CENTRAL LUZON DOCTORS’ HOSPITAL

EDUCATIONAL INSTITUTION, INC.

(A wholly-owned Subsidiary of Central Luzon Doctors’ Hospital, Inc.)
Romulo Highway, San Pablo, Tarlac City
! (045) 982-5019/982-5052/982-0264 ⌨ (045) 982-0780

DEPARTMENT OF NURSING

Jimlord A. Garcia
BSN - 2D

1. ) Cardiac Catherization

Definition: Cardiac catheterization, often known as cardiac cath or heart catheterization,

is a medical technique for diagnosing and treating certain heart diseases. It allows doctors to
examine the heart in detail in order to diagnose abnormalities and perform other tests or
operations.

Indication:  
* Confirm suspected heart disease, including coronary artery disease, myocardial disease,
valvular disease and valvular dysfunction

* To determine the location and extent of the disease process.

* To assess the following:

- Stable, severe angina unresponsive to medical management

- Unstable angina pectoris

- Uncontrolled heart failure, ventricular dysrhythmias, or cardiogenic shock associated

with acute myocardial infarction, papillary muscle dysfunction, ventricular aneurysm, or septal
perforation.

Nursing Responsibility:

1. Monitor the patient’s heart rate and rhythm, respiratory and pulse rates, and blood
pressure frequently.

2. Monitor the patient’s vital signs every 15 minutes for 2 hours after the procedure, every 30
minutes for the next 2 hours, and then every hour for 2 hours.

3. If no hematoma or other problems arise, begin monitoring every 4 hours. If vital signs are
unstable, check every 5 minutes and notify the practitioner.

4. Observe the insertion site for a hematoma or blood loss. Additional compression may be
necessary to control bleeding.

5. Check the patient’s color, skin temperature, and peripheral pulse below the puncture site.

6. Enforce bed rest for 8 hours. If the femoral route was used for catheter insertion, keep the
patient’s leg extended for 6 to 8 hours.

7. If medications were withheld before the test, check with the practioner about resuming their
administration.

8. Administer prescribed analgesics.

9. Make sure a posttest ECG is scheduled to check for possible myocardial damage.

2. ) Cardiac Surgery

Definition: Any surgical treatment performed on your heart or any related blood arteries
near where they join to the heart is referred to as cardiac surgery. These procedures may
sometimes affect the tissues or structures right near to the heart.

Indication:
- Heart failure

- Infection with no control

- Embolisms

- Massive vegetations

- Severe valvar and perivalvar lesions

- Infection caused by microorganisms

Nursing Responsibility:
- Restoring cardiac output

- Maintaining adequate tissue perfusion

- Maintaining body temperature

- Preventing infection

- Preventing fluid and electrolyte imbalances

- Preventing impaired gas exchange

- Promoting cerebral circulation

- Pain control

Acquired Cardiovascular Disorders

1.) Bacterial Endocarditis

Definition - Bacterial endocarditis is a bacterial infection of the heart's inner layer or its
valves. The heart contains four valves. These valves allow blood to flow freely through the heart
and lungs and out to the rest of the body. These valves may not function properly when a
person develops bacterial endocarditis. This can make the heart work harder to pump blood to
the rest of the body. The heart can't always pump enough blood out. Bacterial endocarditis is a
potentially fatal condition.

Assessment :
- A blood culture test - will be ordered to determine whether the infection is caused by
bacteria, fungus, or other microbes. Other blood tests can reveal if your symptoms are due to
anything else, including anemia.

- A transthoracic echocardiogram - is a non-radiating imaging test used to view your

heart and its valves. This test uses ultrasound waves to create an image of your heart, with the
imaging probe placed on the front of your chest. Health care practitioners can use this imaging
test to look for signs of damage or abnormal movements of your heart.

 - When a transthoracic echocardiogram doesn't give the HCP enough information to

adequately analyze your heart, he or she may perform a transesophageal echocardiogram.
This allows you to see your heart via your esophagus.

- To gain a better picture of your heart's electrical activity, an electrocardiogram (.

ECG or EKG) may be requested. This test can detect an irregular heart rate or rhythm. 12 to 15
delicate electrodes will be attached to your skin by a technician. Electrical leads (wires)
connect the electrodes to the EKG equipment.

