Medical Surgical Nursing

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MEDICAL – SURGICAL NURSING ABU TAMIER R. TAN, RN, MAN
NOTRE DAME OF JOLO COLLEGE

Health Sciences Department
Bachelor of Science in Nursing
Nursing Care Management 212
Course Title : CARE OF CLIENT WITH PROBLEMS IN OXYGINATION,

FLUID AND ELECTROLYTES, INFECTIOUS
INFLAMMATORY, AND IMMUNOLOGIC
RESPONSE, CELLULAR ABBERATIONS,
ACUTE AND CHRONIC
Credit Units : 8 UNITS
Pre-Requisite Subjects : NCM 109
Contact Hours/Week :
Class Schedule : Blended Learning Mode/ Face to Face Meeting
Prepared by : Mr. Abu Tamier R. Tan, RN, MAN
Vision/Mission
We, the Notre Dame of Jolo college community, guided by the values of faith, hope, and love; and sharing the
charism of the Oblates of Mary Immaculate, aspire to serve the people from all walks of life, especially the
poor in Sulu and Tawi-Tawi. We envision ourselves to be catalyst of change, lovers of peace, and living
witnesses of God’s love.
Our common endeavor is: To provide education that is global, excellent, and truly responsive to the needs of
the community today, and in the next millennium. To mold citizens to be socially and ecologically
responsible, peace-loving, and community-oriented; to evolve dynamic programs for research, human
resource development, and community involvement; we strive to achieve this vision through democratic and
collaborative process.
Institutional Attributes:
As an Oblate Institution we produce graduates who are:
1. RESPECTFUL of diversity to build harmonious relationship with one another.
2. SERVICE ORIENTED geared toward addressing the needs of the changing time for development of
one’s economy.
3. ENVIRONMENT FRIENDLY to contribute ideas and efforts for environmental protection, conservation
and rehabilitation.
4. ACCOUNTABLE in the generation of sound decision to solve problems and address challenges.
5. COLLABORATIVE LEADRESHIP AND GOVERNANCE in engaging diverse communities to adapt to
changes in the 21st century.
Program Outcomes
1. Apply knowledge of physical, social, natural and health sciences, and humanities in the practice of
nursing.
2. Provide safe, appropriate, and holistic care to individuals, families, population group and community
utilizing nursing process.
3. Apply guidelines and principles of evidence-based practice in the delivery of care.
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4. Practice nursing in accordance with existing laws, legal, ethical and moral principles.
5. Communicate effectively in speaking, writing and presenting using culturally appropriate language.
6. Document to include reporting up-to-date client care accurately and comprehensively.
7. Work effectively in collaboration inter, intra-and-multi-disciplinary and multi-cultural teams.
8. Practice beginning management and leadership skills in the delivery of client care using a systems
approach.
9. Engage in lifelong learning with a passion to keep current with national and global developments in
general, and nursing and health developments in particular.
10. Demonstrate responsible citizenship and pride of being a Filipino.
11. Apply techno-intelligent care systems and processes in health care delivery.
12. Adapt nursing core values in the practice of the profession.
Course Outcomes
1. Apply knowledge of physical, social, natural and health sciences and humanities in the practice
of nursing.
2. Utilize the nursing process in developing plans of care for an individual with simple health
problems.
3. Apply guidelines and principles of evidence-base practice in the delivery of nursing care.
4. Practice nursing in accordance with existing laws, legal, ethical, and moral principles related to
nutrition and diet therapy.
5. Communicate effectively using therapeutic and culturally sensitive language in the nurse-
patient/family interactions.
6. Document client care accurately and comprehensively.
7. Collaborate effectively with a group/team.
8. Apply beginning management and leadership skills in the delivery of health care.
9. Engage in lifelong learning to keep current with national and global trends in health and nursing
practice.
10. Advocate for responsible citizenship and pride as a Filipino nurse.
11. Apply techno-intelligent care systems and processes in health care delivery.
12. Adopt the nursing core values in the practice of the profession.
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LEARNING MODULE 1
Introductory Concept to Perioperative Nursing
Description: This course deals with concepts, principles, theories and techniques on Perioperative Nursing.
Hence, Operating Room is a special branch of nursing that is concerned with perioperative client care,
encompassing the three phases of the surgical experience – preoperative preparation, intraoperative
judgement and management, and postoperative care. The learners are expected to utilize the nursing
process and the basic nursing skills as primary tool in health promotion, disease prevention, restoration,
maintenance, and rehabilitation. Blended learning shall be utilized as teaching delivery mode. To develop
cognition and skills and facilitate learning, graphic organizers, video clips, jpeg images, case analyses and
writing to learn worksheets will be used. Formative and summative assessment will also be employed.
Intended Learning Outcome: Given a sample client for surgery the student will engage in the concept of
perioperative nursing by:
1. Define what is surgery

2. Discussing the different conditions requiring surgical interventions
3. Classifying surgical procedure according to the purpose, degree of risk, urgency
4. Describing the different risk factors to surgery and effects of surgery to the client
5. Identifying the categories of Perioperative nursing and surgical procedures.
6. Describing the factors that increase or decrease the risk in the phase of perioperative nursing.
7. Appreciating the knowledge, skills, and attitude necessary for providing quality care of the clients
undergoing surgery.
Time Frame / Class Schedule:
Date and Time Class Meeting Remarks
 The students read and view the

 Flipped learning via messenger primer on blended learning,
apps. /via SMS text. graphic organizers, and policies.
 Modular/ Self-directed
learning.  Student will engage on readings
 Face to face meeting. related to the concept of
 Introductory concept of Perioperative nursing. May
Perioperative Nursing on contact the instructor on group
module 1 and sub topic module discussion via messenger
1 application /chat discussion.
 Quiz No. 1
Values integrated cross-linked concepts/values to be integrated:

 Effective communicator
 Accountable,
 Critical thinker
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Concepts Notes
INTRODUCTION
Author: Pamela Pagunsanan - VillaCarlos
 In modern society, surgery has become a common method of treating disease and promoting health.
In the last few decades, the complexities of surgery have increase greatly, and the entire organ
system can be transplanted to replace non- functioning body parts. All surgical procedure can be
great and permanent or brief and temporary.
 The goal of perioperative nursing practice is to assist clients and their families and significant others
to achieve a level of wellness equal to or greater than that which they had before the procedure.
(AORN). Therefore, client care during the perioperative phase demands knowledge of and skill in
perioperative care and also requires an in-depth understanding of related disease process that have
brought the client to seek treatment. To provide quality care, perioperative nursing incorporates
application of the nursing process and allows for multiple nursing roles.
What is SURGERY
 a branch of medicine that encompasses Preoperative, Intraoperative, Postoperative care of
patients. The discipline is both an art and science.
 Treatment of disease, injury, etc. by manual and operative means (Webster, 1978).
 The three phases of surgery are together referred to PERIOPERATIVE period.
Perioperative Nursing
 Is a term to describe the nursing care provided in the total surgical experience of the patient.
THREE PHASE’S OF SURGERY
THE PREOPERATIVE PHASE

 Begins when the client agrees to and is scheduled for surgery and ends with his/her transfer
to the surgical suite.
ADMISSION to the surgical Unit


Preparation for surgery (Physical, Psychosocial, Spiritual, Legal)

Transport to the O.R
ENDS: When the patient is transported into the PRIORITY FOCUS:

OR table.
INTRAOPERATIVE PHASE
 Corresponds to the period in which anesthesia is administered, the operation is done and
the client is transferred into the Post Anesthesia Care Unit (PACU).
ADMISSION to the O.R.


ANESTHESIA SURGERY

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Recovery Room/ PACU
ENDS: When the patient is transferred to PRIORITY:

RR/PACU
POSTOPERATIVE PHASE
 Refers to the clients stay in up to his/her discharge from the PACU to follow up home clinic
visit.
ADMISSION to the RR/PACU


Back to the surgical unit

DISCHARGE

Follow- up care
ENDS: When the doctor discontinues, follow up PRIORITY:

care, and when healing of wound is complete
Surgical Conscience
 Awareness that develops from a knowledge base of the importance of adherence to principles of
aseptic and sterile techniques.
Surgical Procedure
 Invasive incision into the body tissues or a minimally invasive entrance into a body cavity for either
therapeutic or diagnostic purposes during which protective reflexes or self – care abilities are
potentially compromised.
The four (4) types of conditions requiring surgery

1. OBSTRUCTION – impairments to the flow of the vital organs
e.g., blood, urine, bile, CSF
2. PERFORATION – rupture of an organ
e.g., ruptured appendicitis, ruptured uterus
3. EROSION – wearing off of a surface or membrane
e.g. peptic ulcer disease
4. TUMOR – abnormal new growth
e.g., brain tumor, breast tumor, bone tumor
CLASSIFICATION OF SURGERY ACCORDING TO PURPOSE
CLASSIFIACTION PURPOSE EXAMPLES

Diagnostic Determine the presence of disease Biopsy, lumbar tap, colonoscopy,
endoscopy
Exploratory Estimate the extend of the disease or injury Exploratory laparotomy, pelvic
laparotomy
Curative Removes/repair damage tissues Excision of tumor
Ablative Removing disease organ that can’t wait

anymore
Reconstructive Partial or complete restoration; bringing Plastic surgery of the face following a
back original appearance and function severe burn
Constructive Repairing damage tissue/congenitally Plastic surgery of a congenital cleft
defective organ palate
Transplant Replacement of malfunction organ Kidney transplant
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Palliative Relieves symptoms but does not cure the Bypass surgery, colostomy,
underlying diseases debridement of necrotic tissue,
resection of nerve roots.
CLASSIFIACTION OF SURGERY ACCORDING TO URGENCY
CLASSIFICATION INDICATION EXAMPLES

Emergent - the patient requires Without delay Bladder or intestinal obstruction
immediate attention; disorders Extensive burns
maybe life threatening. Fractured skull
Gunshot or stab wounds
Perforated ulcer
Severe bleeding
Urgent – surgical problem Within 24 – 30 hours Acute gallbladder infection
requires prompt attention Kidney or urethral stones
Bleeding hemorrhoids
Eroding bleeding cancerous tumors
Planned/Required – patients Requires surgery Cataract removal
need to undergo surgery within a few weeks or Tonsillectomy
months Gallbladder removal – when acute
inflammation is not present
Prostatectomy – without bladder
obstruction
Elective – patient should have Failure to have surgery Simple hernia repair
surgery is not catastrophic Scar repair
Hemorrhoidectomy – not bleeding
Hemorrhoids
Vaginal repair
Optional – decision rest with the Preference of the Cosmetic surgery
patient patient
DEGREE OF RISK FOR SURGERY

1. Age
2. General health
3. Medications
 Anticoagulants
 Tranquilizer
 Corticosteroids
 Diuretics
4. Mental status
MAJOR SURGERY MINOR SURGERY

 Complicated and prolong  few complication
 Vital organs are removing  it can be performed at OPD
 High risk – post operative  Advantages: 1. It reduces
complication physiological stress to the patient 2.
 Large losses of blood may occur Less evidence of hospital acquired
infection
 Disadvantages: less opportunity to
assess for post – operative
complications
HEALTH PROBLEMS THAT INCREASE SURGICAL RISK

AGING
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 GERIATRIC PRIORITY - Older clients have less physiologic reserve (the ability of an organ to return to
normal after a disturbance in its equilibrium) than younger clients.
DANGER THERAPEUTIC APPROACH
 Potential for injury is greater in aged.  Consider using doses for therapeutic
 Diminished blood flow. effect.
 Diminished percentage of body fluids.  Anticipate problems from chronic disorder
 Diminished sensory function. such as anemia, obesity, DM,
 Decrease in kidney function and change in liver hypoproteinemia.
function.  Adjust nutritional intake to conform to
 Decrease thirst response. higher protein and vitamin needs.
 Decrease in mental functioning (Dementia)  When possible, cater to set patterns in
 Poor nutrition and chronic disease (hypertension, older patients, such as sleeping and eating.
DM, cachexia)
 Medication such as morphine and barbiturates in
the usual dosage may cause confusion,
disorientation, and respiratory depression.
DANGER FOR NEWBORN AND INFANTS TODDLER

 Low blood volume  FEAR: Separation, painful events, not
 Immature body temperature waking up after the surgery
 Immature kidney, liver, and immune system
OBESITY
 Risk for infection  Encourage weight reduction if permits.
 Impaired cardiac function  Anticipate postoperative obesity- related
 Increase potential for post-operative complication.
pneumonia and other pulmonary  Be alert for respiratory complications.
complications because greatly obese patient  Adequately splint abdominal incision
tends to hypo ventilate (slow, shallow when moving or coughing.
breathing)  Be aware that some drugs should be dose
 Increase difficulty involved in technical aspects according to ideal body weight versus
of performing surgery; wound dehiscence is actual weight to prevent overdose.
greater.  Never attempt to move an impaired client
 Has altered response to many drugs and without assistance or without using
anesthetics proper body mechanics.
 Decrease for likelihood of early ambulation.  Avoid IM injections in morbidity obese
individuals.
 Obtain dietary consultation early in
patient’s post-operative course.
POOR NUTRITION
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Preoperative malnutrition greatly impairs wound  Attempt to improve the nutritional status
healing. before and after surgery through enteral
 Increase the risk of wound infection and shock. or parenteral feedings.
 Recommend repair of dental carries and
proper mouth hygiene to prevent
respiratory tract infection.
FLUID AND ELECTROLYTES IMBALANCES

 Dehydration and electrolyte imbalances can  Assess client fluid and electrolyte status.
have an adverse effect in terms of general  Rehydrate client parenterally and orally as
anesthesia and anticipated volume loses prescribe.
associated with surgery, causing shock and  Monitor for evidence of electrolyte
cardiac dysrhythmias. imbalance.
 Be aware of expected drainage amounts
and composition; report excess of
abnormality.
 Monitor the patient intake and output; be
sure to include all body fluid losses.
PRESENCE OF DISEASE
 Many surgical procedures may be  Maintain diligence in nursing
complicated in the presence of assessment.
cardiovascular compromise. The client  Avoid fluid overload.
may experience dysrhythmias, shock, or  Prevent prolonged immobilization.
cardiac arrest during surgery.  Note evidence of hypoxia and initiate
therapy.
 Encourage change of position.
PRESENCE OF DIABETES MELLITUS

 Hyper glycemia  Recognize the sign and symptoms of
 Risk for wound infection and delayed wound ketoacidosis and glycosuria, which can be
healing. threaten otherwise uneventful surgical
experience.
 Monitor blood glucose and be prepared to
administer insulin even though the patient
maybe on NPO.
 DRUG ALERT: most diabetic medications
should be continued right up until surgery
despite NPO status; however, metformin
(Glucophage) should be held owing to the
risk of lactic acidosis when food and fluids
are withheld.
PRESENCE OF ALCOHOLISM
 Alcoholism is usually accompanied by problems  Be prepared for rapid sequence induction to
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of Malnutrition. The client may also have an lessen the chance of vomiting and aspiration.
increase tolerance to anesthetics.  Anticipate the acute withdrawal syndrome
(Delirium tremens). Within 72 hours of the
last alcoholic drinks.
PRESENCE OF PULMONARY AND UPPER RESPIRATORY DISEASE

 Chronic pulmonary illness may contribute to  Client with chronic pulmonary problems
hypoventilation, leading to pneumonia and should be treated preoperatively to reduce
atelectasis. Surgery may need to be postponed the risk of atelectasis and pneumonia and
if the client has upper respiratory tract infection prevent respiratory depression and narcotics.
because it increases the likelihood of a more
serious illness. E.g. Pneumonia.
CONCURRENT OR PRIOR TO PHARMACOTHERAPY

 Hazards exist when certain medications re  Notify the health care provider and
given contaminant with others, including herbal anesthesiologist if the patient is taking any of
substances. the following.
a. Certain antibiotics may interrupt nerve

transmission when combine with curariform
muscle relaxant. This may cause respiratory
muscle paralysis and apnea.
b. Anti-depressant particularly Monoamine

Oxidase Inhibitors (MAOI’s) and St. John
Wort, an herbal product, increase
hypotensive effects of anesthesia.
c. Phenothiazine increases hypotensive action

of anesthesia.
d. Diuretics, particularly thiazides, may cause

electrolytes imbalance and respiratory
depression during anesthesia.
e. Steroids inhibit wound healing.
f. ANTI COAGULANT SUCH AS warfarin and

heparin; or medications or herbals that may
affect coagulation such as aspirin, gingko
biloba, NSAID’, ticlopidine, and clopidogrel
may cause unexpected bleeding.
Learning Episode:
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 The students shall have self- reading, work on critical thinking checkpoint and graphic organizers and
reflective journaling. Instructed to follow time lines in the submission of their written outputs and
answers. The students can contact at the cell phone number, messenger and email provided for
clarification and further understanding of the concepts and instruction.
Assessment of Learning:
 Graphic organizers and answering the quiz.
SUB TOPIC 1: PREOPERATIVE NURSING

Intended Learning Outcome: Given a sample client for surgery the student will engage in the concept of
PREOPERATIVE nursing by:
1. Identifying the nursing interventions done in preparing to the client before surgery.
2. Comprehend the importance of preoperative preparation of surgical patient including the securing of
inform consent.
3. Identifying the nursing interventions done in preparing the client on the day of surgery.
4. Listing down the nursing interventions done Preoperative.
Time Frame / Class Schedule:
 Flipped learning via messenger

apps. /via SMS text.  Student will continue to engage
 Modular/ Self-directed learning on readings related to the
 Introductory concept of concept of the sub topic 1
Perioperative Nursing on (Preoperative nursing)
module 1 and sub topic module
1 (informed consent)

 Effective Communicator
 Accountable
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Concept notes:
PREOPERATIVE CONSENT/INFORMED CONSENT

Author: Pamela Pagunsanan – VillaCarlos
 Is the process (not just a mere) of informing the patient about the surgical procedure and obtaining
consent from him or her.
 Is a legal requirement.
 Hospital has a standard operative permit approve by the hospital legal department.
PURPOSES
1. To ensure that the patient understand the nature of the treatment, including potential
complications.
2. To indicate that the patient decision was made without pressure.
3. To protect the patient against an unauthorized procedure, and to ensure that the procedure is
performed on the correct body part.
4. To protect the surgeon and the hospital against legal action by the patient who claims that the
unauthorized procedure was performed.
PROCEDURES REQUIRING A PERMIT

1. Surgical procedures where scalpel, scissors, hemostat or electrocoagulation may be used.
2. Entrance into a body cavity.
3. Radiologic procedure, particularly if contrast material is required.
4. General anesthesia, local infiltration and regional block.
CONSIDIRATION FOR OBTAINING INFORM CONSENT

Minor – Emancipated minor’s:
a.
Adult – b.
c.
If physically or mentally incompetent – d.
e.
OBTAINING INFORMED CONSENT

1. The SURGEON is responsible for obtaining the consent for surgery.
2. Sign a separate consent form from each procedure or operation.
3. Signature is obtained with the patient’s correct understanding of what is to occur and secured
without pressure or distress.
4. No sedation should be administered to the patient before he/she signs the consent.
5. Patient giving consent should be of legal age and mentally competent.
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6. Minor may need a parent or legal guardian to sign the consent form.
7. Older client may need a parent or legal guardian to sign the consent form, alcohol or other chemical
substances – the spouse or responsible relative of legal age may sign when the urgency of the
procedure does not allow time for the patient to remain mental competence.
8. Mentally incompetent – a legal guardian who may be either an individual or an agency should sign.
9. The NURSE may WITNESS the patients signing of the consent from.
10. If the patient is unable to write, an “X” to indicate his sign is acceptable if there is a signed witness to
his mark
WHEN CONSENT IS NOT NEEDED?

1. During emergency cases.
 in a life-threatening situation, consent to treat and stabilize is not essential.
 Permission for life saving procedure, especially for a minor, may be accepted from a legal
guardian or responsible relative by telephone, fax, or other written communication.
 If it is obtained by telephone. Two (2) RN’s should monitor the call and sign form, which is
signed later by the patient or legal guardian or arrival of the facility.
2. If the patient wave’s his/her rights.
PATIENT’S RIGHT TO REFUSE A SURGICAL PROCEDURE

1. The patient has the right to withdraw written consent at any time before the surgical procedure.
 The surgeon is notified, the patient is not taken into the OR.
 The circulating nurse documents the situation on the patients records.
 The surgeon should explain the medical consequences’ of refusing the surgical procedure.
 The surgical procedure is postponed until the patient makes a final decision; the procedure
may be cancelled.
PREOPERATIVE INSTRUCTIONS: Preoperative Regimen
Assessment: Nursing History

a. Allergies
 Prescription and non- prescription drugs.
 Food allergies- seafood, iodine.
 Other allergies- Tape, latex glove, soap, antiseptic solution.
 PURPOSE: To avoid exposing the patient to allergies.
b. Previous Surgery
c. Smoking
d. Alcohol and other mind-altering substances
PHYSICAL PREPARATION
Nutrition
 Review the physician’s prescriptions regarding NPO before surgery.
 Withhold solid foods and liquids as prescribed to avoid aspiration; usually for 6 t 8 hours before
general anesthesia and for approximately 3 hours before surgery with local anesthesia.
 Insert an IV line and administer IV fluids, if prescribed; IV catheter should be large enough to
administer blood products if they required.
 Administer parenteral nutrition (PN) as prescribed; usually PN is prescribed for clients who are
malnourished, have protein or metabolic deficiencies from underlying disease, or cannot ingest food.
Elimination
 Preparation of bowel is imperative for intestinal surgery because bacteria can invade and can cause
sepsis.
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 if the client is to have intestinal or abdominal surgery, then an enema, laxative, or both may
prescribed the day or night before surgery.
 the client should void immediately before surgery.
 insert a Foley catheter, if prescribed; Foley catheters should be emptied immediately before surgery,
and the nurse should document the amount and characteristics of urine.
Surgical site
 Shave prep equipment: Dry sponge, Portable clippers, razor
 Removal of hair from the operative site is not necessary for surgical procedures.
 Ideal methods to remove unwanted are either by depilatory or by clipping the hair using disposable
clippers
 Either of these methods eliminates the possibility of cutting or scratching the skin caused by shaving,
which may create an opening for microbial contamination of the surgical wound.
 clean the surgical site with a mild antiseptic or antibacterial soap the night before surgery, as
prescribed
 shave the operative site, as prescribed; shaving may be done in the operating room
 removal of hair (using A.O.R.N’s recommendations) should be performed not more than 2 hours
prior to surgical procedure.
 Never shave the face, eyebrows, or eye lashes unless specifically ordered by the surgeon.
 Hygiene/Shaving- decrease the risk for wound infection.
 Bath /shower all patients for elective surgery. Bath the patient preoperatively within 12 hours prior
to OR.
 Client’s nails should be trimmed and free of polish, surgical cap.
 Shaving is done preferably at the OR before the surgery. Shaving increases the infection rate to
5.56% from 0.6% where shaving was not done
 RAZOR- gross cut, ELECTRIC CLIP- tend to nip the skin, DIPILATORY AGENT- showed no visible injury
Moving Purposes
a. Purposes- to maintain blood circulation, to stimulate respiratory functions, to decrease stasis of gas
in the intestine, to facilitate early ambulation
A. Legs exercise
B. Deep breathing exercise
C. Coughing exercise
Deep Breathing and Coughing Exercise
a. Instruct the client that sitting position gives the best lung expansion for coughing and deep
breathing exercises
b. Instruct the client to breathe deeply three times a day, inhaling through the nostrils and exhaling
slowly through pursed lips
c. Instruct the client the client that the third breath should be held for 3 second; then the client should
cough deeply three times
d. The client should perform exercise every 1 to 2 hours
Incentive Spirometry
a. Instruct the client to assume sitting position or upright position
b. Instruct the client to place the mouth tightly around the mouth piece
c. Instruct the client to inhale slowly to raise and maintain the flow rate indicator, usually between the
600 and 900 marks on the device
d. Instruct the client to hold the breath for 5 seconds and then to exhale through purse lips
e. Instruct the client to repeat this process 10 times every hour
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Figure 1 on module 1 sub – topic: Incentive spirometry
Leg and foot Exercises

a. Gastrocnemius (calf) pumping: instruct the client to move both ankles by pointing the toes up and
then down
b. Quadriceps (thigh) setting: instruct the client to press the back of the knees; this contracts and
relaxes the thigh and calf muscles to prevent thrombus formation
c. Foot circles movements: instruct the client to rotate each foot in a circle
d. Hip and knee movements: instruct the client to flex the knee and thigh and to straighten the leg.
Holding the position for 5 seconds before lowering (not performed if the client is having abdominal
surgery or if the client has a back problem)
Figure 2: Leg and foot exercises
Splinting the Incision

a. If the surgical incision is abdominal or thoracic, instruct the client to place a pillow, or one hand with
the other hand on top, over the incisional area
b. During deep breathing exercise and coughing, the client presses gently against the incisional area to
splint or support it
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Figure 3: Splinting the incision site
PREOPERATIVE INSTRUCTIONS: Postoperative Regimen

 Discuss the post anesthesia recovery room routines and emergency equipment.
 Discuss pain management.
 Explain unusual activity restrictions and precautions related to getting up for the first time post-
operatively.
 Discuss dietary alterations
 Discuss post-operative dressing and drains
 Discuss the need to remove jewelry, make – up, and all the prostheses (e.g., dentures, eye glasses,
hearing aid, wig, etc.).
 Teach the patient about deep breathing exercises, leg exercises, ways to turn and move.
 Complete the pre-operative checklist.
Learning episode
 The students shall have self-readiness. Engage in virtual discussions by inquiries, ideas and updates
through synchronous and asynchronous session. Work and formulate their graphic organizers
together with their group on think pair share and work on writing to learn work sheet.
 Graphic organizer
 Quiz
SUBTOPIC 2: INTRAOPERATIVE NURSING
Intended Learning Outcomes:
 Given a sample client for surgery the student will engage in the concept of INTRAOPERATIVE nursing
by Inferring the nursing interventions done in the client on the day of surgery by:
1. Applying knowledge of the types of anesthesia and the basic actions and uses of anesthetic
agents and medications.
2. Identifying common drugs in surgery.
3. Demonstrating knowledge and skills on drug handling in a sterile environment.
4. Applying the best standard of practice in the operating room.
5. Comparing and contrast aseptic technique and sterile technique
6. Demonstrating the roles and function of the member of the surgical team.
Time Frame/ Class Schedule: August 13, 2020 ( Week 2/ 3 hours)

 Subtopic 2: Intraoperative nursing.  Student will continue to

 Flipped-learning engage on readings related
 Modular/Self-directed learning to the concept of the sub
 Face to face meeting topic 2 (intraoperative
nursing)
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III. Values integrated cross-linked concepts/values to be integrated:

 Accountable
INTRAOPERATIVE PHASE
 The period of surgery
 It includes procedure to create and maintain safe therapeutic environment for the client and
health care personnel
 Overall goal: Safety of the patient
Arrival in the Operating Room
1. Guidelines to eliminate wrong sit and wrong procedure surgery

a. The surgeons meets with the client in the preoperative area and uses indelible ink to mark the
operative site.
b. In the Operating Room, the nurse and the surgeon ensure and reconfirm that the operative site has
been appropriately marked
c. Just before starting the surgical procedure, a time out is conducted with all members of the
operative team present to identify appropriate surgical site again.
2. When the client arrives in the Operating Room nurse will verify the identification bracelet with the client’s
verbal response and will review the client’s chart.
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3. The client chart will be checked for completeness and reviewed for informed consent forms, history and
physical examination and allergic reaction information.
4. Physicians prescriptions will be verified and implemented.
5.The IV line maybe initiated at this time (or in the preoperative area), if prescribed
6. The anesthesia team will administer the prescribed anesthesia
MEDICAL CONDITION THAT INCREASES RISK DURING SURGERY

 Bleeding disorders such as thrombocytopenia, hemophilia
 Diabetes mellitus
 Chronic pain
 Heart disease such as recent myocardial infarction, dysrhythmias, heart failure, or peripheral
vascular disease
 Obstructive sleep apnea
 Liver disease
 Fever
 Chronic respiratory disease, such as emphysema, bronchitis, or asthma
 Immunological disorders, such as leukemia, infection with human immune deficiency syndrome,
bone marrow depression, or use of chemotherapy or immunosuppressive agents
ANESTHESIA
 A state of narcotics, analgesia, relaxation, and loss of reflex
 A physician (anesthesiologist), or certified registered nurse anesthetist (CRNA) administer the
anesthesia in the OR.
When wear off? When all (3) System are no longer affected.
S-ENSORY
A-UTONOMIC
M-OTOR
TECHNIQUES OF ANESTHESIA ADMINISTRATION UTILIZED IN THE OR INCLUDES
1. GENERAL ANESTHESIA
 Patient is made UNCONSCIOUS
2. CONDUCTION ANESTHESIA
 Anatomical site is anesthetized by infiltration or topical application of various anesthetic
agents.
 A peripheral nerve block may produce by injecting an agent about nerve’ (s) supplying
sensation to the operative site, or a block may be placed at a central level.
 Local anesthesia and topical anesthesia are established by employing anesthetic agent
immediately about the area to be treated.
 May be supplemented by varying degrees of general anesthesia or sedation.
FOUR LEVELS OF SEDATION

1. Minimal sedation and analgesia (the patient responds normally)
2. Moderate sedation (conscious sedation)
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3. Deep sedation (the patient is not easily aroused but maintain respiration)
4. Anesthesia in which the patient requires assisted ventilation
COMMON INHALATION: VOLATILE INTRAVENOUS

LIQUIDS 1. THIOPENTAL Na
1. Ether 2. Methohexital Na
2. Halothane (Fluorane) 3. Valium
3. Methoxyflurane (Pentrane) 4. Midazolam
4. Eflurane (Ethrane) 5. Fentanyl
5. Isoflurane (Forane) 6. Ketamine Hydrochloride
6. Desflurane (Suprane) 7. Propofol
7. Sevoflurane (Ultane)
INHALATION: GAS LOCAL ANESTHESIA:

1. Nitrous oxide (Laughing gas) 1. Chloroprocaine
2. Cyclopropane 2. Procaine
3. Lidocaine
4. Prilocaine
General Anesthesia- loss of all sensation and STAGES OF ANESTHESIA

consciousness. Stage I / Beginning of Anesthesia
Protective reflexes are loss.  Sensation of warmth.
Action: blocks awareness center of the brain.  Exaggerated noises. Ringing, roaring, buzzing
Routes: IV infusion, inhalant anesthetics. in the ear.
Advantage: vital signs can be controlled. Stage II/ Excitement or Delirium
Disadvantage: Respiratory depression and  Struggling, shouting, talking, laughing or
cardiovascular system is affected crying.
 Irregular RR and PR.
Stage III/ Surgical Anesthesia
Regional Anesthesia- temporary interruption f the  Unconscious and lies quietly.
transmission of the nerve impulse to specific area.  RR, PR is regular. Skin is slightly flushed.
Patient remains conscious  Lid and gag reflex are lost.
Stage IV
 Respiration is swallow, pulse rate is weak,
Spinal Anesthesia- needle is inserted into pupils are widely dilated, and no constriction
SUBARACHNOID spaces. to light.
Location: L3 and L4  Cyanotic and leading to death.
Not done in patient with increase ICP.
Position: lateral position or sitting position
SUBSTANCE THAT CAN AFFECT THE CLIENT IN SURGERY
Antibiotics Antihypertensive
 Antibiotics potentiate the action of  Antihypertensive medications can interact
anesthetic agents with anesthetic agents and cause
bradycardia, hypotension, and impaired
circulation
Anticholinergics Corticosteroids
 Medications with anticholinergics effects  Can cause adrenal atrophy and reduce the
increase the potential for confusion ability of the body to withstand stress
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 Before and during surgery dosages maybe

increase temporarily
Anticoagulant Diuretics
 Alter normal clotting factors and increase  Diuretics potentiate electrolyte
risk for hemorrhaging  imbalances after surgery
 ASPIRIN (acetylsalicylic acid) and non-
steroidal anti-inflammatory drugs are
commonly used medications that can alter
clotting mechanism
 These medications should be discontinued
at least 48 hours before surgery or as
specified by the surgeons.
Anticonvulsant Herbal Substances

 Long term used of anti-convulsant can alter  Herbal substances can interact with
the metabolism of anesthetic agent anesthesia and cause a variety of adverse
effects. These substances may need to be
stopped at a specific time before surgery.
During the preoperative period, the client
needs to be asked if he or she is taking an
herbal substance
Antidepressant Insulin
 May lower the blood pressure during  The need for insulin after surgery in a
anesthesia diabetic may be reduced because the client’s
nutritional intake is decreased, or the need
for insulin may be increased because of the
stress response and intravenous
administrations of glucose solutions
Antidysrhythmic
 Reduce cardiac contractility and impair cardiac conduction during anesthesia
GENERAL INFORMATION
 Anesthesia, involves the administration of potentially lethal drugs and gases in various methods.
 Oftentimes, depress the CNS.
 It induces the state of partial or total loss of sensation, to permit the performance of surgery or other
painful procedures.
 This condition is also concerned with controlling motor, sensory, mental, and reflex functions.
 A physician (Anesthesiologist), or Certified Registered Nurse Anesthetist (CRNA) administered the
anesthesia in the operating room.
 Using an anesthesia preoperative evaluation form, the anesthesia provider does the following (prior
to patient’s arrival in the operating room).
o identifies the patient and discusses the patient medical, surgical, anesthesia, and
drug/medication history.
o Review’s the patient laboratory work and diagnostic studies and the history and physical
examinations report made by the surgeon.
o Performs a pertinent physical examination of the patient.
o Asks the patient if he/she had a previous surgery and if he/she has an unusual response to
anesthesia or any familial history of unusual responses to anesthesia.
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o Explains a “plan of anesthesia”. Including risks, benefits and alternatives to the particular
anesthesia modality (if any alternative methods are permissible). To the patient.
o Gives the patient an opportunity to ask relevant questions about alternative methods of
anesthesia.
o Follows through with the agreed plan for anesthesia.
o Verifies the site and side of the procedure with the patient and with the chart, as well as
position of the table that the patient will assume for the administration of the anesthesia.
TYPES OF ADMINISTRATION OF ANESTHESIA:

GENERAL ANESTHESIA
 A state of consciousness is produced by anesthetic agents, with the desired result of amnesia,
analgesia, and muscular relaxation. SENSATION OF PAIN ALL OVER THE BODY IS CONTROLLED.
BALANCED ANESTHESIA
 This type of anesthesia uses a combination of drugs in an amount sufficient to effects HYPNOSIS,
ANALGESIA, and MUSCULAR RELAXATION to an optimum degree and to keep undesirable effects to a
minimum. This is often referred to as NEUROLEPTANESTHESIA.
LOCAL/ REGIONAL ANESTHESIA

 This type of anesthesia is produced in a limited area and does not affect the consciousness of the
client. The sensory nerves in one area or region of the boy are anesthetized. It is sometimes called
CONDUCTION ANETHESIA.
 Anatomical site are anesthetized by infiltration or topical application of the agents.
SPINAL / EPIDURAL ANESTHESIA

 This type of anesthesia is produced by injecting an agent beneath the membrane of the spinal cord.
Sensation of pain is blocked at a level below the diaphragm. Like local anesthesia, there is no loss of
consciousness in the clients which had been given spinal or epidural anesthesia.
GENERAL ANESTHESIA
ACTION
 When the anesthetic takes the form of an inhalant or introduced through IV push, it breaks the
association of pathways in the CEREBRAL CORTEX. This will lead to a more or less a complete lack of
sensory perception and motor functions.
 When an adequate amount of anesthetic drugs circulates in the brain, the client slowly
UNCONSCIOUS and LOSES HIS/HER REFLEX.
Here, the client undergoes different levels of unconsciousness
LEVEL OF UNCONSCIOUSNESS
1. Induction stage- the client begins to feel drowsy, dizzy, and amnesic and eventually loses the
consciousness.
2. Excitement stage- the client initially feels excited and has irregular breathing; he/she show
movements of the extremities and then feels relaxed, with slight hypnosis afterwards.
3. Operative Stage- the client experience regular respiration, contraction of the pupils, loss of reflex,
muscle relaxation, loss of auditory sensation, and depression of vital functions.
4. Danger stage- the client’s vital signs are too depressed; he/she exhibits no breathing and has a weak
or absent pulse or heartbeat.
Techniques in Administering Anesthesia

1. Inhalation
2. Intravenous fluid
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Figure 2 on sub topic 2: Mask inhalation anesthesia
Adverse effects of administration techniques

 Mask inhalation- a significant amount of gas may leak into room because of an ill-fitting facemask.
 Endotracheal administration- this method will lead into the following complications:
a. Trauma to the teeth
b. Pharynx, vocal cord or trachea
c. Dysrhythmias
d. Hypoxia and hypoxemia e accidental esophageal or endobronchial intubation; aspiration of GIT

content.
e. Tracheal collapse.
NURSING RESPONSIBILITIES
MASK INHALATION
 Anticipate the sized of the mask to be used.
 Prepare the anesthesia machine
 Connect the client to the monitoring machines to keep the track of the vital functions of
the client.
 Ensure that the client has an empty stomach and was placed on NPO at least 6-8 hours
prior to the induction of anesthesia.
 Place the client in a supine position and give emotional support to the client.
ENDOTRACHEAL ADMINISTRATION
 -Apply pressure on the CRICOID CARTILAGE- the complete ring around the inferior wall of the larynx
below the thyroid cartilage prominence to obstruct the esophagus and immobilize the trachea.
 -SELLICK MANEUVER- It prevents the regurgitation and aspiration of stomach contents. Compression
must begin with the client awake or before induction drugs are injected. It must continue until the
ETT cuff is inflated and when the anesthesia provider decides that it safe to release pressure.
GENERAL ANESTHETICS
Agent Route of Form Comments

Administration
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Thiopental Intravenous Stable Liquid  Rapid induction

 Short duration
 Respiratory depressant
 Can cause laryngospasm and
hypotension (opiate or
additional agents required for
additional adequate pain
control.
Propofol Intravenous Stable Liquid  Rapid induction

(Diprovan)  Short duration
 Can be used for continuous
infusion with clear – headed
rapid recovery
Ketamine Intravenous Stable Liquid  Short acting anesthetic

(Ketalar) Intramuscular  Long-acting analgesic
 Used for pediatric and wound
burn procedure and trauma
cases
 May cause emergent
hallucinations if given in a
larger dose in adult.
Nitrous oxide Inhalation Compressed  Commonly used

Gas  Employed with other agents
to potentiate their action to
produce deeper anesthesia.
Halothane Inhalation Volatile Liquid  Slow smooth induction

 Maintenance
 May cause bradycardia
 May cause ventricular
arrythmias if epinephrine
given.
Enflurane Inhalation Volatile Liquid  Rapid induction

 Maintenance
 Rapid recovery
 May cause hypotension
 Associated with seizures in
children
 Less often used
Isoflurane Inhalation Volatile Liquid  Maintenance

(Forane)  Good relaxation
 Cardiovascular stability
 Used for cardiac patient
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Sevoflurane Inhalation Volatile Liquid  Rapid induction (useful for

mask induction in children)
 Rapid recovery
 Good relaxation
 May cause emergence
delirium in children
BALANCED ANESTHESIA
 Neuroleptanalgesia- is a state of intense analgesia and amnesia achieved by administering a

combination of a narcotic (potent analgesics) and neuroleptic (psychotropic tranquilizer) drugs.
 Unconsciousness may or may not occur. However the analgesia, amnesia, and sedation produced are
not true anesthesia.
 This is the result of NARCOTIC- NEUROLEPTIC drug administration supplemented by the inhalation of
NITROUS OXIDE AND O2. It reduces motor activity and anxiety; it potentiates a hypnotics and
analgesics effects.
Methods of administration
1. Accomplished by combine intravenous administration and inhalation of drugs.
DRUGS USED FOR BALANCED ANESTHESIA

The following are the commonly used:
1. INTRAVENOUS
a. Thiobarbiturate derivatives (thiopental sodium [penthotal], methohexital [brevital]).
b. Diazepam (Valium)
c. Midazolam (Dormicum)
2. INHALATION DRUGS
a. Halothane (fluthane)
b. Nitrous chloride
c. Isoflorane (forane)
d. Desflurane (suprane)
e. Sevoflurane (ultane)
ADVERSE EFFECT OF BALANCED ANESTHESIA

 It may affect the behavior and attitude of the client post-operatively. The client may manifest anger,
irritability, and preoccupation with death.
Nursing Responsibilities:
 Prepare the following instrument: face mask, needle with syringe, and anesthesia machine.
 Connect the client to the monitoring machines to keep his/her vital signs under closed watch.
 The nurse should be very sensitive to complaint of pain by the client so that the anesthesiologist can
adjust the dosage of the anesthetic drugs.
 The nurse should be constantly aware of the client’s vulnerability to auditory stimuli, including
conversation and room noise.
LOCAL ANESTHESIA
TOPICAL ANESTHESIA
 The anesthetic drug is applied directly to the SKIN, MUCOUS MENBRANE, to a serous surface, or into
an open wound.
 The onset of this type of medication occurs within a minutes.
 The duration of anesthesia is from 20 to 30 minutes.
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Nursing Responsibility
 Ensure that the client has an empty stomach and was placed on NPO at least 6 to 8 hours prior to
the induction of anesthesia.
 Connect the client to the monitoring machines.
 Prepare the needed topical drugs, sterile gloves, and other equipment’s needed.
 Identify all medications the client has recently received or currently taking.
 Ask the client about known or suspected previous drugs reactions
 Give emotional support.
LOCAL INFILTRATION
 The drugs is injected INTRACUTANEOUSLY & SUBCUTANEOUSLY into the tissue at and around the
incision site to block peripheral sensory nerve stimuli at their origin.
Nursing Responsibilities
 NPO at least 6-8 hours
 Ask the client about known or suspected previous drug reactions.
 Prepare the needle with syringe, anesthesia (e.g., lidocaine), CB with anti-septic solutions and gloves.
 Observe the client, including his/her facial expressions. Note his/her response to conversation and
state of alertness.
 Monitors the patient v/s and symptoms such a skin color and temp and presence of nausea and
vomiting.
 Give emotional support
CONDUCTION ANESTHESIA
 Nerve Blocks; Spinal, Epidural, and Caudal

 Loss of sensation in a particular body part is produced by inhibiting the transmission of sensory nerve
impulses to that area.
 The anesthetic drugs are injected around a specific nerve or group of nerve to block the pain
impulses. However, the clients remain conscious, with or without IV sedation. Example: nerve block,
spinal and epidural anesthesia.
NERVE BLOCK
 Is the injection of anesthetic drugs into and around a nerve or a group of nerves in the involved area.
It interrupts the conduction of sensory, motor, and or sympathetic transmission along o selected
nerve.
NURSING RESPONSIBILITIES
 NPO at least 6-8 hours
 Check the client vital signs
 Prepare the needle with the syringe; double cuff tourniquet, Esmarch bandage, IV catheter and
pressure source.
 Prepare the anesthetic drugs. Lidocaine, bupivacaine, cotton balls with solution, sterile gloves.
 Ask the client suspected previous drug reaction.
 Monitor client vital signs
SPINAL AND EPIDURAL ANESTHESIA

 This is a type of regional anesthesia where the drugs is delivered to selected areas, referred to as
DERMATOMES, to prevent motor and sensory sensation.
 Needle is inserted into Sub arachnoids space
 Location: lumbar 3 and lumbar 4
 Not done in patient with increase ICP
25
 Normal ICP (10-15 mmHg)
EPIDURAL ANESTHESIA
 Also called PERIDURAL / EXTRADURAL ANESTHESIA.
 Achieved by injecting local anesthetic into the surrounding of Dura matter, by way of lumbar
puncture.
NURSING RESPONSIBILITIES OF SPINAL ANDEPIDURAL ANESTHESIA

 NPO 6-8 hours
 Ask the client about suspected previous drug reactions.
 Connect the client to the monitoring machines.
 Check the blood pressure before, during, and after the spinal anesthesia since hypotension is
common.
 Prepare the equipment needed for skin prep;
 Antiseptic solution (oftentimes, it is betadine solution); sterile kidney basin, sterile forceps, gloves
and sterile OS 4x4.
 Prepare hypodermic needle with syringe
 On the anesthesia table, open a sterile pack needed for skin prep.
Prepare the spinal tray during the induction which include the following:
a. A sterile penetrated drape

b. Ampules of anesthetics
c. Gauze square, forceps, antiseptic solution and applicator stick.
d. Spinal needle or spinal catheter
e. Sterile gloves
f. Medicine needed for anesthesia
g. Place client in the desired position chosen by the anesthesia provider.
LATERAL POSITION
SITTING POSITION
h. MONITOR THE CLIENT FOR CNS STIMULANT AND CARDIAC DEPRESSION, WHICH ARE SIGNS OF A
SYSTEMIC TOXIC REACTION.
Figure 5 Site of spinal needle inserted to the epidural space

26
Figure 6 Lateral and sitting position
Complications of Spinal and Epidural Anesthesia
1. Transient or permanent neurologic complication from cord trauma and loss of spinal fluid with
decreased intracranial pressure syndrome – example includes
a. Spinal headache
b. Auditory and ocular disturbances
2. Ruptured nucleus pulposus
3. True spinal headache caused by persistent cerebrospinal fluid leak through the needle hole in the
dura
4. Respiratory paralysis (“total spinal”) – through to be a result of medullary hypoperfusion caused by
sympathetic block
5. Hypotension – this is brought about by the circulatory depressant effect and stasis of blood because
of interference with the venous return from motor paralysis and anterior dilatation in the lower
extremities. A sudden change in the body position may be followed by a sudden drop in the blood
pressure. However, a slight head – down position may increase venous return to the heart.
COMMONLY USED CONDUCTION ANESTHESIA
AGENT ROUTE OF CONCENTRATION/DOSE COMMENTS

ADMINISTRATION
Lidocaine Spinal 5% /100 mg Rapid onset; shorter acting
(Xylocaine)
Bupivacaine Spinal 0.75% /15-22.5 mg Longer acting: longer analgesia after
(Marcaine, return of sensation.
Sensorcaine)
Tetracaine Spinal 0.5%- 1.0% or 5-12 mg Rapid onset; longer acting with higher
(Pentocaine) dosage and/ or added ephedrine.
Lidocaine Epidural/Caudal 1.0%-2.0% / 500 mg Rapid onset; shorter duration.
(Xylocaine)
Bupivacaine Epidural/ Caudal 0.25-0.75% / 150 mg Longer acting; OBSTERIC; POST
(Marcaine, OPERATIVE ANALGESIA including
27
Sensorcaine) obstetrics as infusion via catheter;

cardiac arrest in higher dosage
reported.
Lidocaine Regional nerve 1.0%- 2.0% / 500 mg; 5% / Rapid onset; double cuffed tourniquet
(Xylocaine) block/ Retrograde 40-60 ml required.
(Bier) Intravenous (200-300 mg)
block
Bupivacaine Regional nerve 0.25% - 0.5% Long acting
(Marcaine, block
Sensorcaine)
Lidocaine Local 0.25% - 2% Commonly used
(Xylocaine) 500 mg
Bupivacaine Local 0.25% - 0.5% Long acting
(Marcaine, 225 mg
Sensorcaine)
Lidocaine Topical liquid 2% or 4% Low toxicity; short acting intra-

(Xylocaine) ointment; gel 2% / 15-30 ml; tracheally cystosopy; other
4% 15 ml endoscopies.
Lidocaine Topical cream 4% or 5% On intact skin or mucous membranes;
(LMX 4; LMX not for open wounds or ophthalmic
5) use; superficial skin procedures; to
lessen the pain of subsequent
puncture (children); may take 5-40
mins. To be effective; occlusive
dressing for skin use.
Lidocaine/ Topical dressing use 2.5% /2.5% As per lidocaine 4%-55 cream;
prilocaine for skin (up 1-2 (25 mg / 25 mg/g) occlusive (EMLA)
hours) before the 1-2/ 10cm2
procedure.
Cocaine Topical liquid 2%-10% (4% common) / High potency; rapid absorption
200mg through mucous membranes; ENT
procedures.
Tetracaine Topical liquid 0.5%-1.0 % Rapid onset; ophthalmic use mucous
(Pontocaine) ointment; cream 0.5%- 1.0% membranes (anorectal)
 All conduction anesthetic agent, when administer in greater than recommended dosage or if
accidentally given IV (or by idiosyncratic reaction), may cause EXTREME AGITATION, CONVULSION,
CARDIAC ARREST, AND DEATH.
 Resuscitative equipment and drugs must be immediately available whenever these agents are
employed.
 The dosages of agents listed in this table are approximate, modified by the patients weight, height,
duration of the procedure (with incremental dosage), and cardiac arrhythmias.
 Vasoconstrictors such as ephedrine and epinephrine can be added to an anesthetics agent to prolong
the effect of the block. A diffusing agents such as hyaluronidase may be added to local anesthetics to
hasten the onset of the anesthetics effects.
 This table list only several of the most commonly used anesthetics agents in the dosages used
primarily for adult patients.
Monograph of Common Drugs used in Surgery
Category: Antimicrobial (Anti-infective; antibiotics)

General Description: chemical agents that eliminate living organisms pathogenic to the host (Patient). The
methods for classifying these agents include:
28
 Mechanism of action- inhibition of protein synthesis, activity on the cell membrane, alteration of the
nucleic acid metabolism.
 Spectrum of activity- gram positive or negative
 Similarity in chemical structure: Penicillin’s; cephalosporins; aminoglycosides; sulfonamides.
 Source- living organism; chemical synthesis.
Selection is based on the organism’s sensitivity, patient variations, and the relative toxicity of the proposed
agent.
EXAMPLES: include but not limited to:
 Penicillin’s (e.g., ampicillin)
 Cephalosporins (e.g., Cefazolin [ancef]
 Aminoglycosides (e.g., neomycin sulfate; gentamycin sulfate [geramycin]
 Sulfonamides (e.g., gantrisin)
 Others (e.g., bacitracin, chloromycetin, vancomycin, tetracycline)
ADMINISTRATION METHODS: In saline irrigation solution

Nursing Considerations for Surgery:
1. Although cephalosporins may be used for patient allergic t penicillin, some patient may show
sensitivity and subsequently develop allergies to this group.
2. All drugs in irrigation solution in the sterile field must be labeled to avoid confusion with plain
solutions.
3. All agents used in irrigation must be documented on the Intraoperative record.
Category: Anticoagulants
General Description: anticoagulant are given to prolong the time it takes the blood to clot by preventing the
conversion of fibrinogen to fibrin. In addition they are used to prevent the occurrences of clot enlargement or
fragmentation (thromboembolism).
EXAMPLES: Heparin (generic, Liquaemin Sodium)
Administration method: I.V. (Administered by the Anesthesiologist) or in irrigation solution (Heparinized
saline solution)
Nursing consideration for surgery:
1. It is clinically safer and far more accurate to measure the dose in units than in milligrams.
2. IV heparin must be administered via infusion pump.
3. Heparin should be administered in an isotonic sodium chloride solution (I.V.), not a sodium chloride
irrigation solution.
4. Heparin is available in units/ml
Category: Hemostatic Agents
General Description: hemostatic agents reduce capillary bleeding and arrest blood flow, thereby assisting in
blood clotting during surgery.
EXAMPLES:
 absorbable gelatin sponge (e.g., Gelfoam)
 microfibrillar collagen (e.g., Aventine)
 oxidized cellulose (e.g., surgical; oxycel)
 topical thrombin
 systemic hemostatic/ Amicar
Administration method: placed topically on the bleeding surface to absorb blood and reduce bleeding;
sprayed directly on area.

1. Topical thrombin is reconstituted before use, and is generally used with gel foam for greater
absorbency. It can also be used in spray form.
2. Amicar must be reconstituted, and is given IV.
29
3. Gel foam does not have to be removed; however, the oxidized cellulose should be removed after
hemostasis has been accomplished.
4. Aventine is applied directly to the bleeding area in dry-powdered form, but will adhere to wet gloves,
instruments, or tissue surfaces. Handle with smooth, dry forceps.
Category: Oxytocics
 Normally found in the posterior pituitary gland and stimulate smooth muscle of the uterus
during childbirth, thereby forcing the uterus to contract and thus decrease bleeding after
cesarean section.
EXAMPLES: Oxytocin (Pitocin) Methergine
Administration Method: added to IV (by anesthesiologist)
Nursing Considerations for surgery:
1. Store at temperature below 25 degree Celsius (77 F); avoid freezing.
2. Oxytocics has an anti-diuretic effect; monitor intake and out-put.
3. They are usually administered after delivery of the placenta.
4. Use cautiously in patients with history of cervical or uterine surgery and primigravida women over 35
years of age.
5. Rotate the bottle gently to distribute the drug in solution.
6. IV methergine is used for emergencies only.
Category: Steroids (Anti-inflammatory)

General Description: corticosteroid hormones are produced naturally by the adrenal cortex. They are used in
surgery to reduced inflammation and possible post-operative swelling.
EXAMPLES: include but not limited to:
 Decadron
 Hexadol
 Solu-cortef
 Solu-medrol
 Depo-medrol
 Aristocort
 Kenalog
Administration Method: administered parenterally to the affected site by the surgeons.

1. Label syringe on back table to avoid accidental usage.
2. Hydrocortisone (Solu-cortef) should be given deep IM.
Category: Diagnostic Imaging Agents

General description: Contrast-imaging agents are also known as Radiopaque media. They allow radiologic
visualization of internal structures during operative procedure, such as intra-operative cholangiograms,
cystoretrogrades, and so on.
EXAMPLE; Renografin ( Cholangiography, hystersalpingography)
 Cystografin, cysto-conray (Cystoconray)
 Hypaque
 Hyskon
Administration method: direct instillation into duct or organ via tube or special catheter

1. Although the incidence of iodine hypersensitivity related to contrast media is low, preoperative
assessment of problems associated with previous x-ray procedure should be reported immediately.
2. Be prepared to treat any adverse reactions (usually with Benadryl) when using contrast media.
3. The surgeon is responsible for the instillation of agent during the x-ray procedure.
Category: Dyes
30
General Description: solutions used to stain or mark specific surface or area. Most solutions for skin marking
have been replaced by “sterile marking pens”; however, dyes can also be used to color solutions or to test
the patency of specific organs.
EXAMPLES: Methylene blue, indigo carmine
Administration methods:
 Added to solution
 Administered directly into structure
 Used as a topical marker on skin
Nursing consideration:
1. No adverse effects have been reported
2. May be diluted per surgeons preference
3. Rinse container immediately after use as it may cause permanent discoloration

4. If instilled permanently, document use on intraoperatively
Category: Diuretics
General descriptions: reduce the body total volume of water and salt by increasing their urinary excretion.
EXAMPLES: furosemide (Lasix), mannitol (Osmitrol)
Methods of administration: IV (by administration)
Nursing consideration:
1. Lasix should be given over 1 to minutes
2. Monitor serum potassium levels. Make note of patients on digitalis.
3. Mannitol solution often crystallizes, especially at low temperatures. Therefore, store it in a solution
warming cabinet.
4. Do not used solution with undissolved crystals
Category: Central Nervous System Agents
General description: CNS agents are those that affect the body’s response to stimuli, coordination of activity,
and level of consciousness. This category includes agents such as analgesics, tranquilizer, anticonvulsants,
and anesthetic agents.
 All these agent can alter the patients perception of pain or well-being, and must be used with
extreme caution since unfavorable interactions and /or reactions are often encountered.
EXAMPLES:
1. ANALGESICS
 Fentanyl and fentanyl derivatives (sublimaze) alfenta; sufenta
 Morphine sulfate
 (Demerol) meperidine
 Codeine
 (dilaudid) hydromorphone
NOTE: in high doses, narcotic analgesics can be further classified as anesthetic agents, and are administered
by the anesthesiologist and or/or C.R.N.A., not the perioperative nurse.
2. TRANQUILIZER- reduce anxiety without inducting sleep. Most tranquilizer have muscle relaxant and
anti-convulsive properties, and closely resembles sedative hypnotics in pharmacologic properties.
 Valium (Diazepam)
 Midazolam (verse)
 Droperidol (Inspane)
Administration: IV
1. Know the institutional policies for administration protocols before administering these agents.
2. During local procedure, document all patient response every 15 minutes or more often as needed.
3. Keep antagonist agents available when administering these agents.
Category: Emergency protocol Drugs
General Description: this category includes:
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 Cardiac stimulants (epinephrine)

 Vasoconstrictor (Levophed)
 Vasodilators( nipride)
 Cardiotonics (digitalis)
 Antiarrhymics (Lidocaine)
Supplemental drugs and solutions

 In addition to the previous categories, the surgical patient may receive additional drugs and
solution to maintain hemostasis during the perioperative period. These agents include:
1. Volume expander, to increase circulating fluid volume (examples includes hespan, albumin, and
hetasarch)
2. Blood and blood components, to restore blood volume ( examples include fresh frozen plasma,
washed packed cell, whole blood, cryoprecipitate, and factor VIII.)
3. Intravenous solution with or without electrolytes. (examples include D5W, D5LR, and lactate ringers).
STANDARD OF PRACTICE IN THE OPERATING ROOM
What is standard?
 Desired and achievable level of performance against which we can measure actual performance.
STANDARD IN THE OPERATING ROOM

1. Aseptic Technique
2. Operating Room Attire
3. Surgical Scrub
Aseptic Technique
 Set of specific practices and procedures performed under carefully controlled conditions with the
goal of minimizing contamination by pathogens.
 Is a group of procedures that prevent the contamination of microorganisms through the knowledge
and principles of contain and control.
 Purpose of aseptic technique: The absence of pathogenic organism in the clinical setting
Sterile Technique
 Comprises methods by which contamination of an item is prevented by maintaining the sterility of
the item/area involved in the procedure.
 Different in implementation, yet linked in their concepts of preventing contamination, these
principles have a vital role in protecting the patient from unwarranted post-operative infection.
PRINCIPLES OF ASEPTIC TECHNIQUE

1. All items in a sterile field must be sterile.
2. Sterile packages or fields are opened or created as close as possible to time of actual use.
3. Moist areas are not considered sterile.
4. Contaminated items must be removed immediately from the sterile field.

