NCM 112 MEDICAL SURGICAL NURSING ENDTERM

CARE OF CLIENTS WITH PROBLEMS IN CELLULAR

ABERRATIONS, ACUTE AND CHRONIC COMPLEMENT CASCADE
THE IMMUNE SYSTEM  chemicals released by cells to signal other cells for
 Provides protection against reinforcement
invasion by microorganisms
from outside the body. ACQUIRED IMMUNITY
 Protects the body from  acquired from the exposure to environment
internal threats and  T-Cell Immunity
maintains the internal o Cell mediated immunity
environment by removing o from thymus gland
dead or damaged cells. o Suppressor T cells
o Helper T cells
o Cytotoxic T cells
 cells that are toxic to other cells
 B-Cell Immunity
o Humoral immunity
o Effector B cells
 plasma cells
 produce antibodies – peptides that cling to the
infection so the infection could no longer
adhere to the host
o Memory B cells
 clonal cells
 MOUTH  remembers the enemy for life
o dirtiest part of the human body
 GOUTRITIS LYMPHOCYTES VERSUS PHAGOCYTES
o increase in dietary uric acid LYMPHOCYTES PHAGOCYTES
 UREA Lymphocytes are small Phagocytes are cells that
o end product of protein white blood cells that play ingest and destroy foreign
 NITROGEN a major role in the particles, pathogens, and
o enters the body and goes out as still nitrogen immunity cell debris
 LACRIMAL FLUID (tears) Includes T cells, B cells, and Includes macrophages,
 TEARS natural killer cells neutrophils, monocytes,
o keeps the conjunctiva lubricated dendritic cells, and mast
cells
INNATE IMMUNITY Mediate adaptive immune Mediate innate immune
 inside, present at birth responses responses
Trigger a specific immune Trigger a non-specific
G – Glucose response against a immune responses against
U – Urea particular pathogen a particular pathogen
L – Lysozymes
P – Protein  NEUTROPHILS
S – Salt (Sodium) o kill bacteria, fungi and foreign debris
 MONOCYTES
 STOMACH ACID o clean up damaged cells
o produced by parietal cells  EOSINOPHILS
o kill parasites, cancer cells and involved in allergic
PHAGOCYTES response
 White blood cells  LYMPHOCYTES
 technically known as Leukocytes o help fight viruses and make antibodies
 Neutrophils (60-80%)  BASOPHILS
o kills bacteria, fungi and foreign debris o involved in allergic response
 Macrophages
o larger cells
o monocytes RHEUMATOID ARTHRITIS (RA)
o clean up damage cells  is an inflammatory disorder of unknown origin that
 Basophils (1%) primarily involves the synovial membrane of the joints.
o involved in allergic response  Musculoskeletal disorder
 Eosinophils (1%)  Arthro means “joints”
o kill parasites, cancer cells and involved in allergic  Caused by unknown or linken with autoimmune
response disorders, causing pannus formation of the synovial
 Natural Killer Cells fluid and membrane.
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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM
PATHOPHYSIOLOGY
 Phagocytosis produces enzymes within the joint. The
enzymes break down collagen, causing edema,
proliferation of the synovial membrane, and ultimately
pannus formation. Pannus destroys cartilage and erodes
the bode. The consequence is loss of articular surfaces
and joint motion.
 Muscle fibers undergo degenerative changes. Tendon
and ligament elasticity and contractile power are lost.
 RA affects 1% of the population worldwide, affecting
women two to four times more often than men.
MAST CELLS
 Histamine –  permeability of cell membrane
 Heparin – maintains the integrity of mast cells, prevents
coagulation
 Without inflammation, there is no repair
PANNUS FORMATION
CLINICAL MANIFESTATIONS
Clinical features are determined by the stage and severity of
the disease.
 Joint pain, swelling, warmth, erythema, and lack of
function are classic symptoms
 Palpation of joints reveals spongy or boggy tissue
 Fluid can usually be aspirated from the inflamed joint
CHARACTERISTIC PATTERN OF JOINT INVOLVEMENT
 Begins with small joints in hands, wrists, and feet
 Progressively involves knees, shoulders, hips, elbows,
ankles, cervical spine, and temporomandibular joints
 Symptoms are usually acute in onset, bilateral, and
symmetric
 Joints may be hot, swollen, and painful; joint stiffness
often occurs in the morning
 Deformities of the hands and feet can result from
misalignment and immobilization
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EXTRAARTICULAR FEATURES
 Fever, weight loss, fatigue, anemia, sensory changes,
and lymph node enlargement
 Raynaud’s phenomenon (cold-and stress-induced
vasospasm)
 Rheumatoid nodules, nontender and movable; found in
subcutaneous tissue over bony prominences
 Arteritis, neuropathy, scleritis, pericarditis,
splenomegaly, and Sjögren syndrome (dry eyes and
mucous membranes)
ASSESSMENT AND DIAGNOSTIC METHODS
 Several factors contribute to an RA diagnosis:
 Rheumatoid factor is present in about ¾ of patients
 RBC count and C4 complement component ;
erythrocyte sedimentation rate 
 C-reactive protein and antinuclear antibody test results
may be positive
 Arthrocentesis and X-rays may be performed
ORGAN TRANSPLANT
 Organ transplantation was first successfully undertaken
in humans in the 1950s,
 For a successful organ transplant, it is necessary to have
as close a Human Leukocyte Antigen (HLA) match
between the donor and the recipient as possible. The
poorer the HLA match, the greater likelihood that
rejection will occur.
 Identical twins tend to be the closest HLA matches,
often having the same HLA type, and have the least risk
of rejection.
 Siblings have a 1 in 4 possibility of having a close HLA
match; after that the chances of a good match become
much less with both other family members and
unrelated individuals.
In the Philippines, the Department of Health (DOH) lists
that human transplantable organs include the kidneys,
liver, lungs, heart, intestines, and pancreas, in addition to
human tissues such as eye tissues (corneas, sclera, etc.),
bones, skin, and blood vessels. When it comes to organ
transplantation, the kidneys are among the most
common. In fact, in 2019, over 10,430 kidney transplants
were recorded in Southeast Asia alone, whereas other
regions such as the Americas and Europe registered far
more. This procedure is considered a medical feat, but is
going through the process of getting one as complex?
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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM

*The most important things to remember is the timeframe

for the onset of symptoms as you can often determine what
type of rejection it is based on time alone

MANIFESTATION OF SYSTEMIC ANAPHYLACTIC REACTION

 Neurologic
o Headache
o Dizziness
o Paresthesia
o Feeling of impending doom
TRANSPLANT REJECTION  Skin
 is a process in which a transplant recipient’s immune o Pruritus
system attacks the transplanted organ or tissue. o Angioedema
o Erythema
o Urticaria
 Respiratory
o Hoarseness
o Coughing
o Sensation of narrowed airway
o Wheezing
o Stridor
o Dyspnea, tachypnea
o Respiratory arrest
 Cardiovascular
o Hypotension
TRANSPLANT REJECTION o Dysrhythmias
 Hyperacute o Tachycardia
o Occurs minutes to hours after transplantation o Cardiac arrest
o No treatment (organ must be removed)  Gastrointestinal
 Acute o Cramping, abdominal pain
o Occurs days (one week) to month after o Nausea, vomiting
transplantation o Diarrhea
o T-cytotoxic lymphocytes attack to the transplanted
organ MANAGEMENT
 Chronic  issues that need to be considered when caring for
o Occurs over months to years individuals who have received an organ or tissue
o Most common in lung transplants transplant include:
o increased risk of infection
SOME COMMON SIGNS AND SYMPTOMS o graft injection
 Pain at the site of the transplant o psychological issues
 Feeling ill
 Flu-like symptoms
 Fever
 Weight change
 Swelling
 Decreased urine output

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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM

NURSING MANAGEMENT FOR INCREASED RISK OF  Demyelination (destruction of myelin) results in

INFECTION impaired transmission of nerve impulses.
 Isolation
 Strict aseptic technique
 Monitor the vital signs for indications of infection (a rise PATHOPHYSIOLOGY
in temperature may be the first indicator of infection)  cause of MS is not known
 Wound dressing  defective immune response probably plays a major role
 Ensure regular oral hygiene  sensitized T cells inhabit the CNS and facilitate the
 Monitor intravenous (IV) cannulas for signs of infiltration of other agents that damage the immune
inflammation and infection, change q72 hours system.
 Monitor blood tests for signs of an increased WBC  The immune system attack leads to inflammation that
destroys myelin and oligodendroglial cells that produce
NURSING MANAGEMENT FOR GRAFT REJECTION myelin in the CNS.
 Administer prescribed medications:  Plaques of sclerotic tissue appear on demyelinated
o immunosuppressant medications axons, further interrupting the transmission of
 Azathioprine IV or oral impulses.
 Mycophenolate mofetil IV or oral
 Ciclosporin (cyclosporin) IV or oral
 Basiliximab IV Tacrolimus IV or oral
 Sirolimus Oral
 Antithymocyte immunoglobulin IV
 Corticosteroids IV or oral
 Pt. recognize rejection symptoms
 Blood tests should be monitored depending on the
organ transplanted: WBC, urea and electrolyte levels
and liver function tests.