Imaging – chest X-ray, CT scan, or MRI may show enlargement of the heart and/or infection
in the lungs, as well as possible spread in other organs

S&SX

• Common symptoms of endocarditis include:

• heart murmur, which is an abnormal heart sound of turbulent blood flow through the heart

• pale skin

• fever or chills

• night sweats

• muscle or joint pain

• nausea or decreased appetite

• a full feeling in the upper left part of your abdomen

• unintentional weight loss

• swollen feet, legs, or abdomen

• cough or shortness of breath

Therapeutic Management

Antibiotic - If the endocarditis is caused by bacteria, it will be treated with intravenous

antibiotic therapy. HCP will advise to the patient to take antibiotics until the infection and
related inflammation are effectively treated. Antibiotic therapy typically takes up to six
weeksTrusted Source to complete.

Surgery - Long-term infective endocarditis or endocarditis-related heart valve deterioration

may necessitate surgery to repair. Dead tissue, scar tissue, fluid buildup, and debris from
infected tissue may be removed through surgery. The damaged heart valve may also be
repaired or removed, and replaced with either man-made or animal tissue.

Nursing Intervention
- Assess the patient’s vital signs at least every 4 hours. (Rationale:To assist in
creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the
antibiotics and fever-reducing drugs administered. )
- Remove excessive clothing, blankets and linens. Adjust the room temperature.
( Rationale: To regulate the temperature of the environment and make it more comfortable for
the patient. )

- Administer the prescribed antibiotic and anti-pyretic medications. ( Rationale:

Use the antibiotic to treat bacterial infection (endocarditis), which is the underlying cause of the
patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and
normalize the body temperature. )
- Offer a tepid sponge bath. ( Rationale: To facilitate the body in cooling down and to
provide comfort.)

- Elevate the head of the bed. ( Rationale: Head elevation helps improve the expansion
of the lungs, enabling the patient to breathe more effectively. )

2.) Cardiac Dysrithmias

Definition - An arrhythmia is a heartbeat that is irregular. It indicates that the heart is

not in its normal beat. It could feel like the heart missed a beat, added a beat, or is "fluttering,"
or that it's beating too quickly (which physicians call tachycardia) or too slowly (which doctors
call bradycardia) (called bradycardia). Arrhythmias can be life-threatening or completely
innocuous.

Assessment:
- Obtain health history to identify any previous occurrences of decreased cardiac output,
including syncope (fainting), fatigue, lightheadedness, dizziness, chest discomfort, and
palpitations.
– Identify coexisting conditions that may be the cause of the dysrhythmia (eg, heart
disease, chronic obstructive pulmonary disease).

– Review medications as some (Digoxin) can cause dysrhythmias.

– Conducts a physical assessment to observe for signs of diminished cardiac output

(changes in LOC. Inspect the skin (may be pale and cool). Assess signs of fluid retention (neck
vein distention; crackles and wheezes in the lungs).

– Auscultates for extra heart sounds (S3 and S4). Measure blood pressure, and determines
pulse pressures. A declining pulse pressure indicates reduced cardiac output. 

S&SX
• Palpitations (a feeling of skipped heartbeats, fluttering, or "flip-flops")

• Pounding in your chest

• Dizziness or feeling lightheaded

• Fainting

• Shortness of breath

• Chest pain or tightness

• Weakness or fatigue (feeling very tired)

• Anxiety

• Blurry vision

• Sweating

 Therapeutic Management:
Medicines that treat uneven heart rhythms include:

• Adenosine (Adenocard)

• Atropine (Atropen)

• Beta-blockers

• Calcium channel blockers

• Digoxin (Digitek, Digox, Lanoxin)

• Potassium channel blockers

• Sodium channel blockers

Nursing Intervention:
- Monitoring and managing dysrhythmias Record BP, HR and rhythm, rate and
depth of respirations, and breath sounds to determine the dysrhythmia’s
hemodynamic effect.

- Ask patients about episodes of lightheadedness, dizziness, or fainting.

- Obtain a 12-lead ECG to continuously monitor the patient and to track the
dysrhythmia.

- Administer antiarrhythmic medications as prescribed.

