyperstimulate ang muscles
a. Nitroglycerin/Nitrates (Nitrostat, Nitrol, natin)
Nitro-Bid, Isordil)
- Nursing Responsibility:
- Vasodilators; anti-anginal, anti-chest
pain i. Assess pulse rate before
administration of the drug (para
- Direct relaxing effect on vascular malaman kung mabilis ang tibok o hindi,
smooth muscle resulting in generalized dahil kung mabagal ang tibok ng puso,
vasodilation wag mo na bigyan ng beta blockers
- Can be taken sublingual or thru patch dahil mas lalong babagal to)
- Nursing Responsibility: ii. Administer with food to prevent GI

upset (Kung alam mo nang may acid,
i. Ask for biting sensation of the drug don’t give medicine to to the stomach
under the tongue without food)
ii. Instruct patient not to chew the drug iii. Do not administer Propranolol to
iii. Nitrates are photosensitive clients with DM. It causes
hypoglycaemia, instead other olol drugs
(they lose their potency when exposed because propranolol may cause
to light) hypoglycemia
iv. Take maximum of three doses at 5- c. Calcium-channel blocking agents
min interval
-dipine
v. gradual change of position to prevent
orthostatic hypotension (kasi may - Verapamil (Isoptin), Nifedipine
(Calcibloc),Diltiazem (Cardizem)

- Inhibit calcium ion transportation into - Assess for signs and symptoms of
myocardial cells to depress inotropic bleeding
and chronotropic activity, decreasing
- Keep Protamine Sulfate available
cardiac workload
- Do not aspirate or massage when
- Inotropic- contractility or strength of
given subcutaneously
your heart to do pumping
- Monitor PTT levels
- Chronotropic- pertaining to the pattern,
rate, rhythm of heart rate d.3. Coumadin
- Si calcium channel blockers, nirerelax - Assess for signs and symptoms of
niya yung heart bleeding
- It has vasodilation effect - Keep Vit K available
- It reduces coronary vasospasm - Monitor Prothrombin Time
- Nursing Responsibility: - Minimize green leafy vegetable in the
diet
i. Assess heart rate and BP
2.Oxygen Administration
ii. Monitor hepatic and renal function
iii. Administer 1 hr before or 2 hrs after
meals. 1. Assess hemodynamic function
(bleeding time), V/S and pain
d. Platelet Aggregation Inhibitors (Anti-
platelets) 2. Assess and report ECG findings
d.1 Aspirin (ASA) (blood thinning effect) 3. O2 administration
- Assess for signs and symptoms of 4. Advise rest periods
bleeding
5. Position in semi-Fowler’s position
- Avoid straining at stool (kapag
constipated) 6. Avoid smoking; observe proper diet
- Do not give ASA with Coumadin (blood 7. Seek medical attention if angina lasts
thinning pareho) longer than 20min
- ASA should be given with food 8. Avoid stressors that causes angina
(ulcerative medications) C. Myocardial Infarction
- Observe for signs of toxicity – tinnitus (traydor na sakit)
(it can be a sign that aspirin needs to be
discontinued) -The formation of localized necrotic
(location of dead tissues) areas within
d.2 Heparin Sodium the myocardium. Prolonged ischemia
lasting more than 35 to 45 minutes
produces irreversible cellular damage

and necrosis of the myocardium. Death 1. Transmural MI- extending from
of cardiac tissues are always called endocardium to epicardium
irreversible.
2.Subendocardial MI- affects
endocardial muscles
3. Intramural MI- seen in patchy areas of
the myocardium and is usually
associated with long standing angina
pectoris
Degree of Heart Damage
1. Zone of Ischemia
- Inverted T wave
- Repolarization is impaired but can be
restored
- Cardiac cells are still viable (buhay pa
PATHOPHYSIOLOGY mga cells)
Endothelial injury- endothelium are 2. Zone of Injury
inside lining of blood vessels that has
- Cells are viable if reperfusion (pwede
sustained injury from desquamation
pa maputback into normal) of the heart
(Squamous cells) of endothelium. Kung
are still present, pwede nagcardiac
nagbabakbak to, it would be a good site
catheterization kya natanggal blockage
of collection that may promote plaque
formation wherein an area in - Heart does not fully repolarized
bloodstream composed of materials that
- ST segment elevation
will clog the blood flow. The more na
nagdedesquamate, the more 3. Zone of infarction
magaattach ng fatty deposits kaya
nagdedecrease ng coronary tissue - Cells are no longer viable (may
perfusion, leading to coronary ischemia necrosis na, nabulok na); necrosis
somehow same with angina pectoris. occurred
But if it will left untreated it will lead to - Presence of pathologic Q wave –
hypoxia, pag nagkaron ng tissue death reflects lack of depolarization
due to blocked coronary artery,
nagkakaron ng myocardial infarction. Signs / Symptoms
Usually it is in the left side of the heart 1. Chest Pain
(bakit sa left side of the heart, usually sa
lower portion) - Crushing, substernal (beneath
sternum), severe, prolonged and
Types of MI persistent, unrelieved by rest or

nitroglycerine; often radiating to one or - Detect for occult bleeding during
both arms, the neck and the back administration
- Long in duration (>15min) - Assess neurologic status which may
indicate GI bleeding or cardiac
-May occur even at rest
tamponade
2. Anxiety
b. Analgesics
- Feeling of “doom”
- This is a priority. Pain may cause
3. Dyspnea shock.
4. Diaphoresis - Morphine Sulfate, Lidocaine, or

Nitroglycerine are administered
5. Oliguria (w/o sufficient enough blood intravenously
to be pumped by your heart, wala ring
dugon a makakarating sa kidney and will c. Angiotensin-Converting Enzyme
release urine) (ACE) Inhibitors
6. Fever - It prevents conversion of Angiotensin I

to Angiotensin II (enzyme responsible to
7. GI disturbance increase our sodium level, blood
Diagnostic Test volume, blood pressure), thereby
decreasing BP, increasing excretion of
1.ECG- ST segment elevation, Inverted sodium and fluid (diuresis) and
T wave, absence or presence of decreasing oxygen demand.
pathologic Q wave
d. Anticoagulant and antiplatelet
2. Blood Chemistry- increased Troponin medications
I and T, CK-MB, LDH, triglyceride, WBC
level (bcoz of impending tissue death), - Heparin, Coumadin
low HDL e. Others (Beta-adrenergic blockers,
Medical Management diazepam)
1. Pharmacologic Therapy RAAS mahalaga para mamaintain ating

blood pressure,
a. Thrombolytics
Blood volume, sodium level. Pinapataas
- It dissolve and lyse thrombus in a niya mga
coronary artery
Ito. ACE prevent RAAS for hyperactivity.
- E.g. Streptokinase, Urokinase, and
Tissue Plasminogen Activator (TPA) Wise and Easy Tips 4.1 How Can We
Easily Remember
- Administration is most crucial between
3 to 6 hours after the initial infarction has Drug Names and their Actions?
occurred Truly permanence in remembering
different drug names and their actions or

therapeutic effects has been a challenge - A specially designed balloon-
not only to nursing students but even tippedcatheter is inserted under
among professional nurses. Since fluoroscopy and advanced to the site of
you’re encountering plenty of drug the coronary obstruction
classes already here’s a tip to remember
i. Low salt, low fat, low cholesterol, high
them easily. How? Be watchful for the
fiber diet
ENDINGS (or suffixes, we call it in
English grammar) of each drug name ii. Avoid saturated fats
because MOST OF THEM, IF NOT ALL
will suggest their actions or therapeutic iii. No restrictions are placed on activity
effects. within the patient’s limitation
Here’s a few: b. Coronary Artery Bypass Graft (CABG)
A. Beta – adrenergic blocking agents - Its main purpose is myocardial

(often called Beta-blockers) usually end revascularization
with “-olol” hence you find Propranolol, - Commonly used grafts are the
Metoprolol, Nadolol, etc. saphenous vein and internal mammary
B. Calcium-channel blocking agents artery.
(often called Calcium-blockers) usually - Nursing responsibility:
end with “-dipine” hence you find
Amlodipine, Nidefipine, Nicardipine, etc. i. Administer nitroglycerine for pain relief
C. Statins usually ends with this name ii. Promote rest periods
itself hence you find Simvastatin, iii. Stop activity immediately when chest
Atorvastatin, Lovastatin, etc. pain occurs
D. Thrombolytic agents usually end with MONA + THROMBOLYTICS
“-kinase or -ase” hence you find
streptokinase, urokinase, tenecteplase, M- orphine O- xygen N-itrates TIV A-
anistreplase, etc. nticoagulant (heparin) + Thrombolytics
(dissolving the blood
E. ACE Inhibitors usually ends with “-
pril” hence you find Captopril, Enalapril, Complications of MI
Lisinopril, etc. 1. Arrhythmias
2. Surgical Management 2. Cardiogenic Shock
a. Percutaneous Transluminal Coronary 3. CHF
Angioplasty (PTCA)
4. Thromboembolism
-keep plaque formations compressed
5. Pericarditis
- Mechanical dilatation of the coronary
vessel wall by compressing the 6. Ventricular aneurysm
atheromatous plaque 7. Rupture of Myocardium

Nursing Intervention body’s tissues and organs, including the
heart itself (Smeltzer et al, 2016). If no
1. Assess hemodynamic status, V/S,
regular rhythm will be observed with the
ECG, pain
normal pumping of the heart, called
2. Assess patency of IV line dysrhythmia or arrhythmia, life-
threatening conditions may arise.
3. Monitor RR before and during
Morphine administration A. Dysrhythmias
4. Observe CBR - Abnormal cardiac rhythms which are

due to the following factors:
5. Position in Semi-Fowler’s position
a. Tissue ischemia
6. Monitor urine output; notify if less than
30mL/hr. Kung weight mo 60kg, dat b. Hypoxemia
napproduce mo rin ay 60ml/hr
c. SNS and PNS influences
7. Increase fluid intake
d. Lactic acidosis
8. Observe low fat, low salt, high fiber
e. Electrolyte imbalances (e.g.
diet
potassium)
9. Decrease environmental stimuli
Common Dysrhythmias after MI
1. Sinus Dysrhythmia
- An irregularity in the heart rhythm
originating in the sinus node, that shows
either elevated heart rate, decreased, or
both
a. Sinus tachycardia
- Heart beats rhythm is normal, rate is

above normal.
Lesson 2: Management of the
Clients with Dysrhythmias - Ang taas ng R wave at so close to
each other
Lesson Proper
- Treatment: digitalis administration
Without a regular rate and rhythm, the (Lanoxin, a form of digoxin. A known
heart may not perform efficiently as a positive inotropic and negative
pump to circulate oxygenated blood and chronotropic)
other life-sustaining nutrients to all of the

b. Sinus bradycardia (Mas nakakatakot kesa sa atrial dahil
may pulse at bp na involve)
-Forms:
i. Premature Ventricular Contractions
- Heart beats rhythm is normal, rate is
(PVC) – ectopic beat originating from
below normal
the ventricle and discharged at a faster
- Ang layo ng R wave form rate
- Treatment: Atropine
Sulfate to block vagal stimulation
(nakakavagal ng tibok ng <3) (anti
cholinergic drug or para sympathetic
nervous system)
c. Sinus arrhythmia ii. Ventricular tachycardia – 101-250bpm
- Regular irregularity in rhythm which is

related to respiratory exchange. No
treatment (treatment is cause specific)
2. Atrial Dysrhythmia (nasa atrial naman
ang problema dito)
- Premature Atrial Contraction (PAC) is iii. Ventricular fibrillation – random and
an ectopic beat that originates in the chaotic discharge of impulse at a rate
atria and is discharged at a rate faster exceeding 300bpm; it produces clinical
than that of the sinus node (AV node death
again, delay it is replaced with ectopic, it
is originated somewhere in atria, rather
than AV node)
- 3 Forms:
i. Atrial tachycardia: 150-250 bpm
ii. Atrial flutter: 250-350 bpm (we hardly 4. Conduction Defects / Heart Blocks /
find the PQST) AV Blocks Degree of AV Blocks:
iii. Atrial Fibrillation: >350bpm a. First degree – impulse is SLOW to go

through AV node
3. Ventricular Dysrhythmia
b. Second degree – SOME impulse go
- Decreased diastolic filling and cardiac through the AV node; some do not
output decreases tissue perfusion which
can lead to absence of pulse and BP

c. Third degree – no impulse from SA 2. Pacemakers (may magsisilbing
node gets through the AV node alternative na pacemaker)
Asystole- no contraction or SA node at
all
- Electronic device that provide
electrical stimuli to the heart
muscle
Types:
a. Fixed – with preset rate; independent
of the patient’s own rhythm
b. Demand – triggers electrical firing
only when the heart rate slows down
Medical Management
1. Antidysrhythmic Drugs
• Class I: Fast Sodium Channel Blockers
Ia : Quinidine, Procainamide,
Disopyramide
Ib : Lidocaine, Mexilitine
Ic: Flecainide
• Class II: Beta – adrenergic Blockers
1. Check HR regularly and compare with
Propranolol and Acebutalol the set rate of pacemaker
• Class III : Potassium – acting 2. Inspect the site of insertion for signs
Antiarrhythmics (Prolong repolarization) of infection
-rone (it can make the heart beat so
3. Cleanse the site and change the
fast)
dressing regularly
Adenosine and Amiodarone
4 Cardioversion and Defibrillation
(Cordarone)
The aim in both is to deliver electrical
• Class IV : Calcium Channel Blockers
energy to the heart to stun the heart
Verapamil, Nifedipine and Diltiazem momentarily and thus allow a normal
sinus rhythm to kick in via the heart’s
• Others normal pacemaker (i.e. the sinoatrial
Phenytoin, Digoxin node)

Defibrillation- treatment for immediately pump oxygenated blood in response to
life-threatening arrhythmias with which metabolic needs.
the patient does not have a pulse (e.g.
Causes
ventricular fibrillation or pulseless
ventricular tachycardia) MI or any cause of heart damage
Cardioversion- is any process that aims Cardiomyopathy
to convert an arrhythmia back to sinus
rhythm. These scenarios may be Cardiac conduction defects
associated with chest pain, pulmonary Ventricular Overload
edema, syncone or hypotenson. It is
also used in less urgent cases. (e.g. Hypertension
atrial fibrillation) Classification
4. Cardiopulmonary Resuscitation 1.Left – Sided Heart Failure
-consists of use of chest compressions -Central manifestations
and artificial ventilation to maintain
circulatory flow and oxygenation during -Left ventricle cannot effectively pump
cardiac arrest blood out of the ventricle into the aorta
and systemic circulation
Lesson 3: Management of the
Clients with Heart Disease -CAD and Hypertension are most
Complications common causes
Lesson Proper -Increased left ventricular end-diastolic

blood volume increases the left
CVDs as discussed in the first two ventricular end-diastolic pressure which
lessons if left untreated, mismanaged, or decreases blood flow from the left atrium
with poor body defense mechanisms forcing fluids to move from the
due to certain reasons may develop into pulmonary capillaries into the pulmonary
numerous complications. Lesson 3 tissues causing lung congestion
provides a major heart disease
complication namely heart failure or -Remember “L”eft ventricle and “L”ungs:
congestive heart failure. Although in fluid goes back to the lungs
nursing students’ independent learning, -Always Heart-origin
they still may find other heart disease
complications in their textbooks such as -Nireretun nalang yung blood since
cardiogenic shock, thromboembolism, ayaw na magpump nung left ventricle
cardiac arrest and other related. 2.Right – Sided Heart Failure
A. Congestive Heart Failure -It occurs when the right side of the
- A sequel of MI heart cannot eject blood and cannot
accommodate all the blood that normally
- A state of circulatory congestion returns to it from the venous circulation
characterized by inability of the heart to

-Resulting from oncotic pressure that 2.ABG (low oxygen saturation)
pushes fluids into the cells
3.Echocardiogram (Reveals heart
- Caused by Cor Pulmonale (Pulmonary enlargement)
hypertension) and left heart failure
4.ECG
-Leads to accumulation of fluids in
E.2Right-Sided Congestive Heart
systemic venous system
Failure
-Fluids goes back in the lower body part
1.Signs and Symptoms (RSCHF)
-Always Lung-origin
2.Jugular Vein Distention
E.1Left-Sided Congestive Heart Failure
3.Hepatomegaly
Signs and Symptoms (LSCHF)
4.Portal hypertension
1.Dyspnea
5.Ascites
2.Orthopnea
6.Peripheral Edema (Pitting/Dependent)
3.Rales/crackles
7.Splenomegaly
4.Productive cough
8.Jaundice
5.Blood-tinged frothy sputum
9.Hemolytic Anemia
6.Wheezing
10.Internal Hemorrhoids
7.Pleural effusion
11.Leg Varicosities
8.Dizziness
12.Weight Gain
9.Syncope
13.S3 and S4 Sounds
10.Fatigue
14.Elevated CVP reading
11.Anorexia
Wise and Easy Tips 4.2 RHF v.s. LHF,
12.Hypokalemia which is which?
13.Clubbing of fingers It may not apply to all clinical
manifestations of heart failure but
14.Polycythemia
oftentimes the word “Peripheral
15. S3 and S4 sounds Manifestations” pertaining to RHF and
“Central Manifestations” pertaining to
16. PAP, PCWP LHF are helpful when distinguishing the
17. urine output two.
Diagnostic Test (LSCHF) When we say peripheral manifestations

for RHF it should be thought that these
1.Chest X-ry (reveals heart enlargement are signs and symptoms we observe
and pulmonary congestion)

distal from the thoracic part of the body. ii.Loop Diuretics – Furosemide (Lasix);
Examples are neck vein engorgement, Bumetamide (Bumex) (tinanggal din
hepatomegaly, ascites, leg varicosities, potassium hindi lang si sodium)
peripheral edema, etc
iii.Potassium-Sparing – Spironolactone
On the other hand, central (Aldactone); Triamterene (Dyrenium)
manifestations for LHF are signs and (ineexcrete kasi natin si sodium dahil
symptoms noticeably occurring within pag tinanggal mo si Na, tinanggal mo in
the core or the thoracic part of the body. fluid, kaya nagcoconserve tayo ng K, we
Examples are DOB, productive cough, want to sustain functional level of
crackles, pleural effusion, etc. potassium, because if there wont be
potassium, your heart cant pump
Diagnostic Test (RSCHF)
properly)
1.Chest X-ray
-Assess for s/sx of hypokalemia when
2.ABG administering thiazide and loop diuretics
3.Echocardiogram -Give potassium supplement and

potassium rich-foods
4.Liver Function
-Best administered early in the morning
5.ECG or early in the afternoon
Medical Management d.Digitalis
1. Pharmacologic Treatment -Major therapy for CHF
a.ACE Inhibitors (decrease blood -(+) inotropic; (-) chronotropic effect
pressure)
-E.g. Lanoxin (Digoxin), Crystodigin
-Promotes vasodilation and dieresis (Digitoxin)
-E.g. Captopril (Capoten), Enalapril -Assess heart rate before administration,
(Vasotec) withhold if below 60 or above 100bp
b.Beta – blockers -Assess digoxin toxicity: B – radycardia
c.Diuretics (For your right heart failure A – norexia
there is peripheral edema, for you left
heart failure, there is pulmonary edema) N – ausea and vomiting D - ysrhythmias
Types of Diuretics Used: (sodium and A – ltrered visual perception

potassium are always against each (yellow/green halos) M – ales:
other) gynecomastia
i.Thiazides – Chlorothiazide (Diuril); 2.Other Treatment