5. Gowns are considered sterile only in the front, from chest to waist and from the hands to slightly
above the elbow.
6. Only areas that can be seen by the clinician are considered sterile, i.e., the back of the clinician is not
sterile.
7. Tables are considered sterile only at or above the level of the table.
8. Non-sterile items should not cross above a sterile field.
9. When pouring fluids, only the lip and inner cap of the pouring container is considered sterile. The
pouring container should not touch the receiving container, and splashing should be avoided.
10. Edges of sterile areas or fields (generally the outer inch) are not considered sterile.
11. When in doubt about sterility, discard the potentially contaminated item and begin again.
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12. A safe space or margin of safety is maintained between sterile and nonsterile objects and areas.
13. Tears in barriers are considered breaks in sterility.
14. There should be no talking, laughing, coughing, or sneezing across a sterile field.
15. Personnel with colds should avoid working while ill or apply a double mask.
OPERATING ROOM ATTIRE

Purpose:
 To provide effective barriers that prevents the dissemination of microorganisms to the patient and to
protect personnel from infected patients.
a. Scrub suit
b. Head cover/surgical cap
c. Surgical mask
d. Shoe/shoe cover
e. Sterile gown
f. Sterile gloves
THE SURGICAL HAND SCRUB
 Even though sterile gloves must cover the surgical team hands, it is mandatory, for several reasons,
that surgical scrub must be performed according to acceptable technique prior to the beginning of
each procedure. For example, hands may carry pathogenic bacteria acquired from other sources
within the environment, or gloves may become punctured or torn during the procedure, exposing
the patient and the team to microbial contamination.
Purpose:
• Remove debris and transient microorganisms from the nails, hands, and forearms.
• Reduce the resident microbial count to a minimum, and
• Inhibit rapid rebound growth of microorganisms.
RECOMMENDED PRACTICES FOR TRAFFIC PATTERNS IN THE PERIOPERATIVE PRACTICE SETTING

Unrestricted Area Semi-restricted Area Restricted Area
 Patient reception Area  Storage areas for clean and  Operating Suites
 Locker Rooms sterile supplies  Scrubbing Area
 Lounges  Work areas for storage and  All personnel are
 Offices processing of instruments required to wear full
 Street clothes are  Corridors to restricted areas surgical attire
permitted of the suite  Mask are required where
 Recovery Room open sterile supplies or
 Personnel should wear the scrub persons are
proper attire without the located
mask
SURGICAL TEAM
The surgical team is divided into two smaller teams with different role and functions:
1. The STERILE TEAM, composed of:
 Surgeon
 Second assistant, if needed
 Scrub nurse
 Others- student nurse, surgical intern, nurse trainee
2. The NON STERILE TEAM, composed of :

 Anesthesia provider
 Circulating nurse
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 Perianesthesia nurse/Nurse anesthetist

 Others ( e .g., nursing auxiliary, biomedical technician, laboratory or x- ray personnel)
THE STERILE TEAM- Is so called because their members stay in the sterile field. The sterile field is a specially
prepared area of the OR, often occupying the area immediately surrounding the operating table, where the
client is drapes. Before member of the sterile team enter the sterile field, they perform the sterile surgical
scrub surgical scrub of their hands and arms and don sterile gowns and sterile gloves. They observe the
aseptic technique to establish and maintain a sterile field. They ensure all items needed for the surgical
procedure are sterile and handled accordingly.
NON STERILE TEAM- assumes the responsibility of maintaining the sterility and observing the aseptic
technique during the surgical procedure. They handle the supplies and equipment that are considered sterile,
following the principles of the aseptic technique, non - sterile team supplies, carry out direct client care, and
handle situations that may arise during the preoperative care period.
The surgical team may also include biomedical technician, nursing auxiliary, and other healthcare
practitioners who may be needed to set up and operate specialized equipment’s’ or monitoring devices
during the surgical procedure.
FUNCTIONS OF THE SURGICAL TEAM
THE STERILE TEAM

SURGEON
 Head of the surgical team and is regarded as the “ captain of the ship”
 Makes the preoperative diagnosis based on observed clinical manifestations; selects and performs
the surgical procedure to cure or alleviate a disease; and provides preoperative, intraoperative, and
post -operative care to the client.
 Assumes full responsibility for all acts of medical judgments and for the management of the surgical
client.
 Determine specific site for operations.
 Determine the appropriate position in consultation with the anesthesia provider.
FIRST ASSISTANT
 Performs skin preparation.
 Places the client on the position decided by the surgeons.
 Helps maintain visibility of the surgical site, control bleeding, close wounds, and apply dressings.
 Handles tissue and instruments.
 Documents the operating techniques used during the surgery
SCRUB NURSE
Before the operation
 Can ask for the following: name of the surgeon, contemplated operations, signed consent,
compliance to NPO, and the removal of the prosthesis, jewelries, nail polish, and lipsticks.
 Any inconsistency should be correct or validated. Check the following documents that are necessary
for the operation: clearance for surgery, BT forms, and diagnostic result.
 Validates the surgeon for the preference of the sutures, and surgical instrument/supplie
 Accounts for all sponges, sharps, and instrument before and after the procedure.
 Checks and labels the drugs and syringes that will be used in the operation.
During the Operation

 Prepares and arranges the sterile instrument and supplies needed during the operation.
 Establishes and maintain the integrity, safety, and efficiency of the sterile field throughout the
procedure.
 Informs the surgeon of the drug used during the surgery.
 If two scrub nurses are necessary, one may prepare the instrument that will be used during the
operation. While the other passes instrument and supplies to the surgeon.
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After the Operation

 Accounts for all sponges, sharps, and instruments after the surgery.
 Cleans the patient by removing unnecessary prep solution, adhesive tapes, blood and the like.
 Assist in the transfer of client from the OR bed to the stretcher or hospital bed using assistive device.
 Assist in the after care of the room.
 Ensures that all specimens removed from the client are properly labeled
THE NON - STERILE TEAM

ANESTHESIOLOGIST
 Induces and maintain anesthesia at the required level.
 Manage untoward physiologic reactions of the client throughout the surgical procedure.
 Oversees the care of the client in the PACU until the client has regained control of his/her vital
functions.
 Acts as consultant or manager for the problems of acute and chronic respiratory insufficiency,
therapy, as well for the variety of fluid, electrolyte and metabolic disturbances.
 Documents the induction of anesthesia and the response of the client.
CIRCULATING NURSE
Before the Operation
 Accompanies the client when he/she transferred to the OR.
 Identifies and report any potential danger in the environment or stressful situation involving the
client.
 Keep personal items of the client such as religious article, hearing aid, eye glasses, dentures,
jewelries, and the like if the client is alone; otherwise, endorses these items to the relatives.
 Ensures that OR lights and negatosope are functioning.
 Records all the sponges, sharps, and instruments to be used during the operation.
 Ensure the safety and comfort of the client on the way to and from OR:
 Checks for the effectiveness and safety of the equipment’s, e. g., monitoring equipment’s and
electrocautery machine.
 Ensure that the OR table is locked.
 Applies necessary straps/restrains on the client and places him/her in a comfortable position.
 Provide roll or pads necessary to avoid pressure on the client.
 Checks if the stretcher to be used is functioning well.
 Assist the anesthesiologist in inducting anesthesia.
 Prepares the equipment’s needed for skin preparation.
 Performs SKIN PREPARATION if the policy of the institution requires it.
 Directs all activity of all learners, e.g., orientees and students, in the OR.
During the Operation

 Provide promptly any supplies, instrument and equipment’s as needed.
 Provides assistance to any member of the sterile team.
 Acts as a COMMUNICATION LINK between events, and between team members in the sterile
field and persons who are not in the OR but are concerned on the outcome of the surgical
procedure.
 Request for blood products when needed.
 Ensures that everyone complies with the principles of asepsis.
 Ensure patient safety throughout the procedure.
After the Operation

 Determine the outcome of the final count as correct or incorrect, including the need for a
radiograph to look for a lost item.
 Write an incident report on counts that remain unresolved.
 Records any medications the surgeons used in the surgical site.
 Give health teaching to the clients or to the S.O
 Assist in transferring the patient from OR table to PACU.
BIOMEDICAL TECHNICIANS
 Checks for the safety and standard compliance regarding the instruments and equipment’s to be
used during the surgery.
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 Set up and operates facility-owned equipment’s to be used during the surgery.
NURSING AUXILIARIES (Orderlies, Nursing Aides)

 Assist the client in getting into and out of the OR.
 Run errands for OR personnel.
 Assist in positioning the OR light properly.
 In other institution, assist with some procedure such as shaving an intended area of the client’s
body prior to surgery.
Learning Episode:
 The students shall have self-readiness. Engage in virtual discussions by inquiries, ideas and updates
through synchronous and asynchronous sessions. Work and formulate their graphic organizers on
writing to learn work sheet, compare and contrast, clinical medication work sheet and evaluation
examination.
 Quiz
SUB TOPIC 3: Postoperative Nursing

Intended Learning Outcomes:
 Given a sample client for surgery the student will engage in the concept of Postoperative nursing by:
1. 1.Inferring the nursing interventions done in the Postoperative phase (immediate, intermediate, and
extended postoperative period)
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2. Applying the knowledge in the care of the post-operative patient throughout the post-operative
period.
3. Describing the major Postoperative complications its symptoms, prevention, and treatment.
Time Frame/ Class Schedule: August 20, 2020 ( Week 3/ 3 hours)

 Modular/Self-directed learning  Student will continue to
 Face to Face meeting engage on readings related
to the concept of the sub
topic 3 (postoperative
nursing)

 Problem solving skills
 Accountable
Postoperative Phase
STAGES
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1. Immediate stage- (1 – 4 hours) after surgery

2. Intermediate stage -(4 – 24 hours) after surgery
3. Extended stage - (1 – 4 days) after surgery/ last follow – up visit
IMMEDIATE POST OPERATIVE CARE

Respiratory
 Position
- Left lateral with neck extended and upper arm supported on pillow
- Supine with head to side and chin extended forward
 Check presence of gag reflex
 Maintain artificial airway in place until gag reflex and swallow have returned
 Administer oxygen as ordered
 Assess rate and depth of respiration
 Assess breath sound for:
- Wheezing, stridor – partial obstruction, laryngo or bronchospasm
- Crackles – pulmonary edema
 Monitor for signs of atelectasis, pneumonia or pulmonary embolism
Cardiovascular
 Assess the skin and check capillary refill
 Assess peripheral pulses
 Assess peripheral edema
 Monitor for BLEEDING
 Assess pulse rate and rhythm:
- Bounding pulse – hypertension, fluid overload, excitement
- Fast, thread pulse – shock
 Monitor for sign and symptom of hypo and hypertension
 Monitor for cardiac dysrhythmias
 Assess for Homan’s sign
Musculoskeletal
 Assess for movement of extremities
 Review of positioning orders
MODIFIED ALDRETE SCALE
CHARCTERISTICS SCORE
Activity o Moves 4 extremities voluntarily or on command 2
o Moves 2 extremities voluntarily or on command 1
o Unable to move any extremities 0
Respiration o Able to deep breath and cough freely 2
o Dyspnea or limited breathing 1
o Apnea 0
Circulation o Blood pressure  20% of pre – anesthetic level 2
o Blood pressure = 20 – 40% of pre – anesthetic level 1
Blood pressure  50% of pre – anesthetic level 0

Consciousness o Fully awake 2
o Arousable on calling 1
o Not responding 0
Arterial Oxygen o Maintain SaO2  92% on room air 2
o O2 needed to maintain O2  90% 1
o O2 saturation  90% even without O2 supplement 0
INTERMEDIATE POSTOPERATIVE CARE
Monitor Respiratory Status

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 Encourage to cough and deep breath q 1 – 2°

- instruct the client to splint incision
 Encourage to turn bed q 2°
 Encourage early ambulation
 Use of incentive spirometer
 Auscultate lungs q 4°
Monitor Cardiovascular Status
 Encourage leg exercise q 2° while in bed
 Apply antiembolism stocking
 Assess vital signs, color, temperature of skin q 4°
Promote Fluids and Electrolyte Balance
 Measures I&O
 Irrigate NGT properly using NSS
Promote Optimum Nutrition

 Maintain IV infusion as ordered
 Assess return of peristalsis
 Progressive increase diet
Promote Return of Urinary Function

 Assess ability to void
 Report to surgeon if client has not voided within 8 hours after surgery
 Check bladder distention
Patients are usually discharge from PACU/RR when:

 They are conscious and oriented
 They are able to maintain a clear airway. Deep breath and cough freely
 Vital signs have been stable or consistent with pre0opeative vital signs for at least 30 minutes
 Protective reflexes (eg. Gag reflex, swallowing, cough, etc.)
 They are able to move 4 extremities
 Intake and urinary output is adequate
 They are afebrile/ febrile condition had been attended to
 Dressing are dry and intact
POSTOPERATIVE COMPLICATIONS
PNUEMONIA AND ATELECTASIS
 Pneumonia: an inflammation of the alveoli cause by an infectious process that may develop 3 – 5
days postoperatively as a result of infection, aspiration, or immobility
 Atelectasis: a collapsed or airless state of the lung that may be result of airway obstruction caused by
accumulated secretions or failure of the client to deep breath or ambulate about after surgery; a
post-operative complication that usually occurs 1 – 2 days after surgery
Assessment
a. Asses for factors that may increase the risk of pneumonia and atelectasis
b. Assess for Dyspnea and increased respiratory rate
c. Assess for crackles over involved lung area
d. Assess for elevated temperature
e. Assess for productive cough and chest pain
Interventions
1. Assess lung and breath sounds
2. Reposition the client every 1 to 2 hours
3. Encourage the client to deep breathe, cough and use the incentive Spirometer
4. Provide chest physiotherapy and postural drainage, as prescribed
5. Encourage fluid intake and early ambulation
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6. Use suction to clear secretions if the client is unable to cough
ASPIRATION
a. Caused by inhalation of food, gastric content, water, or blood in the tracheobronchial system.
b. Anesthetics and narcotics depress the central nervous system, causing inhibition of gag or cough
reflexes.
c. Nasogastric tube insertion renders both upper and lower esophageal sphincter partially
incompetent.
d. Usually, evidence of atelectasis occurs within 2 minutes of aspiration. Other symptoms include
tachypnea, dyspnea, cough, wheezing, bronchospasm, rhonchi, crackles, hypoxia, and frothy sputum.
HYPOXEMIA
 Hypoxemia an inadequate concentration of oxygen in arterial blood; in the post-operative client,
hypoxemia can be due to swallow breathing from the effects of anesthesia or medications
Assessment
a. Restlessness
b. Diaphoresis
c. Dyspnea
d. Tachycardia
e. Hypertension
f. Cyanosis
Interventions
1. Monitor for signs of hypoxemia
2. Notify the physician
3. Monitor lung sounds and pulse oximeter
4. Administer oxygen as prescribed
5. Encourage deep breathing and coughing and use of the incentive Spirometer
6. Turn and reposition the client frequently; encourage ambulation
PULMONRY EMBOLISM
 An embolus blocking the pulmonary artery and disrupting blood flow to one or more lobes of the
lungs
Assessment
a. Sudden Dyspnea
b. Sudden sharp chest pain or upper abdominal pain
c. Cyanosis
d. Tachycardia
e. A drop in BP
Interventions:
1. Notify the physician immediately because pulmonary embolism may be life- threatening and
requires emergency action
2. Monitor vital signs
3. Administer oxygen and medications as prescribed
HEMORRHAGE
 Is a copious escape of blood from the blood vessels.
Classifications of hemorrhage are as follow:

1. GENERAL
a. Primary- occur at the time of operation
b. Intermediary- occurs within the first few hours after surgery.
c. Secondary- occurs sometime after surgery due to ligature slip from blood vessel and erosion of blood
vessel.
2. According to blood vessels

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a. capillary- slow, general oozing from capillaries

b. venous- bleeding that is dark in color and bubble out
c. arterial- bleeding that spurts and is bright red in color
3. According to location
a. evident or external- visible bleeding o the surface
b. internal (concealed)- bleeding that cannot be seen
Clinical manifestations
1. Apprehension; restlessness; thirst, cold, moist, pale skin; and pallor
2. Pulse increase, respirations become rapid and deep (“air hunger”), temperatures drops
3. With progression of hemorrhage
a. Decrease cardiac output and narrowed pulse pressure
b. Rapidly decreasing blood pressure, as well as hematocrit and hemoglobin
c. Patient grow weaker until DEATH occur
Nursing interventions:
a. Inspect the wound as a possible site of bleeding. Apply pressure dressing over external bleeding site.
b. Increase IV fluid infusion rate and administer blood if necessary and as soon as possible.
NURSING PRIORITY: the client should be monitored closely for signs of increase bleeding tendencies after
transfusions. Numerous, rapid blood transfusion may induce coagulopathy and prolonged bleeding time.
c. Ligation of bleeders by the surgeon as necessary
THROMBOPHLEBITIS
 Thrombophlebitis is an inflammation of a vein, often accompanied by clot formation
 Veins in legs are affected most commonly
Assessment
a. Vein inflammation
b. Aching or cramping pain
c. Vein feels hard and cord like and is tender to touch
d. Elevated temperature
Interventions:
1. Monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis; notify the
physician if any of these signs are present
2. Elevate the extremity 30 degrees without allowing any pressure on the popliteal area
3. Encourage the use of antiembolism as prescribed; remove stocking twice a day to wash and inspect the
legs
4. Use an intermittent pulsatile compression device as prescribed
5. Perform passage range of motion exercises every 2 hours if the client is confined to bed rest
6. Encourage early ambulation, as prescribed
7. Do not allow the client to dangle the legs
8. Instruct the client not to sit in one position for an extended period of time
9. Administer anticoagulants such as Heparin sodium or warfarin (coumadin) as prescribed
URINARY RETENTION
 Urinary retention is an involuntary accumulation of urine in the bladder as a result of loss of
muscle tone
 It is caused by the effects of anesthetics or opioids analgesics and appears 6-8 hours after
surgery
Assessment
a. Inability to void
b. Restlessness and diaphoresis
c. Lower abdominal pain
d. Distended bladder
e. Hypertension
f. On percussion, bladder sounds like a drum
Interventions
1. Monitor for voiding
2. Assess for a distended bladder
3. Encourage ambulation when prescribed
4. Encourage fluid intake unless contraindicated
5. Assist the client to void by helping to stand
6. Provide privacy
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7. Pour warm water over the perineum or allow the client to hear running water to promote voiding
8. Contact the physician and catheterize the client as prescribed after all non-invasive technique have been
attempted
CONSTIPATION
 Constipation is an abnormal infrequent passage of stool
 When a client resumes a solid diet postoperatively, failure to pass stool within 48 hours may
indicate constipation
Assessment
a. Absence of bowel movements
b. Abdominal distention
c. Anorexia, headache, and nausea
Interventions
1. Assess bowel sounds
2. Encourage fluid intake up to 300 ml/day unless contraindicated
3. Encourage early ambulation
4. Encourage consumption of fiber foods unless contraindicated
5. Provide privacy and adequate time for bowel elimination
6. Administer stool softeners and laxative as prescribed
PARALYTIC ILEUS
 Paralytic ileus is failure of appropriate forward movement of bowel contents
 The condition may occur as a result of anesthetic medications or of manipulation of the bowel
during the surgical procedure
Assessment
a. Vomiting post-operatively
b. Abdominal distention
c. Absence of bowel sounds, bowel movements, and flatus
Figure 7 Paralytic ileus
Interventions
1. Monitor intake and out put
2. Maintain NPO status until bowel sounds return
3. Maintain patency of NGT if in place
4. Encourage early ambulation
5. Administer IV fluids or PN, as prescribed
6. Administer medications as prescribed to increase gastrointestinal motility and secretions
7. If ileus occurs, it is treated first non-surgically with bowel decompression by insertion of NGT
attached o intermittent or constant suction
WOUND INFECTION
 Wound infection may be caused by poor aseptic technique or a contaminated wound before
surgical exploration; existing client conditions such as diabetes mellitus or Immunocompromised
may place the client at risk
 Infection usually occurs 3 – 6 days after surgery
 Purulent material may exit from the drains or separated wound edges
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Assessment
a. Fever and chills
b. Warm, tender, painful, and inflamed incision site
c. Edematous skin at the incision and tight skin sutures
d. Elevated WBC count
Interventions
1. Monitor temperature
2. Monitor incision site for approximation of suture line, edema, or bleeding, and signs of infection
(REEDA: redness, erythema, ecchymosis, drainage, approximation of the wound edges) notify the
physician if signs of wound infection is present
3. Maintain patency of drains, and assess drainage amount, color, and consistency
4. Maintain asepsis and change the dressing as prescribe
5. Administer antibiotics as prescribed
WOUND DEHISCENCE AND EVISCERATION

 Wound Dehiscence is separation of the wound edges at the suture line; it is usually occurs 6 to 8
days after surgery
 Wound Evisceration is most common among obsess client, clients who had abdominal surgery;
or those who have poor wound healing ability
 Wound evisceration is an emergency
Figure 8 (A) wound dehiscence (B) wound evisceration
Assessment for Dehiscence

a. Increased drainage
b. Opened wound edges
c. Appearance of underlying tissues through the wound
Assessment for Evisceration

a. Discharges of serosanguineous fluid from a previously dry wound
b. The appearance of loops bowel or other abdominal contents through the wound
c. Clients reports feeling of popping sensation after coughing or turning
Interventions
1. Place the client in a low-fowlers position with the knees bent to prevent abdominal tension on an
abdominal suture line
2. Cover the wound with a sterile normal saline dressing
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3. Notify the physician
4. Prevent wound infection through strict asepsis

5. Administer anti-emetic as prescribed to prevent vomiting and further strain on the abdominal
incision
6. Instruct the client to splint the abdominal incision when coughing; this action assists in preventing or
worsening these complications
7. Prepare the client for surgery as necessary
Learning Episode:
 At the end of the topic the student shall have self-readiness. Engage in virtual discussions by
inquires, ideas and updates through synchronous and asynchronous sessions. Work and formulate
their graphic organizer on writing to learn work sheet and quiz.
 Long quiz
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Learning Module 2
INFECTIOUS AND INFLAMMATORY DISORDERS OF ADULTS
Intended Learning Outcomes: At the end of the learning log the students shall be able to
 Define and describe the definitions of each adult disorders
 Understand the concept and its pathophysiologic basis on client with infectious, inflammatory and
cellular aberrations, acute and chronic.
 Classify assessment parameters appropriate for determining the characteristics and severity of the
major symptoms of disease.
 Compare and contrast the diagnostic examination of different infectious, inflammatory and cellular
aberrations acute and chronic disorders.
 Identify and select appropriate medications and treatments for clients with disorders.
 Inferring the nursing interventions on the different disorders under inflammatory and cellular
aberrations disorders.
Time frame/class schedule:

Date and Time Class meeting Remarks
 Self-study on Infectious and  Students work on Graphic
Inflammatory Disorders of Organizer
Adults.  Contact teacher for
clarification of less
comprehend
topics/concept

 Accountable
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Concept notes
INFECTIOUS AND INFLAMMATORY DISORDERS

Authors: Linda Anne Silvestri
Sandra M. Nettina
Respiratory System
 In order to differentiate between the normal and abnormal assessment findings, an understanding of
respiratory function and the significance and the significance of abnormal diagnostic test result is
essential.
Primary functions of the respiratory system
 Provides oxygen for metabolism in the tissues

 Removes carbon dioxide, the waste product of metabolism
Secondary functions of the respiratory system
 Facilitates sense of smell

 Produces speech
 Maintains acid-base balance
 Maintains body water levels
 Maintains heat balance
The respiratory system is composed of the upper and lower respiratory tracts.
Upper respiratory tract

1. Nose: Humidifies, warms, and filters inspired air
2. Sinuses: Air-filled cavities within the hollow bones that surround the nasal passages and provide
resonance during speech
3. Pharynx
a. Passageway for the respiratory and digestive tracts located behind the oral and nasal cavities
b. Divided into the nasopharynx, oropharynx, and laryngopharynx
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4. Larynx
a. Located above the trachea, just below the pharynx at the root of the tongue; commonly
called the voice box
b. Contains two pairs of vocal cords, the false and true cords
c. The opening between the true vocal cords is the glottis.
d. The glottis plays an important role in coughing, which is the most fundamental defense
mechanism of the lungs.
5. Epiglottis
a. Leaf-shaped elastic structure attached along one end to the top of the larynx
b. Prevents food from entering the tracheobronchial tree by closing over the glottis during
swallowing
Lower respiratory tract

1. Trachea: Located in front of the esophagus; branches into the right and left mainstem bronchi at the carina
2.Mainstem bronchi
 Begin at the carina

 The right bronchus is slightly wider, shorter, and more vertical than the left bronchus.
 The mainstem bronchi divide into secondary or lobar bronchi that enter each of the five lobes of the
lung.
 The bronchi are lined with cilia, which propel mucus up and away from the lower airway to the
trachea, where it can be expectorated or swallowed.
3. Bronchioles
 Branch from the secondary bronchi and subdivide into the small terminal and respiratory bronchioles
 The bronchioles contain no cartilage and depend on the elastic recoil of the lung for patency.
 The terminal bronchioles contain no cilia and do not participate in gas exchange.
4. Alveolar ducts and alveoli
 Acinus (plural acini) is a term used to indicate all structures distal to the terminal bronchiole.
 Alveolar ducts branch from the respiratory bronchioles.
 Alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas
exchange.
 Type II alveolar cells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces
the surface tension in the alveoli; without surfactant, the alveoli would collapse.
5. Lungs
 Located in the pleural cavity in the thorax

 Extend from just above the clavicles to the diaphragm, the major muscle of inspiration
 The right lung, which is larger than the left, is divided into three lobes: the upper, middle, and lower
lobes.
 The left lung, which is narrower than the right lung to accommodate the heart, is divided into two
lobes.
 The respiratory structures are innervated by the phrenic nerve, the vagus nerve, and the thoracic
nerves.
 The parietal pleura lines the inside of the thoracic cavity, including the upper surface of the
diaphragm.
 The visceral pleura covers the pulmonary surfaces.
 A thin fluid layer, which is produced by the cells lining the pleura, lubricates the visceral pleura and
the parietal pleura, allowing them to glide smoothly and painlessly during respiration.
 Blood flows through the lungs via the pulmonary system and the bronchial system.
ASSESSMENT:
 Health history focuses on the physical and functional problems and the effects of the patient.
 Major signs and symptoms of respiratory disease are:
 Dyspnea (subjective feeling of difficult labored breathing).
 Cough (a reflex that protects the lungs from the accumulation of secretions or inhalation
of foreign bodies).
47
 Sputum production (it is the reaction of the lungs to any constant recurring irritants).
 Chest pain or discomfort
 Wheezing (high – pitched, musical sound heard mainly on expiration [ASTHMA] or
inspiration [BRONCHITIS]).
 Hemoptysis (expectoration of blood from the respiratory tract).
 Clubbing of Fingers:
- It is a sign of lung disease that is found in the patient with chronic hypoxic conditions.
 Cyanosis :
- A bluish discoloration of the skin, a very late indicator of hypoxia.
- Appears when there is at least 5g/dl of unoxygenated hemoglobin.
 Chest configuration:
- Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2.
4 main deformities of the chest associated with respiratory disease:
Barrel Chest  Occurs as a result of overinflation of the

lungs.
 There is an increase in the anteroposterior
diameter of the thorax.
Funnel Chest  (Pectus excavatum), occurs when there is
depression in the lower portion of the
sternum.
Pigeon Chest  (Pectus carinatum), occurs as a result of
displacement of the sternum.
Kyphoscoliosis  Characterized by elevation of the scapula
and a corresponding S- shaped spine.
DIAGNOSTIC EVALUATION
PULMONARY FUNCTION TESTS (PFTs)

 Tests used to evaluate lung mechanics, gas exchange, and acid-base disturbance through spirometry
measurements, lung volumes, and arterial blood gas levels.
Pre-procedure
 Determine whether an analgesic that may depress the respiratory function is being administered.
 Consult with the physician regarding holding bronchodilators before testing.
 Instruct the client to void before the procedure and to wear loose clothing.
 Remove dentures.
 Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test.
Post-procedure
 Client may resume normal diet and any bronchodilators and respiratory treatments that were held
before the procedure.
ARTERIAL BLOOD GAS STUDIES
 Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps indicate the
acid-base state and how well oxygen is being carried to the body.
Pre procedure
 Perform Allen’s test before drawing radial artery specimens.

 Have the client rest for 30 minutes before specimen collection to ensure accurate measurement of
body oxygenation.
 Do not turn off oxygen unless the ABG sample is prescribed to be drawn with the client breathing
room air.
 Avoid suctioning the client before drawing an ABG sample because the suctioning procedure will
deplete the client’s oxygen resulting in inaccurate ABG results.
Post procedure
48
 Place the specimen on ice.

 Note the client’s temperature on the laboratory form.
 Note the oxygen and type of ventilation that the client is receiving on the laboratory form.
 Apply pressure to the puncture site for 5 to 10 minutes or longer if the client is receiving
anticoagulant therapy or has a bleeding disorder.
 Transport the specimen to the laboratory within 15 minutes.
PULSE OXIMETRY
 Pulse oximetry is a noninvasive test that registers the oxygen saturation of the client’s hemoglobin.
 The capillary oxygen saturation (SaO2) is recorded as a percentage.
 The normal value is 96% to 100%.
 After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen pressure,
PaO2, on ABG testing), the reserve oxygen, that oxygen attached to the hemoglobin (SaO 2), is drawn
on to provide oxygen to the tissues.
 A pulse oximeter reading can alert the nurse to hypoxemia before clinical signs occur.
Procedure
 A sensor is placed on the client’s finger, toe, nose, ear lobe, or forehead to measure oxygen
saturation, which then is displayed on a monitor.
 Maintain the transducer at heart level.
 Do not select an extremity with an impediment to blood flow.
 A pulse oximetry reading lower than 91% necessitate physician notification; if the reading is lower
than 85%, oxygenation to body tissues is compromised, and a reading lower than 70% is life-
threatening.
SPUTUM STUDEIS
 Sputum is obtained for analysis to identify pathogenic organism and to determine whether
malignant cells are present.
 EXPECTORATION, is the usual method for collecting sputum specimen.
IMAGING STUDIES:
Pulmonary angiography
 An invasive fluoroscopic procedure in which a catheter is inserted through the antecubital or femoral
vein into the pulmonary artery or one of its branches
 Involves an injection of iodine or radiopaque contrast material
Pre-procedure
 Obtain informed consent.

 Assess for allergies to iodine, seafood, or other radiopaque dyes.
 Maintain NPO status of the client for 8 hours before the procedure.
 Monitor vital signs.
 Assess results of coagulation studies.
 Establish an intravenous access.
 Administer sedation as prescribed.
 Instruct the client to lie still during the procedure.
 Instruct the client that he or she may feel an urge to cough, flushing, nausea, or a salty taste
following injection of the dye.
 Have emergency resuscitation equipment available.
49
Post- procedure

 Avoid taking blood pressures for 24 hours in the extremity used for the injection.
 Monitor peripheral neurovascular status of the affected extremity.
 Assess insertion site for bleeding.
 Monitor for delayed reaction to the dye.
Chest X – Ray
 This may reveal an extensive pathologic process in the lungs in the absence of symptoms.
Computed Tomography
 Lungs are scanned in successive layers by a narrow beam x – rays. Images produced provide a cross
section view of the chest.
Laryngoscopy and bronchoscopy
 Direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope
Pre procedure

 Maintain NPO status for the client from midnight before the procedure.
 Obtain vital signs.
 Assess the results of coagulation studies.
 Remove dentures and eyeglasses.
 Prepare suction equipment.
 Establish an intravenous (IV) access as necessary and administer medication for sedation as
prescribed.
 Have emergency resuscitation equipment readily available.
Post procedure

 Maintain the client in a semi-Fowler’s position.
 Assess for the return of the gag reflex.
 Maintain NPO status until the gag reflex returns.
 Have an emesis basin readily available for the client to expectorate sputum.
 Monitor for bloody sputum.
 Monitor respiratory status, particularly if sedation has been administered.
 Monitor for complications, such as bronchospasm or bronchial perforation, indicated by facial or
neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax.
 Notify the physician if fever, difficulty in breathing, or other signs of complications occur following
the procedure.
Thoracentesis
 Removal of fluid or air from the pleural space via a transthoracic aspiration
Pre procedure
 Obtain vital signs.
 Prepare the client for ultrasound or chest radiograph, if prescribed, before procedure.
 Assess results of coagulation studies.
 Note that the client is positioned sitting upright, with the arms and shoulders supported by a table
at the bedside during the procedure (Fig. 58-1).
50
 If the client cannot sit up, the client is placed lying in bed toward the unaffected side, with the head
of the bed elevated.
 Instruct the client not to cough, breathe deeply, or move during the procedure.
Post procedure

 Monitor respiratory status.
 Apply a pressure dressing, and assess the puncture site for bleeding and crepitus.
 Monitor for signs of pneumothorax, air embolism, and pulmonary edema.
Biopsy
 May be performed to obtain lung tissue for examination to identify the nature of the lesion.
 For the identification of pathogenic organism.
UPPER RESPIRATORY TRACT DISORDERS
Viral Rhinitis (Common Cold)

 Most frequent viral infection.
 Characterized by nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise.
Management:
 Adequate fluid intake, rest, warm salt water gargles.
Obstructive Sleep Apnea (OSA)

 It is a disorders characterized by recurrent episodes of upper airway obstruction and a reduction in
ventilation.
Risk Factors:
 Obesity
 Male gender
 Postmenopausal status
 Advanced age
Manifestations:
 Snoring/snorting
 Gasping/choking
 Witnessed apneic episodes
Management:
 Weight loss
 Avoidance of alcohol
 CPAP (Continuous Positive Airway Pressure)
 BiPAP (Bilevel Positive Airway Pressure)
 CPAP is used to prevent airway collapse
 BiPAP makes breathing easier and results in a lower average airway pressure.
 Surgical procedure also may be performed to correct OAS (Simple Tonsillectomy may be effective).
51
LOWER RESPIRATORY TRACT DISORDERS
Atelectasis
 Refers to the closure or collapse of the alveoli.
 May be acute or chronic.
Manifestations:
 Increasing dyspnea
 Cough
 Sputum production
 Decreased breath sounds and crackles are heard over the affected area.
 TACHYPNEA, DYSPNEA, and MILD to MODERATE HYPOXEMIA are hallmarks of the severity of
atelectasis.
Preventions:
 Frequent turning
 Early mobilization
 Voluntary deep breathing (at least every 2 hours)
 Use of incentive spirometry
 Secretion management technique
Management:
 Goal is to improve ventilation and remove secretion.
 PEEP (Positive End – Expiratory Pressure), a simple mask and one way valve system that provides
varying amounts of expiratory resistance.
 Chest physical therapy (chest percussion and postural drainage)
 Nebulizer treatment with bronchodilator
 Bronchoscopy
PNUEMONIA
 Respiratory diseases are rampant today because it is easier spread in crowded areas. it is one of the
most common respiratory problems and it affects all stages of life.
 Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including
bacteria, mycobacteria, fungi, and viruses.
 The edema associated with inflammation stiffens the lungs, decreases lung compliances and vital
capacity, and causes hypoxemia.
 Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that
may predispose and place the patient at risk for microbial invasion.
Pathophysiology and Etiology

1. The organism gain access to the lungs through aspiration of oropharyngeal contents, by inhalation of
respiratory secretions from infected individuals, by way of the bloodstream, or from direct spread to
the lungs as a result of surgery or trauma.
2. Patients with bacterial pneumonia may have under lying disease that impairs host defense;
pneumonia arises from endogenous flora of the person whose resistance has been altered, or from
aspiration of oropharyngeal secretions.
a. Immunocompromised patients includes those receiving corticosteroids or immunosuppressants,
those with cancer, those being treated with chemotherapy or radiotherapy, those undergoing
organ transplantation, alcoholics, intravenous drug abusers, and those with human
immunedeficiency virus (HIV) disease and Acquired immunodeficiency syndrome (AIDS).
b. These people who had an increased chance of developing overwhelming infection. Infectious
agents includes aerobic and anaerobic gram negative bacilli, staphylococcus, Nocardia fungi,
Candida, viruses such as cytomegalovirus (CMV), pneumocystis carinii, reactivation of
tuberculosis, and others.
3. When bacterial pneumonia occurs in a healthy person, there usually is a history of preceding viral
illness.
4. Other predisposing factors include condition interfering with normal drainage of the lung as tumor,
general anesthesia and postoperative immobility, depression of the central nervous system from
drugs, neurologic disorders, or other conditions, and intubation or respiratory instrumentation.
52
5. Persons over 65 years old have a high mortality rate, even with antimicrobial therapy.
Pneumonia can be classified by microbiologic etiology, location, or type.
1. Microbiologic etiology—Pneumonia can be viral, bacterial, fungal, protozoan, mycobacterial,

mycoplasmal, or rickettsial in origin.
2. Location—Bronchopneumonia involves distal airways and alveoli; lobular pneumonia, part of a lobe;
and lobar pneumonia, an entire lobe.
Figure 9 of module 2: Locations of pneumonia
3. Classification
Pneumonia is classified into four:1. community-acquired pneumonia (CAP) and 2. hospital-acquired

pneumonia (HAP), 3. pneumonia in the immunocompromised host, and 4. aspiration pneumonia.
Community Hospital Acquired Pneumonia in the Aspiration Pneumonia:

Acquired Pneumonia (HAP) immunocompromised
Pneumonia (CAP) host:
-Occurs in the -AKA nosocomial -Examples are -refers to the pulmonary
community settings pneumonia Pneumocystis carinii consequence’s resulting
or within the 1st 48 pneumonia (PCP), fungal from entry of endogenous or
hours of -onset of pneumonia pneumonia and exogenous substances into
hospitalization symptoms are more mycobacterium the lower airway
than 48 hours after tuberculosis
admission to the -The most common form of
hospital -Patients who are aspiration pneumonia is
immunocompromised co a bacterial infection from
-HAP is the most lethal mmonly develop aspiration of bacteria that
nosocomial pneumonia from normally reside in the upper
infection and the organisms of low airways.
leading cause of death virulence.
in patients with such -Aspiration pneumonia may
infections occur in the community or
hospital setting.
-The causative -Common -Pneumonia in -Common pathogens are S.

agents for CAP that microorganisms that immunocompromised pneumonia, H.influenza,
53
needs are responsible for HAP hosts may be caused by and S. aureus.
hospitalization include Enterobacter the organisms also
include streptococc species, Escherichia observe in HAP and CAP.
us pneumoniae, H. coli, influenza, Klebsiel
influenza, Legionell la
a, species, Proteus, Serra
and Pseudomonas tia marcescens, S.
aeruginosa. aureus, and S.
pneumonia.
Clinical manifestation
 Pneumonia varies in its signs and symptoms depending on its type but it is not impossible to
diagnose a specific pneumonia through its clinical manifestations.
 Sudden onset; shaking chill; rapidly rising fever of 39.5 ℃ to 40 ℃ (101 ℉ to 105 ℉ ¿
 Cough productive of purulent sputum
 Pleuritic chest pain aggravated by respiration/coughing
 Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use of accessory muscles of
respiration, fatigue
 Rapid, bounding pulse
Diagnostic evaluation
1. Chest x-ray. Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple
abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or
diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may
be clear.
Chest x – ray may also show the presence/extent of pulmonary disease
2. Gram ‘s stain, culture, and sensitivity studies of the sputum may indicate offending organism.
3. Blood culture to detect bacteremia (bloodstream invasion) occurring with bacterial organism.
4. Immunologic test for detecting microbial antigens in serum, sputum, and urine.
Nursing interventions
 These nursing interventions, if implemented appropriately, would result in the achievement of the
goals of the management of pneumonia.
To improve airway patency:

 Removal of secretions. Secretions should be removed because retained secretions interfere with
gas exchange and may slow recovery.
 Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
 Humidification may loosen secretions and improve ventilation.
 Coughing exercises. An effective, directed cough can also improve airway patency.
 Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes
secretions.
To promote rest and conserve energy:
 Encourage avoidance of overexertion and possible exacerbation of symptoms.
 Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and
breathing and should change positions frequently to enhance secretion clearance and pulmonary
ventilation and perfusion.
To promote fluid intake:

 Fluid intake. Increase in fluid intake to at least 3L per day to replace insensible fluid losses.
To maintain nutrition:
54
 Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
 Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper
nutrition. Provide a high caloric, high protein diet with small, frequent meals.
To promote patient’s knowledge:
 Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and
symptoms, and the need for follow-up.
 Instruct patient about the factors that may have contributed to the development of the disease.
 Teach client using proper hand – washing techniques, disposing respiratory secretions properly,
and receiving vaccines as appropriate will assist in preventing the spread of infection.
TUBERCULOSIS
Pulmonary tuberculosis (PTB) is a chronic respiratory disease common among crowded and poorly ventilated
areas.
 An acute or chronic infection caused by Mycobacterium tuberculosis, tuberculosis is
characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and
cavitation.
 Tuberculosis is an infectious disease that primarily affects the lung parenchyma.
 The primary infectious agent, M. tuberculosis, is an acid-fast aerobic rod that grows slowly and is
sensitive to heat and ultraviolet light.
 Because M. tuberculosis is an aerobic bacterium, it primarily affects the pulmonary system,
especially the upper lobes where the oxygen content is highest, but it also affect other areas of
the body, such as the brain, intestines, peritoneum, kidney, joints, and liver.
 TB has an insidious onset, and many clients are not aware of symptoms until the disease is well
advanced
 Improper noncompliant use of treatment programs may cause the development of mutations in
a MULTI DRUG STRAIN OF TB (MDR-TB)
RISK FACTORS FOR TUBERCULOSIS

 child younger than 5 years old
 Drinking unpasteurized milk if the cow is infected with Bovine TB
 Homeless individuals or those from a lower socioeconomic group, minority group, or refugee group
 individuals in constant, frequent contact with untreated or undiagnosed individual
 individuals living in the crowded areas, such as long-term care facilities, prisons, and mental health
facilities
 Older client
 Individuals with malnutrition, infection, immune dysfunction or human immunodeficiency virus
infection immunosuppressed as a result of medication therapy individual who abuses alcohol or is IV
drug user.
Pathophysiology
Tuberculosis is a highly infectious, airborne disease.
 Inhalation. Tuberculosis begins when a susceptible person inhales mycobacteria and becomes
infected.
 Transmission. The bacteria are transmitted through the airways to the alveoli, and are also
transported via lymph system and bloodstream to other parts of the body.
 Defense. The body’s immune system responds by initiating an inflammatory reaction and
phagocytes engulf many of the bacteria, and TB-specific lymphocytes lyse the bacilli and normal
tissue.
 Protection. Granulomas new tissue masses of live and dead bacilli, ate surrounded by
macrophages, which form a protective wall.
55
 Ghon’s tubercle. They are then transformed to a fibrous tissue mass, the central portion of which
is called a Ghon tubercle.
 Scarring. The bacteria and macrophages turns into a cheesy mass that may become calcified and
form a collagenous scar.
 Dormancy. At this point, the bacteria become dormant, and there is no further progression of
active disease.
 Activation. After initial exposure and infection, active disease may develop because of a
compromised or inadequate immune system response.
CLASSIFICATION
Data from the history, physical examination, TB test, chest x-ray, and microbiologic studies are used to
classify TB into one of five classes.
 Class 0. There is no exposure or no infection.

 Class 1. There is an exposure but no evidence of infection.
 Class 2. There is latent infection but no disease.
 Class 3. There is a disease and is clinically active.
 Class 4. There is a disease but not clinically active.
 Class 5. There is a suspected disease but the diagnosis is pending.
After an incubation period of 4 to 8 weeks, TB is usually asymptomatic in primary infection.
 Nonspecific symptoms, Nonspecific symptoms may be produced such as fatigue, weakness,
anorexia, weight loss, night sweats, and low-grade fever, with fever and night sweats as the
typical hallmarks of tuberculosis.
 Cough, The patient may experience cough with mucopurulent sputum.
 Hemoptysis, Occasional hemoptysis or blood on the saliva is common in TB patients.
 Chest pains, The patient may also complain of chest pain as a part of discomfort.
 Lethargy
 Weight loss
 Low grade fever
 Chills
 Night sweats
Diagnostic evaluation
 Sputum smear and culture – detection of acid fast bacilli (AFB) in stained smears is the first
bacteriologic clue of TB. Obtain first in the morning on three consecutive days.
 Sputum culture – a positive culture for M. tuberculosis confirms a diagnosis of TB.
 Chest x – ray may also show the presence/extent of pulmonary disease
 Tuberculin skin test (PPD or Montoux test)
o A positive montoux reaction does not mean that active disease is present but indicates
previous exposure to TB of the presence of inactive disease once the test result is positive, it
will be positive in any future test.
o Purified Protein Derivative containing 5 tuberculin units is administered ID in the forearm
o An area of induration measuring of 10 mm in diameter, 48-72 hours after injection. Indicate
that the individual has been exposed to TB
o For individuals with HIV virus infection or who are immunosuppressed, a reaction of 5 mm
or more is considered positive
o Once an individual’s skin test is positive, a chest x ray is necessary to rule out TB
Medical management
56
Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12 months.
 First line treatment. First-line agents for the treatment of tuberculosis are
1. isoniazid (INH)
2. rifampin (RIF)
3. ethambutol (EMB)
4. pyrazinamide
 Active TB. For most adults with active TB, the recommended dosing includes the administration
of all four drugs daily for 2 months, followed by 4 months of INH and RIF.
 Latent TB. Latent TB is usually treated daily for 9 months.
 Treatment guidelines. Recommended treatment guidelines for newly diagnosed cases of
pulmonary TB have two parts: an initial treatment phase and a continuation phase.
 Initial phase. The initial phase consists of a multiple-medication regimen of INH, rifampin,
pyrazinamide, and ethambutol and lasts for 8 weeks.
 Continuation phase. The continuation phase of treatment include INH and rifampin or INH and
rifapentine, and lasts for an additional 4 or 7 months.
 Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for 6 to 12 months.
 DOT. Directly observed therapy may be selected, wherein an assigned caregiver directly observes
the administration of the drug.
PHARMACOLOGIC AGENT
The first line antituberculosis medications include:•
 Isoniazid (INH). INH is a bactericidal agent that is used as prophylaxis for neuritis, and has side
effects of peripheral neuritis, hepatic enzyme elevation, hepatitis, and hypersensitivity.
 Rifampin (Rifadin). Rifampin is a bactericidal agent that turns the urine and other body
secretions into orange or red, and has common side effects of hepatitis, febrile reaction,
purpura, nausea, and vomiting.
 Pyrazinamide. Pyrazinamide is a bactericidal agent which increases the uric acid in the blood and
has common side effects of hyperuricemia, hepatotoxicity, skin rash, arthralgias, and GI distress.
 Ethambutol (Myambutol). Ethambutol is a bacteriostatic agent that should be used with caution
with renal disease, and has common side effects of optic neuritis and skin rash.
Nursing intervention
Nursing interventions for the patient include:
 Promoting airway clearance. The nurse instructs the patient about correct positioning to
facilitate drainage and to increase fluid intake to promote systemic hydration.
 Adherence to the treatment regimen. The nurse should teach the patient that TB is a
communicable disease and taking medications is the most effective means of preventing
transmission.
 Promoting activity and adequate nutrition. The nurse plans a progressive activity schedule that
focuses on increasing activity tolerance and muscle strength and a nutritional plan that allows for
small, frequent meals.
 Preventing spreading of tuberculosis infection. The nurse carefully instructs the patient about
important hygienic measures including mouth care, covering the mouth and nose when coughing
and sneezing, proper disposal of tissues, and handwashing.
 Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use of a private
room with negative pressure in relation to surrounding areas and a minimum of six air changes
per hour.
 Disposal. Place a covered trash can nearby or tape a lined bag to the side of the bed to dispose of
used tissues.
57
 Monitor adverse effects. Be alert for adverse effects of medications.
CLIENT EDUCATION: TB
 instruct the client about the need for  instruct the client and the family member
adequate nutrition and well balance diet to about through hand washing
promote wound healing and to prevent  inform the client that the sputum culture is
recurrent of infection needed every 2 to 4 weeks once
 instruct the client to increase the intake of medication therapy is initiated
food rich in vitamin C, iron, and protein  Inform the client that when the result of 3
 Instruct the client to cover the mouth and sputum cultures are negative, the client is
nose when coughing, or sneezing and to no longer considered infectious and usually
put used tissue into plastic bags can return to former employment
 Instruct the client regarding the
importance of compliance with treatment,
follow up care, sputum cultures as
prescribed
INFLUENZA
 Also known as the seasonal flu; highly contagious acute viral respiratory infection.
 Maybe cause by several viruses
 Yearly vaccination is recommended to prevent the disease, especially for those who are older than
50 years of age, individuals with chronic illness or who are immunocompromised, those living in
institutions, and health care personnel providing direct care to clients (the vaccination is
contraindicated in individuals with egg allergies).
AVIAN INFLUENZA A (H5N1)
 Affects birds; does not usually affects humans; however, human cases have been reported in some
countries.
 An H5N1 vaccine has been developed for use if a pandemic virus were emerge.
 Reported symptoms are similar to those that are associated with influenza.
 Prevention measures include thoroughly cooking poultry products, avoiding contact with animals,
frequent and proper handwashing, and cleaning and disinfecting surfaces that have become
contaminated with secretions.
SWINE FLU (H1N1) INFLUENZA
 A strain of flu that consists of genetic materials from swine, avian, and human influenza viruses.
 In 2009 H1N1 was spreading fast around the world, so the World Health Organization called it a
pandemic. Since then, people have continued to get sick from swine flu, but not as many.
Mode of transmission
 Droplet
o The same way as the seasonal flu. When people who have it cough or sneeze, they spray tiny
drops of the virus into the air. If you come in contact with these drops, touch a surface (like
a doorknob or sink) where the drops landed, or touch something an infected person has
recently touched, you can catch H1N1 swine flu.
Signs and symptoms

58
Figure 10: Symptoms of H1N1 – 2009
 Cough  Headache
 Fever  Chills
 Sore throat  Fatigue
 Stuffy or runny nose  Vomiting and diarrhea commonly occur
 Body aches
 Like the regular flu, swine flu can lead to more serious problems including pneumonia,
a lung infection, and other breathing problems. And it can make an illness
like diabetes or asthma worse. If you have symptoms like shortness of breath, severe vomiting, pain
in your belly or sides, dizziness, or confusion, call your doctor right away.
Preventions
 The Centers for Disease Control and Prevention recommends annual flu vaccination for everyone age
6 months or older. Flu vaccines for 2018-19 protect against the viruses that cause swine flu and one
or two other viruses that are expected to be the most common during flu season.
 The vaccine is available as an injection or a nasal spray. The nasal spray is approved for use in healthy
people 2 through 49 years of age who are not pregnant. The nasal spray isn't recommended for
some groups, such as pregnant women, children between 2 and 4 years old with asthma or
wheezing, and people who have compromised immune systems.
These measures also help prevent flu and limit its spread:
o Stay home if you're sick. If you have the flu, you can give it to others. Stay home for at least 24 hours
after your fever is gone.
o Wash your hands thoroughly and frequently. Use soap and water, or if they're unavailable, use an
alcohol-based hand sanitizer.
o Contain your coughs and sneezes. Cover your mouth and nose when you sneeze or cough. Wear a face
mask if you have one. To avoid contaminating your hands, cough or sneeze into a tissue or the inner
crook of your elbow.
o Avoid contact. Stay away from crowds if possible. And if you're at high risk of complications from the
flu — for example, you're younger than 5 or you're 65 or older, you're pregnant, or you have a chronic
medical condition such as asthma — consider avoiding swine barns at seasonal fairs and elsewhere.
EBOLA VIRUS
 Is a rare but deadly virus that causes fever, body aches, and diarrhea, and sometimes bleeding inside and
outside the body.
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 As the virus spreads through the body, it damages the immune system and organs. Ultimately, it causes
levels of blood-clotting cells to drop. This leads to severe, uncontrollable bleeding.
 The disease was known as Ebola hemorrhagic fever but is now referred to as Ebola virus.
 It kills up to 90% of people who are infected.
Signs and symptoms
 fever  Other symptoms can include rash, red

 headache eyes, hiccups, cough, sore throat, chest
 joint and muscle aches pain, difficulty breathing or swallowing,
 weakness and internal or external bleeding.
 diarrhea  Symptoms of EVD can appear from two to
 vomiting 21 days after exposure, though eight to
 stomach pain ten days is common.
 lack of appetite  An individual without symptoms is NOT
 abnormal bleeding contagious.
Mode of transmission
 EVD is transmitted through direct contact with an infected person’s bodily fluids or exposure via
contaminated needles. It is not transmitted through water, air, or food.
Diagnostic test
 Diagnosis is difficult because early symptoms are nonspecific. If EVD is suspected, laboratory testing
includes ELISA, IgM ELISA, PCR, virus isolation, and IgM and IgG antibodies (used later in the course
of EVD).
Treatment
 Treatment of EVD involves supportive therapy related to maintaining fluid and electrolyte balance,
oxygenation, blood pressure support, and treating complications.
CDC RECOMMENDATIONS FOR MANAGING PATIENTS

 Be alert for EVD in patients with fever of 38.6 degrees Celsius (101.5 degrees Fahrenheit); symptoms
such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained
hemorrhage; and risk factors within the past 3 weeks (travel history to affected countries, exposure
to individual with EVD, or direct handling of bats, rodents, or primates from disease-endemic
countries).
 EVD patients should be isolated in a private room with standard, contact, and droplet precautions in
place.
 The CDC has specific recommendations related to infection prevention and control, including the use
of the following personal protective equipment (PPE):
o Double gloves
o Waterproof boot covers that go to at least mid-calf or waterproof leg covers
o Single use fluid resistant or imperable gown that extends to at least mid-calf or coverall
without intergraded hood.
o Respirators, including either N95 respirators or powered air purifying respirator (PAPR)
o Single-use, full-face shield that is disposable
o Surgical hoods to ensure complete coverage of the head and neck
o Apron that is waterproof and covers the torso to the level of the mid-calf should be used if
Ebola patients have vomiting or diarrhea
 Visitors should be restricted. Exceptions may be considered on an individual basis, and then visitors
should be trained and a logbook kept of all who enter the room.
CORONA VIRUS 2019 (COVID-19)

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Coronavirus Disease 2019 (COVID-19) identified as the cause of an outbreak first discovered at a local
seafood /wild animal market in Wuhan, China. The COVID-19 has been declared by the World Health
Organization (WHO) as a pandemic where it is reported that around 5,000,000 people are affected in more
than 200 countries around the world.
 Coronavirus 2019 (COVID-19) is a disease caused by a new strain of coronavirus called severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) that can cause symptoms from common cold to
more severe disease such as pneumonia and eventually it may lead to death especially those in
vulnerable groups such as the elderly, the very young, and people with an underlying chronic health
condition.
Pathophysiology
 COVID-19 is a betacoronavirus, like MERS and SARS, all of which have their origins in bats.
 The sequences from US patients are similar to the one that China initially posted, suggesting a
likely single, recent emergence of this virus from an animal reservoir.
 When person-to-person spread has occurred with MERS and SARS, it is thought to have
happened mainly via respiratory droplets produced when an infected person sneezes, similar to
how influenza and other respiratory pathogens spread.
 Most coronaviruses infect animals, but not people; in the future, one or more of these other
coronaviruses could potentially evolve and spread to humans, as has happened in the past.
 Many of the patients have direct or indirect contact with the Wuhan Huanan Seafood Wholesale
Market that is believed to be the original place of the outbreak of COVID-19.
 Due to the possibility of transmission from animal to human, CoVs in livestock and other animals
including bats and wild animals sold on the market should be constantly monitored.
 In addition, more and more evidence indicates the new virus COVID-19 is spread via the route of
human-to-human transmission because there are infections of people who did not visit Wuhan
but had close contact with family members who had visited Wuhan and got infected.
Causes
Coronaviruses are named for the crown-like spikes on their surface.
 There are four main sub-groupings of coronaviruses, known as alpha, beta, gamma, and delta.
 Human coronaviruses were first identified in the mid-1960s.
 The seven coronaviruses that can infect people are 229E (alpha coronavirus), NL63 (alpha
coronavirus, OC43 (beta coronavirus), and HKU1 (beta coronavirus).
 Other human coronaviruses are MERS-CoV, SARS-CoV, and COVID-19.
Statistics and incidences

An outbreak of pneumonia of unknown etiology in Wuhan City was initially reported to WHO on December
31, 2019.
 Chinese health authorities have confirmed more than 40 infections with a novel coronavirus as
the cause of the outbreak.
 Reportedly, most patients had epidemiological links to a large seafood and animal market; the
market was closed on January 1, 2020.
 Globally, there are 5,030,914 confirmed cases and 326,182 deaths confirmed as of May 21, 2020.
 The United States has the highest number of coronavirus cases in the world with more than 1.5
million cases (New York City being the most affected).
 Most countries have declared nationwide lockdowns and have restricted travel.
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 International conveyance cases identified on the Diamond Princess cruise ship currently in
Japanese territorial waters have reached 712.
For confirmed COVID-19 infections, reported illnesses have ranged from people being mildly sick to people
being severely ill and dying; these symptoms may appear in as few as 2 days or as long as 14 after exposure
based on what has been seen previously as the incubation period of MERS viruses.
 Fever
 Dry cough
 Shortness of breath
Other symptoms may include:
 Sore throat
 Runny nose
 Diarrhea
 Fatigue/tiredness
 Difficulty of breathing (in severe cases)
Assessment and diagnostic findings
At this time, diagnostic testing for COVID-19 can be conducted only at CDC
 To increase the likelihood of detecting infection, CDC recommends collection of three specimen
types: lower respiratory, upper respiratory, and serum specimens for testing.
 CDC has deployed multidisciplinary teams to Washington, Illinois, California, and Arizona to assist
health departments with clinical management, contact tracing, and communications.
 CDC has developed a real-time Reverse Transcription-Polymerase Chain Reaction (rRT-PCR) test
that can diagnose COVID-19 in respiratory serum samples from clinical specimens.
 Currently, testing for this virus must take place at CDC, but in the coming days and weeks, CDC
will share these tests with domestic and international partners.
 CDC uploaded the entire genome of the virus from all five reported cases in the United States to
GenBank.
 CDC is also growing the virus in cell culture, which is necessary for further studies, including for
additional genetic characterization.
Medical management
The best way to prevent infection is to avoid being exposed to this coronavirus.
 Hand hygiene. Wash hands often with soap and water for at least 20 seconds; if water and soap
are not available, use an alcohol-based hand sanitizer.
 Keep hands off your face. Avoid touching the eyes, nose, and mouth with unwashed hands.
 Maintain social distancing. Avoid close contact with people at least 3 feet (1 meter) who are sick,
and stay at home when you are sick.
 Proper cough and sneeze etiquette. Cover your cough or sneeze with a tissue, then throw the
tissue in the trash.
 Supportive care. People infected with COVID-19 should receive supportive care to help relieve
symptoms.
 Severe cases. For severe cases, treatment should include care to support vital organ functions.
For Healthcare Workers

 Healthcare workers are the very people who will be working day-and-night to treat and assist
coronavirus patients are among the most exposed population for becoming infected. The protection
of vulnerable members is one of the priorities for the response to COVID19 outbreaks. Occupational
health services in healthcare facilities play a vital role in helping, supporting, and ensuring that
workplaces are safe and healthy and addressing health problems when they arise. WHO emphasizes
the rights and responsibilities of health workers, including explicit criteria required to preserve
occupational safety and health.
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Health worker rights include that employers and managers in health facilities:
 Assume overall responsibility to ensure that all necessary preventive and protective measures
are taken to minimize occupational safety and health risks.
 Provide information, instruction, and training on occupational safety and health, including;
o Refresher training on infection prevention and control (IPC)
o Use, putting on, taking off and disposal of personal protective equipment (PPE).
 Provide adequate IPC and PPE supplies (masks, gloves, goggles, gowns, hand sanitizer, soap and
water, cleaning supplies) in sufficient quantity to healthcare or other staff caring for suspected or
confirmed COVID-19 patients, such that workers do not incur expenses for occupational safety
and health requirements.
 Familiarize personnel with technical updates on COVID-19 and provide appropriate tools to
assess, triage, test and treat patients and to share infection prevention and control information
with patients and the public.
 As needed, provide appropriate security measures for personal safety.
 Provide a blame-free environment for workers to report on incidents, such as exposures
to blood or bodily fluids from the respiratory system or to cases of violence, and to adopt
measures for immediate followup, including support to victims.
 Advise workers on self-assessment, symptom reporting and staying home when ill.
 Maintain appropriate working hours with breaks.
 Consult with health workers on occupational safety and health aspects of their work and notify
the labor inspectorate of cases of occupational diseases.
 Not be required to return to a work situation where there is continuing or serious danger to life
or health, until the employer has taken any necessary remedial action.
 Allow workers to exercise the right to remove themselves from a work situation that they have
reasonable justification to believe presents an imminent and serious danger to their life or
health. When a health worker exercises this right, they shall be protected from any undue
consequences.
 Honor the right to compensation, rehabilitation, and curative services if infected with COVID-19
following exposure in the workplace. This would be considered occupational exposure and
resulting illness would be considered an occupational disease.
 Provide access to mental health and counseling resources.
 Enable co-operation between management and workers and/or their representatives.
Health workers should:
 Follow established occupational safety and health procedures, avoid exposing others to health
and safety risks and participate in employer-provided occupational safety and health training.
 Use provided protocols to assess, triage and treat patients.
 Treat patients with respect, compassion, and dignity.
 Maintain patient confidentiality.
 Swiftly follow established public health reporting procedures of suspected and confirmed cases.
 Provide or reinforce accurate infection prevention and control and public health information,
including to concerned people who have neither symptoms nor risk.
 Put on, use, take off and dispose of personal protective equipment properly.
 Self-monitor for signs of illness and self-isolate or report the illness to managers, if it occurs.
 Advise management if they are experiencing signs of undue stress or mental health challenges
that require support interventions.
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 Report to their immediate supervisor any situation which they have reasonable justification to
believe presents an imminent and serious danger to life or health.
Pharmacologic agent
 There is no specific antiviral medication yet is recommended for COVID-19 infection, and no current
vaccine to prevent it.
Nursing management
Nursing management for patients with COVID-19 infection include the following:
 Travel history. Health care providers should obtain a detailed travel history for patients being
evaluated with fever and acute respiratory illness.
 Physical examination. Patients who have fever, cough, and shortness of breath and who has
traveled to Wuhan, China recently must be placed under isolation immediately.
Nursing diagnosis
Based on the assessment data, the major nursing diagnosis for a patient with COVID-19 are:
 Infection related to failure to avoid pathogen secondary to exposure to COVID-19.