- Assess for factors that contribute to the dysrhythmia (eg, caffeine, stress,
nonadherence to the medication regimen) and assist the patient in making lifestyle
changes that adress these issuses. 

- Minimising anxiety At the time of dysrhythmic event, maintain a calm and

reassuring attitude to foster a trusting relationship with the patient and assists in
reducing anxiety.

- Promote a sense of confidence in living with a dysrhythmia. For example, while

administering a medication at a dysrhythmia event and it begins to reduce the
incidence of dysrhythmia, communicate that information to the patient. 

- Teaching patient self-care Present the information in terms that are understandable
and in a manner that is not frightening or threatening.

- Explain the importance of taking medications regularly to maintain therapeutic

serum levels of antiarrhythmic agents.

- If dysrhythmia is potentially lethal, establish with the patient and family a plan
of action to take in case of an emergency. 

3.) Pulmonary Artery Hypertension

Definition - Pulmonary arterial hypertension (PAH) is a chronic condition

marked by unusually high blood pressure (hypertension) in the pulmonary artery, which
transports blood from the heart to the lungs. Pulmonary arterial hypertension is one
type of pulmonary hypertension, which is a more general term. Pulmonary hypertension
develops when the majority of the lungs' relatively small arteries narrow in diameter,
increasing the resistance to blood flow through the lungs. Blood pressure rises in the
pulmonary artery and the right ventricle of the heart, which pumps blood into the
pulmonary artery, to overcome the increased resistance. Increased blood pressure can
eventually harm the heart's right ventricle.

Assessment:
• Vital signs – a loud pulmonic 2nd heart sound upon auscultation, which is usually a murmur
or a gallop; tachycardia

• Blood tests – B-type Natriuretic Peptide (BNP), Basic Metabolic Panel (BMP), Complete
Metabolic Panel (CMP), Liver Function Tests (LFTs) are all useful in diagnosing pulmonary
hypertension

• Electrocardiogram (ECG) – to check for any irregularity in heartbeat

• Exercise stress test – use of ECG while the patient is on a treadmill or a stationary bike

• Chest X-ray – to check for any enlargement of the heart’s right ventricle

• Echocardiogram – utilizes sound waves to create images of the heart

• Cardiac catheterization (right-sided) and angiogram – to directly measure the pressure in the

right ventricle and the pulmonary arteries

• Cardiac CT scan / MRI

• Pulmonary function test -a non-invasive test using a spirometer to measure how much air the
lungs can hold

• Genetic test – if there is a suspected hereditary or genetic involvement

S&SX
• Shortness of breath  (Dyspnea) during exercise, but may also be present while at rest
eventually

• Chest pain that can be described as pressure-like

• Swelling (edema) in the lower extremities

• Swelling of the abdomen (ascites)

• Bluish discoloration of the mucosa, lips and skin (cyanosis)

• Chest palpitations and/or tachycardia

• Fatigue

Therapeutic Management
• Anticoagulant medicines – such as warfarin to help prevent blood clots.

• Diuretics (water tablets) – to remove excess fluid from the body caused by heart failure.

• Oxygen treatment – this involves inhaling air that contains a higher concentration of oxygen
than normal.

 Nursing Intervention:
- Assess the patient’s vital signs and characteristics of heartbeat at least every 4 hours.
Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue
perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.
( Rationale: To assist in creating an accurate diagnosis and monitor effectiveness of medical
treatment. Heart murmur or gallop upon auscultation could indicate pulmonary hypertension.
The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the
patient’s status which require immediate referral to the physician.

- Administer prescribed medications for pulmonary hypertension.

Rationale: Vasodilators – to relax the blood vessels, thereby opening the narrowed blood
vessels and improve blood flow

Guanylate cyclase (GSC) stimulators – to increase the level of nitric oxide which can relax the
pulmonary arteries, thereby decreasing the pressure in them

Endothelin receptor antagonists – to stop the endothelin from narrowing the arterial walls

Calcium channel blockers – to relax the muscles in the arterial walls

Digoxin – to help the heart pump more blood and treat arrythmias

Anticoagulants (usually warfarin) – to reduce the formation of blood clots in the pulmonary
arteries

Diuretics – to reduce excess fluid in the body through urination, thereby decreasing cardiac
workload 

- Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is within

the target range, or as ordered by the physician. ( Rationale: To increase the oxygen level and
achieve an SpO2 value within the target range.)

