Medical Surgical Nursing

Nurse Licensure Examination Review
Handouts
MEDICAL-SURGICAL NURSING
REVIEW
Course Outline
I. Client in Pain
II.Perioperative Nursing Care
III.Alterations in Human Functioning
a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions
b. Disturbances in Metabolic and Endocrine Functions
c. Disturbances in Elimination: Gastrointestinal Problems
d. Disturbances in Fluids and Electrolytes: Renal & Genitourinary Functions
e. Disturbances in Cellular Functioning: Cancer and Hematologic Problems
f. Disturbances in Auditory & Visual Functions
g. Disturbances in Musculoskeletal Functions
IV. Client in Biologic Crisis: Life threatening Conditions of the Human Body
- Shock
V. Emergency & Disaster
- First-aid and Cardiopulmonary Support
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I. CLIENT IN PAIN
Pain – the fifth vital sign

- an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Basic Categories of Pain:

1. Acute Pain – sudden pain which is usually relieved in seconds or after a few weeks.
2. Chronic Pain (Non-Malignant) – constant, intermittent pain which usually persists even after healing of the injured
tissue
3. Cancer-Related Pain- May be acute or chronic; may or may not be relieved by medications
Pain Transmission:
1. Nociceptors are called pain receptors. These are the free nerve endings in the skin that respond to intense,
potentially damaging stimuli.
2. Peripheral Nervous System
3. Central Nervous System
4. Descending Control System
Factors Influencing Pain Response

1. Past Experience – e.g. trauma
2. Anxiety and Depression
3. Culture - beliefs
4. Age – infants are more sensitive
5. Gender
6. Placebo Effect
Characteristics of Pain
1. Intensity –mild, moderate, excruciating
2. Timing – morning or evening, duration may be longer or shorter
3. Location
4. Quality – burning, aching, stabbing
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5. Personal Meaning to pain – tolerance to pain may be different from one person to the other due to some personal
reasons such as economic reasons, work condition, etc.
6. Aggravating and Alleviating factors – patient’s environment
7. Pain Behaviors - facial expressions with pain
Pain Assessment
1. Evaluate: Cause, Location, Character and Intensity
2. Numeric Pain Scale – 5-severe pain - 0 – no pain
3. Descriptive Pain Scales – mild, moderate, severe
4. Visual Analogue Scales
5. Faces Pain Scale
Nurse’s Role in Pain Management

1. Identify goals for Pain management
a. Decrease intensity, duration or frequency
b. Factors in identifying goals:
i. Severity of pain
ii. Harmful effects of pain to the client
iii. Duration of the pain
2. Establish Nurse-Patient Relationship and Teaching

a. Acknowledge the verbalization of pain by the client
b. Relieve patient’s anxiety
c. Teach measures how to relieve pain
3. Provide Physical care
a. Teach and assist in self-care
b. Environmental conditions
c. Application of ice/heat on painful area
4. Manage anxiety related to Pain

a. Teach about the nature of pain that may be felt by the client and reassure him/her
b. Teach alternative measures to relieve pain
c. Stay with the client/ frequent communication with the client
5. Pain Medications may be administered as:

a. Balanced Anesthesia – given to avoid experiencing pain
b. PRN – “Pro Re Nata” – as needed
c. Preventive – taken before pain is felt
d. Individualized Dosage
e. Patient-Controlled Analgesia (PCA) – patient takes medication if pain felt is becoming intolerable
6. Non-pharmacologic Interventions
a. Cutaneous Simulation and Massage
b. Ice and heat therapies
c. Transcutaneous Electrical Nerve Stimulation
d. Distraction
e. Relaxation Techniques
f. Guided Imagery
g. Hypnosis
II. PERIOPERATIVE CARE
o Phases of Perioperative Nursing
a. Pre-operative Nursing
b. Inraoperative Nursing
c. Post-operative Nursing
A. Pre-operative Care
Pre-admission and Admission Test
1. Psychological support
2. Client Education:
a. Importance and practice of breathing exercises
b. Location & support of wound
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c. Importance of early ambulation
d. Inform and practice leg exercises, positioning, turning
e. Anesthesia and analgesics
f. Educate regarding drains and dressings to be received post-op
g. Recovery room policies and procedures
3. Informed consent
a. At least 18 years of age
b. In sound mind- without psychologic disorder
c. Not under the influence of drugs or alcohol
d. Immediate relative over 18 years old
4. Physical Assessment and preparation

