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TOPIC 1. NURSING CARE OF AT-
RISK AND SICK ADULT CLIENTS
WITH ALTERATIONS/PROBLEMS
IN NUTRITION, AND
GASTROINTESTINAL,
METABOLISM AND ENDOCRINE,
PERCEPTION AND
COORDINATION, ACUTE AND
CHRONIC.
THE NURSING PROCESS
A. Assessment
✓ 1.Subjective data History
✓ 2.Objective Data
B. Analysis / Nursing Diagnosis
C. Planning
• Planning for health
promotion
• 2. Planning for health
restoration and
maintenance
D. Implementation of care of
clients
1. Independent nursing care
• Physiologic care
• Psychosocial care
• Spiritual care
2. Independent care
• Pharmacological
• Therapeutics
• Complementary and
• Alternative therapies
• Nutritional and diet
therapies
• Surgical intervention
• Immunologic Therapy
E. Client Education
F. Evaluation of the Outcome of
Care G. Reporting and
documentation of Care
Assessment. The first step and
involves critical thinking skills and
data collection; subjective and
objective.
Nursing Diagnosis. Employing
clinical judgment assists in the
planning and implementation of
patient care. North American
Nursing Diagnosis Association
(NANDA) provides list of Nursing
Diagnosis.
Maslow's Hierarchy of Needs
• Basic Physiological need
• Safety and Security
• Love and Belonging
• Self-Esteem • It is a problem-solving approach
• Self-Actualization to clinical decision-making within
Planning. Goals and outcomes are a healthcare organization. It
formulated. integrates the best available
Goals should be: scientific evidence with the best
• Specific available experiential (patient
• Measurable or Meaningful and practitioner) evidence.
• Attainable or Action- • This problem-solving approach
Oriented to clinical practice encourages
• Realistic or Results-Oriented nurses to provide individualized
• Timely or Time-Oriented patient care
Implementation. Step which
involves action or doing and the Why is EBP important in
actual carrying out of nursing nursing?
interventions outlined in the plan of • Evidence-based practice is
care. important because it aims to
provide the most effective care
Evaluation. This final step of the that is available, with the aim of
nursing process is vital to a positive
improving patient outcomes.
patient outcome. Whenever a health
• Patients expect to receive the
care provider intervenes or
implements care, they must most effective care based on the
reassess or evaluate to ensure the best available evidence.
desired outcome has been met, • It enables nurses to make data-
partially met or unmet backed solutions that
incorporate clinical expertise
TOPIC 2. EVIDENCED-BASED and current research into the
PRACTICES FOR THE CARE OF decision-making process.
CLIENTS WITH ACUTE AND • Adopting EBP, can improve
CHRONIC patient outcomes and patient,
ALTERATIONS/PROBLEMS IN family, and healthcare provider
NUTRITION AND GASTRO- satisfaction.
INTESTINAL, METABOLISM AND • It can also reduce costs and the
ENDOCRINE, PERCEPTION AND risk of harm by decreasing
COORDINATION unnecessary tests and
procedures.
A. Importance of Evidenced-
Based Practice How does EBP benefit Nurses
B. Clinical Questioning Using and Patients?
PICOT Format • Evidence-based practice in
C. Appraisal of Collected nursing provides nurses with the
Evidences scientific research to make well-
D. Integration of Evidences to Care founded decisions.
of Clients • Through EBP, nurses can stay
E. Evaluation of Outcomes of updated about new medical
Evidence-Based Nursing
protocols for patient care. By
F. Documentation searching for documented
interventions that fit the profiles
What is Evidence-based practice of their patients, nurses can
(EBP) in Nursing?
increase their patients' chances
• Evidence-based practice is a for recovery.
vital part of enhancing critical • It enables nurses to evaluate
care nursing practice, which is research, so they understand
essential for providing quality the risks or effectiveness of a
care to patients. diagnostic test or treatment
• It is a crucial tool for delivering • The application of EBP enables
high-quality care in numerous nurses to include patients in their
nursing specialties.

care plans.
• This allows patients to have a
proactive role in their own
healthcare since they can voice
concerns, share their values and
preferences and make
suggestions on how they want to
proceed.
Examples of EBP in the daily
practice of nursing
• Infection Control
Nurses play a key role in helping to
prevent illness by keeping the
healthcare environment clean,
wearing personal protective
clothing, using barrier precautions,
and practicing correct handwashing.
Although nurses are busy with many
responsibilities, the time it takes to
control infection is well worth the
effort.
• Oxygen Use in Patients with
COPD
For patient health and safety, it is
essential that nurses follow
evidence-based practice nursing
when it comes to giving oxygen to
patients with COPD. Despite the
belief by some that providing oxygen
to these patients can create serious
issues such as hypercapnia,
acidosis, or even death, the
evidence-based protocol is to
provide oxygen to COPD patients.
This practice can help prevent
hypoxia and organ failure. Giving
oxygen, which is the correct
treatment based on the evidence,
can enhance COPD patients’ quality
of life and help them live longer.
Examples of Non-
Pharmacological EBP Nursing
Interventions
➢ Use of exercise to fight
cancer-related fatigue.
• Cancer survivors have named
cancer-related fatigue a major
cause of distress in their lives,
according to the National
Comprehensive Cancer
Network.
• Exercise (or physical activity) is
the only research-based
intervention proven to relieve
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cancer-related fatigue and
recommended for practice by
the Oncology Nursing Society
(ONS).
• The ONS uses a stoplight color
model to guide interventions for
symptom management. Green
for "go" are interventions
recommended for practice, such
as exercise to manage fatigue.
➢ Encourage patients to chew
gum after abdominal surgery.
• Chewing gum is thought to
reduce post-operative ileus
(POI) "a malfunction of intestinal
motility" — by aiding the
recovery of the digestive
system. One surgical unit
nursing team offers sugar-free
gum to alert patients and
instructs them to chew four times
a day or more starting six hours
after surgery.
• This intervention is a result of an
EBP nursing research pilot
study. This simple, cost-effective
intervention can reduce POI,
reduce costs, and alleviate the
patient's pain and suffering
Integrating EBP into Clinical
practice
• Developing an institutional
culture of EBP is essential to
support effective change in
practice.
• The first step to integrating EBP
in an institution is selecting a
framework in which decisions
are made.
• The next step is to ask the
clinical question. Developing a
PICOT question is crucial to
ensure you are identifying the
clinical problem.
EBP helps nurses determine an
effective course of action for the
delivery of care, it involves the
following five steps:
1. Formulate a well-built clinical
question to identify a problem.
(ASK)
2. Gather the best evidence.
(ACQUIRE)
3. Analyze the evidence.
(APPRAISE)
4. Apply the evidence to clinical
practice. (APPLY)
5. Evaluate the result.
(ASSESS/AUDIT)
Formulating Question using
PICOT(TT)
What is a PICOT (TT) Question?
✓ The PICOT question format is a
consistent "formula" for
developing answerable,
researchable questions.
✓ It is a helpful approach for
summarizing research questions
that explore the effect of therapy,
prevention, diagnosis, etiology,
and prognosis.
✓ When you write a good one, it
makes the rest of the process of
finding and evaluating evidence
much more straightforward.
✓ P: Population/patient - age,
gender, ethnicity, individuals
with a certain disorder
✓ I: Intervention/indicator
(Variable of Interest) - exposure
to a disease, risk behavior,
prognostic factor
✓ C: Comparison/control - could
be a placebo or "business as
usual" as in no disease, absence
of risk factor, Prognostic factor B
✓ O: Outcome – the risk of
disease, the accuracy of a
diagnosis, rate of occurrence of
adverse outcome
✓ T: Time - the time it takes for the
intervention to achieve an
outcome or how long
participants are observed
✓ T: Type of Question (Is this a
diagnosis, therapy, prognosis,
etiology/harm, or prevention
question?)
✓ T: Type of Study Design (What
study design would best answer
this question? RCT, Cohort,
Case Series, etc.
Note: Not every question will have
an intervention (as in a meaning
question) or time (when it is implied
in another part of the question)
component.
Example PICOT question:

1. In adult patients with total hip
replacements, how effective is
pain medication compared to
aerobic stretching in controlling
postoperative pain during the
perioperative and recovery
time?
2. For patients 65 years and older,
how does the use of an influenza
vaccine compare to not
receiving the vaccine influence
the risk of developing
pneumonia during flu season?
Guide template on how to create
a PICOT question
Example 1 - Therapy
Scenario:
You have a female patient
who has recently been diagnosed
with SLE. Her rheumatologist
suggested she start on Plaquenil for
her joint pain, but she is interested in
alternative therapies because she
heard about success a neighbor had
with turmeric tea. • P- patients with
SLE
• I- turmeric tea
• C- Plaquenil (standard drug
therapy)
• O- reduction of joint pain
Question: In adult patients with
SLE, is consuming turmeric tea
more effective than Plaquenil at
reducing joint pain?
• This question could be more
specific (Gender specific? What
counts as a reduction in joint pain?)
but is still a therapy question. We're
comparing an alternative therapy
(turmeric tea) with a more standard
drug therapy (Plaquenil).
Example 2 - Diagnosis/Diagnostic
Test
Scenario:
Your patient has a history of
blood clots and after they came in to
your clinic with right calf discomfort
and tightness, you're concerned
about DVT. You remember reading
about the limitations of duplex
ultrasound and calf veins, and are
wondering if a d-dimer assay can
help you rule out DVT more
accurately.
• P- adults
• I- d-dimer assay
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• C- ultrasound
• O- more accurate diagnosis of DVT
Question: Is d‐dimer assay more
accurate at ruling out deep vein
thrombosis compared to
ultrasound?
Example 3 - Etiology
Scenario:
Your female patient is
concerned about her risk of
developing breast cancer. Her friend
was recently diagnosed and
mentioned that her smoking might
have been a factor. Your patient and
her wife have lived together for 10
years, and while she doesn't smoke,
her partner does. Is she at an
increased risk over someone
without daily exposure to second-
hand smoke?
• P- female nonsmokers w/ daily
secondhand smoke exposure
• I-
• C- female nonsmokers w/o daily
smoke exposure
• O- develop breast cancer
• T- over ten years
Question: Are female non-smokers
with daily exposure to second-hand
smoke over a period of ten years or
greater more likely to develop breast
cancer when compared with female
non-smokers without daily exposure
to secondhand smoke?
Example 4 - Prognosis
Scenario:
Your patient, who owns a
bakery, recently participated in their
employer's wellness program. Their
BMI is within a normal range, but
they have a family history of obesity,
and are concerned about the impact
of carbs may have on maintaining a
healthy weight.
• P- patient with a family history of
obesity
• I- carbs intake; specific diet?
• C-
• O- keeping BMI below 25; healthy
weight management
Question: Does dietary
carbohydrate intake influence
healthy weight maintenance (BMI
30)?
TOPIC 3. RELEVANT LEGAL,
MORAL AND ETHICAL
STANDARDS OF CARE
A. Patient’s Bill of Rights
B. Advanced Directives, Living
Will
C. Ethical Principles on
Beneficence, Non-
maleficence, Autonomy, and
Justice
D. RA 9442: Magna Carta for
Persons with Disability
E. RA 10054: Motorcycle
Helmet Law
F. Scope of Nursing Practice
Based on RA 9173
A. Patient’s Bill of Rights
1. Right to Appropriate Medical
Care and Humane Treatment
2. Right to Informed Consent
3. Right To Privacy and
Confidentiality
4. Right to Information
5. The Right To Choose Health
Care Provider and Facility
6. Right to Self-Determination
7. Right to Religious Belief
8. Right to Medical Records
9. Right to Leave
10. Right to Refuse Participation in
Medical Research
11. Right to Correspondence and to
Receive Visitors
12. Right to Express Grievances
13. Right to be Informed of His
Rights and Obligations as a
Patient
1. Right to Appropriate Medical
Care and Humane Treatment
Every person has a right to
health and medical care
corresponding to his state of
health, without any
discrimination and within the
limits of the resources,
manpower and competence
available for health and medical
care at the relevant time. If any
person cannot immediately be
given treatment that is medically
necessary, he shall, depending
on his state of health, either be
directed to wait for care, or be
referred or sent for treatment
elsewhere, where the