 Deficient knowledge related to unfamiliarity with disease transmission information.
 Hyperthermia related to increase in metabolic rate.
 Impaired breathing pattern related to shortness of breath.
 Anxiety related to unknown etiology of the disease.
NURSING CARE PLANS AND GOALS
The following are the major nursing care planning goals for COVID-19:
 Prevent the spread of infection.

 Learn more about the disease and its management.
 Improve body temperature levels.
 Restore breathing pattern back to normal.
 Reduce anxiety.
Listed below are the nursing interventions for a patient diagnosed with COVID-19:
 Monitor vital signs. Monitor the patient’s temperature; the infection usually begins with a high
temperature; monitor the respiratory rate of the patient as shortness of breath is another
common symptom.
 Monitor O2 saturation. Monitor the patient’s O2 saturation because respiratory compromise
results in hypoxia.
 Maintain respiratory isolation. Keep tissues at the patient’s bedside; dispose secretions
properly; instruct the patient to cover mouth when coughing or sneezing; use masks, and advise
those entering the room to wear masks as well; place respiratory stickers on chart, linens, and so
on.
 Enforce strict hand hygiene. Teach the patient and folks to wash hands after coughing to reduce
or prevent the transmission of the virus.
 Manage hyperthermia. Use appropriate therapy for elevated temperature to maintain
normothermia and reduce metabolic needs.
 Educate the patient and folks. Provide information on disease transmission, diagnostic testing,
disease process, complications, and protection from the virus.
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Evaluation
Nursing goals are met as evidenced by:
 Patient was able to prevent the spread of infection.

 Patient was able to learn more about the disease and its management.
 Patient was able to improve body temperature levels.
 Patient was able to restore breathing pattern back to normal.
 Patient was able to reduce anxiety.
DOCUMENTATION GUIDELINES
Documentation guidelines for a patient with COVID-19 include the following:
 Individual findings, including factors affecting, interactions, nature of social exchanges, specifics
of individual behavior.
 Cultural and religious beliefs, and expectations.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.
Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

 MERS or Middle East respiratory syndrome is a zoonotic disease (spreads from animals to people)
that can cause severe respiratory illness. It was first identified in Saudi Arabia in 2012 and has
infected more than 2,000 individuals worldwide.
 Middle East respiratory syndrome (MERS) is caused by a novel coronavirus (Middle East respiratory
syndrome coronavirus, or MERS‐CoV).
 Through first reported in Saudi Arabia, it was later identified that the first known cases of MERS
occurred in Jordan in April 2012.
 Most MERS patients developed severe respiratory illness with symptoms of fever, cough, and
shortness of breath.
 A large MERS outbreak occurred in the Republic of South Korea linked to a traveler from the
Arabian Peninsula in 2015.
 Travel-associated cases have been identified in Algeria, Austria, China, Egypt, France, Germany,
Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia, Turkey,
United Kingdom (UK), and United States (US).
 CDC has published guidance for health departments and healthcare infection-control programs
for investigating potential cases of MERS and preventing its spread.
Pathophysiology
 MERS is considered an international threat to public health.
 Compared with severe acute respiratory syndrome coronavirus (SARS-Cov), MERS-CoVcan

establish infection in monocyte-derived macrophages (MDMs) and macrophages.
 The virus induces the release of proinflammatory cytokines, leading to severe inflammation and
tissue damage, which may manifest clinically as severe pneumonia and respiratory failure. [
 Vascular endothelial cells located in the pulmonary interstitium may also be infected by MERS-
CoV, and, because MERS-CoV receptor DPP4 is expressed in different human cells and tissues,
dissemination of the infection may occur.
 Interestingly, lymphopenia has been noted in most patients infected with MERS-CoV, as was
noted in SARS infections.
 This is due to cytokine-induced immune cell sequestration and release and induction of
monocyte chemotactic protein-1 (MCP-1) and interferon-gamma-inducible protein-10 (IP-10),
which suppresses the proliferation of human myeloid progenitor cells.
Causes
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 Coronaviruses are the largest of all RNA viruses, with positive-sense single-stranded RNA genomes of
26-32 kb.
 Betacoronavirus. MERS-CoV is a recently discovered betacoronavirus of lineage C that was first

reported in Saudi Arabia in 2012; the exact origin of this novel coronavirus is still unknown;
MERS-CoV is closely related to two coronaviruses of the same lineage found in bats, which may
indeed be its wild reservoir.
 Dromedary camels. Specific mechanisms for transmission from animals are unclear but appear to
involve contact with dromedary camels or their urine, as well as the consumption of their
undercooked meat or unpasteurized dairy products.
Statistics and Incidences
About 3 or 4 out of every 10 patients reported with MERS have died.
 In May 2014, CDC confirmed two unlinked imported cases of MERS in the United States—one to
Indiana, the other to Florida; both cases were among healthcare providers who lived and worked
in Saudi Arabia; both traveled to the U.S. from Saudi Arabia, where scientists believe they were
infected.
 Since 2012, 2,374 laboratory-confirmed cases of infection with MERS-CoV have been reported to
the World Health Organization (WHO), including at least 823 related deaths.
 Twenty-seven countries have reported MERS cases.
 On the Arabian Peninsula, countries include Bahrain, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar,
Saudi Arabia, United Arab Emirates (UAE), and Yemen.
 Other countries reporting travel-associated MERS include Algeria, Austria, China, Egypt, France,
Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Thailand, Tunisia,
Turkey, United Kingdom (UK), and the United States.
 The vast majority of these cases have so far occurred in the Kingdom of Saudi Arabia.
 The largest MERS outbreak outside of Saudi Arabia occurred in 2015 in the Republic of Korea; the
outbreak involved 186 confirmed cases and caused 36 deaths.
 The outbreak sparked quarantine of more than 5,000 individuals and the closure of 2,000 schools
before ending.
Physical examination findings associated with MERS-CoV infection are similar to those presenting with
any flu-like symptoms, including the following:
 Fever
 Rhinorrhea, mostly clear
 Pulmonary findings, including hypoxemia, rhonchi, and rales (some patients may have a normal
auscultation)
 Tachycardia
 Hypotension may occur with severe illness, reflecting systemic inflammatory response syndrome
Assessment and diagnostic findings
Most state laboratories are approved to test for Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
using CDC’s rRT-PCR assay.
 rRT-PCR assay. FDA issued an Emergency Use Authorization (EUA) on June 5, 2013, to authorize
use of CDC’s 2012 real-time reverse transcription–PCR assay to test for MERS-CoV in clinical
respiratory, serum, and stool specimens.
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 Serology. Serologic testing for MERS-CoV is available as a research/surveillance test from the
CDC; it is not considered a diagnostic test but may offer valuable epidemiologic data; it must be
ordered in consultation and with approval of CDC via the EOC.
 Laboratory studies. Laboratory findings at presentation may include leukopenia, lymphopenia,
thrombocytopenia, and elevated lactate dehydrogenase levels; these are most likely with
increasing severity of illness.
 Imaging studies. Chest imaging findings are abnormal in more than 80% of MERS cases; ground-
glass opacity (GGO) is found in over 60% of chest radiographs, with about 20% incidence of
consolidation; some infiltrates may be nodular.
Medical management
Management of the Middle East respiratory syndrome (MERS) coronavirus (MERS-CoV) infection is
supportive; this includes hydration, antipyretic, analgesics, respiratory support, and antibiotics if needed for
bacterial superinfection.
 Consultations. Upon suspicion of MERS, the patient should be placed in an airborne infection
isolation room (AIIR) with a minimum of 12 air exchanges per hour, and personnel protection
equipment (PEP) appropriate for contact and airborne precautions (gown, gloves, goggles, and N-
95 respirator mask or powered air purifier respirator [PAPR]) should be used.
 Medical care. Medical care is supportive and depends on the severity of illness.
 Prevention. No MERS-CoV vaccine is commercially available; prevention of infection in areas
where MERS-CoV is being actively transmitted requires avoidance of potentially infectious
secretions and careful attention to hand and respiratory hygiene.
PHARMACOLOGIC MANAGEMENT
No medications have been approved for the treatment of coronavirus infections. Clinical trials are needed to
establish any benefit from ribavirin and/or interferon alfa
Nursing management
 Nursing care for a patient with MERS-CoV include the following:
Nursing Assessment
 Assessment of a patient with MERS-CoV include:

 History. A high index of suspicion is necessary to suspect MERS, and a travel and exposure history is
essential to the diagnosis; keys to the case definition of MERS is a history of residence or travel in the
Arabian Peninsula, in countries where MERS-CoV is known to be circulating in dromedary camels, or
where human infections have recently occurred and exposure within the incubation period of 14 days.
 Physical exam. Clinical manifestation is indistinguishable from other common respiratory viruses and
may range from no symptoms to rapidly progressive multiorgan failure and death.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis for a patient with MERS-CoV include the
following:
 Infection related to failure to avoid pathogen secondary to exposure to MERS-CoV.

 Deficient knowledge related to unfamiliarity with disease transmission information.
 Hyperthermia related to increase in metabolic rate.
 Ineffective airway clearance related to excessive production of pulmonary secretions.
 Anxiety related to unknown etiology of the disease.
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Nursing Care Planning and Goals
The major nursing care plan goals for a patient with MERS-CoV are:
 Prevent the spread of infection.

 Learn more about the disease and its management.
 Reduce increase in temperature.
 Provide a patent airway.
 Reduce anxiety.
Nursing Interventions
Nursing interventions for the patient with MERS-CoV include the following:
 Monitor vital signs. Monitor the patient’s temperature; the infection usually begins with a high
temperature; monitor the respiratory rate of the patient as shortness of breath is another
common symptom.
 Educate the patient and folks. Include the patient and folks in creating the teaching plan,
beginning with establishing objectives and goals for learning at the beginning of the session;
provide clear, thorough, and understandable explanations and demonstrations; and give
information with the use of media.
 Reduce increase in temperature. Adjust and monitor environmental factors like room
temperature and bed linens as indicated; encourage ample fluid intake by mouth; eliminate
excess clothing and covers, and give antipyretic medications as prescribed.
 Ensure patent airway. Teach the patient the proper ways of coughing and breathing. (e.g., take a
deep breath, hold for 2 seconds, and cough two or three times in succession); position the
patient upright if tolerated, and encourage patient to increase fluid intake to 3 liters per day
within the limits of cardiac reserve and renal function.
 Reduce anxiety. Use presence, touch (with permission), verbalization, and demeanor to remind
patients that they are not alone and to encourage expression or clarification of needs, concerns,
unknowns, and questions; accept patient’s defenses; do not dare, argue, or debate; converse
using a simple language and brief statements; and allow the patient to talk about anxious
feelings and examine anxiety-provoking situations if they are identifiable.
Evaluation
Nursing evaluation of goals for a patient with MERS-COV are met as evidenced by:
 Prevention of the spread of infection.

 Acquired knowledge about the disease and its management.
 Reduction in levels of temperature.
 Patent airway achieved.
 Reduction in anxiety.
Documentation Guidelines
Documentation guidelines for a patient with MERS-CoV include the following:
 Individual findings, including factors affecting, interactions, nature of social exchanges, specifics
of individual behavior.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.
ACUTE RESPIRATORY FAILURE

 Sudden and life-threatening deterioration of the gas exchange function of the lungs.
Etiology
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 Airway obstruction
 Restrictive lung disease
 Central nervous system disorder, such as head trauma or stroke
 Drug overdose
 Anesthesia and surgical procedures
Pathophysiology
 ARF occurs when O2 and CO2 exchange in normal lungs fails to full fill the oxygen needs of the body,
causing alveolar hypoventilation. Effects include hypoxia (partial pressure of arterial oxygen [PaO 2] <
80mmHg) with or without hypercapnia (partial pressure of arterial carbon dioxide [PacO 2 ] > 45
mmHg.
Manifestations
 Dyspnea
 Tachypnea
 Tachycardia
 Headache
 Cyanosis
 Anxiety, confusion and restlessness
 Decreased or absent breath sounds
 Adventitious breath sounds such as crackles and wheezing
Diagnostic Test
 Arterial blood gas studies
 ECG
 Chest radiograph
Nursing management
 Correct the underlying cause
 Restore and maintain patent airway by suctioning or performing endotracheal intubation as ordered.
 Administer oxygen therapy to maintain adequate alveolar ventilation.
 Monitor ABG, pulse oximetry, vital signs.

 Assess the patient understanding of the management and initiate some form of communication (to
express concerns and needs).
ACUTE RESPIRATORY DISTRESS SYNDROME

 A severe form of acute lung injury.
 Characterized by:
a. A sudden and progressive pulmonary edema.
b. Increasing bilateral infiltrates (chest x – ray).
c. Hypoxemia unresponsive to oxygen supplement (regardless of the amount of PEEP).
d. The interstitial edema causes compression and obliteration of the terminal airways
and leads to reduced lung volume and compliance.
e. The chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema
may not be noted until there is a 30% increase in fluid content
 Causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, disseminated
intravascular coagulation, drug ingestion, aspiration, and inhalation of toxic substances.
Assessment
 Tachypnea
 Dyspnea
 Decreased breath sounds
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 Deteriorating ABG levels

 Hypoxemia despite high concentrations of delivered oxygen
 Decreased pulmonary compliance
 Pulmonary infiltrates
Interventions
 Identify and treat the cause of the acute respiratory distress syndrome.
 Administer oxygen as prescribed.
 Place the client in a Fowler’s position.
 Restrict fluid intake as prescribed.
 Provide respiratory treatments as prescribed.
 Administer diuretics, anticoagulants, or corticosteroids as prescribed.
 Prepare the client for intubation and mechanical ventilation using PEEP.
PULMONARY EMBOLISM
 Occurs when a thrombus forms (most com-monly in a deep vein), detaches, travels to the right side
of the heart, and then lodges in a branch of the pulmonary artery.
 Clients prone to pulmonary embolism are those at risk for deep vein thrombosis, including those
with prolonged immobilization, surgery, obesity, pregnancy, congestive heart failure, advanced age,
or a history of thromboembolism.
 Fat emboli can occur as a complication following fracture of a long bone and can cause pulmonary
emboli.
 Treatment is aimed at prevention through risk factor recognition and elimination.
Assessment Findings
 Apprehension and restlessness Blood-  Dyspnea accompanied by anginal and

tinged sputum pleuritic pain, exacerbated by inspiration
 Chest pain Feeling of impending doom
 Cough  Hypotension
 Crackles and wheezes on auscultation  Petechiae over the chest and axilla
 Cyanosis Shallow respirations
 Distended neck veins  Tachypnea and tachycardia
PRIORITY NURSING ACTIONS! Actions to Take If a Pulmonary Embolism is Suspected

1. Notify the Rapid Response Team.
2. Reassure the client and elevate the head of the bed.
3. Prepare to administer oxygen.
4. Obtain vital signs and check lung sounds.
5. Prepare to obtain an arterial blood gas.
6. Prepare for the administration of heparin therapy or other therapies.
7. Document the event, interventions taken, and the client’s response to treatment.
Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea, apprehension
and restlessness, a feeling of impending doom, cough, hemoptysis, tachypnea, crackles, petechiae
over the chest and axillae, and a decreased arterial oxygen saturation. If suspected, the nurse
immediately notifies the Rapid Response Team. The nurse stays with the client, reassures the client,
and elevates the head of the bed. The nurse prepares to administer oxygen and obtains the vital
signs and checks lung sounds. The nurse continues to monitor the client closely, prepares the client
for tests prescribed to confirm the diagnosis, and prepares to obtain an arterial blood gas. When
prescribed, the client is prepared for the administration of heparin therapy or other therapies such
as embolectomy or placement of a vena cava filter if necessary. Finally, the nurse documents the
event, interventions taken, and the client’s response to treatment.
PNEUMOTHORAX
 Accumulation of atmospheric air in the pleural space, which results in a rise in intrathoracic pressure
and reduced vital capacity .
TYPES:
Simple Pneumothorax  A simple or spontaneous pneumothorax

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which occurs when air enters the pleural

space through a breach of either the
parietal or visceral pleura.
Traumatic Pneumothorax  Occurs when air escapes from laceration in

the lungs itself and enters the pleural
space or from a wound in the chest wall.
Tension Pneumothorax  Occurs when air is drawn into the pleural

space from a lacerated lung or through a
small opening or wound in the chest wall.
Manifestations
 Pain is usually sudden and may be pleuritic

 Slight chest discomfort
 Tachypnea
 Air hunger
 Increasing hypoxemia
 Hypotension
Management
 The goal of treatment is to evacuate the air or blood from the pleural space.
 Pleural cavity can be decompressed by needle aspiration (THORACENTESIS) or by chest tube
drainage.
 Chest wall is opened surgically (Thoracotomy) if more than 150 ml of blood is aspirated initially if the
chest tube output continues at greater than 200ml/h.
 Patient with a possible TENSION PNEUMOTHORAX should immediately be given in a high
concentration of supplemental oxygen.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
 Also known as chronic obstructive lung disease and chronic airflow limitation
 Chronic obstructive pulmonary disease is a disease state characterized by airflow obstruction caused
by emphysema or chronic bronchitis.
 Progressive airflow limitation occurs, associated with an abnormal inflammatory response of the
lungs that is not completely reversible.
Risk Factors
 Exposure to tobacco smoke
 Smoking
 Occupational exposure (dust, chemicals)
 Ambient air pollution
 Genetic abnormalities
Manifestations:
 Characterized by three primary symptoms
1. Chronic cough
2. Sputum production
3. Dyspnea on exertion
 Cough may be intermittent and may unproductive
 Dyspnea may be severe, and persistent
 Chronic hyperinflation leads to “barrel chest” thorax configuration
Complications:
 Respiratory insufficiency and failure
 Pneumonia
 Chronic atelectasis
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 Pneumothorax
 Pulmonary arterial hypertension
Management:
 Smoking cessation
 Administer a low concentration of oxygen (1 to 2 L/min) as prescribed; the stimulus to breathe
is a low arterial PO2 instead of an increased PCO2.
 Monitor pulse oximetry.
 Provide respiratory treatments and CPT.
 Instruct the client in diaphragmatic or abdominal breathing techniques and pursed-lip breathing
techniques.
 Record the color, amount, and consistency of sputum.
 Suction fluids from the client’s lungs, if necessary, to clear the airway and prevent infection.
 Monitor weight.
 Encourage small frequent meals to maintain nutrition and prevent dyspnea.
 Provide a high-calorie, high-protein diet with supplements.
 Encourage fluid intake up to 3000 mL/day to keep secretions thin, unless contraindicated.
 Place the client in a Fowler’s position and leaning forward to aid in breathing.
 Allow activity as tolerated.
 Administer bronchodilators as prescribed, and instruct the client in the use of oral and inhalant
medications.
 Administer corticosteroids as prescribed for exacerbations.
 Administer mucolytics as prescribed to thin secretions.
 Administer antibiotics for infection if prescribed.
ASTHMA
 Chronic inflammatory disorder of the airways that causes varying degrees of obstruction in the
airways.
 Asthma is marked by airway inflammation and hyperresponsiveness to a variety of stimuli or triggers.
 Asthma causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
associated with airflow obstruction that may resolve spontaneously; it is often reversible with
treatment.
 Asthma severity is classified based on the clinical features before treatment.
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 Status asthmaticus is a severe life-threatening asthma episode that is refractory to treatment and
may result in pneumothorax, acute cor pulmonale, or respiratory arrest.
Manifestation:
 Three most common symptoms:
1.cough
2. dyspnea
3. wheezing
 Asthma attack often occurs at night or early in the morning
 Generalized chest tightness
 Expiration requires effort and prolonged
 Centra; cyanosis (late sign)
Management:
1. Quick – relief medications:
a. Short acting beta2-adrenergic agonists (Albuterol), for relief of acute symptoms and prevention of exercise
– induced asthma.
b. Anticholinergics (Ipratropium bromide), reduce intrinsic vagal tone of the airway.
2. Long acting control medications:

a. Corticosteroids, most potent and effective anti-inflammatory medications currently available. A spacer
should be used, and a rinse mouth after (to prevent thrush).
Interventions

 Monitor pulse oximetry.
 Monitor peak flow.
 During an acute asthma episode, provide interventions to assist with breathing (Box 58-15).
Client education
 Instruct the client on the intermittent nature of symptoms and need for long-term management.
 Instruct the client to identify possible triggers and measures to prevent episodes.
 Instruct the client on the management of medication and proper administration.
 Instruct the client on the correct use of a peak flowmeter.
 Help the client develop an asthma action plan with the primary provider and teach the client what to
do if an asthma episode occurs.
 Help the client develop an asthma action plan with the primary provider and teach the client what to
do if an asthma episode occurs.
V: Learning Episode: The students shall have self- reading, work on critical thinking checkpoint
and graphic organizers and reflective journaling. Instructed to follow time lines in the
submission of their written outputs and answers. The students can contact at the cell phone
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number, messenger and email provided for clarification and further understanding of the
concepts and instruction.
VI. Assessment of Learning: Please refer to Module 2.1 for graphic organizers and answering the
quiz.
NEUROMUSCULAR DISORDER
GUILLAIN-BARRE SYNDROME (POLYRADICULONEURITIS)

 Guillain-Barré syndrome (GBS) is an acute, rapidly progressing, ascending inflammatory
demyelinating polyneuropathy of the peripheral sensory and motor nerves and nerve roots. GBS is
most often, but not always, characterized by muscular weakness and distal sensory loss or
dysesthesias. GBS is the most frequently acquired demyelinating neuropathy. It affects 1 in 100,000
people and must be identified quickly to initiate treatment and decrease life-threatening
complications. Usually, GBS occurs a few days or weeks following symptoms of a respiratory or GI
viral infection. Occasionally, surgery or vaccinations will trigger the syndrome. The disorder can
develop over the course of hours, days, or weeks. Maximum weakness usually occurs within the first
2 weeks after symptoms appear, and by the third week of the illness, 90% of all patients are at their
weakest. About 30% of those with GBS have residual weakness after 3 years, and the recurrence
rate is approximately 3%.
 Mortality results from respiratory failure, autonomic disturbances, sepsis, and complications of
immobility and occurs at a rate of about 5% despite intensive medical care.
1. Believed to be an autoimmune disorder that causes acute neuromuscular paralysis due to
destruction of the myelin sheath surrounding peripheral nerve axons and subsequent slowing of
transmission.
2. Viral infection, immunization, or other event may trigger the autoimmune response.
3. About 30% to 40% of cases are preceded by Campylobacter infection, an acute infectious diarrheal
illness.
4. Cell-mediated immune reaction is aimed at peripheral nerves, causing demyelination and,

possibly, axonal degeneration.
Clinical Manifestations
1. Paresthesia’s and, possibly, dysthesias.
2. Acute onset of symmetric progressive muscle weakness; most often beginning in the legs and
ascending to involve the trunk, upper extremities, and facial muscles. Paralysis may develop.
3. Difficulty with swallowing, speech, and chewing due to cranial nerve involvement.
4. Decreased or absent deep tendon reflexes, position and vibratory perception.
5. Autonomic dysfunction (increased heart rate and postural hypotension).
6. Decreased vital capacity, depth of respirations, and breath sounds.
7. Occasionally spasm and fasciculations of muscles.
Diagnostic Evaluation
1. History and neurologic exam. Progressive weakness, decreased sensation, decreased deep tendon
reflexes.
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2. Lumbar puncture for CSF examination—reveals low blood cell count, high protein.
3. Electrophysiologic studies—nerve conduction velocity shows decreased conduction velocity of
peripheral nerves.
Management
1. Plasmapheresis produces temporary reduction of circulating antibodies to reduce the severity and
duration of the GBS episode.
2. High-dose immunoglobulin therapy is used to reduce the severity of the episode.
3. ECG monitoring and treatment of cardiac dysrhythmias. 4. Analgesics and muscle relaxants as
needed.
5. Intubation and mechanical ventilation if respiratory paralysis develops.
Complications
1. Respiratory failure
2. Cardiac dysrhythmias
3. Complications of immobility and paralysis
4. Anxiety and depression
Nursing Assessment
1. Assess pain level due to muscle spasms and dysthesias.
2. Assess cardiac function including orthostatic BPs.
3. Assess respiratory status closely to determine hypoventilation due to weakness.
4.Performcranialnerveassessment,especiallyninthcranial nerve for gag reflex.
5. Assess motor strength.
Nursing Diagnoses
 Ineffective Breathing Pattern related to weakness/paralysis of respiratory muscles
 Impaired Physical Mobility related to paralysis
 Imbalanced Nutrition: Less Than Body Requirements, related to cranial nerve dysfunction
 Impaired Verbal Communication related to intubation, cranial nerve dysfunction
 Chronic Pain related to disease pathology
 Anxiety related to communication difficulties and deteriorating physical condition
Maintaining Respiration
1. Monitor respiratory status through vital capacity measurements, rate and depth of
respirations, breath sounds.
2. Monitor level of weakness as it ascends toward respiratory muscles.
3. Watch for breathlessness while talking, a sign of respiratory fatigue.
4. Maintain calm environment, and position the patient with head of bed elevated to provide
for maximum chest excursion.
5. As much as possible, avoid opioids and sedatives that may depress respirations.
6. Monitor the patient for signs of impending respiratory failure; heart rate above 120 or
below 70 beats/minute; respiratory rate above 30 breaths/minute; prepare to intubate.
Avoiding Complications of Immobility
1. Position the patient correctly, and provide ROM exercises.
2. Encourage physical and occupational therapy exercises to regain strength during the
rehabilitative period.
3. Assess for complications, such as contractures, pressure ulcers, edema of lower extremities,
and constipation.
4. Provide assistive devices, as needed, such as cane or wheelchair, for patient to take home.
5. Recommend referral to rehabilitation services or physical therapy for evaluation and
treatment.
Promoting Adequate Nutrition
1. Auscultate for bowel sounds; hold enteral feedings if bowel sounds are absent to prevent
gastric distention.
2. Assess chewing and swallowing ability by testing CN V, IX and X; if function is inadequate,
provide alternate feeding.
3. During rehabilitation period, encourage a well-balanced, nutritious diet in small, frequent
feedings with vitamin supplement if indicated.
4. Recommend referral to dietitian for evaluation and proper diet therapy.
Maintaining Communication
1. Develop a communication system with the patient who cannot speak.
2. Have frequent contact with the patient, and provide explanation and reassurance,
remembering that the patient is fully conscious.
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3. Provide some type of patient call system. Because standard call lights cannot be
activated by the severely weak patient, provide adaptive call light and/or some type of
constant monitoring and surveillance to meet patient’s needs.
4. Recommend referral to speech therapy for evaluation and treatment.
5. Refer to counselor, social workers, or psychologist to develop/enhance coping skills and
regain sense of control.
Relieving Pain
1. Administer analgesics as required; monitor for adverse reactions, such as hypotension,
nausea and vomiting, and respiratory depression.
2. Provide adjunct pain management therapies, such as therapeutic touch, massage,
diversion, guided imagery.
3. Provide explanations to relieve anxiety, which augments pain.
4. Turn the patient frequently to relieve painful pressure areas.
Reducing Anxiety
1. Get to know the patient, and build a trusting relationship.
2. Discuss fears and concerns while verbal communication is possible.
3. Reassure the patient that recovery is probable.
4. Use relaxation techniques such as listening to soft music.
5. Provide choices in care, and give the patient a sense of control.
6. Enlist the support of significant others.
Community and Home Care Considerations
 Be aware that GBS is a significant cause of new long-term disability for at least 1,000 people per year
in the United States, necessitating long-term rehabilitation and community reintegration. Outcome
can range from mild paresthesias to death. The chance of recovery is significantly affected by age,
antecedent gastroenteritis, disability, electrophysiologic signs of axonal degeneration, latency to
nadir, and duration of active disease.
 Given the young age at which GBS sometimes occurs, the patient and family must be treated as an
integral unit, assessing family communication, knowledge, adjustment, and use of support systems.
 Include in caregiver training strategies the need for exercise, positioning, and activity to prevent
secondary complications, such as contractures, deep vein thrombosis (DVT), hypercalcemia, and
pressure ulcers.
Patient Education and Health Maintenance
1. Advise the patient and family that acute phase lasts 1 to 4 weeks, then the patient stabilizes and
rehabilitation can begin; however, convalescence may be lengthy, from 3 months to 2 years.
2. Instruct the patient in breathing exercises or use of incentive spirometer to reestablish normal
patterns.
3. Teach the patient to wear good supportive and protective shoes while out of bed to prevent injuries
due to weakness and paresthesia.
4. Instruct the patient to check feet routinely for injuries because trauma may go unnoticed due to
sensory changes.
5. Reinforce maintenance of normal weight; additional weight will further stress the motor abilities.
6. Encourage the use of scheduled rest periods to avoid over-fatigue.
7. Refer the patient/family for more information and support to such agencies as The Guillain-Barré
Syndrome Foundation International, www.gbsfi.com.
Evaluation: Expected Outcomes
 Normal respiratory rate and rhythm, shallow, unlabored
 Performs assistive ROM exercises every 2 hours; no pressure ulcers or edema present
 Gag reflex present, eating small meals without aspiration
 Uses short phrases and head nodding to communicate effectively
 Verbalizes decreased pain
 Verbalizes reduced anxiety
Learning Module 3
NCM 112: SEXUALLY TRANSMITTED DISEASES
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 Defining what is sexually transmitted disease and its facts.

 Comparing and contrasting the HIV and AID’s.
 Listing appropriate nursing intervention in the care of client with sexually transmitted
disease.
 Identifying and select appropriate medications and treatments for client with STD.
 Executing appropriate client health education and preparation for patient undergoing
assessment.

  Students will engage
and work on Graphic
Organizer.
 Contact teacher for
comprehend topic/
concepts.

 Accountable
SEXUALLY TRANSMITTED DISEASES
Facts about STD
 The term sexually transmitted disease (STD) is used to refer to a condition passed from one person to
another through sexual contact. You can contract an STD by having unprotected vaginal, anal, or oral
sex with someone who has the STD.
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 An STD may also be called a sexually transmitted infection (STI) or venereal disease (VD).
 That doesn’t mean sex is the only way STDs are transmitted. Depending on the specific STD,
infections may also be transmitted through sharing needles and breastfeeding.
CHLAMYDIAL INFECTION
 Chlamydial infection is a common STD that occurs in both men and women, particularly in
adolescent and young adults.
 Women are asymptomatic or present with cervicitis; men are frequently asymptomatic but may
preset with urethritis.
Pathophysiology and etiology
 Chlamydial infection in women is the result of sexual intercourse, with infection entering the vagina,
infecting the cervix, and possibly spreading up through the endometrium and fallopian tubes.
 C. tracomatis is the most common sexually transmitted pathogen.
 May be asymptomatic or have vaginal discharge – may be clear mucoid to creamy discharge.
 May have dysuria and mild pelvic discomfort
 Cervix maybe covered by thick mucopurulent discharge and be tender, erythematous, edematous,
and friable
Diagnostic test
 Antigen detection test on cervical smear

 Chlamydia culture from cervical exudate
 Screening urinalysis in males for leukocytes, if positive result, confirmed by antigen detection test
 Screening test in females by urinalysis is a chlamydia antigen detection test that has proven effective
Medical management
 Antibiotic regimen include:

o Azithromycin (Zithromax) 1g orally in a single dose
o Doxycycline 100 mg orally twice a day for 7 days
o Erythromycin and ofloxacin (floxin) may also be used
 Current or most recent sexual partners should be tested and treated despite test result.
Complications
 Pelvic inflammatory disease (PID)

 Ectopic pregnancy or infertility secondary to untreated or recurrent PID
 Transmission to neonate born through infected birth canal
 Advise abstinence from sexual intercourse until treatment has been completed and follow – up
culture result is negative.
 Ensure that partner is treated at the same time; recent partner should receive treatment despite lack
of symptoms and negative chlamydia test result
 Report case to local public health department (chlamydia is a reportable infectious disease in most of
the US)
 Ensure that patient begin treatment and will have access to prescription and transportation for
follow – up
 Explain mode of transmission, complication, and the risk for other STD
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GONNORHEA
 Gonnorhea is a common STD that affects men and women, causing cervicitis in women and urethritis
in men.
 In women it can be easily ascend to the uterus and fallopian tubes if untreated
 Gonnorhea is caused by the gram – positive diplococci Neisseria gonorrhoeae

 Infection occurs through sexual transmission, causing cervicitis in women, and possible conjunctivitis,
pharyngitis, and proctitis
 Untreated infection may lead to pelvic inflammatory disease, generalized dissemination, or
gonococcal arthritis
 Clinically asymptomatic in women

 May cause mucopurulent vaginal discharge
 Vaginal speculum examination may reveal cervical discharge and inflammation
 Cervical motion tenderness and tender pelvic organs on bimanual examination if infection has begun
to ascend
 a white, yellow, beige, or green-colored discharge from the penis or vagina
 pain or discomfort during sex or urination
 more frequent urination than usual
 itching around the genitals
 sore throat
 Gram stain of cervical secretions and culture on Thayer Martin agar.

 DNA testing of cervical secretions (quicker and accurate, can be done simultaneously for chlamydia).
 Pharyngeal or conjunctival secretions can be tested if pharyngitis or conjunctivitis are suspected.
 Joint aspiration and blood cultures may be necessary if disseminated infection is suspected.
Management
 Uncomplicated gonococcal infection of the cervix, urethra (in men), or rectum (in men or women)
can be treated with a single-dose antibiotic, such as:
a. Cefixime (Suprax) 400 mg orally.
b. Ceftriaxone (Rocephin) 125 mg I.M.
 Ceftriaxone is recommended for pharyngeal and conjunctival infections.
 Disseminated infections require I.V. or I.M. therapy, such as:
a. Ceftriaxone 1 g I.M. or I.V. every 24 hours.
b. Cefotaxime (Claforan) 1 g I.V. every 8 hours.
c. Ceftizoxime(Cefizox)1gI.V.every8hours.
d. Spectinomycin 2 g I.M. every 12 hours. Note: Not available in the United States.
 For I.V. or I.M. therapy, patient is switched to oral therapy 24 to 48 hours after improvement.
 In all cases of suspected gonorrhea, concomitant treatment of chlamydia is recommended with
appropriate second antibiotic agent. Only if a reliable chlamydia test with negative result is obtained
would therapy be given just for gonorrhea.
D R U G A L E R T Fluoroquinolone therapy is no longer recommended for treatment of gonorrhea in the
United States due to resistance.
Complications
1. PID, ectopic pregnancy, and infertility.
2. Disseminated infection.
3. Ophthalmia neonatorum and sepsis (rare) caused by infant born through infected birth canal.
Nursing Assessment
1. Question patient on history of STDs, STD protection, sexual activity, usual women’s health care
practices.
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2. Obtain history of symptoms in patient and partner— incubation period is usually 3 to 7 days in men,
but symptoms are typically overlooked in women.
3. Assess for ability to change lifestyle practices that may have led to STD.
Nursing Diagnosis
 Risk for Infection related to sexual activity
Stopping Transmission of STD
1. Administer antibiotics, as prescribed, explaining adverse effects to patient.
2. Make sure that patient can obtain prescription medication at discharge.
3. Monitor for relief of pain, discharge, and other symptoms.
4. Explain importance of sexual abstinence until symptoms are totally resolved and until therapy is
complete in patient and partner.
5. Report to public health department and tell patient that information will be obtained to ensure
testing of sexual contacts.

1. Teach patient about all possible STDs, their prevalence, and their mode of transmission.
2. Advise patient of complications of gonorrhea and chlamydia.
3. Teach protection of STDs by abstinence, monogamous relationships, use of female and male condoms.
4. Stress the importance of follow-up examination and testing to ensure eradication of infection. Encourage
follow- up for routine women’s health care and periodic STD screening.
5. For additional information, refer to American Social Health Association, www.ashastd.org, or Planned
Parent- hood Foundation—Health Information, www.planned parenthood.org/STI/.
 Reports resolution of symptoms and use of condoms at follow-up visit
Figure 11: Gonococcal urethritis Figure 12: Gonococcal cervicitis

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Figure 14: Gonococcal ophthalmia
Figure 13: Gonorrhea - gram stain of urethral

discharge
Figure 16: Disseminated gonorrhea - skin lesion
Figure 15: Bartholin’s Abscess

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SYPHILIS
 It is a bacterial infection that is most often spread through sexual contact.
 Syphilis is a sexually transmitted infectious (STI) disease caused by the bacterium Treponema
pallidum.
 This bacterium causes infection when it gets into broken skin or mucus membranes, usually of the
genitals. Syphilis is most often transmitted through sexual contact, although it also can be
transmitted in other ways.
 Syphilis occurs worldwide, most commonly in urban areas. The number of cases is rising fastest in
men who have sex with men (MSM). Young adults ages 20 to 35 are the highest-risk population.
Because people may be unaware that they are infected with syphilis, many states require tests for
syphilis before marriage. All pregnant women who receive prenatal care should be screened for
syphilis to prevent the infection from passing to their newborn (congenital syphilis).
Four stage of syphilis
1.Primary syphilis
 The primary stage of syphilis occurs about three to four weeks after a person contracts the bacteria.
It begins with a small, round sore called a chancre. A chancre is painless, but it’s highly infectious.
This sore may appear wherever the bacteria entered the body, such as on or inside the mouth,
genitals, or rectum.
 On average, the sore shows up around three weeks after infection, but it can take between 10 and
90 days to appear. The sore remains for anywhere between two to six weeks.
 Syphilis is transmitted by direct contact with a sore. This usually occurs during sexual activity,
including oral sex.
Figure 17: Primary syphilis in male – chancre

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Figure 18: Primary syphilis in female – chancre
2. Secondary syphilis
 Skin rashes and a sore throat may develop during the second stage of syphilis. The rash won’t itch
and is usually found on the palms and soles, but it may occur anywhere on the body. Some people
don’t notice the rash before it goes away.
Figure 19: Secondary syphilis on the palms
Figure 20: Secondary syphilis - Papulosquamous rash
Other symptoms of secondary syphilis may include:
 Headaches
 swollen lymph nodes  weight loss
 fatigue  hair loss
 fever  aching joints
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 These symptoms will go away whether or not treatment is received. However, without treatment, a
person still has syphilis. Secondary syphilis is often mistaken for another condition.
3.Latent syphilis
 The third stage of syphilis is the latent, or hidden, stage. The primary and secondary symptoms
disappear, and there won’t be any noticeable symptoms at this stage. However, the bacteria remain
in the body. This stage could last for years before progressing to tertiary syphilis.
4.Tertiary syphilis
 The last stage of infection is tertiary syphilis. According to the Center for Disease Control and
Prevention, approximately 15 to 30 percent of people who don’t receive treatment
for syphilis will enter this stage. Tertiary syphilis can occur years or decades after the initial infection.
Tertiary syphilis can be life-threatening. Some other potential outcomes of tertiary syphilis include:
 blindness
 deafness
 mental illness
 memory loss
 destruction of soft tissue and bone
 neurological disorders, such as stroke or meningitis
 heart disease
 neurosyphilis, which is an infection of the brain or spinal cord
Figure 21: Late syphilis - serpiginous gummata of forearm
Figure 22: Cardiovascular syphilis - narrowing of coronary ostia in aortas

84
Diagnostic test
The health care provider will perform a physical exam and ask about the symptoms. Tests that may be done
include:
 Examination of fluid from sore (rarely done)
 Echocardiogram, aortic angiogram, and cardiac catheterization to look at the major blood vessels
and the heart
 Spinal tap and examination of spinal fluid
 Blood tests to screen for syphilis bacteria (RPR, VDRL, or TRUST) If the RPR, VDRL, or TRUST tests are
positive, one of the following tests will be needed to confirm the diagnosis:
o FTA-ABS (fluorescent treponemal antibody test)
o MHA-TP
o TP-EIA
o TP-PA
Medical management
 Primary and secondary syphilis are easy to treat with a penicillin injection. Penicillin is one of the
most widely used antibiotics and is usually effective in treating syphilis. People who are allergic to
penicillin will likely be treated with a different antibiotic, such as:
o Doxycycline
o Azithromycin
o Ceftriaxone
 If the patient is having neurosyphilis, advice to get daily doses of penicillin intravenously. This will
often require a brief hospital stay. Unfortunately, the damage caused by late syphilis can’t be
reversed. The bacteria can be killed, but treatment will most likely focus on easing pain and
discomfort.
 During treatment, make sure to avoid sexual contact until all sores on the body are healed and the
doctor tells the patient it’s safe to resume sex. If sexually active, advise the partner should be
treated as well. Don’t resume sexual activity until you and your partner have completed treatment.
How to prevent syphilis The best way to prevent syphilis is to practice safe sex. Use condoms during any type
of sexual contact. In addition, it may be helpful to:
o Use a dental dam (a square piece of latex) or condoms during oral sex.
o Avoid sharing sex toys.
o Get screened for STIs and talk to your partners about their results.
o Syphilis can also be transmitted through shared needles. Avoid sharing needles if using
injected drugs.
PUBIC LICE
 Pubic lice are tiny wingless insects that infect the pubic hair area and lay eggs there. These lice can
also be found in armpit hair, eyebrows, moustache, beard, around the anus, and eyelashes.
Causes
 Pubic lice are most commonly spread during sexual activity. In very rare cases, pubic lice can spread
through contact with objects such as toilet seats, sheets, blankets, or bathing suits (that you may try
on at a store).
 Animals cannot spread lice to humans.
 Other types of lice include:
o Body lice
o Head lice
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 You are at greater risk for pubic lice if you:

o Have many sexual partners (high incidence in men who have sex with men)
o Have sexual contact with an infected person
o Share bedding or clothing with an infected person
 Pubic lice cause itching in the area covered by pubic hair. Itching often gets worse at night. The
itching may start soon after getting infected with lice, or it may not start for up to 2 to 4 weeks after
contact.
Other symptoms can include:
o Local skin reactions to the bites that causes skin to turn red or bluish-gray
o Sores in the genital area due to bites and scratching
Diagnostic test
The health care provider will do an exam to look for:

o The lice
o Small gray-white oval eggs (nits) attached to the hair shafts in the outer genital area
o Scratch marks or signs of a skin infection
 Because pubic lice may cause an eye infection in young children, eyelashes should be looked at with
a high-powered magnifying glass. Sexual transmission, and potential sexual molestation, should
always be considered if pubic lice are found in children.
 Adult lice are easy to identify with a special magnifying device called a Dermoscope. Pubic lice are
often referred to as "the crabs" because of their appearance.
 Teenagers and adults with pubic lice may need to be tested for other sexually transmitted infections
(STIs).
Medical management
Medicines
Pubic lice are often treated with medicines that contain a substance called permethrin. To use this medicine:
 Thoroughly work the medicine into your pubic hair and surrounding area. Leave it on for at least 5 to 10
minutes, or as directed by your provider.
 Rinse well.
 Comb your pubic hair with a fine-toothed comb to remove eggs (nits). Applying vinegar to pubic hair before
combing may help loosen the nits.
 In case of eyelash infestation, applying soft paraffin three times daily for 1 to 2 weeks may help.
 Most people need only one treatment. If a second treatment is needed, it should be done 4 days to 1 week
later.
 Over-the-counter medicines to treat lice include Rid, Nix, LiceMD, among others. Malathione lotion is another
option.
 Sexual partners should be treated at the same time.
OTHER CARE
While you are treating pubic lice:
o Wash and dry all clothing and bedding in hot water.

o Spray items that cannot be washed with a medicated spray that you can buy at the store. You can
also seal items in plastic bags for 10 to 14 days to smother the lice.
Prevention
 Avoid sexual or intimate contact with people you who have pubic lice until they have been treated.
 Bathe or shower often and keep your bedding clean. Avoid trying on bathing suits while you are
shopping. If you must try on swimwear, be sure to wear your underwear. This may prevent you from
getting or spreading pubic lice.
HUMAN PAPILLOMAVIRUS INFECTION
 HPV maybe asymptomatic but frequently causes Condyloma Acuminatum or Genital warts.
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 Sexually transmitted disease; highly contagious.
 More than 20 types of HPV can infect the genital tract, many are asymptomatic, and multiple types
coexist.
 Visible warts are cause by HPV type 6 and 11.
 Other types (16,18,31,33,35) have been associated with cervical dysplasia.
 Incubation period of up to 8 months.
 Single or multiple soft, fleshy painless growth of the vulva, vagina, cervix, urethra, or anal area.
 Maybe subclinical infection and still contagious
 Occasional vaginal bleeding, discharge, odor, and dyspareunia
Figure 23: Condyloma acuminatum, penile
Figure 24: Condyloma acuminatum, vulva
Figure 25: Condyloma acuminatum, anal

Diagnostic test
 Pap smear – show characteristic cellular changes (koilocytosis).

 Acetic acid swabbing on vaginal examination will whiten lesions and make them more identifiable.
 Anoscopy or urethroscopy may be necessary to identify anal and urethral lesions.
 Viral DNA or RNA tests to detect subclinical cases; however, the significance of positive and negative
results has not been determined.
Medical management
 External lesions may be treated by patient with multiple application of topical preparation.
o Podofilox (Condylox) – applied with cotton swab or finger to visible warts twice a day for 3
days, then no treatment for 4 days; maybe repeated for up to 4 cycles of therapy.
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o Imiquimod (Aldara) – applied by finger three times a week for up to 16 weeks; may be
washed off 6 to 10 hours after application.
o neither agent should be used during pregnancy.
 Noncervical lesions may be treated by health care provider with topical preparations, such as
podyphillin, trichloacetic acid, or 5 – flouracil.
 Cryotherapy, electrocautery, laser treatment, or local excision of large or cervical lesions.
 Highly, recurrent in first 3 months may require retreatment.
Complications
 Implicated in cervical intraepithelial neoplasia.
 May cause neonatal laryngeal papillomatosis if infant born through infected birth canal.
 Obstruction of anal canal, vagina by enlarging lesions.
 Scarring and pigment changes if treatment not employed properly.
 Improving body image
o Explain to the patient that the goal of the therapy is to remove the visible lesions; however,
HPV will not be cure or eliminated
o Encourage patient to comply with treatment schedule and inspect areas for resolution of
lesions or redevelopment of new lesions.
o Advise patient of high recurrence rate; 3 months follow up visit is advisable; if lesions
redevelop, patient should follow up for retreatment.
o Advice the patient to use condom to prevent transmission, although their use
does not guarantee protection from HPV. Condom use will protect against other STDs.
o Encourage female patient to follow up regularly for PAP smears because HPV has been
associated with cervical neoplasia.
o Advise patient of risk of neonate during delivery; patient should receive close prenatal care
if pregnant.
HERPES GENITALIS
 Herpes genitalis is a viral infection that causes lesions of the cervix, vagina, and external genitalia.

 Caused by HSV, usually type 2
 Sexually transmitted
 Recurrent infection; virus lies dormant in dorsal root ganglia of spinal nerves between outbreaks.
 Lesions occur 2 to 10 days after initial exposure, sometimes with fever, malaise, lymphadenopathy
and headache for primary infection.
 Lesions are preceded by sensation of tingling; proceed from vehicles of erythematous, edematous
base to painful ulcers that crust and heal without scars.
 Internal lesions may cause watery discharge, dyspareunia.
 Recurrent lesions may be stimulated by fever, stress, illness, local trauma, menses, and sunburn.
 Occasionally infection maybe asymptomatic.
Figure 26: Primary herpes, male

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Figure 27: Primary herpes, female
Diagnostic test
 Viral culture – identifies HSV.

 Pap smear – may show characteristics cellular changes.
 Tzanck smear – fluid from vesicle or scraping from base of ulcer is stained to show characteristic
changes.
 Antibody test on genital lesions for screening and diagnosis
Medical management
 Antivirals, such as Acyclovir (Zovirox), Famiclovir (famvir), and Valacyclovir (Valtrex) suppress virus
and decrease length, severity, and shedding of infection.
o Topical treatment (acyclovir) is the least effective.
o Oral therapy maybe episodic, whenever the first signs of a recurrence are recognized, or
continuous to suppress recurrent infection.
o Intravenous administration (acyclovir) may be necessary for severe infection of for
immunocompromised patient.
o Oral therapy given intermittently as soon as occurrence is identified, or continuously in the
oral form to suppress recurrences in severe and frequent infections.
 Pain medication – ranges from acetaminophen and non – steroidal anti – inflammatory drugs to oral
narcotics.
 Local comfort measures, such as lidocaine gel, sitz baths, and compresses.
 Immunization is under investigation for high risk people (those who have multiple partners or have a
partner with herpes genitalis). Recent phase II clinical trials of an investigational three stage vaccine
proved ineffective.
Complications
 Meningitis
 Neonatal infection if infant born through infected canal
 Relieving pain
o Demonstrate and encourage the use of warm sitz bath to increased blood supply to the
areas and facilitate healing.
o Instruct the patient to keep the area clean and dry. Pat dry with a clean towels or use blower
dryer. Wear loose cotton undergarments and loose clothing.
o Encourage bed rest if case is severe.
o Administer pain medication as prescribe.
o Encourage patient to avoid in a warm sitz if urination is painful.
o Insert indwelling catheter if urination is extremely painful or if retention occurs.
o Encourage fluid intake.
 Restoring skin integrity

o Administer antiviral agent and teach patient its proper use and side effects.
o Keep lesions clean and dry
o Teach patient not to rub or scratch lesions
o Apply moist tea bags to lesions while supine. Tannic acid facilitate healing.
 Improving self – esteem
o Explore with patient her feelings about herpes and its effects on relationship.
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o Reiterate that when patient is feeling better physically, her feelings about herself will
improve.
o Discuss effect of stress on future outbreaks. Assist patient to identify stressor in her life and
to cope with stress. Review stress reduction methods, such as relaxation, breathing and
imagery.
o Encourage patient to discuss her feelings with family and significant others.
 Restoring satisfying sexual function
o Teach patient to avoid intercourse from first sign of active outbreak to resolution of lesions
(at least 2 weeks with primary infection, approximately 1week with recurrent infections).
o Teach patient that shedding of virus through genital secretion is possible even during
asymptomatic period, so partner must be notified.
o Inform patient that she and or her partner should use condom for intercourse, but condoms
may not be fully protective.
o Explore possibility of noncoital aspects of sexual relationship.
HIV Disease and AIDS
 Acquired immunodeficiency syndrome (AIDS) is define as the most severe form of a continuum
illness of associated with human immunodeficiency virus (HIV) infection. It cause a slow
degeneration of the immune system with the development of opportunistic infections and
malignancies. HIV disease implies the entire course of HIV infection, from asymptomatic infection
and early symptoms of AIDS.

 The causative agent is a retrovirus that infects and depletes the “protector” cells of the immune
system, called lymphocytes. B lymphocytes secrete antibodies into the body fluids, or humors: this is
known as humoral immunity. T lymphocytes can penetrate living cells, a process called cell –
mediated immunity.
 Monocytes and macrophages, whose role is to present antigen to T cells, thereby initiating the
body’s immune response, are also infected by HIV.
 Once HIV has entered the body, it attaches most efficiently to CD4 molecules, which are
predominantly located on the cell membrane of T4 – helper lymphocytes. HIV destroys the CD4
molecules as enters to infect the T4 lymphocytes.
 With progressive invasion of HIV, cellular and humoral immunity declines and opportunistic
infections that characterize this disease begin to emerge.
 Body fluid known to transmit HIV are blood, vaginal secretions, semen, and breast milk.
 HIV is transmitted by injection of blood or blood components, by sexual contact (vaginal/anal
intercourse, oral sex), and perinatally from an infected mother to the child.
High – Risk Groups for HIV transmission

1. Homosexual or bisexual men
2. Intravenous (IV) drug users
3. Transfusion and blood products recipients (before 1885)
4. Heterosexual contacts of HIV – positive individuals
5. Newborn babies of mothers who are HIV positive
1.Primary manifestations
 Persistent cough with or without sputum production, shortness of breath, chest pain, fever.
 From Pneumocytis carinii pneumonia (most common), bacterial pneumonia, Mycobacterium
tuberculosis, disseminated Mycobacterium avium complex, cytomegalovirus (CMV), Histoplasma,
Kaposi’s sarcoma, Cryptococcus, Legionella, and other pathogens.
2. Gastrointestinal manifestations
 Diarrhea, weight loss, anorexia, abdominal cramping, rectal urgency (tenesmus).
 From enteric pathogens including Salmonella, Shigella, Campylobacter, Entamoeba histolyca, CMV,
M. avium complex, herpes simplex, Strongyloides, Giardia, Cryptoporidium, Isopora belli, Chlamydia,
and others.
3.Oral manifestations
 Appearance of oral lesions, white plaques on oral mucosa, and angular cheilitis from Candida
Albicans of mouth and esophagus.
 Vesicles with ulceration from herpes simplex virus.
 White, thickened lesions on lateral margins of tongue from history of leukoplakia.
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 Oral warts due to HPV and associated with gingivitis.

 Periodontitis progressing to gingival necrosis.
4.Central Nervous System manifestations

 Cognitive, motor, and behavioral symptoms (AIDS dementia complex/HIV encephalopathy).
 Demonstrated by mental slowing, impaired memory and concentration, loss of balance, lower
extremity weakness, ataxia, apathy, and social withdrawal.
 From CNS toxoplasmosis, cryptococcal meningitis, herpes virus infection, CMV (causing retinopathy
and blindness), and CNS lymphoma.
5.Malignancies
 Kaposi’s sarcoma (aggressive tumor involving skin, lymph nodes, GIT, and lungs).
 Non – Hodgkin lymphoma and lymphomas.
 Cervical carcinoma.
Diagnostic test
 History of risk factors/high – risk behavior.
 Positive blood test for HIV
o Enzyme – linked immunosorbent assay (ELISA) – serologic test for detecting antibody to
HIV.
o Western blot test – used to confirm a positive result of ELISA
o Once infected with HIV, it can take the body 3 – 6 months to develop enough antibody to
HIV for the test result to be positive, resulting in a false negative – test if evaluated early.
o Occasionally a sample that test reactivity by ELISA may give an intermediate result by
Western blot. The cause of an indeterminate result may be early HIV seroconversion of error
during interpretations of the test. The test should be repeated every 2 – 3 months of the
Western blot become positive or there Is no longer suspicion on HIV disease.
o There are three FDA-approved rapid HIV test available. They are blood test that can show
result in about 10 minutes. A negative result is definitely negative, but a positive result must
be confirmed positive by the ELISA.
o Orasure is an FDA – approved HIV test that uses saliva rather than blood. The results are
available in about 3 days.
o Calypte HIV – 1 urine EIA is FDA – approved HIV test that uses urine. A positive result must
be confirm positive by ELISA.
 Lymphocytes panel shows decreased CD4 count.