Hydrochlorothiazide (Esidrix)
a.Low salt diet

b.Activity – balance program of activity body must also be evident in working
and rest simultaneously with the heart as to
ensure the aforementioned purpose of
c.Oxygen therapy
the cardiovascular system. This last
Nursing Intervention lesson proper will describe different
peripheral vascular disorders and will
1.Providing Oxygenation help student use nursing process as to
a.Oxygen therapy via nasal cannula @ promote healing and wellness among
2-3LPM as ordered the affected individuals.
b.Semi or High Fowler’s positioning Peripheral vascular diseases refers to

conditions of reduced blood flow due to
2.Promoting rest and activity altered or diseases peripheral
3.Decreasing anxiety vasculature (Arteries and veins)
-Anxiety causes breathlessness which I.Two Major Classification of PVD

may be perceived as severity of heart A. Arterial Disorders
failure
B. Venous Disorders
4.Facilitating fluid balance, nutrition and
elimination IV. Common Forms of Arterial
Disorders
-Control sodium intake (minamanas na
kasi ang patient) A. Arteriosclerosis
-Monitor I and O (wag hayaan na pati si -Hardening of the muscle fibers and
renal napabayaan) endothelial lining of small arteries
-Avoid Valsalva maneuver B. Atherosclerosis
5.Provide skin care - Accumulation of atheroma in the tunica

intima of the blood vessels
-Change position at regular interval
Collaborative Management
-Use protective devices to prevent
pressure sores - Low fat diet
Lesson 4: Management of the - Antihyperlipidemics: bile acid

Clients with Peripheral Vascular sequestrants, nicotinic acid, statins
Diseases - Antihypertensives
Lesson Proper - Lower the extremities below the heart
The heart, even in its perfect condition - Warm compress and avoid cold
or functionality, cannot perform alone temperature
adequate oxygenation and delivery of
nutrients to body tissues. The patency or - Encourage walking
integrity of blood vessels in the entire

C.Thromboangitis Obliterans - pulsatile mass over the abdomen
(Buerger’s disease) (AAA)
- Recurring inflammation of the - low back pain
intermediate and small arteries and
- flank pain
veins of the lower and upper extremities
- shock
- It is associated with cigarette smoking,
genetic factors, immunologic factors and Collaborative Management
coagulation abnormalities
- The most common characteristic /
manifestation is intermittent claudication - Antihypertensive drugs
Collaborative Management 2. Surgical treatment
- Eliminate cigarette smoking - Surgical graft if aneurysm is greater

than 4cm and enlarging
- Calcium – channel blockers (if
associated with hypertension) 3. Nursing Management
- Antiplatelet agents a. Maintaining Tissue Perfusion
- Amputation of ulcerated fingers and -VS and hemodynamic measurement

toes -Urine output, BUN, creatinine levels
D. Aneurysm -Assess peripheral pulses
- A localized, irreversible dilatation of an b.Promoting Fluid Volume
artery secondary to an alteration in the
integrity of its wall, overdistention -Check dressing for excessive drainage
- Most common type is Abdominal Aortic -Assess for abdominal pain or backpain
Aneurysm (AAA) (retroperitoneal hemorrhage)
Classification of Aneurysm -Assess hgb and hct values
a. Fusiform – involves outpouching of E. Raynaud’s Disease

both sides of the artery -The intermittent vasospasms of the
b. Saccular – involves outpouching of arteries in the fingers and toes due to
only one side of the artery cold exposure and emotional stress
c. Dissecting – Involves separation or -Aggravated by smoking

tear in the tunica intima and tunica -Raynaud’s phenomenon – unilateral
media affectation of the extremities
Risk Factors : smoking, heredity and Collaborative Management
HPN
-Avoid exposure to cold
Signs and Symptoms

-Stop smoking -Minimize parenteral injections if on
thrombolytic therapy
-Vasodilators
(magiging prone si patient sa bleeding)
-Analgesics as ordered
2. Surgical treatment
-Symphathectomy (similar to carpal
tunnel syndrome) to relieve vasospastic a. Thromboembolectomy
symptoms
b. Vena Cava Filter
-Amputation of gangrenous extremities
V. Common Forms of Venous
1. Maintaining Tissue Perfusion
Disorders
-Bed rest
A. Deep Vein Thrombosis
- Elevate legs to promote venous return
-It is caused by Virchow’s Triad:
and alleviate edema
1. Venous stasis (pulling of blood)
- Compression support stocking
2. Vessel wall injury
- Avoid long periods of standing or
3. Hypercoagulability of the blood sitting
-Life – threatening because it may lead 2. Promote comfort
to pulmonary embolism
- Administer analgesics as ordered
Signs and Symptoms
-Edema and swelling of the affected
extremities
-Warm skin
-Prominent superficial veins
-Tenderness
-Calf pain (Homan’s sign)
1.Pharmacologic therapy
a. Anticoagulants
-Heparin SC or IV
-Coumadin
b. Thrombolytics

Lesson 1: Body Fluids and c. Transcellular Fluids (TF) – the
Electrolytes: A Review on Normal smallest division among the ECF
Composition, Functions and compartments. Examples are CSF,
Regulations serosa, synovial fluids, humors of the
eyeball, digestive juices (juices
Duration: 1 hour
responsible for breaking down foods that
Approximately 60 Percent of the weight we eaten, HCL) , urine
of an adult consists of fluids (water and
Electrolytes). In general, younger people
have a higher percentage of body fluid
than older people, and men have
proportionately more body fluid than
women. People who are obese have
less fluid than those who are thin
because of fat cells containing little
water .The skeleton also has a lower
water content. Muscle, skin, and blood
are known to have the highest amount
of water in the body.
I. Amount and Composition of Body
Fluids
A. Body Fluids Per Compartments
1. Intracellular Fluids (ICF) – 70%;
fluids inside the cells; located primarily B. Body Water Distribution According
in the skeletal muscle mass to Age and Sex
2. Extracellular Fluids – 30%; fluids 1. Infant – 80% of body weight
outside the cells, between cells, and
cavities 2. Male adult – 60% of body weight
a. Interstitial Fluids (ISF) – fluids 3. Female adult – 50% of body weight

between cells; (fluids that separate cells 4. Old – 45-55% of body weight
from the body) (if pt has edema, tha
whenever there would be increasing C. Functions of Body Water
amt, there will be edema) it contains 11
ECF – maintains blood volume;
to 12 L
transport system to and from the cell
b. Intravascular Fluids (IVF) – blood
ICF – internal aqueous medium for
plasma; approximately 3 L(vein, artery)
cellular chemical function (different cells
(sa inside may fluids at yun ay IVF or
in our body compromises of different
plasma)
organelles also) (mga organelles wont
function without ICF, it serves as a fuel)

Maintenance of normal body Accounts on insensible fluid loss via
temperature (kapag may change sa sweat; 600ml/day
body temp ng person, may something
The chief solutes in sweat are
wrong sa fluids or status of hydration,
Sodium, Chloride and Potassium
hindi lahat ay may lagnat baka kasi
dehydrated lang) Water vapor from respiration;
approximately 300ml/day
Elimination of waste products (sweat..
etc) Approximately 8liters of fluid circulate
through the GI system every 24 hours
D. Factors that Affects Total Body
Water The usual loss of GI tract is ss100 to
200ml daily.
1. Age- as we age, body water is
starting to go down Comparing Daily Intake and Output
2. Gender- higher level of water in males INTAKE
than females
Oral Fluid- 1,200mL
3. Input and Output- whatever the input
of pt is, should be the same with their Water on foods- 1,000mL
output Water in Metabolism- 300mL
Ways for Fluid Output: Total- 2, 500mL
i. Sensible fluid loss- fluid that OUTPUT
can be measured (urine)
ii. Insensible fluid loss-cannot be Urine Output- 1,500mL
measured (sweat, secretions, Stool- 200mL
water vapor from breathing,
stools) Skin- 500mL
II. Organs for Fluid Loss Lungs- 300mL
1. Kidney Total- 2,500mL
1-2 L of urine output in adults 2. Passive Transport Mechanism

(does not require ATP for continuous
General rule : 1ml of urine/kg/hr movement of body)
E.g. 70 kg=70ml a. Diffusion – transport of solutes from
(kung gano yung timbang, ganon raw area of ↑ concentration to area of
karami yung dapat iihi per hour) ↓concentration across a semi-permeable
membrane (RBCs, WBCs, nutrients,
2. Skin micro and macronutrients) (nagmomove
3. Lungs lang is solutes)
4. GIT b. Osmosis – transport of solvent from

area of ↓concentration to area of

↑concentration across a semi-permeable b. (No cells in the body would be doing
membrane (increasing amt of fluids) their action unless these two electrolytes
(nagmomove na solute, nagmomove pa will be doing their exchanges)
solvent)
3. Hydrostatic Pressure
Higher concentrated- maraming solutes
- The “pushing force” of the blood
F-ressure, you don’t appreciate diffusion pressing against the blood vessels
without pressure because it transport walls. (Whenever there would be rise in
higher concentration to lower the vol in a compartment, gano din yung
concetration (parang pabango) F- pressure) (Kapag maraming volume,
articles, solutes lang tinatransport ng nagkakahigh blood pressure)
diffusion
4. Oncotic pressure/colloid osmotic
H2Osmosis pressure
c. Facilitated Diffusion – This process - Pressure needed to overcome the pull
does not require ATP but does require of CHON. E.g. albumin (Wherever
cell membrane proteins which are called protein will be going to, meron ding
carrier proteins to carry the molecules water)
across the cell membrane from an area
- Pull or absorb fluid from interstitial
of higher concentration to an area of
spaces (Kapag mataas ang protein baka
lower concentration. E.g. Vitamin C,
magkaron ng hyperaccumulation of fluid
glucose, amino acids (if the one who
in interstitial spaces). If interstitial is filled
needs to be transported is larger
with volume, nagkakaron ng edema
molecules. That’s how youll know if yun
ang tawag at hindi diffusion) (Can be 3. Fluid Concentration
similar to osmosis, it can also move
what it has to be moving from lower to Osmolarity – concentration of solute
higher concentration) per liter of solution
2. Active Transport Mechanism Osmolality – concentration of

solute per kg of
a. Sodium – Potassium Pump – solution; concentration of
transport of Na+ and K+ into and out of particles
the cell requiring an energy (ATP) to
cause the movement (v. important for -275 – 295mOsm/kg
creation of functions in the body) Serum osmolality – concentration of
(wherein the sodium from extracellular particles in the plasma
fluids will be going inside the cell, the K
will be going out naman. Na and K Tonicity – the effect of water/solution
shouldn’t be staying together, on the water’s osmotic pressure
magkaaway sila) (your cardiac cells 1. Osmotic Pressure – the power of a
wont do their action which is to pump solution to draw water across a semi-
blood unless sodium will come in diff permeable membrane (e.g. cell
cells in our heart. DEPOLARIZATION) membrane)

- ↑ osmotic pressure (whenever there is in the body) (severely dehydrated) (very
compartment wherein it will be dilute, malabnaw na malabnaw)
dependent with movement of soln in the
c. Hypertonic solution
body thru mechanism of osmosis) : ↑
pulling force (kasi si osmosis is pulling ↑solute concentration than plasma
water from lower to higher
concentration) When exposed to hypertonic solution,
cells will shrink
- Cell shrinks if on ↑ osmotic pressure
(hypertonic) E.g. D5LR, D10W, D5NSS
- Cell swells if on ↓ osmotic pressure Indication: for intracellular overload

(hypotonic) (lahat ng cells ay magsshrink, para
maattract yung tubig at mapunta sa
- E.g. Red blood cell: if exposed on blood vessel, yung tubig ng patient na
hypotonic solution will swell If exposed extra e mapupunta sa blood vessels,
on hypertonic solution will shrink they will travel until kidney, and it will be
excreted as urine therefore, the pt will
2. Tonic Solution
be free from intracellular overload) (D5
a. Isotonic solution (All cells in the body) except D5W ay hypertonic)
No fluid movement or change in 4. Mechanisms That Control Body
volume within the cell Fluids
No change on the cell size 1. Thirst
E.g. Plain NSS or 0.9 NaCl, D5W, 2. Kidneys
Lactated Ringer’s Solution
3. ADH- causes increased water
Indication: for intravenous dehydration reabsorption in the distal convoluted
(dehydrated intravenous compartment, tubules and collecting ducts hormone
blood vessels lang ang dehydrated, produced by hypothalamus. Pinipigilan
kokonti plasma kaya nadedehydrated sobra mong pag-ihi
mga ugat) (we try to expand first
4. RAAS (Renin – Angiotensin –
vasculature of pt)
Aldosterone - System)- Renin is a
b. Hypotonic solution hormone produced by the kidney
wherein expected to stimulate another
↓solute concentration than the blood
hormone also which is an angiotensin
plasma
coming from the liver. AAldosterone
When exposed to hypotonic solution, hormone in the body produced by
cells will swell adrenogland particular adrenal cortex,
retention of sodium in the body.
E.g. 0.45 NaCl, 0.25 NaCl Whenever theres a need to increase Na,
Indication: for intracellular dehydration attacts H2O
(not only vasculature, but the other cells

5. Atrial Natriuretic Hormone,
Baroreceptors, Osmoreceptors- ANH Na 135 –
came from your heart, capable (nas 145
producing small amts of hormone that a mƐq/L
bloo
can control body fluids. Baroreceptors d
responsible for controlling pressure in strea
the body. Osmoreceptors responsible m)
for attraction of releasing H2O in the K 3.5 – 5 mƐq/L
body ff osmosis. Ca 4.5 – 5.5 mƐq/L L
HPO 1.7 – 2.6 mƐq/L
5. Electrolytes 4
Cl 98 – 108
>body systems wont do their function
mƐq/L
without electrolytes Mg 1.5 – 2.5 mƐq/L
Chemical compounds in solution that
have the ability to conduct an electrical General Functions of Electrolytes
current
1. Promote neuromuscular activity
Break into charged particles called
ions 2. Maintain body fluid volume and
osmolality (wherever sodium will go,
Positively charged ions (CATIONS); water as well)
negatively charged ions (ANIONS)
3. Distribute body water between fluid
Major Extracellular Cation – Na+ compartments
(Sodium)
4. Regulate acid – base balance
Major Intracellular Anion – Cl-
(Chloride)
Major Intracellular Cation – K+
(Potassium) (Resting stage of cell);
Major Anion – HPO -
(Phosphate)
Depolarization- sodium rushing in the
cells, whenever cell needs to do its
function, we need to do sodium-
potassium pump, soidum will come
inside cell, making cells highly positive
which we called depolarization to such Function of the Renin to excite,
extent that it reaches its peak of action, stimulate the liver to produce
it will create cellular activity. Walang Angotensinogen enzyme w/c is
pagtibok ng puso until an exchange bet. responsible for the production of
Na at K will exchange inside the cells. Angiotensin 1 which alter on is
converted into Angiotensin 2.

Angiontensin 1 is an inactive form of a
vasoconstrictor and vasoconstrictor
wholl do power of putting back the
normality of blood vol, bp, NA is
Angiontensin 2. To convert you need an
ACE. Angiontensin Converting Enzyme
(magttransform ng Angiontensin 1 to 2).
It is now to stimulate several target cells
and target hormones as well. What will it
target? The aldosterone. The
angiotensin II will target the adrenal
gland particularly the Adrenal cortex to
release aldosterone hormone. It will be
of help in increasing sodium in body. Lesson 2: Management of the
Sodium retention kasi yun main prob e Clients with Body Fluid Imbalances
nauubos sodium. Kidneys instead Duration: 1.5 hour
producing urine, pipigilan niya ihi mo.
Lesson Proper
Para di mawalan ng Na. Another power
of Angiotensin 2 is to stimulate your Lesson 2 presents the common body
baroreceptors located in many blood fluids alterations or deviations-from-
vessels in body kasi responsible for normal. Particularly, it will differentiate
vasoconstricting movement of blood fluid volume deficit and excess then
vessels. kapag nagiging narrower or even further classify these two as to
smaller yung compartment, the bp will when we say the concentration of fluid
rise up. Osmoreceptors responsible for imbalances imbalance become isotonic,
stimulating hypothalamus to produce hypotonic or hypertonic. Moreover,
more ADH to be release leading water these homeostatic imbalances shall find
retention enters mechanism. Because of appropriate medical or nursing
this, there’ll be a command to drink managements as to promote healing
some more water. And kidney not to and wellness.
excrete so much.
This discussion outline can also find
supportive topics or information from the
recommended medical – surgical
nursing textbooks hence independent
learning is encouraged. Similar to
previous course units, nursing students
will still expect to find helpful learning
tips, activities or exercises and case
scenario analysis which will develop
nursing competencies among them.