appropriate care can be
provided. If the patient has to
wait for care, he shall be
informed of the reason for the 3.
delay.
2. Right to Informed Consent
• The patient has a right to a clear,
truthful and substantial
explanation, in a manner and
language understandable to the
patient, of all proposed
procedures, whether diagnostic,
preventive, curative,
rehabilitative or therapeutic,
wherein the person who will
perform the said procedure shall
provide his name and
credentials to the patient,
possibilities of any risk of
mortality or serious side effects,
problems related to
recuperation, and probability of
success and reasonable risks
involved:
• Provided, That the patient will
not be subjected to any
procedure without his written
informed consent, except in the
following cases:
a. Emergency cases
b. when the health of the
population is dependent on
the adoption of a mass
health program to control
epidemic;
c. when the law makes it
compulsory for everyone to
submit a procedure;
d. When the patient is either a
minor, or legally
incompetent, in which case a
third party consent Is
required;
e. when disclosure of material
information to patient will
jeopardize the success of
treatment, in which case,
third party disclosure and
consent shall be in order;
f. When the patient waives his
right in writing.
• In case the patient is
incapable of giving consent
and a third party consent is
required; i. spouse; ii. son or
daughter of legal age; iii.
NCM 116 A MEDSURG
either parent; iv. brother or
sister of legal age, or v.
guardian.
3. Right to Privacy and✓
Confidentiality
✓ The patient has the right to
privacy and protection from
unwarranted publicity. All
identifiable information about the
patient must be kept confidential
even after death.
✓ Confidential information can be
disclosed in the following cases:
• When the patient’s medical
or physical condition is in
controversy in a court
litigation and the court, in its
discretion, orders the patient
to submit to physical or
mental examination of a
physician.
• When public health or safety7.
so demands.
• When the patient waives this
right.
4. Right to Information
✓ In the course of his/her
treatment and hospital care, the
patient or his/her legal guardian
has a right to be informed of the
result of the evaluation of the
nature and extent of his/her
disease, any other additional or
further contemplated medical
treatment on surgical procedure
or procedures. 8.
✓ The patient or his/her legal
guardian has the right to be
informed by the physician or
his/her delegate of his/her
continuing health care
requirements following
discharge.
✓ At the end of his/her
confinement, the patient is
entitled to a brief, written
summary of the course of his/her9.
illness.
5. The Right to Choose Health
Care Provider and Facility
✓ The patient is free to choose the
health care provider to serve him
as well as the facility except
when he is under the care of a
service facility or when public
health and safety so demands or
when the patient expressly
waives this right in writing.
6. Right to Self-Determination
The patient has the right to avail
himself/herself of any
recommended diagnostic and
treatment procedures. Any person
of legal age and of sound mind may
make an advance written directive
for physicians to administer
terminal care when he/she suffers
from the terminal phase of a
terminal illness. Provided that
a.) he is informed of the medical
consequences of his choice;
b.) he releases those involved in his
care from any obligation relative
to the consequences of his
decision;
c.) his decision will not prejudice
public health and safety.
Right to Religious Belief
✓ The patient has the right to
refuse medical treatment or
procedures which may be
contrary to his religious beliefs,
subject to the limitations
described in the preceding
subsection:
✓ Provided, that such a right shall
not be imposed by parents upon
their children who have not
reached the legal age in a life-
threatening situation determined
by the physician.
Right to Medical Records
✓ The patient has the right to view
the contents of his medical
records except for psychiatric
notes and incriminatory
information. He may obtain from
the health care institution a
reproduction of the same record
whether or not he has fully
settled the financial obligation.
Right to Leave
The patient has the right to leave the
hospital or any other healthcare
institution regardless of his physical
condition: Provided that:
✓ He/she is informed of the
medical consequences of
his/her decision
✓ He/she releases those involved
in his/her care from any

obligation relative to the
consequences of his decision;
✓ His/her decision will not
prejudice public health and
safety.
10. Right to Refuse Participation in
Medical Research
The patient has the right to be
advised if the health care provider
plans to involve him in medical
research, including but not limited
to human experimentation which
may be performed only with the
written informed consent of the
patient:
✓ Provided, That, an institutional
review board or ethical review
board in accordance with the
guidelines set in the Declaration
of Helsinki be established for
research involving human
experimentation:
✓ Provided, further, That the
Department of Health shall
safeguard the continuing
training and education of future
health care
providers/practitioners to ensure
the development of health care
delivery in the country:
✓ Provided, furthermore, That the
patient involved in the human
experimentation shall be made
aware of the provisions of the
Declaration of Helsinki and its
respective guidelines.
11. Right to Correspondence and
to Receive Visitors
✓ The patient has the right to
communicate with relatives and
other persons and to receive
visitors subject to reasonable
limits prescribed by the rules and
regulations of the health care
institution.
12. Right to Express Grievances
✓ A patient has the right to express
grievances regarding any
violations of his or her right this
is through the grievance's
procedure of the health care
provider or health care facility
which served him or her and to
the appropriate state licensing
agency.
13. Right to be Informed of His
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Rights and Obligations as a
Patient
✓ The Department of Health, in
coordination with health care
providers, professional and civic
groups, the media, health
insurance corporations, people’s
organizations, and local
government organizations, shall
launch and sustain a nationwide
information and education
campaign to make known to
people their rights as patients,
as declared in this Act. Such
rights & obligations of patients
shall be posted on a bulletin
board conspicuously placed in a
healthcare institution.
B. Advanced Directives, Living
Will
Advance Directive
• Is a written document by a
competent person, regarding
their health care preference.
• Allow individual to provide
directions about the kind of
medical care they do or do
not want if they become
unable to make or
communicate their decisions.
• An Advance Directive may
include a living will and/or a
durable power of attorney for
health care.
The Patient Self-Determination
Act (PSDA)
• A federal law and compliance
is mandatory. It is the
purpose of this act to ensure
that a patient's right to self-
determination in health care
decisions is communicated
and protected.
• The Patient Self-
Determination Act (PSDA)
was established in 1990 as a
federal law, mandating that
hospitals
a) determine whether patients
have an advance directive
(AD) and
b) make AD document resources
available to patients (Teno,
Gruneir, Schwartz, Nanda &
Wetle, 2007).
The main types of Advance
Directives:
1. Durable Power of Attorney for
Health Care
2. Living Will
❖ Durable Power of Attorney for
Health Care
✓ Allows an individual to appoint
someone, called HCP, agent, or
surrogate, to make health care
decisions for him or her should
he or she lose the ability to make
decisions or communicate his or
her wishes.
❖ Living Will
✓ A written directive regarding the
course, continuation, or
discontinuation of medical
treatment in the event that a
person becomes incompetent.
✓ The living will be only used at the
end of life if a person is
terminally ill or permanently
unconscious. The living will
describe the type of medical
treatment the person would want
or not want to receive in these
situations. It can describe under
what conditions an attempt to
prolong life should be started or
stopped. This applies to
treatments including, but not
limited to dialysis, tube feedings,
or actual life support (such as
the use of breathing machines).
❑ Things to consider when writing
a Living Will
✓ If you want the use of
equipment such as dialysis
machines (kidney machines) or
ventilators (breathing
machines) to help keep you
alive.
✓ Do not resuscitate orders
(instructions not to use CPR if
breathing or heartbeat stops).
✓ If you want fluid or liquid
(usually by IV) and/or food
(tube feeding into your
stomach) if you couldn't eat or

drink.
✓ If you want treatment for pain,
nausea, or other symptoms,
even if you can't make other
decisions (this may be called
comfort care or palliative care).
✓ If you want to donate your
organs or other body tissues
after death.
❖ Care Strategies
1. Nurses should assist patients
and families trying to deal with
end of life care issues.
2. Patients may be willing to
discuss their health situation and
mortality with a nurse rather than
with a family member and should
be supported in doing so.
3. Patients should be assisted in
talking with their family/proxy
about their treatment and care
wishes.
4. Patients should be assessed for
their ability to cope with the
information provided.
5. Nurses must be mindful of and
sensitive to the fact that race,
culture, ethnicity, and religion
can influence the health care
decision-making process.
6. Patients must be respected for
their decision to not complete an
AD and reassured that they will
not be abandoned or receive
substandard care if they do not
elect to formulate an AD.
7. Nurses should be aware of the
institution’s mechanism for
resolving conflicts between
family members and the patient
or proxy or between the
patient/family and care providers
and assist the parties in using
this resource.
8. Nurses should be aware of
which professional in their
agency/institution is responsible
for checking with the patient that
copies of the AD have been
given to their primary-care
provider(s), to their proxy, and
that the patient is carrying a
wallet-size card with AD and
contact information
❖ Guiding Principles
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✓ All people have the right to
decide what will be done with
their bodies.
✓ All individuals are presumed
to have decision-making
capacity until deemed
otherwise.
✓ All patients who can
participate in a conversation,
either verbally or through
alternate means of
communication, should be
approached to discuss and
record their treatment
preferences and wishes.
✓ Health care professionals can
improve end-of-life (EOL)
care for elderly patients by
encouraging the use of
advance directives (ADs).
✓ tube. Mr. Suarez’s daughter says
❖ Ethical Implications
✓ A nurse or other health care
professional may decline to
participate in the withholding
or withdrawing of medical
treatment if it contradicts the
nurse's personal and/or
professional convictions.
✓ Just as the concept of the
Advance Directive is not for
every patient, it is also not for
every critical care nurse.
There will be no legal
ramifications if a nurse finds it
impossible to care for a
patient who has an Advance
Directive.
✓ This is a very personal,
moral, and ethical decision
for the critical care nurse. The
responsibility is the timely
and appropriate transfer of
care to another nurse who
can treat and respect the
personal directives of this
patient
CASE SAMPLE
Mr. Suarez is a 73-year-old
man who is estranged from his wife.
Since he prefers that she doesn’t
make any medical decisions for him
should the need arise, he has filled
out an advance directive naming his
daughter as his health care proxy.
He has suffered from diabetes for
many years and is adamant that he
does not want dialysis—even if it
would sustain his life. He does,
however, wish to have tube feeding
for however long it will sustain him (if
necessary).
One evening while his
overnight aide is caring for him, Mr.
Suarez has a seizure. He is taken to
the hospital immediately, but never
regains consciousness and doctors
do not expect him to do so. They
want to put him on dialysis (as his
diabetes is worsening) and a
feeding tube (as there is no other
way for him to receive nutrients). His
daughter informs the doctors of her
father’s end-of-life wishes. The
doctors warn her that without
dialysis her father will pass away
more quickly, even with the feeding
that although she is aware, she
wants them to carry out her father’s
wishes. They do so and the feeding
tube gives Mr. Suarez a few more
days of life, though not as many as
he would have had by adding
dialysis.
C. Ethical Principles of
Beneficence, Non-Maleficence,
Autonomy and Justice
✓ The principles commonly used
in healthcare ethics – justice,
autonomy, non-maleficence,
and beneficence – provide us
with an additional foundation
and tools to use in making
ethical decisions.
✓ Each of these principles will be
reviewed in this presentation.
✓ The concept of justice is
presented last because it is the
most complex
Mr. A, a 38-year-old
accountant, has been diagnosed
with a progressive brain disorder
which he had inherited from his
late father. This disease is
characterized by progressive
degeneration of nerve cells in the
brain. The time from disease
emergence to death is often about
10 to 30 years. As for Mr. A, his life
expectancy is only within 10 years.
With uncontrollable twitching,
contractions, and dementia, Mr. A