 CBC may show anemia and low WBC count.
 Chest Radiograph – to detect the presence indicator disease (e.g., P. carinii pneumonia, candidiasis
of esophagus, Kaposi sarcoma, etc.).
 Neuropsychological testing – to identify cognitive deficits associated with HIV dementia.
 Viral Load (quantitative HIV RNA) is a measure of the amount of amount of HIV in the blood. A
higher number (greater than 750,000) indicates HIV is more active; therefore is replicating at a faster
rate. This can be predictive of a faster rate of disease progression, which decreases the time
between the HIV transmission and death. A viral load test can be undetectable, meaning the amount
of virus is less than 150; therefore, the virus could not be found.
Medical management
Specific treatment
1. Antiretroviral therapy (ART) consist of medication that belongs to three different classifications
because they acts to prevent HIV replication at three different points along the replication process.
The standard for ART is to make a minimum of three different drugs that come from at least two
different drugs classifications.
2. Highly active antiretroviral therapy (HAART) refers to any medication regimen that can expected to
decrease the viral load to non – detectable.
3. Classes of antiretroviral drugs:
 Nucleoside reverse transcriptase inhibitors (NRTIs) such as zidovudine (AZT), didanosine
(ddI), stavudine (d4T)
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 Non – nucleoside reverse transcriptase inhibitors (NNRTIs) such as nevirapine (Viramune),

efavirenz (Sustiva)
 Protease inhibitors (PIs) such as indinavir (crixivan), ritonavir (Norvir), and saquinavir
(Fortavase).
Goals of antiviral therapy:

 Prolong life and improve quality of life.
 Reduce viral load to as low as possible for as long as possible.
 Increased the CD4 count.
Indications for antiviral therapy:

 Acute retroviral syndrome or less than 6 months since seroconversion.
 HIV symptoms such as oral thrush.
 No HIV symptoms but has a CD4 count of 500/mm3 of less than/or a viral load greater than 20,000.
NURSING INTERVENTIONS
1. Provide respiratory support.
2. Administer oxygen and respiratory treatments as prescribed.
3. Provide psychosocial support as needed.
4. Maintain fluid and electrolytes balance.
5. Monitor for signs of infections
6. Prevent the spread of infections.
7. Initiate standard and other precautions as necessary.
8. Provide comfort as necessary.
9. Provide meticulous skin care.
10. Provide adequate nutritional support as prescribe.
V: Learning Episode: The students shall have self- reading, work on critical thinking checkpoint
and graphic organizers and reflective journaling. Instructed to follow time lines in the
submission of their written outputs and answers. The students can contact at the cell phone
number, messenger and email provided for clarification and further understanding of the
concepts and instruction.
VI. Assessment of Learning: Please refer to Module 2.1 for graphic organizers and answering the
quiz.
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Learning Module 4
NCM 212: Gastrointestinal Disorders
 Identifying the major organs and structures of the gastro intestinal system.
 Discussing the important information to ascertain about gastrointestinal health.
 Describing common diagnostic test performed on client gastrointestinal disorders.
 Explaining the symptoms of irritable bowel syndrome.
 Describing the features of appendicitis and peritonitis.
 Describing the features of Peptic ulcer disease and Vit B12 deficiency.
 Discussing the nursing management on gastrointestinal disorders.
 Comparing and contrasting acute and chronic pancreatitis.
 Comparing and contrasting cholelithiasis, cholecystitis, choledocholithiasis.
 Discussing the nursing management and interventions of pancreatic disorders.

and work on Graphic
Organizer.
comprehend topic/
concepts.
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 Accountable
GASTROINTESTINAL DISORDERS
Sandra M. Nettina
ANATOMY AND PHYSIOLOGY
Functions of the gastrointestinal system

 Process food substances
 Absorb the products of digestion into the blood
 Excrete unabsorbed materials
 Provide an environment for microorganisms to
 synthesize nutrients, such as vitamin K
 For risk factors associated with the gastrointestinal system
Risk Factors Associated with the Gastrointestinal System

 allergic reactions to food or medicationsCardiac, respiratory, and endocrine disorders that
may lead to slowed gastrointestinal (GI) movement or constipation
 Chronic alcohol use
 Chronic high stress levels
 Chronic laxative use
 Chronic use of aspirin or nonsteroidal anti-inflammatory drugs Diabetes mellitus, which
may predispose to oral candidal infections or other GI disorders
 Family history of GI disorders
 Long-term GI conditions, such as ulcerative colitis, that may predispose to colorectal
cancer
Neurological disorders that can impair movement, particularly with chewing and
swallowing
 Previous abdominal surgery or trauma, which may lead to adhesions
 Tobacco use
Mouth
 Contains the lips, cheeks, palate, tongue, teeth, salivary glands, muscles, and maxillary bones
 Saliva contains the enzyme amylase (ptyalin), which aids in digestion.
Esophagus
 Collapsible muscular tube about 10 inches long
 Carries food from the pharynx to the stomach
The stomach
 Contains the cardia, fundus, the body, and the pylorus
 Mucous glands are located in the mucosa and prevent autodigestion by providing an alkaline
protective covering.
 The lower esophageal (cardiac) sphincter prevents reflux of gastric contents into the esophagus.
 The pyloric sphincter regulates the rate of stomach emptying into the small intestine.
 Hydrochloric acid kills microorganisms, breaks food into small particles, and provides a chemical
environment that facilitates gastric enzyme activation.
 Pepsin is the chief coenzyme of gastric juice, which converts proteins into proteases and peptones.
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 Intrinsic factor is necessary for the absorption of vitamin B12.

 Gastrin controls gastric acidity.
Small intestine
 The duodenum contains the openings of the bile and pancreatic ducts.
 The jejunum is about 8 feet long.
 The ileum is about 12 feet long.
 The small intestine terminates in the cecum.
Pancreatic intestinal juice enzymes
 Amylase digests starch to maltose.
 Maltase reduces maltose to monosaccharide glucose.
 Lactase splits lactose into galactose and glucose.
 Sucrase reduces sucrose to fructose and glucose.
 Nucleases split nucleic acids to nucleotides.
 Enterokinase activates trypsinogen to trypsin.
Large intestine
 About 5 feet long
 Absorbs water and eliminates wastes
 Intestinal bacteria play a vital role in the synthesis of some B vitamins and vitamin K.
 Colon: Includes the ascending, transverse, descending, and sigmoid colons and rectum
 The ileocecal valve prevents contents of the large intestine from entering the ileum.
 The anal sphincters control the anal canal.
Peritoneum: Lines the abdominal cavity and forms the mesentery that supports the intestines and blood
supply
Liver
 The largest gland in the body, weighing 3 to 4 pounds
 Contains Kupffer’s cells, which remove bacteria in the portal venous blood
 Removes excess glucose and amino acids from the portal blood
 Synthesizes glucose, amino acids, and fats
 Aids in the digestion of fats, carbohydrates, and proteins
 Stores and filters blood (200 to 400 mL of blood stored)
 Stores vitamins A, D, and B and iron
 The liver secretes bile to emulsify fats (500 to 1000 mL of bile/day).
Hepatic ducts
 Deliver bile to the gallbladder via the cystic duct and to the duodenum via the common bile duct.
 The common bile duct opens into the duodenum, with the pancreatic duct at the ampulla of Vater.
 The sphincter prevents the reflux of intestinal contents into the common bile duct and pancreatic
duct.
Gallbladder
 Stores and concentrates bile and contracts to force bile into the duodenum during the digestion of
fats
 The cystic duct joins the hepatic duct to form the common bile duct.
 The sphincter of Oddi is located at the entrance to the duodenum.
 The presence of fatty materials in the duodenum stimulates the liberation of cholecystokinin, which
causes contraction of the gallbladder and relaxation of the sphincter of Oddi.
Pancreas
 Exocrine gland
a. Secretes sodium bicarbonate to neutralize the acidity of the stomach contents that enter the
duodenum
b. Pancreatic juices contain enzymes for digesting carbohydrates, fats, and proteins.
 Endocrine gland
a. Secretes glucagon to raise blood glucose levels and secretes somatostatin to exert a hypoglycemic
effect
b. The islets of Langerhans secrete insulin.
c. Insulin is secreted into the bloodstream and is important for carbohydrate metabolism.
DIAGNOSTIC PROCEDURES
Upper gastrointestinal tract study (barium swallow)
 Examination of the upper gastrointestinal tract under fluoroscopy after the client
Pre procedure:
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 NPO after midnight the day of the test
Post procedure
 A laxative may be prescribed.

 Instruct the client to increase oral fluid intake to help pass the barium.
 Instruct the patient to increased oral fluid intake
 Monitor stools for the passage of barium (stools will appear chalky white) because barium can cause
a bowel obstruction.
Lower gastrointestinal tract study (barium enema)
 A fluoroscopic and radiographic examination of the large intestine is performed after rectal
instillation of barium sulfate.
 The study may be done with or without air.
Pre procedure
 A low-fiber diet is given for 1 to 2 days before the test.

 A clear liquid diet and laxative are given the evening before the test.
 NPO after midnight the day of the test Cleansing enemas may be prescribed on the morning of the
test.
Post procedure
 Instruct the client to increase oral fluid intake to help pass the barium.
 Administer a mild laxative as prescribed to facilitate emptying of the barium.
 Monitor stools for the passage of barium.
 Notify the physician if a bowel movement does not occur within 2 days.
Gastric Analysis
 Requires the passage of the NGT into the stomach to aspirate gastric contents for the analysis of
acidity (pH), appearance, and volume; the entire gastric contents are aspirated, and then specimens
are collected every 15 minutes for 1 hour.
 Histamine or pentagastrin may be administered subcutaneously to stimulate gastric secretions; these
medications may produce a flushed feeling.
 Esophageal reflux of gastric acid may be diagnosed by ambulatory pH monitoring; a probe is placed
just above the lower esophageal sphincter and connected to an external recording device. It provides
a computer analysis and graphic display of results.
Pre procedure
 Fasting for 8 to 12 hours is required before the test.
 Use of tobacco and chewing gum are avoided for 6 hours before the test.
 Medications that stimulate gastric secretions are withheld for 24 to 48 hours.
Post procedure
 Client may resume normal activities.
 Refrigerate gastric samples if not tested within 4 hours.
Upper gastrointestinal Fiberoscopy

 Also known as esophagogastroduodenoscopy b. Following sedation, an endoscope is passed down
the esophagus to view the gastric wall, sphincters, and duodenum; tissue specimens can be
obtained.
Pre procedure
 The client must be NPO for 6 to 12 hours before the test.
 A local anesthetic (spray or gargle) is administered along with medication that provides conscious
sedation and relieves anxiety, such as intravenous (IV) midazolam (Versed), just before the scope is
inserted.
 Atropine sulfate may be administered to reduce secretions, and glucagon may be administered to
relax smooth muscle.
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 Client is positioned on the left side to facilitate saliva drainage and to provide easy access of the
endoscope.
 Airway patency is monitored during the test and pulse oximetry is used to monitor oxygen
saturation; emergency equipment should be readily available.
Post procedure
 Client must be NPO until the gag reflex returns (1 to 2 hours).
 Monitor for signs of perforation (pain, bleeding, unusual difficulty swallowing, elevated
temperature).
 Maintain bed rest for these dated client until alert.
 Lozenges, saline gargles, or oral analgesics can relieve a minor sore throat (not given to the client
until the gag reflex returns).
Anoscopy, proctoscopy, and sigmoidoscopy
 Anoscopy requires the use of a rigid scope to examine the anal canal; the client is placed in the knee-
chest or left lateral position.
 Proctoscopy and sigmoidoscopy require the use of a flexible scope to examine the rectum and
sigmoid colon; the client is placed on the left side with the right leg bent and placed anteriorly.
 Biopsies and polypectomies can be performed.
Pre procedure
 Enemas are administered to cleanse the bowel.
Post procedure
 Monitor for rectal bleeding and

 signs of perforation and peritonitis
-Guarding of the abdomen
-Increased fever and chills
-Pallor
-Progressive abdominal distention and abdominal pain Restlessness
-Tachycardia and tachypnea
Stool specimens
 Testing of stool specimens includes inspecting the specimen for consistency and color and testing for
occult blood.
 Tests for fecal urobilinogen, fat, nitrogen, parasites, pathogens, food substances, and other sub-
stances may be performed; these tests require that the specimen be sent to the laboratory.
 Random specimens are sent promptly to the laboratory.
 Quantitative 24- to 72-hour collections must be kept refrigerated until they are taken to the
laboratory.
 Some specimens require that a certain diet be followed or that certain medications be withheld;
check agency guidelines regarding specific procedures.
Urea breath test
 The urea breath test detects the presence of Helicobacter pylori, the bacteria that cause peptic
ulcer disease.
 The client consumes a capsule of carbon-labeled urea and provides a breath sample 10 to 20
minutes later.
 Certain medications may need to be avoided before testing; these may include antibiotics or
bismuth subsalicylate (Pepto-Bismol) for 1 month before the test; sucralfate (Carafate) and
omeprazole (Prilosec) for 1 week before the test; and cimetidine (Tagamet), famotidine (Pepcid),
ranitidine (Zantac), or nizatidine (Axid) for 24 hours before breath testing.
 H. pylori can also be detected by assessing serum antibody levels.
Liver biopsy
 A needle is inserted through the abdominal wall to the liver to obtain a tissue sample for biopsy and
microscopic examination.
Pre procedure
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 Assess results of coagulation tests (prothrombin time, partial thromboplastin time, platelet count).
 Administer a sedative as prescribed.
 Note that the client is placed in the supine or left lateral position during the procedure to expose the
right side of the upper abdomen.
Post procedure
 Assess vital signs.

 Assess biopsy site for bleeding. Position: Right -side lying position to place pressure on the area of
biopsy, preventing bleeding.
GASTROINTESTINAL DISORDERS
Sandra M. Nettina
INFLAMMATORY BOWEL DISEASE
 is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. It

results from a complex interplay between genetic and environmental factors. Similarities involve (1)
chronic inflammation of the alimentary tract and (2) periods of remission interspersed with episodes
of acute inflammation. There is a genetic predisposition for IBD, and patients with this condition are
more prone to the development of malignancy.
The two major types of inflammatory bowel disease are ulcerative colitis (UC) and Crohn disease (CD).
 ULCERATIVE COLITIS (UC): A chronic condition of unknown cause usually starting in the rectum and
distal portions of the colon and possibly spreading upward to involve the sigmoid and descending
colon or the entire colon. It is usually intermittent (acute exacerbation with long remissions), but
some individuals (30%–40%) have continuous symptoms. Cure is effected only by total removal of
colon and rectum/rectal mucosa.
 It is also an inflammatory disease of bowel that results in poor absorption of nutrients.
 This condition causes long-lasting inflammation and sores (ulcers) in the innermost lining of your
large intestine (colon) and rectum.
 Both ulcerative colitis and Crohn's disease usually involve severe diarrhea, abdominal pain, fatigue
and weight loss.
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Figure 28: Colon and Rectum
PATHOPHYSIOLOGY AND ETIOLOGY OF ULCERATIVE COLITIS

1.The exact cause of ulcerative colitis is UNKNOWN. Possible theories include:
a. Genetic predisposition.
b. Environmental factors may trigger disease (viral or bacterial pathogens, dietary).
c. Immunologic imbalance or disturbances
d. Detect intestinal barrier causing hypersensitive mucosa and increased permeability.
e. Defect repair of mucosal injury, which may develop into a chronic condition.
2. Multiple crypt abscesses develop in intestinal mucosa that may become necrotic and lead to
ulceration.
3. most common in young adulthood and middle life, peak incidence at 20 – 40 years of age.
4. incidence greatest in Caucasians of Jewish descent.
Risk factors
 Age. Most people who develop IBD are diagnosed before they're 30 years old. But some people don't
develop the disease until their 50s or 60s.
 Race or ethnicity. Although whites have the highest risk of the disease, it can occur in any race. If
you're of Ashkenazi Jewish descent, your risk is even higher.
 Family history. You're at higher risk if you have a close relative — such as a parent, sibling or child —
with the disease.
 Cigarette smoking. Cigarette smoking is the most important controllable risk factor for developing
Crohn's disease. Although smoking may provide some protection against ulcerative colitis, the overall
health benefits of not smoking make it important to try to quit.
 Nonsteroidal anti-inflammatory medications. These include ibuprofen (Advil, Motrin IB, others),
naproxen sodium (Aleve), diclofenac sodium (Voltaren) and others. These medications may increase
the risk of developing IBD or worsen disease in people who have IBD.
 Where you live. If you live in an industrialized country, you're more likely to develop IBD. Therefore, it
may be that environmental factors, including a diet high in fat or refined foods, play a role. People
living in northern climates also seem to be at greater risk.
 Diarrhea – maybe blood or contain pus and mucus.

 Tenesmus (painful straining), sense of urgency, and frequency.
 Increased bowel sounds; abdomen may appear flat, but, as condition continues, abdomen may
appear distended.
 There more often is weight loss, fever, dehydration, hypokalemia, anorexia, nausea and vomiting,
iron deficiency anemia, and cachexia (general lack of nutrition and wasting with chronic disease).
 Crampy abdominal pain
 The disease usually begins in the rectum and sigmoid and spreads proximally, at times, involving the
entire colon. Anal area maybe irritated and reddened; left lower abdomen may be tender on
palpation.
 There is a tendency for the patient to experience remission and exacerbations.
 Increased risk of developing colorectal cancer.
 May inhibit extracolonic manifestation of eye, joint, and skin complaints.
Diagnosis is based on a combination of laboratory, radiologic, endoscopic, and histologic findings.
Laboratory Tests
2. Stool examination – to rule out enteral pathogens; fecal analysis positive for blood during
active disease.
3. Complete blood count - hemoglobin and hematocrit may be low due to bleeding; WBC may
increase.
4. Increased prothrombin time possible.
5. Elevated ESR erythrocyte sedimentation rate.
6. Decrease serum level of potassium, magnesium, and albumin may be present.
Other diagnostic test
1. Barium enema – to assess extent of disease and detect psuedopolyps, carcinoma, and strictures, may
show haustral markings, narrow, lead – pipe appearance; superficial ulceration.
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2. Flexible proctosigmoidoscopy/colonoscopy findings reveal mucosal erythema and edema, ulcers,

inflammation that begin distally in the rectum and spreads proximally for variable distances.
Psuedopolyps and friable tissue may be present.
3. Changes in crypt height, loss of crypts, crypt abscess with neutrophils infiltrates on biopsy.
MEDICAL MANAGEMENT
Drug therapy
1. 5 – aminosalicylic acid – sulfasalazine (Azulfidine) – main stay drug for acute and maintenance
therapy, dose related side effects include vomiting, anorexia, headache, skin discoloration,
dyspepsia, and lowered sperm count.
2. Oral salicylates, such as mesalamine (Pentasa), olsalazine (Dipentum) – appear to be as effective as
sulfasalazine and are used when patients are allergic to sulfa.
o Nephrotoxicity can occur with mesalamine; diarrhea; with olsalazine.
3. Mesalamine enema available for proctosigmoiditis; suppository for proctitis.
4. Corticosteroids – primary agent used in the management of inflammatory disease. Should be treated
concomitantly with 5 – aminosalicylic acid preparations to benefit from their potential steroid
sparring effects. Corticosteroids must be prepared slowly over 6 – 8 weeks period;
o Prednisolone (Delta – cortef) IV, to induce remission of acute severe disease.

o Prednisone (Orsone) – orally, for moderate to severe disease.
o Hydrocortisone (Corftef) – enema used for proctitis and left sided colitis.
5. Immunosuppressive drugs – purine analogues, 6 mercaptopurine, azathioprine may be indicated
when patient is refractory or dependent or corticosteroids.
6. Antidiarrheal medications may be prescribed to control diarrhea, rectal urgency and cramping,
abdominal pain ; not routinely ordered – treat with caution.
SURGICAL INTERVENTIONS
1. Total Proctocolectomy with permanent ileostomy

a. The procedure is curative and involves the removal of the entire colon (colon, rectum, and
anus with anal closure).
b. The end of the terminal ilium forms the stoma, which is located in the right lower quadrant.
2. Kock ileostomy (continent ileostomy)
a. The Kock ileostomy is an intraabdominal pouch that stores the feces and is constructed from
the terminal ilium.
b. The pouch is connected to the stoma with a nipple like valve constructed from a portion of
the ileum. The stoma is flush with the skin.
c. A catheter is used to empty the pouch, and a small dressing or adhesive bandage of worn
over the stoma between emptying’s.
3. Ileoanal reservoir
a. Creation of an ileoanal reservoir is a two stage procedure that involves the excision of the
rectal mucosa, an abdominal colectomy, construction of a reservoir to the anal canal, and a
temporary loop ileostomy.
b. The ileostomy is closed 3 – 4 month after the capacity of the reservoir is increase and has
had time to heal.
4. Ileoanal anastomosis
a. Does not require and ileostomy
b. A 12 – to 15 cm rectal stump is left after the colon is removed, and the small intestine is
inserted into this rectal sleeve anastomosed.
c. Ileorectostomy requires a large, compliant rectum.
5. Preoperative colostomy and ileostomy interventions.
a. Consult with enterostomal therapist to assist in identifying optimal placement of the
ostomy.
b. Reinforce instructions to eat a low – fiber diet for 1 – 2 days before surgery as prescribed.
c. Administer intestinal antiseptic and antibiotics of prescribed to cleanse the bowel and to
decrease the bacterial content of the colon.
d. Administer laxative and enemas as prescribe.
6. Postoperative colostomy interventions.
a. Place petrolatum gauze over the stoma as prescribe to keep moist, followed by a dry, sterile
dressing if a pouch (external) system is not in place.
b. Place a pouch system on the stoma as soon as possible.
c. Monitor the stoma for size, unusual bleeding, or necrotic tissue.
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d. Monitor for color changes in the stoma.

e. Note that the normal stoma color is PINK to BRIGHT RED and SHINY, indicating highly
vascularity.
f. Note the a pale pink stoma indicates low hemoglobin and hematocrit levels, and a purple
– black stoma indicates compromised circulation, requiring health care practitioner
notifications.
g. Monitor the functioning of the colostomy and check for bowel sounds
h. Expect that the stool is liquid in the immediate postoperative period but becomes more
solid, depending on the area of the colostomy; ascending colon – liquid; transverse colon –
loose to semiformed; and descending colon – close to normal.
i. Monitor the pouch system for proper fit and signs of leakage.
j. Empty the pouch when it is one third full.
k. Fecal matter should not be allowed on the skin.
l. Administer analgesics and antibiotics as prescribed.
m. Assist to irrigate the perineal wound (if present) as prescribed, and monitor for signs of
infection.
n. Reinforce instructions about the stoma care and irrigations.
Colostomy Irrigation
Purpose: an enema is given through the stoma to stimulate bowel emptying.
Description: irrigation is performed by instilling 500 – 1000 ml of Luke warm tap water through
the stoma and allowing the water and stool drain into a collection of bag.
Procedure:
o If ambulatory, position the client sitting on the toilet
o If on bed rest, position the client on his or her side
o Hang the irrigation bag so that the bottom of the bag is level of the client shoulder or
slightly higher.
o Insert the irrigation tube carefully without force.
o Clamp the tubing if cramping occurs; release the tubing as cramping subside.
o Avoid frequent irrigations, which can lead to loss of fluid and electrolytes.
o Perform irrigation at about the same time each day.
o Perform irrigation preferably 1 hour after a meal.
o To enhance effectiveness of the irrigation, massage the abdomen gently.
o. Reinforce instruction that normal activities may be resumed when approved by the health
care provider.
7. Post-operative ileostomy interventions.
 Note that normal stool is liquid.
 Monitor for dehydration and electrolyte imbalance.
1. 1.Acute phase: Maintain NPO status and assist to administer fluids and electrolytes intravenously or
via parenteral nutrition as prescribed.
2. Restrict the client activity to reduce intestinal activity.
3. Monitor bowel sounds and for abdominal tenderness and cramping.
4. monitor stool, noting color, consistency, and the presence or absence of blood.
5. monitor for bowel preparation, peritonitis, and hemorrhage.
6. Following the acute phase, the diet progresses from clear liquid to low – fiber diet; usually a low fiber
is tolerated.
7. Reinforce instruction about diet; usually a low fiber, high – protein diet with vitamins and iron
supplements is prescribe.
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8. Reinforce instruction to avoid gas – forming foods, milk products, and food such as whole- wheat
grains, nuts, raw fruits and vegetable, pepper, alcohol, and caffeine containing products.
9. Reinforce instruction to avoid smoking.
10. Administer medication as prescribed, which may include a combination of medications such as
salicylate compounds, corticosteroids, immunosuppressants and antidiarrheal.
CROHN’S DISEASE
 Can be found in portions of the alimentary tract from the mouth to the anus but is most commonly
found in the small intestine (terminal ileum). It is a slowly progressive chronic disease of unknown
cause with intermittent acute episodes and no known cure.
 Crohn’s disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract, but
most often affects the terminal ileum and lead to thickening and scarring, a narrowed lumen, fistulas,
ulceration, and abscesses. It is characterized by remissions and exacerbations.
Figure 29: Site of crhons disease on small intestine

PATHOPHYSIOLOGY AND ETIOLOGY
1.Exact cause is UNKOWN for this disease. It is thought to be multifunctional with the following theories:
 genetic predisposition.
 environmental agents may trigger the disease such as infection (viral or bacterial overload) or dietary
factors.
 Immunologic imbalance or disturbances
 Defect in the intestinal barrier that increases the permeability of the bowel.
 Defect in the repair of mucosal injury leading to chronic conditions.
 Cigarette smoking is a risk factor in developing disease and increase execrations. In contrast,
cigarette smoking seems to have a protective effect with ulcerative colitis.
2. Intestinal tissue is thickened and edematous; ulcers enlarge, deepen, and form transverse and longitudinal
linear ulcer that intersects, resembling cobblestone appearance. The deep penetration of this ulcers may
form fissure, abscesses and fistulae. The healing and the fibrosis of these lesions may lead to stricture.
3.The rectum is usually speared from disease, and “skip lesions: are discontinuous areas of diseased bowel.
4.Transluminal inflammation Is a characteristic finding of this disease as well as granulomas.
5. Involvement of the upper GI (mouth, esophagus stomach, and duodenum) is rare and if present, there is
usually disease elsewhere.
6.May occur at any age, but occurs mostly in those between 15 and 35 years of age.
7.Higest incidence with Caucasians of Jewish descent.
8.The clinical presentation can be divided into three patterns:

a. Inflammatory
b. Fibrostenotic (stricturing)
c. Perforating (Fistulizing)
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9.Recurrence tend to fall the same pattern for each individual patient and may provide an approach to
treatment.
CLINICAL MANIFESTATION
These are characterized by exacerbations and remissions maybe abrupt or insidious.
 Crampy pain in the right lower quadrant.

 Chronic diarrhea – usual consistency is soft or semi – liquid. Bloody stool or steatorrhea (due to
malabsorption) may occur.
 Fever may indicate infectious complication such as abscess.
 Fecal urgency and tenesmus.
 Palpable right lower quadrant fullness or mass may be palpated, which corresponds to adherent
loops of bowel or abscess.
 Rectal examination may reveal a perirectal abscess, fistula, fissure, or skin tags, which represent
healed perineal lesions.
 The inflammatory pattern may display malabsorption, weight loss and less abdominal pain.
Fibrostenotic pattern may display a partial small bowel obstruction, diffuse abdominal pain, nausea,
vomiting, and bloating;
perforating pattern may display a sudden profuse diarrhea sue to enteroenteric fistula, fever, and
localized tenderness due to abscess, or other fistulizing symptoms such as pneumaturia and
recurrent UTI.
 Complete Blood Count may show mild leukocytosis, thrombocytosis, anemia.
 Elevated ESR.
 Stool analysis may reveal leukocytes but no enteric pathogens.
 Upper GI and SB follow through barium studies may show the classics “string signs” at the terminal
ilium.
 Colonoscopy. This exam allows your doctor to view your entire colon using a thin, flexible, lighted
tube with an attached camera. During the procedure, your doctor can also take small samples of
tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis.
o It is a procedure of choice. Typical findings include presence of skin lesions, cobblestoning,

ulceration and rectal sparing.
 Flexible sigmoidoscopy. Your doctor uses a slender, flexible, lighted tube to examine the rectum and
sigmoid, the last portion of your colon. If your colon is severely inflamed, your doctor may perform
this test instead of a full colonoscopy.
Figure 30: Colonoscopy

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Figure 31: Sigmoidoscopy
 Care is similar to the client with ulcerative colitis; however, surgery is avoided for as long as possible
because recurrence of the disease process in the same region is likely to occur.
APPENDICITIS
 Is inflammation of the vermiform appendix caused by an obstruction of the intestinal lumen from
infection, stricture, fecal mass, foreign body, or tumor.
 The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal valve.
 Because the appendix empties into the colon inefficiently and its lumen is small, it is prone to
becoming obstructed and is vulnerable to infection (appendicitis).
Figure 32: The Appendix obstruction and inflammation
 Obstruction. The appendix becomes inflamed and edematous as a result of becoming kinked or
occluded by a fecalith, tumor, or foreign body.
 Inflammation. The inflammatory process increases intraluminal pressure, initiating a
progressively severe, generalized, or periumbilical pain.
 Pain. The pain becomes localized to the right lower quadrant of the abdomen within a few
hours.
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 Pus formation. Eventually, the inflamed appendix fills with pus.
 Abdominal pain (initially generalized but within a few hours becomes localized in the right lower
abdomen [McBurney point]; worsens on gentle percussion and when the patient coughs)
 Anorexia
 Nausea
 Vomiting (one or two episodes)
 Low-grade fever
 Malaise
 Constipation
 Walking bent over to reduce right lower quadrant pain
 Sleeping or lying supine, keeping right knee bent up to decrease pain
 Normal bowel sounds
 Rebound tenderness and spasm of abdominal muscles common (pain in the right lower quadrant
from palpating the lower left quadrant)
 Abdominal tenderness completely absent, if appendix positioned retrocecally or in the pelvis;
instead, flank tenderness revealed by rectal or pelvic examination
 Abdominal rigidity and tenderness that worsen as condition progresses; sudden cessation of
abdominal pain signaling perforation or infarction
Figure 33: Eliciting abdominal pain
 Physical examination consistent with clinical manifestations.

 White blood cells (WBC) count reveals moderate leukocytosis (10,000 – 16,000/mm) with shift to the
left (increased neutrophils).
 Urinalysis to rule out urinary disorders.
 Abdominal X – ray may visualize shadow consistent with fecalith in appendix; perforation will reveal
free air.
 Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions.
SURGICAL MANAGEMENT
Immediate surgery is typically indicated if appendicitis is diagnosed.
 Appendectomy. Appendectomy or the surgical removal of the appendix is performed as soon as it is
possible to decrease the risk of perforation.
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Figure 34: Appendectomy
 Laparotomy and laparoscopy. Both of these procedures are safe and effective in the treatment of
appendicitis with perforation.
Preoperative interventions
 Maintain NPO status.
 Assist to administer fluids intravenously to prevent dehydration.
 Monitor signs of ruptured appendix and peritonitis.
 Position the client right side – lying position or low semi – fowlers position to promote comfort.
 Monitor bowel sounds
 Apply ice pack to the abdomen for 20 – 30 minutes every hours as prescribed.
 Assist to administer antibiotics as prescribed.
 Avoid laxative or enemas.

 Avoid the application of heat to the abdomen of client with appendicitis. Heat can cause rupture of
the appendix leading to peritonitis, a life-threatening conditions.
Postoperative interventions
 Monitor temperature for signs of infection.
 Monitor incision for sign of infection such as redness, swelling, and pain.
 Maintain NPO status until bowel function has returned.
 Advance diet gradually as tolerated and as prescribe, when the bowel sound has returned.
 If ruptured of the appendix has occurred, expect a drain to be inserted, or the incision may be left
open to heal from the inside out.
 Position the client to the right side – lying position or to semi-fowlers position, with legs flexed, to
facilitate drainage.
 Change the dressing as prescribed and record the type and amount of drainage.
 Perform wound irrigation if prescribe.
 Maintain nasogastric suction and patency of the NGT if present.
 Assist to administer antibiotics and analgesics as prescribe.
PERITONITIS
 Peritonitis is a generalized or localized inflammation of the peritoneum, the membrane lining the
abdominal cavity and covering visceral organs.
Figure 35: Peritonitis

Primary peritonitis – acute and spontaneous condition; relatively rare
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 Persons with nephrosis or cirrhosis; the offending organism is most often Echerichia coli.
 May occur in young females; introduced through uterine tubes or blood due to pathogenic bacteria
such as streptococci, pneumococci, or gonococci.
Secondary peritonitis – contamination of peritoneal cavity by GI fluid and microorganism
 Complications of appendicitis, diverticulitis, peptic ulcer disease, biliary tract disease, colon
inflammation, volvulus, strangulated obstruction, perforation and abdominal cancer.
 May occur after abdominal trauma; gunshot wound, stab wound, or blunt trauma from motor
vehicle accident.
 May occur postoperative complications.
o May occur after intraoperative intestinal spillage
o Compromised patient are vulnerable (those with DM, malignancy, malnutrition, or steroids).
 May result from continuous ambulatory peritoneal dialysis.
 Pain. At first, there is diffuse pain, which tends to become constant, localized, and more intense over
the site of the pathologic process.
 Tenderness. The affected area of the abdomen becomes extremely tender and distended, the
muscles become rigid, and movement could aggravate it further.
 Nausea and vomiting often occur; peristalsis diminished; anorexia is present.
 Altered vital signs. A temperature of 37.8C to 38.3C can be expected along with an increased pulse
rate.
 Shallow respirations may result from abdominal distention and upward displacement of the
diaphragm. Note: with generalized peritonitis, large volumes of fluids may be lost into abdominal
cavity (can account for losses to 5 L/day).
 WBC to show leukocytosis (leukopenia if severe).
 Urinalysis may indicate urinary tract problems as primary source.
 Peritoneal aspiration (paracentesis) to demonstrate blood, pus, bile, bacteria (Gram’s stain),
amylase.
 Abdominal X – rays may show free air in peritoneal cavity, gas, and fluid collection in small and large
intestine, generalized bowel dilatation, intestinal wall edema.
 CT scan of the abdomen may reveal abscess formation, intrabdominal mass, and ascites.
MANAGEMENT
 Treatment of inflammatory conditions preoperatively and postoperatively with antibiotics therapy
may prevent peritonitis. Broad spectrum antibiotics therapy to cover aerobic and anaerobic
organism is initial treatment, followed by specific antibiotic therapy after cultured and sensitivity
results.
 Bed rest, NPO status, respiratory support if needed.
 IV fluids and TPN
 Analgesics and antiemetics for nausea and vomiting.
 NG intubation to decompress the bowel.
 Operative procedure to close the perforation, remove infection source (ie, inflamed organ, necrotic
tissue)drain abscess, and lavage peritoneal cavity.
 Abdominal paracentesis may be done to remove accumulating fluid.
 Blood transfusion, if appropriate.
 Oral feedings after return of bowel sounds and passage of gas and/ or feces.
PEPTIC ULCER DISEASE

 A peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus
in portions accessible to gastric secretions; erosion may extend through the muscle.
 The ulcer may be referred to as gastric, duodenal, or esophageal, depending on its location.
 The most common peptic ulcers are gastric ulcers and duodenal ulcers.
Gastric ulcers
 A gastric ulcer involves ulceration of the mucosal lining that extends to the submucosal layer of the
stomach.
 Predisposing factors include stress, smoking, the use of corticosteroids, NSAIDs, alcohol, history of
gastritis, family history of gastric ulcers, or infection with H. pylori.
 Complications include hemorrhage, perforation, and pyloric obstruction.
Assessment:
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 Burning, aching, or gnawing pain in the upper epigastrium occurring 30 minutes to 1 hour after meals
(rarely at night);
 Unrelieved by eating
 Epigastric tenderness
Interventions
 Monitor vital signs and for signs of bleeding.
 Administer small, frequent bland feedings during the active phase.
 Administer H2-receptor antagonists or proton pump inhibitors as prescribed to decrease the
secretion of gastric acid.
 Administer antacids as prescribed to neutralize gastric secretions.
 Administer anticholinergics as prescribed to reduce gastric motility.
 Administer mucosal barrier protectants as prescribed 1 hour before each meal.
 Administer prostaglandins as prescribed for their protective and antisecretory actions.
Client education
 Avoid consuming alcohol and substances that contain caffeine or chocolate.
 Avoid smoking.
 Avoid aspirin or NSAIDs.
 Obtain adequate rest and reduce stress.
Interventions during active bleeding
 Monitor vital signs closely.
 Assess for signs of dehydration, hypovolemic shock, sepsis, and respiratory insufficiency.
 Maintain NPO status and administer IV fluid replacement as prescribed; monitor intake and output.
 Monitor hemoglobin and hematocrit.
 Administer blood transfusions as prescribed.
 Prepare to assist with administering medications as prescribed to induce vasoconstriction and reduce
bleeding.
Surgical interventions
 Total gastrectomy: Removal of the stomach with attachment of the esophagus to the jejunum or
duodenum; also called esophago- jejunostomy or esophagoduodenostomy
 Vagotomy: Surgical division of the vagus nerve to eliminate the vagal impulses that stimulate
hydrochloric acid secretion in the stomach
 Gastric resection: Removal of the lower half of the stomach and usually includes a vagotomy; also
called antrectomy
Billroth I: Partial gastrectomy, with the remaining segment anastomosed to the duodenum; also
called gastroduodenostomy (Fig. 56-1)
Billroth II: Partial gastrectomy, with the remaining segment anastomosed to the jejunum; also
called gastrojejunostomy (Fig. 56-2) f. Pyloroplasty: Enlargement of the pylorus to prevent or
decrease pyloric obstruction, thereby enhancing gastric emptying.
Postoperative interventions

 Place in a Fowler’s position for comfort and to promote drainage.
 Administer fluids and electrolyte replacements intravenously as prescribed; monitor intake and
output.
 Assess bowel sounds.
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 Monitor nasogastric suction as prescribed.

 Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns.Progress the diet from NPO
to sips of clear water to six small bland meals a day, as prescribed when bowel sounds return.
 Monitor for postoperative complications of hemorrhage, dumping syndrome, diarrhea,
hypoglycemia, and vitamin B12 deficiency.
Duodenal ulcers
 A duodenal ulcer is a break in the mucosa of the duodenum.
 Risk factors and causes include infection with H. pylori; alcohol intake; smoking; stress; caffeine; the
use of aspirin, corticosteroids, and NSAIDs.
 Complications include bleeding, perforation, gastric outlet obstruction, and intractable disease.
Assessment
 Burning, gnawing pain in the right epigastrium occurring 2 – 3 hours after meal, possibly causing the
client to awaken at night;
 Relieved by eating
 Pyrosis (Heartburn), nausea and vomiting
 GI bleeding, a slow oozing manifested by melena or a sudden, rapid loss of large amounts of blood
through hematemesis.
Interventions
 Instruct the client about a bland diet, with small frequent meals.
 Provide for adequate rest.
 Encourage the cessation of smoking.
 Instruct the client to avoid alcohol intake, caffeine, the use of aspirin, corticosteroids, and NSAIDs.
 Administer medications to treat H. pylori and antacids to neutralize acid secretions as prescribed.
 Administer H2-receptor antagonists or proton pump inhibitors as prescribed to block the secretion of
acid.
 Surgical interventions: Surgery is performed only if the ulcer is unresponsive to medications or if
hemorrhage, obstruction, or perforation occurs.
VITAMIN B12 DEFICIENCY
 Vitamin B12 deficiency results from an inadequate intake of vitamin B12 or a lack of absorption of
ingested vitamin B12 from the intestinal tract. 2. Pernicious anemia results from a deficiency of
intrinsic factor, necessary for intestinal absorption of vitamin B12; gastric disease or surgery can
result in a lack of intrinsic factor.
Assessment
 Severe pallor
 Fatigue
 Weight loss
 smooth, beefy red tongue
 Slight jaundice
 Paresthesias of the hands and feet
 Disturbances with gait and balance
Interventions
 Increase dietary intake of foods rich in vitamin B12 if the anemia is the result of a dietary deficiency.
Foods Rich in Vitamin B12

 Brewer’s yeast
 Citrus fruits
 Dread beans
 Green, leafy vegetable
 Liver
 Nuts
 Organ meat
Interventions
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 Administer vitamin B12 injections as prescribed weekly initially and then monthly for maintenance
(lifelong) if the anemia is the result of a deficiency of intrinsic factor or disease or surgery of the
ileum.
PANCREATIC DISORDERS
 The pancreas secretes pancreatic enzymes including amylase and lipase, through the pancreatic duct
when stimulated by cholecystokinin and secretin to aid in digestion of carbohydrates and fat in the
small intestine. The pancreas also secretes hormones, such as insulin and glucagon, that help to
regulate and maintain normal serum glucose.
 Pancreatitis, which is the inflammation of the pancreas, can be acute or chronic in nature. It may be
caused by edema, necrosis or hemorrhage. In men, this disease is commonly associated to
alcoholism, peptic ulcer or trauma; in women, it’s associated to biliary tract disease. Prognosis is
usually good when pancreatitis follows biliary tract disease, but poor when the factor is alcoholism.
Mortality rate may go as high as 60% when the disease is associated from necrosis and hemorrhage.
(Schilling McCann, 2009).
ACUTE PANCREATITIS
 Acute pancreatitis is an inflammation of the pancreas, ranging from mild edema to extensive
hemorrhage, resulting from various insults to the pancreas. It is defined by a discrete episode of
abdominal pain and serum enzymes elevations. The structure and function of the pancreas usually
return to normal after an acute attack. Chronic pancreatitis occurs when there is persistent cellular
damage to the pancreas.
1. Excessive alcohol consumption is the most common cause in the United States.
2. Also commonly caused by biliary tract disease, such as cholelithiasis, acute and chronic
cholecystitis.
3. Less common causes are bacterial or viral infection, blunt abdominal trauma, peptic ulcer
disease, ischemic vascular disease, hyperlipidemia, hypercalcemia; the use of
corticosteroids, thiazide diuretics, and oral contraceptives; surgery on or near the pancreas
or after instrumentation of the pancreatic duct by ERCP; tumors of the pancreas or ampulla;
and a low incidence of hereditary pancreatitis.
4. Mortality is high (10%) because of shock, anoxia, hypotension, or multiple organ
dysfunction.
5. Attacks may resolve with complete recovery, may recur without permanent damage, or may
progress to chronic pancreatitis.
6. Autodigestion of all or part of the pancreas is involved, but the exact mechanism is not
completely understood.
(Depends on severity of pancreatic damage.)
 Abdominal pain, usually constant, mid epigastric or periumbilical, radiating to the back or flank.
Patient assumes a fetal position or leans forward while sitting (known as “proning”) to relieve
pressure of the inflamed pancreas on celiac plexus nerves. Pain can be mild to incapacitating.
 Nausea and vomiting.
 Fever.
 Involuntary abdominal guarding, epigastric tenderness to deep palpation, and reduced or absent
bowel sounds.
 Dry mucous membranes; hypotension; cold, clammy skin; cyanosis; and tachycardia, which may
reflect mild to moderate dehydration from vomiting or capillary leak syndrome (third space loss).
 Shock may be the presenting manifestation in severe episodes, with respiratory distress and acute
renal failure.
 Purplish discoloration of the flanks (Turner’s sign) or of the periumbilical area (Cullen’s sign) occurs in
extensive
 hemorrhagic necrosis of the pancreas.
DIAGNOSTIC EXAMINATION
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 Serum amylase, lipase, glucose, bilirubin, alkaline phosphatase, lactate dehydrogenase, AST, ALT,
potassium, and cholesterol may be elevated.
 Serum albumin, calcium, sodium, magnesium and, possibly, potassium may be low due to
dehydration, vomiting, and the binding of calcium in areas of fat necrosis.
 Abdominal X-ray to detect an ileus or isolated loop of small bowel overlying pancreas. Pancreatic
calcifications or gallstones may suggest an alcohol or biliary etiology.
 CT scan is the most definitive study for determining pancreatic changes.
 Chest X-ray for detection of pulmonary complications. Pleural effusions are common, especially on
the left, but may be bilateral.
Management
Depending on severity of episode, management focuses on alleviation of symptoms and support of patient to
prevent complications.
1. Restoration of circulating blood volume with I.V. crystal- loid or colloid solutions or blood products.
2. Maintenance of adequate oxygenation reduced by pain, anxiety, acidosis, abdominal pressure, or
pleural effusions.
3. Pain control to alleviate pain and anxiety, which increases pancreatic secretions.
4. Rest of the GI tract.
a. Withhold oral feedings to decrease pancreatic secretions.
b. NG intubation and suction to relieve gastric stasis, distention, and ileus, if needed.
5. Maintenance of alkaline gastric pH with H 2-receptor antagonists and antacids to suppress acid drive
of pancreatic secretions and to prevent stress ulcer complications of acute illness.
6. Nutrition provided or treatment of malnutrition with parenteral feedings as needed.
7. Pharmacotherapy.
a. Electrolyte replacements as needed.
b. Sodium bicarbonate to reverse metabolic acidosis.
c. Insulin to treat hyperglycemia.
d. Antibiotic therapy for documented infection or sepsis.
8. Surgical intervention if complications occur.
a. Incision and drainage of infection and pseudocysts.
b. Debridement or pancreatectomy to remove necrotic pancreatic tissue.
c. Cholecystectomy for gallstone pancreatitis.
Complications
1. Pancreatic ascites, abscess, or pseudocyst.
2. Pulmonary infiltrates, pleural effusion, acute respiratory distress syndrome.
3. Hemorrhage with hypovolemic shock.
4. Acute renal failure.
5. Sepsis and multiple-organ dysfunction syndrome.
GERONTOLOGIC ALERT The incidence of severe, systemic complications of pancreatitis increases with age.
Assess for any changes in mental status in an older person with pancreatitis as an indicator of an underlying
complication. Acute pancreatitis in an older person without other precipitating factors may indicate an
underlying pancreatic tumor obstructing the pancreatic duct.
NURISNG INTERVENTIONS
Controlling Pain
1. Administer opioid analgesics, as ordered, to control pain. 2. Assist patient to a comfortable position.
3. Maintain NPO status to decrease pancreatic enzyme secretion.
4. Maintain patency of NG suction to remove gastric secretions and to relieve abdominal distention, if
indicated.
5. Provide frequent oral hygiene and care.
6. Administer antacids or H2-receptor antagonists as prescribed.
7. Report increase in severity of pain, which may indicate hemorrhage of the pancreas, rupture of a
pseudocyst, or inadequate dosage of the analgesic.
Restoring Adequate Fluid Balance

1. Monitor and record vital signs, skin color, and temperature.
2. Monitor
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intake and output and weigh daily.

3. Evaluate laboratory data for hemoglobin, hematocrit, albumin, calcium, potassium, sodium, and
magnesium levels and administer replacements as prescribed.
4. Observe and measure abdominal girth if pancreatic ascites is suspected.
5. Report trends in falling BP or urine output or rising pulse, because this may indicate hypovolemia and
shock or renal failure.
Improving Respiratory Function

1. Assess respiratory rate and rhythm, effort, oxygen saturation, and breath sounds frequently.
2. Position in upright or semi-Fowler’s position to enhance diaphragmatic excursion.
3. Administer oxygen supplementation, as prescribed, to maintain adequate oxygen levels.
4. Report signs of respiratory distress immediately.
5. Instruct patient in coughing and deep breathing to improve respiratory function.

1. Instruct patient to gradually resume a low-fat diet.
2. Instruct patient to increase activity gradually, providing for daily rest periods.
3. Reinforce information about disease process and precipitating factors. Stress that subsequent bouts of
acute pancreatitis may destroy the pancreas, cause additional complications, and lead to chronic
pancreatitis.
4. If pancreatitis is a result of alcohol abuse, patient needs to be reminded of the importance of eliminating
all .
CHRONIC PANCREATITIS
 Chronic pancreatitis is defined as the persistence of pancreatic cellular damage after acute
inflammation and decreased pancreatic endocrine and exocrine function.

1. Alcohol abuse is the most common cause; less common causes are hyperparathyroidism, hereditary
pancreatitis, malnutrition, and trauma to the pancreas.
2. With chronic inflammation, destruction of the secreting cells of the pancreas causes maldigestion
and malabsorption of protein and fat and possibly diabetes mellitus if islet cells of the pancreas have
been affected.
3. As cells are replaced by fibrous tissue, obstruction of the pancreatic and common bile ducts and
duodenum may result.
 Pain is usually located in the epigastrium or left upper quadrant, frequently radiating to the back;
similar to that observed in acute pancreatitis, but more constant and occurring at unpredictable
intervals. As the disease progresses, recurring attacks of pain will be more severe, more frequent,
and of longer duration.
 Weight loss, nausea, vomiting, anorexia.
 Malabsorption and steatorrhea occur late in the course of the disease.
 Diabetes mellitus.
 Serum amylase and lipase may be normal to low because of decreased pancreatic exocrine function.
 Fecal fat analysis determines need for pancreatic enzyme replacement.
 Bilirubin and alkaline phosphatase may be elevated if biliary obstruction occurs.
 Secretin and cholecystokinin stimulatory test results are abnormal.
 Plain abdominal X-ray to determine diffuse calcification of the pancreas.
 CT scan identifies pancreatic structural changes, such as calcifications, masses, ductal irregularities,
enlargement, and pseudocysts.
 ERCP defines ductal anatomy and localizes complications, such as pancreatic pseudocysts and ductal
disruptions.
Management
1. Pain management.
2. Correction of nutritional deficiencies.
3. Pancreatic enzyme replacement.
4. Treatment of diabetes mellitus.
5. Endoscopic placement of pancreatic stent allowing free flow of pancreatic juices through distorted and
irregular/narrowed pancreatic duct.
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6. Surgical interventions to reduce pain, restore drainage of pancreatic secretions, correct structural
abnormalities, and manage complications.
a. Pancreaticojejunostomy—side-to-side anastomosis of pancreatic duct to jejunum to drain
pancreatic secretions into jejunum.
b. Revision of sphincter of ampulla of Vaterbyasphincteroplasty, in which the sphincter is sewn
open to allow free flow of pancreatic juices.
c. Drainage of pancreatic pseudocyst into nearby structures or by external drain.
d.Resection of part of pancreas (Whipple procedure, distal pancreatectomy) or removal of entire
pancreas (total pancreatectomy).
e. Autotransplantation of islet cells.
Complications
1. Pancreatic pseudocyst.
2. Pancreatic ascites and pleural effusions.
3. GI hemorrhage.
4. Biliary tract obstruction.
5. Pancreatic fistula.
Controlling Pain
1. Assess and record the character, location, frequency, and duration of pain.
2. Determine precipitating and alleviating factors of the patient’s pain.
3. Explore the effect of pain on patient’s lifestyle and eating habits.
4. Administer or teach self-administration of analgesics (opioids), as ordered, to control pain.
a. Use nonpharmacologic methods to promote relaxation, such as distraction, imagery, and progressive
muscle relaxation.
b. Assess response to pain-control measures, and refer to chronic pain management clinic, if indicated.
Improving Nutritional Status

1. Assess nutritional status, history of weight loss, and dietary habits, including alcohol intake.
2. Administer pancreatic enzyme replacement with meals, as prescribed.
3. Administer antacids or H2-receptor antagonists to prevent neutralization of enzyme supplements, as
indicated.
4. Monitor intake and output and daily weight.
5. Assess for GI discomfort with meals and character of stools.
6. Monitor blood glucose levels and teach balanced, low concentrated carbohydrate diet and insulin
therapy as indicated.
D R U G A L E R T : Warn the patient that dangerous hypoglycemic reaction may result from use of insulin
while drinking alcohol and skipping meals.
7. Identify foods that aggravate symptoms and teach low-fat diet.
Relieving Anxiety About Surgical Intervention

1. Describe planned surgical intervention and the expected results.
a. Decreased pain.
b. Ability to eat better and improve general condition.
2. Prepare patient for adverse effects and complications of surgery.
a. Total pancreatectomy will cause permanent diabetes mellitus, dependence on insulin, severe
malabsorption, and the need for lifelong pancreatic enzyme replacement.
b. Malnutrition and debility increase patient’s risk for poor healing and complications of surgery.
3. Assist patient to prepare for surgery by encouraging abstinence of alcohol and intake of nutritional and
vitamin supplements.
4. Encourage patient to enlist help of support network and strengthen appropriate coping mechanisms.
5. After surgery, provide meticulous care to prevent infection, promote wound healing, and prevent routine
complications of surgery .

1. Instruct patient regarding correct use of analgesics.
2. Instruct in proper administration of pancreatic enzyme replacement.
a. Take just before or during meals.
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b. May be enteric coated. Do not crush or chew tablets; powder may be obtained if swallowing
tablets is difficult.
c. Take with antacid or take H2-receptor antagonist as directed to prevent pancreatic enzyme
from being destroyed by gastric acid secretions.
3. Advise patient to monitor number and characteristics of stools; report increased stools or food intolerance.
4. Diabetic teaching with follow-up to monitor progression of condition, if applicable.
5. Stress that no treatment will be effective if alcohol consumption is continued.
Cholelithiasis
1. Stones occur when cholesterol supersaturates the bile in the gallbladder and precipitates out of the bile.
The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant, producing
inflammatory changes in the gallbladder.
a. Cholesterol stones are the most common type of gallstones found in the United States.
b. Four times more women than men develop cholesterol stones.
c. Women are usually older than age 40, multiparous, and obese.
d. Stone formation increases in users of contraceptives, estrogens, and cholesterol-lowering
drugs, which are known to increase biliary cholesterol saturation.
e. Bile acid malabsorption, genetic predisposition, and rapid weight loss are also risk factors for
cholesterol gallstones.
Cholecystitis
1. Acute cholecystitis, an acute inflammation of the gallbladder, is most commonly caused by gallstone
obstruction.
a. Secondary bacterial infection may occur and progress to empyema (purulent effusion of the
gallbladder).
2. Acalculous cholecystitis is acute gallbladder inflammation without obstruction by gallstones.
a. Occurs after major surgical procedures, severe trauma, or burns.
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3. Chronic cholecystitis occurs when the gallbladder becomes thickened, rigid, and fibrotic and
functions poorly. Results from repeated attacks of cholecystitis, calculi, or chronic irritation.
Figure 36: How gallstone form
Choledocholithiasis
1. Small gallstones can pass from the gallbladder into the common bile duct and proceed to the
duodenum. More commonly they remain in the common bile duct and can cause obstruction,
resulting in jaundice and pruritus.
2. Common bile duct stones are frequently associated with infected bile and can lead to cholangitis
(inflammation/ infection in the biliary system).
3. A typical clinical picture includes biliary pain in the upper abdomen, jaundice, chills and fever, mild
hepatomegaly, abdominal tenderness and, occasionally, rebound tenderness.
1. Gallstones that remain in the gallbladder are usually asymptomatic.

2. Biliary colic can be caused by gallstones.
a. Steady, severe, aching pain or sensation of pressure in the epigastrium or right upper
quadrant, which may radiate to the right scapular area or right shoulder.
b. Begins suddenly and persists for 1 to 3 hours until the stone falls back into the gallbladder or
is passed through the cystic duct.
3. Acute cholecystitis causes biliary colic pain that persists more than 4 hours and increases with
movement, including respirations.
a. Also causes nausea and vomiting, low-grade fever, and jaundice (with stones or
inflammation in the common bile duct).
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b. Right upper quadrant guarding and Murphy’s sign (inability to take a deep inspiration when
examiner’s fingers are pressed below the hepatic margin) are present.
4. Chronic cholecystitis causes heartburn, flatulence, and indigestion. Repeated attacks of symptoms
may occur resembling acute cholecystitis.
 Oral cholecystography, ultrasonography, and HIDA scan may show stones or inflammation.
 ERCP or PTC to visualize location of stones and extent of obstruction.
 Elevated conjugated bilirubin and alkaline phosphatase because of obstruction.
Management
 Supportive management may include I.V. fluids, NG suction, pain management, and antibiotics (with
a positive culture).
 A cholecystostomy tube may be placed percutaneously into the gallbladder to decompress the organ
in preparation for future surgery. This may be placed by interventional radiology.
 Surgical management:
a. Cholecystectomy, open or laparoscopic
b. Intraoperative cholangiography and choledochoscopy for common bile duct exploration.
c. Placement of a T-tube in the common bile duct to decompress the biliary tree and allow access
into the biliary tree postoperatively.
 Oral therapy with chenodeoxycholic acid, ursodeoxycholic acid (Actigall), or a combination of both to
decrease the size of existing cholesterol stones or to dissolve small ones.
a. Indicated for patients at high risk for surgery because of co-morbid conditions.
b. Major adverse effects include diarrhea, abnormal liver function tests, increases in serum
cholesterol.
 Direct contact therapy by which a local cholelitholytic agent is infused by a catheter directly into the
gallbladder or through a percutaneous transhepatic biliary catheter.
a. Indicated for a symptomatic, high-risk patient whose gallbladder can be visualized by a
radiographic study.
b. Adverse effects include pain from the catheter, nausea, transient elevations of liver function tests
and white blood cell (WBC) count.
 After cholecystectomy, intracorporeal lithotripsy may be used to fragment retained stones in the
common bile duct by pulsed laser, or hydraulic lithotripsy applied through an endoscope directly to
the stones. The stone fragments are removed by irrigation or aspiration. Retained stones may also
be removed by basket retrieval through the endoscopic or percutaneous transhepatic biliary
approach.
Complications
1. Cholangitis.
2. Necrosis, empyema, or perforation of the gallbladder.
3. Biliary fistula through the duodenum.
4. Gallstone ileus.
5. Adenocarcinoma of the gallbladder.
Relieving Pain
1. Assess pain location, severity, and characteristics.
2. Administer medications or monitor PCA to control pain.
3. Assist in attaining position of comfort.
Restoring Normal Fluid Volume

1. Administer I.V. fluids and electrolytes as prescribed.
2. Administer antiemetics, as prescribed, to decrease nausea
and vomiting.
3. Maintain NG decompression, if needed.
4. Begin food and fluids, as tolerated, after acute symptoms
subside or postoperatively.
5. Observe and record amount of biliary tube drainage, if
applicable.