Types Fluid Imbalances
1. Fluid Volume Deficit
2. Fluid Volume Excess
Dehydration- loss of water alone, most
common fluid disturbance
Fluid Volume Deficit- loss of water and
electrolytes
A. Fluid Volume Deficit (FVD)
1. Risk Factors:
a. Age/Gender- as we age, water of our
body is diminishing
b. Illness
c. Environmental factors- the hotter it
gets, the higher tendency we lose water
d. Lifestyle and Diet- not all person are
into drinking water
2. Two Forms:
a. Isotonic / Iso-osmolar FVD- Manifestations
b. Hypertonic / Hyperosmolar FVD Thirst
Weight loss
Elevated temperature
Dry mouth
Warm, flushed, dry skin
Soft, sunken eyeballs
Tachycardia, low BP, Tachypnea,
Altered LOC (compensatory mechanism
as well) (kapag nawawalan ng tubig,
your heart will increase heartbeat para
macompensate pagkukulang ng o2 and
nutrients)

Diagnostic Test 2. Monitor skin turgor, mucosa and
tongue
1. ↑hct (hematocrit) and BUN (your
kidney is having products of excreting 3. Safety measures such as side rails
waste products like BUN)
B. Fluid Volume Excess
2. ↑S.G. (Specific gravity eg. Urine)
1. Risk Factors
higher than 0.35- highly concentrated
ang ihi, masyadong concentrated ang a. Excessive administration of hypotonic
dugo mo non, kulang sa tubig solution
3. ↑Plasma concentration b. Increase production of ADH
4. ↑serum osmolality 2. Two Forms
5. ↑Na+ level a. Isotonic / Iso-osmolar FVE
Nursing Diagnosis b. Hypotonic / Hypo-osmolar FVE
1. Fluid Volume Deficit r/t diarrhea
2. Ineffective Tissue Perfusion r/t fluid
loss
3. Risk for Impaired Skin Integrity
4. Risk for Imbalanced Nutrition: Less
than Body Req’t
5. Risk for Injury r/t loss of electrolytes
6. Activity Intolerance
Medical Management (Sa ihim
potassium ang nawawala) Signs and Symptoms
1. Fluid replacement: Altered LOC
i. Oral replacement- kapag mga LBM Altered LOC
give them ORS
(swelling in the brain: increased
ii. IV and ECF replacement – not intracranial pressure
capable of drinking water. PLR, PNSS,
D5W, KCl via titration (ihalo gamot sa Hyperventilation (due to fluid
isang solution) overload)
Nursing Management Sudden weight gain
1. Monitor VS, I&O, weight q4 (most Warm, moist skin

sensitive implication of hydration) ↑ ICP, ↑BP, ↓HR
Low serum Na+ levels

Edema / peripheral edema D
Diagnostic Test
1. CVP increases- due to high BV and
BP
2. Serum Na+ increases
3. Chest x-ray- reveals pleural effusion Lesson 3: Management of the
Clients with Electrolyte Imbalances
4. ↓serum osmolality Duration: 2 hours
5. ↑BUN, creatinine Lesson Proper
Nursing Diagnosis In this lesson, nursing students will
1. Fluid Volume Excess r/t fluid overload apply their basic understanding of
secondary to HF, RF, etc. electrolyte functions and its regulatory
mechanisms to different electrolyte
2. Ineffective Breathing Pattern r/t fluid imbalances. Electrolyte alterations or
overload in the lungs secondary to imbalances readers will encounter are
pulmonary edema only either above or below the serum
Collaborative Management normal levels (e.g. hypernatremia vs
hyponatremia). Discussion will begin
1. Strict Fluid Restriction with the normal functions or activities of
2. Low salt diet each electrolyte then will introduce the
expected imbalances summarizing
3. Administration of diuretics definition, etiology, clinical
4. Infusion of hypertonic IV solution manifestations, diagnostic tests and
(transported to blood stream then kidney medical-surgical managements.
then be excreted) A. Sodium
5. Assess mental status - Major electrolyte for water regulations
6. Monitor I&O, weight, VS, electrolyte - Necessary for glucose to be
status transported to the cells
7. Comfort measures, skin care for - Controls ECF osmotic pressure (the
edema higher a Na is, there will be attraction of
Edema H2O)
Accumulation of fluids in the interstitial - Necessary for neuromuscular

spaces or ECF functioning, intracellular chemical
reactions
Causes: excess body water and Na+,
hypertension, renal failure, - Maintains acid – base balance
↓oncotic pressure, ↑hydrostatic pressure - “water follows sodium”

- Daily requirement is minimum of Na+ loss with water loss or excess
2gm/day (dilution) , or nadilute na ng maraming
tubig
- Serum sodium level: 135 – 145 mEq/L
(hypo/hypernatremia” Causes:
- Urine sodium level: 20 – 220 mEq/L i. Treatment with diuretics (loop
diuretics such as furosemide) (known to
- Sources: canned, processed, instant
be promoting diuresis, and excretion or
goods, junk foods, seasoning, seafoods
removal of certain electrolytes in the
Different Regulatory Mechanism for body
Sodium
ii. Low sodium intake (sodium
1. Thirst (hypothalamus will set in responsible for neuromuscular activity)
sensation that will do drinking, kapag
iii. GI losses (vomiting, diarrhea)
mataas Na, ay need na uminom ng
water) iv. ↓Aldosterone secretion- Addison’s
disease (Adrenal cortex would not be
2. Glomerular Filtration- filters Na
sufficient enough to produce
before expelling urine, reabsorption of
aldosterone the pt would not be normally
RBC, and secretion of urine containing
conserving sodium and youll lose it
waste products. Sodium should not be
through urine, etc
continuously excreted in our body.
Because you will be dehydrated. v. Burns, small bowel obstruction
3. RAAS- whenever there is overactivity vi. Excessive diaphoresis
of our kidneys, liver, Na will also be
Signs and Symptoms (↓ECF, ↑ICF)
increasing. Whenever our body is
experiencing low level of blood volume, Headache
low level of bp, and low sodium, RAAS
will do something to increase sodium Muscle weakness (very reliant to Na-
such as aldosterone. K pump)
4. Osmotic Pressure- high OP, high Na Fatigue and apathy
5. Aldosterone- hormone produced by Postural hypotension

adrenal gland particularly adrenal Anorexia, n&v
cortex; to retain sodium in the body as
well as water. Abdominal cramps (Decrease
peristalsis)
6. Na-K pump
Weight loss
Two Forms of Sodium Imbalances
Feelings of apprehension
A.1 Hyponatremia (Sodium Deficit)
Seizures and coma
Dry skin and oral mucosa

Diagnostic Test ii. High Na+ intake, low water intake
1. Serum Na level- <135 mEq/L iii. ↑ sensible loss- diaphoresis, burns,
fever (causes of dehydration), the more
2. ↓S.G.-<0.010
patient lose water, the more higher the
3. ↓ serum osmolality (Concentration of value of the Na
our blood) <280mOsm/kg
iv. Rapid infusion of Saline/IV (they are
Medical Management so high in Na)
1. IV Fluid Replacement v. Diabetes Insipidus (involves

antidiuretic hormone, hyposecretory
a. Isotonic Solution (PNSS)- if 115-130 problem of pituitary gland, our body isn’t
mEq/L only (manageable level of having sufficient supply of antidiuretic
hyponatremia) hormone, nawawalan ng pamigil sa
b. Hypertonic solution (0.3 saline normal na ihi. Nagkakacopius dilute
solution)- if <115mEq/L- if too much urine.
dehydration vi. Cushing’s Syndrome (prob of adrenal
2. Replace other electrolytes depleted gland, hypersecretory of corticosteroid,
(K,Ca,HCO3) collective term with many hormones
produced by adrenal cortex such as
Nursing Management aldosterone. If in excessive level, the
1. Monitor serum Na+, I & O, VS more aldosterone, the more u conserve
especially PR- due to shock-like or elevate sodium in the body. Tataas
symptoms din tubig sa katawan. Lumolobo tingnan
mga tao na merong ganyan. EDEMA.
2. Restrict excessive water intake- to Third spacing.
prevent Na dilution
Signs and Symptoms
3. Salt, salty foods in diet
Extreme thirst
4. Safety precautions
Dry, sticky mucous membrane
A.2 Hypernatremia (Sodium Excess)
Oliguria (the more sodium na meron,
Na+ excess with water excess or loss the more water naattract para magstay
of water but with high level of Na; sa body kaya less urination)
>135mEq/L
Excitement, agitation, tremors, muscle
High serum osmolality twitching
Either FVD or FVE with ↑ serum Red, dry, swollen tongue
osmolality
Tachycardia, possible hypertension
Causes: (kapag mataas Na, tataas den blood
i. More water than Na+ is lost from the volume, the higher the bp)
body- e.g. hyperventilation, diarrhea Restlessness followed by fatigue

Disorientation and hallucination - Potassium-rich foods: banana, dried
fruits, orange, raw carrot, tomato, baked
Edema
potato, melon, watermelon
Diagnostic Test
Regulatory Mechanism
1. Serum Na+ level
1. Insulin
2. ↑S.G.
-pampababa ng glucose, from the
3. ↑ osmolality bloodstream, insulin will carry glucose to
diff cells in the body, sa mga muscular
Medical Management cells kasi nakakalata yun, If your water
1. IV infusion + diuretics- D5W, PLR follows sodium, your potassium shall
plus diuretics follow glucose.
2. Dialysis (renal failure) (per MDs - Activates sodium-potassium pump

order) - Kapag wala tayong sufficient amt of
3. Strict sodium restriction insulin,ay lalata lata tayo kasi walang
insulin na magstimulate ng sodium
Nursing Management potassium pump na nahehelp magfx ng
1. Monitor serum Na, VS, I & O nervous tissues
2. Restrict Na in the diet - ↑ insulin : ↑ K permeability
3. Edema monitoring 2. Catecholamine
4. Monitor behavior changes -Adrenal medulla responsible for

catecholamine which is responsible to
5. Avoid drugs that increases Na+ level increase or decrease potassium in our
like antibiotics, cortisone, antitussive body esp when patient need for cardiac
(merong Na sad ulo kaya bawla ibigay support. Magbigay ng epinephrine to
kasi madadagdagan lalo yung sodium) increase HR with potassium bc K is
B. Potassium- works hand in hand with main electrolyte for increase of cardiac.
Na, they balance each other Epinephrine is on catecholamine. Pag
masyado mataas si potassium, bigyan
- 3.5 – 5 mEq/L rin ng catecholamine.
- Excitability of nerve and muscles - ↑ K : ↑ heart contraction
- Acts on ICF osmotic pressure - Activates RAAS → ↑Na+ and H2O
- Water and acid-base balance retention → ↑K excretion
- K deficit → alkalosis 3. Aldosterone
- K excess → acidosis -if you have high aldosterone in blood its

like trying to increase also the sodium
- Dietary requirement: 40 – 60 mEq/L level.
daily

-↑ aldosterone : ↓ K+ Medical Management
4. ADH 1. Potassium replacement therapy
- ↑ ADH : ↓ K+ a. KCl drip- KCl 20mEq (10ml) +90 cc of
PNSS or D5W, never bolus
Two Forms of Potassium Imbalance
2. Potassium – sparing diuretics
B.1 Hypokalemia
3. Potassium supplement- Kalium durule
K+ loss; <3.5 mEq/L
4. ↑K, ↓Na diet
Causes:
Nursing Management
i. GI disturbances (suctioning, vomiting,
diarrhea) 1. Give potassium rich foods
ii. Excessive urination (polyuria and 2. Monitor for ECG changes and serum
polykuria know the difference) K
iii. Excessive use of laxative 3. Give 6-8ounces of H20 when
administering potassium supplement
iv.↓ potassium intake
(bcs it is gastric irritant to dilute the K
Signs and Symptoms supplement)
Anorexia, n & v, abdominal distention, 4. Recognize drugs that increases loss

↓bowel motility of potassium
Dysrhythmias (K is the chief 5. IV POTASSIUM (POTASSIUM

electrolyte for heartbeat), possible CHLORIDE/KCL)
cardiac arrest
• 20 – 60 mEq/L (stock:40mEq/20mL)
Muscle
• Usually given 40mEq/1L of PNSS or
weakness→Paresthesia→Paralysis
via titration
polyuria
• Make sure KCL will not exceed
Diagnostic Test 60mEq/L (verify to the physician bcos it
can lead to v strong contraction of heart)
1. ECG changes- best indicator of
hypokalemia • Never given via bolus or IV push!
- Flat T wave • Use small needle / cannula (gauge #22

or #24) because KCl is very irritating to
- ST segment depression the vein
- Presence of U wave • Locate for the largest vein
2. Ph increases (potassium is highly • Use warm compress on IV site if with
acidic) pain
3. Serum K+ level

• Monitor for swelling and tenderness (it Oliguria or anuria
can lead to phlebitis)
Metabolic acidosis
• Contraindications: Spironolactone
Possible cardiac arrest (hyperactive
(potassium sparing med, youll be
contraction of the heart)
doubling potassium to pt and can be life-
threatening), Captopril (ACE inhibitor Diagnostic Test
and can lead to hyperkalemia)
1. ECG changes- best indicator of
B.2 Hyperkalemia hyperkalemia
>5mEq/L - Prolonged QRS complex
Causes: - Elevated ST segment
i. ↑ potassium intake - Peak T wave (patient with
hyperTkalemia, hypUkalemia is peak U
ii. ARF / CRF- impaired urination
wave)
iii. Excessive use of K – sparing
2. Serum K level
diuretics (it can lead to hyperkalemia)
3. ABG-shows metabolic acidosis
iv. ↑ACE inhibitor (-pril medication) (ACE
is needed for increasing Na in the body) Medical Management
(kapag binigay kay pt, bababa si
sodium, kaso mageelevate yug K sa 1. Pharmacologic treatment
blood) a. Potassium-wasting diuretics
v. Multiple Blood Transfusion for 1-3 b. Bicarbonate (highly basic component
weeks (more blood cells that we give to in our body, alkalinic)
the pt, the higher the potassium)
c. 10% glucose with regular insulin/IV
vi. Burns- 1st 48 hours: HyperK (All of
the potassium in the cells came out, d. Loop Diuretics (not only lower down
either they vaporize, or it will find the sodium but also the potassium)
another space, in the plasma) 2. Dialysis
vii. Addison’s disease- low Nursing Management
aldosterone, cortisol levels: increase K
retention (hyposecretion of aldosterone 1. Monitor ECG and serum K level
you are not consuming enough sodium changes
in the body, the lesser sodium, the more 2. Monitor urine output and VS- if <250
potassium. mL/8hr notify physician, HR check
Signs and Symptoms 3. Check blood products before infusion-
Muscle weakness → paralysis date, crossmatch
(potassium whether higher or lower can 4. Restrict potassium-rich foods
cause muscle weakness to the pt)

5. Monitor for drugs that can increase 3. Calcium in citrates
potassium
- Phosphates, citrates located
C. Calcium
Regulatory Mechanism (endocrines
- Muscular contraction, movement of the chief regulator of calcium)
muscles
1. PTH- increases blood calcium levels
- Works closely with Phosphorus in parathyroid glands
(phosphate) and Magnesium
2. Vitamin D- enable calcium to be
-when calcium elevates itself kailangan reabsorbed by the GIT particularly small
mababa si magnesium at phosphorus. intestine
- Most abundant mineral in the body 3. Calcitonin- decreases blood calcium
levels for homeostasis
- Ratio of 10,000 : 1 (ECF : ICF)
Two Forms of Potassium
- Works in impulse transmission
Imbalance
(heartbeat, muscle contraction, BP, etc.
they will never be happening with C.1 Hypocalcemia
sodium and potassium alone we need
<4.5mEq/L
calcium)
Causes:
- Needed for blood coagulation
i. Lack of calcium intake
- Normal rate: 4.5 – 5.5 mEq/L or 8.5 –
10.5 mg/dL ii. Chronic diarrhea
- Dietary allowance: 1 – 1.2g daily iii. Hypoalbuminemia- calcium attached
on proteins (albumin), calcium at
- Only 30-40% of total calcium is
albumin ay magkasama
absorbed in the GIT
iv. Renal Failure- one normal function is
- Sources of calcium: sardines, milk,
production of Vitamin D, kung wala yon
yogurt, cheese, spinach, tofu,
ay you wont be absorbing sufficient level
broccoli,etc.
of calcium
3 types
v. Hormonal Imbalances - ↓PTH (PARA
1. Ionized Calcium or Unbound TUMAAS ang calcium), ↑calcitonin
Calcium
vi. ↑HPO4- low level of calcium and low
- Free flowing; found in muscles for level of potassium
contractions
vii. Alkalosis
2. Bound Calcium
Signs and Symptoms (they are all
- Attached in albumin of plasma; found signs of hyperactive muscular tissues or
in proteins cells, nagpunta sila sa cells imbis na

blood kaya nagcacause silang i. ↑ Ca intake
contractions dun)
ii. Kidney dysfunction
Numbness
iii. Malignant bone tumors- compact of
Tingling sensation Ca in specific part of the bone
Convulsions, seizure iv. ↑PTH, ↓calcitonin levels
Diarrhea v. ↓P, ↓Na
Osteoporosis, fractures vi. Steroid therapy (corticosteroids)-
promotes bone resorption- high Ca
Tetany, spasm
levels- our osteoblast overactivity of
Trousseau’s sign, Chvostek’s sign osteoblast will do extraction of calcium
to our bone cells to be transported to
Dysrhythmia bloodstream. It will reabsord so much
Cardiac arrest calcium in skeleton and will go to
bloodstream
vii. Fracture- thinning of the bone,
1. Pharmacologic Treatment escape of calcium and will go to
a. Calcium Gluconate- incorporation bloodstream
b. Oral calcium salts, supplement Signs and Symptoms
c. Phosphate Binder- to lower HPO4: Depression, apathy

high Ca e.g aluminum hydroxide Arrhythmias, heart block, cardiac
d. Vit D, PTH supplement arrest
2. IV Fluid Replacement Blood abnormally clots
a. D5W for Calcium Gluconate- never Pathologic fractures

PNSS because high Na causes calcium Muscle flaccidity (sa dugo marami
loss ang calcium hind isa ibang cells)
3. High calcium diet Constipation, n & v (GI contents will
4. Safety precaution on seizure harde)
tendencies Severe thirst and polyuria
5. Monitor Ca levels, VS and ECG Flank pain- because of kidney stones
changes (Crystallized calcium_
C.2 Hypercalcemia Collaborative Management
>5.5 mEq/L 1. Pharmacologic treatment
Causes:

a. Diuretics (Loop Diuretics)- help i. Low Mg intake
patient excrete
ii. Diuresis and diarrhea
b. Calcitonin per IM
iii. ↓PTH leading to ↓Ca levels
c. Mithramycin (Mithracin)- it reduces Ca
iv. Hypoalbuminemia
levels
v. Excessive suctioning
2. IV therapy
vi. Alcoholism
a. Normal Saline per IV- to promote Ca
excretion vii. Intestinal Resection, IBD
3. Increase fluid intake (3-4L/day)- to Signs and Symptoms
reduce risk of stone formation in the
kidneys and relieve thirst Hyperxecitability with muscle
weakness:
4. Acid – ash fruit juices (prune juice,
cranberry juice), ascorbic acid - Tremors, hypereflexia,
tetany→paresthesia→seizure
- Lowers stone formation
Laryngeal stridor and dysphagia
5. Protect from injury to prevent fracture
(Wala masyadong calcium sa cells) Mood alterations
D. Magnesium ↓ Ca levels
- Found in the ICF Trousseau’s and Chvostek’s sign
- Regulates muscle excitability Collaborative Management