succumbed to depression. He
even attempted suicide by
ingesting all his antidepressants.
He was later found unconscious in
his apartment and was rushed to
the emergency room of a nearby
medical facility. The assigned
nurse found a note in his shirt
pocket that explained his actions
and his refusal to any medical
assistance that might be offered.
32 years old male having three
children diagnosed with CLD, was
operated liver transplantation in
public sector hospital. The liver
was taken from live donor 28 years
old wife of the patient. On 3rd post
op day the patient start severe
bleeding with tachycardia and
hypotension. Patient become
unconscious and was rushed to
operation room (OR). Meanwhile
patient crashed and Cardio
Pulmonary Resuscitation (CPR)
started. After 6 hours of CPR
patient cardiac activity was
resumed, but still bleeding from
drain and body orifices. Patient
was on high inotropic support and
back to back transfusion of blood
and blood product to maintain
hemoglobin and platelet of patient.
Later on patient expired and his
wife remain in hospital till her
recovery.
Jehovah’s Witness case, A
competent adult patient loses a
massive amount of blood from a
blood vessel bleeding in an acute
duodenal ulcer. The best chance
of saving his life is an urgent blood
transfusion along with operative
intervention to arrest the bleeding.
The patient refuses blood but asks
for treatment instead with the best
available non-blood products, and
surgery, accepting the substantial
risk that surgery without blood
transfusion is much less likely to
save his life than surgery with
blood transfusion.
The patient’s wishes ought to
be respected as stated in the
patients’ bill of rights under Right to
Religious Belief. - The patient has
the right to refuse medical
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treatment or procedures which
may be contrary to his religious
beliefs. The emergency
department (ED) was full all day.
Patients were waiting up to seven
hours to be seen. Room five was
reserved as of 4:00 pm and a
sterile clean was done. The nurse
walked to the front of the hospital
at 4:30 pm to meet a patient. She
sat with a patient and her mother to
inquire how the patient was doing
and for the patient to explain the
reason she was at the ED. The
patient explained she had her
menstrual cycle for the past two
weeks and her hemoglobin level
was now at six so she needed
blood transfusion. The nurse then
got up and told the patient to come
with her. The patient was taken
into the ED bypassing all the other
persons that were present and had
been waiting for an extended time.
D. RA 9442: Magna Carta for
Persons with Disability
✓ The primary law with respect to
the rights of persons with
disabilities in the Philippines is
Republic Act (R.A.) No. 7277 or
the Magna Carta for Disabled
Persons – An act providing for
the rehabilitation, self-
development and self-reliance of
persons with disabilities and
their integration into the
mainstream of society and for
other purpose.
✓ The act was amended in 2006
by Republic Act No. 9442 – “An
act providing for the
Rehabilitation and Self-reliance
of Disabled Persons and Their
Integration to the Mainstream of
Society and Other Purposes
granting Additional Privileges
and Incentives and Prohibitions
on Verbal, Non-Verbal Ridicule
and Vilification Against Persons
with Disability,”
E. RA 10054: Motorcycle Helmet
Law
✓ An act mandating all motorcycle
riders to wear standard
protective motorcycle helmets
while driving and providing
penalties, therefore.
✓ SECTION 1. Short Title. - This
Act shall be known as the
"Motorcycle Helmet Act of
2009".
✓ SEC. 2. Declaration of Policy. -
It is hereby declared the policy of
the State to secure and
safeguard its citizenry,
particularly the operators or
drivers of motorcycles and their
passengers, from the ruinous
and extremely injurious effects
of fatal or life-threatening
accidents and crashes. Towards
this end, it shall pursue a more
proactive and preventive
approach to secure the safety of
motorists, their passengers and
pedestrians at all times through
the mandatory enforcement of
the use of standard protective
motorcycle helmet.
✓ SEC. 3. Mandatory Use of
Motorcycle Helmets.
✓ SEC. 4. Exemption. - Drivers of
tricycles shall be exempted from
complying with the mandatory
wearing of motorcycle helmets
as provided in this Act.
✓ SEC. 5. Provision of
Motorcycle Helmets.
✓ SEC. 6. Implementation. - The
Department of Transportation
and Communications (DOTC),
with its attached agency, the
Land Transportation Office
(LTO), is mandated by this Act to
issue guidelines necessary to
implement the provisions of this
Act.
✓ SEC. 7. Penalties.
✓ SEC. 8. Nationwide Public
Information Campaign.
F. Scope of Nursing Practice
Based on RA 9173
✓ RA 9173 or known as the
Philippine nursing act of 2002
is an act that assumes to the
responsibility for the protection
and improvement of the
nursing profession by
instituting measures that will
result in relevant nursing

education, humane working
conditions better career
prospects and a dignified
existence of our nurses.
✓ Article VI – section 28 titled as
scope of nursing practice
covers, but not limited to,
nursing care during conception,
labor, delivery, infancy,
childhood, toddler, preschool,
school age, adolescence,
adulthood, and old age.
Nurse Scope of Practice
There are 2 parts to understanding
scope of practice – there is scope of
professional practice and scope of
the individual’s practice.
1. Professional Practice: The
scope of the professional
practice is set by legislation —
professional standards such as
competency standards, codes of
ethics, conduct and practice and
public need, demand and
expectation. It may therefore be
broader than that of any
individual within the profession.
To practice within the full scope
of practice of the profession may
require individuals to update or
increase their knowledge, skills
or competence.
2. Individual Practice: The scope
of practice of an individual Nurse
also includes that which the
individual is.
➢ Educated
➢ Authorized and
➢ Competent and confident to
perform.
❑ Article VI – Nursing Practice
❑ It shall be the duty of the nurse to:
c) Provide health education to
individuals, families and
communities;
d) Teach, guide and supervise
students in nursing education
programs including the
administration of nursing
services in varied settings such
as hospitals and clinics;
undertake consultation
services; engage in such
activities that require the
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utilization of knowledge and Collaborative Care Model
decision-making skills of a ✓ Patient-Centered Team Care
registered nurse; and ✓ Population-Based Care
e) Undertake nursing and health ✓ Measurement-Based Treatment
human resource development to Target
training and research, which ✓ Evidence-Based Care
shall include, but not limited to, ✓ Accountable Care
the development of advance • Collaborative Maps
nursing practice.
TOPIC 5. NURSES’ ROLE AS A
That this section shall not apply to MEMBER OF THE RESEARCH
nursing students who perform TEAM
nursing functions under the direct
supervision of a qualified faculty: Roles and responsibilities of a
a.) Provided, further, That in the research Nurse:
practice of nursing in all settings,
the nurse is duty-bound to ✓ File Preparation – put all the
observe the Code of Ethics for documentation needed to
nurses and uphold the complete a study visit in a file
standards of safe nursing prior to the participant’s arrival at
practice. The nurse is required to the clinic,etc.
maintain competence by ✓ Recruitment – this is a process
continual learning through that starts off with identifying
continuing professional where one will find the
education to be provided by the appropriate subjects, informing
accredited professional the site staff of what the study
organization or any recognized entails and what patient
professional nursing population is required for the
organization: study and then approaching the
b.) Provided, finally, That the potential study participants of
program and activity for the the study.
continuing professional ✓ Patient preparation – ensure
education shall be submitted to the participant understand what
and approved by the Board.” the procedures he/she will have
for the visit/s.
TOPIC 4. ✓ Case report form entry – This
A. INTER-PROFESSIONAL CARE gets done when all the relevant
MAPS information is documented in
B. COLLABORATIVE CARE OF specific forms as requested by
CLIENTS WITH ACUTE AND the sponsor.
CHRONIC ALTERATIONS/ ✓ Education – ongoing education
PROBLEMS is given to the participants
regarding the study; medication;
COLLABORATIVE CARE
possible side-effects of
➢ The result of multiple providers medication; laboratory results
communicating with each other etc.
about a patient’s diagnosis and
✓ Counselling – this gets done at
treatment. three sessions prior to the start
Ex. Patients with chronic or complex
of ARV’s or one at the start of
conditions, especially, need
other medication. The research
collaborative care to ensure that
their healthcare plan is properly nurse continues with noting of
coordinated between multiple adherence of medication as well
providers, laboratories, pharmacies, as follow-up visits. Compliance
and healthcare facilities. is vital as it will impact on the
outcome of the research results.
5 essential elements of the ✓ Informed Consent – this is a
process that starts at the first
 NCM 116 A MEDSURG
contact with the participant and Professional Identification Card. enhancement of nursing
ends at the end of the study ✓ It was passed to institute practice, thus improving health
measures that will continuously care for the public.
TOPIC 6. CONTINUING improve the competence of ✓ The purpose of continuing
PROFESSIONAL DEVELOPMENT Filipino professionals and make education is to ensure that
PROGRAMS them attuned to the nurses stay abreast of current
development and industry practices, enhance their
A. In-Service Training Programs advancements in their chosen professional competence, learn
B. Continuing Education field. about new technology and
Program treatment regimens, and update
C. Formal Education A. In-service Training their clinical skills.
D. Self-Directed Learning Programme ✓ It is all the learning activities that
Initiatives ✓ In-service training is the training occur after an individual has
1. On-line learning given by the employer to an completed his basic education.
E. Health Advocacy Programs employee to enable the (Cooper)
1. Tobacco-free programs individual to execute a specific
2. Healthy lifestyle activity efficiently. C. Formal Education
3. Fall prevention ✓ It is part of continuing education. ✓ Formal education is a structured
F. Professional Decorum ✓ In-service training is deliberately and systematic form of learning.
planned to meet the needs of the This is the education of a certain
Continuing Professional employer in order to make up standard delivered to students
Development Programs deficiencies in technical and by trained teachers. To make
scientific information in an sure formal learning is
✓ It used to describe the learning
employee, such as the teaching standardized and all learning
activities professionals engage
of techniques and procedures institutions (e.g. schools,
in to develop and enhance their
that the employee has to colleges, universities, etc.)
abilities.
execute in her/his job (Douglas, comply with these standards,
✓ CPD is a holistic approach
1996:281). formal education in a country is
towards the enhancement of
✓ e.g. Basic Life Support (BLS) governed by organizations.
personal skills and proficiency
Provider; Advanced ✓ Formal education is classroom-
throughout a professional’s
Cardiovascular Life Support based, meaning everything a
career.
(ACLS) Provider Course; ECG & student learns comes from
✓ CPD combines different
Pharmacology; Airway books and other educational
methodologies to learning,
Management; ECG materials with the sole purpose
which includes training courses,
Interpretation Course; IV of educating students.
seminars, workshops,
Therapy Course; Trauma Life ✓ Levels: Preschool, Primary
conferences and events,
Support school, Secondary school, and
webinars and online eLearning
B. Continuing Education Post-secondary school.
programs.
Program ✓ The highest level of education
✓ CPD can also include sharing
✓ It means an institution-approved one can pursue is post-graduate
best practice techniques,
short learning program or an education.
thoughts and ideas, all focused
institution-approved whole ❖ Informal Education
on an individual improving within
program. ✓ Informal education lacks the
the work environment.
✓ It usually refers to college structure and standards of
✓ It is an ongoing process of
courses or other vocational formal education.
frequently improving skills and
training obtained by older adults ✓ Learning happens outside the
competencies to enhance
or working professionals. classroom, whether in
workplace performance and
✓ It is important for an individual’s educational locations like
future career prospects.
competitiveness and museums and libraries or in
employability, but it also noneducational locations like at
Republic Act No. 10912
enhances social inclusion, home or in non-educational
✓ Otherwise known as the
active citizenship, and personal organizations.
“Continuing Professional
development. ✓ And unlike formal education
Development (CPD) Act of
✓ It is designed to promote and settings, informal education is
2016”, is an act that requires
enrich knowledge, improve skills completely optional.
CPD as the mandatory
and develop attitudes for the ❖ Non-formal Education
requirement for the renewal of a