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1. Instruct patient in care of tubes or catheters that may be in place at discharge.

a. Observe for bleeding or drainage around insertion site.
b. Replace dressing per facility protocol.
c. Report change or decrease in drainage.
2. Review discharge instructions for activity, diet, medications, and postoperative follow-up.
3. Emphasize symptoms of complications to be reported, such as increased or persistent pain, fever,
abdominal distention, nausea, anorexia, jaundice, unusual drainage.
4. Encourage follow-up as indicated.

 States pain relief
 Performs activities without complaints of fatigue
IV. Learning Episode:
 After studying, the students shall have self-readiness. Engage in virtual discussions by inquires, ideas and
updates through synchronous and asynchronous sessions. Work and formulate their graphic organizers
with their group on concept mapping, writing to learn work sheet and evaluation exam.
Learning Module 5
NCM 112: RENAL DISORDERS
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 Defining the primary functions of the kidney and other structures in the urinary system
 Listing tests performed for the diagnosis of urologic and renal system diseases.
 Identifying laboratory tests performed to diagnose urologic and renal system diseases
 Differentiate pyelonephritis and glomerulonephritis.
 Give examples of conditions that predispose to renal calculi.
 Identify methods for eliminating small renal calculi and larger stones.
 Differentiate acute and chronic renal failure.
 Explain pathophysiologic problems associated with chronic renal failure.
 Describe sources of organs for kidney transplantation.
 Identify nursing methods for managing pruritus.
 Explain the purposes and methods of dialysis.
 Discuss nursing assessments performed when caring for clients undergoing dialysis.

and work on Graphic
Organizer.
comprehend topic/
concepts.

 Accountable
URINARY SYSTEM
ANATOMY AND PHYSIOLOGY
Kidney anatomy
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 Each person has two kidneys; one is attached to the left abdominal wall at the level of the last
thoracic and first three lumbar vertebrae and the other is on the right.
 The kidneys are enclosed in the renal capsule.
 The renal cortex is the outer layer of the renal capsule, which contains blood-filtering mechanisms
(glomeruli).
 The renal medulla is the inner region, which contains the renal pyramids and renal tubules. Together
the renal cortex, pyramids, and medulla constitute the parenchyma, or functional unit of the kidneys.
 from the pelvis of the kidneys through the ureters and empties into the bladder.
 Nephrons, the functional units of the kidney.
Ureters, Bladder, and Urethra:
 The urine formed in the Nephrons flows into the renal pelvis and then into the ureters, which are
long fibromuscular tubes that connect each kidney to the bladder.
 The urinary bladder is a muscular hallow sac located just behind the pubic bone. Capacity of the
adult bladder is 400 – 500 ml.
 The urethra arises from the base of the bladder, in the male, it passes through the penis; in the
female, it opens just anterior to the vagina.
Functions of kidneys
 Maintain acid-base balance

 Excrete end products of body metabolism
 Control fluid and electrolyte balance
 Excrete bacterial toxins, water-soluble drugs, and drug metabolites
 Secrete renin to regulate the blood pressure and
 erythropoietin to stimulate the bone marrow to produce red blood cells.
 Synthesize vitamin D for calcium absorption and regulation of the parathyroid hormones.
Urine production
 As fluid flows through the tubules, water, electrolytes, and solutes are reabsorbed and other solutes
such as creatinine, hydrogen ions, and potassium are secreted.
 Water and solutes that are not reabsorbed become urine.
 The process of selective reabsorption determines the amount of water and solutes to be secreted.
Risk factors associated with renal disorders
Risk Factors Associated with Renal Disorders

 Chemical or environmental toxin exposure Contact sports
 Diabetes mellitus
 Family history of renal disease
 Frequent urinary tract infections Heart failure
 High-sodium diet
 Hypertension
 Medications
 Trauma
 Urolithiasis or nephrolithiasis
Changes in Micturition (Voiding)
Changes in Amount or Color of Urine

1. Hematuria—blood in the urine, may be gross (visible by color change) or microscopic.
 Considered a serious sign and requires evaluation.

 Color of bloody urine depends on several factors including the amount of blood present and the
anatomical source of the bleeding.
o Dark, rusty urine indicates bleeding from the upper urinary tract.
o Bright red bloody urine indicates lower urinary tract bleeding.
o Microscopic hematuria is the presence of red blood cells (RBCs) in urine, which can be seen
only under a microscope; urine appears normal.
 Hematuria may be due to a systemic cause, such as blood dyscrasias, anticoagulant therapy, or
extreme exercise.
 Painless hematuria may indicate neoplasm in the urinary tract.
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 Hematuria is common in patients with urinary tract stone disease and may also be seen in renal
tuberculosis, polycystic disease of kidneys, acute pyelonephritis, thrombosis and embolism involving
renal artery or vein, and trauma to the kidneys or urinary tract.
2. Polyuria—large volume of urine voided in given time.
 Volume is out of proportion to usual voiding pattern and fluid intake.

 Demonstrated in diabetes mellitus, diabetes insipidus, chronic renal disease, use of diuretics.
3. Oliguria—small volume of urine.
 Output between 100 and 500 mL/24 hours.

 May result from acute renal failure, shock, dehydration, fluid and electrolyte imbalance.
4. Anuria—absence of urine output.
 Outputlessthan50mL/24hours.
 Indicates serious renal dysfunction requiring immediate medical intervention.
Symptoms Related to Irritation of the Lower Urinary Tract
1. Dysuria—painful or difficult urination.
 Burning sensation seen in wide variety of inflammatory and infectious urinary tract conditions.
2. Frequency—voiding occurs more frequently than usual when compared with patient’s usual pattern or
with a generally accepted norm of once every 3 to 6 hours.
 Determine if habits governing fluid intake have been altered it is essential to know normal voiding
pattern to evaluate frequency.
 Increasing frequency can result from a variety of conditions, such as infection and diseases of urinary
tract, metabolic disease, hypertension, medications (diuretics).
3. Urgency—strong desire to urinate that is difficult to postpone.
 Due to inflammatory conditions of the bladder ,prostate, or urethra; acute or chronic bacterial
infections; neurogenic voiding dysfunctions; chronic prostatitis or bladder outlet obstruction in
men; overactive bladder; and urogenital atrophy in postmenopausal women.
4. Nocturia—urination at night, which interrupts sleep.
 Causes include urologic conditions affecting bladder function, poor bladder emptying, bladder outlet
obstruction, or overactive bladder.
 Metabolic causes include decreased renal concentrating ability or heart failure, hyperglycemia, and
the increased urine production at rest that occurs with aging.
5. Strangury—slow and painful urination; only small amounts of urine voided. Wrenching sensation at end of
urination produced by spasmodic muscular contraction of the urethra and bladder.
1. Blood staining may be noted.

2. Seen in numerous urological conditions, including
severe cystitis, interstitial cystitis, urinary calculus, and bladder cancer.
Symptoms Related to Obstruction of the Lower Urinary Tract
1. Weak stream—decreased force of stream when compared to usual stream of urine when voiding.
2. Hesitancy—undue delay and difficulty in initiating voiding.
 May indicate compression of urethra, outlet obstruction, neurogenic bladder.
3.Terminal dribbling—prolonged dribbling or urine from the meatus after urination is complete. May be
caused by bladder outlet obstruction.
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4. Incomplete emptying—feeling that the bladder is still full even after urination. Indicates either urinary
retention, overactive bladder, or a condition that prevents the bladder from emptying well; may lead to
infection.
5. Urinary retention—inability to void.
Involuntary Voiding
1. Urinary incontinence—involuntary loss of urine; may be due to pathologic, anatomical, or

physiologic factors affecting the urinary tract.
2. Nocturnal Enuresis—involuntary voiding during sleep. May be physiologic during early childhood;
thereafter, may be functional or symptomatic of obstructive or neurogenic disease (usually of lower
urinary tract) or dysfunctional voiding.
Urinary Tract Pain
1. Genitourinary (GU) pain not always present in renal disease, but is generally seen in the more
acute conditions of the urinary tract.
2. Kidney pain—may be felt as a dull ache in costovertebral angle; or may be a sharp, colicky pain felt in
the flank area that radiates to the groin or testicle. Due to distention of the renal capsule; severity
related to how quickly it develops.
3. Ureteral pain—felt in the back and/or abdomen can radiate to groin, urethra, penis, scrotum, or
testicle.
4. Bladder pain (lower abdominal pain or pain over supra pubic area)—may be due to bladder infection
overdistended bladder, or bladder spasms.
5. Urethral pain—from irritation of bladder neck, from foreign body in canal, or from urethritis due to
infection or trauma; pain increases when voiding.
6. Pain in scrotal area—due to inflammatory swelling of epididymis or testicle, torsion of the testicle,
or scrotal infection.
7. Testicular pain—due to injury, mumps, orchitis, torsion of spermatic cord, testes, or testes appendix.
8. Perineal or rectal discomfort—due to acute or chronic prostatitis, prostatic abscess, or trauma.
9. Back and leg pain—may be due to cancer of prostate with metastases to bone.
10. Pain in glans penis—usually from prostatitis; penile shaft pain results from urethral problems; may
also be referred pain from ureteral calculus.
Normal Renal Function Values
 Blood urea nitrogen level, 8 to 25 mg/dL

 Serum creatinine level, 0.6 to 1.3 mg/dL
 Serum uric acid level, 2.5 to 8.0 mg/dL
Determination of serum creatinine level
 A test that measures the amount of creatinine in the serum. Creatinine is an end product of protein
and muscle metabolism.
Analysis
 Creatinine level reflects glomerular filtration rate.

 Renal disease is the only pathological condition that increases the serum creatinine level.
 Serum creatinine level increases only when at least 50% of renal function is lost.
Determination of blood urea nitrogen (BUN) level
 A serum test that measures the amount of nitrogenous urea, a byproduct of protein metabolism in
the liver.
Analysis
 BUN levels indicate the extent of renal clearance of urea nitrogenous waste products.
 An elevation does not always mean that renal disease is present.
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 Some factors that can elevate the BUN level include dehydration, poor renal perfusion, intake of a
high-protein diet, infection, stress, corticosteroid use, gastrointestinal (GI) bleeding, and factors that
cause muscle breakdown.
 When the BUN and serum creatinine levels increase at the same rate, the ratio of the BUN to
creatinine remains constant; elevated serum creatinine and BUN levels suggest renal dysfunction.
Urinalysis
 A urine test for evaluation of the renal system and renal disease
Interventions
 Wash perineal area and use a clean container for collection.

 Obtain 10 to 15 mL of the first morning voiding if possible.
 Refrigerated samples may alter the specific gravity.
 If the client is menstruating, note this on the laboratory requisition form.
Specific gravity determination
 A urine test that measures the ability of the kidneys to concentrate urine
Interventions
 Specific gravity can be measured by a multiple- test dipstick method (most common method),
refractometer (an instrument used in the laboratory setting), or urinometer (least accurate method).
 Factors that interfere with an accurate reading include radiopaque contrast agents, glucose, and
proteins.
 Cold specimens may produce a false high reading.
 Normal value is 1.016 to 1.022 (may vary depending on the laboratory).
 An increase in specific gravity (more concentrated urine) occurs with insufficient fluid intake,
decreased renal perfusion, or increased ADH.
 A decrease in specific gravity (less concentrated urine) occurs with increased fluid intake or diabetes
insipidus; it may also indicate renal disease or the kidneys inability to concentrate urine.
Urine culture and sensitivity testing
 A urine test that identifies the presence of microorganisms (culture) and determines the specific
antibiotics to treat the existing microorganism (sensitivity) appropriately
Interventions
 Clean the perineal area and urinary meatus with a bacteriostatic solution.
 Collect the midstream sample in a sterile container.
 Send the collected specimen to the laboratory immediately.
 Identify any sources of potential contaminants during the collection of the specimen, such as the
hands, skin, clothing, hair, or vaginal or rectal secretions.
 Urine from the client who drank a very large amount of fluids may be too dilute to provide a
positive culture.
Creatinine clearance test
 The creatinine clearance test evaluate show well the kidneys remove creatinine from the blood.
 The test includes obtaining a blood sample and timed urine specimens.
 Blood is drawn when the urine specimen collection is complete.
 The urine specimen for the creatinine clearance is usually collected for 24 hours, but shorter periods
such as 8 or 12 hours could be prescribed.
 The creatinine clearance test provides the best estimate of the glomerular filtration rate (GFR) and
the normal GFR is 125 mL/min.
Interventions
 Encourage fluids before and during the test.

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 Instruct the client to avoid caffeinated beverages during testing.

 Check with the physician regarding the administration of any prescribed medications during testing.
 Instruct the client about the urine collection. e. At the start time, ask the client to void (or empty the
tubing and drainage bag if the client has a Foley catheter) and discard the first sample.
 Collect all urine for the prescribed time.
 Keep the urine specimen on ice or refrigerated and check with the laboratory regarding adding a
preservative to the specimen during collection.
 At the end of the prescribed time, ask the client to empty the bladder (or empty the tubing and
drainage bag if the client has a Foley catheter) and add that final urine to the collection container.
 Send the labeled urine specimen to the laboratory in a biohazard bag along with the requisition.
 Document specimen collection, time started and completed, and pertinent assessments.
Uric acid test
 A 24-hour urine collection sample is tested to diagnose gout and kidney disease.
Interventions
 Encourage fluid intake and a regular diet during testing.

 Follow the same procedure for urine collection as with the creatinine clearance test.
Vanillylmandelic acid (VMA) test
 The test is a 24-hour urine collection to diagnose pheochromocytoma, a tumor of the adrenal gland.
 The test determines catecholamine levels in the urine.
Interventions
 Check with the laboratory regarding medication restrictions.

 Instruct the client to avoid foods such as caffeine, cocoa, vanilla, cheese, gelatin, licorice, and fruits
for at least 2 days before and during urine collection and to check with the physician regarding the
administration of any prescribed medications before or during testing.
 Instruct the client to avoid stress; encourage adequate food and fluid intake during the test.
 Follow the same procedure for urine collection as for the creatinine clearance test.
KUB (kidneys, ureters, and bladder) radiography
 An x-ray of the urinary system and adjacent structures to detect urinary calculi.
Interventions
 No specific preparation is necessary.
Bladder ultrasonography (bladder scanning)
 Bladder ultrasonography is a noninvasive method for measuring the volume of urine in the bladder.
 Bladder ultrasonography may be performed for evaluating urinary frequency, inability to urinate, or
amount of residual urine (the amount of urine remaining in the bladder after voiding).
Computed tomography (CT) and magnetic resonance imaging (MRI)
 These imaging methods provide cross-sectional views of the kidney and urinary tract.
Intravenous pyelography
 An x-ray procedure in which an intravenous injection of a radiopaque dye is used to visualize and
identify abnormalities in the renal system.
Pre procedure intervention

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 Obtain an informed consent.

 Assess the client for allergies to iodine, seafood, and radiopaque dyes.
 Withhold food and fluids after midnight on the night before the test.
 Administer laxatives if prescribed.
 Inform the client about possible throat irritation, flushing of the face, warmth, or a salty or metallic
taste during the test.
Post procedure interventions

 Instruct the client to drink at least 1 L of fluid unless contraindicated.
 Assess the venipuncture site for bleeding.
 Monitor urinary output.
 Monitor for signs of a possible allergic reaction to the dye used during the test and instruct the client
to notify the physician if any signs of an allergic reaction occur.
Renal angiography
 An injection of a radiopaque dye through a catheter inserted into the femoral artery to examine the
renal blood vessels and renal arterial supply
Pre procedure interventions

 Assess the client for allergies to iodine, seafood, and radiopaque dyes.
 Inform the client about a possible feeling of burning or heat along the vessel when the dye is
injected.
 Withhold food and fluids after midnight on the night before the test.
 Instruct the client to void immediately before the procedure.
 Administer enemas if prescribed.
 Shave injection sites as prescribed.
 Assess and mark the peripheral pulses.
 Assess vital signs and peripheral pulses frequently as prescribed

 Maintain bed rest and apply a sandbag or other device that will provide pressure to prevent
bleeding, if prescribed, at the insertion site for 4 to 8 hours.
 Instruct the client to maintain a supine position with the leg straight (the head of the bed should not
be elevated greater than 20 degrees for 8 hours, or as prescribed).
 d. Assess the temperature, color, movement, and sensation (CMS) of the toes of the involved
extremity with each vital sign check.
 e. Inspect the catheter insertion site for bleeding or swelling with each vital sign check.
 The dye used in a renal angiography may be nephrotoxic; therefore encourage increased fluids
unless contraindicated and monitor urinary output
Renal scanning
 An intravenous (IV) injection of a radioisotope for visual imaging of renal blood flow, glomerular
filtration, tubular function, and excretion
Pre procedure intervention

 Assess for allergies.
 Inform the client that the test requires no dietary or activity restrictions.
 Assist with administering the radioisotope as necessary.
 Instruct the client to remain motionless during the test.
 Instruct the client that imaging may be repeated at various intervals before the test is complete.

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 Encourage fluid intake unless contraindicated.

 Assess the client for signs of delayed allergic reaction such as itching and hives.
 The radioisotope is eliminated in 24 hours;
 wear gloves for excretion precautions.
 Follow standard precautions when caring for incontinent clients and double-bag client linens per
agency policy.
Renal biopsy
 Insertion of a needle into the kidney to obtain a sample of tissue for examination; usually done
percutaneously
Pre procedure interventions
 Assess vital signs.

 Assess baseline coagulation studies; notify the physician if abnormal results are noted.
 Withhold food and fluids after midnight the night before the test.
Interventions during the procedure:
 Position the client prone with a pillow under the abdomen and shoulders.
 Monitor vital signs, especially for hypotension and tachycardia, which could indicate bleeding.
 Provide pressure to the biopsy site for 30 minutes. Monitor the hemoglobin and hematocrit levels
for decreases, which could indicate bleeding.
 Place the client in the supine position and on bed rest for 8 hours as prescribed.
 Check the biopsy site and under the client for bleeding.
 Encourage fluid intake of 1500 to 2000 mL as prescribed.
 Observe the urine for gross and microscopic bleeding.
 Instruct the client to avoid heavy lifting and strenuous activity for 2 weeks.
 Instruct the client to notify the physician if either a temperature greater than 100 F or hematuria
occurs after the first 24 hours Post procedure.
LOWER URINARY TRACT INFECTIONS
 A UTI is caused by the presence of pathogenic microorganisms in the urinary tract with or without
signs and symptoms. Lower UTIs may predominate at the bladder (cystitis) or urethra (urethritis).
 Bacteriuria refers to the presence of bacteria in the urine (103 bacteria/mL of urine or greater
generally indicates infection).
 In asymptomatic bacteriuria, organisms are found in urine, but patient has no symptoms.
Recurrent UTIs may indicate the following:
Relapse—recurrent infection with an organism that has been isolated during a prior infection
Reinfection—recurrent infection with an organism distinct from previous infecting organism
1. Ascending infection after entry by way of the urinary meatus.
 Women are more susceptible to developing acute cystitis because of shorter length of urethra;
anatomical proximity to vagina, periurethral glands, and rectum (fecal contamination); and the
mechanical effect of coitus.
 Women with recurrent UTIs typically have gram- negative organisms at the vaginal introitus; there
may be some defect of the mucosa of the urethra, vagina, or external genitalia of these patients
that allows enteric organisms to invade the bladder.
 Poor voiding habits may result in incomplete bladder emptying, increasing the risk of recurrent
infection.
 Acute infection in women most commonly arises from organisms of the patient’s own intestinal
flora (Escherichia coli)
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2. Although E. coli causes 86% of UTIs, other pathogens, such as Klebsiella species, Proteus species, and
Staphylococcus saprophyticus, may also cause these infections.
3. In men, obstructive abnormalities (strictures, prostatic hyperplasia) are the most frequent cause.
4. UTI is a considerable source of nosocomial infection and sepsis in older adults.
5. Upper urinary tract disease may occasionally cause recurrent bladder infection.
1. Dysuria, frequency, urgency, nocturia

2. Supra pubic pain and discomfort
3. Microscopic or gross hematuria
GERONTOLOGIC ALERT The only sign of UTI in the elderly patient may be mental status changes.
1. Urine dip stick may react positively for blood ,white blood cells (WBCs), and nitrates indicating
infection.
2. Urine microscopy shows RBCs and many WBCs per field without epithelial cells.
NURSING ALERT Urinalysis showing many epithelial cells is likely contaminated by vaginal secretions
in women and is therefore inaccurate in indicating infection. Urine culture may be reported as
contaminated as well. Obtaining a clean-catch, midstream specimen is essential for accurate results,
and catheterization may be necessary in some patients.
3. Urine culture is used to detect presence of bacteria and for antimicrobial sensitivity testing.
4. Patients with indwelling catheters may have asymptomatic bacterial colonization of the urine
without UTI.
5. In these patients, UTI is diagnosed and treated only when symptoms are present.
Management
1. Antibiotic therapy according to sensitivity results

 A wide variety of antimicrobial drugs are available.
 Urinary infections usually respond to drugs that are excreted in urine in high concentrations;
a potentially effective drug should rapidly sterilize the urine and thus relieve the patient’s
symptoms.
2. For uncomplicated infection
o Women with uncomplicated cystitis may be treated with a 3-day course of a

fluoroquinolone such as ciprofloxacin (Cipro), a 7-day course of nitrofurantoin
(Macrodantin), or a 3-day course of co-trimoxazole (Bactrim, Septra). Seven to 10 days of
therapy are recommended for women over age 65.
 Men are treated with 7 to 10 days of antibiotic therapy.

 Follow-up culture to prove treatment effectiveness may be indicated.
 Adverse effects include nausea, diarrhea, drug-related rash, and vaginal candidiasis.
3. Pregnant women are usually treated for 7 to 10 days.
4. Women with recurrent infections may be treated longer, undergo diagnostic testing to rule out a
structural abnormality, or be maintained on a daily dose of antibiotic as prophylaxis.
5. For severe discomfort with voiding, phenazopyridine (Pyridium) may be ordered three times per day
for 2 days.
Complications
1. Pyelonephritis
2. Hematogenous spread resulting in sepsis
Relieving Pain
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1. Administer or teach self-administration of antibiotic— eradication of infection is usually accompanied by

rapid resolution of symptoms.
2. Encourage patient to take prescribed analgesics and antispasmodics if ordered.
3. Encourage rest during the acute phase if symptoms are severe.
4. Encourage plenty of fluids to promote urinary output and to flush out bacteria from urinary tract.
Increasing Understanding and Practice of Preventive Measures
1. For women with recurrent UTIs, give the following instructions:
o Reduce vaginal introital concentration of pathogens by hygienic measures.

o Wash genitalia in shower or while standing in bathtub— bacteria in bath water may gain
entrance into urethra. c. Cleanse around the perineum and urethral meatus after each
bowel movement, with front-to-back cleansing to minimize fecal contamination of
periurethral area.
2. Drink liberal amounts of water to lower bacterial concentrations in the urine.

3. Avoid bladder irritants—coffee, tea, alcohol, cola drinks, and aspartame.
4. Decrease the entry of microorganisms into the bladder during intercourse.
-avoid immediately after sexual intercourse.
-a single dose of an oral antimicrobial agent may be prescribed after sexual intercourse.
5. Avoid external irritants such as bubble baths, talcum powders, perfumed vaginal cleansers or deodorants.
6. Patients with persistent bacteria may require long-term antimicrobial therapy to prevent colonization of
periurethral area and recurrence of UTI.
 Take antibiotic at bedtime after emptying bladder to ensure adequate concentration of drug
overnight because low rates of urine flow and infrequent bladder emptying predispose to
multiplication of bacteria.
 Use self-monitoring tests (dipsticks) at home to monitor for UTI.
1. Advise women with simple, uncomplicated cystitis that they do not require follow-up as long as symptoms
are completely resolved with antibiotic therapy. Men usually need follow-up cultures and possibly additional
testing if more than one episode of infection.
2. Instruct patient to void frequently (every 2 to 3 hours) and to empty bladder completely because this
enhances bacterial clearance, reduces urine stasis, and prevents reinfection. Infrequent voiding distends the
bladder wall, leading to hypoxia of bladder mucosa, which is then more susceptible to bacterial invasion.
3. Instruct patients who have had UTIs during pregnancy to have follow-up studies.
4. Female patients with uncomplicated but recurrent cystitis may self-administer a 2- or 3-day course of
antibiotics when symptoms begin if prescribed.
5. Cranberry juice or capsules may help to prevent cystitis by altering the bladder mucosa so that the bacteria
cannot attach. Acidophilus and cranberry capsules are available in health food and vitamin stores.
INTERSTITIAL CYSTITIS
 Interstitial cystitis (also called painful bladder syndrome) is a syndrome of chronic, cystitis-like
symptoms in the absence of bacterial infection.
1. The etiology of interstitial cystitis in unknown. However, theories include an inflammatory or

autoimmune process that alters the normal configuration of cells in the bladder epithelium, although
infectious, neurological, psychological, and vascular origins are also considered possible.
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 One plausible theory is a neurogenic origin, in which an initial peripheral inflammatory response
later activates the sacral nerves to continue to respond without evidence of continued inflammation.
 Mast cell involvement in the inflammatory response also seems a plausible etiology, with many
patients having a concomitant history of allergies.
2. The bladder is normally lined with a gel-like substance composed of glycosaminoglycans (heparin,
hyaluronic acid, and chondroitin) that acts as an impermeable barrier to irritating solutes such as
potassium.
3. Disruption to the bladder epithelium leads to irritant seepage, which produces the symptoms.
4. The bladder wall is chronically inflamed with no evidence of bacterial infection.
5. Occurs far more frequently in women than in men.
 Intermittent flares of urgency and frequency that resolve spontaneously may occur early.
 Urgency may be extreme and frequency (as many as 16 times per day) and nocturia increase with
duration of symptoms.
 Bladder pain may be continuous, may increase during voiding, or may present as diffuse perineal,
vaginal, suprapubic, or lower back pain.
 Symptoms are exacerbated by sexual intercourse and at the time of menstruation.
 Symptoms may be present for 5 to 7 years before diagnosis is made.
1. Tender bladder base during pelvic examination, assessed by palpation of the anterior vaginal wall.
2. Cystoscopy under anesthesia with bladder biopsies and bladder distention; presence of bleeding or
ulcerations on bladder distention is characteristic of some cases of interstitial cystitis.
3. Urodynamic tests commonly reveal a small bladder capacity with early sensation of urgency and, in some
cases, poor detrusor function with incomplete bladder emptying.
4. In potassium sensitivity testing, symptoms are produced when potassium is placed in bladder; however,
the use of this test is controversial as inflammation also produces a positive test.
5. Diagnosis is usually made by ruling out other potential causes of symptoms, including radiation or chemical
cystitis, gynecologic or urologic malignancies, STD, and urolithiasis.
Management
 Treatment is individualized and focused on symptom control.

 Dietary modification to identify foods that act as triggers can be accomplished through an
elimination diet. Possible triggers are citrus fruits, tomatoes, caffeinated beverages, carbonated
beverages, chocolate, and spicy foods.
 Bladder retraining (increasing intervals between voiding) is commonly necessary to increase bladder
capacity that has been diminished by frequent voiding; pelvic floor strengthening with Kegel
exercises can help with urgency and frequency.
 Oral administration of pentosan polysulfate (Elmiron) relieves symptoms in some patients, with
maximal effect seen after 3 to 6 months; many continue this therapy for years.
DRUG ALERT Pentosan polysulfate (Elmiron) has anticoagulant properties; therefore, it should not be used by
patients taking other anticoagulant drugs or in conditions associated with increased risk for bleeding.
 Antihistamines may be beneficial for patients who have allergies.

 Tricyclic antidepressants may be helpful for their analgesic, anticholinergic, and antihistaminic
effects. Gabapentin (Neurontin) is also used for the chronic pain.
 Bladder distention during cystoscopy under general anesthesia relieves symptoms in 20% to 25% of
patients, especially those with small bladder capacity. Relapse commonly occurs 3 months
posttreatment, however, and the effectiveness of this treatment diminishes with repeated use.
 Intravesical therapy with various substances, including silver nitrate and dimethyl sulfoxide, may be
used.
 Transcutaneous electrical nerve stimulation has demonstrated some relief for the pain syndrome
associated with interstitial cystitis.
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 Surgical intervention may be performed in extreme cases, although its success is limited. Procedures
include implantation of a sacral neuromodulation device, removal of bladder epithelial lesions, and
cystectomy with urinary diversion.
Complications
1. Psychosocial problems related to pain, urgency, and frequency

2. Secondary bacteriuria
Nursing Assessment
1. Assess voiding patterns including frequency, nocturia, urgency (a voiding diary is helpful). Determine
if symptoms increase in relation to certain foods, menstrual cycle, or sexual intercourse.
2. Assess level of pain using a scale of 1 to 10; determine if pain increases during or after voiding and if
bladder spasms occur. Some practitioners may use a symptom questionnaire such as the O’Leary-
Sant Interstitial Cystitis Symptom and Problem Indices or the Pelvic Pain and Urgency/Frequency
questionnaire.
3. Perform abdominal examination and assist with pelvic examination, if indicated, to rule out
gynecologic causes and to identify location of pain on palpation.
4. Assess impact on relationships and quality of life.
Controlling Pain
1. Administer pharmacologic agents, as ordered, to relieve pain and other symptoms. Counsel
patient on adverse effects, such as drowsiness, with antihistamines and tricyclic
antidepressants.
2. Instruct patient in comfort and preventive measures, such as application of heating pad,
avoidance of bladder irritants (caffeine, alcohol, chocolate, and acidic or spicy foods), and
avoidance of known allergens.
3. If prescribed, teach patient self-catheterization and the self-administration of intravesical
medications.
Improving Urinary Elimination
1. Encourage patient to use a voiding diary as well as a dietary record to make associations
between intake of certain foods or fluids and increase in symptoms.
2. Set up bladder retraining program to increase bladder capacity and reduce symptoms
o Have patient start with every 10- to 15-minute voiding intervals during the day.
o Instruct patient to gradually (every week or two) increase intervals by 15 minutes.
oThe ultimate goal (over a period of about 3 months) should be voiding intervals of 3 1⁄2
hours during the day.
o Teach Kegel exercises to help strengthen supporting muscles. Warm baths and perineal
massage may help with relaxation before exercises.
o Make a referral for biofeedback training, if needed, to enhance Kegel exercises.
3. Advise patient to restrict fluids only when necessary due to impending limited access to
toilet facilities; normal fluid intake should be encouraged otherwise.
4. Assess patient’s response to pharmacologic therapy.
Strengthening Coping
1. Inquire about patient’s ability to work and carry on roles as spouse, parent, etc. based on
frequency and discomfort.
2. 2. Explore with patient positive coping strategies for self and family in dealing with chronic
illness.
3. 3. Encourage counseling as needed.
 Teach patient mechanism of action and adverse effects of pharmacologic therapies.

 Teach self-catheterization using clean technique, if needed, to self-administer medications or
accomplish complete bladder emptying.
 Provide information about food and fluids known to be bladder irritants.
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 Refer for additional information and support to agencies such as Interstitial Cystitis Association,
www.ichelp.org.
NEPHROLITHIASIS AND UROLITHIASIS
 Nephrolithiasis refers to renal stone disease; urolithiasis refers to the presence of stones in the
urinary system. Stones, or calculi, are formed in the urinary tract from the kidney to bladder by the
crystallization of substances excreted in the urine.
1. Most stones (75%) are composed mainly of calcium oxalate crystals; the rest are composed of
calcium phosphate salts, uric acid, struvite (magnesium, ammonium, and phosphate), or the amino
acid cystine.
2. Causes and predisposing factors:
o Hypercalcemia and hypercalciuria caused by hyperparathyroidism, renal tubular acidosis,

multiple myeloma, and excessive intake of vitamin D, milk, and alkali
o Chronic dehydration, poor fluid intake, and immobility
o Diet high in purines and abnormal purine metabolism (hyperuricemia and gout)
o Genetic predisposition for urolithiasis or genetic disorders (cystinuria)
o Chronic infection with urea-splitting bacteria (Proteus vulgaris)
o Chronic obstruction with stasis of urine, foreign bodies within the urinary tract
o Excessive oxalate absorption in inflammatory bowel disease and bowel resection or ileostomy
o Living in mountainous, desert, or tropical areas
3. Stones may be found anywhere in the urinary system and vary in size from mere granular deposits
(called sand or gravel) to bladder stones the size of an orange.
4. One out of three patients with stones are men; in both sexes, the peak age of onset is between ages
40 to 60.
5. Most stones migrate downward (causing severe colicky pain when the stone obstructs the ureter)
and are discovered in the lower ureter. Spontaneous stone passage can be anticipated in 80% to 90%
of patients with calculus less than 5 mm in size.
6. Some stones may lodge in the renal pelvis, ureters, or bladder neck, causing obstruction, edema,
secondary infection and, in some cases, nephron damage.
7. Those with stones for the first time have a 50% risk of recurrence within the next 7 to 10 years.
1 .Pain pattern depends on site of obstruction
o Renal stones produce an increase in hydrostatic pressure and distention of the renal pelvis and
proximal ureter causing renal colic. Pain relief is immediate after stone passage.
o Ureteral stones produce symptoms due to obstruction as they pass down the ureter (ureteral colic).
o Bladder stones may be asymptomatic or produce symptoms similar to cystitis.
2.Obstruction—stones blocking the flow of urine will produce symptoms of colic, chills, and fever.
3.GI symptoms include nausea, vomiting, diarrhea, abdominal discomfort—due to renointestinal reflexes
and shared nerve supply (celiac ganglion) between the ureters and intestine.
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Figure 37: Areas where calculi may obstruct the urinary system. The ensuring clinical manifestations depends
on the site of manifestation. Stone that have broken loose may obstruct the flow of urine, cause severe
pain, and injure the kidney.
1. Kidney, ureters, and bladder radiography may show stone.

2. IVU—to determine site and evaluate degree of obstruction.
3. Regular ultrasound may be as sensitive with good technique; however, it won’t show radiolucent
stones.
4. Spiral CT scan stone study—special CT technique to assess for stone in ureter; it is the study of choice
and will show all stones.
a. Requires no preparation and is noninvasive.
b. Takes only 10 minutes.
5. Analysis of available stone material—crystals can be identified by polarization microscopy, X-ray

diffraction, and infrared spectroscopy.
6. Urinalysis—hematuria and pyuria; pH less than 5.5 indicates uric acid stone; more than 7.5 indicates
struvite stone; urine culture and drug sensitivity studies to detect infection.
7. Serum kidney function tests, electrolytes, calcium, phosphorus, uric acid, and magnesium levels;
serum parathyroid hormone may also be evaluated.
Management
General Principles
1. If it is a small stone (¿ 5 mm) and able to treat as outpatient, 80% to 90% of patients will pass stone
spontaneously with hydration, pain control, and reassurance.
2. Patient may be hospitalized for intractable pain, persistent vomiting, high-grade fever, obstruction
with infection, bilateral ureteral calculi, and solitary kidney with obstruction.
Extracorporeal Shock Wave Lithotripsy
1. Noninvasive technique and treatment of choice for radiopaque stones less than 2 cm in diameter
and greater than 4 mm and located in the kidney or ureter above the iliac crest. For stones below the
iliac crest, ureteroscopy may be performed.
2. High-energy shock waves are directed at the kidney stone, disintegrating it into minute particles that
pass in the urine. (A shock wave is a large, condensed wave of energy produced by high-speed
motion.)
3. Patient is placed on specially designed table and immersed in a water bath or placed on an
adjustable stretcher positioned over a cushion of water.
o In water bath model, shock waves travel through water surrounding the patient.
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o In cushion model, a layer of gel lies between the stretcher and water; shock waves move
through the cushion and gel.
4. Position of the kidney stone is located by fluoroscopy, and the shock waves are targeted directly at
the stone. The shock waves do not affect soft tissue.
5. Eliminates need for surgery in majority of patients and can be repeated for recurrent stones with no
apparent risk to kidney structure or function. Long term side effects may include increased risk of
hypertension or diabetes.
6. Complications include pain, urinary infection, and perirenal hematoma (bleeding around kidney).
Percutaneous Nephrolithotomy
For stones in renal collecting system or upper portion of ureter and larger than 2.5 cm in diameter.
1. Under fluoroscopic or ultrasound guidance, a needle is advanced into collecting system; guide wire is
advanced into renal pelvis or ureter.
2. Tract is dilated with mechanical dilators or high-pressure balloon dilator until nephroscope can be inserted
up against stone.
3. Stones can be broken apart with hydraulic shock waves or a laser beam administered by way of
nephroscope; fragments are removed using forceps, graspers, or basket.
4. May be combined with extracorporeal shock wave lithotripsy.
5. Complications include hemorrhage, infection, and extravasation of urine.
Figure 38: (A) Extracorporeal shock wave lithotripsy for renal calculi dissolution. (B) a percutaneous
nephrostomy tract permits access to the collecting system of the kidney for removal of renal calculi under
direct vision via a nephroscope.
Percutaneous Stone Dissolution (Chemolysis)
1. A multiholed nephrostomy tube(catheter)is placed in kidney; offers a pathway for introduction of solvent
(depending on chemical composition of stone) to be infused into stone. A second catheter may be used for
drainage.
2. Used for struvite, uric acid, and cystine stones.
3. May be used to shrink large stones before other retrieval methods or to irrigate debris after lithotripsy
procedures.
4. Irrigating solution introduced at a continuous rate that patient can tolerate without flank pain or elevation
of intrarenal pressure above 25 cm H2O (most I.V. infusion pumps can be adapted for use and set to alarm
should pressure exceed this level).
5. Patient receives antimicrobial agents before, during, and after procedure to maintain sterile urine.
6. Complications include infection (renal and perirenal abscesses, pyelonephritis, septic shock) and
thrombophlebitis and pulmonary embolism (associated with immobilization).
Ureteroscopy
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1. Used for distal ureteral calculi; may be used for midureteral calculi.
2. Flexible or rigid ureteroscopes are used in conjunction with baskets or graspers.
3. Electrohydraulic, ultrasonic, or laser equipment may also be used to fragment stone.
4. A stent may be inserted and left in place after surgery to maintain patency of ureter.
Open Surgical Procedures
 Indicated for only 1% to 2% of all stones, rarely performed, most likely to be done percutaneously or
laparoscopically if indicated.
1. Pyelolithotomy – removal of stones from kidney pelvis
2. Coagulation pyelolithotomy – intraoperative injection of certain coagulation factors in the renal
pelvis, producing a coagulum that entraps the stones and expedites their removal.
3. Nephrolithotomy – incision into kidney or removal of stone
4. Nephrectomy – removal of kidney; indicated when kidney is extensively and irreparably damaged
and is no longer a functioning organ; partial nephrectomy sometimes done.
5. Ureterolithotomy – removal of stone in ureter
6. Cystolithotomy – removal of stone from bladder
Controlling pain
1. 1.Give prescribe NSAID or opioids analgesic (usually IV or IM) until cause of pain can be removed.
2. Encourage patient to assume position that brings some relief.
3. Reassess pain using pain scale
4. Administer antiemetics (IM or rectal suppositories) as indicated for nausea.
Maintaining Urine Flow
1. Administer fluids orally or I.V. (if vomiting) to reduce concentration of urinary crystalloids and ensure
adequate urine output.
NURSING ALERT Avoid overhydration, which may result in increased distention at stone location,
causing an increase in pain and associated symptoms.
2. Monitor total urine output and patterns of voiding. Report oliguria or anuria.
3. Strain all urine through strainer or gauze to harvest the stone; uric acid stones may crumble. Crush
clots, and inspect sides of urinal/bedpan for clinging stones or fragments.
4. For outpatient treatment, patient may use a coffee filter to strain urine.
5. Help patient to walk, if possible, because ambulation may help move the stone through the urinary
tract.
Controlling Infection
1. Administer parenteral or oral antibiotics, as prescribed during treatment, and monitor for adverse
effects.
2. Assess urine for color, cloudiness, and odor.
3. Obtain vital signs, and monitor for fever and symptoms of impending sepsis (tachycardia,
hypotension).
Recovery from Surgical Interventions for Stone Disease
1. Encourage fluids to accelerate passing of stone particles.

2. Teach about analgesics that still may be necessary for colicky pain, which may accompany passage
of stone debris.
3. Warn that some blood may appear in urine for several weeks.
4. Encourage frequent walking to assist in passage of stone fragments.
5. Teach patient to strain urine through a coffee filter or stone strainer and to save stone for analysis.
6. Teach patient to take alpha-adrenergic blockers to help dilate ureter, thus improve stone passage.
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Prevention of Recurrent Stone Formation
1. For patients with calcium oxalate stones
 Instruct on diet—avoid excesses of calcium and phosphorus; maintain a low-sodium diet (sodium
restriction decreases amount of calcium absorbed in intestine). (Note: Patient should not decrease
calcium intake; rather, should maintain regular intake.)
 Teach purpose of drug therapy—thiazide diuretics to reduce urine calcium excretion, allopurinol
therapy to reduce uric acid concentration.
2. For patients with uric acid stones

a. Teach methods to alkalinize urine to enhance urate solubility.
b. Instruct on testing urine pH.
c. Teach purpose of taking allopurinol—to lower uric acid concentration.
d. Provide information about reduction of dietary purine intake (low protein—red meat, fish, fowl).
3. For patients with infected (struvite) stone
a. Teach signs and symptoms of urinary infection (in patients with neurologic or spinal cord disease, teach
use of dipsticks to evaluate urine for nitrites and leukocytes); encourage patient to report infection
immediately; must be treated vigorously.
b. Try to avoid prolonged periods of recumbency—slows renal drainage and alters calcium metabolism.
4. For patients with cystine stones (occur in cystinuria, a hereditary disorder of amino acid transport).
a. Teach patient to alkalinize urine by taking sodium bicarbonate tablets (Soda Mint) to increase cystine
solubility; instruct patient how to test urine pH with a pH indicator.
b. Teach patient about drug therapy with D-penicil- lamine (Depen)—to lower cystine concentration, or
dissolution by direct irrigation with thiol derivatives.
c. Explain importance of maintaining drug therapy consistently.
5. For all patients with stone disease
 Explain need for consistently increased fluid intake (24-hour urinary output greater than 2 L)—lowers
the concentration of substances involved in stone formation.
o Drink enough fluids to achieve a urinary volume of 2,000 to 3,000 mL or more every
24 hours.
o Drink larger amounts during periods of strenuous exercise and in hot humid
weather, due to perspiration.
 Encourage a diet low in sugar and animal proteins— refined carbohydrates appear to lead to
hypercalciuria and urolithiasis; animal proteins increase urine excretion of calcium, uric acid, and
oxalate.
 Increase consumption of fiber—inhibits calcium and oxalate absorption.
 Save any stone passed for analysis. (Only patients with more than one episode of urolithiasis are
advised to have a metabolic evaluation.)
 Can discontinue urine straining once stone is passed.
ACUTE RENAL FAILURE

 Acute renal failure (ARF) is the rapid loss of kidney function from renal cell damage.
 Occurs abruptly and can be reversible
 ARF leads to cell hypoperfusion, cell death, and decompensation of renal function.
 The prognosis depends on the cause and the condition of the client.
 Near-normal or normal kidney function may resume gradually.
Causes
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 Prerenal: Outside the kidney; caused by intravascular volume depletion, dehydration, decreased
cardiac output, decreased peripheral vascular resistance, decreased renovascular blood flow, and
prerenal infection or obstruction.
 Intrarenal: Within the parenchyma of the kidney; caused by tubular necrosis, prolonged pre renal
ischemia, intrarenal infection or obstruction, and nephrotoxicity (Box 62-3).
 Postrenal: Between the kidney and urethral meatus, such as bladder neck obstruction, bladder
cancer, calculi, and postrenal infection .
Phases of ARF and interventions

Onset: Begins with precipitating event
Oliguric phase to 1000 mL plus the measured urinary output.
 Administer medications as prescribed, such as diuretics (furosemide [Lasix]), to increase renal blood
flow and diuresis.
Diuretic phase
 Urine output rises slowly, followed by diuresis (4 to 5 L/day).

 Excessive urine output indicates that damaged nephrons are recovering their ability to excrete
wastes.
 Dehydration, hypovolemia, hypotension, and tachycardia can occur.
 Level of consciousness improves.
 Laboratory analysis (see Box 62-4)
 Administer IV fluids as prescribed, which may contain electrolytes to replace losses.
Recovery phase (convalescent)
 Recovery is a slow process; complete recovery may take 1 to 2 years.

 Urine volume returns to normal.
 Memory improves
 Strength increases.
 The older adult is less likely than a younger adult to regain full kidney function.
 Laboratory analysis (see Box 62-4)
 ARF can progress to chronic renal failure (CRF)
 The signs and symptoms of acute renal failure are primarily caused by the retention of nitrogenous
wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes.
Assessment: Assess objective and subjective data noted in the phases of ARF (see Box 62-4).
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Interventions
 Monitor vital signs, especially for signs of hypertension, tachycardia, tachypnea, and an irregular
heart rate.
 Monitor urine and intake and output (hourly in ARF) and urine color and characteristics.
 Monitor daily weight (same scale, same clothes, same time of the day), noting that an increase of 1⁄2
to 1 lb/day indicates fluid retention.
 Monitor for changes in the BUN, serum creatinine, and serum electrolyte levels.
 Monitor for acidosis (may be treated with sodium bicarbonate).
 Monitor urinalysis for protein level, hematuria,
 casts, and specific gravity.
 Monitor for altered level of consciousness caused by uremia.
 Monitor for signs of infection because the client may not exhibit an elevated temperature or an
increased white blood cell count.
 Monitor the lungs for wheezes and rhonchi and monitor for edema, which can indicate fluid
overload.
 Administer a prescribed diet, which is usually a low- to moderate-protein (to decrease the workload
on the kidneys) and high-carbohydrate diet.
 Restrict potassium and sodium intake as prescribed based on the electrolyte level.
 Administer medications as prescribed; be alert to the mechanism for metabolism and excretion of
all prescribed medications.
 Be alert to nephrotoxic medications, which may be prescribed (see Box 62-3).
 Be alert to the health care provider’s adjustment of medication dosages for renal failure.
 Prepare the client for dialysis if prescribed; continuous renal replacement therapy may be used in
ARF to treat fluid volume overload or rapidly developing azotemia and metabolic acidosis.
 Provide emotional support by allowing opportunities for the client to express concerns and fears
and by encouraging family interactions.
 Promote consistency in caregivers.
 Also refer to the section in this chapter on special problems in renal failure and interventions.
CHRONIC RENAL FAILURE

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 CRF is a slow, progressive, irreversible loss in kidney function, with a GFR less than or equal to 60
mL/min for 3 months or longer.
 It occurs in stages and results in uremia or end- stage renal disease.
 Hypervolemia can occur because of the kidneys’ inability to excrete sodium and water; hypovolemia
can occur because of the kidneys’ inability to conserve sodium and water.
 Chronic renal failure affects all major body systems and requires dialysis or kidney transplantation to
maintain life.
Primary causes
 May follow ARF

 Diabetes mellitus and other metabolic disorders
 Hypertension
 Chronic urinary obstruction
 Recurrent infections
 Renal artery occlusion
 Autoimmune disorders
Assessment
 Assess body systems for the manifestations of CRF (Box 62-5).

 Assess psychological changes, which could include emotional lability, withdrawal, depression,
anxiety, suicidal behavior, denial, dependence-independence conflict, and changes in body image
Interventions
 Same as the interventions for ARF

 Administer a prescribed diet, which is usually a moderate-protein (to decrease the workload on the
kidneys) and high-carbohydrate, low- potassium, and low-phosphorus diet.
 Provide oral care to prevent stomatitis and reduce discomfort from mouth sores.
 Provide skin care to prevent pruritus.
 Teach the client about fluid and dietary restrictions and the importance of daily weights.
 Provide support to promote acceptance of the chronic illness and prepare the client for long- term
dialysis and transplantation, or explain to the client about his or her choice to decline dialysis or
transplantation.
 Special problems in renal failure and interventions (Box 62-6)
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 Activity intolerance and insomnia

 Fatigue results from anemia and the buildup of wastes from the diseased kidneys.
 Provide adequate rest periods.
 Teach the client to plan activities to avoid fatigue.
 Administer mild central nervous system depressants as prescribed to promote rest.
Anemia
 Anemia results from the decreased secretion of erythropoietin by damaged nephrons resulting in
decreased production of red blood cells.
 Monitor for decreased hemoglobin and hematocrit levels.
 Administer epoetin alfa (Epogen, Procrit) or darbepoetin alfa (Aranesp), hematopoietics, as
prescribed to promote maturity of the red blood cells.
 Administer folic acid (vitamin B9) as prescribed.
 Administer iron orally as prescribed, but not at the same time as phosphate binders.
 Administer stool softeners as prescribed because of the constipating effects of iron.
 Note that oral iron is not well absorbed by the gastrointestinal tract in CRF and causes nausea and
vomiting; parenteral iron (iron sucrose [Venofer] or sodium ferric gluconate complex [Ferrlecit]) may
be used if iron deficiencies persist despite folic acid or oral iron administration.
 Administer blood transfusions if prescribed; blood transfusions are prescribed only when necessary
(acute blood loss, symptomatic anemia) because they decrease the stimulus to produce red blood
cells; note that certain clients’ religious beliefs (e.g., Jehovah’s Witness) may refuse blood and blood
products.
 Blood transfusions also cause the development of antibodies against human tissues, which can
make matching for organ transplantation difficult.
Gastrointestinal bleeding
 Urea is broken down by the intestinal bacteria to ammonia; ammonia irritates the gastrointestinal
mucosa, causing ulceration and bleeding.
 Monitor for decreasing hemoglobin and hematocrit levels.
 Monitor stools for occult blood.
 Instruct the client to use a soft toothbrush.
 Avoid the administration of acetylsalicylic acid (aspirin) because it is excreted by the kidneys; if
administered, aspirin toxicity can occur and prolong the bleeding time.
Hyperkalemia
 Monitor vital signs for hypertension or hypotension and the apical heart rate; an irregular heart rate
could indicate dysrhythmias.
 Monitor the serum potassium level; an elevated serum potassium level can cause tall, peaked T
waves, flat P waves, a widened QRS complex, and a prolonged PR interval; decreased cardiac output;
heart blocks; fibrillation; or asystole (Fig. 62-1).
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 Provide a low-potassium diet, avoiding foods high in potassium (see Chapter 9 for a listing of foods
that are high in potassium).
Hypermagnesemia
 Results from decreased renal excretion of magnesium.
 Monitor for cardiac manifestations such as bradycardia, peripheral vasodilation, and hypotension.
 Monitor central nervous system (CNS) manifestations of decreased nerve impulse transmission, such
as drowsiness or lethargy.
d. Monitor neuromuscular manifestations, such as reduced or absent deep tendon reflexes or weak
or absent voluntary skeletal muscle contractions.
 Administer loop diuretics as prescribed, such as furosemide (Lasix).
 Administer calcium as prescribed for resulting cardiac problems.
 Avoid medications that contain magnesium, such as antacids, laxatives, or enemas. h. During severe
elevations, avoid foods that increase magnesium levels (see Chapter 9 for a listing of foods that are
high in magnesium).
Hyperphosphatemia
 As the phosphorus level rises, the calcium level drops; this leads to the stimulation of parathyroid
hormone, causing bone demineralization. b. Treatment is aimed at lowering the serum phosphorus
level.
 Administer phosphate binders such as calcium carbonate (TUMS), calcium acetate (PhosLo), or
sevelamer (Renagel) as prescribed with meals to lower serum phosphate levels.
 Avoid the use of aluminum hydroxide preparations to bind phosphates because they are associated
with dementia and osteomalacia.
 Administer stool softeners and laxatives as prescribed because phosphate binders are constipating.
 Teach the client about the need to limit the intake of foods high in phosphorus (see Chapter 9 for a
listing of foods that are high in phosphorus).
Hypertension
 Caused by failure of the kidneys to maintain BP homeostasis
 Monitor vital signs for elevated blood pressure. c. Maintain fluid and sodium restrictions as
prescribed.
 Administer diuretics and antihypertensives as prescribed.
 Administer propranolol (Inderal), a b- blocker, as prescribed; propranolol decreases renin release
(renin causes vasoconstriction and subsequent hypertension).
Hypervolemia
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 Monitor vital signs for an elevated blood pressure.

 Monitor intake and output and daily weight for indications of fluid retention.
 Monitor for periorbital, sacral, and peripheral edema.
Monitor the serum electrolyte levels.
 Monitor for hypertension and notify the health care provider for sustained elevations.
 Monitor for signs of CHF and pulmonary edema, such as restlessness, heightened anxiety,
tachycardia, dyspnea, basilar lung crackles, and blood-tinged sputum; notify the physician
immediately if signs occur.
 Maintain fluid restriction.
 Avoid the administration of large amounts of IV fluids.
 Administer diuretics such as furosemide (Lasix) as prescribed.
 Teach the client to maintain a low-sodium diet.
 Teach the client to avoid antacids, cold
 remedies, or other products containing sodium bicarbonate.
Hypocalcemia
 Results from the high phosphorus level and the inability of the diseased kidney to activate vitamin
D
 The absence of vitamin D causes poor calcium absorption from the intestinal tract.
 Monitor the serum calcium level.
 Administer calcium supplements as prescribed.
 Administer activated vitamin D as prescribed.
 See for a listing of foods that are high in calcium.
Hypovolemia
 Monitor the vital signs for hypotension and tachycardia.

 Monitor for decreasing intake and output and a reduction in the daily weight.
 Monitor for dehydration.
 Monitor electrolyte levels.
 Provide replacement therapy based on the serum electrolyte level values.
 Provide sodium supplements as prescribed, based on the serum electrolyte level.
Infection
 The client is at risk for infection caused by a suppressed immune system, dialysis access site, and
possible malnutrition.
 Monitor for signs of infection.
 Avoid urinary catheters when possible; if used, provide catheter care.
 Provide strict asepsis during urinary catheter insertion and other invasive procedures. Instruct the
client to avoid fatigue, which decreases body resistance.
 Instruct the client to avoid persons with infections.
 Administer antibiotics as prescribed, monitoring for nephrotoxic effects.
Metabolic acidosis
 The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis.
Administer alkalizers such as sodium bicarbonate as prescribed.
 Note that clients with CRF adjust to low bicarbonate levels and as a result do not become acutely ill.
Muscle cramps
 Occur from electrolyte imbalances and the effects of uremia on peripheral nerves
 Monitor serum electrolyte levels
 . Administer electrolyte replacements and medications to control muscle cramps as prescribed.
d. Administer heat and massage as prescribed.
Neurological changes
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 The buildup of active particles and fluids causes changes in the brain cells and leads to confusion and
impairment in decision- making ability.
 Peripheral neuropathy results from the effects of uremia on peripheral nerves.
 Monitor the level of consciousness and for confusion.
 Monitor for restless leg syndrome, which is also common during dialysis treatments.
 Teach the client to examine areas of decreased sensation for signs of injury.
Ocular irritation
 Calcium deposits in the conjunctivae cause burning and watering of the eyes.
 Administer medications to control the calcium and phosphate levels as prescribed.
 Administer lubricating eye drops.
 Protect the client from injury.
 Provide a safe and hazard-free environment.
 Use side rails as needed.
Potential for injury
 The client is at risk for fractures caused by

 alterations in the absorption of calcium, excretion of phosphate, and vitamin D metabolism. b.
 Provide for a safe environment.
 Avoid injury; tissue breakdown causes increased serum potassium levels.
Pruritus
 To rid the body of excess wastes, urate crystals are excreted through the skin, causing pruritus.
 The deposit of urate crystals (uremic frost) occurs in advanced stages of renal failure.
 Monitor for skin breakdown, rash, and uremic frost.
 Provide meticulous skin care and oral hygiene.
 Avoid the use of soaps.
 Administer antihistamines and antipruritics as prescribed to relieve itching.
 Teach the client to keep the nails trimmed to prevent local infection from scratching.
Psychosocial problems
 Listen to the client’s concerns to determine how the client is handling the situation.
 Allow the client time to mourn the loss of kidney function.
 With client permission, include the family members in discussions of the client’s concerns.
 Provide education about treatment options and support their decision.
 Offer information about support groups.
 Provide end-of-life care for the client with end-stage renal disease.
HEMODIALYSIS
 Hemodialysis is the process of cleansing the client’s blood.

 It involves the diffusion of dissolved particles from one fluid compartment into another across a
semipermeable membrane; the client’s blood flows through one fluid compartment of a dialysis
filter, and the dialysate is in another fluid compartment.
Functions of hemodialysis
 Cleanses the blood of accumulated waste products

 Removes the byproducts of protein metabolism such as urea, creatinine, and uric acid from the
blood
 Removes excess body fluids
 Maintains or restores the buffer system of the body
 Corrects electrolyte levels in the body
Principles of hemodialysis
 The semipermeable membrane is made of a thin, porous cellophane.

141
 The pore size of the membrane allows small particles to pass through, such as urea, creatinine, uric
acid, and water molecules.
 Proteins, bacteria, and some blood cells are too large to pass through the membrane.
 The client’s blood flows into the dialyzer; the movement of substances occurs from the blood to the
dialysate by the principles of osmosis, diffusion, and ultrafiltration.
 Diffusion is the movement of particles from an area of higher concentration to one of lower
concentration.
 Osmosis is the movement of fluids across a semipermeable membrane from an area of lower
concentration of particles to an area of higher concentration of particles.
 Ultrafiltration is the movement of fluid across a semipermeable membrane as a result of an
artificially created pressure gradient.
Dialysate bath
 A dialysate bath is composed of water and major electrolytes.