(neuromuscular function): 1. Dietary supplements – green leafy
- Aids in Calcium absorption, Na-K vegetables, whole grain cereals, milk,
pump meat, etc.
- Aids in CHO and CHON metabolism 2. Magnesium salts po or IV
- Regulated by PTH 3. Monitor urine output before, during,

and after Mg administration
- Known “vasodilator”
4. Safety precautions
- Normal level: 1.5 – 2.5 mEq/L
D.2 Hypermagnesemia
- Sources: fish, meats, green leafy
vegetables (chlorophyll - rich) >5.5mEq/L
Two Forms of Magnesium Imbalance Causes:
D.1 Hypomagnesemia i. Renal failure
<1.5mEq/L ii. Diabetic ketoacidosis
Causes: iii. Excessive Mg administration

iv. Excessive use of antacids (MgOH)
Signs and Symptoms
↓BP
Thirst, nausea and vomiting
Drowsiness
Loss of deep tendon reflex (DTR)
1. Ca Gluconate / IV
2. Dialysis
3. Monitor VS (esp RR and BP), DTRs,
UO, and LOC during therapy

Terminologies to Remember become cuboidal or squamous type
and they are becoming stratified
• Cancer. A disease of the cell in
meaning nagpatong patong na yung
which the normal mechanisms of the
iba’t ibang uri ng cell.
control of growth and proliferation
• Dysplasia. Changes in cell size,
have been altered. Cells go through
shape and organization.
cell division, maturation from
• Anaplasia. Reverse cellular
primitive form to a fully matured
development to a more primitive or
cell. At any moment that this cell
embryonic cell type. From a full
division would not be followed or
mature and functional cell all of a
programmed well by the body or it
sudden, the cell is trying to regress
would be a reversal type meaning
which shouldn’t be happening.
from the matured type of cells it
• Metastasis. Spread of cancer cells to
reverts from matured naging
distant parts of the body to set up
immature pa siya or premature cell
new tumors. Spreading of cancer
which shouldn’t be happening. It is
cells.
invasive, spreading directly to
• Oncology. The medical specialty
surrounding tissues as well as to new
that deals with the diagnosis,
sites in the body. Also called
treatment and study of cancer.
malignant neoplasm.
• Adenocarcinoma. Cancer that arises
• Benign neoplasm. A harmless
from glandular tissues. E.g. cancer of
growth that does not spread or
the breast, lung, thyroid, colon and
invade other tissues. Very specific to
pancreas. “Carcinoma” meaning
a particular body point. No signs of
cancer tumor capable of being
spreading.
malignant. “Adeno” means gland.
• Neoplasia. Abnormal cellular
Applicable to body tissues or organs
changes and growth of new tissues.
of the body that are capable of
“plasia” meaning proliferation,
producing secretions. Cancers
increase, spreading. “neo” means
arising from the different glands of
new.
the body.
• Hyperplasia. Increase in cell • Carcinoma. A form of cancer that is
number. Abnormally increasing to composed of epithelial cells;
such extent, we no more need them. develops in tissue coverings or
• Hypertrophy. Increase in cell size. linings of the body such as skin,
• Metaplasia. Replacement of one uterus, or breast.
adult cell type by a different adult • Sarcoma. A cancer of supporting or
cell type. It is common in lung connective tissues such as cartilage,
cancer, meron tayong lung cancer bones, muscles or fats.
kung saan our cells are normally in • Carcinogens. Factors associated
columnar epithelia and yet it s with cancer causation, e.g. radiation,
replace with different forms and chemicals, viruses, physical agents.
shapes of cells that it is either

B. Failure of the Immune
Response Theory
✓ Advocates that all individuals possess

cancer cells. However, the cancer cells
are recognized by the immune response
system (If you have normal system). So,
the cancer cells undergo destruction.
Failure of the immune response system
leads to inability to destroy the cancer
cells. If any chance that the immune
system would not be sufficient enough
to perform their function to assume their
purpose for the body then definitely
there would be a failure of immune
Pathogenesis of Cancer (Cancer system making these cancer cells to
Development Explained take full opportunity which is to make
Theoretically) – It requires further themselves proliferating.
proving still, wala pang law of cancer. C. Defective Cellular Proliferation
The real cause of cancer is remaining (Growth) and Defective Cellular
idiopathic. Differentiation
A. Cellular Transformation and ✓ Defective Cellular Proliferation o
Derangement Theory Normal cells respect the boundaries and
✓ Conceptualizes that normal cell may territory of the cells surrounding them.
be transformed into cancer cells due to (The cardiac cells will never go to the
exposure to some etiologic agents. Ex. If lung parenchyma). They will not invade
you had leukemia and the reason stated a territory that is not their own. Cancer
by your doctor is because you have cells do the opposite, i.e., they have no
been exposed to carcinogenic agent due regard for cellular boundaries
to your job, baka yung pasyente ay and will grow on top of one another and
dating nagtrartabaho sa mga factory also on top of or between normal cells.
wherein there is exposure to toxic Also known as metastasis which is the
substances like lead and asbestos or spread of cancer cells from the place
nitrogenous wastes. These substances where they first formed to another part
may at any moment affect the normal of the body.
cells to deranged themselves to have
malformations. Baka ang isang tao ✓ Defective Cellular Differentiation o
repetitively or over the years are Cellular differentiation is normally an
exposed to etiologic or carcinogenic orderly process that progresses from a
agents and therefore your normal cells state of immaturity (which has the
are affected leading to malformations potential to perform all body functions)
and malfunctioning. to a state of maturity (mature cells

performing only specific functions). Ex. ✓ Act by causing cell mutation or
From hemocytoblast, ang katawan natin alteration in cell enzymes and proteins
ay magdedecide pa yan further if these → altered cell replication. ✓ Examples:
primitive cells would further transform
becoming an RBC, WBC or platelet. So 1.Industrial Compounds o Vinyl
yun yung normal natin, from primitive chloride (plastic manufacture, asbestos
forms from the stem cells they will go factories, construction works) o
through different processes until such Polycyclic aromatic hydrocarbons
time that they will be assuming what (refuse burning, auto and truck
particular cell they would be. Cancer emissions, oil refineries), air pollution
cells alter these normal functions by O Fertilizers, weed killers o Dyes o
“dedifferentiation” or reverting mature Analine dyes (beauty shops and home
cells to their immature or use) – specially those with ammonia o
undifferentiated state. “De” as a prefix Hair bleach
means removal. Inaalis mo yung orderly O Drugs o Tobacco (tar, nicotine),
process of evolution or production or alcohol o Cytotoxic drugs (Melphalan)
progression of certain bodily process in
the body. Primitive cell would not be 2.Hormones – Many of our hormonal
useful for our body because they need therapies are lipid base or fat base. Ang
to be specific of what cell they would be problema sa mga fat base medications
so that the function will be specific as ay one ingested or once injected to the
well. body they tend to attract more fats to be
deposited in us. The more fats we
Etiologic Factors (Carcinogens) – accommodate in the body, the more
What gives you cancer? prone we are to malformations of cells.
A. Viruses Kasi ang mga cells din naman like the
cancer cells are made of lipids. It
✓ “Oncogenic viruses” – Not necessarily because they would be assuming their
many viruses would be very associated cell types eventually. Kung sobra sobra
to cancer its just that some of the ka sa katawan mo ng mga lipids na
viruses as well are making us prone to kung minsan baka mga bad cholesterol
acquisition of cancer because of pa yung mga iniinvite natin sa katawan
immunosuppression natin, all the more we would be prone to
tumor formations like myoma (highly
✓ May be one of the multiple agents
made of fats and calcium). Paano ka
acting to initiate carcinogenesis.
nakakuha ng fatty depositions na yon?
✓ Prolonged or frequent viral infections Sometimes, related to estrogen
may cause breakdown of the immune production.
system or overwhelm the immune O Estrogen
system. “Failure of the Immune
Response Theory”. O Diethylstilbestrol (DES)
B. Chemical Carcinogens

3.Foods, preservatives o Nitrates O Oncogene (hidden/repressed genetic
(bacon, smoked meat) - Longganisa o code for cancer that exists in all
Talc (polished rice, salami, chewing individuals) → when exposed to
gum) o Food sweeteners – carcinogens → changes in cell structure
Commercially prepared o Nitrosomines → becomes malignant. – Mana-mana
(rubber baby nipples) lang. Cancer may run in the blood of the
family
o Aflatoxins (mold in nuts and
grains, milk, cheese, peanut butter) O Regardless of the cause, several
cancers are associated with familial
o Polycyclic hydrocarbons
patterns. E.g. retinoblastoma,
(charcoal broiling) – Wag masyadong
pheochromocytoma (tumor arising in the
sinusunog. The more na sunod siya, the
adrenal medulla – uncontrolled
more na siya ay nagkaroon siya ng
hypertensive crisis),
uling-uling dahil sa pagkakaihaw. It
could be carcinogenic to us also. Wilm’s tumor (most common type of
kidney cancer in children), lung cancer,
breast cancer – These kind of cancers
C. Physical Agents does not choose a particular patient
because of age kasi akala ng iba we
1. Radiation o From x-rays or develop cancers because of the aging
radioactive isotopes o From process.
sunlight/ultraviolet rays
Predisposing Factors – What may
2. Physical irritation/trauma o Pipe expose us further to cancer?
smoking o Multiple deliveries o Jagged
tooth, irritation of the tongue, “overuse of A. Age
any organ/body part”. – Yung mga
✓ Older individuals are more prone to
pagpapaopera sa isang tao, ang
operasyon sa isang patient hanggat Cancer; they have been exposed to
maari last resort yan eh. Hanggat maari carcinogens longer; they may have
di natin pinabayaan yung mga patient na developed immune system alteration or
mauuwi sa surgical operation because it deterioration. – As we age, our systemic
predisposes us to a lot of danger also. functions will also deteriorate, the same
Hindi normal na hinihiwa yung isang tao thing applies with our immune system
for certain a surgical purpose because it making us so prone to cancer.
predispose you also to many life B. Sex – Biological orientation for sexual
threatening factors along the way. difference
D. Hormones ✓ Women – more prone to breast,
o E.g. estrogen as replacement therapy uterus, cervix cancer.
increases incidence of vaginal and O They are more prone to breast cancer
cervical adenocarcinoma because we do not expect males to
E. Genetics have this highly fatty compose breast

tissue. Kasi sa mga males its more of normal bacterias, kaya lang kung yung
muscles. As compared to the males it normal flora ay dadagdagan mo pa ng
would be more on fatty depositions and mga bacteria coming from the raw
that’s understandable kasi more on fats foods, dahil nga ang mga raw foods ay
naman talaga ang breast. Kaya lang, the hindi naman luto edi syempre buhay ang
mere fact that you have these bacteria niyan. The more na
distributions of too much fats in a nadadagdagan yung mga bacteria sa
particular body part, the more prone you loob ng tiyan mo lalo dumadami yung
are to cell mutations kasi ang mga bacteria whether it is good or bad
tumors would either is both highly made because kahit yung mga good bacteria
of fats and calcium in excessive number may become
opportunist eventually. Halimbawa, kung
✓ Men – more prone to prostate, lung ikaw yung patient na laging sinisikmura
cancer. or numinipis na yung bituka or sikmura
O Males are prone to lung cancer mo because of your dietary habits na
because of vices like smoking, vape hindi maganda at patuloy ka pa kakain
smoking – hindi naman ito common sa ng mga pagkain na di health or di luto,
kababaihan edi lalong dumami yung flora or dadami
din yung opportunist. Mayroon sila
C. Urban vs. Rural residence magiging opportunity to attack body
parts that are starting to erode (wear
✓ Cancer is more common among
away) like with ulcers.
urban dwellers than rural residents
(because of greater exposure to ✓ Due to influence of environmental
carcinogens such as pollution, enjoying factors as national diet, ethnic customs,
of the foods that may no more be type of pollutions.
healthy for some people like fast foods
which contains preservatives) E. Occupation
D. Geographic Distribution ✓ E.g. Chemical factory workers,

farmers, radiology department personnel
✓ E.g., cancer of the stomach in Japan,
cancer of the breast in USA. – It is F. Heredity
because of the lifestyle or culture they
✓ Greater risk with positive family
were at. In Japan, China, Korea,
history.
common sa kanila yung gastric cancer,
colon cancer because may culture kasi G. Stress
sila na mahilig talaga sila kumain ng
mga medyo hilaw or rarely cooked ✓ Depression, grief, anger,
foods. From cooking, the more we cook aggression, despair or life stresses
foods mas patay ang mikrobyo non eh. decrease immunocompetence (affect
Dahil patay ang mga mikrobyo, you are hypothalamus and pituitary gland).
not introducing so much bacteria in your ✓ Immunodeficiency may spur the
GI tract. GI tract has flora already or growth and proliferation of cancer cells.

– If you under stressed and if you are Halimbawa, kung maaga kang
immunosuppressed, don’t expect your nagkaroon ng menstruation so
blood cells would be producing normally. maaga ka rin nakaexperience ng
Dahil stress ka you don’t expect normal fluctuation between the estrogen
functioning of your kidneys for producing and the progesterone. That
hormone that will flood the release or fluctuation is the repetitive or the
production of our necessarily blood cells scheduled increase of estrogen
like the RBCs, kaya nga pag may production in the body which is
patient na lagging puyat nagaanemic happening during the menstrual
sila kasi nga di sufficient yung lakas ng cycle. Kapag marami kang
kanilang katawan to produce the estrogen sa katawan mo, mas
necessary number of cells. The more marami ka rin magiging fluid
and many times that you would be under retention and fatty depositions
stressed you would be under anemia, making you prone to cancer type
hypotensive, hypertensive because of
stress, you are only predisposing ✓ Early menarche ✓ Late
yourselves to the incidence of cancer menopause
also. ✓ Nulliparous or older than 30 years
H. Precancerous lesions at the birth of a first child or Late
pregnancy/High Risk pregnancy
✓ May undergo transformation into
cancer lesions and tumors. 2. Lung Cancer
✓ E.g. pigmented moles, burns scars, ✓ Tobacco use

senile keratosis, leukoplakia, benign ✓ Asbestos
polyps(kuntil)/adenoma of the colon or
stomach, fibrocystic disease of the ✓ Radiation exposure
breast.
✓ Air pollution
I. Obesity
3. Colorectal Cancer
✓ Studies have linked obesity to breast
and colorectal cancer particularly with ✓ Greater incidence in men
fat depositions
✓ Familial polyposis – Multiple
Common Causes per Cancer Types – appearance of polyps inside the colon
Specify their possible causes
✓ Ulcerative colitis – If the patient prior
1. Breast Cancer - It is because of to experience of Colorectal Cancer is
hormonal imbalance between diagnosed with Ulcerative colitis hindi
estrogen and progesterone kasi nakakagulat na nagkaroon siya ng
with these individuals maaga sila cancer. Ulcerative colitis is a kind of
naexpose with abnormal inflammatory bowel disease. May
production or increase in the dalawang uri ng inflammatory bowel
production of estrogen. disease may tinatawag tayo na Crohn's

disease and Ulcerative colitis. Patient ▪ Multiple sex partners
with Ulcerative colitis, everyday of their
▪ Sexual partner who has had multiple
life they are experiencing drastic
sex partner
diarrhea, dumi ng dumi and di
nakakatunaw ng maayos ng kanilang ✓ Human papilloma virus and AIDS
pagkain and the reason is because their (acquired immunodeficiency syndrome)
colons are devastated already. Ang – Meaning kung mayroon kang AIDS,
itsura ng bituka ng mga may Ulcerative hindi malayo na magkaroon ka ng
colitis they have this tortured and injured cancer kasi nga immunosuppressed
colon. The more na nasusugatan ang
mga colon the more we don’t expect ✓ Low socioeconomic status – Cervical
them to do their task. The task of the cancer is one of the most easily
colon is to dry out the stool and be preventable form of female cancer if
formed when you pass them out. You early screening and diagnosis is made.
will pass out watery stool kasi sila Madami ang namamatay sa cervical
diarrheic. If Ulcerative colitis is left cancer dahil yung awareness level nila
untreated, siya yung isa sa mga about this condition is very low. Mostly
common causes ng colon cancer. Colon ay from middle and low-income
cancer could be a secondary disease. It countries. Yun ay dahil sa country na
could be preceded by difference GI yon mismo, limited yung screening
disorder like Ulcerative colitis. coverage. So may struggle talaga
socially (e.g., perceived stigma and
✓ High – fat, low – fiber diet discrimination) and structurally (e.g.,
4. Prostate Cancer healthcare access and source of care)
and it may influence the decision of the
✓ Common among males who are 50 patient to seek health care services for
years old and older cervical cancer.
✓ African – Americans have the highest ✓ Cigarette smoking

incidence of prostate cancer in the
6. Head and Neck Cancer
world.
✓ More common among males
✓ Positive family history – It could be
running on the blood of the family ✓ ✓ Alcohol and tobacco use
Exposure to cadmium
✓ Poor oral hygiene
5. Cervical Cancer – Overusing of
the genitalia. Introducing ✓ Long term sun exposure
materials or object to genitalia
✓ Occupational exposures – asbestos,
that are not acceptable
tar, nickel, textile, wood or leather work,
✓ Sexual behavior machine tool experience.
▪ First intercourse at an early age 7. Skin Cancer Prepared:

✓ Individuals with fair complexion – diabetes mellitus. Diba yung mga patient
Masyadong mapuputi. Yung mga di na may diabetes, kapag nasugatan di
gaanong mapuputi sila yung may agad gumagaling. Pero kapag ang
protection pa from UV light or sunlight. patient walang problema sa kanyang
Yung mapuputi masyado na ilan satin ay blood glucose level and yet meron
less lang yung protection. It is because siyang mga sugat na imbis na gumaling
yung mga tao na maraming melanin sa dumadami pa, it could be wounds that
katawan nila kaya medyo maitim yung are arising from cancer incidence.
kulay nila kasi that is actually they’re 3. U – unsual bleeding or discharge –
protective color or protection from Common among the females. Baka
sunlight. merong uterine, cervical, ovarian
✓ Positive family history problem. Baka mamaya tapos na yung
menstrual period and then ilang days
✓ Moles (nevi) lang nagdaan nagmemenstrual period
nanaman siya and it’s becoming
✓ Exposure to coal tar, creosote, profuse, mas marami pa.
arsenic, radium
4. U – unexplained sudden weight
✓ Sun exposure between 10 AM to 3 loss – May mga tao na di naman
PM – It is because you have there very nagdidiet pero bumabagsak yung
bright and strong sunlight already. timbang nila. May mga tao na
pumapayat pero lumalaki yung tiyan
Warning Signals of Cancer – An early
detection naman nila like the incidence of liver
cirrhosis or liver cancer. Lumalaki yung
1. C – change in bowel or bladder kanilang mga liver and at the same time
habits – If the patient is repetitively lumiit yung katawan nila. Kasi nga
experiencing diarrhea and no more without liver you would not be able to
becoming normal for a person kasi ang absorb nutrients for your body. They’re
diarrhea nangyayari yan in 2 to 3 days not into strict diet and yet they are
lamang. Pero kung isang linggo ng experiencing weight loss, may be the
nagdiarrhea yung patient tapos patient is with cancer such as colon,
nagtatake naman siya ng gamot and it gastric, liver cancer. It is because
seems like they’re not working for him or whether we accept it or not, pag
her then this individual must seek nagkaroon ka ng cancer ang lahat ng
consultation right away. A week or two kinakain mong pagkain ay hindi lamang
of diarrhea is alarming already not just ikaw ang nakakanibang because the
because of dehydration only but cancer themselves would also be in
because of other possible causation like need with nutrients. Makikihati sila sayo
cancer ng nutrient na dapat sana sa mga
normal systems mo napunta pero
2. A – sore that does not heal –
napupunta ang massive portion sa mga
Sometimes, may mga sugat sa katawan
cancer cells as they proliferate.
natin na kaya hindi gumagaling galling is
because of certain disorders like