✓ Non-formal learning is a mix of
formal and informal.
✓ While it doesn’t have a syllabus
or curriculum and isn’t
necessarily taught by people
who are licensed to teach, it’s
more structured than informal
learning.
✓ Examples of non-formal learning
are organizations like the Boy or
Girl Scouts, non-credit adult III.
education courses, seminars,
and conferences.
D. Self-Directed Learning
Initiatives IV.
✓ A learning strategy which
allows learners take charge of
their own learning process
(diagnosis learning needs,
identify learning goals, select
learning strategies, and ❖
evaluate learning ✓
performances and outcomes).
✓ A learning process where
people take initiative to “plan, ✓
carry out and evaluate their
own learning experiences”
(Merriam & Caffarella, 1999 , p.
293).
✓ Adults controlling their own ✓
learning process, or “Learning
in which decision around what
to learn, how to learn it, and
how to decide if one has
learned something well
enough are all in the hands of
learners” (Brookfield, 2013, p.
90).
✓ Self-directed learning gives
learners the freedom and
autonomy to choose the what,
why, how, and where of their ❖
learning (Francis, 2017)
Four dimensions of self-directed
learning:
I. Self-Regulation is the ability
to plan, direct, and control
one’s emotions, thoughts, and
behaviors during a learning ❖ DISADVANTAGES
task.
II. Motivation is the desire to
engage in an activity that
emerges from the inherent
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enjoyment of an activity or a
sense of obligation to engage
in a task. A growth mindset is a
major factor influencing
motivation: believing that
intelligence, personality, and
abilities are flexible and
dynamic, shaped by
experience, and changing over
the lifespan (Dweck, 2006).
Personal Responsibility
(also called responsibility,
initiative, and ownership) is a
willingness to take full
responsibility for one’s actions.
Autonomy is the ability to
recognize available choices
and take charge of one’s
learning, and control choices
through ongoing reflection and
evaluation.
On-line learning
It is a method of education
whereby students learn in a fully
virtual environment.
It refers to an internet-based
learning environment that can
connect students of diverse
backgrounds who boast different
perspectives.
A higher education institution will
use a learning management
system, or LMS, to facilitate
online learning, which can take
the form of asynchronous
learning (where students are not
required to be online at the same
time and utilize discussion
threads and e-mails to complete
coursework) or synchronous
learning (where students must
be online at the same time).
ADVANTAGES
1. Efficiency
2. Accessibility Of Time And
Place
3. Affordability
4. Improved Student
Attendance
5. Suits A Variety Of Learning
Styles
1. Inability To Focus On
Screens
2. Technology Issues
3. Sense Of Isolation
4. Teacher Training
5. Manage Screen Time
E. Health Advocacy Programs
✓ Coming from a Latin word that
means “call to one’s aid,”
advocacy refers to the act of
providing support, with the goal
of promoting certain issues and
making a change in one’s life. To
achieve this goal, strong people
or advocates speak out on
someone else’s behalf. They
help others tackle their adverse
experiences, as well as raise
and influence public awareness.
They also create ways for how
these people can speak out.
✓ Advocacy is one strategy to
raise levels of familiarity with an
issue and promote health and
access to quality health care and
public health services at the
individual and community levels.
❖ Tobacco-Free Programs
✓ The Philippines is one of 15
countries worldwide with a
heavy burden of tobacco-related
ill health.
✓ According to the World Health
Organization’s 2013
standardized estimate of
smoking prevalence, 35% of
men, 6.4% of women, and
20.6% of the Philippines’
population overall are daily
tobacco smokers.
✓ The Philippines has been a
Party to the WHO Framework
Convention on Tobacco Control
(WHO FCTC) since 2005.
✓ Tobacco Control Program that
aims to reduce the prevalence of
tobacco use and decrease the
overall ill effects of tobacco
through policies and legislation
on tobacco control.
❖ SMOKING CESSATION
PROGRAM
✓ Tobacco use has been widely
recognized as one of the
commonly shared behavioral
risk factors that lead to the 4
major non-communicable
diseases (NCDs) which are

cardiovascular diseases,
cancer, chronic respiratory
diseases and diabetes mellitus.
✓ It is one of the most serious
avoidable risk factors for
premature death and chronic
illness from tobacco-related
diseases that needs to be
addressed.
✓ The Tobacco Control
component of the Lifestyle
Related Diseases Prevention
and Control Program primarily
aims to reduce non-
communicable diseases caused
by cigarette smoking.
✓ It implements the World Health
Organization (WHO) MPOWER
measures which monitors
tobacco use and policies,
protects people from exposure
to second-hand smoke, offers
help to quit tobacco use, warns
people of its dangers, enforces
bans on tobacco advertising,
and reduces the affordability of
tobacco products.
✓ This program helps create an
enabling environment to help
current tobacco users quit,
protect people from secondhand
smoke and prevent young
people from taking up the habit.
❖ Healthy Lifestyle
✓ A healthy lifestyle is one which
helps to keep and improve
people's health and well-being.
✓ Many governments and non-
governmental organizations
work at promoting healthy
lifestyles.
✓ They measure the benefits with
critical health numbers,
including weight, blood sugar,
blood pressure, and blood
cholesterol.
✓ Healthy Lifestyle Program that
aims to inform and encourage
Filipinos from all walks of life to
practice a healthy lifestyle by
making a personal commitment
to physical activity, proper
nutrition, and the prevention or
cessation of smoking and
alcohol consumption
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✓ The "Pilipinas Go 4 health" is
a nationwide healthy lifestyle
movement that aims to inform
and encourage Filipinos to
practice a healthy lifestyle by
making a personal commitment
to avoid the 4 risk factors -
unhealthy diet, physical
inactivity, tobacco use and
harmful use of alcohol and to
promote and establish a
sustainable environment for
healthy living.
❖ Fall Prevention
How Is a Fall Defined?
✓ Any unintentional (witnessed
or unwitnessed) change in
position where the resident ends
up on the floor, ground, or other
lower level.3
❖ Fall risk and prevention
strategies should be considered
after:
✓ A move into a long-term care
home, or within the home;
✓ A change in health status;
✓ Changes in medications;
✓ A history of falls, or a new fall
has occurred
❖ Falls Prevention Strategies
✓ Different fall prevention
strategies may be needed for
each patient.
✓ Ideally, the care team,
patients, and families will
work together to find the
strategies that work best for
each individual.
✓ Goals of care for each patient
should be considered when
looking at fall prevention.
✓ For example, promoting
walking and exercise may be
suitable for one patient but
not for another
✓ If you notice new things that
may increase the risk of a fall,
like stumbling or dizziness,
be sure to document them
and inform all staff. It may be
time to reassess the patient's
risk of falling.
F. Professional Decorum
• It is an unwritten code of
conduct regarding the
interactions among the
members in a healthcare
setting.
• Professional decorum or
professional etiquette is
about presenting yourself
with polish and
professionalism that
demonstrates you can be
trusted and taken seriously.
• It means being comfortable
around people and making
them comfortable around you
while working hand in hand in
meeting both the patient and
nurse’s expected goals.
9 Ways to Demonstrate Your
Professionalism in Nursing
1. Communicate effectively
2. Have a positive attitude
3. Attend to patients with
compassion
4. Deliver top-quality care
5. Collaborate with others
6. Be accountable for your actions
7. Dress professionally
8. Stay knowledgeable about
current standards for best
practice
9. Adhere to a high standard of
ethics
Basic concepts of the Code of
Ethics
1. Rights – According to the
Webster dictionary, a right means
“something to which one has a just
claim or the power or privilege.” One
example of rights is often discussed
in hospital premises, such as the
rights of the patient. Nurses must be
aware of these rights since
sometimes patients may refuse the
nursing care that they could give.
Remember that it is also the right of
the patient to refuse such as a
procedure or medication even
thought that your purpose as a
nurse is to help him or her.
2. Autonomy – The concept of
autonomy can be seen during the
decision-making of undergoing such
procedures whether invasive or not.
Informed consent is one example of
how a nurse can practice the

concept of autonomy. Nurses must
be able to accept the fact that an
individual may have different cultural
and religious backgrounds that
could influence his or her
submission to medical procedures.
Using a written consent during such
cases can protect the patient and
the hospital in particular against
legal violations of invading the
privacy of an individual
3. Beneficence and
nonmaleficence – These concepts
can be seen during rendering
nursing care. It is very important that
nursing care must do not harm
(beneficence) but rather be safe for
the patient. Likewise, nursing care
must also be sure enough that it
cannot lead to intentional harm
(nonmaleficence). Patients
nowadays are very sensitive
regarding these concepts, so nurses
are challenged to give quality
nursing care every day.
4. Fidelity – Most of the time, this
term is correlated to a marital
relationship. However, nurses
should have fidelity towards four
major parts of her profession:
patient, company, community, and
environment. Fidelity is being
accountable for your actions
towards each individual or group
you encounter.
TOPIC 7. FILIPINO CULTURE,
VALUES AND PRACTICES IN
RELATION TO THE CARE OF AT-
RISK AND SICK ADULT CLIENT
WITH ACUTE AND CHRONIC
ALTERATIONS/PROBLEMS IN
NUTRITION, AND GASTRO-
INTESTINAL, METABOLISM AND
ENDOCRINE, PERCEPTION AND
COORDINATION
FILIPINO CULTURE, VALUES
AND PRACTICE
A. Family Solidarity
B. Filipino Family Values
✓ Communication
✓ Helping others & Gratitude
✓ Respect
✓ Independence
✓ Service
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✓ Trust
C. Filipino Family Culture and
Tradition
Health Beliefs and Behaviors
➢ Different Asian cultures apply
various models in perceiving and
interpreting symptoms and illness.
➢ These models influence their
decisions to seek medical treatment
and service.
What can you say about the
health behavior of those living
from:
✓ Rural Community
✓ Urban Community
❖Mystical Causes
Attributed to experiences or
behaviors such as ancestral
retribution.
❖ Personalistic Causes
Associated with social punishment
or retribution from supernatural
forces such as evil spirit, witch or
sorcerer (mangkukulam) forces cast
these spells on people if they are
jealous or feel disliked.
They seek priest or (albularyo) for
treatment and protection.
❖ Naturalistic Causes
Naturalistic causes include a host of
factors ranging from natural forces
(thunder, lightning, drafts, etc.) to
excessive stress, food and drug
incompatibility, infection, or familial
susceptibility.
❖ Response to Illness
Adults tend to cope with illness with
the help of
✓ Family - greatly influence
patients' decisions about health
care.
✓ Friends
✓ Faith in God
❑ Coping Styles
✓ Patience and Endurance
(Tiyaga)
✓ Flexibility (Lakas ng Loob)
✓ Humor (Tatawanan ang
problema)
✓ Fatalistic Resignation (Bahala
Na)
✓ Devastating shame (Hiya)
✓ Sensitivity to criticism (Amor
Propio)
TOPIC 8. ONLINE DATA
BASES/JOURNAL ARTICLES
RELATED ASSESSMENT AND
PROVISION OF CARE OF AT-
RISK AND SICK ADULT CLIENT
WITH ACUTE AND CHRONIC
ALTERATIONS/PROBLEMS IN
NUTRITION, AND GASTRO-
INTESTINAL, METABOLISM AND
ENDOCRINE, PERCEPTION AND
COORDINATION
❖ Database embraces many
different concepts:
✓ Paper records maintained by a
single practitioner.
✓ Computerized collections of files
from health plans to discharge
abstract.
✓ Databases of all hospitals in a
given state from cancer, trauma
and other patient's health
conditions registries maintained
by health institutions and
researchers to major national
health survey data of different
health agencies.
✓ As commonly used and meant in
this report, a database (or,
sometimes, data bank, data set,
or data file) is ''a large collection
of data in a computer, organized
so that it can be expanded,
updated, and retrieved rapidly
for various uses" (Webster's
New World Dictionary, 2nd ed.)
Health Information System
✓ SYSTEMS that Capture, Stores,
Transmits, Manages health data
or activities.
✓ are used to collect, process, use,
and
✓ report health information.
✓ Information from a health
information system can be used