- Educate patient on stress management, deep breathing exercises, and relaxation

techniques. ( Rationale: Stress causes a persistent increase in cortisol levels, which has been
linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline
levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing
stress is also an important aspect of dealing with fatigue.)

4.) Cardiomyopathy

Definition - Cardiomyopathy is a cardiac muscle condition that makes it difficult

for the heart to pump blood throughout the body. There are numerous causes, signs and
symptoms, as well as therapies, for the various kinds of the disease. Cardiomyopathy causes
the heart muscle to grow big, thick, and inflexible in most cases. In some cases, scar tissue is
used to replace damaged heart muscle tissue. The heart becomes weaker as cardiomyopathy
progresses. The heart loses its ability to pump blood around the body and loses its ability to
maintain a normal electrical rhythm. Heart failure or arrhythmias, or abnormal heartbeats, can
follow. Other difficulties, such as cardiac valve disorders, can arise from a weakening heart.

Assessment:
• Obtain vital signs every 15 minutes during acute phase.

• Assess the patient for changes in neurological function hourly and as clinically indicated.

• Assess for skin warmth, color, and capillary refill time.

• Assess for chest discomfort because myocardial ischemia may result from poor perfusion.

• Assess heart and lung sounds to evaluate the degree in heart failure.

S&SX
• There might be no signs or symptoms in the early stages of cardiomyopathy. But as the
condition advances, signs and symptoms usually appear, including:

• Breathlessness with activity or even at rest

• Swelling of the legs, ankles and feet

• Bloating of the abdomen due to fluid buildup

• Cough while lying down

• Difficulty lying flat to sleep

• Fatigue

• Heartbeats that feel rapid, pounding or fluttering

• Chest discomfort or pressure

• Dizziness, lightheadedness and fainting

• Signs and symptoms tend to get worse unless treated. In some people, the condition
worsens quickly; in others, it might not worsen for a long time.

Therapeutic Management:
• Angiotensin-converting enzyme (ACE) inhibitors – promote vasodilation of the blood vessels,
lowering the pressure and improving the blood flow

• Beta blockers – reduce heart rate and blood pressure 

• Calcium channel blockers – reduce blood pressure; usually used in hypertrophic

cardiomyopathy

• Angiotensin II receptor blockers – similar to ACE inhibitors and can be used if the patient
does not tolerate ACE inhibitors

• Anti-arrhythmic, usually digitalis or  digoxin  – improves the contraction of heart muscles,
regulate heart rhythm and reduces heartbeat

• Inotropes – improve the function of the heart to pump blood in severe heart failure

• Diuretics – facilitate elimination of excess fluid in the body through urination

• Anti-coagulants – prevent clot formation

• Anti-inflammatory drugs – reduce inflammation

• Electrolytes – maintain fluid and electrolyte balance; treat hypocalcemia which is common in
cardiomyopathy patients

Nursing Intervention:
- Assess the patient’s vital signs and characteristics of heartbeat at least every 4
hours. Assess breath sounds via auscultation. Observe for signs of decreasing peripheral
tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.
( Rationale: To assist in creating an accurate diagnosis and monitor effectiveness of medical
treatment. Breath sounds of crackles/rales are important signs of heart failure which is a
complication of cardiomyopathy. The presence of signs of decreasing peripheral tissue
perfusion indicate deterioration of the patient’s status which require immediate referral to the
physician. )

- Administer the cardiac medications, and diuretics as prescribed. ( Rationale: To

alleviate the symptoms of cardiomyopathy and to treat the underlying condition.)

- Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above

the target range, or as ordered by the physician. ( Rationale: To increase the oxygen level and
achieve an SpO2 value within the target range. )

- Educate patient on stress management, deep breathing exercises, and relaxation

techniques. ( Rationale: Stress causes a persistent increase in cortisol levels, which has been
linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline
levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels.)

5.) Systemic Hypertension

Definition - Systemic Hypertension is high blood pressure in the systemic

arteries - the vessels that carry blood from the heart to the body's tissues (other than the
lungs). High systemic (or body) blood pressure is usually caused by the constriction of the
small arteries (arterioles).