NURSING MANAGEMENT FOR PSYCHOLOGICAL ISSUES

 Patients may face a number of psychological issues RISKS
while waiting for and receiving an organ transplant:  MS may occur at any age but typically manifests in
o guilt that someone may have to die in order for an young adults between the ages of 20 and 40 years;
organ to become available;  it affects women more frequently than men.
o anxiety regarding organ rejection; • Geographic prevalence is highest in Europe, New
o fear of death. Zealand, Southern Australia, the Northern United
States, and Southern Canada.
Nurses can support and help patients in coming to terms • Low Vitamin D levels and limited sunlight exposure
with their fears and worries through the application of • Certain autoimmune diseases – People with existing
good communication skills: autoimmune conditions, including thyroid disease,
 Observe patients’ body language to assess signs of pernicious anemia, psoriasis, type 1 diabetes, or
anxiety and worry. inflammatory bowel disease, are at a slightly increased
 Actively listen to fears and worries and offer risk.
appropriate support.
 Empower patients through education so that they can
make decisions about and be actively involved in their
own care.
 Identify and encourage the use of appropriate coping
strategies
 Encourage family members and significant others to
support patients
 Recognize the need for other support services, such as
counselling, to be involved in patients’ care

MULTIPLE SCLEROSIS CLINICAL MANIFESTATIONS

 Multiple sclerosis (MS) is a  Signs and symptoms are varied and multiple and reflect
chronic, degenerative, the location of the lesion (plaque) or combination of
progressive disease of the lesions.
central nervous system  Primary symptoms: fatigue, depression, weakness,
(CNS) characterized by small numbness, difficulty in coordination, loss of balance,
patches of demyelination in and pain
the brain and spinal cord.  Visual disturbances: blurring of vision, diplopia (double
vision), patchy blindness (scotoma), and total blindness.

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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM

 Spastic weakness of the extremities and loss of MEDICAL MANAGEMENT

abdominal reflexes; ataxia and tremor.  Because no cure exists for MS, the goals of treatment
 Cognitive and psychosocial problems; depression, are:
emotional ability, and euphoria. o to delay the progression of the disease,
 Bladder, bowel, and sexual problems possible. o manage chronic symptoms, and
o treat acute exacerbations.
MAIN SYMPTOMS OF MULTIPLE SCLEROSIS  An individualized treatment program is indicated to
 Central relieve symptoms and provide support.
o Fatigue  Management strategies target the various motor and
o Depression sensory symptoms and effects of immobility that can
o Cognitive impairment occur.
o Unstable mood  Radiation therapy may be used to induce
 Throat immunosuppression.
o Dysphagia
 Muscular PHARMACOLOGIC THERAPY
o Weakness Disease Modification
o Cramping  Interferon beta-1a (Rebif) and Interferon beta-1b
o Spasm (Betaseron) subcutaneously. Interferon beta-1a,
o Lack of coordination Avonex, IM once a week.
 Senses  Glatiramer Acetate (Copaxone) to reduce the rate of
o Increased sensitivity to pain relapse in the RR course of MS; SQ daily.
o Tingling  IV Methylprednisolone to treat acute relapse in the
o Burning relapsing remitting course.
o Pins and needles feeling  Mitoxantrone (Novantrone) is administered via IV
 Visual infusion q3 months for patients with secondary-
o Nystagumus progressive or worsening relapsing-remitting MS.
o Optic neuritis
o Diplopia SYMPTOM MANAGEMENT
 Mouth  Baclofen (Lioresal) is the medication of choice for
o Difficulty swallowing food treating spasticity; Benzodiazepines (Valium),
o Sudden slurring Tizanidine (Zanaflex), and Dantrolene (Dantrium) may
o or stuttering in speech also be used to treat spasticity.
 Urinary  Amantadine (Symmetrel), Pemoline (Cylert), or
o Frequent urination Fluoxetine (Prozac) to treat fatigue.
o Incontinence  Beta-adrenergic blockers (Inderal), Antiseizure Agents
 Digestive System (Neurontin), and Benzodiazepines (Klonopin) to treat
o Sudden change in urinary frequency Ataxia
o Constipation
o Diarrhea NURSING PROCESS: ASSESSMENT
 Assess actual and potential problems associated with
SECONDARY MANIFESTATIONS RELATED TO the disease: neurologic problems, secondary
COMPLICATIONS complications, and impact of disease on patient and
 Urinary tract infections, constipation family.
 Pressure ulcers, contracture deformities, dependent  Assess patient’s function, particularly ambulation, when
pedal edema patient is well rested and when fatigued; look for
 Pneumonia weakness, spasticity, visual impairment, incontinence,
 Reactive depressions and osteoporosis and disorders of swallowing and speech.
 Emotional, social, marital, economic, and vocational  Assess how MS has affected the patient’s lifestyle, how
problems the patient is coping, and what the patient would like to
improve.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 MRI (primary diagnostic tool) to visualize small plaques NURSING PROCESS: NURSING DIAGNOSIS
 Electrophoresis study of the cerebrospinal fluid (CSF);  Impaired bed and physical mobility related to weakness,
abnormal immunoglobulin G antibody (oligoclonal muscle paresis, spasticity
bonding)  Risk for injury related to sensory and visual impairment
• Evoked potential studies and urodynamic studies  Impaired urinary and bowel elimination related to
• Neuropsychological testing as indicated to assess nervous system dysfunction
cognitive impairment  Impaired verbal communication and risk for aspiration
• Sexual history to identify changes in sexual function related to cranial nerve involvement
 Disturbed thought processes (loss of memory,
dementia, euphoria) related to cerebral dysfunction