1. Drive policy & Decision making
2. Research
3. Health outcomes
PAPER-BASED METHOD
1. Continuity of care stops-
misplaced
2. records
3. illegible handwriting- poses
misinterpretation of data.
4. Patient privacy is compromised
5. Manual data are difficult to
aggregate
6. Actual time for patient care is
limited
eHealth SYSTEM METHOD
1. Data are readily mapped,
enabling more targeted
interventions and feedback.
2. Data can be easily retrieved and
recovered (backed-up)
3. Redundancy of data
minimized.
4. Data for clinical research
becomes available.
5. Resources are used efficiently
Types of Health Information
Systems
✓ Clinical and Administrative
Systems for Managing Patient
Information on an Administrative
Level
✓ Financial and Clinical Health
Information Systems
✓ Electronic Health Record and
Patient Health Record
✓ Subject- and Task-Based
Systems
INFORMATION AND
COMMUNICATION
TECHNOLOGIES (ICT)
“Diverse set of technological
tools and resources used to
communicate and to create,
disseminate, store and manage
information”
mobile phones, computers, internet,
broadcasting technologies (radio &
television) geared towards
Improving people's access and
utilization of health care in the
philippine community setting.
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eHealth
✓ cost effective way of using ICT in
health services, health
surveillance, health literature,
health education and research
(WHO,2012)
1. Communicating with patients
• teleconferencing;
• electronic emails
• short message service (SMS)
2. Recording, Retrieving, and
Mining data
• Electronic Medical Record
(EMR)
3. Patient Health Teachings
• Electronic tools (radio, tv,
smartphones, tablets
Types of Health Information
Systems in the Philippines
✓ DOH recognizes ICT for health in
is attaining Universal Health Care.
✓ drafted NATIONAL eHEALTH
STRATEGIC FRAMEWORK
(2010-2016)- vision of improving
health access, quality, efficiency,
and patient safety and satisfaction
for reducing cost and enabling
policymakers, individuals and
communities to make the best
health decision.
Electronic Medical Records
(EMR) and Geographic
Information System (GIS)
• Health Professionals can track
the frequency and locale of
diseases in real-time.
• Makes consulting in different
facilities easier.
• Each patient record is usually
used more frequently
•
• Can utilize health services from
womb to tomb
Community-based EMR
• CHITS (Community Health
Information Tracking System) (
2004) UP, now used in
Pasay,Quezon City, Navotas
• SEGRHIS (Segworks Rural
Health Information System)
Davao
Telemedicine and eLearning
• Delivery of health care services
where distance is a critical factor
by all health care professionals
using ICT for exchange of valid
information for diagnosis,
treatment and prevention of
diseses and injuries, evaluation
and research (WHO)
❖ Telemedicine
✓ BuddyWorks
• Allowed RHU physician in
GIDAs to send telereferrals
to medical specialists at the
Philippine General Hospital
via short message service
(SMS)
✓ RxBox
• Funded by DOST with UP,
mobile computer connected
with medical devices such
as, ECG, pulse oximeter,
Heart rate, blood pressure
for mobile deployment to
rural health centers.
• Allows video and chat
conferencing with
specialists.
❖ eLearning
✓ eIMCI (electronic Integrated
Management of Childhood
Illness)
• developed in 2009 by
Ateneo Innovation Center.
• Electronic version of IMCI
accessible on mobile
devices.
✓ NTHC eLearning Videos
• Funded by USA, created
eLearning on Tuberculosis,
stroke, bird flu, and child
poisoning.
Health Information System and
Electronic Reporting
❖ eFHSIS (Electronic Field Health
Service Information System)
• An online version of the
FHSIS developed by DOH
where you can upload the
FHSIS data-output report –
produced at the provincial
health office reported in
FHSIS.
• Target/client list – used to

monitor particular groups
that are eligible for a certain
program of DOH.
• Individual health record –
serves as the building block
or foundation of the FHSIS.
Health Information System and
Electronic Medical Record
❖ Wireless access to Health
• Implemented in 2010,
Tarlac
- Connecting Health
Centers through
broadband internet
access.
TOPIC 9. ATTRIBUTES AND
CORE VALUES OF A NURSE IN
ADULT HEALTH CARE
1. Human dignity
One of the most important
values of nursing is to respect
the dignity of their patients. This
means treating patients with
kindness and thoughtfulness as
you provide care, and
remembering to consider their
emotions about the situation as
you talk with them, care for them
and educate them about their
health. Valuing human dignity
also means acknowledging the
rights of each patient to choose
healthcare services and
maintain privacy, which are two
other important nursing values
2. Integrity
In nursing, integrity is vital to
connecting with patients and
providing ethical, quality care.
Integrity refers to making
honest, moral decisions. Nurses
should practice integrity in their
workplace to meet their health
facilities standards for care and
aid the recovery of their patients.
Patients may have more
confidence in nurses who
perform their duties with
integrity, which makes patients
more comfortable and willing to
receive necessary treatment for
their illnesses or injuries.
3. Altruism
Altruism for nurses means being
NCM 116 A MEDSURG
considerate of the well-being of
your patients and colleagues.
You can show this nursing value
by advocating for fair treatment
of your patient, encouraging
fellow nurses to take breaks
while you step in and answering
questions from patients' families
as best as you can. An important
part of altruism is to not expect
something in return for your
care, which means providing
care outside of your typical
duties or without need for
acknowledgement.
4. Social justice
The value of social justice
means understanding and
upholding moral and legal
healthcare standards for every
patient. This involves distributing
all services and treatments
equally amongst patients who
need them. You may practice
social justice by actively
listening to the needs of
individual patients and providing
them with treatments and
accommodations necessary for
their recovery. This way, they
feel more comfortable and trust
in your team's abilities.
5. Diversity
Valuing diversity helps nurses
stay open-minded and treat
patients regardless of their
identity or ideals. When you
value diversity, you can ensure
your treatment of a patient
meets moral and ethical
standards, makes the patient
comfortable and helps them
recover from their condition.
Diversity in the nursing
community may also refer to a
healthcare facility's commitment
to hiring employees with various
backgrounds and identities and
treating them all with respect.
6. Ingenuity
While you typically follow
directions and rules as a nurse,
ingenuity is a value that
encourages critical thinking and
helping create treatments and
strategies that help patients. As
a field of science, healthcare is
always changing, and the
nurses who work directly with
patients often have a deep
understanding which aspects of
healthcare can change to
provide better treatment options
and techniques. To practice
ingenuity, it's a good idea to
continually study medical
advancements.
7. Compassion
Compassion is a value important
to nursing because being
compassionate helps patients
feel respected ruing their
medical care. You can show
compassion in a variety of ways,
like listening to patients'
concerns, quickly addressing
those concerns and speaking
kindly as you administer
treatments and ask questions.
For many nurses, this is one of
the key components to providing
quality care.
8. Trustworthiness
Establishing trust helps nurses
better understand the needs of
those in their care and increases
the chances that a patient
cooperates with treatments.
Patients who trust their
healthcare providers also have
less stress and may recover
better from their illnesses or
injuries. To show your
trustworthiness, be interested in
how your patient's care is
affecting them, answer their
questions honestly and tell them
important and accurate
information as soon as you can.
9. Accountability
Accountability is another value
important in nursing. Being
accountable means
acknowledging your actions and
learning from mistakes, which is
especially important for your
growth in the nursing profession
because each action you take
affects patients. A good goal for
nurses is to admit your mistakes
to supervisors as soon as you
realize them, which allows you to

correct them and continue to
give your patients the quality
care they deserve.
10. Curiosity
The nursing community values
curiosity because it encourages
nurses to keep learning and
improve the skills needed to
succeed. Personal and
professional curiosity can help
you determine your nursing
goals, how you measure
success and what areas of
nursing you have a strong
interest. In addition, a sense of
curiosity allows you to
investigate concerns about
treatment and ask questions on
the job to learn more about the
roles of your colleagues.
11. Autonomy
Medical autonomy refers to a
patient's right to accept or refuse
healthcare services like
treatments and procedures. This
is an ethical nursing value that
aims to respect and not
influence a patient's healthcare
choices, which may make
patients feel more at ease and
encourage them to seek other
healthcare services when they
need them. You may show your
respect to autonomy by
educating patients on their
options without bias and
supporting their decisions.
12. Precision
Precision is an important value
for nurses because precise,
accurate care best fulfills the
needs of patients and creates a
safe environment for medical
procedures and recovery. As a
nurse, try to strive for precision
in all aspects of your role,
including understanding a who need your help and trying to
specific patient's treatment plan,
providing families and patients
with accurate information and
sanitizing all rooms and
instruments to avoid germs and
bacteria. This can help you
maintain the standards of your
facility and improve the health of
your patients.
NCM 116 A MEDSURG
13. Empathy
Another nursing value is
empathy, which helps nurses
see a situation from their
patient's perspective. This
allows you to understand more
deeply how a patient might feel
and what they might need from
their medical team, and this can
help you administer successful
treatment plans. You can use
empathy to address a patient's
concerns from their point of
view, which is helpful when
educating them about
suggested procedures and
understanding how to put them
at ease.
14. Professionalism
For nurses, professionalism is
the standard by which they
measure their performance and
reputation. The specific aspects
of your performance and
reputation may include your
ability to care for patients
successfully, your attitude
toward colleagues and patients
and your ability to work as a
team with other nurses and
doctors. Maintaining a standard
of professionalism ensures that
you understand the importance
of your job and strive to perform
those duties well.
15. Loyalty
A nurse may value loyalty to
their job and their patients. This
may mean you dedicate yourself
to finishing a patient's treatment,
performing all the duties of your
job as best as you can and
continuing to learn about
relevant medical advancements.
You can also show you value
loyalty by advocating for patients
resolve every one of their
concerns.
16. Excellence
The nursing community highly
values a commitment to
providing excellent service. As a
nurse, you may strive to improve
your knowledge so you can
provide your patients with
excellent quality support during
their time in your facility. Other
ways to make excellence a goal
are to get involved in creating
patient care plans, ask your
colleagues questions when you
don't understand something and
prepare for many situations
through continued coursework,
practice and studying.
TOPIC 10. A. NUTRITIONAL-
METABOLIC
PATTERNS/RESPONSES TO
ALTERED NUTRITION
1. Disturbances in Ingestion
✓ Gastroesophageal Reflux
(GERD)
✓ Hiatal Hernia
✓ Achalasia
The functions of the digestive
system are:
• Ingestion. Food must be placed
into the mouth before it can be
acted on; this is an active,
voluntary process called
ingestion.
• Propulsion. If foods are to be
processed by more than one
digestive organ, they must be
propelled from one organ to the
next; swallowing is one example
of food movement that depends
largely on the propulsive
process called peristalsis
(involuntary, alternating waves
of contraction and relaxation of
the muscles in the organ wall).
• Food breakdown: mechanical
digestion. Mechanical digestion
prepares food for further
degradation by enzymes by
physically fragmenting the foods
into smaller pieces, and
examples of mechanical
digestion are: mixing of food in
the mouth by the tongue,
churning of food in the stomach,
and segmentation in the small
intestine.
• Food breakdown: chemical
digestion. The sequence of
steps in which the large food
molecules are broken down into
their building blocks by enzymes