5. U – unexplained anemia – Hindi The Cancer Detection Examinations –
naman laging puyat or pagod, wala Ruling out the problem
naming lahi na anemic sila, wala
A. Cytologic Examination or
namang Iron Deficiency Anemia and yet
Papanicolau test (Pap’s Exam, Pap
anemic pa rin yung patient. May be the
Smear)
patient could have been suffering from a
type of cancer like bone cancer, baka 1) Cytologic specimen can be obtained
may bone cancer that’s why the bone from tumors that tend to shed cells from
marrow are not sufficiently producing their surface, e.g. G.I. tract through
RBC at all. endoscopy; respiratory tract through
laryngoscopy and bronchoscopy; genitor
6. T – thickening or lump in the breast
– urinary tract through colposcopy of the
of elsewhere – Normally are smooth
cervix and vagina, cystoscopy of the
when touching and yet suddenly may
bladder, laparoscopy of the pelvic and
napapansin ka may lumalaking tissue
abdominal cavity.
which is normally not found there.
2) Preparation for Pap Exam of the
7. I – indigestion or difficulty in
Cervix
swallowing
▪ No menstruation. – It would give a dirty
8. O – obvious change in wart or mole
result.
– Mga warts or nunal na lumalaki for no
known reason and sometime baka ▪ No vaginal sexual intercourse 24 hours
nagiging masakit pa before the test.
9. N – nagging cough or hoarseness ▪ No vaginal douching 24 hours before
of voice – best example yung mga ubo the test. – Kapag hugas na hugas yung
na nagsimula yung semester tapos ari ng babae eh baka magkaroon ng
hanggang ngayong inuubo. Lalo na false negative result or false positive
yung ubo or phlegm are streaks with result
blood, it may be more than COPD baka
nagiging lung cancer. Nagging cough – ▪ Avoid inserting cervical cap, cervical
when they cough it is really diaphragm, spermicide or condom into
troublesome, it gives them a hard time the vagina 24 hours before the test –
to speak already. Hoarseness of voice – They may alter the result that we are
they are losing their voice at all, looking for.
magugulat sila nakakapagsalita naman 3) Interpretation of Papanicolau Test
sila and all of a sudden hindi sila results are as follows:
makapagproduce ng speeches for no
known reason.Naiibuka yung bibig nila • Class I Normal
at may nasasabi naman sila but as they • Class II Inflammation
converse nawawala yung kanilang
salita. It could be a sign of laryngeal • Class III Mild to Moderate Dysplasia
cancer. (tumor formation)
• Class IV Probably Malignant

• Class V Malignant – It might require K. Monoclonal Antibodies
chemoradiotherapy because they are
now malignant.
Comparison of the Characteristics of Benign and Malignant Neoplasm
B. Biopsy. Involves obtaining tissue Characteristics Benign Malignant
samples by needle aspiration or incision A. Speed of Growth Grows slowly Grows rapidly
of tumor. It is the only definitive means B. Capsule Encapsulated Not encapsulated
of diagnosing cancer. – Confirmatory
C. Cell Characteristics Well differentiated mature cells; Poorly differentiated (anaplastic
test cells function poorly type)
D. Recurrence Extremely unusual when surgically Common following surgery
C. Ultrasound removed
E. Metastasis (Spreading) Never occur Very common
D. Nuclear Magnetic Resonance F. Effect of neoplasm Not harmful to host Always harmful
(Abnormal new growth)
Imaging (MRI) G. Prognosis (the chance of Very good prognosis Poor prognosis
survival)
E. Radiologic Examinations (X-rays)
F. Radiologic Techniques (Use of
Radioisotopes)
G. Computerized Axial Tomography
(CT scan)
H. Antigen Skin Test e.g., injecting
Dinitrochlorbenzene (DNCB) – Skin
related cancers or issues
I. Laboratory Test
✓ Alpha-feto-protein (AFP) – Nasa

dugo. It is important when you’d like to
rule out the possibility of liver cancer
✓ Human Chorionic Gonadotropin

(HCG) – Either in the blood or urine.
This is not about pregnancy test, there
are other form OB related cancers
wherein HCG is also present. A. Proliferation of Cancer Cells
✓ Prostatic Acid Phosphatase 1) Pressure – due to increase in size of
neoplastic growth – Halimbawa, kung
✓ Prostatic Specific Antigen (PSA) -
nagkaroon ka ng tumor in the brain at
Common in colon cancer and prostate
tumor sa brain mo tumubo sa pituitary
cancer
gland at naging mas malaki pa siya kay
✓ Carcinoembryonic Antigen (CEA) – pituitary gland. It will put so much
Common in colon cancer pressure to the pituitary gland to such
extent it will alter the normal function of
J. Endoscopic Examination

pituitary gland. That’s the danger of thorax area or abdominal area of the
putting or developing pressure from the patient. Kasi nga yung lymphatic vessels
increasing size of the tumor or kulani ng katawan natin na dapat
nagcocollect ng waste products natin
2) Obstruction – as tumor continues to
nagbara. Kung magbabara yung mga
grow, hollow organs and vessels
kulani di makakawa lahat ng ating waste
become compressed and obstructed.
products and the consequence they will
o E.g., esophagus, bronchi, ureters, settle in a certain body part wherein they
bowel, blood vessels, lymphatic system. are more invited. Example will be the
o Halimbawa, yung ulcerative colitis. third spacing or interstitial spaces like
Nanggaling yan sa maraming tumor serous cavities. ➢ E.g. effusion into the
formations kasi wherein the tumor pleural cavity (pleural effusion); effusion
formations are also becoming ruptured into the abdominal cavity (ascites)
or nagkakasira sila. Pag ang bituka ng
tao nagkabuhol buhol sa dami ng 5) Ulceration and Necrosis
tumors or cancer cells maaring magsara ➢ Result as the tumor erodes blood
yon. Di na makakadumi. vessels and pressure on tissue causes
3) Pain ischemia → tissue damage and bleeding
→ infection – Yung mga tumor na yan
➢ Due to: pag internally occurring or sa loob ng
katawan nangyayari pwede yang
O Pressure on nerve endings
magrupture kasi ang mga tumors
(nociceptors)
whether it is benign or malignant are
O Distention of organs/ vessels o Lack always prone to rupturing kasi wala
of O2 to tissues and organs o Release namang buto and they are only soft
of pain mediators by the tumor tissues. The fact that they’re only soft
tissues the more they over distend the
➢ A late sign of Cancer – You don’t higher the chance that any moment they
expect pain in the early stage of cancer will pop or rupture.
kasi wala pa namang pressure or
obstruction doon. There’s no 6) Vascular Thrombosis, Embolus,
overdistention yet of a certain body part Thrombophlebitis
wherein pain is expected to occur.
➢ Tumors tend to produce abnormal
4) Effusion coagulation factors that cause increased
clotting
➢ When lymphatic flow is obstructed,
there may be effusion in serous cavities. (pulmonary emboli → life-threatening). –
(pleura, pericardium, peritoneum) – Ang Yung mga tumors na yan they will over
pinaka common na tinatamaan ng excite the coagulation factors like
effusion for many cancer types would be thromboplastin. Masyado silang
peritoneum. Kaya common sa mga may nahyhyperactivate to such extent na di
liver cancer, gastric cancer, duodenal naman kailangan na nagblood clot yung
cancer. Many types of cancer in the ating dugo pero blood clot pa ng blood

clot. The more na nagproproduce ka ng that increases or accelerates bone
blood clot syempre the more na breakdown and release of calcium. – If
nagproproduce ng danger. Those blood osteoclast activity will be overactive, it
clots from first stage being a thrombus will release so much calcium in the body
they may become embolus. Thrombus is or from the bones. Kapag nawala lahat
a blood clot attach to blood vessel ng calcium sa buto, pupunta siya sa
linings and should that happen that they mga tumor imbis na yung buto yung
detach from blood vessel linings they pinapatibay ng calcium, ang pinapatibay
would become embolus. At yung ng calcium yung tumors or cancer cells.
embolus na yon habang dumadaloy sa
katawan mo palaki rin yon ng palaki kasi ➢ Also results from metastasis to the
nga may abnormal, may hyperactive bones.
coagulation factors na lalong ➢ Enhanced by immobilization and
nagpapalaki ng blood clot and any dehydration. – Yung mga patient na may
moment pwede yang bumara sa kung cancer dapat mas lalo kang magengage
saan man like in pulmonary artery or in sa healthy life style. Halimbawa you still
coronary artery themselves. Blocking do exercise kung kaya mor in naman
those blood vessels would always be life dahil mas kailangan ng mga may cancer
threatening yan.. It is because the more a patient is
immobile or more bed ridden, the more
na ineentertain niya sa utak na
B. Paraneoplastic Syndrome - magpapakalata siya or di na siya
malignant cells produce enzymes, gagalaw. Immobilization or lack of
hormones and other substances activity will promote further release of
1. Anemia calcium from the bones. Mas lalong
matutuwa sila osteoclast, lalo silang
➢ Cancer cells produce chemicals that magaalis ng maraming calcium from the
interfere with RBC production. bones dahil di gumgalaw.
➢ Iron uptake is greater in the tumor 3. DIC (Disseminated Intravascular
that that deposited in the liver. – Mas Coagulation) – very common in
malakas ang kain ng mga tumor sa iron dysfunctional pregnancies, abruptio
kesa sa other body parts ➢ Blood loss placenta, abortion
may result from bleeding.
➢ More likely to occur in cancer of the
2. Hypercalcemia – Walang tumor na lungs, pancreas, stomach, prostate.
walang lamang calcium. They will never
➢ Precipitated by the release of tissue
develop as a tumor without calcium ions.
It is the calcium ions that makes tumor thromboplastin or endothelial injury. –
strong in construction. Nagpapasa sila because of overactivity
of blood clotting factors.
➢ Tumors of the bone, squamous cell
C. Anorexia – Cachexia Sydrome
lung cancer, cancer of the breast
produce a parathyroid – like hormone

➢ The final outcome of unrestrained The more na mas maraming tinatake up
cancer cell growth. na sodium ions si cancer cells the more
na magreretain tayo ng water sa
➢ Malignant neoplasms deprive normal katawan which is the explanation bakit
cells of nutrition. – It is because yung nagkakaroon ng effusion incidences like
kinakain ni patient di naman napupunta ascites, pleural effusion or bakit
sa bodily systems niya, napunta na lahat minamanas ang ilan sa cancer types. It
sa cancer cells kasi mas matakaw yon is because tumors or cancer cells have
or mas makapangyarihan in term the power to take up sodium ions.
uptaking Wherever your sodium goes your water
will follow.
➢ Tumors produce alteration in enzyme
system necessary for normal ➢ Cancer cells produce anorexigenic
metabolism → stored fat is lost, tissues substances that act in the satiety center
lose nitrogen (negative Nitrogen of the hypothalamus, causing anorexia.
balance). – Yung mga cancer cells may power sila
para tanggalin yung gana sa pagkain.
➢ Tumors revert to anaerobic
They are attacking the hypothalamus.
metabolism → consume glucose;
Thirst and hunger center for the body is
deplete glycogen stores in the liver and
in the hypothalamus. Ang consequence
convert glucose to lactate. – Kasi dapat
nangangayayat ka kasi di ka
usually ang ginagawa natin ay aerobic
nagugutom.
metabolism lamang. Pero magiging
insufficient na si aerobic kaya eventually ➢ Taste sensation, diminishes or
yung katawan natin naganaerobic na becomes altered and the individual may
siya. When we do anaerobic have aversion to eating, particularly
metabolism, instead of consuming only meat. – Nawawalan ng panlasa.
ATP from the oxygen we breath, from
the glucose we consume or we can take Staging and Grading of Neoplasia –
from the foods we consume and even Cluster and determine the extent
the glycogen stores will be use up by the ▪ Staging is determining the size of the
body. Kasi nga nagiging insufficient na tumor and existence of metastases. –
yung kinakain natin at yung oxygen na Inaalam lang kung gaano kalaki or
nanggagaling sa nilalanghap natin, gaano katagal na si cancer cell
ultimo yung stored energy in the form of
glycogen will be use up by your cancer ▪ Grading is classification of tumor cells.
cells. – classifying by appearance
➢ Protein depletion, serum albumin ▪ Staging is necessary at the time of

levels increase. diagnosis to determine the extent of
disease (local versus metastatic), to
➢ Tumors take up Na+. Water retention determine prognosis and to guide proper
masks malnutrition and is not management.
immediately reflected as weight loss. –

▪ The American Joint Committee of Cancer Prevention
Cancer (AJCC) has developed the TNM
• Skin. Avoid exposure to sunlight – For
Classification System that can be
skin cancer
applied to all tumor types
• Oral. Annual oral examination
✓ T – tumor size
• Breast. Monthly BSE (breast self-
✓ N – presence or absence of regional examination) from age 20.
lymph node involvement
• Lungs. Avoid cigarette smoking;
✓ M – presence or absence of distant annual chest X-ray.
metastasis
• Colon. Digital (finger) rectal
▪ T – primary tumor examination for persons over age 40.
Rectal biopsy, proctoscopic
✓ Tx – primary tumor is unable to be examination, Guaiac stool examination
assessed. (occult blood examination – internal
✓ To – no evidence of primary tumor. bleeding) [Kung may Gastric cancer,
ang dumi kahit nagdudugo na yung
✓ Tis – carcinoma in situ – Nakita na sikmura mo kailanman ay di magiging
may tumor siya pero it is highly localized pula, it will turn to blackish in color. Yung
or specific to a body part only, no signs iba kaya itim yung dinumi nila because
of metastasis or increasing size of certain meal or medications that the
patient has consumed and it is a normal
✓ T1, T2, T3, T4 – increasing size and/ side effect] for person age 50 and
or local extent of primary tumor above.
▪ N - presence or absence of regional • Uterus. Annual Pap’s smear from age
lymph node involvement ✓ Nx – 40.
regional lymph node is unable to be
assessed. • Basic. Annual physical examination
and blood examination.
✓ No – no regional lymph node
Dietary Recommendations Against
involvement.
Cancer
✓ N1, N2, N3, N4 – increasing • Avoid obesity.
involvement regional lymph nodes
• Cut down on total fat intake.
▪ M – absence or presence or distant
metastasis ✓ Mx – metastasis is unable • Eat more high fiber foods – raw fruits
to be assessed. and vegetables, whole grain cereals.
✓ Mo – absent or distant metastasis • Include foods rich in Vitamin A & C in

daily diet.
✓M1 – presence of distant metastasis

• Include cruciferous vegetables in the “rectomy”- removal). We all know that
diet – broccoli, cabbage, cauliflower, sex hormones like estrogen and
brussel sprouts. progesterone are continuously produce
by the ovary. It is a possibly that one
• Be moderate in the consumption of
from the two ovaries may be remove
alcoholic beverages.
surgically for the purpose of retarding
• Be moderate in the consumption of salt only the too much secretion of estrogen.
– cured, smoked – cured and nitrate-
B. Chemotherapy – are not always
cured foods.
given via IV
Different Therapeutic Modalities for
• Objectives
Cancer or Medical Surgical Nursing
for Cancer ✓ To destroy all malignant tumor cells
• Surgical Interventions without excessive destruction of normal
cells. – It may sound so positive that it
• Chemotherapy doesn’t necessarily destruct the normal
cells but in reality tinatamaan talaga the
• Radiation Therapy
good and the bad cells of the body.
• Immunotherapy
✓ To control tumor growth if cure is no
• Bone Marrow Transplantation longer possible.
A. Surgical Interventions ✓ Used as adjuvant therapy. – It is an
1. Preventive Surgery. Removal of enhancement therapy.
precancerous lesions or benign tumors. • Contraindications
2. Diagnostic Surgery. Biopsy.
✓ Infection. The anti – tumor drugs are
3. Curative Surgery. Removal of an immunosuppressives. – Kung ikaw ay
entire tumor (en bloc resection). – As a may infection, which would explain hat
whole you are already immunosuppressed at
magchechemotherapy ka pa na
4. Reconstructive Surgery. Improvement magiimmunosupressed din sayo then
of structure and function of an organ. that would be a double effect. We only
5. Palliative Surgery. Relief of put the patient’s life in danger.
distressing signs and symptoms;
✓ Recent surgery. The drugs may retard
retardation of metastasis. E.g.
healing process. – Yung mga
oophorectomy in the client with cancer
naoperahan from their tumors na
of the breast to reduce estrogen
tinanggalan at gusto pa silang
secretion, thereby retard metastasis. –
ichemotherapy nung doctor just for the
Too much production of estrogen would
purpose of preventing the possibility of
not be healthy among the women that’s
metastasis kahit natanggal na yung
why these individuals who already have
tumor hindi sila agada gad
breast cancer may undergo
ichemotherapy unless galing na yung
oophorectomy (“oophoro” – ovaries and

kanilang naging sugat. Kasi kung hindi muna lahat ng vitals ng patient just
pa gaanong galing yung kanilang tahi at before this patient will allowed for
chinimotherapy mo yan may chance na chemotherapy.
mag dihis or worst evisceration. It is
Classification of Chemotherapeutic
because retard the healing process.
Drugs
✓ Impaired Renal or Hepatic function.
A. Alkylating Agents
The drugs are nephrotoxic and
hepatotoxic. – That is why during the ❖ Alter DNA structure by preventing
chemotherapy sessions they are kept DNA replication and transcription of
monitor for liver and kidney functions RNA (hindering cells growth and
using their blood. E.g., SGPT. It is division) – The consequence of which
because tinitgnan nung mga doctor would be cell growth of both the normal
kung in the middle of their and abnormal cell. It doesn’t necessarily
chemotherapy the patient’s liver and choose only the cancer cells kaya nga
kidney healthy and normal. both the normal and abnormal cells are
affected.
✓ Recent Radiation Therapy. Also,
immunosuppressive. – Hindi sinasabay ❖ E.g., Cytoxan, Myeleran, Leukeran,
sa chemotherapy kasi both Mustargen, Platinol – all are given via IV
immunosuppressive.
B. Antimetabolites
✓ Pregnancy. The drugs may cause
❖ Foster cancer cell death by interfering
congenital defects. – That’s why during
pregnancy kung may cancer si mother, cell metabolism
may be papatapusin muna yung ❖ Interfere with biosynthesis of nucleic
pregnancy niya at kapag siya ay acids necessary for RNA and DNA
nakapanganak na. That’s the time na synthesis
baka siya ay magchemotherapy kung
may nakita mang cancer sa kanya ❖ Cell cycle phase specific for S phase
during pregnancy period. Hindi or synthesis phase – Phases of cell
ichemotherapy ang isang nanay na may division such interphase, anaphase,
anak sa kanyang sinapupunan because metaphase. This medication is specific
it is teratogenic for the baby and the for synthesis phase just before mitosis
mother. begin ❖ E.g., Methotrexate (MTX), 5 FU
Fluoracil, Thioguan, Purinethol, Cytosan
✓ Bone Marrow Depression. These
– U, Floxuriding (FUDR)
drugs may aggravate the condition. The
WBC levels must be within normal limits. C. Plant Alkaloids
– It because during the chemotherapy
session blood counts of the patient will ❖ Bind to microtubule proteins during
also go down. It will be life threatening. It metaphase, causing mitotic arrest. The
is very important that the doctor will go cell cannot divide and dies – Metaphase
proper clearance first, meaning icheck is when chromatids is lining at the
center. Meaning when mitosis phase or

mitotic division will be removed among ❖ Interfere with RNA and DNA
the cancer cells there is no way that this synthesis
cancer cells would still be able to
replicate causing death among them. ❖ Cell cycle non-specific
(Metaphase is the third phase of mitosis,
❖ E.g, Adriamycin, Blenoxane,
the process that separates duplicated
Cosmegen, Cerubiine, Mithramycin,
genetic material carried in the nucleus of
Mutamycin, Novantrone - TIV F.
a parent cell into two identical daughter
Nitrosources – It could be a medication
cells.) ❖ Cell cycle phase specific for M
for brain cancer
phase
❖ Similar to ankylating agents
❖ Vinca alkaloids
❖ Can cross blood brain barrier – Circle
• E.g., vincristine (Oncovin), and
of willis. It is because circle of willis does
vinblastine (Velban)
not allow any medications to easily
❖ Taxanes come through to our brain tissues.
• E.g., Paclitaxel and Docetaxel - TIV ❖ E.g., Semustine, Lomustine,