a. Physical Preparation – NPO, remove dentures, jewelries, clothesetc.
b. Nutritional & Fluid Status – should be well hydrated
c. Drug or alcohol Use – may experience delirium or intoxication to anesthetic drugs
because ormal doses do not usually take effect to these patients and require heavier
dose to achieve anesthetic effect.
d. Respiratory Status - teach breathing exercises
e. Cardiovascular Status – should have controlled and stable cardiovascular functioning
before operation to prevent intraoperative problems
f. Hepatic & Renal Functions – normal functioning is important in absorbing anesthetic
drugs
g. Endocrine Functions- important in monitoring to prevent hypo/hyperglycemia,
thyrotoxicosis, acidosis
h. Immune Functions – allergies esp. to anesthetic drugs
i. Psychosocial Factors – emotional and psychological preparation to ensure
cooperation fom the patient with the procedures
j. Spiritual & Cultural Beliefs - blood transfusions, transplants, ligation, etc are against
other culture & religion.
5. Pre-operative drugs – given 20-60 mins.pre-operative

o Makes patient drowsy, keep siderails up
6. Proper positioning
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Semi-Fowlers HOB elevated at 30 Head injury, pot-op cranial surgery,

degrees post-op cataract removal, increased
ICP, dyspneic patients
Fowlers HOB elevated at 45 Head injury, pot-op cranial surgery;

degrees post-op abdominal surgery; post-op
thyroidectomy, post-op cataract surgery,
increased ICP; dyspnea
High-Fowler’s HOB elevated at 90 Pneumothorax, hiatus hernia

degrees
Supine/ Dorsal Lying on back w/ small Spinal cord injury, urinary

Recumbent pillow under head catheterization
Lying on abdomen with Amputation of legs/feet, post lumbar

head turned to the side puncture, post myelogram, post
tonsillectomy & adenoidectomy (T&A)
Lateral / Side lying Lying on side, weight Post-abominal surgery, post

on the lateral side, the tonsillectomy & adenoidectomy (T&A),
lower scapula and post-liver biopsy ( right side down), post
lower iliac. pyloric stenosis (right)
Lying on side, weight Unconscious client

on the clavicle,
humerus and anterior
aspect of the iliac.
Lying on back with Perineal, rectal & vaginal procedures

knees and legs bent
and raised on a stir up
Trendelenburg Head & body lowered, Shock

feet elevated
Reverse Head elevated , feet Cervical traction

Tredelenburg lowered
Elevate extremity Support with pillows Post-op surgical procedure on

extremity, cast, edema,
thrombophlebitis
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Prone
Supine Lateral Recumbent
Sim’s Position Reverse High-Fowler’s

Trendelenburg
Jack-Knife Lithotomy
B. Intra-operative Care
1. Ensure sterility of all instruments and supplies at the operating field
Principle: STERILE TO STERILE, CLEAN TO CLEAN

Sterile objects touches only sterile surfaces/objects
Clean objects touches only clean surfaces/objects
Sterilization techniques:
o Autoclave – Steam, Ethyl Oxide (Gas)
o Glutaraldehyde Solution- Cidex
2. Ensure safety of client in the operating table- prevent falls, drape the patient properly, provide warmth
3. Stay with the client to relieve anxiety and support during anesthesia
Anesthesia Administration:
a. General Anesthesia via Inhalation
b. General Anestheisia via Intravenous
c. Regional Anesthesia - local anesthesia
d. Conduction Blocks/ Spinal Anesthesia – Epidural & Spinal Block
- for operation below the waist line
- patient is awake during operation
4. Perform sponge count, instrument count and needle count