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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM

 Ineffective individual coping related to uncertainty of

diagnosis
 Impaired home maintenance management related to
physical, psychological, and social limits imposed by MS
 Potential for sexual dysfunction related to lesions or
psychological reaction

NURSING PROCESS: PLANNING

 The major goals of the patient may include promotion
of physical mobility, avoidance of injury, achievement of
bladder and bowel continence, promotion of speech
and swallowing mechanisms, improvement of cognitive
function, development of coping strengths, improved
home maintenance management, and adaptation to
sexual dysfunction.
NURSING INTERVENTIONS
 Promoting Physical Mobility
 Preventing Injury
 Enhancing Bladder and Bowel Control
 Managing Speech and Swallowing Difficulties
 Improving Sensory and Cognitive Function
 Strengthening Coping Mechanisms
 Improving Home Management
 Promoting Sexual Function
DIABETES MELLITUS TYPE 1 VS TYPE 2
 Promoting Home- and Community-Based Care
TYPE 1 DIABETES TYPE 2 DIABETES
EXPECTED PATIENT OUTCOMES  Occurs when the  Occurs due to insulin
 Reports improved physical mobility pancreas is unable to resistance (i.e. when the
 Remains free of injury produce enough insulin body does not respond
 Attains or maintains improved bladder and bowel  Tends to develop at a well to insulin)
control young age  Tends to develop at an
 Participates in strategies to improve speech and  Cannot be prevented older age
swallowing  Require insulin therapy  Can be prevented with
 Compensates for altered thought processes lifestyle changes
 Demonstrates improved coping strategies  Can be managed with
 Adheres to plan for home maintenance management lifestyle modifications
 Adapts to changes in sexual function alone if diagnosed early
 Both share symptoms of frequent urination, increased
thirst, extreme hunger, unintentional weight loss, fatigue,
DIABETES MELLITUS blurry vision, sores or wounds that heal slowly, and
 Diabetes mellitus is a group of metabolic disorders numbness and tingling sensation in hands and feet.
characterized by elevated levels of blood glucose  Both can benefit from lifestyle modifications such as a
(hyperglycemia) resulting from defects in insulin healthy diet, physical activity, blood sugar level
secretion, insulin action, or both. monitoring, and management of stress and other existing
 Three major acute complications of diabetes related to health conditions.
short-term imbalances in blood glucose levels are
o hypoglycemia, TYPE 1 (FORMERLY INSULIN-DEPENDENT DIABETES
o diabetic ketoacidosis (DKA), and MELLITUS)
o hyperglycemic hyperosmolar nonketotic syndrome  About 5% to 10% of patients with diabetes have type 1
(HHNS) diabetes. It is characterized by destruction of the
 Long-term hyperglycemia may contribute to chronic pancreatic beta-cells due to genetic, immunologic, and
microvascular complications (kidney and eye disease) possibly environmental (eg, viral) factors. Insulin
and neuropathic complications. injections are needed to control the blood glucose
 Diabetes is also associated with an increased occurrence levels.
of macrovascular diseases, including coronary artery  Type 1 diabetes has a sudden onset, usually before the
disease (myocardial infarction), cerebrovascular disease age of 30 years.
(stroke), and peripheral vascular disease
TYPE 1 DIABETES: FAST FACTS
 Type 1 diabetes affects about 1.6 million people in the
U.S.
 Type 1 diabetes can be triggered by any virus, including
a cold
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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM

 Most people with T1D are diagnosed in the ER as
children
 People who have type 1 diabetes require insulin
o Measure the height and weight and examine the
skin for evidence of dryness or slowly healing sores;
note signs of hyperglycemia, record vital signs, and
collect a urine specimen; perform a blood glucose
level determination using a bedside glucose
monitor.

NURSING DIAGNOSES
 Imbalanced nutrition: less than body requirements
related to insufficient caloric intake to meet growth and
development needs and the inability of the body to use
nutrients.
 Risk for impaired skin integrity related to slow healing
process and decreased circulation.
DIABETES MELLITUS – TYPE 1 SIGNS AND SYMPTOMS:  Risk for infection related to elevated glucose levels.
 Polyuria  Deficient knowledge related to complications of
o  Urination hypoglycemia and hyperglycemia.
 Polydipsia  Deficient knowledge related to appropriate exercise and
o  Thirst activity.
 Polyphagia
o  Hunger NURSING CARE PLANNING AND GOALS
 Weight loss  Maintaining adequate nutrition.
 Fatigue  Promoting skin integrity.
  Frequency of infections  Preventing infection.
 Rapid onset  Regulating glucose levels.
 Insulin dependent  Learning to adjust to having a chronic disease.
 Familial tendency  Learning about and managing hypoglycemia and
 Peak incidence hyperglycemia, insulin administration, and exercise
o from 10 to 15 years needs for the child.

CURE NURSING INTERVENTIONS

 by replacing or renewing 1. Ensure adequate and appropriate nutrition.
insulin-producing cells and 2. Prevent skin breakdown.
stopping the body’s own 3. Prevent skin infection.
attack on these cells 4. Regulate glucose levels.
TREAT 5. Provide Client and family teaching in the management
 with new devices and of hypoglycemia and hyperglycemia.
therapies that optimize
blood glucose and treat or EVALUATION: Goals are met as evidenced by:
prevent diabetic  Maintained adequate nutrition.
complications  Promoted skin integrity.
PREVENT  Prevented infection.
 from starting or  Regulated glucose levels.
progressing using vaccines  Learned adjust to having a chronic disease.
and other therapies  Learned about and managing hypoglycemia and
hyperglycemia, insulin administration, and exercise
CLINICAL MANAGEMENT needs for the child.
 Insulin use
 Diet regimen ALLERGY (HYPERSENSITIVITY)
 Regular Physical Activity  An abnormal, individual response to certain substances
 Monitoring that normally do not trigger such an exaggerated
reaction.
NURSING MANAGEMENT  In some types of allergies, a reaction occurs on a second
NURSING ASSESSMENT and subsequent contact with the allergen.
 HISTORY  Skin testing may be done to determine the allergen.
o symptoms leading up to the present illness;
appetite, weight loss or gain, evidence of polyuria TYPES OF ALLERGIES
or enuresis in a previously toilet-trained child,  Skin Contact
polydipsia, dehydration, irritability and fatigue o Poison plants
 PHYSICAL EXAM o Latex
o Animal dander

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 NCM 112 MEDICAL SURGICAL NURSING ENDTERM

o Jewelry
 Ingestion
o Milk
o Medication
o Nuts & shellfish
 Injection
o Injection
o Bee sting
 Inhalation
o Pollen
o Dust
o Mold and mildew
o Animal dander

ASSESSMENT
1. History of exposure to allergens
2. Itching, tearing, and burning of eyes and skin
3. Rashes
4. Nose twitching, nasal stuffiness

ALLERGY SYMPTOMS
 Sneezing
 Labored breathing
 Rash
 Runny nose
 Edema
 Cough
 Redness
 Lacrimation
 Headache

NURSING INTERVENTIONS
1. Identification of the specific allergen
2. Management of the symptoms with antihistamines,
anti-inflammatory agents, or corticosteroids
3. Ointments, creams, wet compresses, and soothing
baths for local reactions
5. Desensitization programs may be recommended

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