Carmunstine
❖Epidophyllotoxins
G. Miscellaneous Drugs – They may
• E.g., Etoposide and Teniposide act like adjuvant, its either they enhance
D. Hormonal Agents the therapeutic effect of prementioned
chemotherapeutic drugs or they manage
❖ Steroids and Sex Hormones side effects that may be produce by the
chemo drugs
• Alter the endocrine environment to
make it less conducive to growth of ❖ Unknown or too complex to
cancer cells categorize
• Cell cycle phase non-specific – They ❖ E.g., Asparaginase, procarbazine
are not choosing whether its metaphase,
anaphase, synthesis phase they would Method of Administration for
be attacking. They will only give your Chemotherapeutic Drugs
cancer cell no conducive place for
• Oral
growth.
• Subcutaneous
• E.g., Diethylstilbesterol, Androgen,
Estrogen, Antiestrogen, Progestin, • Intravenous
Anticortical Compounds, Antiadrenal
• Intra-arterial perfusion
E. Antitumor Antibiotics
• Intrathecal - into the spine
(Anthracyclines)
• Vascular access graft
❖ Affect RNA to make environment less
favorable for cancer growth • Intraperitoneal – into the tummy

Safe Handling of Chemotherapeutic around the IV bottle mix with chemo
Agents drug including the entire length of the IV
tubing. They don’t allow the IV tubing
1. Wear mask, gloves and back –
and bottle be pass through with sunlight
closing gown. – Enclosed yung buong
and UV light. It is because they believe
katawan. Usually, the ones that prepare
chemotherapy may travel through UV
the chemo drugs are the oncologic
light.
doctors but there are also oncologic
nurse na allowed for the preparation of 9. Contaminated needles and syringes
medications must be disposed in a clearly marked
special container; “leak - proof”,
2. Skin contact with drug must be
“puncture - proof”.
washed immediately with soap and
water. Eyes must be flushed 10. Dispose half – empty ampoules,
immediately with copious amount of vials, IV bottles by putting into plastic
water. – Kasi nga yung chemo drug kasi bag, seal and then into another plastic
pag napunta sayo yan pati ikaw bag or box, clearly marked before
nachemo ka na rin, walang pinipiling placing for removal. Label as
patient “Hazardous waste”. – The chemo and
radiation materials, hindi basta basta
3. Sterile/alcohol – wet cotton pledgets
tinatapon. Some other institutions
should be used – wrapped around the
naglalagay ng trash bin for radioactive
neck of the ampule or vial when
wastes.
breaking and withdrawing the drug. –
The chemo effect may come also in your 11. Handwashing should be done before
body and after removal of gloves.
4. Expel air bubbles on wet cotton. – It is 12. Trained personnel only should be
not expelled in the air, it must be involved in use of drugs.
properly expelled in a wet cotton
13. Ideally, preparation of drugs should
5. Vent vials to reduce internal pressure be in laminar flow conditions with filtered
after mixing. air –We don’t casually prepare chemo
drugs in an open-air room. Some
6. Wipe external surface of syringes and
doctors used vacuum box to prepare the
IV bottles.
medications.
7. Avoid self – inoculation by needle
Nursing Interventions for
stab. – Avoid needle stick injury kahit
Chemotherapeutic Side Effects
wala ng laman yung syringe may chemo
effect pa rin yun 1. G.I. System – nausea and vomiting,
diarrhea, constipation
8. Clearly label the hanging IV bottle
with ANTINEOPLASTIC a. Administer antiemetic to relieve
CHEMOTHERAPY. – Some other nausea and vomiting. – The simple kind
hospitals would practice the use of would be Plasil (Metoclopramide) but for
paper bag or black bag that would wrap severe cases of nausea or vomiting

there would be a lot more medication to • Avoid people infection.
be given na higit ang lakas compare kay
c. Thrombocytopenia
plasil
• Protect from trauma.
b. Replace fluid – electrolyte losses, low
– fiber diet to relieve diarrhea. • Avoid ASA.
c. Increase fluid intake and fibers in diet 4. Genito – Urinary System
prevent/ relieve constipation.
a. Hemorrhagic cystitis – Bleeding,
2. Integumentary System traumatize, inflamed urinary bladder
a. Pruritus, urticaria and systemic signs. • Provide 2 – 3 L of fluids per day.
• Provide good skin care. b Urine color changes
b. Stomatitis - Singaw • Reassure that it is harmless.
• Provide good oral care. 5. Reproductive System
• Avoid hot and spicy food. a. Premature menopause or
amenorrhea
c. Alopecia
• Reassure that menstruation resumes
• Reassure that it is temporary.
after chemotherapy.
• Encourage to wear wigs, hats or head
Antiemetics to Relieve Nausea and
scarf. – It is depressing for them. It
Vomiting Related to Chemotherapy –
would have a psychological effect.
Malalakas, not as simple as plasil. Some
d. Skin pigmentation of the medications would be given as
anticonvulsant, antianxiety,
• Inform that it is temporary. – Side
antipsychotic drug. Pero kahit yun ang
effect only
therapeutic effect, they could assume
e. Nail changes other therapeutic role like an antiemetic.
Don’t put in your mind that all
• Reassure that nail may grow normally medications will be given just because
after chemotherapy. of the therapeutic effect that you are
3. Hematopoietic System only oriented to. Pwedeng magkaroon
Pancytopenia – “pan” meaning overall, ng dual or multi therapeutic effect ang
“cyto” means blood cells, “penia” means isang gamot.
low count 1. Dronabinol (Marinol)
A .Anemia 2. Ondansetron (Zofran) – most
• Provide frequent rest periods. common
b. Neutropenia 3. Granisetron (Kytril)
• Protect from infection.

4. Alprazolam (Zanax) – binibigay as • Palliation – Relieving signs and
anxiolytic tranquilizing medication to symptoms ❖ Sources of Radiation
some patient who have anxiety Therapy
disorders. Dun talaga siya gamot pero
may possibility kasi na kailangan ng • External Radiation Therapy
malakas na gamot nung patient for (Teletherapy). Administered through an
nausea and vomiting na hindi kayang Xray machine
irelieve ni plasil kaya siya mabibigyan ng ❖ Side Effects of Radiation Therapy
isang antianxiety drug din na may effect
na antiemetic din naman 1. Skin Reactions
5. Lorazepam (Ativan) – anticonvulsant Erythema, dry/moist desquamation. –

but may be given also as antiemetic Scaling of the skin, para siyang
nagdandruff. Kasi nga they are prone to
6. Haloperidol (Haldol) – antipsychotic dehydration because of the radiation
drug but it can also be given as a relief
for nausea and vomitting Atrophy, telangiectasia (kita yung ugat,
parang mga spider webs),
7. Prochlorperazine (Compazine) depigmentation, necrotic/ulcerative
Summary of Effects of Chemotherapy lesions.
✓ Antineoplastic drugs affect both Nursing Responsibilities:

normal and cancer cells by disrupting • Observe for early signs of skin
cell function and division at various point reactions and report.
of cell cycle.
• Keep area dry
✓ Most cancer drugs are most effective
against cells that multiply rapidly – • Wash area with water, no soap and pat
neoplasms, bone marrow cells, cells in dry (do not rub). – Kasi nga sensitive
the GI tract and cells in the skin or hair ang mga skin ng mga nagraradiation
follicles. Adverse reactions to cancer • Do not apply ointments, powders or
drugs tend to occur in these organs. lotions on the area.
✓ Chemotherapeutic agents should not • Do not apply heat, avoid direct
be used during pregnancy or lactation. sunshine or cold.
Congenital defects may occur in the
• Use soft cotton fabrics for clothing.
fetus.
• Do not erase markings on the skin.
C. Radiation Therapy
These serves as guide for areas of
❖ Role in Cancer Intervention irradiation.
• Primary curative role 2. Infection
• Adjunct to other therapy Due to bone marrow suppression. –

WBC suppression as well Nursing
Responsibilities:

• Monitor blood counts weekly 8. Nausea and vomiting
• Good personal hygiene, nutrition, 9. Headache
adequate rest
10. Hair loss/ alopecia
• Teach signs of infection to report to
11. Cystitis
physician
12. Social Isolation
3. Hemorrhage
Platelets are vulnerable to radiation. – ❖ Principles of Radiation Protection
May cause thrombocytopenia Nursing – “DTS”
Responsibilities: 1. Distance. Maintain a distance of at
• Monitor platelet count. least 3 feet when not performing nursing
procedures. – Radioactive yung mga
• Avoid physical trauma or use of patient or kung di maiiwasan, you may
aspirin. – May lead to uncontrollable wear lead apron
bleeding • Teach signs of hemorrhage. –
specially in the gums • Monitor stool 2. Time. Limit contact for 5 minutes
and skin for signs of hemorrhage. each time, a total of 30 minutes per shift.
• Use of direct pressure over injection 3. Shielding. Use lead shield during
sites until bleeding stops. contact with client.
4. Fatigue ❖ Teaching Guidelines Regarding

Radiation Therapy
Result of high metabolic demands for
tissue repair and toxic waste removal. 1.It is painless.
Plenty of rest and good nutrition. 2.Lie very still on a special table while
5. Weight loss the intervention is being given and you
may be placed in a special position to
Anorexia, pain and effect of cancer. maximize tumor irradiation.
6. Stomatitis 3.Each treatment usually lasts for few
Ulceration of oral mucous membrane. minutes. You may hear sounds of the
machine being operated, and the
Nursing Interventions: machine may move during the therapy.
• Administer analgesic before meals. – It is anxiety provoking.
• Bland diet, no smoking/alcohol. 4.As a safety precaution for the therapy

personnel, you will remain alone in the
• Good oral hygiene/saline rinses q 2°. treatment room while the machine is in
• Sugarless lemon drops or mints to operation. – Like in a common X-ray
increase salivation. procedure, wala ka naman dapat ibang
kasama in the radiation room except for
7. Diarrhea yourself. The one conducting the

procedure would be inside a cubicle i. Done after menstruation.
which is radiation proof.
ii. During standing position, note
5.The technologist will be right outside specifically for symmetry of the breasts.
your room observing you through a iii. In lying position, elevate shoulders on
window or by closed – circuit TV. You the side examined with pillow support.
may communicate. iv. Palpate the breast from periphery to
the center in circular motion.
6.There is no residual radioactivity after
radiation therapy. Safety precautions are 2. Mammogram – it chooses no gender
necessary only during the time you are
i. This involves X – ray examination of
actually receiving irradiation. You may
the breast.
resume normal activities of daily living. –
Meaning don’t think that if you ii. The breast is supported on flat, firm
underwent radiation therapy you will be surface.
treated extra special, hindi, walang
kakaibang consideration sayo. iii. This involves use of 2 X – ray films.
C. Pathophysiology
CARE OF THE CLIENT WITH BREAST 1. a classic symptom that defines breast
CANCER cancer include:
A. Risk Factors Associated with O Firm, nontender, nonmobile mass o

Breast Cancer Solidarity, irregularly shaped mass o
Adherence to muscle or skin causing
✓ Menarche before age 11 dimpling effect – the reason why it is not
mobile.
✓ Menopause after age 50
Nakalubog o Involvement of upper outer
✓ Family history of breast cancer – quadrant or central nipple portion of
especially mother or sister breast o Asymmetry of the breasts
✓ Nulliparity or birth of first child after • “Orange peel” skin – particularly
age 30 on the area where tumor is
palpated o Retraction of nipple o
✓ History of uterine cancer Abnormal discharge from nipple
✓ Link with obesity, diabetes and D. Stages of Cancer
hypertension ✓ Stage I. Tumor size is up to 2 cm.
✓ Presence of benign breast disease ✓ Stage II. Tumor size is up to 5 cm with
B. Prevention axillary lymph node involvement.
1. Breast Self-Examination (BSE) ✓ Stage III. Tumor size is more than

5cm, with axillary and neck lymph node
i. Start from age 20.
involvement ✓ Stage IV. Metastasis to

distant organs (liver, lungs, bone and the operation kahit natahi yung naging
brain). sugat ng patient there is a possibility
that the cancerous area will continue to
E. Collaborative Management
produce secretions na kahit kailangan
1. Surgery dapat di maipon sa katawan ng tao. Kasi
kapag naipon yon sa katawan ng tao
O Lumpectomy/ Tylectomy. Involves madedelay yung healing process and
removal of the lump. – bukol lang worst magaagravate yung condition.
O Simple Mastectomy. Involves removal Temporarily lang.
of the entire breast. The pectoralis O DBCT exercises to prevent postop
muscles and the nipples remain intact. – respiratory complications.
Magkaroroon ng skin grafting kung
kailangan. (Skin grafting is a surgical 5. Surgery: Postoperative Care o Place
procedure that involves removing skin client in semi – Fowler’s position with
from one area of the body and moving it, arm elevated on pillows, abducted. To
or transplanting it, to a different area of promote venous return and prevent
the body. This surgery may be done if a edema.
part of your body has lost its protective
O Monitor Hemovac output
covering of skin due to burns, injury, or
(serosanguinous for the first 24 hours).
illness.)
o Check behind patient for bleeding.
O Modified Radical Mastectomy (MRM). Blood flows to the back by gravity. o
Involves removal of the entire breast, Post warning signs against taking blood
pectoralis major muscle and the axillary pressure, starting IVs, or drawing blood
lymph nodes. – Inaalis pati kulani to on the affected side.
prevent the chance of metastasis.
O Initiate exercise to prevent stiffness
Cancer cells have the ability to travel
and contractures of shoulder girdle. o
through lymph nodes.
Reinforce special mastectomy exercises
O Radical Mastectomy (Halstead as prescribed.
Surgery). Involves removal of the entire
O Provide adequate analgesia to
breast, pectoralis major and minor
promote ambulation and exercise. o
muscles, axillary and neck lymph nodes.
Encourage regular coughing and deep
It is followed by skin grafting.
breathing exercise. o Prepare client for
2. Chemotherapy size and appearance of the incision and
provide support when incision is viewed
3. Radiation Therapy for the first time.
4. Surgery: Preoperative Care o O Provide client with detailed
Psychosocial Support. Include the information concerning breast
husband when necessary. o Teach arm prosthesis. o Fitting is not possible for 4
exercises to prevent lymph edema. – 6 weeks. o A temporary prosthesis or
O Inform about wound suction drainage, lightly padded bras worn until healing is
e.g. hemovac, Jackson – Pratt. – After complete. o Teach patient to avoid

constrictive clothing and report ▪ Hold a cigarette
persistent edema, redness, or infection
▪ Injections, withdrawal of blood, BP –
of incision.
taking – specially on the side of
O Teach patient the importance of mastectomy c. “DOs”
continuing monthly breast examination
▪ Wear loose rubber gloves when
on the remaining breast.
washing dishes
6. Prevention of Lymphedema – Edema
▪Wear a thimble when sewing
formation either on the upper or the
lower extremities who underwent an ▪ Apply lanoline hand cream to prevent
operations in the breast area or upper dryness ▪ Contact AMD if arm gets red,
extremities yung paggagalingan ng warm, or hard / swollen.
lymphedema. The edema formation in
the lymphatic vessels might aggravate ▪ Return for check – up
the condition or might the excite the ▪ Wear “Life Guard Med Aid” tag:
possibility of metastasize. Iniiwasan na CAUTION – LYMPHEDEMA.
mamaga yung kamay nung patient
particularly on the side wherein in the
breast surgery has been performed.
a. “AVOIDs”
▪ Cuts
▪ Scratches
▪ Pinpricks
▪ Hangnails
▪ Insect Bites
▪ Burns
▪ Strong detergents
b. “DON’Ts” (on the affected arm or
side)
▪ Carry purse/anything heavy
▪ Wear wristwatch/jewelry – may put
pressure
▪ Pick at/ cut cuticles
▪ Work near thorny plants/ dig in garden
▪ Reach into hot oven

Pain: the 5th Vital Sign Visceral-internal organs (liver, pancreas)
(stomache ache, abdominal pain,
- An unpleasant sensory and emotional
anginal pectoris)
experience associated with actual or
potential tissue damage 2. Neuropathic Pain – always chronic
that occurs or results from injury or
- Personal and private sensation of hurt
malfunction of PNS/CNS (e.g. cancers,
- Harmful stimulus that signals current phantom limb pain, diabetic neuropathy)
impending tissue damage (it is a
symptom that something is wrong in the
B. Classification According to Duration and Severity
body) Acute Pain Chronic Pain
- Pattern of response that protects an ✓ Seconds - < 6 months ✓ 6 months – years
organism from harm (A defense ✓ Short in duration and sudden onset ✓ Long in duration and remote onset
mechanism)
✓ Intensity: mild to severe ✓ Intensity: mild to severe
Perioperative- all parts ✓ Localized ✓ Generalized
I. Classification of Pain ✓ Sympathetic nervous system ✓ Parasympathetic nervous system
A. Classification According to the ✓ Diaphoresis + ↑ VS ✓ Dry & warm skin + normal VS
Cause ✓ Dilated pupils ✓ Normal or dilated pupils
1. Nociceptive Pain – resulting from
noxious (harful/injurious) stimuli which
transmits in an orderly manner (e.g. C. Classification According to
sprains, bone fractures, burn, bumps, Location
bruises, inflammation, etc.) (merong 1. Phantom Pain – pain that comes
system or process) from detached body parts (e.g. phantom
Types limb pain)
a. Somatic Pain – caused by 2. Radiating Pain – felt on the source of

mechanical, thermal, chemical, pain that extends to nearby tissues (e.g.
electrical, etc. affecting voluntarily MI)
controlled body tissues (e.g. skeletal 3. Intractable Pain – pain unresponsive
muscles) (consciously controlled) to medical treatment (e.g. cancers) II.
Somatic-somato- physically observed Pain Transmission
bodily structures 1. Transduction
b. Visceral Pain – caused by ischemia, - The phase wherein noxious stimuli
compression or injury of the involuntarily trigger the release of biochemical
controlled body parts (e.g. internal mediators (e.g.
organs) (opposite of somatic pain)
prostaglandin, bradykinin, serotonin,
histamine, substance P) that sensitize
nociceptors.