 The dialysate need not be sterile because bacteria and viruses are too large to pass through the
pores of the semipermeable membrane; however, the dialysate must meet specific standards, and
water is treated to ensure a safe water supply.
Interventions
 Monitor vital signs before, during, and after dialysis; the client’s temperature may elevate because of
slight warming of the blood from the dialysis machine (notify the physician about excessive
temperature elevations because this could indicate sepsis; obtain samples for blood culture as
prescribed for excessive temperature elevations).
 Monitor laboratory values before, during, and after dialysis.
 Assess the client for fluid overload before dialysis and fluid volume deficit following dialysis.
 Weigh the client before and after dialysis to determine fluid loss.
 Assess the patency of the blood access device before, during, and after dialysis.
 Monitor for bleeding; heparin is added to the dialysis bath to prevent clots from forming in the
dialyzer or the blood tubing.
 Monitor for hypovolemia and shock during dialysis, which can occur from blood loss or excess fluid
and electrolyte removal.
 Provide adequate nutrition; the client may eat before or during dialysis.
 Identify the client’s reactions to the treatment and support coping mechanisms; encourage
independence and involvement in care.
 Withhold antihypertensives and other medications that can affect the blood pressure or result in
hypotension until after the hemodialysis treatment. Also withhold medications that could be
removed by dialysis, such as water-soluble vitamins, certain antibiotics, and digoxin (Lanoxin).
ACCESS FOR HEMODIALYSIS
Subclavian and femoral catheter

 A subclavian (subclavian vein) or femoral (femoral vein) catheter may be inserted for short-term or
temporary use in ARF.
 The catheter is used until a fistula or graft matures or develops, which is typically 6 weeks, or may be
required when the client’s fistula or graft access has failed because of infection or clotting.
Interventions
 Assess insertion site for hematoma, bleeding, catheter dislodgement, and infection.
 These catheters should only be used for dialysis treatments.
 Maintain an occlusive dressing over the catheter insertion site.
Subclavian vein catheter

 The catheter is usually filled with heparin and capped to maintain patency between dialysis
treatments.
 The catheter should not be uncapped except for dialysis treatments.
 The catheter may be left in place for up to 6 weeks if no complications occur.
Femoral vein catheter

 Assess the extremity for circulation, temperature, and pulses.
 Prevent pulling or disconnecting of the catheter when giving care.
 Because the groin is not a clean site, meticulous perineal care is required.
 Use an IV infusion pump or controller with microdrip tubing if a heparin infusion through the
catheter to maintain patency is prescribed.
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 The client with a femoral vein catheter should not sit up more than 45 degrees or lean forward,
because the catheter may kink and occlude.
External arteriovenous shunt (Fig. 62-2)

 Two Silastic cannulas are surgically inserted into an artery and vein in the forearm or leg to form an
external blood path.
 The cannulas are connected to form a U shape; blood flows from the client’s artery through the
shunt into the vein.
 A tube leading to the membrane compartment of the dialyzer is connected to the arterial cannula.
 Blood fills the membrane compartment, passes through the dialyzer, and is returned back to the
client through a tube connected to the venous cannula.
 When dialysis is complete, the cannulas are clamped and reattached, reforming the U shape.
Advantages
 The external arteriovenous shunt can be used immediately following its creation.
 No venipuncture is necessary for dialysis.
Disadvantages
 Disconnection or dislodgment of the external shunt

 Risk of hemorrhage, infection, or clotting
 Potential for skin erosion around the catheter site
Interventions
 Avoid getting the shunt wet.

 Wrap a dressing completely around the shunt and keep it dry and intact.
 Keep cannula clamps at the client’s bedside or attached to the arteriovenous dressing for use in case
of accidental disconnection.
 Teach the client that the shunt extremity should not be used for monitoring BP, drawing blood,
placing IV lines, or administering injections.
 Fold back the dressing to expose the shunt tubing and assess for signs of hemorrhage, infection, or
clotting.
 Monitor skin integrity around the insertion site.
 Auscultate for a bruit and palpate for a thrill, although a bruit may not be heard with the shunt.
 Notify the physician immediately if signs of clotting, hemorrhage, or infection occur.
Signs of clotting
 Fibrin-white flecks noted in the tubing b. Separation of serum and cells

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 Thrill absent on palpation

 Coolness of the tubing or extremity
 Tingling sensation at site or in extremity
Internal arteriovenous fistula (see Fig. 62-2)
 A permanent access of choice for the client with CRF requiring dialysis
 The fistula is created surgically by anastomosis of a large artery and large vein in the arm.
 The flow of arterial blood into the venous system causes the vein to become engorged (matured or
developed).
 Maturity takes about 4 to 6 weeks, depending
 exercises such as ball squeezing, which help the fistula mature.
 The fistula is required to be mature before it can be used because the engorged vein is punctured
with a large-bore needle for the dialysis procedure.
 Subclavian or femoral catheters, peritoneal dialysis, or an external arteriovenous shunt can be used
for dialysis while the fistula is maturing or developing.
Advantages
 Because the fistula is internal, the risk of clotting and bleeding is low.
 The fistula can be used indefinitely.
 Fistulas have a decreased incidence of infection because it is internal and is not exposed.
 Once healing has occurred, no external dressing is required.
 The fistula allows freedom of movement.
Disadvantages
 The fistula cannot be used immediately after insertion so planning ahead for an alternate access for
dialysis is important.
 Needle insertions through the skin and tissues to the fistula are required for dialysis.
 Infiltration of the needles during dialysis can occur and cause hematomas.
 An aneurysm can form in the fistula.
 Congestive heart failure can occur from the increased blood flow in the venous system.
 Arterial steal syndrome can develop in a client with an internal arteriovenous fistula. In this
complication, too much blood is diverted to the vein, and arterial perfusion to the hand is
compromised.
Internal arteriovenous graft (see Fig. 62-2)
 The internal graft may be used for chronic dialysis clients who do not have adequate blood vessels
for the creation of a fistula.
 An artificial graft made of Gore-Tex or a bovine (cow) carotid artery is used to create an artificial vein
for blood flow.
 The procedure involves the anastomosis of an artery to a vein using an artificial graft.
 The graft can be used 2 weeks after insertion. e. Complications of the graft include clotting,
aneurysms, and infection.
Advantages
 Because the graft is internal, the risk of clotting and bleeding is low
 The graft can be used indefinitely.
 The graft has a decreased incidence of infection. Once healing has occurred, no external dressing is
required.
 The graft allow freedom of movement.
Disadvantages
 The graft cannot be used immediately after insertion.

 Needle insertions through the skin and tissues to the graft are required for dialysis.
 Infiltration of the needles during dialysis can occur and cause hematomas.
 An aneurysm can form in the graft; additionally, grafts clot more frequently than arteriovenous
fistulas.
 Arterial steal syndrome can develop (too much blood is diverted to the vein, and arterial perfusion to
the hand is compromised).
 Congestive heart failure can occur from the increased blood flow in the venous system.
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Interventions for an arteriovenous fistula and arteriovenous graft
 Teach the client that the extremity should not be used for monitoring blood pressure, drawing
blood, placing IV lines, or administering injections.
 Teach the client with an arteriovenous fistula hand-flexing exercises such as ball squeezing (if
prescribed) to promote graft maturity.
 Note the temperature and capillary refill of the extremity.
 Palpate pulses below the fistula or graft, and monitor for hand swelling as an indication of ischemia.
 Monitor for clotting.
a. Complaints of tingling or discomfort in the extremity.
b. Inability to palpate a thrill or auscultate a bruit over the fistula or graft.
 Monitor for arterial steal syndrome.
 Monitor for infection.
 Monitor lung and heart sounds for signs of CHF.
 Notify the physician immediately if signs of clotting, infection, or arterial steal syndrome occur.
 To ensure patency, palpate for a thrill or auscultate for a bruit over the fistula or graft. Notify the
physician if a thrill or bruit is absent.
COMPLICATIONS OF HEMODIALYSIS (Box 62-7)
Air embolus
 Introduction of air into the circulatory system

 Results in cardiopulmonary complications
Assessment
 Dyspnea and tachypnea

 Chest pain
 Hypotension
 Reduced oxygen saturation
 Cyanosis
 Anxiety
 Changes in sensorium
 Interventions (see Priority Nursing Actions box)

145
Disequilibrium syndrome
 A rapid change in the composition of the extracellular fluid occurs during hemodialysis. b. Solutes are
removed from the blood faster than from the cerebrospinal fluid and brain; fluid is pulled into the
brain, causing cerebral edema. c. Occurs more frequently in a new client during the initial onset of
hemodialysis.
Assessment
 Nausea and vomiting
 Headache
 Hypertension
 Restlessness and agitation
 Muscle cramps
 Confusion
 Seizures
Interventions
 Slow or stop the dialysis.
 Notify the physician if signs of disequilbrium syndrome occur.
 Reduce environmental stimuli.
 Prepare to administer intravenous hypertonic saline solution, albumin, or mannitol (Osmitrol) if
prescribed.
 Prepare to dialyze the client for a shorter
 period of time at reduced flow rates to prevent its occurrence.
Dialysis encephalopathy
 An aluminum toxicity from dialysate water sources containing aluminum; also can occur from
ingestion of aluminum-containing antacids (phosphate binders). This is not a common occurrence.
Assessment
 Progressive neurological impairment b. Mental cloudiness

 Speech disturbances
 Dementia
 Muscle incoordination
 Bone pain
 Seizures
Interventions
146
 Monitor for the signs of dialysis encephalopathy.

 Notify the physician if signs of dialysis encephalopathy occur.
 Administer aluminum-chelating agents as prescribed so that the aluminum is released and dialyzed
from the body.
KIDNEY TRANSPLANTATION
 A human kidney from a compatible donor is implanted into a recipient.

 Kidney transplantation is performed for irreversible kidney failure; specific criteria is established for
eligibility for a transplant.
 The recipient must take immunosuppressive medications for life.
Living related donors
 The most desirable source of kidneys for transplantation is living related donors who closely match
the client.
 Donors are screened for ABO blood group, tissue-specific antigen, human leukocyte antigen
suitability, mixed lymphocyte culture index (histocompatibility); donors are also screened for the
presence of any communicable diseases and undergo a complete medical evaluation as well as a
nephrology consultation.
 The donor must be in excellent health, with two properly functioning kidneys.
 The emotional well-being of the donor is determined.
 Complete understanding of the donation process and outcome by the donor is necessary.
Cadaver donors
 Cadaver donors must meet the institution’s criteria of brain death.

 Cadaver donors usually need to be younger than 70 years.
 Cadaver donors must have normal renal function, although “marginal” donor organs have been used
with the consent of the recipient.
 No malignant disease outside the central nervous system can be present.
 No generalized infection or communicable disease can be present.
 No renal trauma can be present.
 The potential donor must be negative for communicable diseases at the time of donation
 Once cerebral death has been established for a potential donor, restoration of intravascular volume,
weaning from vasopressors, and establishing diuresis are crucial; management of the donor is
determined by organ bank personnel.
 Continuous ventilation, and normal blood pressure and heart rate are maintained until the kidneys
and other organs are surgically removed.
Cold ischemic time
 Cold ischemic time is the time elapsed between the cessation of blood flow to the kidney and the
time required for anastomosis of the kidney in the recipient.
 The maximum transplantation time is up to 72 hours.
Preoperative interventions
 Verify histocompatibility tests of donor, which will be done by organ bank personnel.
 Administer immunosuppressive medications to the recipient for 2 days before the transplantation, as
prescribed.
 Maintain strict aseptic technique for the recipient.
 Verify that hemodialysis of the recipient was completed 24 hours before transplantation.
 Ensure that the recipient is free of any infections.
 Assess renal function studies.
 Encourage discussion of feelings of the donor and the recipient.
 Provide psychological support to the live donor or cadaver donor family and the recipient.
Postoperative interventions for the recipient

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 Urine output usually begins immediately if the donor was a living donor; it may be delayed for a few
days or more with a cadaver kidney.
 Hemodialysis may be performed until adequate kidney function is established.
 Monitor vital signs, central venous pressure (CVP), and pulse oximetry for signs of complications.
 Monitor urine output hourly; immediately report a urine output less than 100 mL/hr.
 Monitor IV fluids closely; for the first 12 to 24 hours, IV fluid replacement is based on hourly urine
output.
 Administer prescribed diuretics and osmotic agents.
 Monitor daily weight to evaluate fluid status.
 Monitor daily laboratory results to evaluate renal function, including hematocrit, BUN, and serum
creatinine levels, and monitor urine for blood and specific gravity.
 Position the client in a semi-Fowler’s position to promote gas exchange, turning from the back to the
nonoperative side.
 Monitor Foley catheter patency; the Foley catheter remains in the bladder for 3 to 5 days to allow
for anastomosis healing.
 Note that urine is pink and bloody initially but gradually returns to normal within several weeks or
day.
 Notify the physician if gross hematuria and clots are noted in the urine.
 Monitor the three-way bladder irrigation, if present, for clots; irrigate only if a physician’s
prescription is present.
 Remove the Foley catheter as soon as possible to prevent infection.
 Maintain aseptic technique and monitor for infection; infection is the primary cause of death in the
first year post-transplant.
 Maintain strict aseptic technique with wound care.
 Monitor for bowel sounds and for the passage of flatus; initiate a specific diet and oral fluids as pre-
scribed when flatus and bowel sounds return (usually, fluids, sodium, and potassium are restricted if
the client is oliguric).
 Maintain good oral hygiene, monitoring for stomatitis and bacterial and fungal infections.
 Encourage coughing and deep-breathing exercises.
 Administer medications as prescribed, which may include antifungal medications, antibiotics,
immunosuppressive agents, and corticosteroids.
 The client is usually ambulated after 24 hours. 22. Assess for organ rejection by monitoring of
laboratory values closely.
 Promote live donor and recipient relationship.
 Monitor both the donor and recipient for depression.
 Provide the recipient with instructions following the kidney transplantation (Box 62-11).
 Assist the recipient to cope with the body image disturbances that occur from long-term use of
immunosuppressants.
 Advise the recipient of available support groups.
Graft rejection
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Assessment
Hyperacute rejection
 Hyperacute rejection occurs at the time of anastomosis of the organ.

 Interventions: Removal of rejected kidney
Acute rejection
 Most common type; occurs most frequently within 6 weeks postoperatively, but can occur any time
post-transplant.
 Interventions: Potentially reversible with increased immunosuppression and if treated early;
administer high doses of corticosteroids, or monoclonal antibodies if corticosteroids are ineffective.
RENAL CALCULI
 Calculi are stones that can form anywhere in the urinary tract; however, the most frequent site is the
kidneys.
 Problems resulting from calculi are pain, obstruction, tissue trauma, secondary hemorrhage, and
infection.
 The stone can be located through radiography of the kidneys, ureters, and bladder; intravenous
pyelography; CT scanning; and renal ultrasonography.
 A stone analysis will be done after passage to determine the type of stone and assist in determining
treatment.
 Urolithiasis refers to the formation of urinary calculi; these form in the ureters.
 Nephrolithiasis refers to the formation of kidney calculi; these form in the renal parenchyma.
 When a calculus occludes the ureter and blocks the flow of urine, the ureter dilates, producing
hydroureter (see Fig. 62-5).
 If the obstruction is not removed, urinary stasis results in infection, impairment of renal function on
the side of the blockage, hydronephrosis (see Fig. 62-5), and irreversible kidney damage.
Cause
 Family history of stone formation

 Diet high in calcium, vitamin D, protein, oxalate, purines, or alkali
 Obstruction and urinary stasis
 Dehydration
 Use of diuretics, which can cause volume depletion
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 Urinary tract infections and prolonged urinary catheterization

 Immobilization
 Hypercalcemia and hyperparathyroidism
 Elevated uric acid level, such as in gout
Assessment
 Renal colic, which originates in the lumbar region and radiates around the side and down to the
testicles in men and to the bladder in women
 Ureteral colic, which radiates toward the gentalia and thighs
 Sharp, severe pain of sudden onset
 Dull, aching pain in the kidney
 Nausea and vomiting, pallor, and diaphoresis calculi; these form in the ureters. during acute pain
 Urinary frequency, with alternating retention
 Signs of a urinary tract infection
 Low-grade fever
 High numbers of red blood cells, white blood cells, and bacteria noted in the urinalysis report
 Gross hematuria
Interventions
 Monitor vital signs, especially the temperature, for signs of infection.

 Monitor intake and output.
 Assess for fever, chills, and infection.
 Monitor for nausea, vomiting, and diarrhea.
 Encourage fluid intake up to 3000 mL/day, unless contraindicated, to facilitate the passage of the
stone and prevent infection.
 Administer fluids intravenously as prescribed if unable to take fluids orally or in adequate amounts to
increase the flow of urine and facilitate passage of the stone.
 Provide warm baths and heat to the flank area (massage therapy should be avoided).
 Administer analgesics at regularly scheduled intervals as prescribed to relieve pain.
 Assess the client’s response to pain medication.
 Assist the client in performing relaxation techniques to assist in relieving pain.
 Encourage client ambulation, if stable, to promote the passage of the stone.
 Turn and reposition the immobilized client to promote passage of the stone.
 Instruct the client in the diet restrictions specific to the stone composition if prescribed.
 Prepare the client for surgical procedures if prescribed For the client with renal calculi, strain all urine
for the presence of stones and send the stones to the laboratory for analysis.
Stone composition
 A special diet, such as an alkaline-ash or acid-ash diet, may be prescribed, depending on the
physician’s preference.
Alkaline-Ash Diet
Outcome
- Diet increases the pH of the urine.

- Diet reduces the acidity of the urine.
- Foods to Include Fruits except cranberries, plums, prunes, and tomatoes Milk
Most vegetables
- Rhubarb
- Small amounts of beef, halibut, veal, trout, and salmon
Acid-Ash Diet
Outcome
- Diet decreases the pH of the urine. Diet makes the urine more acidic.
- Foods to Include Bread, cereal, whole grains, Cheese, eggs
Corn and legumes Cranberries, prunes, plums, tomatoes Meat, fish, oysters, poultry
Calcium phosphate stones

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 Caused by supersaturation of urine with calcium and phosphate

 Diet includes acid-ash foods because calcium stones are alkaline.
 Dietary prescription may include decreasing intake of foods high in calcium and phosphate to reduce
urinary calcium content and avoiding excess vitamin D intake to prevent stones from forming.
 Medications prescribed for calcium stones may include phosphates, thiazide diuretics, and
allopurinol (Zyloprim).
Calcium oxalate stones
 Caused by supersaturation of urine with calcium and oxalate

 Diet includes acid-ash foods because calcium stones are alkaline.
 Dietary prescription may include decreasing the intake of foods high in calcium and avoiding oxalate
food sources to reduce urinary oxalate content and stone formation.
 Oxalate-rich food sources include tea, almonds, cashews, chocolate, cocoa, beans, spinach, and
rhubarb.
 Allopurinol, pyridoxine (vitamin B6), or magnesium oxide may be prescribed for clients with oxalate
stones.
Struvite stones
 Composed of magnesium and ammonium phosphate

 Struvite stones are caused by urea-splitting bacteria and tend to form in alkaline urine.
 Diet includes acid-ash foods and includes limiting high-phosphate foods such as dairy products, red
and organ meats, and whole grains to reduce urinary phosphate content.
 Treatment includes controlling infection with antibiotics (long-term antibiotic use may be
prescribed).
Uric acid stones
 Caused by excess dietary purine or from gout b. Tend to form in acidic urine
 Dietary prescription to reduce urinary purine content may include alkaline-ash foods and decreased
intake of high-purine foods such as organ meats, gravies, red wines, and sardines.
 Allopurinol may be prescribed to lower uric acid levels.
Cystine stones
 Caused by cystine crystal formation; tend to form in acidic urine

 Diet includes alkaline-ash foods; dietary prescription also may include a low intake of methionine, an
essential amino acid that forms cystine. Therefore, the client would be instructed to avoid meat,
milk, cheese, and eggs.
 Dietary measures also focus on encouraging fluid intake up to 3 L/day, unless contraindicated, to
help dilute the urine and prevent cystine crystals from forming.
 Long-term antibiotic use may be prescribed for clients with cystine stones.
TREATMENT OPTIONS FOR RENAL CALCULI
Cystoscopy
Cystoscopy may be done for stones in the bladder or lower ureter.
 No incision is made.
 One or two ureteral catheters are inserted past the stone; the stone may be manipulated and
dislodged by the procedure and the catheters may guide the stones mechanically downward as they
are removed.
 The catheters are left in place for 24 hours to drain the urine trapped proximal to the stone and to
dilate the ureter.
 A continuous chemical irrigation may be prescribed to dissolve the stone.
Extracorporeal shock wave lithotripsy (ESWL)

151
 A noninvasive mechanical procedure for breaking up stones located in the kidney or upper ureter
so that they can pass spontaneously or be removed by other methods
 No incision is made and no drains are placed; a stent may be placed to facilitate passing stone
fragments.
 Fluoroscopy is used to visualize the stone and ultrasonic waves are delivered to the area of the stone
to disintegrate it.
 The stones are passed in the urine within a few days.
Pre procedure:
 Maintain the client on an NPO status for 8 hours before the procedure.
Post procedure
 Monitor vital signs, especially for hypotension and tachycardia, which could indicate bleeding.
 Monitor intake and output.
 Monitor for bleeding.
 Monitor for pain and signs of urinary obstruction.
 Instruct the client that if a ureteral stent is placed to help the stone pass, it is usually removed in 1 to
2 weeks.
 Instruct the client to increase fluid intake to flush out the stone fragments.
 Inform the client that ambulation is important
EPIDIDYMITIS
 Acute or chronic inflammation of the epididymis that occurs as a result of a UTI, STI, prostatitis, or
long-term use of a bladder catheter .
 The infective organism travels upward through the urethra and ejaculatory duct and along the vas
deferens to the epididymis.
Assessment
 Scrotal pain
 Groin pain
 Swelling in the scrotum and groin
 Pus and bacteria in the urine
 Fever and chills
 Abscess development
Interventions
 Encourage fluid intake.

 Encourage bed rest with the scrotum elevated to prevent traction on the spermatic cord, facilitate
drainage, and relieve pain.
 Instruct the client in the intermittent application of cold compresses to the scrotum.
 Instruct the client in the use of tub or sitz baths.
 Instruct the client in the administration of antibiotics for self and sexual partner if the cause is
chlamydial or gonorrheal infection.
 Instruct the client to avoid lifting, straining, and sexual contact until the infection subsides.
 Instruct the client to limit the force of the stream because organisms can be forced into the vas
deferens and epididymis from strain or pressure during voiding.
 Teach the client that condom use can help prevent urethritis and epididymitis.
 Teach the client measures to prevent UTI or STI recurrence.
UROSEPSIS
 Urosepsis is a gram-negative bacteremia originating in the urinary tract.

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 The most common causative organism is Escherichia coli.

 In a client who is immunocompromised, the most common cause is infection from an indwelling
urinary catheter or an untreated UTI.
 The major problem is the ability of this bacterium to develop resistant strains.
 Urosepsis can lead to septic shock if not treated aggressively.
Assessment
 Fever is the most common and earliest manifestation.
Interventions
 Obtain a urine specimen for urine culture and sensitivity before administering antibiotics.
 Administer antibiotics intravenously as prescribed, usually until the client has been afebrile for 3 to
5 days.
 Administer oral antibiotics as prescribed after the 3- to 5-day afebrile period.
URETHRITIS
 Inflammation of the urethra commonly associated with a sexually transmitted disease; may occur
with cystitis.
 In men, urethritis most often is caused by gonorrhea or chlamydial infection.
 In women, urethritis most often is caused by feminine hygiene sprays, perfumed toilet paper or
sanitary napkins, spermicidal jelly, UTI, or changes in the vaginal mucosal lining.
Assessment
 Pain or burning on urination

 Frequency and urgency
 Nocturia
 Difficulty voiding
 Males may have clear to mucopurulent discharge from the penis.
 Females may have lower abdominal discomfort.
Interventions
 Encourage fluid intake.

 Prepare the client for testing to determine whether a sexually transmitted infection (STI) is present.
Administer antibiotics as prescribed.
 Instruct the client in the administration of sitz or tub baths.
 If stricture occurs, prepare the client for dilation of the urethra and instillation of an antiseptic
solution.
 Instruct the female client to avoid the use of perfumed toilet paper or sanitary napkins and feminine
hygiene sprays.
 Instruct the client to avoid intercourse until the symptoms subside or treatment of the STI is
complete.
 Instruct the client about STIs if this is the cause. a. Prevent STIs by the use of latex condoms or
abstinence.
- All sexual partners during the 30 days before diagnosis with chlamydial infection should be
notified, examined, and treated if indicated.
- Chlamydial infection often coexists with gonorrhea; diagnostic testing is done for both STIs.
- Treatment for STIs includes antibiotics as prescribed to treat the causative organism.
- The most serious complication of chlamydial infection is sterility.
- Follow-up culture may be requested in 4 to 7 days to evaluate the effectiveness of medications.
URETERITIS
 An inflammation of the ureter commonly associated with bacterial or viral infections and
pyelonephritis
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Assessment
 Dysuria
 Frequent urination
 Clear to mucopurulent penile discharge in males
Interventions
 Treatment includes identifying and treating the underlying cause and providing symptomatic relief.
 Administer metronidazole (Flagyl) or clotrimazole (Mycelex) as prescribed for treating Trichomonas
infection.
 Administer nystatin (Mycostatin) or fluconazole (Diflucan) as prescribed for treating yeast infections.
 Doxycycline (Vibramycin) or azithromycin (Zithromax) may be prescribed for treating chlamydial
infections.
PYELONEPHRITIS
 An inflammation of the renal pelvis and the parenchyma commonly caused by bacterial invasion
 Acute pyelonephritis often occurs after bacterial contamination of the urethra or following an
invasive procedure of the urinary tract.
 Chronic pyelonephritis most commonly occurs following chronic urinary flow obstruction with reflux.
 Escherichia coli is the most common causative bacterial organism.
Acute pyelonephritis
 Acute pyelonephritis occurs as a new infection or recurs as a relapse of a previous infection.

 It can progress to bacteremia or chronic pyelonephritis.
Assessment
 Fever and chills

 Nausea
 Flank pain on the affected side
 Costovertebral angle tenderness
 Headache
 Dysuria
 Frequency and urgency
 Cloudy, bloody, or foul-smelling urine
 Increased white blood cells in the urine
Chronic pyelonephritis
 A slow, progressive disease usually associated with recurrent acute attacks

 Causes contraction of the kidney and dysfunction of the nephrons, which are replaced by scar tissue
 Causes the ureter to become fibrotic and narrowed by strictures
 Can lead to renal failure
Assessment
 Frequently diagnosed incidentally when a client is being evaluated for hypertension

 Poor urine-concentrating ability
 Pyuria
 Azotemia
 Proteinuria
Interventions
 Monitor vital signs, especially for elevated temperature.

 Encourage fluid intake up to 3000 mL/day to reduce fever and prevent dehydration.
 Monitor intake and output (ensure that output is a minimum of 1500 mL/24 hr).
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 Monitor weight.
 Encourage adequate rest.
 Instruct the client in a high-calorie, low-protein diet. 7. Provide warm, moist compresses to the flank
area to help relieve pain.
 Encourage the client to take warm baths for pain relief.
 Administer analgesics, antipyretics, antibiotics, urinary antiseptics, and antiemetics as prescribed.
 Monitor for signs of renal failure.
 Encourage follow-up urine culture.
inquiries, ideas and updates through synchronous and asynchronous sessions. Work and formulate
their graphic organizer with their group on concept map, working to learn work sheet, and quiz.
VI. Assessment of Learning: Please refer to Module 2.1 for graphic organizers and answering the quiz.
Learning Module 6
NCM 212: Reproductive System (Male and Female)
155
 Giving four examples of structural disorders that affects the male reproductive system.
 Explain the technique and purpose of performing testicular self-examination.
 Explain how prostatic hyperplasia compromises urinary elimination and the system it
produces.
 Discuss the nursing care management for client with BPH.
 Explain the pathophysiology and etiology of pelvic inflammatory disorders and the
nursing management of interventions important to include in their care.

and work on Graphic
Organizer.
comprehend topic/
concepts.

 Accountable
REPRODUCTIVE SYSTEM (MALE AND FEMALE)
BENIGN PROSTATIC HYPERPLASIA

156
 BPH is enlargement of the prostate that constricts the urethra, causing urinary symptoms. One of
four men who reach age 80 will require treatment for BPH.
1. The process of aging and the presence of circulating androgens are required for the development of
BPH.
2. The prostatic tissue forms nodules as enlargement occurs.
3. The normally thin and fibrous outer capsule of the prostate becomes spongy and thick as
enlargement progresses.
4. The prostatic urethra becomes compressed and narrowed, requiring the bladder musculature to
work harder to empty urine.
5. Effects of prolonged obstruction cause trabeculation (formation of cords) of the bladder wall,
decreasing its elasticity.
Figure 39: Looking at prostatic enlargement in BPH
1. In early or gradual prostatic enlargement, there may be no symptoms because the bladder musculature
can initially compensate for increased urethral resistance.
2. Obstructive symptoms—hesitancy, diminution in size and force of urinary stream, terminal dribbling,
sensation of incomplete emptying of the bladder, urinary retention.
3. Irritative voiding symptoms—urgency, frequency, nocturia.
1. American Urologic Association Symptom Index score greater than 7 (uses rating of questions about the
obstructive and irritative symptoms): 0 to 7, mild; 8 to 19, moderate; 20 to 35, severe
2. Rectal examination—smooth, firm, symmetric or asymmetric enlargement of the prostate
3. Urinalysis—to rule out hematuria and infection
4. Serum creatinine and BUN—to evaluate renal function 5. Serum PSA—to rule out cancer, but may also be
elevated in BPH
6. Optional diagnostic studies for further evaluation:
 Urodynamics—measures peak urine flow rate, voiding time and volume, and status of the bladder’s
ability to effectively contract
 Measurement of post-void residual urine; by ultrasound or catheterization
 Cystourethroscopy—to inspect urethra and bladder and evaluate prostatic size
 Uroflow—demonstrates voiding pattern
Management
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1. Patients with mild symptoms (in the absence of significant bladder or renal impairment) are
followed annually; BPH does not necessarily worsen in all men.
2. Pharmacologic management.
a. Alpha-adrenergic blockers, such as doxazosin (Car- dura), tamsulosin (Flomax), terazosin (Hytrin),
and alfuzosin (Uroxatral)—relax smooth muscle of bladder base and prostate to facilitate voiding.
DRUG ALERT Although prescribed for their effect on prostatic smooth muscle, alpha-adrenergic
blockers (except for tamsulosin and alfuzosin) also have an antihypertensive effect. Dosage is usually
titrated up from an initial small dose. It is commonly recommended that the first dose, or all once-
per-day doses, be taken at bedtime.
b. Finasteride (Proscar), dutasteride (Avodart)—antian- drogen effect on prostatic cells, reverses or

prevents hyperplasia. Women should not handle drug because it can be absorbed through skin and is
pregnancy category X. In addition, patients taking dutasteride cannot donate blood.
DRUG ALERT Finasteride present in semen may have deleterious effects on the fetus of pregnant
women.
4. Surgery—TURP(formerly most common procedure), transurethral incision of the prostate, or open

prostatectomy for very large prostates, usually by suprapubic approach. open prostatectomy for very
large prostates, usually by suprapubic approach.
5. PVP is starting to replace TURP; it is done through a cystoscope, using a laser to vaporize diseased
prostatic tissue.
6. TUMT and TUNA (or PROSTIVA) are both office-based procedures that use heat to destroy diseased
prostatic tissue.
7. Indigo interstitial laser therapy of the prostate is another procedure that is done on an outpatient
basis.
Complications
1. Acute urinary retention, involuntary bladder contractions, bladder diverticula, and cystolithiasis
2. Vesicoureteral reflux, hydroureter, hydronephrosis
3. Gross hematuria, UTI
Nursing Assessment
1. Obtain history of voiding symptoms, including onset, frequency of day and nighttime urination,
presence of urgency, dysuria, sensation of incomplete bladder emptying, and decreased force of
stream. Determine impact on quality of life.
2. Perform rectal (palpate size, shape, and consistency) and abdominal examination to detect
distended bladder, degree of prostatic enlargement.
3. Perform simple urodynamic measures—uroflowmetry and measurement of post-void residual, if
indicated.
Facilitating Urinary Elimination
1. Provide privacy and time for patient to void.

2. Assist with catheter introduction with guide wire or by way of suprapubic cystotomy as indicated.
a. Monitor intake and output. b. Maintain patency of catheter.
3. Administer medications, as ordered, and monitor for and teach patient about adverse effects.
1. Alpha-adrenergic blockers—hypotension, orthostatic hypotension, syncope (especially after
first dose), impotence, blurred vision, rebound hypertension if discontinued abruptly.
2. Finasteride and dutasteride—hepatic dysfunction, impotence, interference with PSA testing,
presence in semen with potential adverse effect on fetus of pregnant woman.
4. Assess for and teach patient to report hematuria, signs of infection.

1. Explain to patient not undergoing treatment the symptoms of complications of BPH—urinary retention,
cystitis, increase in irritative voiding symptoms. Encourage reporting these problems.
158
2. Advise patients with BPH to avoid certain drugs that may impair voiding , particularly OTC cold medicines
containing sympathomimetics such as phenyl- propanolamine.
3. Advise patient that irritative voiding symptoms do not immediately resolve after relief of obstruction;
symptoms diminish over time.
4. Tell patient postoperatively to avoid sexual intercourse, straining at stool, heavy lifting, and long periods of
sitting for 6 to 8 weeks after surgery, until prostatic fossa is healed.
5. Advise follow-up visits after treatment because urethral stricture may occur and regrowth of prostate is
possible after TURP.
6. Be aware of herbal or “natural” products marketed for “prostate health.”
 Advise patients that saw palmetto has shown some efficacy in reducing symptoms of BPH in a
number of clinical trials.
 The active ingredient in commercial preparations is lipidosterolic extract of Serenoa repens, and the
dosage is 160 mg twice per day.
 It should be taken with breakfast and an evening meal to minimize GI adverse effects.
 Although it appears safe and there are no known drug interactions, tell patients they must discuss
use of saw palmetto with their health care providers.
PELVIC INFLAMMATORY DISEASE
 PID is an infection that may involve the cervix, fallopian tubes, and ovaries.
1. Incidence has been increasing; high recurrence rate because of reinfections.

2. Commonly polymicrobial; causative agents include N. gonorrhoeae, C. trachomatis, anaerobes,
gram-negative bacteria, and streptococci. Cervical infection ascends through the endometrium, into
the fallopian tubes, and possibly into the peritoneal cavity.
3. Predisposing factors include multiple sexual partners, early onset of sexual activity, use of IUDs (wick
promotes ascension of bacteria), and procedures, such as therapeutic abortion, cesarean sections,
and hysterosalpingograms.
Table 1 : Pelvic inflammatory disease clinical signs and symptoms
NURSING ALERT Localized right- or left-lower quadrant tenderness with guarding, rebound, or palpable
mass signifies tubo ovarian abscess with peritoneal inflammation. Immediate evaluation and surgical
intervention are necessary to prevent rupture and widespread peritonitis.
159
 Fever—especially with gonococcal infections.

 Cervical discharge—mucopurulent.
 Cervical motion tenderness—especially with gonococcal infections.
 Irregular bleeding.
 GI symptoms—nausea, vomiting, acute abdomen usually signify abscess.
 Urinary symptoms—dysuria, frequency.
 Presentation with chlamydia may be mild.
Management
1. Antibiotics—combinations of tetracyclines, penicillins, and cephalosporins, orally or parenterally

depending on patient’s condition, such as:
a. Cefotetan(Cefotan)2gI.V.every12hoursplusdoxycycline 100 mg I.V. or orally every 12 hours.

b. Clindamycin(Cleocin)900mgI.V.every8hoursplus gentamicin (Garamycin) 2 mg/kg of body
weight I.V. or I.M. as loading dose; followed by 1.5 mg/kg every 8 hours as maintenance
dosage. (A single daily dose of gentamicin may be substituted.)
c. Ceftriaxone 250 mg I.M. once per day plus doxycycline 100 mg orally twice per day for 14
days, with metronidazole 500 mg orally twice per day for 14 days.
2. Parenteral therapy can be switched to oral therapy 24 hours after improvement is shown (reduced
fever, decreased pain, resolution of nausea and vomiting).
a. Doxycycline100mgorallytwiceperdayfor14days.
b. Metronidazole 500 mg orally twice per day for 14 days may be added.
NURSING ALERT If patient with PID is to be treated at home, stress the importance of follow-up,
usually in 48 hours to determine if oral antibiotic treatment is effective. Advise patient to report
worsening of symptoms immediately.
3. Inpatient treatment required if uncertain diagnosis; abscess; pregnancy; severe infection with
nausea, vomiting, and high fever; cannot take oral fluids; prepubertal or immunodeficient patient; or
more aggressive antibiotics required to preserve fertility.
4. Surgical treatment or interventional drain placement may be necessary to drain abscess or later to
treat adhesions or tubal damage.
Complications
1. Abscess rupture and sepsis.

2. Infertility because of adhesions to fallopian tubes and ovaries.
 Ectopic pregnancy caused by inability of fertilized egg to pass stricture.

 Dyspareunia because of adhesions.
 Encourage compliance with antibiotic therapy for full length of prescription.

 Stress the need for sexual abstinence and pelvic rest (nothing in vagina, including no douching or
tampons) until follow-up visit and testing ensure cure.
 Advise testing and possible treatment for all sexual partners (within past 60 days). Tell patient that
diagnosis of chlamydia or gonorrhea necessitates reporting to public health department and partners
will be traced.
 Educate about safer sexual practice.
INTEGUMENTARY SYSTEM
SYSTEMIC LUPUS ERYTHEMATOSUS

160
 Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease. Discoid lupus
may also occur with predominant skin lesions.
1. The T-lymphocyte system is affected for unknown reasons, and the failure of its regulatory
system may result in an inability to slow or to halt the production of inappropriate
autoantibodies.
2. B lymphocyte–stimulating factors are produced and this too may lead to production of
autoantibodies.
3. Autoantibodies may combine with other elements of the immune system to activate
immune complexes. These immune complexes and other immune system constituents
combine to form complement, which is deposited in organs, causing inflammation and
tissue necrosis.
4. More women, particularly in childbearing years, are affected than men.
Skin:
 Butterfly-shaped rash of the malar region of the face, characterized by erythema and edema.
 Discoid lesions are scarring, ring-shaped, involving the shoulders, arms, and upper back.
 Discoid lesions may also result in erythematous, scaly plaques on the face, scalp, external ear, and
neck, resulting in alopecia.
Arthritis:
 Generally bilateral and symmetric, involving the hands, wrists, and other joints.
 Can resemble RA and may be mistaken for it, especially early in the course of the disease.
 Unlike RA, the arthritis is nonerosive; that is, no joint destruction is seen on X-ray. May (occasionally)
be erosive, representing some overlap with RA.
 Tendon involvement is common and may lead to deformities or tendon rupture.
Cardiac:
 Pericarditis, Pleural effusion, Myocarditis. , Endocarditis, Coronary artery disease.
Pulmonary:
 Pleuritis, Pleural effusion, Lupus pneumonitis, Pulmonary hemorrhage, Pulmonary embolism.
GI:
 Oral ulcers, Acute or subacute abdominal pain, Pancreatitis, Spontaneous bacterial peritonitis,
Bowel infarction.
Renal: occurs in 50% of patients, with as many as 15% of patients developing renal failure.
a. Nephritis.
i. Mesangial nephritis—mild form, can be reversible, best prognosis.

ii. Focal segmental glomerulonephritis—active necrotic or sclerosing lesions.
iii. Proliferative—may be focal or diffuse. Diffuse carries good prognosis.
iv. Membranous nephritis—may persist for years without serious renal function decline. May pre-
sent as nephrotic syndrome.
v. Sclerosing nephritis—increase in the amount of matrix material in the glomeruli.
b. Renal thrombosis—rare.
Central nervous system:

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a. Neuropsychiatric disorders.
i. Depression.
ii. Psychosis.
b. Transient ischemic attacks, stroke.
c. Epilepsy.
d. Migraine headache.
e. Myelopathy.
f. Guillain- Barré syndrome.
g. Chorea and other movement disorders.
Hematologic:
a. Hemolytic anemia.
b. Leukopenia.
c. Thrombocytopenia.
Vascular:
a. Hypertension.
b. Raynaud’s phenomenon.
Constitutional:
a. Fever.
b. Weight loss.
C. Fatigue.
1. CBC—leukopenia, anemia (may be hemolytic), thrombocytopenia.
2. ANA—positive in more than 90% of patients with SLE; predominant pattern is homogeneous.
3. Anti-dsDNA—97% specific for lupus.
4. ESR—generally elevated.
5.Complement levels—generally decreased when disease is active.
6.Urinalysis—hematuria, proteinuria, and active sediment (RBC casts).
7. 24-hour urine for protein and creatinine clearance.
8.Chest X-ray may show changes.
9.X-ray of hands and wrists—non-destructive arthritis.
10.Computed tomography (CT) scan or MRI.
o Brain—to define any neurologic manifestations.

o Abdomen—to rule out other abdominal processes in a patient with abdominal pain.
o Cerebral arteriogram—to look for evidence of cerebral vasculitis.

o Magnetic resonance angiography.
Management
Pharmacologic
 NSAIDs to reduce pain and inflammation.

 Antimalarials to decrease disease activity.
 Corticosteroids to reduce inflammatory process.
 Immuno suppressives to suppress immune process; research is ongoing to develop lymphocyte-
specific immunosuppressants and biologic modifiers to stop autoantibody production.
 Antihypertensives and diuretics to treat hypertension and fluid overload, if present due to renal
disease
 Calcium channel blockers for Raynaud’s phenomenon.
Nonpharmacologic
 1.Avoid direct exposure to sunlight to reduce the chance of exacerbation.

 2.Behavior modification to prevent exacerbations and to reduce symptoms.
 3.Joint protection and energy conservation.
Other Management
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 1.Close follow-up for evaluation of cardiac, neurologic, renal, and other body systems.
 Referral to specialists for systemic manifestations.
Complications
 Renal failure.
 Permanent neurologic impairment.
 Infection.
 Death caused by disease process.
Reducing Pain
 Administer and teach self-administration of medications to reduce disease activity and of additional
analgesics as ordered.
 Suggest the use of hot or cold applications, relaxation techniques, and nonstrenuous exercise to
enhance pain relief.
 Monitor for adverse reactions to corticosteroids
Increasing Control Over Disease Process
 Instruct patient to avoid factors that may exacerbate disease.

o Avoid exposure to sunlight and ultraviolet light.
o Use sunscreen with sun protection factor of 15 or greater. Avoid prolonged sun exposure.
o Wear protective, lightweight clothing, with long sleeves, and hats.
o Avoid use of tanning beds.

 Avoid exposure to drugs and chemicals.
o Avoid exposure to hair spray.
o Avoid exposure to hair-coloring agents.
o Medications—obtain provider advice before taking any medications or supplements.
 Teach self-administration of pharmacologic agents to reduce disease activity.
 Encourage good nutrition, sleep habits, exercise, rest, and relaxation to improve general health and
to help prevent infection.
 Encourage expression of feelings, counseling, or referrals to social work, occupational therapy, as
needed.
Maintaining Skin and Mucous Membrane Integrity
 Apply topical corticosteroids to skin lesions as ordered.

 Suggest alternative hairstyles, scarves, and wigs to cover significant areas of alopecia.
 Encourage good oral hygiene and inspect mouth for oral ulcers.
 Avoid hot or spicy foods that may irritate oral ulcers.
 Apply topical agents or analgesics to reduce pain and to promote eating.
Reducing Fatigue
 Advise patient that fatigue level will fluctuate with disease activity.
 Encourage patient to modify schedule to include several rest periods during the day; pace activity
and exercise according to body’s tolerance; use energy-conservation techniques in daily activities.
 Teach relaxation techniques, such as deep breathing, progressive muscle relaxation, and imagery to
reduce emotional stress that causes fatigue.
Preserving Urinary Elimination
 Assist with monitoring of urinary status as indicated by degree of renal involvement.

o Monitor intake and output and urine specific gravity.
o Measure urine protein, microalbumin, or obtain 24- hour creatinine clearance, as ordered.
o Check test results of serum blood urea nitrogen and creatinine.

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 Stress that close follow-up is essential, even in times of remission, to detect early progression of
organ involvement and to alter drug therapy.
 Advise on the use of special cosmetics to cover skin lesions.
 Advise about reproduction.
o Avoid pregnancy during time of severe disease activity.
o Immunomodulators may have teratogenic effects.
o Use of some drugs for treatment of SLE can result in sterility.
 Stress that any complementary or alternative therapies should be discussed with the health care
provider.
 For additional information and support, refer to agencies, such as the Lupus Foundation,
www.lupus.org, or the American Occupational Therapy Association, www.aota.org.
inquiries, ideas and updates through synchronous and asynchronous sessions. Work and formulate
their graphic organizer with their group on concept map, working to learn work sheet, and quiz.
VI. Assessment of Learning: Please refer to Module 2.1 for graphic organizers and answering the quiz.
Learning Module 7
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NCM 112: CELLULAR ABERRATIONS (ACUTE AND CHRONIC)
I. Intended Learning Outcomes: At the end of the learning log the students shall be able to
 Understand the concept and its pathophysiologic basis on client with alterations in
cellular aberrations acute and chronic.
 Use the nursing process as a framework for care of client with cellular aberrations.
 Describe the cellular aberrations disorders, their manifestations and indicated nursing
interventions.
 Identify the nurses roles in the prevention of cancer and in health education
 Formulate plan of care for the client with early stage and advanced cancer
 Identifying and select appropriate medications and treatments for client with cellular
aberration disorders.
 Value the nurse’s role in providing quality, comprehensive, individualized, ethical and
humane care of clients with cancer.
II. Time frame/class schedule:

 Self-study on Cellular  Students will engage
Aberrations (Acute and and work on Graphic
Chronic) Organizer.
comprehend topic/
concepts.

 Accountable
IV.Concept Notes
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Introduction
Sandra M. Nettina
Cancer was recognized in ancient times by skilled observers who gave it the name “CANCER”
(Latin, Cancri, CRAB) because it stretches out in many directions like the legs of the crab.
Cancer occurs in all strata of our society. It afflicts all people of all ages, in all socioeconomic
and cultural backgrounds and both sexes. It is much - dreaded disease. it poses tremendous
physiologic, psychosocial, cognitive, spiritual and economic impact to the afflicted individuals
and their significant others.
Cancer may spell death to some and mutilation to others. The legends surrounding cancer
(malignant disease) often focusing on incurability, help foster feelings of hopelessness and
powerlessness. Nurses too, may have the same negative attitudes that exist in the society.
Therefore, it is imperative for nurses to examine their own feelings and try to work them
through, both by increasing their knowledge of the disease and its treatment and by discussing
feeling openly with members of the health team. These will enable help clients and their
families.
Nurses are involved in all phases of the cancer experience: Prevention, detection, diagnosis,
treatment, rehabilitation, survivorship and palliative and terminal care. Cancer nursing skills are
vital in all health care settings because clients are in the home, office, clinic, acute care setting,
rehabilitation setting and hospice.
Despite significant advances in detection, diagnosis and treatment, cancer continues to be a

significant health problem. Perhaps, the greatest role any nurse can play in assisting individuals
in the prevention and early detection of cancer. Cancer nursing is challenge to the creativity,
skill and commitment of the nurse.
CANCER
 Is a neoplastic disorder that can involve all body organs with manifestations that vary
according to the body system affected and type of tumor cells.
 Cells lose their normal growth – controlling mechanism, and the growth of cell is
uncontrolled
 Cancer produces serious health problems such as impaired immune and hematopoietic
(blood – producing) function, altered gastrointestinal tract structure and function,
motor and sensory deficits, and decreased respiratory functions.
 Cure is considered to be achieved when the client exhibits no evidence of disease,
reference points of 5 and 10 years survival rates are used. After cure the client would
have the same expected life span as age-and sex-matched persons without cancer.
METASTASIS
 Cancer cell move from their original location to other sites
Routes of Metastasis
a) Local seeding – distribution of shed cancer cells occurs in the local area of the
primary tumor.
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b) Bloodborne metastasis – tumor cell enter the blood, which is the most common
cause of cancer spread.
c) Lymphatic spread – primary sites rich in lymphatic are more susceptible to early
metastatic spread.
CELL ALTERATIONS
 Hyperplasia- involves an increase in the number of cells in a tissue, it may be a
normal or an abnormal cellular response.
 Hypertrophy-increase size of a tissue or organ brought about enlargement of its cell
rather than cell multiplication
 Atrophy- a wasting away of normally developed organ or tissue due to degeneration
of cells
 Dysplasia- refers to change in size, shape, or arrangement of normal cell into bizarre
cells; it may precede an irreversible neoplastic change.
 Anaplasia- involves a change in DNA cell structure and in their orientation to one
another, characterized by loss of differentiated, irregularly shaped cells usually are
malignant.
 Neoplasia- the formation of abnormal cell
 Metastasis- the metastatic process may be divided into three stages:
a) Invasion – neoplastic cells from primary tumor invade into surrounding tissue with
penetration of blood or lymph; this occurs because cells are not encapsulated.
b) Spread- tumor cell spread through lymph or circulation or by direct expansion.

c) Establishment and growth- tumor cell are established and grow at secondary site; in
lymph filter (Lymph nodes) or in organs from venous circulation.
Cancer Classification
 SOLID TUMORS: associated with the organs from which they develop, such as
breast cancer or lung cancer
 HEMATOLOGICAL CANCERS: originate from blood cell – forming tissues, such as
leukemia’s, lymphomas, and multiple myeloma.
PATHOGENESIS OF CANCER
 Cellular transformation and derangement theory
 Conceptualizes that normal cells may be transformed into cancer cells due to
exposure to some etiologic agents.
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 Failure of the Immune Response Theory

 Advocates that all individual possess cancer cells. However, the cancer cell are
recognized by the immune system. Therefore, cells undergo destruction. Failure
of immune response system leads to inability to destroy the cancer cells.
ETIOLOGIC FACTOR TO CANCER

 Healthy cells are transformed by unknown mechanisms or exposure to certain etiologic
agents, including:
a. Viruses (e.g., Cytomegalovirus, Papillomavirus, hepatitis B)
b. Chemical Carcinogens (e.g., Chromium, cobalt, tar, soot, asphalt, certain plastics, aniline
dyes, hydrocarbons in cigarette smoke, air pollutants from industry, crude paraffin oil,
nickel, asbestos, and etc.)
c. physical stressor (e.g., excessive exposure to sunlight or radiation, chronic irritation)
d. hormonal factors (e.g., imbalance of indigenous and exogenous hormones, such as
estrogen or diethylstilbestrol)
e. Genetic factors (e.g., abnormal chromosomes pattern, such as leukemia, and skin
cancers; familial predisposition, such as breast, endometrial, colorectal, stomach, lung,
colon, and kidney cancers)
PREDISPOSING FACTORS TO CANCER
 AGE –older individual are prone to cancer because they have been exposed to
carcinogens longer. In addition, they have developed alterations in immune system.
 SEX- Male: Lung cancer, Prostate, and colorectal cancer Female: Lung cancer, Breast,
colorectal cancer.
 URBAN Vs. RURAL residence- cancer is more common among urban dweller than rural
residents are. This is probably due to greater exposure to carcinogens, more stressful
lifestyle and greater consumption of preservative- cured foods among urban dweller.
 OCCUPATION- e.g. there is a greater risk of exposure to carcinogen among chemical
factory workers, farmers, radiology department personnel.
 HEREDITY- 85-95percentage - environmental 10-15% Genetics
 STRESS- depression, grief, anger, aggression, despair, or life stresses decreases
immunocompetence because of affectation of hypothalamus and pituitary gland.
Immunodeficiency may spur the growth and development of the cancer cell.
 PRECANCEROUS LESIONS- pigmented moles, burn scars, senile keratosis, leukoplakia,
benign polyps or adenoma of the stomach and colon or stomach, fibrocystic disease of
the breast, may undergo transformation into cancerous lesions and tumors.
 OBESITY- studies have linked obesity to breast and colorectal cancer.