is called chemical digestion.
• Absorption. Transport of
digested end products from the
lumen of the GI tract to the blood
or lymph is absorption, and for
absorption to happen, the
digested foods must first enter
the mucosal cells by active or
passive transport processes.
• Defecation. Defecation is the
elimination of indigestible
residues from the GI tract via the
anus in the form of feces.
Physiology of the Digestive
System
Specifically, the digestive system
takes in food (ingests it), breaks it
down physically and chemically into
nutrient molecules (digests it), and
absorbs the nutrients into the
bloodstream, then, it rids the body of
indigestible remains (defecates).
Organs of the Alimentary Canal
✓ Mouth ✓ Pharynx
✓ Esophagus ✓ Stomach
✓ Small Intestine ✓ Large
Intestine
Accessory Digestive Organs
✓ Teeth ✓ Salivary Glands
✓ Pancreas ✓ Liver
✓ Gallbladder
INGESTION
• It is the consumption of a
substance by an organism. In
animals, it normally is
accomplished by taking in a
substance through the mouth
into the gastrointestinal tract,
such as through eating or
drinking. In single celled
organisms’ ingestion takes place
by absorbing a substance
through the cell membrane.
• Besides nutritional items,
substances that may be
ingested include medication
(where ingestion is termed oral
administration), recreational
drugs, and substances
considered inedible, such as
foreign bodies or excrement.
Ingestion is a common route
NCM 116 A MEDSURG
taken by pathogenic organisms
and poisons entering the body.
• Ingestion can also refer to a
mechanism picking up
something and making it enter
an internal hollow of that
mechanism, e.g. "a grille was
fitted to prevent the pump from
ingesting driftwood".
ASSESSMENT FOR CLIENTS
WITH GI COMPLAINTS
1. History of present complaint
regarding specific symptoms.
2. Medication history including
medications
3. Complete nutritional history
4. Psychosocial factors
5. Physical examination including
inspection
6. Bowel elimination patterns
7. Evaluation and diagnostic data
including laboratory tests and
radiologic and endoscopic
examinations
HEALTH HISTORY
• Current complaints, food
intolerance
• Appetite, heartburn, nausea,
vomiting
• Abdominal discomfort, diarrhea,
constipation
• Weight changes
• Food allergies
• Pattern and amount of daily food
intake
• Teeth, mouth, ability to chew,
swallow, dentures
• Change in stool frequency,
amount, color, caliber
• Medications
• Chronic diseases
• Previous surgeries
PHYSICAL EXAMINATION
• Overall health status
• Skin color, hair, nails
• Height and weight
• Inspect mouth, teeth, tongue
• Swallow
• Inspect abdomen, observe skin,
peristalsis
• Auscultate bowel sounds
• Percuss the abdomen
• Palpate the abdomen
LABORATORY TESTS
• Serum albumin and total protein
• Serologic H. pylori testing
• Stool specimen
• Liver function tests
• Pancreatic function tests
DIAGNOSTIC TESTS
• Gastric analysis
• Urea breath test
• Ambulatory pH monitoring
• Esophageal manometry
• Paracentesis
GASTIC ANALYSIS
Gastric analysis consists of a series
of tests used to analyze the contents
of the stomach. The complete series
involves:
A- collecting residual gastric fluid
from a fasting patient
B- collecting basal secretions every
15 minutes for four hours
C- intramuscular administration of a
drug that stimulates gastric acid
output
D- collecting stomach secretions
every 15 minutes for 90 minutes
• Instruct client to abstain from food,
fluids, smoking, chewing gum, and
some medications for 8 to 12 hours
before the test
• Insert NG tube and collect
samples.
UREA BREATH TEST
• is a rapid diagnostic procedure
used to identify infections by
Helicobacter pylori, a spiral
bacterium implicated in gastritis,
gastric ulcer, and peptic ulcer
disease. It is based upon the
ability of H. pylori to convert urea
to ammonia.
• Instruct client to abstain from
food and fluids for 4 hours prior
to the test
• Instruct client to abstain from
antacids, bismuth sulfate,
antibiotics, and Prilosec for 2
weeks prior to the test
MORE DIAGNOSTIC TESTS
• Ambulatory pH Monitor: is a
way for the doctor to see how
much acid is backing up into the

esophagus over a 24-hour
period. The test involves placing
a small catheter in the
esophagus. The catheter is
connected to a small recording
device called a Digitrapper.
✓ Instruct client how to care for the
electrode and data recorder
• Esophageal Manometry: is a
test to assess motor function of
the Upper Esophageal Sphincter
(UES), Esophageal body and
Lower Esophageal Sphincter
(LES).
➢ Instruct client to abstain from
food and fluids up to 8 hours
prior to the test
➢ Assist with insertion of the tube
• Paracentesis: is a medical
procedure involving needle
drainage of fluid from a body
cavity, most commonly the
peritoneal cavity in the
abdomen.
• Ultrasonography
• Radiologic Studies
GASTROESOPHAGEAL REFLUX
DISEASE
GERD (gastroesophageal reflux
disease, or chronic acid reflux) is a
condition in which acid-containing
contents in your stomach
persistently leak back up into your
esophagus, the tube from your
throat to your stomach.
SIGNS AND SYMPTOMS
✓ Burning sensation in your chest
(heartburn), usually after eating,
which might be worse at night
✓ Chest pain
✓ Difficulty swallowing
✓ Regurgitation of food or sour
liquid
✓ Sensation of a lump in your
throat
RISK FACTORS
✓ Obesity
✓ Bulging of the top of the stomach
up into the diaphragm (hiatal
hernia)
✓ Pregnancy
✓ Connective tissue disorders,
such as scleroderma
✓ Delayed stomach emptying
NCM 116 A MEDSURG
CAUSES
✓ GERD is caused by frequent
acid reflux.
✓ When you swallow, a circular
band of muscle around the
bottom of your esophagus
(lower esophageal sphincter)
relaxes to allow food and liquid
to flow into your stomach. Then
the sphincter closes again
✓ If the sphincter relaxes
abnormally or weakens,
stomach acid can flow back up
into your esophagus. This
constant backwash of acid
irritates the lining of your
esophagus, often causing it to
become inflamed.
COMPLICATIONS
✓ Narrowing of the esophagus
(esophageal stricture). Damage
to the lower esophagus from
stomach acid causes scar tissue
to form.
✓ An open sore in the esophagus
(esophageal ulcer). Stomach
acid can wear away tissue in the
esophagus, causing an open
sore to form.
✓ Precancerous changes to the
esophagus (barrett's
esophagus). Damage from acid
can cause changes in the tissue
lining the lower esophagus.
PATHOPHYSIOLOGY
a. Gastroesophageal reflux results
from transient relaxation or
incompetence of lower
esophageal sphincter, sphincter,
or increased pressure within
stomach
b. Factors contributing
gastroesophageal reflux
1. Increased gastric volume
(post meals)
2. Position pushing gastric
contents close
gastroesophageal juncture
(such as bending or lying
down)
3. Increased gastric pressure
(obesity or tight clothing)
4. Hiatal hernia
DIAGNOSTIC TESTS
• Upper endoscopy
• Ambulatory acid (pH) probe
test
• Esophageal manometry
• X-ray of your upper digestive
system
SURGERY AND OTHER
PROCEDURES
GERD can usually be controlled with
medication. But if medications don't
help or you wish to avoid long-term
medication use, your doctor might
recommend:
FUNDOPLICATION
a surgical procedure used to treat
stomach acid reflux
LINX DEVICE
The LINX device is surgically
implanted around the lower end of
the esophagus.
TRANSORAL INCISIONLESS
FUNDOPLICATION (TIF)
an advanced endoscopy procedure
that provides relief from acid reflux
(heartburn) symptoms associated
with chronic gastroesophageal
reflux disease (GERD).
NURSING INTERVENTIONS /
MANAGEMENT
Nursing Assessment
• History
If classic symptoms of heartburn
and acid regurgitation dominate a
patient’s history, then they can help
establish the diagnosis of GERD
with sufficiently high specificity,
although sensitivity remains low
to
compared to 24-hour pH monitoring.
• Physical Examination:
• Assess the patient’s
medical history
• Assess the appearance of
to
the patient
• Assess for patient’s signs
and symptoms
• Assess for epigastric
tenderness
Nursing Diagnosis

• Imbalanced nutrition: less than
body requirements related to
inability to intake enough food
because of reflux.
• Acute pain related to irritated
esophageal mucosa.
• Imbalanced nutrition: more
than body requirements related
to eating to try to assuage pain.
• Risk for aspiration related to
esophageal compromise
affecting the lower esophageal
sphincter.
• Deficient knowledge related to
lack of information regarding
condition/disease process.
• Anxiety related to change in the
health status of the infant
(possible surgical intervention).
Nursing Interventions
• Improve nutrition. Accurately
measure the patient’s weight
and height; encourage small
frequent meals of high calories
and high protein foods; instruct
to remain in upright position at
least 2 hours after meals;
avoiding eating 3 hours before
bedtime; instruct patient to eat
slowly and masticate foods well;
establish a dietary plan for
weekly goals of weight loss of
one pound; encourage patient to
make gradual changes in dietary
habits; provide activities for the
patient that do not center around
or are associated with meals or
snacks.
• Prevent aspiration. Avoid
placing the patient in supine
position, have the patient sit
upright after meals; instruct
patient to avoid highly seasoned
food, acidic juices, alcoholic
drinks, bedtime snacks, and
foods high in fat; elevate HOB
while in bed.
• Enforce health education.
Provide patient and folks with
information regarding disease
process, health practices that
can be changed, and
medications to be utilized;
instruct ·patient and folks in
medications, effects, side
NCM 116 A MEDSURG
effects, and to report to
physician if symptoms persist
despite medical treatment.
• Relieve anxiety. Allow
verbalization of concerns and to
ask inquiries about illness,
treatment, surgery, recovery,
encourage parents to stay with
the child and to assist in care;
communicate frequently with
parents and provide easy to
understand and truthful answers
to questions; utilize pictures,
drawings, and models for
explanations.
Nursing Management
Teach the client to avoid factors that
increase lower esophageal irritation.
- Eat a low-fat, high-fiber diet
- Avoid irritants, such as spicy or
acidic foods, alcohol, caffeine,
and tobacco,
- Avoid food or drink 2 hours
before bedtime or lying down
after eating • 14 PATIENT RIGHTS
- Elevate the head of the bed on
6” to 8” bocks
- Lose weight if necessary
- function, serum magnesium,
Evaluation
- Ingests daily nutritional
requirements in accordance to
his activity level and metabolic
needs.
- Pain is relieved.
- Achieves and maintain an
adequate body weight.
- Maintains patent airway.
- Increased knowledge of actions
that reduce reflux.
- Decreased in their anxiety level
to none or mild.
Documentation
- Individual findings, including
factors affecting, interactions,
nature of social exchanges,
specifics of individual behavior.
- Intake and output.
- 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
Medications
ANTACIDS
• These drugs can help neutralize
acid in the esophagus and
stomach and stop heartburn.
Many people find that
nonprescription antacids provide
temporary or partial relief.
• Side effects:
- Milk-alkali syndrome (headache)
- decreased appetite
- nausea
- vomiting
- unusual fatigue)
- Rare: Urinary urgency and
painful urination
ANTACIDS (Nursing
Responsibilities)
• BASELINE ASSESSMENT
• Assess B/P, ECG and
cardiac rhythm, renal
phosphate, calcium, ionized
calcium.
• INTERVENTION/EVALUATIO
N
✓ Monitor serum BMP, calcium,
ionized calcium, magnesium,
phosphate; B/P, cardiac rhythm,
renal function. Monitor for signs
of hypercalcemia.
• PATIENT/FAMILY TEACHING
✓ Do not take within 1–2 hrs of
other oral medications, fiber-
containing foods.
✓ Avoid excessive use of alcohol,
tobacco, caffeine.
✓ Do not use calcium carbonate
repeatedly with foods high in
vitamin D (such as milk) or
sodium bicarbonate, as it may
cause milkalkali syndrome:
hypercalcemia, distaste for food,
headache, confusion, nausea,
vomiting, abdominal pain,
metabolic alkalosis,
 NCM 116 A MEDSURG
hypercalciuria, polyuria, soft • Occasional (3%–2%): rash, dry mouth,
tissue calcification (calcinosis), Diarrhea, abdominal pain, galactorrhea,
hyperphosphatemia and renal nausea. gynecomastia.
insufficiency. • Rare (2%): Dizziness, • Rare (less than 3%):
asthenia, vomiting, Hypotension, hypertension,
H2 BLOCKERS constipation, upper tachycardia.
✓ These medicines include H2 respiratory tract infection,
blockers, which help block acid back pain, rash, cough. PROKINETICS (Nursing
secretion in the stomach. H2 Responsibilities)
blockers include: cimetidine PROTON PUMP INHIBITORS
(Tagamet), famotidine (Pepcid), (Nursing Responsibilities) • 14 PATIENT RIGHTS
and nizatidine. • 14 PATIENT RIGHTS • BASELINE ASSESSMENT
✓ Side effects: • BASELINE ASSESSMENT • Antiemetic: Assess for
• Occasional (5%): - Lab tests: Monitor urinalysis dehydration (poor skin
Headache. for hematuria and turgor, dry mucous
• Rare (2% or less): proteinuria. Periodic liver membranes, longitudinal
Confusion, constipation, function tests with prolonged furrows in tongue). Assess
diarrhea, dizziness. use. for nausea, vomiting,
• INTERVENTION/EVALUATION abdominal distention, bowel
H2 BLOCKERS (Nursing - Evaluate for therapeutic sounds.
Responsibilities) response (relief of GI
symptoms). Question if GI ✓ INTERVENTION/EVALUATION
• 14 PATIENT RIGHTS discomfort, nausea, diarrhea ✓ Monitor for anxiety,
• BASELINE ASSESSMENT occurs restlessness, extrapyramidal
• Assess • PATIENT/FAMILY TEACHING symptoms (EPS) during IV
epigastric/abdominal pain. - Report headache, onset of administration. Monitor daily
Verify platelet count in black, tarry stools, diarrhea, pattern of bowel activity, stool
critically ill patients abdominal pain. consistency. Assess skin for
- Avoid alcohol. rash. Evaluate for therapeutic
• INTERVENTION/EVALUATION - Swallow capsules whole; do response from gastroparesis
• Monitor daily pattern of not chew, crush, dissolve, or (nausea, vomiting, bloating).
bowel activity, stool divide. Monitor renal function, B/P,
consistency. Monitor for - Take before eating. heart rate.
headache. Assess for ✓ PATIENT/FAMILY TEACHING
confusion in elderly. PROKINETICS • Avoid tasks that require
Consider interrupting • Prokinetic agents, or prokinetics, alertness, motor skills until
treatment in patients who are medications that help control response to drug is
develop thrombocytopenia acid reflux. Prokinetics help established.
• PATIENT/FAMILY TEACHING strengthen the lower • Report involuntary eye,
• May take without regard to esophageal sphincter (LES) and facial, limb movement
food, antacids. cause the contents of the (extrapyramidal reaction).
• Report headache. stomach to empty faster. • Avoid alcohol.
• Avoid excessive amounts of • Side effects:
coffee, aspirin. • Doses of 2 mg/kg or greater, DIET AND LIFESTYLE CHANGES
• Report persistent symptoms or increased length of ✓ Avoid foods and beverages
of heartburn, acid therapy, may result in a triggers: Stay away from foods
indigestion, sour stomach greater incidence of side that can relax the LES, including
effects. chocolate, peppermint, fatty
PROTON PUMP INHIBITORS • Frequent (10%): foods, caffeine, and alcoholic
• These drugs block a protein Drowsiness, restlessness, beverages.
needed to make stomach acid. fatigue, lethargy. ✓ Eat smaller servings: Eating
PPIs include dexlansoprazole • Occasional (3%): Dizziness, smaller portions at mealtime
(Dexilant), esomeprazole anxiety, headache, may also help control
(Nexium), lansoprazole insomnia, breast symptoms. Also, eating meals at
(Prevacid), etc. tenderness, altered least 2 to 3 hours before bedtime
• Side effects: menstruation, constipation, lets the acid in your stomach go
• Frequent (7%): Headache.