 Assessment:
- Subjective Data ( Past health history, Medications, Functional health patterns )

- Objective Data ( Target organ damage )

S&SX:
• Headache, dyspnea,dizziness, tachy-arrhythmias

• Encephalopathy hypertensive. (nauseas, vomiting, mêntal confusion seizures) at

hypertensive crisis

• Acute pulmonary edema (rales and crakles in lungs) at hypertensive crisis

• systolic or dystolic murmur in aortic area Gallop rhythm (s3)

• Weak femural pulse palpation in coarctation of the aorta

• Retinopathy(blurred vision) :on OCT- hemorrages;exsudates

Therapeutic Management

- Diuretics, ACE inhibitors, ARBs, calcium channel blockers, or beta blockers may

be used as initial therapy in the treatment of primary hypertension in older and in younger
patients. Atenolol should not be used. Beta blockers such as carvedilol, nebivolol, and
bisoprolol are preferred].

Nursing Intervention:
- Administer prescribed pain medications. Administer anti-hypertensive medications.
( Rationale: To alleviate the severe headache. To treat the underlying cause of acute Jimgar04

pain, which is hypertension. )

- Place the patient in complete bed rest during severe headaches. ( Rationale: Stress
causes a persistent increase in cortisol levels, which has been linked to people with
hypertension. The effects of stress are likely to increase myocardial workload.)

- Educate patient on stress management, deep breathing exercises, and relaxation

techniques. ( Rationale: Stress causes a persistent increase in cortisol levels, which has been
linked to people with hypertension. Chronic stress may also cause an increase in adrenaline
levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing
stress is also an important aspect of dealing with fatigue. )

 6.) Kawasaki Disease

Definition - Kawasaki disease causes swelling (inflammation) in children in the

walls of small to medium-sized blood vessels that carry blood throughout the body. Kawasaki
disease commonly leads to inflammation of the coronary arteries, which supply oxygen-rich
blood to the heart. Kawasaki disease was previously called mucocutaneous lymph node
syndrome because it also causes swelling in glands (lymph nodes) and mucous membranes
inside the mouth, nose, eyes and throat.

Nursing Assessment:
A child with Kawasaki disease is likely to be very irritable and possibly also in
pain, so getting a full assessment is going to be tricky. Some key things to assess are: 

• Temperature; children with Kawasaki disease often have a fever above 102 degrees

• Skin; look for reddened, swollen and even peeling areas

• EKG: the disease can affect the vessels of the heart causing dysrhythmias, so it’s always a
good idea to have the child on a continuous monitor

• BP and Heart rate: expect tachycardia if the patient is irritable, possible hypotension in cases
of severe dysrhythmia.

S&SX
To receive a diagnosis of Kawasaki disease, a child usually will have a fever greater
than 102.2 F (39 C) for five or more days and at least four of the following signs and symptoms.

• A rash on the main part of the body or in the genital area

• An enlarged lymph node in the neck

• Extremely red eyes without a thick discharge

• Red, dry, cracked lips and an extremely red, swollen tongue

• Swollen, red skin on the palms of the hands and the soles of the feet, with later peeling of
skin on fingers and toes

• Abdominal pain

• Diarrhea

• Irritability

• Joint

• Vomiting

Therapeutic Management
Gamma globulin. Infusion of an immune protein (gamma globulin) through a vein
(intravenously) can lower the risk of coronary artery problems. This helps to reduce
inflammation in the vessels.

 • Aspirin. High doses of aspirin might help treat inflammation. Aspirin can also decrease
pain, joint inflammation and fever. The aspirin dose will likely be lowered once the fever
has been gone for 48 hours.

Kawasaki treatment is a rare exception to the rule that says aspirin shouldn't be given to
children. Aspirin has been linked to Reye's syndrome, a rare but potentially life-
threatening condition, in children recovering from chickenpox or flu. Children with
Kawasaki disease should be given aspirin only under the supervision of a health care
provider.


Nursing Intervention:
• Monitor pain. Monitor pain level and child’s response to analgesia.

• Cardiac monitoring and assessment. Take vital signs as directed by conditions; assess for
signs of mycocarditis (tachycardia, gallop rhythm, chest pain);  and monitor for heart failure.