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5. Aseptic technique in handling and preparing all instruments and supplies
6. Applies grounding device to prevent electrical burn during use of electrosurgical equipment
7. Proper documentation
C. Post-operative Care
1. Immediate assessment of VS, and Neuro VS, drainages, surgical dressing
2. Monitoring of vital signs q 15mins until stable
3. Post-operative positioning depending on the procedure performed
4. Deep breathing exercises
5. Early ambulation
6. Health teaching for Independent (self) care upon discharge
III. ALTERATIONS IN HUMAN FUNCTIONING
1. DISTURBANCES IN OXYGENATION
Arterial Blood Gas
Normal Value
pH Measure of acidity or alkalinity 7.35 – 7.45
pCO2 Partial pressure of carbon dioxide respiratory 35 -45

parameter influenced by lungs only
pO2 Partial pressure of oxygen; measure of amount 80-100

oxygen delivered to lungs
HCO3 Bicarbonate, metabolic parameter influenced only by 22-26

metabolic factors
Respiratory Normal Value Respiratory

Acidosis Alkalosis
pH 7.35 – 7.45
pCO2 35 -45
Normal Compensation HCO3 22-26 Normal Compensation
a. Administer NaHco3 Nursing Intervention a. Breathe into paper

b. Get rid of CO2 bag or cupped
c. Bronchodilators hands
d. Monitor ABG b. Oxygen
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Metabolic Normal Value Metabolic

Acidosis Alkalosis
pH 7.35 – 7.45
Normal Compensation Normal Compensation
pCO2 35 -45
HCO3 22-26
a. Treat underlying cause Restore fluid loss which may be

cause by vomiting, gastric
(Starvation, systemic suction, alkali ingestion,
infections, renal failure, excessive diuretic
Diabetic acidosis, Nursing Intervention

Keratogenic diet,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- A group of conditions assoc. w/ chronic obstruction of airflow entering or leaving the lungs
Major diseases
1. Pulmonary Emphysema – airway is obstructed due to destroyed alveolar walls
2. Chronic Bronchitis- increased mucus production that obstructs airway
3. Asthma
Cause: Medical Management:

1. Cigarette smoking
2. Chronic respiratory infections 1. Bronchodilators
3. Family history of COPD
2. Antihistamines
4. Air pollution
3. Steroids
Clinical Manifestations:
 Few words between breaths 4. Antibiotics
 Pursed-lip breathing 5. Expectorants
 Cyanosis
 Distended neck veins 6. Oxygen therapy at 2LPM – use cautiously
 Barrel chest – increased diameter of thorax
 Pulsus paradoxus –
 Clubbing of fingers Nursing Management:
 Nicotine Stains
1. Administer meds and O2 as ordered
 Pitting edema
 exertional dyspnea or dyspnea at rest 2. Promote adequate activities to enhance
 Enlarged pulsating liver cardiovascular fitness
 Cough- with or without sputum production
CHRONIC BRONCHITIS
“Blue Bloater”
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- An inflammation of the bronchi which causes increased mucus production and chronic cough.
- Chronic condition is diagnosed if symptoms occur for 3 months and for 2 consecutive years.
Cause: Cigarette Smoking, infection, pollution
 Slight gynecomastia
 Productive cough
 Thicker, more tenacious mucus  Petechiae in midsternal area
 Decreased exercise tolerance
 Dyspnea
 Wheezes
Medical Management: see COPD
Nursing Management:
1. Reduce or avoid irritants
2. Increase humidity
3. Administer medications as ordered
4. Chest physiotherapy
5. Postural drainage
6. Promote Breathing techniques
EMPHYSEMA
“Pink Puffer”
- A disorder where the alveolar walls are destroyed causing permanent distention of air spaces.
- (+) dead areas in the lungs that do not participate in gas or blood exchange
Cause: Cigarette smoking, Alpha-anti-trypsin deficiency (an enzyme in the alveolar walls)
Clinical Manifestations: Nursing Management:

1. Dyspnea on exertion 1. Position: Sit up and lean forward
2. Tachypnea
3. Barrel-chest 2. Pulmonary toilet:
4. Wheezes Cough->Breathe deeply->Chest physiotherapy-> turn & position
5. Pinkish skin color
6. Shallow rapid respirations 3. Frequent rest periods
7. Pursed lip breathing
4. Nebulization
5. IPPB – Intermittent Positive Pressure Breathing (aerosolized inhalation)
Asthma
-A condition where there is an increase responsiveness and/or spasm of the trachea and bronchi due to various stimuli which causes
narrowing of airways
Cause and Risk Factors:

1. Family history of asthma
2. Allergens: dust, pollens,
3. Secondary smoke inhalation
4. Air pollution
5. Stress
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Types:
1. Immunologic asthma - occurs in childhood
2. Non-immunologic asthma - occurs in adulthood and assoc w/ recurrent resp infections.
- usually >35 y/o
3. Mixed, combined immunologic and non-immunologic
Clinical Manifestations: Nursing Management:

 Increased tightness of chest, dyspnea
 Tachycardia, tachypnea
 Dry, hacking, persistent cough 1. Promote pulmonary ventilation
 (+) wheezes, crackles 2. Facilitate expectoration
 Pallor, cyanosis, diaphoresis
 Chronic barrel chest, elevated shoulders 3. Health teaching
 distended neck veins
 Breathing techniques
 orthopnea
 Tenacious, mucoid sputum  Stress management
Treatment:
1. Steroids,
2. Antibiotics
3. Bronchodilators, expectorants
4. O2, nebulization, aerosol
Complication: STATUS ASTHMATICUS - a life-threatening asthmatic attack in w/c symptoms of asthma

continues and do not respond to treatment
II. PARENCHYMAL DISORDERS:
PNEUMONIA
- An inflammatory process of lung parenchyma assoc. w/ marked increase in alveolar and interstitial fluids
Etiology:
1. Bacterial / Viral – streptococcus pneumoniae, pseudomonas aeruginosa, influenza
2. Aspiration
3. Inhalation of irritating fumes
Risk factors:
1. Age: too young and elderly are most prone to develop
2. Smoking, air pollution
3. URTI
4. Altered conciousness
5. Tracheal intubation
6. Prolonged immobility: post-operative, bed-ridden patients
1. Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure

2. Cough- productive , rusty/ yellowish/greenish sputum, splinting of affected side, chest retration
3. CXR, sputum culture, Blood culture, increased WBC, elevated sedimentation rate
Nursing Management:
 Promote adequate ventilation- positioning, Chest physiotherapy, IPPB

 Provide rest and comfort
 Prevent potential complications
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 Health teaching: skin care, hygiene
 Drug therapy:
o Antibiotics: penicillin, cephalosphorin, tetracycline, erythromycin
o Cough suppressants
o Expectorants
 Rest and adequate activity
 Proper Nutrition
PULMONARY EDEMA
- often occurs when the left side of the heart is distended and fails to pump adequately
Clinical Manifestation:
o Constant irritating cough, dyspnea, crackles, cyanosis
Pathophysiology:
 Fluid accumulation in the alveolar sacs due to hypovolemia, fluid congestions in the lungs, alveoli are congested
Nursing Management:
1. Diuretics, low sodium diet, I&O
2. promote effective airway clearance, breathing patterns and ventilation
3. Monitor VS
4. Psychological support
5. Administer medications
TUBERCULOSIS
- A chronic lung infection that leads to consumption of alveolar tissues
Etiology: Mycobacterium tuberculosis.
Risk Factors:
1. Poor living conditions, overcrowded