down and your stomach partially
empty.
✓ Eat slowly: Take your time at
every meal.
✓ Chew your food thoroughly: It
may help you remember to do
this if you set your fork down
after you take a bite. Pick it up
again only when you’ve
completely chewed and
swallowed that bite
✓ Stop smoking: Cigarette
smoking weakens the LES.
Stopping smoking is important to
reduce GERD symptoms.
✓ Elevate your head: Raising the
head of your bed on 6-inch
blocks or sleeping on a specially
designed wedge lets gravity
lessen the reflux of stomach
contents into your esophagus.
Don’t use pillows to prop
yourself up. That only puts more
pressure on the stomach.
✓ Stay at a healthy weight: Being
overweight often worsens
symptoms. Many overweight
people find relief when they lose
weight.
✓ Wear loose clothes: Clothes that
squeeze your waist put pressure
on your belly and the lower part
of your esophagus. DIET AND
LIFESTYLE CHANGES
✓ Acupuncture: In one study,
treatment with acupuncture
stopped reflux in the test group
better than PPIs, with results
that lasted longer. We need
more large studies to confirm
this, but early results are
promising.
HIATAL HERNIA
Overview
• Hiatus: Small opening of the
diaphragm where the
esophagus passes through.
• Herniation: Abnormal
protrusion of tissue through
an opening.
• A hiatal hernia occurs when
the upper part of the
stomach pushes through an
opening in the diaphragm
and into the chest cavity.
NCM 116 A MEDSURG
• Type I is the most common
among adults called a SLIDING
HIATUS HERNIA, which
consists of the
gastroesophageal junction
migrating above the diaphragm
while the stomach remains in
position.
• Type II is called a PURE PARA-
ESOPHAGEAL HERNIA, where
the fundus comes through the
diaphragm into the chest cavity
while the gastroesophageal
junction stays in the abdominal
cavity.
•
Type III combines type Iand II
with both the fundus and
gastroesophageal junction come
into the chest cavity.
• Type IV is often called a GIANT
HERNIA because other
structures in the abdomen
beside the stomach can herniate
into the chest cavity.
ETIOLOGY
• Increased pressure from the
abdominal cavity can cause the
herniation of contents from the
abdomen to be pushed into the
chest cavity.
Some of the causes of herniation
are:
• Being Overweight and
Pregnancy
• Prevalence of hiatus hernia
increases with age and body
mass index (BMI)
• Persistent vomiting, Chronic
coughing.
• Heavy lifting, Physical strain, or
Straining for a bowel movement
• A rise in abdominal pressure and
a decrease in thoracic pressure,
such as obesity and chronic lung
disease.
• Injury or trauma to the area such
as force from a seatbelt during
an accident
• Changes in the diaphragm as
you age
• Congenital (Being born with a
larger hiatal opening than usual)
SIGNS AND SYMPTOMS
- Often there are none
- Many people with a hiatus hernia
have no symptoms.
- Acid Reflux Symptom
- The hernia itself does not cause
symptoms. However, if you have
a hiatus hernia, the factors that
normally prevent stomach acid
from refluxing into the
esophagus may not work so
well.
The refluxed acid can cause
inflammation of the lower part of the
esophagus. This can cause one or
more of the following symptoms:
- Heartburn
- Pain in the upper abdomen and
chest.
- Feeling sick.
- An acid taste in the mouth.
- Bloating.
- Belching.
- Difficulty swallowing.
- A burning pain when you
swallow hot drinks.
Some uncommon symptoms may
occur. If any of these symptoms
occur, it can make the diagnosis
difficult, as these symptoms can
mimic other conditions. For
example:
- A persistent cough, particularly
at night, sometimes occurs.
- Other mouth and throat
symptoms sometimes occur
such as gum problems, bad
breath, sore throat, hoarseness,
and a feeling of a lump in the
throat.
- Severe chest pain
- Rarely, in people with a para-
esophageal hernia, the
symptoms can be those of a part
of the bowel being blocked
(obstructed). In this case there
would be severe tummy pain or
 NCM 116 A MEDSURG
chest pain, with retching or being
sick (vomiting).
RISK FACTORS
A hiatal hernia can develop in
people of all ages and both sexes,
although it frequently occurs in
people who are:
- age 50 and older
- overweight and obese
- smokers ENDOSCOPY
DIAGNOSTIC TESTS / LAB
EXAMINATIONS
Diagnosis is done by medical history
and physical examination
ESOPHAGEAL MANOMETRY
NURSING RESPONSIBILITIES
a. Patient assessment and
preparation forthe procedure
b. Explain whatto expectfrom the
procedure
c. Prepare and position the patient
X-RAY d. Prepare the endoscopy room
with the rightinstruments and
devices
e. Preventing infection and quality
assurance
f. Keep thepatient comfortable
g. Vital signs monitoring
NURSING INTERVENTIONS AND
MANAGEMENT
- Secure Consent
- Observe the 14 Rights
- Prepare the patient for
BARRIUM SWALLOW diagnostic tests, as needed.
- Administer prescribed antacids
and other medications
- To reduce intra-abdominal
pressure and prevent aspiration,
have the patient sleep in a
reverse Trendelenburg position
with the head of the bed
elevated.
- Assess the patient’s response to
treatment.
- Observe for complications,
CT SCAN
especially significant bleeding,
pulmonary aspiration, or
incarceration or streangulation
of the herniated stomach
portion.
NURSING DIAGNOSIS
• Acute pain related to swelling
and pressure
• Risk of aspiration related to
reflux of gastric contents
• Risk for ineffective tissue
perfusion related to hernia
NURSING INTERVENTIONS AND
MANAGEMENT
- After endoscopy, watch for signs
of perforation such as falling
blood pressure, rapid pulse,
shock, and sudden pain caused
by endoscope.
- To enhance compliance, teach
the patient about the disorder.
Explain significant symptoms,
diagnostic tests, and prescribed
treatments.
- Review prescribed medications,
explaining their desired actions
and possible adverse effects.
- Teach the patient dietary
changes to reduce reflux.
- Encourage the patient to delay
lying down for 2 hours after
eating
NURSING INTERVENTIONS:
HIATAL HERNIA
1. Prepare the patient for
diagnostic tests, as needed.
2. Administer prescribed antacids
and other medications
3. To reduce intra-abdominal
pressure and prevent aspiration,
have the patient sleep in a
reverse Trendelenburg position
with the head of the bed
elevated.
4. Assess the patient’s response to
treatment.
5. Observe for complications,
especially significant bleeding,
pulmonary aspiration, or
incarceration or strangulation of
the herniated stomach portion.
6. After endoscopy, watch for signs
of perforation such as falling
blood pressure, rapid pulse,
shock, and sudden pain caused
by endoscope.