Same inflammatory agents!! - Neurons of the brain sends signals or
Inflammation and pain are directly pain killers (e.g. endorphins, GABA) to
related to each other (Redness, pain, the area of affectation
swelling, heat). Kunwari nakatapak ka
ng thumbtacks nagkaron ng noxious
stimuli, carried to brain that it must be - It inhibits painful ascending stimuli
III. Pathophysiology of Pain
felt painful na dinadala ng biochemical
mediators. Dadaan sila from the pain Noxious stimuli
receptors. Stimulation of Nociceptors
Nociceptors- pain receptors.

A delta fiber C Fibers
2. Transmission
Substantia gelatinosa
- Transmission of pain from cause of
pain to the perception of pain Spinal cord → brain stem → thalamus →
limbic system → cerebral cortex
(interpretation of pain) (kung gusto mo
alisin yung pain sensation para di na NOCICEPTION
makaexperience ng pain sip t)
Release of Endorphins
- pain control takes place during
transmission pain Inhibits Pain / MODULATION
- e.g. ay masahe. Kung masaket likod

nila, hihingi sila diba ng masahe. Yung
pagmasahe yun yung pain control na From noxious stimuli, the nociceptors
sinasabi dito will be stimulated or sensitized. Function
nito ay went to the brain para
3. Perception mainterpret yung pain na merong
something painful. A delta fiber or C
- Client becomes conscious of the pain
fiber these are nerve fibers. A delta
(bat naramdaman na yung kirot)
fiberusually myelinated fibers na merong
- Brain interprets the signals and mga myelin sheath (Speed up the
localizes the pain (Nociception-pain transmission). Eto yung bilis ng
perception) transmission or process ng pagiisip.
Sharp pain dito hghly excruciating pain).
- Brain relates impulses to past pain
C FIBERS hindi kaya dull pain or slow
experiences
pain lang ganon chronic pain. How
4. Modulation would they reach your brain, kailangan
dumaan ka sa spinal cord. Substantia
- “Descending system” (we don’t want
gelatinosa- structure commonly found in
our body to be in pain that’s why we
dorsal aspect of spinal cord. Theory kasi
modulate it) Kunwari napaltos, or
raw imaginary gate dahil yung body
natalsikan ng mantika, it wont be the
natin magdedecide kung tatanggapn ba
same exp after an hour matanggal yung
yung painsensation or not. If it truly open
kirot dahil sa modulation phase)
itself and allow the brain to get the

sensation. Kapag nagbukas to - Found throughout the spinal cord and
nagkakaron na ng nociception. Now brain stem
your brain will send command to release
- Excitatory and inhibitory effect (carry
painkillers such as endorphins or GABA.
impulses that comes from the brain)
IV. Gate Control Theory
- Responsible for voluntary movement of
- According to Melzack and Wall, the muscle fibers - Examples of
peripheral nerve fibers carrying pain to diseases associated with acetylcholine:
the spinal cord can have their input
i. Myasthenia gravis ii. Alzheimer’s
modified at the spinal cord level before
disease
they reach the brain (Transmission
phase, pwede na iclose si substantia 2. Norepinephrine (neurotransmitter
gelatinosa) and a hormone)
- Small diameter nerve fibers: carry pain - Found in the brain stem and nerve
stimuli through a gate (pain carriers, tracts
they can open the gate)
- Excitatory and inhibitory effect
- Large diameter nerve fibers: carry non-
pain stimuli through a gate (intended to - For wakefulness and arousal (Sleep
close the gate or substantia gelatinosa, cycle)
pwede ihelp si patient sa pagalleviate - E.g. cocaine, amphetamine,
the pain) methamphetamine HCl
- Both nerve fibers enters the same gate 3. Serotonin
which explain its gate closing
mechanism - Found in CNS and brain stem,
especially in spinal cord
- Gate mechanism is thought to be
situated in the substantia gelatinosa in - Inhibitory effect
the dorsal horn of the spinal cord -Responsible for memory, emotions,
- “All pain perception are only mind over mood, wakefulness, temperature
matter” (Melzack and Wall) regulations, sleep, anxiety
- E.g. ventusa stimulating the large - Examples of disorders associated with

nerve fibers serotonin:
i. Narcolepsy ii. Schizophrenia
V. Neurotransmitter (they carry signals 4. Dopamine

into the brain) - Found in the hypothalamus and nerve
- Chemical substances that aids tracts
in transmission of pain or any stimuli - Excitatory effect
1. Acetylcholine

- For voluntary contraction of muscle f. Variations (on and off) n. Physical
fibers - examination of pain
Example of associated disorder: g. Patterns
i. Parkinsonism h. Alleviating factors
5. GABA
- Found in the hypothalamus and CNS O – nset (What time?)
- Produces local anesthesia P – rovoking Factors (What causes and
worsens the pain?)
- For modulation of pain
Q – uality (is it burning, stabbing, sharp
- Generally inhibitory
pain?)
- E.g. Ritalin (Can be given to patients
R – adiation (where do you feel the
with ADHD)
pain? Did it radiate?)
6. Endorphins
S – everity (pain scale: 0-10)
- Found in the CNS widely and PNS
T– iming (duartion)
- Calming effects
Wong – Baker FACES Pain Rating
- Anesthetic/ inhibitory effect Scale: for pediatrics, with language
difficulty and mute which utilizes facial
- Natural pain killers expression or grimaces to assess pain
- E.g. Morphine SO4, Opiates sensation
VI. Pain Assessment VII. Pain Management
A. Characteristics of Pain - It refers to the techniques used

to prevent, reduce or relieve pain
1. JCAHO Components of
Comprehensive Pain Assessment A. Methods of Drug Administration
a. Intensity i. Aggravating factors 1. Oral (including sublingual)
b. Location j. Present pain 2. Rectal

management regimen 3. Transdermal
c. Quality k. Pain management 4. Parenteral
history
a. Patient controlled analgesia
d. Onset l. Effects of pain
b. Intraspinal analgesia
e. Duration m. Person’s goal for pain
control

B. WHO 3-STEP LADDER (Nawala nga kirot nagsuka naman yung
patient sa tapang nung gamot)
Step 1: mild to moderate pain lasting 3-
4hours start with low doses of nonopioid E. Analgesic Drug Therapy
drugs
Anti-oppose to algesia- pain sensation
e.g. Acetaminophen, NSAIDs, Adjuvants
1. Opioids – chemical substance that
Step 2: intermediate pain not controlled has morphine – like action in the body.
by nonopioid; (kapag di naachieve sa The main use is for pain relief. These
step 2) agents work by binding to opioid
receptors, which are found principally in
Use combination of opioid and
the CNS and GIT.
nonopioid drugs
- Examples: Morphine SO4, Meperidine
e.g. Acet/ASA + Codeine or
HCl (Demerol) - Nursing Responsibility:
Hydrocodone or Oxycodone, Tramadol,
other related adjuvants i. Assess RR before and after
administration to prevent atelectasis
Step 3: For severe pain, add higher
dose of opioid to nonopioid or use a ii. Teach DBE and cough exercise
drug that potentiates its analgesic effect using incentive spirometer
e.g. Morphine, Oxycodone, iii. Management for side effects:
Hydromorphone, Methadone, Fentanyl,
a. Sedation – raise the side rails, have
other adjuvants
ambulatory devices, place a call bell
A fourth step is being considered for
b. Constipation - ↑ fiber, give laxatives
patients with pain associated with
as ordered
cancer (Nerve blocks, electrical
stimulation of the spinal cord, c. Hypotension – move patient slowly,
neurosurgical analgesic techniques) monitor BP q15min
d. Urinary retention – insert urinary
catheter if indicated
iv. Laugh therapy (To improve
ventilation)
2. Nonopioids – it inhibits prostaglandin

synthesis - Examples: NSAIDs, ASA,
Adjuvants- refers to either of the Ibuprofen -
medications that are coadministered to Nursing Responsibility:
manage and adverse effect of an opioid
or to so-called adjuvant analgesics that i. Give NSAIDs pc (After meal) –
are added to enhance analgesia because it cause gastric ulcer ii.

NSAIDs side effect – renal impairment, ii. Monitor blood count- it can cause
dyspnea, constipation, headache, bone marrow depression; hepatotoxicity
dizziness
iii. Safety precautions (use of side rails,
iii. If on ASA, monitor for signs of tongue guard) – it has a sedative effect
bleeding – occult blood, bleeding gums, and can cause death due to blocked
easy bruising, epistaxis airway
3. Antidepressants – effects are
believed to be related to their effects on
6. Psychostimulants – used as
neurotransmitter. (they also help to
adjuvant to analgesic therapy to
alleviate the pain)
increase effect to pain - E.g. Ritalin
a. TCA (Tricyclic Antidepressants) for ADHD and depressed patients -
b. MAOIs (Monoamine Oxidase Nursing responsibility:
Inhibitors)
i. Give before bedtime for ADHD
c. SSRI (Selective Serotonin Reactive patients; give on daytime for depressed
Inhibitors) patients ii. Avoid caffeinated
beverages if on Ritalin treatment
D. Neurosurgical Management
4. Corticosteroids – reduces
inflammation and they are therefore 1. Cordotomy – division of certain tracts
useful in treating pain where of the spinal cord to interrupt
inflammation or edema is causing transmission of pain.
symptoms. - E.g. Dexamethasone,
2. Rhizotomy – sensory nerve roots are
Betamethasone - Nursing
destroyed where they enter the spinal
Responsibility:
cord. (nerve roots lang yung tutusukin)
i. Monitor weight, VS and serum
glucose levels – side effects of
corticosteroids 1. Obtain a written consent
ii. Monitor WBC levels – corticosteroid 2. Assess for pain level and neurologic
is immunosuppressive status
5. Anticonvulsants – they are believed 3. Skin care, position and turn the
to suppress rapid and excessive firing of patient q2h
neurons that start a seizure following
pain perception - E.g. diazepam 4. Bowel and bladder management
(Valium) – it increases GABA - Nursing E. Nonpharmacologic
Responsibility: Interventions
i. Give diazepam with food because of 1. Heat and cold application
possible ulceration
2. TENS and PENS

3. Acupuncture and acupressure Preoperative Phase – extends from the
time the client is admitted in the surgical
4. Imagery
unit, to the time he/she is prepared
5. Biofeedback physically, psychosocially, spiritually and
legally for the surgical procedure, until
6. Breathing exercise he/she is transported into the operating
7. Hypnosis room
8. Massage Intraoperative Phase – extends from

the time the client is admitted to the
9. Yoga/ meditation operating room, to the time of
10. Music Therapy administration of anesthesia, surgical
procedure is done, until he/she is
F. General Nursing Responsibility for transported to the recovery room/post-
Pain Management anesthesia care unit
1. Maintain a therapeutic relationship Postoperative Phase – extends from
2. Assess and document systematically the time the client is admitted to the
recovery room (PACU), to the time
3. Intervene using a multidisciplinary he/she is transported back into the
team approach for maximum relief surgical unit, discharged from the
4. Advocate for the patient hospital, until follow-up care.
5 Educate patient and family

6. Clarify orders I. Four Major Types of Pathologic
Processes Requiring Surgical
Interventions
PERIOPERATIVE NURSING
1. Obstruction – impairment to the flow
Surgical Terminologies
of vital fluids. E.g. blood, urine, CSF, bile
Prefixes Meaning Root words Meaning Suffixes Meaning
a
ecto
without, absence
external, outside
adeno
arthro auto
gland
joint self
algia
centesis
pain puncture
viewing removal 2. Perforation – rupture of an organ
intro below blephar eyelid scopy of inflammation
inter between cardio heart ectomy of stone, calculus
(ulcer)
intra within cephalo head itis lith science or study
pan
peri
all cerebro
cheilo
brain logy
lysis
of 3. Erosion – wearing off of a surface or
loose, dissolution tumor
around, near lip bile gall
poly many chole bladder common oma artificial opening membrane (burns)
pseudo false cholecyst bile duct ostomy fixation or
retro choledocho cartilage pexy suturing repair of
supra
behind, posterior
above
chondro vagina rib plasty repair of 4. Tumors – abnormal new growths
colpo costo abdomen rrhaphy
lapar kidney eye
nephro ovary testis
oculo bone ear vein
oophoro renal pelvis II. Classification of Surgical
orchi fallopian tube
osteo Procedure
oto
phlebo
pyel A. Classification According to Degree
salpingo of Risk (Magnitude/Extent)

1. Major Surgery (if the surgery will be a. Ablative Surgery – involves removal
done level of the diaphragm and above of an organ (suffix used is “ectomy”).
with handling of vital organs) E.g. appendectomy
High risk b. Constructive Surgery – involves
repair of congenitally defective organ
Extensive
(suffixes used are “plasty”, “orrhaphy”,
Prolonged (more than 2 hours) “pexy”). E.g. cheiloplasty, orchidopexy
With large amount of blood loss c. Reconstructive Surgery – also

called restorative surgery; involves
Vital organs may be handled or repair of damaged organ (suffixes used
removed are “plasty”, “orrhaphy”, “pexy”). E.g.
Great risk of complications (e.g. plastic surgery after severe burns
transplants, ablative operations, (e.g. 4. Palliative Surgery – to relieve
cholecystectomy), laparascopic surgery distressing signs and symptoms, not
(pwera cholecystectomy and tubal necessarily to cure the disease
ligation); open resection of organs; large
joint replacements; mastectomy with 5. Cosmetic Surgery – improves
reconstruction; and spine, thoracic, appearance. E.g. facelifting
vascular, or intracranial surgery)
2. Minor Surgery
C. Classification According to
Generally not prolonged Urgency
Leads to few serious complications 1. Emergency Surgery
Involves less risk Done without any delay and requires

immediate attention
Some minor operations exceeding
2hours is considered major operation Usually life-threatening
E.g. ruptured appendicitis, VA,
gunshot wound, stabbed wound,
B. Classification According to fractured skull, CS for labor arrest
Purpose
2. Urgent / Imperative Surgery
1. Diagnostic Surgery – to establish
the presence of a disease condition. Done within 24 – 30 hours requiring
E.g. biopsy prompt attention
2. Exploratory Surgery – to determine E.g. CAD, kidney stones, appendicitis

the extent of the disease condition. E.g. (if not ruptured)
exploratory laparotomy
3. Required Surgery
3. Curative Surgery – to treat the
Patient needs to have surgery for
disease condition
well-being

Weeks – months plans 3. Instructing and demonstrating
exercises that will benefit the person
E.g. cataract, thyroid disorder,
during postop period
prostatic hyperplasia, scheduled CS
4. Planning for discharge and any
4. Elective Surgery
projected changes in lifestyle due to
Not absolutely necessary for survival; surgery
even without surgery it will not be life-
B. Assessment
threatening
1. Age
E.g. circumcision, cyst (non-
malignant) Too young and too old are at high risk
for surgery
5. Optional Surgery
2. Fluids and Nutrition
Decision rest on the patient; usually
for aesthetic purposes Nutritional deficiency should be
corrected preop
E.g. plastic / cosmetic surgery
Dehydration and electrolyte
imbalances
D. The Effects of Surgery to the Client
Obesity
1. Stress response is elicited
NPO post midnight – if for major
2. Defense against infection is lowered operative or operative procedures for
airways
3. Vascular system is disrupted
3. Drugs or alcohol use
4. Organs function are disturbed
Alcoholic patients requires higher
5. Body image may be disturbed dose of anesthesia
6. Lifestyle may change Prone to malnutrition and
hepatotoxicity
III. PREOPERATIVE PHASE 4. Respiratory Function
A. Goals Assess RR perioperatively
1. Assessing and correcting physiologic Respiratory function may be

and psychological problems that might depressed during surgery
increase surgical risk Teach DBCT (deep breathing
2. Giving the person and significant coughing tech)
others complete learning/teaching Instruct to stop smoking at least 24h
guidelines regarding surgery preop
5. Cardiovascular Function