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 IMMUNE FUNCTIONS – the incidence of cancer is higher in immunosuppressed

individuals, such as those with acquired immunodeficiency syndrome and organ
transplant recipients who are taking immunosuppressive medications.
COMPARISON OF THE CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASM
NORMAL CELL ABNORMAL CELL

 Predictable life cycle  Unpredictable life cycle
 Differentiation  Undifferentiated
 Contact inhibition  No contact inhibition/disorganized
 Growth rate  Uncontrollable growth rate
Functions: for the well-being of the host  No function/damage of the host
CHARATERISTICS BENIGN MALIGNANT

 Speed of growth  Grows slowly  Grows rapidly
 mode of growth  Remains localized  Infiltrates
surrounding tissues
 capsule  Encapsulated  Not capsulated
 cell characteristics  Well differentiated  Poorly differentiated
mature cells; but cell
poorly function.
 recurrence  Extremely unusual  Common following
when surgically surgery because
removed. cancer cells spread
 metastasis into other tissues.
 Effects of neoplasm  Never occur  Very common
 Not harmful to host,  Always harmful to
unless it compresses host. May result in
tissue or obstruct necrosis, ulceration,
vital organs. hemorrhage,
infection. Produces
 prognosis  Very good cachexia.
 Poor prognosis if
cells are poorly
differentiated and
evidence of
metastasis occur.
PREVENTION, SCREENING, AND EARLY DETECTION

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a.) PRIMARY PREVENTION activities are aimed at intervention before pathologic change has
begun. These can help to reduce cancer risk through alteration of lifestyle behavior to eliminate
or reduce exposure carcinogen.
1. Adopting a more healthy diet
2. Limiting exposure to sun and other sources of ultraviolet radiation
3. Modifying sexual practices
4. Avoiding cigarette smoking and alcohol drinking
5. Decreasing exposure to environmental and occupational carcinogens
BREAST SELF EXAMINATION TESTICULAR SELF EXAMINATION

A. Performing breast self-examination A. Performing testicular self –
(BSE) examination: a day of the month is
 Perform 7 – 10 days after menses selected and the examination is
 Postmenopausal clients or clients performed on the same day each
who had a hysterectomy should month.
select a specific day of the month and Clients instructions
perform BSE monthly on that day Testicular self-examination. The best time to
perform this examination is right after
shower when your scrotal skin is moist and
relaxed, making testicles easy to feel. First,
gently lift each testicle. Each one should feel
like an egg, firm but not hard, and smooth
with no lumps. Then, using both hands,
place your middle fingers on the underside
of each testicle and your thumbs on top.
Gently roll the testicle and your fingers to
feel for any lumps, swelling, or mass. If you
notice any changes from one month to the
next, notify your physician or nurse
practitioner.
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Figure 40:Procedure guidelines Patient education guidelines on BSE

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2.) SECONDARY PREVENTION or early detection provides the opportunity to detect

precancerous lesions or early- stage cancer to treat them promptly.
SUMMARY OF AMERICAN CANCER SOCIETY (ACS) RECOMMENDATIONS FOR THE EARLY

DETECTION OF CANCER IN ASYMPTOMATIC PEOPLE
TEST GENDER AGE FREQUENCY
Sigmoidoscopy Males and females 50 older Every 5 years
Fecal occult blood Males and females 50 and older Every year
test
colonoscopy Males and females 50 and older Every 10 years
Digital rectal Males and females 50 and older Every year
examination
Prostate examination Males 50 and older Every year
Papaniculao test Females All women who are or who have been
(Pap) test sexually active, or who have reached 18
years of age, should have an annual pap test
and pelvic examination. After a woman has
annual examinations, the pap test maybe
performed less frequently at the discretion of
her physician.
Breast self- Females 20 and older Every month
examination (Optional)
Breast clinical Females 20 to 40 Every 3 years
examination Older than 40 Every year
Mammography Females 40 and over Every year
CANCER DETECTION EXAMINATIONS!!!
1. Cytologic Examination - Papanicolaou Test (Pap’s Exam/Pap smear)

 The Pap smear is a screening test for cervical cancer. Cells scraped from the opening of
the cervix are examined under a microscope.
INTERPRETATION OF PAPANICULAO TEST RESULT ARE AS FOLLOWS:

 Class I Normal
 Class II inflammation
 Class III mild to moderate dysplasia
 Class IV probably malignant
 Class V Possibly malignant
 Class I result requires follow – up examination every 1 to 3 years as recommended by
the physician.
 Class II and III results may require repeat pap smear in 3 to 6 months as prescribe.
 Class IV and V results require biopsy as prescribed.
2. Biopsy
 Biopsy is a definitive means of diagnosing cancer and provides histological proof of
malignancy.
 Biopsy involves the surgical incision of a small piece of tissue for microscopic
examination.
Types
 Needle biopsy is done by aspiration of tumor cells with needle and syringe
 Excisional biopsy is done by removing the entire tumor. It is done when the tumor is
small
 Incisional or subtotal biopsy is done by taking only a part of the tumor. This is done
when the tumor is large.
Tissue examination
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 Following excision, a frozen section or a permanent paraffin section is prepared to

examine the specimen.
 The advantage of the frozen section is the speed with section can be prepared and the
diagnosis made, because only minutes are required for this test.
 Permanent paraffin section takes about 24 hours, however it provides clearer details
than the frozen section.
Interventions
 The procedure is usually perform in an outpatient surgical setting
 Prepare the client for the diagnostic procedure, and provide post procedure instructions
 Obtain an inform consent
WARNING SIGN’S OF CANCER

C- Change in bowel or bladder habits
A- sore that does not heal
U- unusual bleeding or discharge
U- unexplained sudden weight loss
U- unexplained anemia
T- thickening or lump in the breast or elsewhere
I- indigestion or difficulty in swallowing
O- obvious change in wart or mole
N- nagging cough or hoarseness of voice
STAGING AND GRADING OF NEOPLASIA

 Staging is determining the size of tumor and existence of metastases.
 Grading is classification of tumor cells
 Staging is necessary at the time of diagnosis to determine the extent of disease (local
versus metastatic), to determine prognosis and to guide the proper management.
 The American joint committee of cancer (AJCC) has developed the TNM classification
system that can be applied to all tumor types.
T- tumor size
N- presence or absence of regional lymph node involvement
M- presence or absence of distance metastasis
T – PRIMARY TUMOR
 Tx- primary tumor is unable to be assessed.
 To- no evidence of primary tumor
 Tis- carcinoma in situ
 T1, T2, T3, T4- increasing size and tumor or local extend of primary tumor
N- Presence or absence or regional lymph node involvement
 Nx- regional lymphnode are unable to assessed
 No- no regional lymph node involvement
 N1, N2, N3- increasing involvement of regional lymph nodes
M- absence or presence or distance metastasis
 Mx- unable to be assessed
 Mo- absence of distant metastasis
 M1- presence of distant metastasis
3.) TERTIARY PREVENTION

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 Treatment modalities for cancer – the choice of treatment modality depends on the
type of tumor, the extent of the disease, and the client co- morbid condition,
performance status, and wishes.
SURGICAL INTERVENTIONS
 Surgery is indicated to diagnosed, stage, and treat cancer.
1. Diagnostic Surgery- this is done by cytologic specimen collection and biopsy
2. Preventive Surgery- this involve removal of precancerous lesions or benign tumor, e.g.,
patient with familial polyposis and ulcerative colitis undergo subtotal colectomies to prevent
colon cancer.
3. Curative Surgery- this involve removal of an entire tumor and surrounding lymphnodes.
Cancer that are localized to the organ of origin and regional lymph nodes are potentially
curable by surgery.
4. Reconstructive Surgery- this is done for improvement of the appearance and function of the
organs affected. This is also an attempt to improve the client’s quality of life.
5. Palliative Surgery- this is done for relief of distressing sign and symptoms or retardation of
metastasis. This is an attempt to improve quality of life.
Examples of palliative surgery are as follows:
a. reduce pain by interrupting nerve pathways or implanting pain control pumps.
b. relieve airway obstruction.
c. relieve obstructions in the GI and GU tracts.
d. relieve pressure in the brain and the spinal cord.
e. prevent hemorrhage.
f. remove infected and ulcerating tumors, and drain abscess.
Side effects of surgery

 Loss or loss of function on a specific body part
 Reduced function as a result of organ loss
 Scarring or disfigurements
 Grieving about altered body image or impaired change in lifestyle
PAIN CONTROL
 Causes of pain
1. Bone destruction
2. Obstruction of an organ
3. Compression of peripheral nerve
4. Infiltration, distention of tissue
5. Inflammation, necrosis
6. Psychological factor, such as fear or anxiety
Interventions:
 Assess the client’s pain; pain is what the client describes or says that it is.
 Collaborate with other member of the health care team to develop a pain management
program.
 Administer oral preparation if possible and if they provide adequate relief pain; the
transdermal route may also be prescribed.
 Mild or moderate pain may be treated with salicylates, acetaminophen (Tylenol), and
Non-Steroidal Anti- inflammatory Drugs (NSAIDs); drug anticoagulants, oral
hypoglycemic, and antihypertensive.
 Severe pain is treated with opioids, such as codeine sulfate, morphine sulfate,
methadone, and hydromorphone hydrochloride (dilaudid). Neuropathic pain is treated
with a variety of anticonvulsants and antidepressants, as well as opioids
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 Subcutaneous injections and continuous IV infusion of opioids provide rapid pain

control; equianalgesic comparison charts should be used when switching routes of
administration of opioids.
 Monitor vital signs and side effects of medications.
 Provide non- pharmacological techniques of pain control, such as relaxation, guided
imaginary, biofeedback, massage, and heat cold application.
 Do not undermedicated the cancer client who is in pain.
RADIATION THERAPY (RT)

 Radiation therapy may be used as a primary, adjuvant, or a palliative treatment
modality. As a primary modality, it is the only treatment used and aims to achieve local
cure of the cancer. (e.g., early stage skin cancer, carcinoma of the cervix, Hodgkin’s
disease)
 As an adjuvant therapy, RT can be done preoperatively and postoperatively to aid in
destruction of cancer cell. In addition it can be used in conjunction with chemotherapy
to enhance destruction of cancer cell.
 RT is the use of high- energy ionizing radiation that destroys a cell’s ability to reproduce
by damaging its DNA.
 Rapidly dividing cells like cancer cells are more vulnerable to radiation therefore,
radiation kills cancer while sparing normal cells from excessive cell death.
THE TYPES OF RADIATION THERAPY ARE AS FOLLOWS:
1.) External Radiation Therapy (Teletherapy, DXT)

 This is administered through a high- energy X – ray or gamma X- ray machine (e.g. linear
accelerator, cobalt, betatron, or a machine containing radioisotope).
 The major advantages of high – energy radiation is its skin – sparing effects. The
maximum effects of radiation occur at tumor deep in the body, not on the skin surface.
 There is no need for isolation.
2.) Internal Radiation Therapy- this is administered within or near the tumor or into the
systemic circulation.
 The two major types of internal RT are as follows:
a. Sealed Source (Bracytherapy). The radioisotope is placed within or near the tumor. The
radioactive material is enclosed in a sealed container.
- Sealed source is used for both intracavity and interstitial therapy.
-INTRACAVITY RT is used to treat cancer of the uterus and cervix. The radioisotope is placed in
the body, generally for 24 to 72 hours (cesium 137 or radium 226)
-INTERSTITIAL THERAPY the radioisotopes is placed in the needles, beads, seeds, ribbon, or
catheters, which are then implanted directly into the tumor (iridium 192, iodine 125, cesium
137, gold 198, or radium 222)
In sealed source of internal radiation, the radioisotope cannot circulate through the client’s
body nor can it contaminate the clients urine, sweat, blood, or vomitus. Therefore, the client’s
body is not radioactive.
b. Unsealed Source. The radioisotopes may be administered intravenously, orally or by
instillation directly into the body cavity.
- in unsealed sources of internal radiation , the radioisotopes circulates through the clients
body. Therefore the clients urine , sweat, blood, and vomitus contain the radioactive isotpe.
-examples of unsealed source of RT are iodine 131 given orally for grave’s disease and tyroid
cancer; altrontium chloride 89 is administered intravenously for relief of painful bony
metastasis.
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PRINCIPLES OF RADIATION PROTECTION

1. DISTANCE maintains a distance of at least 3 feet when not performing nursing procedure.
2. TIME- limit contact with the client for 5 minutes each time, a total of 30 minutes per 8 hour
shift.
3. SHIELDING- use lead shield during contact with client.
 Pregnant staff should not be assigned to client receiving internal RT
 Staff members caring for the client with internal RT should wear dosimeter badge while
in the clients room.
 If the client with cancer of the cervix has radioisotope implant into the uterus, the
following nursing interventions should be implemented:
1. clients back is turned towards the door
2. the client’s should be in a complete bed rest. To prevent dislodgement of radioisotope
3. the client should be given enema before the procedure, bowel movement during the
procedure may cause dislodgement of radioisotope.
4. the client should be given a low fiber diet to inhibit defecation during the procedure
until the device is removed in 2 to 3 days. To prevent dislodgement of the radioisotope
5. the client should have a folycatheter in place during the procedure
6. have long forceps and lead container readily available. Use long forceps to pick up
dislodge radioisotope and place it in the lead container
 The client receiving unsealed source of RT; should have a private room and bath
NURSING INTERVENTIONS FOR SIDE EFFECTS OF RADIATION

1. Skin reactions
 Erythema, dry/moist squamation
 Atropy, telangiectasia, depigmentation, necrotic/ulcerative lesions.
 Observe for early sign of skin reaction and report to the physician
 Keep area dry
 Wash area with water, no soap, and pat dry (do not dry). Mild soap is permitted
 Do not apply ointment, powders, or lotion on the area. Cornstarch may be used
 Do not apply heat; avoid direct sunshine or cold on the area
 Use cotton fabrics for clothing. To prevent skin irritation
 Do not erase marking on the skin. These are guide for areas of irradiation
2. Infection
 This is due to bone marrow suppression
 Monitor blood counts weekly, especially wbc
 Good personal hygiene, nutrition, adequate rest
 Teach the client signs of infection to report to physician
3. Hemorrhage
 Platelets are vulnerable to radiation
Nursing intervention:
 Monitor platelet count
 Avoid physical trauma or use of Aspirin
 Teach signs of hemorrhage to report (e.g., gum bleeding, nose bleeding, black stools)
 Use direct pressure over injection sites until bleeding stops
4. Fatigue
 Result of high metabolic demands for tissue repair and toxic waste removal
5. Stomatitis and Xerostomia (Dry mouth)
 Ulceration of oral mucosa membranes occur
Nursing intervention
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 Administer analgesics before meals as prescribe

 Bland diet, avoid smoking and alcohol
 Good oral hygiene with saline rinses every 2 hours
 Sugarless lemon drop or mint to increase salivation
6. social isolation is also experience by the client due to fear of contaminating others with
radiation.
CHEMOTHERAPY
The term chemotherapy is used to describe cancer-killing drugs. Chemotherapy may be used to:
 Cure the cancer
 Prevent the cancer from spreading
 Relieve symptoms when the cancer cannot be cured
 The goal of chemotherapy maybe cure, control, or palliation of manifestation. It is

systemic intervention. It is recommended when:
a. diseases widespread
b. the risk of undetectable disease is high
c. the tumor cannot be resected and is resistant to radiation
 The objective of chemotherapy is to destroy all malignant tumor cell without
destruction of normal cell
 Chemotherapy has the following characteristics:
a. it affects both normal cell and cancer cell
b. chemotherapy has a fraction cell – kill only certain number of cancer cell. are killed
with each course of chemotherapy. Therefore, chemotherapy must be given in a series.
CLASSIFICATION OF CHEMOTHERAPUTIC AGENTS

Cell cycle -specific groups
a. Antimetabolites b. Vinca c.Epipodophylloxins d. Taxanes e.miscellaneous
-Cytarabine (Ara- c, alkaloids -Etoposide (VP-16) -paclitel -L- Asparaginase
cytosar) -vinorelbine (Taxol)
(Navalbine -Teniposide (VM- -Hydroxyurea
-5 fluoracil (5- FU) -vincristine 26, vumon (hydrea)
(Oncovin)
-Methotrexate vinblastine
(velban)
-Pentostatin
-6mercaptopurine
Antibiotics Cell cycle – non-specific groups

 Bleomycin (Blenoxane) Alkalying agents
Febrile reaction on 1st day  Busulfan (myleran)
Can cause pulmonary fibrosis  Carboplatin (Paraplatin)
 Doxorubicin (Adriamycin)  Cisplatin (CDDP,platinol- AQ)
 Mitomycin C (mitomycin)  Cyslophosphamide (Cytoxan)
 THioptepa
 Mechorethamine HCI (Mustargen)
HOW CHEMOTHERAPY IS GIVEN

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Depending on the type of cancer and where it is found, chemotherapy may be given in a
number of different ways, including:
 Injections or shots into the muscles
 Injections or shots under the skin
 Into an artery
 Into a vein (intravenous, IV)
 Pills taken by mouth
 Shots into the fluid around the spinal cord or brain
When chemotherapy is given over a longer period of time, a thin catheter can be placed into a
large vein near the heart. This is called a central line. The catheter is placed during a minor
surgery.
CONTRAINDICATION TO CHEMOTHERAPY
 Infection
 Recent surgery
 Impaired renal and hepatic function
 Recent radiation therapy
 Pregnancy
 Bone marrow depression
NURSING INTERVENTION FOR CHEMOTHERAPY SIDE – EFFECTS
1. GI system- nausea and vomiting, diarrhea, constipation

 Administer anti-emetic to relieve nausea and vomiting
 Replaces fluids- electrolytes losses, low- fiber diet to relieve diarrhea
 Increase fluid intake
2. Integumentary
 Pruritus’, urticaria, and systemic signs
Provide good skin care
 Stomatitis (oral mucositis)
Provide mouth care
Avoid hot and spicy food
 Alopecia
Reassure that this is temporary
Encourage to wear hat, wigs, head scarf
 Skin pigmentation
Inform that this is temporary
 Nail changes
Reassure that nails may grow normally after chemotherapy
3. Hematopoietic system
 Anemia
Provide frequent rest
 Neutropenia
o Protect from infection
o Avoid people with infection
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o Report fever, chills, diaphoresis, heat, pain, erythema, or exudates on any - body
surface
o Avoid rectal or vaginal procedure
o Avoid fresh foods, raw meat, fish, vegetable, fresh flower, potted plants
o Change IV sites every other day
4. Thrombocytopenia
 Protect from trauma
 Avoid ASA
5. Genito –urinary system

 Hemorrhagic cystitis
Provide 2-3 liters per day
 Urine color changes
Reassure that this is harmless
6. Reproductive system
 Premature menopause or amenorrhea
Reassure that menstruation resumes after chemotherapy
ADVERSE REACTION TO CHEMOTHERAPY ARE AS FOLLOWS

1. HYPERSENSITIVITY If anaphylactic reaction occurs, the following
 Dyspnea nursing interventions are as follows:
 Chest tightness or pain  stop the drug administration
 Pruritus’  maintain iv access with 0.9 NS
 Urticaria (Nacl)
 Tachycardia  keep an open airway
 Dizziness  keep the client on a modified
 Anxiety Trendelenburg position, unless
 Agitation contraindicated
 Inability to speak abdominal pain  notify the physician
 Nausea  monitor clients VS
 Hypotension  administer epinephrine,
 Cloudy mental status aminophylline, diphenhydramine
 Cyanosis and corticosteroids as prescribibed.
EXTRAVASATION
 vesicant chemotherapeutic agent can cause or form a blister and tissue
destruction. e.g., Adriamycin, Oncovin.
 Irritant drugs can produce venous pain at the site and along the vein.
 Pain, erythema, swelling and lack of blood return indicate an extravasation
Nursing intervention:
 Stop the drug administration
 Leave the needle in lace, and attempt to aspirate any residual drugs from the
tubing, needle, and site.
 Administer an antidote, as prescribe
 Apply warm or cold compress as indicated
 Document the appearance of the site before and after chemotherapy
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CANCER OF THE BREAST
 Breast cancer is the most common cancer in women and is the second leading cause of
death from cancer in women in the United States.
1.Most breast cancer begins in the lining of the milk ducts, sometimes in the lobule. Eventually
it grows through the wall of the duct and into the fatty tissue.
Figure 41: Breast tumor sources and sites
2. Family history accounts for approximately 7% of all breast cancers.
a. Current genetic models attribute 5% to 10% of all breast cancer to dominantly

inherited breast cancer susceptibility genes.
b. Two breast/ovarian susceptibility genes have been identified and named BRCA-1
and BRCA-2. Testing may be performed for those patients diagnosed before age
50 with breast and/or ovarian cancer who also have two first-degree relatives
with a similar diagnosis or a combination of three or more relatives (including
males) with breast cancer regardless of age at diagnosis. Women of Ashkenazi
Jewish descent have an increased likelihood of BRCA mutations. Knowledge of a
mutation can help patients make informed decisions to manage their risk for
future breast cancers. It is important to have genetic counseling before the test
because of its implications. Screening is not warranted for general population.
 Present knowledge does not indicate that carcinogens play an important role in
the development of breast cancer.
4. Several models exist that attempt to predict the short- term or lifetime risk of
breast cancer for women with identifiable factors associated with the disease.
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These include the Breast Cancer Pro Statistical Model, the Claus Statistical
Model, and the Gail Risk Model (www.bcra.nci.nih.gov).
Epidemiology of Breast Cancer
Incidence
1. The American Cancer Society estimates that 178,480 (1,700 male) new cases of breast cancer
will be diagnosed in 2007 in the United States, with approximately 40,910 deaths. Breast cancer
incidence rates appear to be decreasing primarily in white women and in younger women.
2. Thereareexpectedtobe62,030casesofDCISin2007.
Survival Rates
1. Five-year overall survival rates:
– Localized: 97%.
– Regional: 78.7%.
– Distant: 23.3%.
In the general population, the relative survival rate is lower among Black women than
White women.
2. Lymph node status is the most important prognostic indicator of disease-free survival.
3. Age, staging (tumor size, lymph node status, and distant metastasis), nuclear grade,
histologic differentiation, and treatment are important prognostic factors for survival.
(Figure)
4. Mortality is declining 1% to 2% in the United States. This may be related to:
a. Change in life style such as diet
b. Early diagnosis—increased use of screening mammography
c. Improved treatment.
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Figure 42: staging of Breast Cancer
NURSING ALERT Black women are more likely than White women to be diagnosed with large
tumors and distant stage disease. Learn about the demographics of your patient population.
Risk Factors
A woman’s lifetime risk of developing breast cancer is 12.5% based on a lifespan of 80 years.
1. Major—sex, increased age, a diagnosis of lobular carcinoma in situ, a prior history of

breast or ovarian cancer, and family history (especially mother, sisters). Approximate
twofold risk in women with affected sister or mother; this increases if more relatives
were affected or if affected close relatives developed breast cancer before menopause.
2. Probable—nulliparity, first child after age 30, late menopause, early menarche, benign
proliferative breast disease, diagnosis of atypical ductal hyperplasia on biopsy, long-
term use of estrogen replacement therapy that increases with duration of use.
3. Controversial—hormonal contraceptive use (estrogen and progestin may stimulate

tumor growth with long- term use), alcohol use, obesity, and increased dietary fat
intake.
4. Results of breast cancer prevention trials have shown a reduction in incidence of breast
cancer in high-risk women treated with tamoxifen or raloxifene. Aromatase inhibitors
are under investigation for use in prevention.
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GERONTOLOGIC ALERT Age is the greatest single risk factor for the development of cancer.
Cancer warning signals may be unheeded in older women, so thorough history-taking and
physical examination is essential.
 A firm lump or thickening in breast, usually painless; 50% located in upper outer
quadrant of breast. Enlargement of axillary or supraclavicular lymph nodes may indicate
metastasis.
 Nipple discharge—spontaneous, may be bloody, clear, or serous.
 Breast asymmetry—a change in the size or shape of the breast or abnormal contours. As
woman changes positions, compare one breast to other.
 Nipple retraction or scaliness, especially in Paget’s disease. (see figure 5)
 Late signs—pain, ulceration, edema, orange-peel skin (peau d’orange) from
interference of lymphatic drainage. (see figure 5)
 Inflammatory breast cancer may present with erythema.
 Many small invasive breast cancers as well as noninvasive breast cancer (DCIS) do not
present with a palpable mass, but are found on mammography.
NURSING ALERT Pain is not usually an early warning sign of breast cancer.
Figure 43 (A) Signs of cancer of the breast. (B) Distribution of carcinomas in different areas of
breast
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Figure 44: Looking at breast dimpling and peau d’ orange
RADIOLOGY AND IMAGING
Mammography
 Low-dose X-ray of breast used to screen for breast abnormalities or may be used when a
lump is found on physical examination. Can detect patients with clustered micro-
calcifications.
 Compression of the breast is used to reduce the amount of radiation absorbed by the
breast tissue and separate over- lapping tissue.
 Two views are taken routinely: craniocaudal and medio- lateral; other views are done as
necessary.
 Best performed at a facility that is accredited by the American College of Radiology. The
machines and staff at these facilities have met specific criteria. Computer- aided
detection has been developed to aid radiologists in detecting abnormalities. See Table
23-1 for mammography categories.
 Mammography is not routinely done if a woman is pregnant.
 The breasts of young women tend to be extremely dense and are poorly suited to
mammography.
 False-negative results occur even in the best facilities; figure may reach 10%.
 Both screen film and digital mammography use X-rays to obtain images. With digital
mammography, a film image is replaced with an electronic image similar to digital
photography. For younger women under age 50, women with radiographically dense
breasts, and premenopausal and perimenopausal women, digital mammography is
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more accurate than film mammography. For all other women, there is no significant
advantage to using digital mammography.
Nursing and Patient Care Considerations
 Recommend regular screening based on established guidelines. Tell patients that

routine screening mammography has been shown to reduce mortality from breast
cancer. Procedure takes approximately 15 minutes.
 Remind patients not to apply deodorant, cream, or powder to breast, nipple, or
underarm areas on examination day.
 Advise that some discomfort may be felt from compressing the breast.
 Patients should have an opportunity to become informed about the benefits,
limitations, and potential harms associated with regular screening. Overdiagnosis of
clinically insignificant disease is possible. Benefits are thought to outweigh the exposure
to low dose of radiation.
 Alert patient that extra views do not imply that the patient has breast cancer.
Ultrasonography
 Uses high-frequency sound waves to get an image of the breast.

 Helps determine if a lump is a cyst or a solid mass.
 May be used if patient is pregnant or is younger than age 35.
 Advise that this test is painless and noninvasive.

 No preparation is necessary.
Additional Imaging Studies
Galactography/Ductogram
 A contrast mammogram is obtained by injection of water-soluble contrast medium into

a duct for patient with persistent bloody nipple discharge. It is a time- consuming
procedure that is not routinely used.
 It may outline an intraductal papilloma.
 Its ability to differentiate benign from malignant lesions is limited.
Magnetic Resonance Imaging
 Produces images from the combination of a magnetic field, radio waves, and computer
processing.
 Used in newly diagnosed breast cancer patients for presurgical planning. May help in
determining extent of disease, multifocality, and unsuspected disease in the
contralateral breast.
 Useful in high-risk women, those with dense breasts, and in those with silicone implants.
 Because MRI is less accessible and more expensive than mammography, it is not useful
for generalized screening. There may be increased false-positive results. MRI-guided
biopsy is not widely available.
Fine-Needle Aspiration
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 Uses a thin needle and syringe to collect tissue or to drain lump after using a local
anesthetic. If it is a cyst, removing the fluid will collapse it; no other treatment may be
needed. Ultrasound may be used to locate a nonpalpable cyst.
 Normal cyst fluid appears straw-colored or greenish. Fluid should be sent for cytology if
it appears suspicious (clear or bloody); otherwise, it is discarded.
 This office procedure uses local anesthetic with results usually within 24 hours.
 It has limited sensitivity, possibly because of insufficient acquisition of cytologic
material.
 Inform patient of small risk of hematoma and infection.

 Adhesive bandage applied after procedure; usually no discomfort.
 Solid lesions may warrant an excisional biopsy.
Needle Biopsy
 Office procedure uses local anesthetic and removes a small piece of breast tissue using a
needle with a special cutting edge.
 For palpable lesions with a high suspicion of malignancy. May provide a tissue diagnosis
quickly—usually approximately 24 hours—without doing an excisional biopsy to plan
definitive surgery.
 Inform patient of small risk of hematoma and infection.

 Tell patient that several passes may be necessary to obtain specimen, with minor
discomfort.
 Pressure dressing applied after procedure.
 Recommend use of acetaminophen (Tylenol) or ibuproen (Advil) for post procedure
discomfort—usually minimal, if any.
Excisional Biopsy
 Surgical removal of a palpable or nonpalpable lesion. A frozen section may be done for
immediate tissue diagnosis.
 Excisional biopsy or lumpectomy entails entire removal of a mass; incisional biopsy
entails partial removal of a mass.
 This outpatient procedure may be performed under local or general anesthesia.
 Curvilinear incision is usually made directly over the mass, which is excised en bloc
including a 1-cm grossly free margin of tissue.
 Pressure dressing is placed, which can be removed in 24 to 48 hours.

 Inform patient to watch for bleeding, hematoma, and signs of infection.
 Recommend analgesics for discomfort and a support bra for comfort.
Management
 Based on type and stage of breast cancer, receptors, and menopausal status. For
women with localized breast cancer, information from clinical trials indicates that
treatment with a breast-preserving procedure has similar survival rates as does
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modified radical mastectomy. Surgery for DCIS may involve only a lumpectomy, but
mastectomy may be necessary for extensive disease.
Surgery
Table 2: Types of Surgery for Breast Cancer
Radiation Therapy
1. In conjunction with breast-preserving procedure as adjuvant (additional) therapy to

decrease incidence of local recurrence for invasive breast cancer and DCIS. May be used
preoperatively to shrink a large tumor to operable size.
2. May be used after a mastectomy in patients with large tumors that involve the chest
wall and/or many positive axillary lymph nodes, may delay reconstruction.
3. Contraindications to a breast-preserving procedure include two primary tumors in
separate quadrant of the breast, history of previous radiation therapy to the breast,
pregnancy, and positive margins.
4. Treatment may be individualized in pregnancy—ie, appropriate surgery followed by
chemotherapy in the second or third trimester and delayed irradiation in order to
preserve the breast.
5. May also be used to alleviate bone pain in metastatic breast cancer.
6. Radiation directed to breast, chest wall, and remaining lymph nodes.
a. Usually five treatments per week for 6 or 7 weeks.

b. A booster or second phase of treatment may be given. c. May include implants of
radioactive material after external treatment completed.
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7. Adverse effects include mild fatigue, sore throat, dry cough, nausea, anorexia; later, skin
will look and feel sun- burned. Eventually, the breast becomes firmer. Complications
include increased arm edema, decreased arm mobility, pneumonitis, and brachial nerve
damage. See page 153 for care of patient undergoing radiation therapy.
8. The FDA has approved a device called Mammo Site that delivers partial breast
irradiation through a balloon temporarily surgically implanted in the breast. Treatment
is twice per day for 5 days. Long-term follow-up studies are needed. Partial breast
irradiation should be performed only as part of a prospective trial.
Chemotherapy
1. Major use is in adjuvant treatment postoperatively; usually begins 4 weeks after surgery
(stressful for patient who just finished major surgery).
2. Treatments are given every 3 to 4 weeks for 6 to 9 months. Because the drugs differ in
their mechanisms of action, combinations of agents are used to treat cancer.
3. Main drugs used for breast cancer include cyclophosphamide (Cytoxan), methotrexate
(Mexate), 5-fluorouracil (5-FU), doxorubicin (Adriamycin), and pacli- taxel (Taxol). For
advanced cancer, docetaxel (Taxotere), vinorelbine (Navelbine), capecitabine (Xeloda),
mitox- antrone (Novantrone), and fluorouracil by continuous infusion and oral forms of
fluorouracil are used.
4. Indications for chemotherapy include:
a. Large tumors, positive lymph nodes, premenopausal women, and poor prognostic
factors. Currently, adjuvant chemotherapy and/or hormonal therapy is recommended
for all patients with invasive breast cancers 1 cm wide or larger.
b. Recent studies have demonstrated that systemic chemotherapy increased survival in

all women regardless of age. This raises questions of whom to treat.
5. Other agents that may be used include:

a. Trastuzumab (Herceptin)—a member of the epithelial growth receptor family; increased
survival when added to chemotherapy in metastatic breast cancer. Treatment is expensive; may
be given to patients who express this gene.
b. Bevacizumab (Avastin)—binds to vascular endothelial growth factor (VEGF) and blocks tumor
blood vessel growth. Used in advanced breast cancer.
c. Biphosphonates, such as pamidronate (Aredia) and zoledronate (Zometa), inhibit bone

reabsorption and help to reduce pain and complications from bone metastasis.
6. Adverse effects include bone marrow suppression, cardiotoxicity, nausea and vomiting,
alopecia, weight gain or loss, fatigue, stomatitis, anxiety, depression, and premature
menopause.
7. Chemotherapy may also be used as primary treatment in inflammatory breast cancer and
occasionally in large tumors; otherwise, preoperative chemotherapy remains investigational.
Endocrine Therapy
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1. Selective estrogen receptor modulators, such as tamoxifen (Nolvadex) and raloxifene (Evista),
bind estrogen receptors, thereby blocking effects of estrogen.
a. Adjuvant systemic therapy after surgery.

b. Benefits all estrogen receptor-positive patients, regardless of menopausal status.
c. Given for at least 5 years; oral administration once or twice per day.
d. Adverse effects include hot flashes, irregular periods, vaginal irritation, nausea and
vomiting, headaches, increased risk of endometrial cancer and thromboembolic events.
e. Women on tamoxifen should have an annual gynecologic assessment if uterus present.
2. Aromatase inhibitors, such as anastrozole (Arimidex) and letrozole (Femara), block

conversion of androgen, which is secreted by the adrenal glands, into estrogen. Large
clinical trials report more favorable outcomes with aromatase inhibitors, and treatment
has shifted from 5 years of tamoxifen therapy to sequential treatment or initial
treatment with an aromatase inhibitor.
a. Anastrozole as well as fulvestrant (Faslodex), an estrogen receptor agonist, may

be used as a second-line therapy after tamoxifen in patients whose cancer has
returned or progressed. In a recent study, letrozole taken after tamoxifen
treatment was completed decreased the recurrence of breast cancer.
b. Aromatase inhibitors are ineffective in premenopausal women.
c. Aromatase inhibitors are less toxic than tamoxifen and pose less risk of blood
clots and endometrial cancer, but may increase risk of osteoporosis. Therefore,
women on aromatase inhibitors should have monitoring of bone health.
3. Hormones may be used in advanced disease. Remissions may last months to several
years. Agents commonly used include:
a. Estrogens, such as diethyl stilbestrol (DES) or ethinyl estradiol (Estinyl), in high

doses to suppress follicle- stimulating hormone (FSH) and luteinizing hormone
(LH) and may decrease endogenous estrogen production.
b. Progestins may decrease estrogen receptors.
c. Androgens may suppress FSH and estrogen production.
d. Aminoglutethimide suppresses estrogen production by blocking adrenal steroids;
“medical adrenalectomy,” especially useful for women with bone and soft tissue
metastasis.
4. Corticosteroids suppress estrogen and progesterone secretion from the adrenals.
D R U G A L E R T Traditionally, breast cancer survivors have not been considered candidates for
estrogen. However, debates and studies continue to be conducted regarding the safety of
estrogen in this population.
Bone Marrow Transplant
 Autologous method after high-dose chemotherapy; may be curative because it allows

high doses of drugs.
 Especially indicated for stage III disease.
Oophorectomy
Removal of ovaries.
189
 Treatment for recurrent or metastatic disease in estrogen receptor-positive

premenopausal women.
 Deprives tumor of primary estrogen source—remissions of 3 months to several years.
 Medical ablation with tamoxifen has been compared to surgical oophorectomy in
estrogen receptor-positive postmenopausal women, and response rates are similar.
 Surgical ablation is now considered second choice because of its increased risks.
 The benefits of tamoxifen in combination with oophorectomy are the subject of ongoing
research.
Adrenalectomy
 Removal of adrenal glands to eliminate androgen production (which converts to

estrogen).
 Rarely done because of need for long-term steroid replacement therapy.
 Remissions may last 6 months to several years. 3. Medical ablation with drugs being
studied.
Complications
1. Metastasis—most common sites: lymph nodes, lung, bone, liver, and brain.
2. Signs and symptoms of metastasis may include bone pain, neurologic changes, weight loss,
anemia, cough, shortness of breath, pleuritic pain, and vague chest discomfort.
Nursing Assessment
1.Assess general health status and underlying chronic illnesses that may have an impact on
patient’s response to treatment.
2. Identify what the patient and family need to know regarding breast cancer and its treatment,
and take measures to decrease their impact. Base education on patient and family needs.
3. Determine level of anxiety, fears, and concerns.

4. Identify coping ability and availability of support systems.
Nursing Diagnoses
Anxiety related to diagnosis of cancer
Deficient Knowledge related to disease process and treatment options
Ineffective Coping by patient or family related to diagnosis, prognosis, financial stress, or
inadequate support
Reducing Anxiety
 Realize that diagnosis of breast cancer is a devastating emotional shock to patient.

Support patient through the diagnostic process.
 Interpret the results of each test in language patient can understand.
 Stress the advances made in earlier diagnosis and treatment options.
Providing Information About Treatment
 Involve patient in treatment planning.

190
 Describe surgical procedures.

 Prepare patient for the effects of chemotherapy; encourge patient to plan ahead for the
common adverse effects of chemotherapy.
 Educate patient about the effects of radiation therapy.
 Teach patient about hormonal therapy. Patient may develop hot flashes with the start
of hormonal therapy or with the discontinuation of HRT at the time of diagnosis of
breast cancer Measures that may help with symptoms of hot flashes include:
o Clonidine, Bellergal-S, antidepressants.

o Various supplements and herbs have been used, but have not been rigorously
tested. Soy has been suggested, but there is no compelling evidence that
phytoestrogens help menopausal symptoms. Indeed, concerns have been raised
regarding stimulating breast cancer cell growth and, therefore, should not be
used.
o Progesterone may be helpful ,but the possible effect on breast cancer needs
further study.
o Repeat information and speak in calm, clear manner.

o Display empathy and acceptance of patient’s emotions.
o Explore coping mechanisms.
o Evaluate where patient is in stages of acceptance.
o Help patient identify and use support persons.
o Obtain visit from support group member.
o Refer for counseling, financial aid, and so forth.
o Resources include American Cancer Society, 800-ACS- 2345, www.cancer.org; National
Cancer Institute, www.cancer.gov; National Alliance of Breast Cancer Organizations,
www.nabco.org; and the Susan G. Komen Breast Cancer Foundation, www.komen.com.
1. Encourage patient to continue close follow-up and to report any new symptoms. Most
women will be seen every 3 months for the first 2 years, every 6 months for the next 3
years, and once per year after 5 years.
2. Stress importance of continued yearly mammogram.
3. Inform patient that yearly laboratory work, bone scan, and chest X-ray may be
performed when clinically indicated.
4. Suggest to patient that psychological intervention may be necessary for anxiety,
depression, or sexual problems.
 Verbalizes less anxiety

 Verbalizes understanding of all treatment options and their adverse effects
 Identifies appropriate coping mechanisms and support systems
CANCER OF THE CERVIX

191
 Cancer of the cervix is the third most common gynecologic malignancy.
 Most common between ages 35 and 55.

 Early sexual activity, multiple sexual partners, history of HIV and other STDs—especially
HPV and HSV (controversial)—are major risk factors.
 Incidence is higher in lower socioeconomic status and in blacks—presumably related to
decreased access to health care and screening.
 Decreased mortality in United States, but most frequent malignancy among women in
developing countries.
 Types (see Figure 6 on module 5):
o Dysplasia (precancer)—atypical cells with some degree of surface maturation.

o Carcinoma in situ—cytology similar to invasive carcinoma, but confined to
epithelium.
o Invasive carcinoma—stroma is involved; 90% are of the squamous cell type.
Spreads by local invasion and lymphatics to vagina and beyond.
Figure 45 on module 5 : Cervical cancer
 Early disease is usually asymptomatic although patient may notice watery, vaginal
discharge.
 Initial symptoms include postcoital bleeding, irregular vaginal bleeding or spotting
between periods or after menopause, and malodorous discharge.
 As disease progresses, bleeding becomes more constant and is accompanied by pain
that radiates to buttocks and legs as well as urinary and rectal symptoms that may be
due to invasion of these organs.
 Weight loss, anemia, edema of lower extremities, and fever signal advanced disease.
 Pap smear—routine screening measure; abnormal results warrant further diagnostic

tests such as colposcopy and biopsy or conization. (see figure 7 on module 5)
192
Figure 46: Pap smear findings in cervical cancer
 Staging is done clinically rather than surgically as with other cancers. Based on physical
findings on abdominal and pelvic examination.
193
 Supplemental imaging can include chest X-ray, I.V. pyelography (IVP), urography,
colposcopy, cystoscopy, proctosigmoidoscopy, computed tomography (CT) scan with I.V.
contrast, and barium studies of the lower colon and rectum.
Management
Dysplasia to Carcinoma in Situ
 Techniques to destroy abnormal cells in the cervical transformation zone

 Cryosurgery, laser therapy, electrocautery (loop electro- surgical excision procedure), or
conization may be performed on outpatient basis.
 Vaginal discharge, bleeding, pain, and cramping result from these procedures in various
degrees, but postoperative convalescence is minimal.
Microinvasive Stage
 Surgical conization—large excision of cervical tissue, may be done under local or general
anesthesia.
 Invasive cervical cancer—extent is staged and treated with hysterectomy, radiotherapy,
or chemotherapy.
Other Management
 Radiotherapy.
o Intracavitary (localized for earlier stage) or external (more generalized dosage to
pelvis for stages IIB through IVB).
o Cisplatin, a radiation sensitizer, is used to improve survival.
 Chemotherapy—cisplatin may be used in combination with radiation for locally
advanced disease or for metastatic disease in which recurrence is common. Other
agents that may be used include doxorubicin (Adriamycin), ifosfamide (Ifex), carboplatin
(Paraplatin), and topotecan (Hycamtin).
 Surgery.
o Simple hysterectomy or a radical trachelectomy (removal of cervix) may be
performed for stage IA.
o Radical hysterectomy and bilateral lymph node resections for stage IB and IIA.
Radiation and chemotherapy may also be considered for these stages after
hysterectomy.
 Pelvic exenteration for advanced cases if the patient is a candidate. Usually done for
patients with isolated central recurrence.
o Removal of the vagina, uterus, uterine tubes, ovaries, bladder, rectum, and
supporting structures and the creation of an ileal conduit and fecal stoma.
o Performed for pelvic recurrence after radiation or chemotherapy.
Complications
1. Spread to bladder and rectum; metastasis to lungs, mediastinum, bones, and liver.
2. Complications of intracavitary radiotherapy include cystitis, proctitis, vaginal stenosis,
uterine perforation.
3. Complications of external radiation include bone marrow depression, bowel
obstruction, fistula.
Nursing Assessment
1. Obtain history of Pap tests, sexual activity, past STDs.

194
2. Obtain history of symptoms.

3. Assess understanding of disease and responses, such as guilt, fear, denial, anxiety.
Nursing Diagnoses
 Anxiety related to cancer and treatment

 Disturbed Body Image related to surgical treatment
Relieving Anxiety
 Assist patient to seek information on stage of cancer, treatment options.

 Prepare patient for hysterectomy or other surgery .
 Prepare patient for radiation therapy to the uterus.
Enhancing Body Image
 Provide emotional support during treatment.

 Encourage patient to take pride in appearance by dressing, putting on makeup as able
 Encourage activity and socialization when patient is able.
 Explain the importance of lifelong follow-up, regardless of treatments, to determine the

response to treatment and detect spread of cancer.
 Refer to cancer support group in community.
eEvaluation: Expected Outcomes
 Reports decreased anxiety, increased decision-making ability

 Reports continued interest in appearance and femininity
ENDOMETRIAL CANCER
 Cancer of the uterus is usually adenocarcinoma of the endometrium of the fundus or

body of the uterus. Most common gynecologic cancer and third leading cancer in
women.
195
Figure 47: Progression of endometrial cancer
 Most patients are postmenopausal with an average age of 61 at time of diagnosis.

 Cause is unknown but associated with increased estrogen stimulation, as in obesity, late
menopause, nulliparity, amenorrhea, and unopposed estrogen replacement.
 Hypertension and diabetes mellitus are also risk factors.
 Irregular bleeding before menopause or postmenopausal bleeding.

 Watery, usually malodorous vaginal discharge.
 Pain, fever, and bowel and bladder dysfunctions are late signs.
 Anemia secondary to bleeding.
 Pelvic and rectovaginal examination—enlarged uterus may be palpated.

 Endocervical aspirate—shows abnormal cells.
 Endometrial biopsy results—may be false-negative.
 Dilation and curettage—most accurate diagnostic tool; hysteroscopy and transvaginal
ultrasound may also be helpful.
 Metastatic workup—includes CA 125 (which may be elevated especially in papillary
serous carcinomas), X-ray studies, and cystoscopy.
Management
 Staging for endometrial cancer is based on surgical aspects versus clinical staging.
o Emphasis is placed on histologic grade, depth of myometrial invasion, and
cervical involvement.
o These parameters assist in prediction of lymph node involvement and help
determine need for lymph node dissection.
196
 Early stage I requires total abdominal hysterectomy with bilateral

salpingooophorectomy (TAH/BSO).
 Advanced stage I and stage II require TAH/BSO and selective lymph node dissection.
 Radiation therapy (intracavitary or external) may be added after surgery or chosen
instead of surgery for more advanced stages or for patients who are high-risk surgical
candidates.
o Acute complications include hemorrhagic cystitis, vaginitis, enteritis, proctitis.
o Chronic complications include vaginal dryness, vaginal stenosis, cystitis, bladder
dysfunction, proctitis, small bowel obstruction, fistulas, strictures, leg edema.
 Hormonal therapy—progestational agents may alter receptor sites in endometrium for
estrogen and thus decrease growth (for metastatic disease); may provide stabilization of
disease.
 Chemotherapy—for metastatic and recurrent disease; low response rate of short
duration.
Complications
 Spread throughout the pelvis; metastasis to lungs, liver, bone, and brain
Nursing Assessment
 Obtain history of menses, pregnancy, estrogen replacement.

 Ask about irregular or postmenopausal bleeding and other symptoms.
 Assess patient’s response to possible diagnosis of cancer— fear, guilt, denial.
Nursing Diagnoses
 Fear related to cancer, treatment options

 Acute Pain related to disease process and surgical treatment
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Relieving Fear
 Support patient through the diagnostic process and reinforce information given by
health care provider about treatment options.
 Prepare patient for radiation therapy, if indicated.
 Prepare patient for hysterectomy, if indicated.
 Provide complete and concise explanations for all care you provide; emphasize the
positive aspects of patient’s recovery.
Relieving Pain
 Administer pain medications as prescribed and monitor patient’s response.

 Encourage use of relaxation techniques, such as deep breathing, imagery, and
distraction, to help promote comfort.
1. Explain importance of reporting postmenopausal bleeding. 2. Encourage keeping follow-up

visits.
3. Explain that surgery or radiation treatment does not prevent satisfying sexual activity.
4. Refer to local cancer support group or American Cancer Society, www.acs.org.
 Verbalizes understanding of diagnosis and treatment chosen 􏰀 Verbalizes decreased

pain
NURSING CARE OF THE PATIENT RECEIVING INTRACAVITARY RADIATION THERAPY
Procedural Considerations
 An applicator (tandems and ovoid’s are most common) is positioned in the endocervical
canal and vagina in the operating room with the patient under anesthesia. (High- dose
remote brachytherapy is also used. This is an outpatient procedure and the treatment
takes just minutes. The radioactive source is removed between treatments.)
 After recovery from anesthesia, X-rays are taken to check correct placement.
 Radiologist inserts radioactive material (radium or cesium) into applicator, which
remains in place 24 to 72 hours. Therapy is individualized according to the stage of
disease and patient’s response to and tolerance of radiation.
 External radiation over pelvis may be supplemented to eliminate cancer spread via
lymphatic system.
Patient Preparation
 Patients require a thorough medical evaluation before treatment to evaluate risks and
precautions related to pre-existing medical problems or special needs.
 An enema is given to evacuate the rectal vault before patient is transferred to the
operating room for application.
 An indwelling catheter is placed in the operating room.
 Encourage patient to bring diversional activities because she will remain on bed rest
during radiation treatment.
 Instruct patient on radiation safety measures:
o Neither patient nor her secretions are radioactive, but the applicator is.
198
o Do not touch source of radiation.

o Notify someone immediately if source is dislodged.
o When applicators are removed, no radioactivity remains.
o Radioactivity is monitored by specially trained personnel.
o No pregnant women or children younger than age 18 are allowed to visit.
o Lead shields may be used to decrease radiation that emanates from the patient.
 Reinforce that the help is readily available.
During Radiation Treatment
 Maintain patient on strict bed rest on her back with head of bed elevated 15 to 30
degrees. Patient may be log rolled three or four times per day. Use convoluted foam
mattress.
 Have patient bathe upper body. Perineal care and linen changes are done by the nursing
staff.
 Maintain patient on a low-residue diet to prevent bowel movements, which could
dislodge the apparatus. Encourage patient to eat several small portions rather than few
large servings. Medication to induce constipation is given.
 Inspect indwelling catheter frequently to ensure proper drainage. A distended bladder
may cause severe radiation burns.
 Encourage fluids to prevent bladder infection.
 Observe for signs and symptoms of radiation sickness nausea, vomiting, fever, diarrhea,
abdominal cramping.
 Check applicator position every 8 hours, and monitor amount of bleeding and drainage
(a small amount is normal).
 Check patient frequently to minimize anxiety, but minimize time spent at bedside to
reduce radiation exposure.
 Mild sedatives or pain medication may be given for patient comfort.
NURSING ALERT Long-handled forceps and a lead-lined container are left in the room after
loading, in the event the radioactive sources are dislodged. Maintain cardinal rules of time,
distance, shielding when caring for the patient.
During Radiation Removal
 Before removal of the applicator, patient is medicated with appropriate analgesic.

 The radioactive sources are removed by radiation personnel and safely stored for
transport.
 The indwelling catheter is removed and then the applicator is removed.
 The patient is given an enema or suppository to reverse the induced constipation.
 Patient should be evaluated for safe ambulation because of prolonged bed rest before
discharge.
NURSING ALERT Rules and regulations regarding radiation safety are strictly enforced to
protect patients and health care workers.
OVARIAN CANCER
 Ovarian cancer is a gynecologic malignancy with high mortality because of advanced
disease by time of diagnosis. It is the leading cause of morbidity of gynecologic cancers.
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Figure 48: Ovarian cancer
 Peak incidence is in fifth decade. One out of 70 women will develop ovarian cancer.
 Cause is unknown but about 10% of cases are associated with family history of breast,
endometrial, colon, or ovarian cancer.
 High-fat diet; smoking; alcohol use; environmental pollutants; and personal history of
breast, colon, or endometrial cancer are also risk factors.
 There is also higher incidence in nulliparous women or women with low parity.
Incidence is inversely proportional to amount of time ovulation is suppressed.
 Epithelial cell tumors constitute 90%; germ and stromal cell tumors, 10%.
 No early manifestations.
 First manifestations—(vague) abdominal discomfort, indigestion, flatulence, anorexia,
pelvic pressure, weight gain or loss, pelvic mass, ovarian enlargement.
 Late manifestations—abdominal pain, ascites, pleural effusion, intestinal obstruction.
 Pelvic examination to detect enlargement, nodularity, immobility of the ovaries.

 Pelvic sonography (transabdominal and transvaginal) and CT scan not helpful for early
detection; ovarian masses greater than 8 to 10 cm are suspicious for malignancy.
 Color Doppler imaging may be used to detect vascular changes within the ovaries.
 Paracentesis or thoracentesis if ascites or pleural effusion is present.
 Laparotomy to stage the disease and determine effectiveness of treatment.
 Increase of CA 125 signifies progression, but not as useful as diagnostic or screening tool
because level can be elevated due to inflammation and other causes.
Management
 TAH/BSO and omentectomy is usual treatment because of delayed diagnosis. Optimal

debulking to less than 1 cm is goal.
 Chemotherapy is more effective if tumor is optimally debulked (less than 1 cm residual
disease); usually follows surgery because of frequency of advanced disease; may be
given I.V. or intraperitoneal.
 Radiation therapy is not usually valuable, although it may be used for local recurrence.
200
 Hormonal therapy with tamoxifen (Tamofen), an anti- estrogen agent, may be used.
Progestins may be used dependent on estrogen receptor/progesterone receptor status.
 Second-look laparotomy may be done after adjunct therapies to take multiple biopsies
and determine effectiveness of therapy. Practice is controversial because it does not
affect survival.
 Immunotherapy is being investigated in clinical trials as stand-alone treatment or in
conjunction with other modalities.
Complications
 Direct intra-abdominal or lymphatic spread, peritoneal seeding
Nursing Assessment
 Obtain history of irregular menses, pain, postmenopausal bleeding.

 Ask about vague GI-related complaints.
 Ask about history of other malignancy and family history of breast or ovarian cancer.
 Assess patient’s general health status in terms of tolerating surgical and adjuvant
therapy.
NURSING ALERT A combination of a long history of ovarian dysfunction and persistent

undiagnosed GI complaints raises the suspicion for ovarian cancer. A palpable ovary in a post-
menopausal woman is abnormal and should be evaluated as soon as possible.
Nursing Diagnoses
 Ineffective Coping related to advanced stage of cancer

201
 Imbalanced Nutrition: Less Than Body Requirements related to nausea and vomiting
from chemotherapy
 Disturbed Body Image related to hair loss from chemotherapy
 Acute Pain related to surgery
 Provide emotional support through diagnostic process; allow patient to express feelings,
and encourage positive coping mechanisms.
 Administer anxiolytic and analgesic medications, as prescribed, and teach patient and
caregivers the potential adverse effects.
 Refer patient to cancer support group locally or the American Cancer Society,
www.acs.org, or the National Cancer Institute, www.cancer.org.
Maintaining Adequate Nutrition
 Administer or teach patient or caregiver to administer antiemetics, as needed, for

nausea and vomiting.
 Encourage small, frequent, bland meals or liquid nutritional supplements able.
 Assess the need for I.V. fluids if patient is vomiting.
 Monitor for passage of gas and bowel movements after surgery. Bowel dysfunction
related to surgery may cause nausea and anorexia.
Maintaining Body Image
 Prepare patient for body image changes with chemotherapy (ie, hair loss).
 Encourage patient to prepare ahead of time with turbans, wigs, hats.
 Encourage patient to enhance appearance with makeup, clothing, jewelry as she is used
to doing.
 Stress the positive effects of patient’s treatment plan.
Relieving Pain
 Prepare patient for surgery as indicated; explain the extent of incision, I.V., catheter,
packing, and drain tubes expected (see page 849 for a discussion of hysterectomy).
 Postoperatively, administer analgesics, as needed, and explain to patient she may be
drowsy.
 Reposition frequently and encourage early ambulation to promote comfort and prevent
adverse effects.
 Explain to patient the onset of menopausal symptoms with ovary removal.

 Tell patient that disease progression will be monitored closely by laboratory tests, and
second-look laparoscopy may be necessary.
202
 Female relatives of patient should notify their physicians; biannual pelvic examinations
may be necessary.
 For women who have not had breast or ovarian cancer, hormonal contraceptives may
decrease the risk of ovarian and endometrial cancer. Multiparity is also protective.
 Openly discusses prognosis, asks appropriate questions, makes plans for short-term
future
 Maintains weight
 Verbalizes satisfaction in appearance with wig
 Verbalizes good control over pain
CANCER OF THE PROSTATE

 Cancer of the prostate is the leading cause of cancer and second leading cause of cancer
death among American men and is the most common carcinoma in men over age 65.
 The incidence of prostate cancer is 30% higher in black men.

 The majority of prostate cancers arise from the peripheral zone of the gland.
NURSING ALERT Annual rectal examination and PSA blood testing are recommended for all
men over age 50 by the American Cancer Society. Men who are at high risk for prostate cancer
(blacks or men with a strong family history of prostate cancer) should begin these annual tests
at age 40.
 Prostate cancer can spread by local extension, by lymphatics, or by way of the

bloodstream.
 The etiology of prostate cancer is unknown; however, there is an increased risk for
persons with a family history of the disease.
 The influences of dietary fat intake, serum testosterone levels, and industrial exposure
to carcinogens are under investigation.
203
Figure 49: Pathway of metastasis of prostate cancer
 Most early-stage prostate cancers are asymptomatic.

 Symptoms due to obstruction of urinary flow:
o Hesitancy and straining on voiding, frequency, nocturia

o Diminution in size and force of urinary stream
 Symptoms due to metastasis:
o Pain in lumbosacral area radiating to hips and down legs (from bone metastases)
o Perineal and rectal discomfort
o Anemia, weight loss, weakness, nausea, oliguria (from uremia)
o Hematuria (from urethral or bladder invasion, or both)
o Lower extremity edema—occurs when pelvic node metastases compromise venous
return
 Digital rectal examination—prostate can be felt through the wall of the rectum; hard
nodule may be felt.
 Transrectal ultrasound-guided needle biopsy (through anterior rectal wall or through
perineum) for histologic study of biopsied tissue, includes Gleason tumor grade if
carcinoma is present.
 Transrectal ultrasonography—sonar probe placed in rectum.
 PSA—serologic marker of prostate cancer.
o Suspicion of prostate cancer if it measures between 4.0 and 10 ng/mL; however,
prostate cancer may also occur at levels under 4.0.
o Most PSA measurements over 10 ng/mL indicate prostate cancer.
o A free PSA level can be used to help stratify the risk of an elevated PSA.
o PSA velocity: PSA increases of 0.75 ng in 1 year could indicate prostate cancer.
 Staging evaluation—skeletal X-rays, CT scan, MRI, bone scan, analysis of pelvic lymph
nodes provide accurate staging information.
 Newer imaging study called the Prostascint scan uses an I.V. infusion of monoclonal
antibody to prostate-specific membrane antigen.
o Immediate and delayed images at 48 and 72 hours may identify soft tissue and
bone metastasis for staging.
204
o Radiation is excreted through urine and feces and body fluids but is very low and
not a risk to others.
o Patient is monitored for signs of allergic reactions following test.
 Research is being conducted on numerous genetic and chromosomal abnormalities.
Overexpression of the AMACR gene was found in 90% of prostate cancer patients.
Testing for this gene could result in identifying prostate cancer at an earlier stage.
Management
Conservative Measures
 Watchful waiting/active surveillance may be indicated in men with Gleason 6 or lower

stage prostate cancer or life expectancy of 10 years or less because prostate cancer may
be slow growing and it is expected that many men will die from other causes. It is
commonly recommended that these patients be followed closely with periodic PSA
determinations and examination for evidence of metastases.
 Symptom control for advanced prostatic cancer in which treatment is not effective:
o Analgesics and opioids to relieve pain.
o Short course of radiotherapy for specific sites of bone pain.
o I.V. administration of beta-emitter agent (strontium chloride 89) delivers
radiotherapy directly to sites of metastasis.
o TURP to remove obstructing tissue if bladder outlet obstruction occurs.
o Suprapubic catheter placement.
o Zolendronic acid (Zometa IV) is given for bone metastasis pain.
Surgical Interventions
 Radical prostatectomy—removal of entire prostate gland, prostatic capsule, and seminal

vesicles; may include pelvic lymphadenectomy.
o Procedure is used to treat stage T1 and T2 prostate cancers.
o Complications include urinary incontinence and impotence, possible rectal
injury.
o Newer nerve-sparing techniques may preserve sexual potency and continence.
 Cryosurgery of the prostate freezes prostate tissue, killing tumor cells without removing
the gland.
Radiation
 External beam radiation or intensity modulated radiotherapy (IMRT) focused on the
prostate—to deliver maximum radiation dose to tumor and minimal dose to
surrounding tissues.
 Brachytherapy—interstitial implantation of radioactive substances into prostate, which
delivers doses of radiation directly to tumor while sparing uninvolved tissue.
 Used to treat stages T1, T2, and T3, especially if patient is not a good surgical candidate.
Both forms of radiation are used in some patients; external beam followed by
brachytherapy.
 Complications include radiation cystitis (urinary frequency, urgency, nocturia), urethral
injury (stricture), radiation enteritis (diarrhea, anorexia, nausea), radiation proctitis
(diarrhea, rectal bleeding), impotence, skin reaction, and fatigue.
Hormone Manipulation (Palliative)
 Prostate cancer is a hormone-sensitive cancer. The aim of hormonal treatment is to

deprive tumor cells of androgens or their by-products and thereby alleviate symptoms
and retard progress of disease.
 Bilateral orchiectomy(removal of testes) results in reduction of the major circulating
androgen, testosterone. A small amount of androgen is still produced by adrenal glands.
205
 Pharmacologic methods of achieving androgen deprivation—also used to reduce tumor

volume before surgery or radiation therapy.
o Luteinizing hormone-releasing hormone (LHRH) agonists (such as leuprolide

[Lupron], goserelin acetate [Zoladex]) reduce testosterone levels as effectively as
orchiectomy.
o Anti-androgen drugs (flutamide [Eulexin], bicalu- tamide [Casodex], nilutamide
[Nilandron]) block androgen action directly at the target tissues (testes and
adrenals) and block androgen synthesis within the prostate gland, and adrenal
glands.
o Combination therapy with LHRH agonist and an anti-androgen blocks the action
of all circulating androgen.
 Complications of hormonal manipulation include hot flashes, nausea and vomiting,
gynecomastia, sexual dysfunction, and osteoporosis.
Complications
 Bone metastasis—vertebral collapse and spinal cord compression, pathologic fractures
 Complications of treatment
Nursing Assessment
 Obtain history of current symptoms; assess for family history of prostate cancer.
 Palpate lymph nodes, especially in supraclavicular and inguinal regions (may be first sign
of metastatic spread); assess for flank pain and distended bladder.
 Assess co-morbidities, nutritional status, and coping before treatment.
Nursing Diagnoses
 Anxiety related to fear of disease progression and treatment options

 Sexual Dysfunction related to effects of therapy 􏰀 Chronic Pain related to bone
metastasis
Reducing Anxiety
 Help patient assess the impact of the disease and treatment options on quality of life.
 Give repeated explanations of diagnostic tests and treatment options; help patient gain
some feeling of control over disease and decisions.
 Help patient and family set achievable goals.
 Convey a sense of caring and reassurance in your physical care.
Achieving Optimal Sexual Function
 Although patient may be ill while experiencing the effects of therapy, he may wonder
about sexual function. Give him the opportunity to communicate his concerns and
sexual needs.
 Let patient know that decreased libido is expected after hormonal manipulation therapy
and impotence may result from some surgical procedures and radiation.
 Expect patient’s behavior to reflect depression, anxiety, anger, and regression.
Encourage expression of feelings and communication with partner.
 Suggest such options as sexual counseling, learning other methods of sexual expression
and consideration of implant, pharmacologic agents, and other options for treatment of
erectile dysfunction.
DRUG ALERT Yohimbine is an herbal preparation sold OTC as an aphrodisiac and treatment for
male erectile dysfunction. Caution patients that it is considered an unsafe herb by the U.S.
206
Department of Agriculture due to its many drug and food interactions and adverse effects,
including hypertension, tachycardia, and tremor.
Controlling Pain
 Administer and teach self-administration of opioid analgesics as ordered; oral sustained-

release opioids, sustained-release transdermal patches, and subcutaneous or epidural
patient-controlled infusion pumps are among the many options.
 Encourage patient to take prescribed aspirin (Ecotrin), acetaminophen (Tylenol), or
NSAIDs for reduction of mild pain or to supplement opioid pain-control regimen.
 Make sure that patient is not undermedicated; help patient and family understand that
addiction is not a concern.
 Teach relaxation techniques, such as imagery, music therapy, progressive muscle
relaxation.
 Use safety measures to prevent pathologic fractures from falls.
 Encourage follow-up and palliative treatment such as radiation therapy to bony lesions
for pain improvement.
 Encourage awareness of prostate cancer in the community.

o Risks include being black, over age 50, and having a first-degree relative with
prostate cancer.
o Routine screening should begin on all men by age 50; earlier for those at risk.
o High-fat diet has also been linked to prostate cancer.
 Encourage and perform routine screening—includes yearly digital rectal examination
and PSA testing until age 75.
 Be aware that an increase in PSA of more than 0.7 ng/ml over 1 year (prostate velocity)
has been associated with prostate cancer.
 Teach patient importance of follow-up for check of PSA levels (every 3 months to 1 year)
and evaluation for disease progression through periodic bone scan or CT scan.
 Teach I.M. or subcutaneous administration of hormonal agents as indicated.
 If bone metastasis has occurred, encourage safety measures around the home to
prevent pathologic fractures, such as removal of throw rugs, using handrail on stairs,
using night-lights.
 Advise reporting symptoms of worsening urethral obstruction, such as increased
frequency, urgency, hesitancy, and urinary retention.
 Advise patient to monitor for signs of metastasis, such as fatigue, weight loss, weakness,
pain, and bowel and bladder dysfunction.
 For additional information and support, refer to agencies, such as US TOO International
Inc., www.ustoo.com; Man to Man, a program of the American Cancer Society,
www.cancer.org; and American Foundation for Urologic Disease, 800-242-2383.
 Discusses treatment options, asks questions

 Verbalizes understanding of sexual dysfunction and interest in seeking sexual
counseling
 Reports pain relief after opioid administration
207
CANCER OF THE LUNG (BRONCHOGENIC CANCER)

 Bronchogenic cancer refers to an epithelial cancer, which originates in the bronchial
surface epithelium or bronchial mucus glands, arising within the wall or epithelial lining
of the bronchus. The lung is also a common site of metastasis by way of venous
circulation or lymphatic spread.
Bronchogenic cancer is classified according to cell type:
o Non-small cell (75% to 80%) includes epidermoid (squamous cell) carcinoma,

adenocarcinoma, and broncheo alveolar carcinoma
o Large cell (20% to 25%) (undifferentiated) carcinoma
Predisposing Factors
1. Cigarette smoking—amount, frequency, and duration of smoking have positive relationship

to cancer of the lung.
2. Occupational exposure to asbestos, poly ciliac aromatic hydrocarbons (from incomplete

combustion of carbon- based fuels, such as wood, coal, diesel, fat, tobacco, incense, or tar),
indoor radon, arsenic, chromium, nickel, iron, radioactive substances, isopropyl oil, petroleum
oil mists alone or in combination with tobacco smoke.
NURSING ALERT Suspect lung cancer in patients who belong to a susceptible, high-risk group
and who have repeated unresolved respiratory infections.
Staging
1. Refers to anatomic extent of tumor, lymph node involvement, atelectasis, bronchus

involvement, and metastatic spread, including malignant pleural effusions.
2. Staging done by:
a. Tissue diagnosis
b. Lymph node biopsy
c. Mediastinoscopy
208
Figure 50: Tumor infiltration in the lungs
Usually occur late and are related to size and location of tumor, extent of spread, and
involvement of other structures.
1. Cough, especially a new type or changing cough, results from bronchial irritation
2. Dyspnea, wheezing (suggests partial bronchial obstruction)
3. Chest pain (poorly localized and aching)
4. Excessive sputum production, repeated upper respiratory infections
5. Hemoptysis
6. Malaise, fever, weight loss, fatigue, anorexia
7. Paraneoplastic syndrome—metabolic or neurologic disturbances related to the
secretion of substances by the neoplasm
8. Symptoms of metastasis—bone pain; abdominal discomfort, nausea and vomiting from
liver involvement; pancytopenia from bone marrow involvement; headache from CNS
metastasis
9. Usual sites of metastasis—lymph nodes, bones, liver
 CT scan of upper chest and abdomen and whole body positron-emission tomography
(PET) scan are indicated in most candidates for surgical resection.
 Cytologic examination of sputum/chest fluids for malignant cells.
 Fiber-optic bronchoscopy for observation of location and extent of tumor; for biopsy.
 PET scan—sensitive in detecting small nodules and metastatic lesions.
 Lymph node biopsy; mediastinoscopy to establish lymphatic spread; to plan treatment.
 Pulmonary function tests (PFTs)—to determine if patient will have adequate pulmonary
reserve to withstand surgical procedure.
 Laboratory testing, including complete blood count, metabolic panel, calcium level, liver
function tests.
Management
209
 Treatment depends on the cell type, stage of disease, and the physiologic status of the
patient. It includes a multidisciplinary approach that may be used separately or in
combination, including:
o Surgical resection.
o Radiation therapy.
o Chemotherapy.
o Immunotherapy.
Complications
 Superior vena cava syndrome—oncologic complication caused by obstruction of major

blood vessels draining the head, neck, and upper torso
 Hypercalcemia—commonly from bone metastasis
 Syndrome of inappropriate antidiuretic hormone (SIADH) with hyponatremia and
abnormal water retention
 Pleural effusion
 Infectious complications, especially upper respiratory infections
 Brain metastasis, spinal cord compression, pulmonary scarring
 With advanced lung cancer—massive hemoptysis, central airway obstruction, malignant
pleural effusion, radiation pneumonitis, venous thrombosis, spinal cord compression,
hypercalcemia, and SIADH
Nursing Assessment
 Determine onset and duration of coughing, sputum production, and the degree of
dyspnea. Auscultate breath sounds. Observe symmetry of chest during respirations.
 Take anthropometric measurements: weigh patient, review laboratory biochemical
tests, and conduct appraisal of 24-hour food intake.
 Ask about pain, including location, intensity, and factors influencing pain.
 Monitor vital signs including oximetry.
Nursing Diagnoses
 Ineffective Breathing Pattern related to obstructive and restrictive respiratory processes

associated with lung cancer
 Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolic state,
taste aversion, anorexia secondary to radiotherapy/chemotherapy
 Acute or Chronic Pain related to tumor effects, invasion of adjacent structures, toxicities
associated with radiotherapy/chemotherapy
 Anxiety and/or depression related to uncertain outcome and fear of recurrence
Improving Breathing Patterns
 Prepare patient physically, emotionally, and intellectually for prescribed therapeutic

program.
 Elevate head of bed to promote gravity drainage and prevent fluid collection in upper
body (from superior vena cava syndrome).
 Teach breathing retraining exercises to increase diaphragmatic excursion with resultant

reduction in work of breathing.
210
 Give prescribed treatment for productive cough (expec- torant, antimicrobial agent) and
mobilize patient, as to erated, to potentially control thickened or retained secretions
and subsequent dyspnea.
 Augment the patient’s ability to cough effectively.
o Splint chest manually with hands.
o Instruct patient to inspire fully and cough two to three times in one exhalation.
o Provide humidifier/vaporizer to provide moisture to loosen secretions.
 Support patient undergoing removal of pleural fluid (by thoracentesis or tube
thoracostomy) and instillation of sclerosing agent to obliterate pleural space and
prevent fluid recurrence.
 Administer oxygen by way of nasal cannula as prescribed.
 Encourage energy conservation through pacing of activities, sitting for tasks.
 Allow patient to sleep in a reclining chair or with head of bed elevated if severely
dyspneic.
 Recognize the anxiety associated with dyspnea; teach relaxation techniques.
 Emphasize that nutrition is an important part of the treatment of lung cancer.

o Encourage small amounts of high-calorie, high- protein foods frequently, rather
than three daily meals.
o Suggest eating major meal in the morning if rapidly becoming satiated and
feeling full are problems.
o Ensure adequate protein intake—milk, eggs, chicken, fowl, fish, cheese, and oral
nutritional supplements if patient cannot tolerate meats or other protein
sources.
 Administer or encourage prescribed vitamin supplement to avoid deficiency states,
glossitis, and cheilosis.
 Change consistency of diet to soft or liquid if patient has esophagitis from radiation
therapy.
 Give enteral or total parenteral nutrition for malnourished patient who is unable or
unwilling to eat.
Controlling Pain
 Take a history of pain complaint; assess presence/absence of support system.