7. To enhance compliance, teach
the patient about the disorder.
Explain significant symptoms,
diagnostic tests, and prescribed
treatments.
8. Review prescribed medications,
explaining their desired actions
and possible adverse effects.
9. Teach the patient dietary
changes to reduce reflux.
10. Encourage the patient to delay
lying down for 2 hours after
eating.
Lifestyle Modification
NURSING RESPONSIBILITIES:
- Health advice concerning:
smoking cessation; weightloss;
small frequent meals at regular
intervals; posture; bending and
lifting in the workplace; sleeping
with an extra pillow.
Surgery or Herniorrhaphy
- Surgery repair of Hiatal Hernia
Nursing responsibilities:
- Secure Consent
- Observe the 14 Rights
- Provide preoperative education,
including visit with OR personnel
before surgery when possible
- Review patient’s history, noting
age, weight, height, nutritional
status, physical limitation and
preexisting conditions
- Adhere to facility infection
control, sterilization, and aseptic
policies and procedures.
- Document allergies, including
risk for adverse reaction to latex,
tape, and prep solutions.
- Review laboratory studies for
possibility of systemic infections
MEDICATIONS AND TREATMENT
H-2-receptor blockers
- reduce acid production
1. cimetidine (TagametHB)
2. famotidine (PepcidAC)
3. nizatidine (AxidAR)
Side effects: constipation, diarrhea,
difficulty sleeping, dry mouth. dry
skin, headaches, ringing in the ears,
and a runny nose.
NCM 116 A MEDSURG
Antacids
- Provide relief
1. Gaviscon
Side effects: constipation, taste
impairment, nausea, vomiting,
stomach cramps, diarrhea.
Proton pump inhibitors (PPIs)
- block acid production and heal
the esophagus.
1. Pantoprazole
2. Lansoprazole
3. Omeprazole
Side effects: headache, abdominal
pain, bloating, diarrhea and nausea
Nursing Responsibilities
a. Assess patient routinely for
epigastric or abdominal pain and
frank or occult blood in the stool,
emesis, or gastric aspirate.
b. Monitor Diarrhea, abdominal
cramping, fever, and bloody
stools
c. Administer doses before meals,
preferably in the morning.
d. Instruct patient to take
medication as directed for the
full course of therapy, even if
feeling better may cause
occasional drowsiness or
dizziness.
e. Advise patient to avoid alcohol,
products containing aspirin or
NSAIDs, and foods that may
cause an increase in GI irritation
f. Advise patient to report any
adverse effects
ACHALASIA
• Achalasia is a rare but serious
disease/condition that affects
the esophagus, the tube that
carries food from the throat to
the stomach, wherein it is
difficult for food and liquid to
pass from the esophagus into
the stomach.
• There is degeneration of the
esophageal muscles and, more
importantly, the nerves that
control the muscles.
• Approximately 1 in 100,000
people will get it.
PATHOPHYSIOLOGY
• Achalasia has been assumed to
result from inflammation and
degeneration of neurons in
the esophageal wall.
• The cause of the inflammatory
degeneration of neurons in
primary achalasia is not known.
• The observations that achalasia
is associated with variants in
the HLA-DQ region and that
affected patients often have
circulating antibodies to enteric
neurons suggest that achalasia
is an autoimmune disorder.
• Some investigators have
proposed that the inflammatory
attack on esophageal neurons in
achalasia is triggered by an
antibody response to viral
infections (eg, herpes zoster,
measles viruses), but data have
been inconclusive.
• A study evaluating T cells in
patients with achalasia found
reactivity to HSV-1, suggesting
that achalasia may be triggered
by HSV-1 infection.
• A genetic predisposition to the
inflammatory degeneration of
ganglion cells in achalasia is
suggested by its association
with variants in the HLA-DQ
region and by its occurrence in
genetic syndromes such as
Allgrove syndrome.
• It has also been suggested that
there may be an allergy-driven
form of achalasia.
SIGNS AND SYMPTOMS
Achalasia symptoms generally
appear gradually and worsen over
time, with symptoms lasting for
 NCM 116 A MEDSURG
months or years. Signs and 1. Esophageal Manometry 3. Upper Endoscopy
symptoms may include:
- Inability to swallow (dysphagia),
which may feel like food or drink
is stuck in your throat
- Regurgitating food or saliva
- Heartburn
- Belching
- Chest pain that comes and goes
- Intense pain or discomfort after
eating
- Coughing at night
- Pneumonia (from aspiration of
food into the lungs)
- Weight loss/malnutrition from
difficulty eating. This is a late
symptom.
- Vomiting Your doctor inserts a thin,
- Dry mouth flexible tube equipped with a
- Dry eyes This test measures the rhythmic light and camera (endoscope)
Eating within 4 hours of going to bed muscle contractions in your down your throat, to examine the
may make symptoms worse. esophagus coordination and force inside of your esophagus and
when exerted you swallow, the by stomach.
CAUSES the esophagus muscles, and how
The exact cause of achalasia is well your lower esophageal 4. Barium Swallow
poorly understood. Researchers sphincter relaxes or opens during a
believe it’s caused by a combination swallow.
of factors, including: 2. X-Rays of Your Upper
- Genetics, or family history Digestive System
- An autoimmune condition (Esophagram)
triggered by a virus
- Degeneration of nerves
- Chagas disease

RISK FACTORS For this test, you’ll swallow a

• People of all races can get barium preparation (liquid or
achalasia. other form) and its
• It’s found equally in men movement through your
and women. esophagus is evaluated
A few potential risk factors include: using X-rays.
• having a spinal cord injury
• getting endoscopic NURSING INTERVENTIONS /
sclerotherapy to treat MANAGEMENT
bleeding or enlarged veins
X-rays are taken after you drink a
• having a viral infection Patient Care
chalky liquid that coats and fills the
• having an autoimmune Some patients with achalasia
inside lining of your digestive tract.
disease The coating allows your doctor to benefit from eating slowly, taking
• age — it’s more common in see a silhouette of your esophagus, small bites, and avoiding swallowing
middle age and older stomach and upper intestine. large volumes of food or liquid.
adulthood Patient education centers on
• sometimes seen in people adaptations the patient may make to
with Down syndrome. avoid esophageal pain,
regurgitation, and weight loss. Some
DIAGNOSTIC TESTS / patients are referred for surgical
LABORATORY EXAMS myotomy or esophageal dilation, but
these procedures vary in their
effectiveness.

• The nurse works with the patient
and family to explore diet and
lifestyle modifications that will
best control dysphagia, which is
prominent in achalasia.
• Education begins with careful
assessment of the scope of
dysphagia, which includes the
following: Swallowing ability with
liquids v/s solids.
• Response to foods of different
textures and temperature.
• Variability of the dysphagia.
• Response to stress, fatigue and
other activities.
• Approaches used by the patient
to manage the dysphagia and
the degree of success.
• Encourage the patient and
provide emotional support.
• Assess the onset and
progression of the symptoms
• Give infants smaller, more
frequent feedings using a nipple
that controls flow well.
• Thickening of the formula with
products such as rice or oatmeal
cereal can significantly help
keep formula and gastric
contents down
• Keep infant upright for 30 to 45
minutes after feeding
• Maintaining a patent airway.
• Assist in diagnostic procedures
as well as surgical procedures
prescribed.
Assess for:
• Substernal pain, bloated or full
feeling, heartburn
• Halitosis,
regurgitation,
dysphagia, retrosternal pain
after meals
Perform/Provide:
• Oral care before and after meals
as needed
• Small frequent meals instead of
3 meals/daily
• Sitting position for meals and
avoid lying position for 2-3 hours
after meals.
• Bland diet
• Sleep with head elevated
• Eat slowly, take fluids with food
NCM 116 A MEDSURG
• Fluids following eating
Teach Patient/Family:
• Avoid coughing, straining,
defecation, bending at waist,
wearing tight clothing at waist
• Avoid sucking on candy,
chewing gum, smoking, using
straw
• Avoid foods such as hot/cold,
caffeine, alcohol, spices, fruit
juices, carbonated drinks
POSSIBLE COMPLICATIONS
Complications may include:
• Backflow (regurgitation) of
acid or food from the
stomach into the esophagus
(reflux)
• Breathing food contents into
the lungs (aspiration), which
can cause pneumonia
• Tearing (perforation) of the
esophagus
MEDICATIONS AND TREATMENT
• Generally considered only if
pneumatic dilation, surgery,
and Botox hasn't been
effective.
• This type of therapy is rarely
indicated.
Medication options include:
a. NITRATES such as
nitroglycerin (Nitrostat),
which help promote
relaxation of the smooth
muscle making up the lower
part of your esophagus
Common side effects:
- headache,
- weakness,
- dizziness,
- lightheadedness,
- nausea, and
- flushing as your body adjusts to
this medication.
ASSESSMENT AND
MONITORING
(Prior to administration)
• Frequency and severity of
angina pain
• Baseline vital signs
• Health history
• Laboratory report: CBC, lipid
profile renal and hepatic
function
(Continued monitoring)
• Side effects
• Worsening symptoms
• Therapeutic response
NURSING RESPONSIBILITIES
Client Education
(Correct self-administration
procedures)
• Angina with activity: take prior to
precipitating activities or
situations
• Acute angina: call emergency
services if pain unresolved
within five minutes after first
dose; while awaiting emergency
care to arrive, may take a
second and third dose five
minutes apart if needed
(Managing side effects)
• Headache: acetaminophen
• ·Orthostatic hypotension:
make position changes
slowly
(Proper storage)
• Store in original container at
room temperature ·Protect
from light and moisture
(Prevention of nitrate tolerance
with patches or extended-release
forms)
• At least 12 hours of nitrate free
time / 24 hours
(Avoid substances that cause
excessive hypotension)
• E.g., alcohol, erectile
dysfunction medications
b. CALCIUM CHANNEL
BLOCKERS such as nifedipine
(Procardia), which can help
lower LES pressure by keeping
calcium from entering cells and
disrupting muscle contractions
Common side effects:
• dizziness
• weakness
• swelling ankles/feet
• joint pain

• leg cramps
• headache
• drowsiness
• tired feeling
• nausea
• diarrhea
• constipation
• stomach pain
• sleep problems (insomnia)
• rash or itching
• urinating more than usual
• flushing
(warmth/redness/tingly
feeling under your skin).
NURSING RESPONSIBILITIES
Assessment & Monitoring
• Assess for anginal pain,
including location, intensity,
duration, and alleviating and
aggravating factors.
• Assess cardiac status with BP,
pulse, respiration and ECG.
• Monitor potassium and liver
function tests throughout
treatment with nifedipine.
• Monitor BP carefully during
titration period. Patient may
become severely hypotensive,
especially if also taking other
drugs known to lower BP.
Withhold drug and notify
physician if systolic BP
• Monitor blood sugar in diabetic
patients. Nifedipine has
diabetogenic properties.
• Monitor for gingival hyperplasia
and report promptly. This is a
rare but serious adverse effect
(similar to phenytoininduced
hyperplasia)
Client Education
• Keep a record of nitroglycerin
use and promptly report any
changes in previous pattern.
Occasionally, people develop
increased frequency, duration,
and severity of angina when they
start treatment with this drug or
when dosage is increased.
• Be aware that withdrawal
symptoms may occur with
abrupt discontinuation of the
drug (chest pain, increase in
NCM 116 A MEDSURG
anginal episodes, MI,
dysrhythmias).
• Inspect gums visually every day.
Changes in gingivae may be
gradual, and bleeding may be
exhibited only with probing.
• ========Seek prompt
treatment for symptoms of
gingival hyperplasia (easy
bleeding of gingivae and gradual
enlarging of gingival mass, 2. Botox (Botolinum Toxin Type
especially on buccal side of A) Injections
lower anterior teeth). Drug will
be discontinued if gingival • This muscle relaxant can be
hyperplasia occurs. injected directly into the
• Research shows that smoking esophageal sphincter with an
decreases the efficacy of endoscopic needle.
nifedipine and has direct and • Botox is generally
adverse effects on the heart in recommended only for people
the patient on nifedipine who aren't good candidates for
treatment. pneumatic dilation or surgery
• Do not breast feed while taking due to age or overall health.
this drug without consulting • Botox blocks the nerves that
physician. typically signal your muscles to
• Instruct the patient to avoid contract, so it can help relax the
concurrent use of alcohol or LES so it opens and allows food
OTC medications and natural or to pass through.
herbal products especially cold • A strong improvement from
preparations, without consulting injection of Botox may help
the doctor. confirm a diagnosis of achalasia.
• Advise patient to take
medication exactly as directed.
Missed doses should be taken
as soon as remembered unless
almost time for next dose.
• Caution patient to change
positions slowly to minimize
orthostatic hypotension.
MEDICATIONS AND TREATMENT
• Achalasia treatment focuses on
relaxing or stretching open the
lower esophageal sphincter.
• Specific treatment depends on
your age, health condition and
the severity of the achalasia
1. Pneumatic Dilation / balloon
3. Heller Myotomy
Dilation
• The surgeon cuts the muscle at
A balloon is inserted by
the lower end of the esophageal
endoscopy into the center of the
sphincter to allow food to pass
esophageal sphincter and
more easily into the stomach.
inflated to enlarge the opening.
• Some people who have a Heller
Nearly one-third of people
myotomy may later develop
treated with balloon dilation
gastroesophageal reflux disease
need repeat treatment within five
(GERD).
years.
• Fundoplication might be
 NCM 116 A MEDSURG
performed at the same time as a
Heller myotomy to avoid GERD.
Fundoplication is usually done
with a minimally invasive
(laparoscopic) procedure.

4. Peroral Endoscopic Myotomy

(POEM)

• It is a minimally invasive
alternative to laparascopic
Heller myotomy.
• The surgeon uses an
endoscope inserted through
your mouth and down your
throat to create an incision in the
inside lining of your esophagus.
• Then the surgeon cuts the
muscle at the lower end of the
esophageal sphincter.
• POEM may also be combined
with or followed by later
fundoplication to help prevent
GERD.

5. Esophagectomy
• Removal of your esophagus is a
last resort treatment