Assess PR, perform ECG as ordered iv. Give empathetic support
If with uncontrolled hypertension, v. Consider the person’s religious
surgery may postponed until corrected preferences and arrange for visit by
priest/minister as desired
6. Immune system (pano kunware
magkikidney transplant e kaso 11. Spiritual Concerns
naghihighblood pano gagawin)
Jehovah’s witnesses – “no blood
Assess for allergies on drugs, blood transfusion“
products, contrast agents, latex, etc.
Protestants – avoid seafoods and
Interview if on corticosteroids
vertebral animals
7. Hepatic Function
Secure result of liver enzyme test,
C. Informed Consent Purposes:
function test
i. To ensure that the client understands
History of hepatitis
the nature of the treatment including the
8. Endocrine function potential complications (explained by the
AMD)
Monitor blood glucose level
ii. To indicate that the client’s decision
Assess thyroid function
was made without pressure
9. Previous Medications Used
iii. To protect the client against any
Assess for history of aspirin use unauthorized procedure
To prevent possible antagonistic iv. To protect the surgeon and hospital

effect of drugs during surgery against legal action by a client who
claims that an unauthorized procedure
10. Neurologic Function was performed
Assess LOC – consider 3cs Circumstances Requiring a Permit
(conscious, coherent, cognitive)
i. Any surgical procedure where
Assess for fear and anxiety about the scalpels, scissors, suture, hemostats of
procedure and address it therapeutically electrocoagulation may be used
Nursing Responsibility to Minimize ii. Entrance into a body cavity – e.g.
Anxiety: paracentesis, bronchoscopy iii. General
i.Explore client’s feelings anesthesia, local infiltration, regional
block
ii. Allow client to speak openly about
fears and concerns Requisites for Validity of Informed
Consent
iii. Give accurate information regarding
surgery (no false reassurance) i. Written permission is best and
is legally acceptable

ii. Signature is obtained with client’s Foot and leg exercise
complete understanding of what to occur
3. Preparing the Person the Evening
iii.Obtained before sedation Before the Surgery
iv. Secured without pressure or duress Preparing the skin – have full bath to
reduce microbes on the skin
v. A witness is desirable – nurse,
physician, or other authorized persons Preparing the GIT – NPO; cleansing
vi. In an emergency, permission via enema as required
telephone or telefax is acceptable vii.
Preparing for Anesthesia – avoid
For minor (below 18yrs), unconscious,
alcohol and smoking at least 24h preop
psychologically incapacitated,
permission is required from responsible Promoting rest and sleep – administer
family member sedatives as ordered
(parent/legal guardian) 4. Preparing the Person on the Day of
Surgery
Early AM care
D. Physical Preparation
i. Awaken 1h before preop medications
1. Before the Surgery
ii.Morning bath and mouth wash
Correct any dietary deficiencies
iii. Provide clean gown
Reduce an obese person’s weight
iv. Remove hairpins, braid long hairs,
Correct fluid and electrolyte
cover hair with cap
imbalance
v. Remove dentures, foreign materials,
Prepare blood products for possible
colored nail polish, hearing aid, contact
blood transfusion
lenses
Treat chronic diseases – DM, heart
vi. Take baseline VS before preop
disease, renal insufficiency
medications
Halt or treat any infectious process
vii. Check id band, skin prep
Treat an alcoholic person with vitamin
viii.Check for special orders – enema, GI
supplements, IVF’s or oral fluids, if
tube insertion, IV line (g.18) ix. Check
dehydrated
NPO
2. Teaching Preop Exercises (early
ix.Have client void before preop
ambulation)
medication
DBCT
xi. Continue to support emotionally
Incentive spirometry
xii. Accomplish “preop care checklist”
Turning exercises

5. Preoperative Medications / E.g. morphine, meperidine HCl
Preanesthetic Drugs Goals: (Demerol)
i. To facilitate the administration of any Side Effects: ↓ RR, n & v, hypotension
anesthetic
5. Prophylactic Antibiotic – to ↓
ii. To minimize respiratory tract flora in the bowel (to prevent
secretions and change in HR iii. To relax infection)
the client and reduce anxiety
Transporting the client to the OR
Commonly Used Preop Meds:
Patient’s Family
1. Sedatives
i.Direct proper visiting room
Given to ↓ anxiety
ii. Doctor informs family immediately
Lowers BP and pulse after surgery
Lowers the administration of iii. Explain reason for long interval of
anesthetics (the higher the dose of waiting: anesthesia prep, skin prep,
anesthesia the higher the complications) surgical procedure, RR iv. Explain what
to expect postop
E.g. barbiturates, Phenobarbital,
nubain, Demerol
Overdose: respiratory depression IV. INTRAOPERATIVE PHASE A.
Members of the Surgical Team
2. Anticholinergics
1. Scrub Team
To ↓ tracheobronchial secretions
a. Operating Surgeon
To ↓ bowel motility and ↑ fluid
retention Leader of Operating Team
Interrupts vagal nerve impulses → ↓ Doer of the operation
HR
b. Assistant to the Surgeon
E.g. Atropine Sulfate
Clerk (Doctor), intern, resident or
Overdose: severe tachycardia, another surgeon
arrhythmias
Holds retractors
3. Tranquilizers
Exposes surgical area
To ↓ anxiety and BP
Clamps all the bleeders or sutures
E.g. Phenergan, Thorazine bleeders
4. Narcotics / Analgesics Tying clamped vessels
Relaxes patient and ↓ anxiety Assist surgeons in ligating bleeders

c. Scrubbed Nurse (Instrument and Maintain lightings
Suture Nurse)
Provide footstools for the team
Prepares and arrange instruments
Carries and opens lap packs
and supply
B. Parts of the Operating Unit
Checks the completeness of
instruments and preliminary count 1. Unrestricted Area
Passes sponges Provides an entrance to and exit from
surgical suite
Assist scrub team during gowning and
gloving Contains the holding or admission
area, hospital lobby and PACU
Assist in draping the patient
Street clothes are permitted here
2. Unscrubbed Team
2. Semi – restricted area
a. Anesthesiologist (either MD or RN)
Provides an access to the procedure
Monitor VS during the surgical
rooms and peripheral support areas
procedure
within the surgical suite
Keeps the surgeon aware of the
PACU, Anesthesia room, packing
patient’s condition
area (autoclave area) with window
In charge of most medication and IV
3. Restricted Area
administrations during the OR procedure
Includes the procedure room in which
Determines if the patient is viable to
surgery is performed
be transferred to PACU
Personnel in OR attire + surgical
b. Pathologists
masks
Consulted by the surgeon on the
diagnosis of the removed tissue or
organ C. OR Attires (Protective Barriers)
Consulted for possible treatment 1. Scrub suits
c. Circulating Nurse 2. Head coverings (cap/hood)
Overseer of the OR 3. Shoe coverings
Maintains sterility of the OR 4. Masks
Assist all the scrubbed for their needs 5. Lead aprons and thyroid shield
Checks the completeness of the chart D. Principles of Surgical Asepsis
Ties the gowns of members – 1. Patient is the center of the sterile field
“stoop and swing method”

2. Only sterile items are used within the e.g) Autoclaving- temperature of 250
sterile field degrees F max of 30 minutes
3. Sterile persons are gowned, gloved, 2.) Dry Heat
masked and with bonnet or cap
a.) Flaming
Hands above the waist
b.) Incineration
Keep your hands away from the face
c.) Hot air oven
Remove all jewelries
d.) Radiation sterilization
Gowns are considered sterile at the
front area
B. Chemical Methods
Sit only if the operation requires or
allows sitting position 1.) Ethylene oxide
4. Tables are sterile at the topmost level 2.) Cold sterilization e.g. Activated
only Glutaraldehyde solution (Cidex)- for
charp instruments
5. Sterile persons touches sterile items
and unsterile persons touches unsterile C. Filtration
only
D. Flash Sterilization- for urgent use but
For sterile persons, avoid still controversial
overreaching over the unsterile fields
For unsterile persons, avoid
overreaching over the sterile fields Categories of Medical and Surgical
Instruments and Supplies According
6. All edges of the mayo table are to Sterilization
considered unsterile
A. Category I (Critical Items)
7. Sterile items are always kept in view
-All items are strictly sterile
8. Microbes are kept irreducibly
minimum -E.g. surgical instruments, cardiac
catheter, implants, etc
Methods of Sterilization
A. Heat Methods
B. Category II (Semi- Critical Items)
1.) Moist Heat
-Sterilization is performed but
a.) Boiling disinfection may be accepted
b.) Pasteurization -“HIGH-LEVEL DISINFECTION”
c.) Steam Therma -endoscope, tonometer, most mucosal
instruments

C. Category III (Non-Critical Items) Respiratory obstruction and failure
-Instruments are accepted CLEAN only Vomiting and aspiration
-“LOW-LEVEL DISINFECTION Shock and Hypotension
-e.g. BP apparatus, thermometer, most Cerebral Complications:
instruments touching intact skin
CVA
E. Types of Anesthesia
Convulsions
1. General Anesthesia
iii. Renal Complucations:
Total loss of consciousness and
Renal ischemia
sensation
2. Regional Anesthesia
Produces amnesia
Reduce all painful sensation without
Methods of administration:
in one region of the body without
i. Inhalation- via face mask or inducing unconsciousness
endotracheal tube
Methods of Administration:
ii. Intravenous
j. Topical application – via spray or
Anesthetic agent given through instillation; e.g. xylocaine (Lidocaine)
inhalation:
k.ii. Local Infiltration – agent injected
i.Halothane (Fluothane) into the tissue around the incisional
area; e.g. Xylocaine 1-2%
ii. Enflurane (Ethrane) iii. Isoflurane
(Forane) iv. Sevoflurane (Sevorane) iii. Nerve Block – anesthetizing a group
of nerve of nerve at a given point
Anesthetic agent given via IV
Examples:
(sometimes via IM):
Digital block – entired finger
i. Thiopental Na (Pentothal Na) ii.
Propofol (Diprivan) iii. Axillary block – whole arm
Ketamine HCl (Ketalar) iv.
Radial block – whole hand
Fentanyl (Sublimaze) v.
Diazepam (Valium) vi. Intercostals nerve block
Midazolam (Dormicum)
Cervical block
Complications of General Anesthesia:
iv. Field block – blocking off the
i. Cardiopulmonary complications: operative site with wall of anesthetic
solution by series of injection into
Cardiac arrhythmias
proximal and surrounding tissues
Cardiac arrest
iv. Spinal and Epidural Block – solution
Bronchospasm and laryngospasm is injected either in spinal space or

epidural space; for surgeries below the Extends from the loss of
diaphragm e.g Laparotomy, lower consciousness to the loss of lid reflex
extremity operations
Reaction: shouting, struggling,
Components of Spinal uncontrolled muscle movement (jerky
Anesthesia: movements, restless)
a. Pontocaine – main anesthetic agent Nursing Responsibility: secure the
patient properly and assist
b. Dextrose 10% in water – diluents
anesthesiologist
c. Ephedrine – vasoconstrictor (to
Stage III (Surgical Anesthesia Stage)
prolong anesthetic effect)
Anesthetic agent given through Extends from the loss of lid reflex to
spinal anesthesia: the loss of most reflexes
i. Procaine (Novocaine) ii. Tetracaine Reaction: reflexes disappear, all
(Pontocaine) iii. Lidocaine (Xylocaine) iv. senses ↓(Anal urethral reflex e
Mepivacaine (Carbocaine) v. nawawala kaya edep na maihi nalang
Bupivacaine (Marcaine) bigla)
Complications of Spinal Anesthesia Surgical procedure is started
Hypotension Nursing Responsibility: skin prep,
insert catheter, position the client
N&V
properly
Headache Respiratory paralysis
Stage IV (Medullary/Danger Stage)
Paraplegia or severe muscle weakness
Characterized by respiratory/cardiac
Cryoanesthesia – produced by marked arrest due to anesthesia overdose
cooling
Nursing Responsibility: assist in
resuscitation
F. Stages of Anesthesia Stage I G. Common OR

(Induction Stage) Instruments/Equipment
Extends from the administration of 1. Lap Pack

anesthesia to the time of loss of
Army Navy (2) - Mayo scissor (1)
consciousness
Thumb or Tissue Forceps (2) -
Reaction: dizzy, drowsy (manlalata)
Bandage scissor (1)
Nursing Responsibility: keep the room
Straight clamps (3) Scalpel (1)
quiet and standby to assist
Curved clamps (3) Blade
Stage II (Excitement/Delirium Stage)
holder (1)
Allis (1) Needle holders (2)

Sharps: Towel clips (4) Polyester (medium green)
- Metzenbaum scissor (1) Nylon (light green)
2. Needles and Sutures
Types of Sutures:
a. Absorbable Sutures
Types:
i. Plain Gut – used to ligate small
vessels and subcutaneous tissue ii.
Chromic / Catgut – used to ligate
larger vessels
iii. Vicryl Plus – used in reproductive
tract
iv. Vicryl Rapide – used to close
mucosa in the mouth
v. Coated Vicryl – used in reproductive
tract Classification of Needles:
vi. Monocryl – used in urinary bladder; According to the Eye

GIT a. Eyed
b. Non-Absorbable Sutures b. Eyeless/Swayed/Atraumatic
Types:
Single arm – 1 needle on suture end
i. Silk – used in serosa of the GIT only
ii. Cotton Double arm – both ends of suture have
iii. Nylon – used by ophthalmologist needles
iv. Polyester fiber c. Spring/French
v. Polythylene According to the Shape
vi. Stainless steel – use of staple a. Non-cutting – rounded body or shaft +

wires pointed end
Common Colors of Suture Packaging: b. Cutting – sharp edge of the body or

shaft + pointed end
Plain gut (yellowish tan)
According to Shaft or Body
Chromic (tan)
a. Straight
Silk (medium blue)
b. Curved
Cotton (pink and white)

A. Goals
H. Samples of Surgical Incisions To maintain adequate body system
functions
1. Butterfly – for craniotomy
Restore homeostasis
2. Limbal – for eye surgeries
Alleviate pain and discomfort
3. Halstead / elliptical – for breast
surgeries Prevent postop complications
4. Abdominal – for abdominal surgeries Ensure adequate discharge planning
and teaching
5. McBurney’s – for appendectomy
6. Lumbotomy / Transverse – for kidney
surgeries B. Transport of the Client from the OR to
RR
Avoid exposure
I. Positions during Surgery
Avoid rough handling
1. Dorsal Recumbent – hernia repair,
mastectomy, bowel resection Avoid hurried movement and rapid
changes in position
2. Trendelenburg – lower abdomen,
pelvic surgeries B.1 Nursing Assessment
3. Lithotomy – vaginal repairs, D and C, 1. Appraise air exchange status and
rectal surgery, APR note the skin color
4. Prone – spinal surgeries, 2. Verify identity, operative procedure,
laminectomy surgeon
5. Lateral – kidney, chest, hip surgeries 3. Assess neurologic status (LOC) –
3Cs
4. Determine VS and skin temperature –
i. Explain purpose of the
if with fever, suspect infection 5.
procedure
Examine operative site and check
ii. Avoid undue exposure dressing
iii. Strap the person t prevent falls 6. Perform safety checks:
iv. Maintain adequate respiratory and Position for good body alignment
circulatory function v. Maintain good
Side rails
body alignment
Restraints for IVFs, BT
7. Require briefings on problems
V. POSTOPERATIVE PHASE
encountered in OR

B.2 Nursing Interventions Promote adequate wound healing
1. Ensure patent airway and adequate Promote and maintain activity and
respiratory function mobility
Lateral position with neck extended Provide adequate psychological
support
Keep airway in place until fully awake
D. Postoperative Complications
Suction secretions
1. Shock – a circulatory collapse due to
DBE
specific factors (e.g. ↓ blood volume,
O2 therapy bleeding, cardiac dysfunction, etc.)
2. Assess status of circulatory system 2. Femoral Phlebitis / Deep

thrombophlebitis – inflammation/injury of
Monitor VS and report abnormalities the blood vessels due to prolonged
Observe for signs of shock and immobility, obesity, hemorrhage
hemorrhage 3. Pulmonary complications:
Continuous care until patient is a. Atelectasis – lung collapse
completely out of anesthesia
b. Bronchitis
c. Bronchopneumonia and lobar
C. Transfer of the Client from RR to the pneumonia
Surgical Unit C.1 Parameters for
Discharge from RR d. Pleurisy
Activity – able to obey commands, 4. Urinary difficulties

e.g. DBCT
a. Retention
Respiration – Easy, noiseless
b. Incontinence
Circulation – BP is within the normal
5. Intestinal obstruction
range
6. Hiccups
Consciousness – responsive
7. Wound Infection Rule of Thumb:
Color – pinkish skin and mucous
membrane 1. Fever 1st 24hours – pulmonary
infections
C.2 Nursing Intervention
2. Within 48hours – UTI
Maintain adequate fluid and
electrolytes 3. Within 72hours – wound infection
Maintain adequate renal function 8. Wound complications Kinds:
Promote rest, comfort and safety 1. Hemorrhage / Hematoma

2. Wound Dehiscence – disruption in the
coaptation of wound edges (wound
breakdown) (kapag bumuka)
3. Wound Evisceration – dehiscence +
outpouching of abdominal organs
(meron lumalabas na vital organs or
tissues)
9. Delirium (Mental Aberration)

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College of Nursing-Medical Surgery Lecture 1

Care of Clients with Problems in

Unit 1 Nursing Care of At Risk and

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

oResonance – low pitched hollow -Normal pulmonary tissue is radiolucent

oApnea (Cessation of breathing) ii.Instruct the client to remove metals

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

Nursing Responsibility: -Instruct the client to remain still during

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

v.Pressure sensation is felt on insertion 13.Arterial Blood Gas

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

Partial rebreather mask

MERCURIO, Toni Ysabel R.

-Client should be in semi or high vii.Procedure is best done 60 to 90

-Hyperventilate client with 100% oxygen 4.Incentive Spirometry

-Apply suction only during the 5.Closed Chest Drainage

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

a. First: good gram (+) coverage viii. Carbapenems

MERCURIO, Toni Ysabel R.

6. Explain signs of complications of 3. Chronic granular – also called

Figure 1.5 Caldwell – Luc Procedure Diagnostic Test

E. Pharyngitis 1. Rapid Strep Test (RST)

- Inflammation of the pharynx caused by -Done by throat swabbing

- Classified as either acute or chronic 2. Nasal swabs and blood cultures

MERCURIO, Toni Ysabel R.

c. Antitussives -Sore throat

-cough suppresant -Snoring / bruxism (teeth grinding)

- Codeine, dextromethorphan -Dysphagia

MERCURIO, Toni Ysabel R.

-Indicated if tonsillitis recurs 5 to 6 times G. Laryngitis

2. Avoid coughing, sneezing, blowing of Preop care:

MERCURIO, Toni Ysabel R.

iv. Establish means of communication

MERCURIO, Toni Ysabel R.

The upper and lower respiratory tract

THE RESPIRATORY PHYSIOLOGY 2. Expiration

A. 4 Distinct Events during 4. Nonrespiratory Air Movements

The transportation or exchange of • Residual volume – the volume

MERCURIO, Toni Ysabel R.

F.Neurologic Control of the

D. Respiratory Sounds 5.Apneustic center – stimulate medulla

MERCURIO, Toni Ysabel R.

Causes: (their aim is to compress or -Dyspnea

MERCURIO, Toni Ysabel R.

MERCURIO, Toni Ysabel R.

B. Acute Tracheobronchitis Signs and Symptoms

-infection of your trachea, going down to -Dry, irritating cough