• Monitor I&O. Closely monitor intake and output, and monitor hydration status by

checking skin turgor, weight, urinary output, specific gravity, and presence of tears.

• Plan periods of rest and activities. Allow the child periods of uninterrupted rest; encourage
the child to move about freely under supervision; provide soft toys and quiet play and
encourage use of hands and fingers; and provide quiet, peaceful environment with
diversional activities.

• Provide oral care. Offer cool liquids (ice chips and ice pops); progress to soft, bland foods;
and give mouth care every 1 to 4 hours with special mouth swabs; use soft toothbrush only
after healing has occurred.

7.) Shock

Definition - Shock is a life-threatening manifestation of circulatory failure.

Circulatory shock leads to cellular and tissue hypoxia resulting in cellular death and
dysfunction of vital organs. Effects of shock are reversible in the early stages and a delay in
diagnosis and/or timely initiation of treatment can lead to irreversible changes including
multiorgan failure (MOF) and death. This activity reviews the evaluation and management of
shock, and explains the role of the interprofessional team in evaluating and treating patients
with this condition.

 Nursing Assessment:
➢ Circulation, Airway, breathing, and Focused assessment of tissue perfusion;
• Vital signs

• Peripheral pulses

• Level of consciousness

• Capillary refill

• Skin (e.g., temperature, color, moisture)

• Urine output

• Brief history Taking

• Events leading to shock

• Onset and duration of symptoms

• Allergies

S&SX
If you go into shock, you may experience one or more of the following:
• rapid, weak, or absent pulse

• irregular heartbeat

• rapid, shallow breathing

• lightheadedness

• cool, clammy skin

• dilated pupils

• lackluster eyes

• chest pain

• nausea

• confusion

• anxiety

• decrease in urine

• thirst and dry mouth

• low blood sugar

• loss of consciousness

 Therapeutic Management
- The HCP treatment plan for shock will depend on the cause of the condition.
Different types of shock are treated differently. For example, the HCP may use:

• epinephrine and other drugs to treat anaphylactic shock

• blood transfusion to replace lost blood and treat hypovolemic shock

• medications, heart surgery, or other interventions to treat cardiogenic shock

• antibiotics to treat septic shock

Nursing Intervention

• Safe administration of blood. ( Rationale:  It is important to acquire blood specimens

quickly, to obtain baseline complete blood count, and to type and crossmatch the blood in
anticipation of blood transfusions.)

• Safe administration of fluids. ( Rationale: The nurse should monitor the patient closely for

cardiovascular overload, signs of difficulty of breathing, pulmonary edema, jugular
vein distention, and laboratory results.)

• Monitor weight. ( Rationale: Monitor daily weight for sudden decreases, especially in the
presence of decreasing urine output or active fluid loss.)

• Monitor vital signs. ( Rationale: Monitor vital signs of patients with deficient fluid volume
every 15 minutes to 1 hour for the unstable patient, and every 4 hours for the stable patient.)

• Oxygen administration. ( Rationale: Oxygen is administered to increase the amount of

oxygen carried by available hemoglobin in the blood.)

8.) Anaphylaxis

Definition - Anaphylaxis is a potentially fatal hypersensitivity reaction caused

by the release of mediators by mast cells, basophils, and recruited inflammatory cells.
Anaphylaxis is described as a set of signs and symptoms that appear minutes or hours after
exposure to a triggering agent, either alone or in combination. It can range from mild to
moderately severe to severe. Although most occurrences are minor, all anaphylaxis has the
potential to be fatal. Anaphylaxis develops quickly, usually within 5 to 30 minutes, and can
linger over many days in exceptional cases.

 Nursings Assessment
• Assess any kind of allergy. The nurse must assess all patients for allergies or previous
reactions to antigens.

• Assess patient’s knowledge. The nurse must also assess the patient’s understanding of
previous reactions and steps taken by the patient and the family to prevent further exposure
to antigens.

• New allergies. When new allergies are identified, the nurse advises the patient to wear or
carry identification that names the specific allergen or antigen.