2. Poor nutritional intake
3. Previous infection
4. Close contact with infected person
5. Inadequate treatment of primary infection
Clinical Manifestations: Diagnostic Tests:
1. Productive cough
2. Hemoptysis 1. CXR
3. Dypnea
4. Rales 2. Sputum acid-fast
5. Malaise 3. Mantoux Test - .1 ml of PPD (Purified Protein Derivative) ;
6. Night Sweats
7. Weight loss Read after 48-72 hrs.
8. Anorexia, vomiting
Induration: 10mm – > positive exposure to TB
9. Indigestion, pallor
bacillus
5 – 9 mm -> doubtful, may repeat
Treatment:
1. Ethambutol
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2. Rifampicin
3. Isoniazid
4. Pyrazinamide
5. Streptomycin
Client Education:
1. TB is infectious but can be cured
2. Transmitted by droplet infection and not carried on articles like clothing or eating utensils
3. Individual is generally considered not infectious after 1- 2 weeks of medication.
4. Medication regimen should be continuous and uninterrupted
5. Regimen is usually 6 months.
6. Regular check-up to monitor progress should be done.
7. Sputum samples are obtained first before drug therapy is started.
8. Advise proper handwashing and use of mask for people in contact with infected persons who are not yet under treatment.
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CARDIOVASCULAR SYSTEM
THE HEART AND MAJOR VESSELS
I. Diagnostic Procedure Venous Disorders:

1. Laboratory Test
2. Electrocardiogram 1. Thrombophlebitis
3. Echocardiography 2. Varicose Veins
4. Central Venous Pressure
5. Pulmonary Artery Pressure/ Swan-Ganz
6. Cardiac Catheterization
II. Diseases of the Vascular System: Cardiac Disorders
Arterial Disorders: a. Angina Pectoris

1. Hypertension b. Myocardial Infarction
2. Arteriosclerosis c. Congestive heart Failure
3. Atherosclerosis d. Valvular Stenosis
4. Aortic Aneurysm e. AV Heart Block
5. Buerger’s Disease (Thromboangitis Obliterans) f. Pacemakers
6. Raynaud’s Disease
A. DIAGNOSTIC PROCEDURES:
Procedure Values / Description Purpose
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1. Laboratory Tests a. Electrolytes – Na, K, Ca, Determines hyperkalemia, Hypernatremia, etc.
Chloride , Mg - determine the ability of the heart to affect circulation and
(see fluids & electrolytes) regulatory functions of fluids and electrolytes.
b. PTT – 16-40 sec.
c. PT – 9-12 sec. - determines ability of the blood to form clot or

thrombus
d. Clotting time – 10 mins.
e. Cholesterol – 150-250 mg/dl

.
f. Triglyceride – 50-250 mg/dl
> LDL (bad cholesterol) - determines the development of atherosclerosis
– 60-180 mg/dl which causes coronary artery disease
> HDL (good cholesterol)
– 30-80 mg/dl
g. BUN – 6-20 mg/dl - test of renal function; determines adequacy of circulation

from the heart to the kidneys and its ability to excrete protein
and urea
h. Enzymes:
> CPK – men- 55-170
- women- 30-135 - cardiac enzymes are present in high
( rises 3-6 hrs after M.I.) concentration in the myocardial tissues ;
determines tissue damage in the myocardium
> LDH – 150-450 u/ml
(rises 12 hrs after M.I.)
> SGOT – 5-40 u/ml
i. ESR- 0-30.– also rises after MI
2. Electrocardiogram P- contraction of the atrium  Determines the

QRS complex- contraction electrical impulse of the
of the ventricles heart
T- Resting state of the
ventricles  Normal impulses
PR interval- contraction of ensures adequate
atrium until the beginning circulation to all body
of the contraction of organs and tissues
ventricles
ST- ventricles moves to a
resting state
Procedure Values / Description Purpose
3. 2-Dimensional Ultrasound of the heart  Determines valvular

Echocardiography deformities, thickening
(2D Echo) of myocardium,
pericardial effusion,etc
4. Central Venous Measures the right atrial  Serves as guide for