 Administer prescribed drug, usually starting with nonsteroidal anti-inflammatory drugs
(NSAIDs) and progressing to adjuvant analgesic and short- and long-acting opioids.
o Administer regularly to control pain.
o Titrate to achieve pain control.
 Consider alternative methods, such as cognitive and behavioral training, biofeedback,
and relaxation, to increase patient’s sense of control. Mind-body modalities (meditation,
hypnosis, relaxation techniques, cognitive- behavioral therapy, biofeedback, and guided
imagery) and massage therapy may be helpful for mood disorders and chronic pain.
Acupuncture may improve pain control.
 Evaluate problems of insomnia, depression, anxiety, and so forth that may be
contributing to patient’s pain.
 Initiate bowel training program because constipation is an adverse effect of some
analgesic/opioid agents.
 Facilitate referral to pain clinic/specialist if pain becomes refractory (unyielding) to usual
methods of control.
 Radiation therapy may be used to treat pain caused by bone metastasis.
Minimizing Anxiety
 Realize that shock, disbelief, denial, anger, and depression are all normal reactions to
the diagnosis of lung cancer.
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 Try to have the patient express concerns; share these concerns with health
professionals. Link patient and family with cancer support groups.
 Encourage the patient to communicate feelings to significant people in his life.
 Expect some feelings of anxiety and depression to recur during illness.
 Encourage the patient to keep active and remain in the mainstream. Continue with
usual activities (work, recreation, sexual) as much as possible.
 Antidepressants may be used to treat depression.
 Teach patient to use NSAID or other prescribed medication, as necessary, for pain
without being overly concerned about addiction.
 Help the patient realize that not every ache and pain is caused by lung cancer; some
patients do not experience pain.
 Tell the patient that radiation therapy may be used for pain control if tumor has spread
to bone.
 Advise the patient to report new or persistent pain; it may be due to some other cause
such as arthritis.
 Suggest talking to a social worker about financial assistance or other services that may
be needed.
 For additional information, contact the American Cancer Society, 1-800-ACS-2345,
www.cancer.org; National Comprehensive Cancer Network, www.nccn.org; Oncology
Nurses Association, www.ons.org.
 Possible referral to mental health professional.
8. Support patient and family to make decisions regarding long-term care, possibly
pulmonary rehabilitation.
 Performs self-care without dyspnea

 Eats small meals four to five times per day; weight stable
COLORECTAL CANCER
 Colorectal cancer refers to malignancies of the colon and rectum. This type is the second
most common visceral cancer in the United States. Colorectal tumors are nearly all
adenocarcinomas. Lymphoma, carcinoid, melanoma, and sarcomas account for only 5%
of colorectal lesions.
Risk factors include:
 Age: risk increases sharply after age 40 with 90% of cases occurring in people over age
50. Previous history of resected colorectal cancer.
 Family history of colorectal cancer is present in 25% of people with colon cancer.
 Polyposis syndromes:
o Adenomatous polyps carry malignant potential (especially if multiple or greater
than 1 cm in size) and are routinely removed during colonoscopy. People with
polyps need periodic colonoscopic surveillance.
o Familial adenomatous polyposis (FAP; also a variant called Gardner’s syndrome)
is an inherited condition characterized by multiple adenomatous polyps of the
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colon, in which cancer will inevitably develop in all affected individuals. As soon
as a diagnosis is confirmed, surgery is recommended. The procedure entails
removal of the colon/rectum with ileal reservoir-anal anastomosis or
proctocolectomy with permanent ileostomy or continent pouch. FAP accounts
for less than 1% of colon cancer.
o Turcot syndrome—an inherited condition characterized by adenomatous polyps
and the coexistence of a central nervous system malignant tumor, such as
glioblastoma.
 Hereditary nonpolyposis colorectal cancer (HNPCC)— hereditary condition with a
markedly increased risk of developing colorectal cancer as well as other cancers, such as
endometrial, ovarian, renal, pancreatic, gastric, and small intestinal. There are few or no
adenomatous polyps, and the bowel may undergo rapid change from normal tissue to
polyp to cancer. Tends to develop at an average of age 44, and 70% arise most
commonly in the right colon. Accounts for about 3% to 6% of all colorectal cancers. A
thorough family history is essential for assessment of suspected HNPCC.
 Chronic ulcerative colitis—increasing risk after 10- year history.
 Incidence is higher in industrialized countries and lower in underdeveloped countries.
Reason unclear but may be related to diet. The Western diet, which is high in refined
grains, processed and red meats, high- fat dairy products, desserts, and fried foods, has
been shown to increase risk of colorectal cancer.
 Immunodeficiency disease.
 Colorectal lesions occur most frequently in the rectum and sigmoid areas; however, it
appears there is a trend toward increasing frequency of right-sided lesions.
 Most adenocarcinomas are ulcerative in appearance. A left-sided lesion tends to be
annular and scarlike; a right- sided lesion tends to be a cauliflower-like mass that
protrudes into the bowel lumen.
 A lesion starts in the mucosal layers of the colonic wall and eventually penetrates the
wall and invades surrounding structures and organs (bladder, prostate, ureters, vagina).
Cancer spreads by direct invasion, lymphatic spread, and through the bloodstream. The
liver and lungs are the most common metastatic sites.
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Figure 51: Types of colorectal cancer
Colorectal cancer is often asymptomatic. If present, symptomatology varies according to

the location of the lesion and the extent of involvement.
1. Right-sided lesions—change in bowel habits, usually diarrhea; vague abdominal

discomfort; black tarry stools; anemia; weakness; weight loss; palpable mass in right
lower quadrant.
2. Left-sided lesions—change in bowel habits, often increasing constipation with bouts

of diarrhea due to partial obstruction; bright, streaked, red blood in stool; cramping
pain; weight loss; anemia; palpable mass.
3. Rectal lesions—change in bowel habits with possible urgent need to defecate,

alternating constipation and diarrhea, and narrowed caliber of stool; bright red blood in
stool; feeling of incomplete evacuation; rectal fullness progressing to dull constant ache.
 Fecal occult blood test (FOBT)—often reveals evidence of carcinoma when the patient is
otherwise asymptomatic.
 Barium enema—useful in detecting smaller tumors.
 Colonoscopy with biopsy—diagnostic procedure of choice after strong suspicious clinical
history or abnormal barium enema. CT colonography, also known as virtual
colonoscopy, may be used for screening.
 Pelvic MRI and endorectal ultrasonography—provide information about cancer
penetration and pararectal lymph nodes.
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 Carcinoembryonic antigen (CEA)—70% of patients have elevated CEA levels. The CEA
level monitors possible recurrence or metastasis.
 CT scan of abdomen, liver, lungs, and brain—may reveal metastatic disease.
Management
Blood Replacement
 Administration of whole blood or packed red blood cells if severe anemia exists.
Surgical Resection
 Treatment of choice for those with resectable lesions. Regional lymph node dissection
determines staging and guides decisions regarding adjuvant therapy. Surgical options
include:
o Laparotomy with wide segmental bowel resection of tumor, including regional

lymph nodes and blood vessels (right hemicolectomy, transverse colectomy, left
hemicolectomy, or sigmoid resection).
o Transanal excision—selected people with tumors less than 11⁄4 inches (3 cm) and
well differentiated less than 3 inches (7.5 cm) from the anal verge, and localized
to the rectal wall may avoid laparotomy.
o Low anterior resection for upper rectal lesions—may include temporary loop
colostomy to protect anastomosis with second procedure for takedown of
colostomy.
o Colonic J pouch—may be offered as a new surgical technique for rectal cancer
o Select patients may be offered laparoscopic cancer surgery, although this
remains controversial.
o Abdominoperineal resection with permanent end colostomy for lower rectal
lesions when adequate margins cannot be obtained, or there is involvement of
anal sphincters. Due to improved stapling devices used deep in the pelvis,
abdominoperineal resection accounts for fewer than 5% of colorectal resections.
o Temporary loop colostomy to decompress bowel and divert fecal stream,
followed by later bowel resection, anastomosis, and takedown of colostomy.
o More extensive surgery involving the removal of other organs if cancer has
spread, such as liver wedge, bladder, uterus, and/or small intestine, may be
performed.
o Unresectable colorectal cancer—diverting colostomy or ileostomy as palliation
for obstructing tumor, laser fulguration, or the placement of an expandable wire
stent.
o Total proctocolectomy or ileal reservoir-anal anastomosis procedure for patients
with FAP and chronic ulcerative colitis before colorectal cancer develops.
Radiation Therapy
 May be used preoperatively to improve resectability of the tumor

 May be used postoperatively as adjuvant therapy to treat residual disease
Chemotherapy
 May be used as adjuvant therapy to improve survival time.

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 May be used for residual disease, recurrence of disease, unresectable tumors, and
metastatic disease.
 Drug combinations may include 5-fluorouracil plus lev- amisole or 5-fluorouracil plus
leucovorin (Wellcovorin). A new drug, irinotecan (Camptosar), is being used in protocols
for advanced colorectal cancer.
Complications
 Obstruction
 Hemorrhage 3. Anemia
 Metastasis
Nursing Assessment
 Interview patient regarding dietary habits and family and medical history to identify risk
factors.
 Question the patient regarding symptomatology of colorectal cancer, changes in bowel
habits, rectal bleeding, tarry stools, abdominal discomfort, weight loss, weakness, and
anemia.
 Palpate abdomen for tenderness (usually not tender), presence of mass.
 Test stool for occult blood.
Nursing Diagnoses
 Imbalanced Nutrition: Less Than Body Requirements related to malignancy effects and
weight loss
 Constipation and/or Diarrhea related to change in bowel lumen
 Chronic Pain related to malignancy, inflammation, and possible intestinal obstruction
 Fatigue related to anemia, radiation, chemotherapy, and metastatic disease
 Fear related to diagnosis, prognosis, potential for complications
Achieving Adequate Nutrition
 Meet the patient’s nutritional needs by serving a high- calorie, low-residue diet for
several days before surgery, if condition permits.
 Observe and record fluid losses, such as may be sustained by vomiting and diarrhea.
 Maintain hydration through I.V. therapy, and record urine output. Metabolic tissue
needs are increased, and more fluids are needed to eliminate waste products.
 Serve smaller meals spaced throughout the day to maintain adequate calorie and
protein intake if not NPO.
 Encourage the patient to participate in meal planning to promote compliance.
 Adjust diet before and after treatments, such as chemotherapy or radiation. Serve clear
liquids, bland diet, or NPO, as prescribed.
 Instruct the patient to take prescribed antiemetic, as needed, especially if receiving
chemotherapy.
Relieving Constipation or Diarrhea
 Monitor amount, consistency, frequency, and color of stool.

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 For constipation, use laxatives or enemas, as needed, and encourage exercise and
adequate fluid/fiber intake to promote bowel motility. For diarrhea, encourage
adequate fluid intake to prevent fluid volume deficit and electrolyte imbalance.
 For diarrhea related to radiation or chemotherapy, administer antidiarrheal medications
and discuss foods that may slow transit time of bowel, such as bananas, rice, peanut
butter, and pasta.
NURSING ALERT Antidiarrheal medications and foods to control diarrhea are contraindicated
for the patient with an obstructing lesion. Use these measures only postoperatively after lesion
resection for control of diarrhea related to cancer therapy.
Relieving Pain
 Assess type and severity of pain, and administer analgesics as needed.

 Evaluate effectiveness of analgesic regimen.
 Investigate different approaches, such as relaxation techniques, repositioning, imaging,
laughter, music, reading, and touch, for control or relief of pain.
Maintaining Energy Level
 Institute an individualized activity plan after assessing the patient’s activity level and
tolerance, noting shortness of breath or tachycardia.
 Allow for frequent rest periods to regain energy.
 Administer blood products or recombinant human erythropoietin, as ordered, if fatigue
is related to severe anemia.
Minimizing Fear
 Encourage the patient and family to express feelings and fears together and separately.
 Acknowledge that it is normal to have negative feelings toward cancer, surgery,
colostomy, and treatment options.
 Provide information and answer questions regarding disease process, treatment
modalities, and complications. Offer diverse educational materials, such as brochures
and videotapes.
 Refer for counseling, if desired.
 Beginning at age 50, men and women should follow one of the following American
Cancer Society guidelines for early detection of colon cancer.
o FOBT every year
o Flexible sigmoidoscopy every 5 years.
o Colonoscopy every 10 years.
o Double-contrast barium enema every 5 to 10 years. e. Stool DNA test, interval
uncertain.
 People with positive FOBTs usually undergo colonoscopy with removal of polyps, if
present.
 Genetic testing can confirm a hereditary diagnosis such as FAP or HNPCC.

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 Provide detailed information or resources about treatment modalities of radiation and

chemotherapy.
 Teach and demonstrate to the patient and/or family the skills necessary for colostomy
management, which may include colostomy irrigation. The ostomy specialty nurse can
provide formal education in this area.
 Initiate a home care nursing referral to assist with wound care, to manage treatment
adverse effects, and to continue teaching colostomy care.
 For additional information and support, refer to the American Cancer Society,
www.acs.org.
 Exhibits weight gain and improves nutritional status by adequate dietary intake
 Has regular soft bowel movements. Minimal pain, controlled with analgesics or other
techniques 􏳞 Able to perform ADLs with adequate amounts of energy; no shortness of
breath on exertion Sleeping well; able to discuss feelings and fears related to surgery,
prognosis, and treatment options
HEPATIC CIRRHOSIS
 Cirrhosis of the liver is characterized by scarring. It is a chronic disease in which there

has been diffuse destruction and fibrotic regeneration of hepatic cells (see Figure 4). As
necrotic tissue is replaced by fibrotic tissue, normal liver structure and vasculature is
altered, impairing blood and lymph flow, resulting in hepatic insufficiency and portal
hypertension.
Figure 13: Fibrotic changes to liver tissue in cirrhosis

 Laënnec’s cirrhosis (macronodular), also known as alcoholic cirrhosis.
o Fibrosis—mainly around central veins and portal areas.
o Usually due to chronic alcohol toxicity and malnutrition.
 Post necrotic cirrhosis (micronodular)
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o Broad bands of scar tissue.

o Because of previous acute viral hepatitis or drug induced massive hepatic
necrosis.
 Biliary cirrhosis
o Scarring around bile ducts and lobes of the liver.
o Results from chronic biliary injury and obstruction of the intrahepatic or
extrahepatic biliary system.
o Partial or total obstruction of the bile ducts can lead to infectious cholangitis and
cirrhosis, which is much rarer than Laënnec’s and post necrotic cirrhosis.
1. Onset is insidious; may take years to develop.

2. Early complaints include fatigue, anorexia, ankle edema in the evening, epistaxis and
bleeding gums, and weight loss.
3. Later complaints because of chronic failure of the liver and obstruction of portal circulation.
o Chronic dyspepsia, constipation, or diarrhea.

o Esophageal varices, dilated cutaneous veins around the umbilicus (caput medusa),
internal hemorrhoids, ascites, splenomegaly, and pancytopenia.
o Plasma albumin is reduced, leading to edema and contributing to ascites.
o Anemia and poor nutrition lead to fatigue and weakness, wasting, and depression.
o Deterioration of mental function from lethargy to delirium to coma and eventual death.
o Estrogen-androgen imbalance causes spider angiomata and palmar erythema;
menstrual irregularities in females; testicular and prostatic atrophy, gynecomastia, loss
of libido, and impotence in males.
4. Bleeding tendencies, such as nosebleeds, easy bruising, hematemesis, or profuse

hemorrhage from stomach and esophageal varices.
 Liver biopsy detects destruction and fibrosis of hepatic tissue.

 Liver scan shows abnormal thickening and a liver mass.
 CT scan determines the size of the liver and its irregular nodular surface.
 Esophagoscopy to determine esophageal varices.
 Paracentesis to examine ascitic fluid for cell, protein, and bacterial counts.
 PTC differentiates extrahepatic from intrahepatic obstructive jaundice.
 Laparoscopy and liver biopsy permit direct visualization of the liver.
 Serum liver function test results are elevated.
Management
 Minimize further deterioration of liver function through the withdrawal of toxic

substances, alcohol, and drugs.
 Correction of nutritional deficiencies with vitamins and nutritional supplements and a
high-calorie and moderate- to high-protein diet.
 Treatment of ascites and fluid and electrolyte imbalances.
o Restrict sodium and water intake, depending on amount of fluid retention.
o Bed rest to aid in diuresis.
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o Diuretic therapy, frequently with spironolactone (Aldactone), a potassium-

sparing diuretic that inhibits the action of aldosterone on the kidneys.
Furosemide (Lasix), a loop diuretic, may also be used in conjunction with
spironolactone to help balance potassium depletion.
o Abdominal paracentesis to remove fluid and relieve symptoms ascitic fluid may
be ultra-filtrated and reinfused through a central venous access device.
o Administration of albumin to maintain osmotic pressure.
 Transjugular intrahepatic portosystemic shunt (TIPS), an interventional radiologic
procedure, may be performed in patients whose ascites are resistant to other forms of
treatment. TIPS is a percutaneously created connection within the liver between the
portal and systemic circulations. A shunt is placed to reduce the portal pressure in
patients with complications related to portal hypertension.
o Complications include bacterial infections, shunt obstruction, encephalopathy,
and increase in coagulopathies.
 Symptomatic relief measures, such as pain medication and antiemetics.
 Treatment of other problems associated with liver failure. Administration of lactulose
(Cephulac) or neomycin (Myciguent) for hepatic encephalopathy.
 Liver transplantation may be necessary.
Complications
 Hyponatremia and water retention.

 Bleeding esophageal varices.
 Coagulopathies.
 Spontaneous bacterial peritonitis.
 Hepatic encephalopathy, which may be precipitated by the use of sedatives, high-
protein diet, sepsis, or electrolyte imbalance.
Nursing Assessment
1. Obtain history of precipitating factors, such as alcohol abuse, hepatitis, or biliary

disease. Establish present pattern of alcohol intake.
2. Assess mental status through interview and interaction with patient.
3. Perform abdominal examination, assessing for ascites (see Figure 5).
4. Observe for bleeding.
5. Assess daily weight and abdominal girth measurements.
Figure 14: Assessing for ascites. (A) to percuss for shifting dullness, each flank is percussed with
patient in a supine position. If fluid is present, dullness is noted at each flank. The most medial
limits of the dullness should be marked as indicated in a. patient should be shifted to the side.
(B) note what happens to the area of dullness if fluid is present; the area of dullness begins at b.
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(C) to detect the presence of fluid wave, the examiner places one hand alongside each flank. A
second person then places a hand, while the other hand remain in place to detect any signs of
fluid impulse. The assistant hand should dampen any wave impulses traveling through the
abdominal wall, unless fluid is present.
Nursing Diagnoses
 Activity Intolerance related to fatigue, general debility, and discomfort

 Imbalanced Nutrition: Less Than Body Requirements related to anorexia and GI
disturbances
 Impaired Skin Integrity related to edema, jaundice, and compromised immunologic
status
 Risk for Injury related to altered clotting mechanisms
 Disturbed Thought Processes related to deterioration of liver function and increased
serum ammonia level
Promoting Activity Tolerance
 Encourage alternating periods of rest and ambulation.

 Maintain some periods of bed rest with legs elevated to mobilize edema and ascites.
 Encourage and assist with gradually increasing periods of exercise.
 Encourage patient to eat high-calorie, moderate-protein meals and to have

supplementary feedings.
 Suggest small, frequent feedings and attractive meals in an aesthetically pleasing setting
at mealtime.
 Encourage oral hygiene before meals.
 Administer or teach self-administration of medication for nausea, vomiting, diarrhea, or
constipation.
Protecting Skin Integrity
 Note and record degree of jaundice of skin and sclerae and scratches on the body.
 Encourage frequent skin care, bathing without soap, and massage with emollient
lotions.
 Advise patient to keep finger nails short.
Preventing Injury Through Bleeding
 Observe stools and emesis for color, consistency, and amount; test each one for occult
blood.
 Be alert for symptoms of anxiety, epigastric fullness, weakness, and restlessness, which
may indicate GI bleeding.
 Observe for external bleeding: ecchymosis, leaking needlestick sites, epistaxis,
petechiae, and bleeding gums.
 Keep patient quiet and limit activity if signs of bleeding are exhibited.
 Administer vitamin K (AquaMEPHYTON) as prescribed.
 Stay in constant attendance during episodes of bleeding.
 Institute and teach measures to prevent trauma:
o Maintain safe environment. b. Gentle blowing of nose.
o Use of soft toothbrush.
 Encourage intake of foods with high vitamin C content.
 Use small-gauge needles for injections, and maintain pressure over site until bleeding
stops.
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 Management of bleeding from esophageal varices can include endoscopic variceal

ligation (banding) or injection sclerotherapy.
Promoting Improved Thought Processes
 Restrict high-protein loads while serum ammonia is high to prevent hepatic

encephalopathy. Monitor ammonia levels.
 Protect from sepsis through good hand washing and prompt recognition and
management of infection.
 Monitor fluid intake and output and serum electrolyte levels to prevent dehydration and
hypokalemia (may occur with the use of diuretics), which may precipitate hepatic coma.
 Keep environment warm and limit visitors.
 Pad the side rails of the bed and provide careful nursing surveillance to ensure patient’s
safety.
 Assess LOC and frequently reorient as needed.
D R U G A L E R T Opioids, sedatives, and barbiturates are used cautiously in the restless

patient with cirrhosis to prevent precipitation of hepatic coma.
 Administer lactulose (Cephulac) or neomycin (Myciguent) through a retention enema or

nasogastric (NG) tube, as ordered, for elevated ammonia levels and decreasing LOC.
 Stress the necessity of giving up alcohol completely.

 Urge acceptance of assistance from a substance abuse program.
 Provide written dietary instructions.
 Encourage daily weighing for self-monitoring of fluid retention or depletion.
 Discuss adverse effects of diuretic therapy.
 Emphasize the importance of rest, a sensible lifestyle, and an adequate, well-balanced
diet.
 Involve the person closest to the patient because recovery usually is not easy and
relapses are common.
 Stress the importance of continued follow-up for laboratory tests and evaluation by a
health care provider.
 Ambulates for 10 minutes each hour

 Tolerates small, frequent feedings
 Skin without breakdown or scratches
 No bleeding or bruising; results of stool tests are negative for occult blood
 Drowsy but easily aroused and oriented
GASTRIC CANCER
 Malignant tumor of the stomach.

 Risk factors include:
o Chronic atrophic gastritis with intestinal metaplasia.
o Pernicious anemia or having had gastric resections (more than 15 years).
o Adenomatous polyps.
 Related factors:
o More common in men and blacks.
o Incidence increases with age.
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Figure 52: Adenocarcinoma of the stomach
Early Manifestations
Typically, patient presents with same symptoms as gastric ulcer; later, on evaluation,
the lesion is found to be malignant.
 Progressive loss of appetite
 Noticeable change in, or appearance of GI symptoms— gastric fullness (early
satiety), dyspepsia lasting longer than 4 weeks
 Blood (usually occult) in the stools
 Vomiting
 May indicate pyloric obstruction or cardiac-orifice obstruction.
 Occasionally, vomiting has a coffee-ground appearance because of slow

leaks of blood from ulceration of the cancer.
Later Manifestations
 Pain, usually induced by eating and relieved by vomiting
 Weight loss, loss of strength, anemia, metastasis (usually to liver), hemorrhage,
obstruction
 Abdominal or epigastric mass
 History—weight loss and fatigue over several months
 Upper GI radiography and endoscopy—afford visualization and provide means
for obtaining tissue samples for histologic and cytologic review
 Imaging, such as bone or liver scan—may determine extent of disease
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Management
 The only successful treatment of gastric cancer is surgical removal. Gastric
resection is surgical removal of part of the stomach.
 If tumor has spread beyond the area that can be excised surgically, cure is not
possible.
o Palliative surgery, such as subtotal gastrectomy with or without
gastroenterostomy, may be performed to maintain continuity of the GI
tract.
o Surgery may be combined with chemotherapy to provide palliation and
prolong life.
Complications
 If surgery is performed, possible risk of hemorrhage or infection
 Dumping syndrome following gastrectomy 3. Metastasis and death
Nursing Assessment
 Assess for anorexia, weight loss, GI symptoms (gastric fullness, dyspepsia,
vomiting).
 Evaluate for pain, noting characteristics/location.
 Check stool for occult blood.
 Monitor CBC to assess for anemia.
Nursing Diagnoses
 Pain related to disease process or surgery
 Risk for Injury, shock and other complications related to surgery and impaired
gastric tissue function
 Imbalanced Nutrition: Less Than Body Requirements related to malignancy and
treatment
Promoting Comfort and Wound Healing

 Turning, coughing, deep breathing every 2 hours to prevent vascular and
pulmonary complications and promote comfort.
 Institute NG suction, if ordered, to remove fluids and gas in the stomach and
prevent painful distention.
 Administer parenteral antibiotics, as ordered, to prevent infection.
 Administer analgesics, as ordered.
Preventing Shock and Other Complications

 Shock and hemorrhage.
o Monitor changes in BP, pulse, and respiration
o Observe the patient for evidence of changes in mental status, pallor,
clammy skin, dizziness.
o Check the dressings and suction canister frequently for evidence of
bleeding.
o Administer I.V. infusions and blood replacement as prescribed.
 Cardiopulmonary complications.
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o Encourage the patient to cough and take deep breaths to promote

ventilatory exchange and enhance circulation.
o Assist the patient to turn and move, thereby mobilizing secretions.
o Promote ambulation, as prescribed, to increase respiratory exchange.
 Thrombosis and embolism.
o Initiate a plan of self-care activities to promote circulation.

o Encourage early ambulation to stimulate circulation.
o Prevent venous stasis by use of elastic stockings, if indicated.
o Check for tight dressings or binder that might restrict circulation.
 Dumping syndrome—a complex reaction that may occur because of excessively

rapid emptying of gastric contents. Manifestations include nausea, weakness,
perspiration, palpitation, some syncope, and, possibly, diarrhea. Instruct the
patient as follows:
o Eat small, frequent meals rather than three large meals.
o Suggest a diet high in protein and fat and low in carbohydrates, and
avoid meals high in sugars, milk, chocolate, salt.
o Reduce fluids with meals, but take them between meals.
o Take anticholinergic medication before meals (if prescribed) to lessen GI
activity.
o Relax when eating; eat slowly and regularly.
o Take a rest after meals.
 Phytobezoar formation (formation of gastric concretion composed of vegetable
matter)—can be seen with partial gastrectomy and vagotomy. After a gastric
resection, the remaining gastric tissue is not able to disintegrate and digest
fibrous foods. This undigested fiber congeals to form masses that become coated
by mucus secretions of the stomach.
o Avoid fibrous foods, such as citrus fruits (skins and seeds), because they
tend to form phytobezoars.
o Stress the importance of adequate chewing.
Attaining Adequate Nutritional Status
 Administer parenteral nutrition, if ordered.

 Follow prescribed diet progressions.
o Give fluids by mouth when audible bowel signs are present.
o Increase fluids according to the patient’s tolerance.
o Offer a diet with vitamin supplements when the patient’s condition
permits.
o Avoid high-carbohydrate foods, such as milk, which may trigger dumping
syndrome.
o Offer diet as prescribed—usually high in protein and calories to promote
wound healing.
 Emphasize the importance of coping with stressful situations. Provide information about
support groups.
 Review nutritional requirements with the patient.
225
 Stress the importance of I.M. vitamin B12 supplements after gastrectomy to prevent
surgically induced pernicious anemia.
 Encourage follow-up visits with the health care provider.
 Recommend annual blood studies and medical checkups for any evidence of pernicious
anemia or other problems.
 Instruct on measures to prevent dumping syndrome.
 States pain decreased to 2 or 3 on 0-to-10 scale

 Vital signs stable; no evidence of complications
 Tolerating small, frequent meals
CANCER OF THE THYROID

 Cancer of the thyroid is a malignant neoplasm of the gland.
Figure 53: Early localized thyroid cancer

 Incidence increases with age. The average age at time of diagnosis is 45.
 There appears to be an association between external radiation to the head and neck in
infancy and childhood, and subsequent development of thyroid carcinoma. (Between
1949 and 1960, radiation therapy was commonly given to shrink enlarged tonsil and
adenoid tissue, to treat acne, or to reduce an enlarged thymus.)
 Papillary and well-differentiated adenocarcinoma (most common).
o Growth is slow, and spread is confined to lymph nodes that surround thyroid
area.
o Cure rate is excellent after removal of involved areas.
 Follicular (rapidly growing, widely metastasizing type).
o Occurs predominantly in middle-aged and older persons.
o Brief encouraging response may occur with irradiation.
226
 Progression of disease is rapid; high mortality.

 Parafollicular-medullary thyroid carcinoma.
o Rare, inheritable type of thyroid malignancy, which can be detected early by a
radioimmunoassay for calcitonin.
 Undifferentiated anaplastic carcinoma.
o The most aggressive and lethal solid tumor found in humans.
o Least common of all thyroid cancers.
o Usually fatal within months of diagnosis.
 Painless nodule
 Sensitivity to cold and mental apathy (hypothyroidism, if tumor has destroyed the
thyroid)
 Sensitivity to heat
 Restlessness
 Overactivity (hyperthyroidism, if excess thyroid hormone production)
 Diarrhea
 Dysphagia
 Anorexia
 Irritability
 Ear pain
 Hoarseness
 Vocal stridor
 Disfiguring thyroid mass
 Hard nodule and enlargement
 Bruits
 A thyroid scan with 99mTc will detect a “cold” nodule with little uptake.
 FNA biopsy.
 Surgical exploration.
Management
 Surgical removal is extensive, as required.

o Postoperative radiation therapy is commonly done to reduce chances of
recurrence.
o Follow-up includes periodic 131I uptake scan to detect evidence of recurrence.
 Thyroid replacement.
o Thyroid hormone is administered to suppress secretion of TSH.
o Such treatment is continued indefinitely and requires annual checkups.
o For unresectable cancer, patient is referred for treatment with 131I,
chemotherapy, or radiation therapy.
Complications
 Untreated thyroid carcinoma can be fatal.
Nursing Assessment
 Explore patient’s feelings and concerns regarding the diagnosis, treatment, and
prognosis.
227
Nursing Diagnosis
 Anxiety related to concern about cancer, upcoming surgery
 Also see Care of the Patient Undergoing Thyroidectomy, page 918.
Allaying Anxiety
 Provide all explanations in a simple, concise manner and repeat important information,
as necessary, because anxiety may interfere with patient’s processing of information.
 Stress the positive aspects of treatment, high cure rate as outlined by health care
provider.
 Encourage support by significant other, clergy, social worker, nursing staff, as available.

 Instruct the patient on thyroid hormone replacement and follow-up blood tests.
 Stress the need for periodic evaluation for recurrence of malignancy.
 Supply additional information or suggest community resources dealing with cancer
prevention and treatment.
 Assist patient in identifying sources of information and support available in the
community.
ACUTE LYMPHOCYTIC AND ACUTE MYELOGENOUS LEUKEMIA
 Leukemias are malignant disorders of the blood and bone marrow that result in an
accumulation of dysfunctional, immature cells that are caused by loss of regulation of
cell division. They are classified as acute or chronic based on the development rate of
symptoms, and further classified by thepre dominant cell type.
 Acute leukemias affect immature cells and are characterized by rapid progression of
symptoms. When lymphocytes are the predominant malignant cell, the disorder is
acute lymphocytic leukemia (ALL); when monocytes or granulocytes are predominant, it
is acute myelogenous leukemia (AML), sometimes called acute nonlymphocytic
leukemia. Biphenotypic leukemia is an acute leukemia with both lymphocytic and
myelogenous cell characteristics.
 The development of leukemia has been associated with:

o Exposure to ionizing radiation.
o Exposure to certain chemicals and toxins (eg, benzene, alkylating agents).
o Human T-cell leukemia—lymphoma virus (HTLV-1 and HTLV-2) in certain areas of
the world, including the Caribbean and southern Japan.
o Familial susceptibility.
o Genetic disorders (eg, Down syndrome, Fanconi’s anemia).
 Approximately one-half of new leukemias are acute. Approximately 85% of acute
leukemias in adults are AML. ALL is most common in children, with peak incidence
between ages 2 and 9.
228
 Childhood ALL is usually cured with chemotherapy alone (≥75%), whereas only 30% to
40% of adults with ALL are cured.
 AML is a disease of older people, with a median age at diagnosis of 67. Even in the
young-old (patients who are younger than age 60), AML is difficult to treat, with a
median survival of 5 to 6 months, despite intensive therapy.
 Common symptoms include pallor, fatigue, weakness, fever, weight loss, abnormal
bleeding and bruising, lymphadenopathy (in ALL), and recurrent infections (in ALL).
 Other presenting symptoms may include bone and joint pain, headache, splenomegaly,
hepatomegaly, neurologic dysfunction.
 CBC and blood smear—peripheral WBC count varies widely from 1,000 to 100,000/mm 3
and may include significant numbers of abnormal immature (blast) cells; anemia may be
profound; platelet count may be abnormal and coagulopathies may exist.
 Bone marrow aspiration and biopsy—cells also studied for chromosomal abnormalities
(cytogenetics) and immunologic markers to classify type of leukemia further.
 Lymph node biopsy—to detect spread.
 Lumbar puncture and examination of cerebrospinal fluid for leukemic cells (especially in
ALL).
Management
 National Comprehensive Cancer Network (NCCN) guidelines provide recommendations

for workup, management, and supportive care of patients with various subtypes of AML
(http://www.nccn.org).
Evidence-based treatment guidelines for management of ALL are published by the
National Cancer Institute (http://www.nci.nih.gov/cancertopics/pdq/treatment/adult
ALL/HealthProfessional).
 Management of AML and ALL is designed to eradicate leukemic cells and allow
restoration of normal hematopoiesis.
o High-dose chemotherapy given as an induction course to obtain a remission
(disappearance of abnormal cells in bone marrow and blood) and then in cycles
as consolidation or maintenance therapy to prevent recurrence of disease. (see
table 2 on module 5)
o Leukapheresis (or exchange transfusion in infants) may be used when
abnormally high numbers of white cells are present to reduce the risk of
leukostasis and tumor burden before chemotherapy.
o Radiation, particularly of central nervous system (CNS) in ALL.
o Autologous or allogeneic bone marrow or stem cell transplantation.
 Supportive care and symptom management.
229
Table 3: Common chemotherapeutic drugs used in acute leukemia
Complications
 Leukostasis: in setting of high numbers (greater than 50,000/mm3) of circulating

leukemic cells (blasts), blood vessel walls are infiltrated and weakened, with high risk of
rupture and bleeding, including intracranial hemorrhage.
 Disseminated intravascular coagulation(DIC).
 Tumor lysis syndrome: rapid destruction of large numbers of malignant cells leads to
alterations in electrolytes (hyperuricemia, hyperkalemia, hyperphosphatemia, and
hypocalcemia), renal failure, and other complications.
 Infection, bleeding, organ damage.
DRUG ALERT Allopurinol is commonly used as part of a regimen to prevent tumor lysis
syndrome. In rare cases, it causes severe, even lethal, skin reactions (toxic epidermolysis
syndrome). Allopurinol should be discontinued for any patient who develops a new skin rash.
230
Nursing Assessment
 Take nursing history, focusing on weight loss, fever, frequency of infections,

progressively increasing fatigability, shortness of breath, palpitations, visual changes
(retinal bleeding).
 Ask about difficulty in swallowing, coughing, rectal pain.

 Examine patient for enlarged lymph nodes, hepato- splenomegaly, evidence of
bleeding, abnormal breath sounds, skin lesions.
 Look for evidence of infection: mouth, tongue ,and throat for reddened areas or white
patches. Examine skin for breakdown, which is a potential source of infection.
Nursing Diagnoses
 Risk for Infection related to granulocytopenia of disease and treatment

 Risk for Injury related to bleeding secondary to bone marrow failure and
thrombocytopenia
Preventing Infection
 Especially monitor for pneumonia, pharyngitis, esophagitis, perianal cellulitis, urinary
tract infection, and cellulitis, which are common in leukemia and which carry sig-
nificant morbidity and mortality.
 Monitor for fever, flushed appearance, chills, tachycardia; appearance of white patches
in mouth; redness, swelling, heat or pain of eyes, ears, throat, skin, joints, abdomen,
rectal and perineal areas; cough, changes in sputum; skin rash.
 Check results of granulocyte counts. Concentrations less than 500/mm 3 put the patient
at serious risk for infection. Administer granulocyte-stimulating and erythropoiesis-
stimulating agents as ordered [eg, epoetin alfa (Procrit) or darbepoetin alfa (Aranesp)].
 Avoid invasive procedures and trauma to skin or mucous membrane to prevent entry of
microorganisms.
 Use the following rectal precautions to prevent infection:
o Avoid diarrhea and constipation, which can irritate the rectal mucosa.
o Avoid use of rectal thermometers.
o Keep perianal area clean.
 Care for patient in private room with strict hand-washing practice. Patients with
prolonged neutropenia may benefit from high efficiency particulate air filtration.
 Encourage and assist patient with personal hygiene, bathing, and oral care.
231
 Obtain cultures and administer antimicrobials promptly as directed. Prophylactic

antimicrobials, antifungals, and antivirals serve to protect the patient from life-
threatening infections.
Preventing and Managing Bleeding
 Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival

hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting,
heavy menses.
 Be alert for signs of serious bleeding, such as headache with change in responsiveness,
blurred vision, hemoptysis, hematemesis, melena, hypotension, tachycardia, dizziness.
 Monitor urine, stools, emesis for gross and occult blood.
 Monitor platelet counts daily.
 Administer blood components as directed.
 Keep patient on bed rest during bleeding episodes.
 Teach infection precautions (see Patient Education Guidelines).
 Teach signs and symptoms of infection and advise whom to notify.

 Encourage adequate nutrition to prevent emaciation from chemotherapy.
232
 Teach avoidance of constipation with increased fluid and fiber, and good perianal care.
 Teach bleeding precautions (see Patient Education Guidelines).
 Encourage regular dental visits to detect and treat dental infections and disease.
 Provide patient and family with information about resources in the community, such as
the Leukemia Society of America and the American Cancer Society .
 Afebrile, without signs of infection

 No signs of bleeding
CHRONIC MYELOGENOUS LEUKEMIA
 Chronic myelogenous leukemia (CML) (ie, involving more mature cells than acute
leukemia) is characterized by proliferation of myeloid cell lines, including granulocytes,
monocytes, platelets, and, occasionally, RBCs.
 Specific etiology unknown, associated with exposure to ionizing radiation and family
history of leukemia. Results from malignant transformation of pluripotent
hematopoietic stem cell.
 First cancer associated with chromosomal abnormality (the Philadelphia [Ph]
chromosome), present in more than 90% of patients.
 Accounts for 25% of adult leukemias and less than 5% of childhood leukemias.
Generally, presents between ages 25 and 60 with peak incidence in the mid-40s.
233
 With progression of illness, enters terminal phase, resembling an acute leukemia that
consists of accelerated phase or blast crisis.
 Insidious onset, may be discovered during routine physical examination.

 About 70% of patients have symptoms at diagnosis such as fatigue, pallor, activity
intolerance, fever, weight loss, night sweats, abdominal fullness (splenomegaly).
 CBC and blood smear: large numbers of granulocytes (usually more than 100,000/mm 3),
platelets may be decreased.
 Bone marrow aspiration and biopsy: hypercellular, usually demonstrates Philadelphia
(Ph1) chromosome.
Management
Treatment guidelines for the management of CML are provided by the NCCN (www.nccn.org).
Chronic Phase
 The introduction of imatinib mesylate (Gleevec) in 2001 changed treatment options for
patients with CML, providing a highly effective oral treatment for newly diagnosed
patients as well as for patients in chronic or accelerated phases. A protein-tyrosine
kinase inhibitor, it works by inhibiting proliferation of abnormal cells and inducing cell
death (apoptosis) in abnormal cells. Adverse effects include edema, diarrhea, muscle
cramps, muscle and bone pain, rash, and, rarely, hepatotoxicity and myelosuppression.
Second-generation tyrosine kinase inhibitors approved for use in patients who develop
resistance to imatinib mesylate included asatinib (Sprycel) andnilotinib (Tasigna).
 For patients who do not respond to tyrosine kinase inhibitors, combinations of
cytarabine (ARA-C) and alpha interferon may be used. Adverse effects (most commonly
fatigue and fever) may be severe.
 Other options include allogeneic (related or unrelated donor) BMT.
 Palliative treatment—controlling symptoms—includes chemotherapy with such agents
as busulfan (Myleran) or hydroxycarbamide (formerly known as hydroxyurea);
irradiation; splenectomy.
Accelerated Phase or Blast Crisis
 High-dose chemotherapy (usually AML regimens) and leukapheresis may be used to

attempt to regain chronic phase.
 Supportive care and palliative care because this phase is usually terminal.
Complications
 Leukostasis.
 Infection, bleeding, organ damage.
 Untreated, CML is a terminal disease with unpredictable survival, on average 3 years.
234
Nursing Assessment
 Obtain health history, focusing on fatigue, weight loss, night sweats, activity
intolerance.
 Assess for signs of bleeding and infection.
 Evaluate for splenomegaly, hepatomegaly.
 Assess for weight gain and edema in patients taking tyrosine kinase inhibitors.
Nursing Diagnosis
 Fear related to disease progression and death
 For patient with CML in blast crisis, see Nursing Care Plan 26-1, pages 984 to 986.
Allaying Fear
 Encourage appropriate verbalization of feelings and concerns.

 Provide comprehensive patient teaching about disease, using methods and content
appropriate to patient’s needs.
 Assist patient in identifying resources and support (eg, family and friends, spiritual
support, community or national organizations, support groups).
 Facilitate use of effective coping mechanisms.
1. Teach patient to take medications as prescribed and monitor for adverse effects.
2. Teach patient method of subcutaneous injection for self- administration of alpha interferon,
and teach strategies for managing such adverse effects as fatigue and fevers.
3. Provide patient and family with information about resources in the community, such as the
Leukemia and Lymphoma
 Demonstrates effective coping skills
CHRONIC LYMPHOCYTIC LEUKEMIA
 Chronic lymphocytic leukemia (CLL) (ie, involving more mature cells than acute
leukemia) is characterized by proliferation of morphologically normal but functionally
inert lymphocytes. Classified according to cell origin, it includes B cell (accounts for
95% of cases), T cell, lymphosarcoma, and prolymphocytic leukemia. The differential
diagnosis includes hairy cell leukemia and Waldenström’s macroglobulinemia.
 Specific etiology unknown. Tends to cluster in families, much more common in Western
hemisphere. Male hormones may play role.
 Most common adult leukemia in United States and Europe. Disease of later years (90%
over age 50); 1.5 times more common in men than in women.
235
 Lymphocytes are immune incompetent and respond poorly to antigenic stimulation.

 In late stages, organ damage may occur from direct lymphocytic infiltration of tissue.
 Variable course, may be indolent for years, with gradual transformation to more
malignant or aggressive disease with 1- to 2-year course.
 Insidious onset, may be discovered during routine physical examination.

 Early symptoms may include painless lymph node swelling, commonly in cervical area,
history of frequent skin or respiratory infections, mild splenomegaly and hepatomegaly,
fatigue.
 Symptoms of more advanced disease include fever, night sweats, weight loss, pallor,
activity intolerance, easy bruising, skin lesions, bone tenderness, abdominal dis-
comfort.
 CBC and blood smear: large numbers of lymphocytes (10,000 to 150,000/mm 3); may
also be anemia, thrombocytopenia, hypogammaglobulinemia.
 Bone marrow aspirate and biopsy: lymphocytic infiltration of bone marrow.
 Lymphnodes biopsy to detects spread.
Management
Symptom Control and Treatments
o Patient with newly diagnosed and indolent CLL is gene ally observed and
followed closely until symptoms develop. Treatment is individualized; NCCN
guidelines suggest clinical trial or various chemotherapy and monoclonal
antibody combinations (www.nccn.org).
o Lymphocyte proliferation can be suppressed with chlorambucil (Leukeran),
cyclophosphamide (Cytoxan), and prednisone (Orasone).
o The purine analogue fludarabine (Fludara) has significant activity in CLL alone or
in combination with rituximab (Rituxan) and/or cyclophosphamide (Cytoxan).
o Monoclonal antibodies, such as alemtuzumab (Campath) and rituximab
(Rituxan), may be used.
o Hairy cell leukemia, a distinctive type of B-cell leukemia with hairlike projections
of cytoplasm from lymphocytes, may be successfully treated with cladribine
(Leustatin), pentostatin (Nipent), or alpha interferon.
o Splenic irradiation or splenectomy for painful splenomegaly or platelet
sequestration, hemolytic anemia.
o Irradiation of painful enlarged lymphnodes.
o Allogeneic bone marrow transplant is also used to treat CLL.
236
Supportive Care
 Transfusion therapy to replace platelets and RBCs.

 Antibiotics, antivirals, and antifungals, as needed, to control infections.
 immunoglobulins or gamma globulin to treat hypogammaglobulinemia.
Complications
 Thrombophlebitis from venous or lymphatic obstruction caused by enlarged lymph

nodes.
 Infection, bleeding.
 Median survival depends on severity of disease; varies from 2 to 7 years.
Nursing Assessment
 Obtain health history, focusing on history of infections, fatigue, bruising and bleeding,
swollen lymph nodes.
 Assess for signs of anemia, bleeding, or infection.
 Evaluate for splenomegaly, hepatomegaly, lymphadenopathy.
Nursing Diagnoses
 Acute Pain related to tumor growth, infection, or adverse effects of chemotherapy

 Activity Intolerance related to anemia and adverse effects of chemotherapy
Reducing Pain
 Assess patient frequently for pain and administer or teach patient to administer
analgesics on regular schedule, as prescribed; monitor for adverse effects.
 Teach patient the use of nonpharmacologic methods, such as music, relaxation
breathing, progressive muscle relaxation, distraction, and imagery to help manage pain.
Improving Activity Tolerance
 Encourage frequent rest periods alternating with ambulation and light activity as
tolerated.
 Assist patient with hygiene and physical care as necessary.
 Encourage balanced diet or nutritional supplements as tolerated.
 Teach patient to use energy-conservation techniques while performing activities of daily
living, such as sitting while bathing, minimizing trips up and down stairs, using shoulder
bag or push cart to carry articles.
 Teach patient to minimize risk of infection

 Teach patient use of medications, as ordered, and possible adverse effects and their
management; also teach patient to avoid aspirin and NSAIDs, which may interfere with
platelet function.
 Provide patient and family with information about resources in the community, such as
the Leukemia and Lymphoma Society and the American Cancer Society
237
 States pain relief

 Performs activities without complaints of fatigue
 After studying, the students shall have self-readiness. Engage in virtual discussions by
inquires, ideas and updates through synchronous and asynchronous sessions. Work and
formulate their graphic organizers with their group on concept mapping, writing to learn
work sheet and evaluation exam.
V. References
1. Nettina, S. (2006). The Lippincott manual of nursing practice (9th Ed.). Philadelphia,
Pennsylvania, United States of America, Wolters Kluwer Health Lippincott Williams &
Wilkins.
2. Silvestri, L. (2016). Saunders comprehensive review for the NCLEX – PN examination. (6th
Ed.). Newport, Rhode Island. W.B. Saunders Company
3. Nu-Vision, Inc., (1992). Lippincott’s Review Series : Medical adequate skills, knowledge and
attitude in the care of sick patient with Surgical Nursing. Philadelphia, Pennsylvania, United
States of medical, surgical problems during young adulthood up to old age
America, J.B. Lippincott Company.

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1

MEDICAL – SURGICAL NURSING ABU TAMIER R. TAN, RN, MAN

NOTRE DAME OF JOLO COLLEGE

Course Title : CARE OF CLIENT WITH PROBLEMS IN OXYGINATION,

Credit Units : 8 UNITS

Pre-Requisite Subjects : NCM 109

Class Schedule : Blended Learning Mode/ Face to Face Meeting

Prepared by : Mr. Abu Tamier R. Tan, RN, MAN

Introductory Concept to Perioperative Nursing

1. Define what is surgery

Time Frame / Class Schedule:

Date and Time Class Meeting Remarks

 The students read and view the

Values integrated cross-linked concepts/values to be integrated:

THREE PHASE’S OF SURGERY

THE PREOPERATIVE PHASE

ADMISSION to the surgical Unit

ENDS: When the patient is transported into the PRIORITY FOCUS:

ADMISSION to the O.R.

Recovery Room/ PACU

ENDS: When the patient is transferred to PRIORITY:

ADMISSION to the RR/PACU

ENDS: When the doctor discontinues, follow up PRIORITY:

The four (4) types of conditions requiring surgery

CLASSIFICATION OF SURGERY ACCORDING TO PURPOSE

CLASSIFIACTION PURPOSE EXAMPLES

Ablative Removing disease organ that can’t wait

CLASSIFIACTION OF SURGERY ACCORDING TO URGENCY

CLASSIFICATION INDICATION EXAMPLES

DEGREE OF RISK FOR SURGERY

MAJOR SURGERY MINOR SURGERY

HEALTH PROBLEMS THAT INCREASE SURGICAL RISK

 Decrease in mental functioning (Dementia)  When possible, cater to set patterns in

DANGER FOR NEWBORN AND INFANTS TODDLER

FLUID AND ELECTROLYTES IMBALANCES

PRESENCE OF DIABETES MELLITUS

PRESENCE OF PULMONARY AND UPPER RESPIRATORY DISEASE

CONCURRENT OR PRIOR TO PHARMACOTHERAPY

a. Certain antibiotics may interrupt nerve

b. Anti-depressant particularly Monoamine

c. Phenothiazine increases hypotensive action

d. Diuretics, particularly thiazides, may cause

e. Steroids inhibit wound healing.

f. ANTI COAGULANT SUCH AS warfarin and

SUB TOPIC 1: PREOPERATIVE NURSING

Time Frame / Class Schedule:

Date and Time Class Meeting Remarks

 Flipped learning via messenger

Values integrated cross-linked concepts/values to be integrated:

PREOPERATIVE CONSENT/INFORMED CONSENT

PROCEDURES REQUIRING A PERMIT

CONSIDIRATION FOR OBTAINING INFORM CONSENT

OBTAINING INFORMED CONSENT

WHEN CONSENT IS NOT NEEDED?

2. If the patient wave’s his/her rights.

PATIENT’S RIGHT TO REFUSE A SURGICAL PROCEDURE

PREOPERATIVE INSTRUCTIONS: Preoperative Regimen

Assessment: Nursing History

 PURPOSE: To avoid exposing the patient to allergies.

Figure 1 on module 1 sub – topic: Incentive spirometry

Leg and foot Exercises

Figure 2: Leg and foot exercises

Splinting the Incision

Figure 3: Splinting the incision site