S&SX
• Generalised flushing of the skin

• Nettle rash (hives) anywhere on the body

• Sense of impending doom

• Swelling of throat and mouth

• Difficulty in swallowing or speaking

• Alterations in heart rate

• Severe asthma

• Abdominal pain, nausea and vomiting

• Sudden feeling of weakness (drop in blood pressure)

• Collapse and unconsciousness

Therapeutic Management
• Epinephrine (adrenaline) to reduce the body's allergic response.

• Oxygen, to help you breathe.

• Intravenous (IV) antihistamines and cortisone to reduce inflammation of the air passages
and improve breathing.

• A beta-agonist (such as albuterol) to relieve breathing symptoms.

Nursing Intervention:
• Monitor client’s airway. ( Rationale: Assess the client for the sensation of a narrowed
airway.)

• Monitor the oxygenation status. ( Rationale: Monitor oxygen saturation and arterial blood

gas values.)

• Focus breathing. ( Rationale: Instruct the client to breathe slowly and deeply.)

• Positioning. ( Rationale: Position the client upright as this position provides oxygenation by

promoting maximum chest expansion and is the position of choice during respiratory
distress.)

• Activity. ( Rationale: Encourage adequate rest and limit activities to within client’s

tolerance.)

• Hemodynamic parameters. ( Rationale: Monitor the client’s central venous pressure (CVP),

pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and
cardiac output/cardiac index.)

• Monitor urine output. ( Rationale: The renal system compensates for low blood

pressure by retaining water, and oliguria is a classic sign of inadequate renal perfusion.)

9.) Toxic Shock Syndrome

Definition - Toxic shock syndrome (TSS) is a rare but life-threatening

condition caused by bacteria getting into the body and releasing harmful toxins. It's often
associated with tampon use in young women, but it can affect anyone of any age – including
men and children. TSS gets worse very quickly and can be fatal if not treated promptly. But if
it's diagnosed and treated early, most people make a full recovery.

Nursing Assessment:
• Medical history – history may include obtaining an open wound or a cut anywhere in the
body. It may also include history of a recent surgery or maybe the use of contraceptives
involving the insertion of a material inside the vagina.

• Physical Assessment – physical examination will support the information gathered during
the history taking. It may also include the identification of new information that the patient
may not be aware of. Risk factors and the presence of any other signs and symptoms may
also be identified during the assessment.

• Blood tests – a series of blood tests may be helpful to identify the presence of organ
damage. A complete blood count and other blood markers may suggest the presence of an
infection.

• Culture and sensitivity – cultures of tissue or fluid samples may signify the presence of any
of the bacterial mediators. Swabs may be taken for this procedure which may come from the
throat, cervix, and/or vagina.

•  Imaging studies will not diagnose toxic shock syndrome although they may be helpful to
assess the extent of damage to the patient’s body.

S&SX
The signs and symptoms of toxic shock syndrome can be non-specific and the condition
can progress rapidly. In general, the following manifestations can be noted in a patient with
toxic shock syndrome:

• Sudden hyperthermia

• Low blood pressure

• Vomiting and diarrhea

• Presence of a rash resembling a sunburn mostly on the palms and soles

• Confusion

• Muscle aches

• Redness of the eyes, mouth, and throat

• Seizures

• Headaches

Therapeutic Management:
Treatment for TSS may include:
• Giving intravenous (through a vein) antibiotics

• Giving intravenous fluid to treat shock and prevent organ damage

• Heart medications in people with very low blood pressure

• Dialysis may be required in people who develop kidney failure

• Giving blood products

• Supplemental oxygen or mechanical ventilation to assist with breathing

• Deep surgical cleaning of an infected wound

Nursing Intervention:
- Assess the patient’s vital signs at least every hour. Increase the intervals between
vital signs taking as the patient’s vital signs become stable. ( Rationale: To assist in
creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the
antibiotics and fever-reducing drugs administered. )

- Remove excessive clothing, blankets and linens. Adjust the room temperature.
( Rationale: To regulate the temperature of the environment and make it more comfortable for
the patient. )

- Administer intravenous fluid therapy. ( Rationale: To facilitate effective tissue perfusion

and maintain circulatory blood volume. )

-  Place the patient on bed rest. Assist him/her with important activities of daily living
or ADLs. ( Rationale: To decrease myocardial workload and oxygen consumption. )