Pressure (CVP) pressure or the pressure of the fluid replacement
greater veins within the thorax
Normal = 5 – 10 cm by threading a catheter into a  Monitor pressures in
Water large central vein. the right atrium and
- Subclavian - Jugular central veins
- Median - Basilic  Administer blood
- Femoral products, TPN, drug
therapy.
End of catheter or Tip –
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positioned at the right atrium or  Obtain venous access
upper portion superior vena cava when peripheral veins
are inadequate
(for femoral insertion, tip is at
the inferior vena cava)  To insert a temporary
pacemaker
 Obtain central venous
samples
5. Swan-Ganz Measures the level of pressure  Monitor pressure in the

Catheter / in the left atrium ff:
Pulmonary Artery c. Right ventricle
Pressure (PAP) 4 Ports: d. Pulmonary artery
a. Thermodilution port e. Distal branches of
b. Balloon Port for inflating the pulmonary
balloon used for placement of artery
catheter  Thermodilution
c. Right atrium Port  Obtain blood for O2
d. Pulmonary atrium port saturation
6. Cardiac Catheter inserted into the right or a. Measure O2

Catheterization left side of the heart and vessels concentration, saturation,
and a dye is introduced tension and pressure in
the chambers of the
Used to determine details on heart
the structure and performance of
the valves, heart and circulation b. Detect shunts
c. To get blood samples
d. Determine cardiac
output & pulmonary
flow
e. Determine need for
bypass surgery
Three types of Blood Vessels:
1. Arteries - carries oxygenated blood

2. Veins - carries unoxygenated blood
3. Capillaries – allows the delivery of nutrients, oxygen and fluids to the tissues
B. DISEASES OF THE VASCULAR SYSTEM:
B. 1.ARTERIAL DISORDERS
HYPERTENSION
Persistent BP above 140 /90
Types of Hypertension Essential hypertension Secondary hypertension
Etiology: unknown etiology caused by other physiologic problems

- most common
- may be caused by an increase in cardiac
output or increase in peripheral resistance
Types of Hypertension Essential hypertension Secondary hypertension
Risk Factors Genetic Renal problems – Renal Failure, Nephritis

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Obesity Endocrine problems – Thyroid problem, DM
Stress Neurologic Disorders – Brain tumors, Trauma
Loss of elastic tissues Pregnancy-Induced HPN
Arteriosclerosis of aorta Many others
Signs & Symptoms BP=140/90 ; headache, fatigue, weakness, dizziness, palpitations, flushing, blurred vision and
epistaxis
Treatment 1. Non-pharmacologic:
 Weight reduction √ Sodium restriction
 Diet modification √ Exercise
 Alcohol & Smoking cessation √ Caffeine Restriction
 Relaxation Techniques
 Potassium, Calcium, Magnesium supplements (to balance sodium and other
electrolytes)
2. Pharmacologic:
 Calcium Agonist: Nifedipine, Verapamil
 Vasodilators: Hydralazine
 Diuretics: Aldactone, hydrochlorothizide
 Adrenergic inhibitors: Propanolol, Clonidine, Methyldopa
Nursing Interventions
1. BP monitoring
2. Correct cause: obesity, diet, stress, etc
3. Regular exercise
4. Salt restrictions
5. Administer medications
6. Teach risk factors
ARTERIOSCLEROSIS
“Obstruction”
- When the arteries become obstructed with plaque and cholesterol, they harden and constrict, and the circulation of
blood through the vessels becomes difficult, forcing the blood through narrower passageways. As a result, blood pressure
becomes elevated.
- Arteriosclerosis occurs when lipids in the blood, including cholesterol, accumulate inside the walls of blood vessels and
reduce the size of the veins or arteries through which blood flows.
ATHEROSCLEROSIS
“Thickening”
- A degenerative condition of the arteries characterized by thickening due to localized accumulation of fats, mainly
cholesterol. The term atherosclerosis refers to a condition in which fatty deposits build up in and on the artery walls,
interfering with the normal flow of blood and oxygen throughout the body. When this happens, the heart has to work harder
to pump blood through the narrowed blood vessels, and a heart attack or a stroke may result.
Predisposing factors:
 cigarette smoking
 high fat levels in the blood
 high cholesterol
 high blood pressure
 obesity
Signs and symptoms:
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The symptoms of atherosclerosis depend on the part of the body where the condition is taking place. Sometimes there
aren't any noticeable symptoms until the condition has advanced to a very serious stage. When the arteries of the heart are
affected, one of the first symptoms is chest pain, often called angina. A person with clogged arteries of the heart may also
have occasional difficulty in breathing and may experience unusual fatigue after short periods of exertion.
Medical & Surgical Interventions for Athero and Arteriosclerosis:

a. Lifestyle Modification ; Reduce Risk Factors
b. Coronary Artery Bypass Graft (CABG
c. Percutaneous Transluminal Coronary Angioplasty (PTCA)
d. Directional Coronary Atherectomy (DCA)
e. Intracoronary Stents
Nursing Intervention:
a. Health Teaching
b. Reduce Risk Factors
c. Restore Blood Supply
d. Pre & Post-op Care for Surgical Patients
e.
AORTIC ANEURYSM
Types of Aneurysm: Thoracic or Abdominal Aortic Aneurysm

Risk Factors: Presence of Atherosclerosis, Infections or a Congenital abnormality
Signs & Symptoms:
Thoracic Aortic Aneurysm Abdominal Aortic Aneurysm (AAA)
Dyspnea Thoracic/chest pain Abdominal Pain

Dysphagia cough Low back pain
voice hoarseness Pulsating Abdominal Mass
Treatment: Surgical Removal of Aneurysm
Nursing Intervention: a. Psychological support

b. Monitor patient for signs of rupture of aneurysm
Triad of manifestations for ruptured abdominal aneurysm:

1. Abdominal pain
2. Back or Flank pain (scrotal pain may also occur)
3. Shock: Bp= >100 systolic; Pulse Rate >100bpm
c. Pre-operative preparation
d. Post-operative care: monitor peripheral circulation
BUERGER’S DISEASE
a.k.a. Thromboangitis Obliterans (TAO)
Definition: Vasculitis of the veins and arteries in the upper & lower extremities
Risk Factors: Men -20-35 y/o, Heavy smokers, hypersensitivity to intradermal injections
Signs & Symptoms: a. pain in legs relieved by immobility,

b. numbness and tingling of toes
c. sensitivity to cold
d. Weak or absent pulsations at the dorsalis pedis, posterior tibial
e. Reddish or Cyanotic extremity which may progress to ulceration or gangrene
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Treatment:
 Calcium Channel Blockers to promote vasodilation
 Rest, Pain Relievers, Avoid exposure to cold
 Surgery: Amputation of extremity is delayed until conservative treatments fail to effect.
 Health teaching on lifestyle modifications, spec. smoking
 Ensure protection of extremities against cold
 Administration of medications as ordered
 Protect client from injury
 Assessment of extremities

RAYNAUD’S DISEASE
Definition: Vasospasm of arteries in the hands (upper extremities only)
Risk Factors: Women, heavy smokers, individuals spec. women with Systemic Lupus
Erythematosus (SLE) or rheumatoid arthritis
Cause: hypersensitivity of fingers to colds, congenital vasospasm, Serotonin release

Signs & Symptoms:
 Cyanosis/pallor of the fingers when exposed to cold environment or emotional stimuli
 Numbness and occasional pain
 Bilateral or symmetrical involvement
Treatment:
 Nifedipine to decrease vasospasm
 Avoid exposure to cold and keep hands warm
 Avoid smoking
Nursing Intervention
 Same as buerger’s disease
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B.2.VENOUS DISORDERS:
THROMBOPHLEBITIS
Definition: Clot disorder in the vein usually at the lower extremity
Risk Factors: Trauma of the blood vessels, stasis, Increased coagulability
Signs & Symptoms: Edema of the extremity,

redness, pain, local induration,
(+) Homan’s sign - calf pain upon
dorsiflexion of foot
a. Use of thromboembolytic (TED) stockings
b. Elevate legs
c. Heparin therapy, as ordered
d. Bed rest
e. Warm compress
VARICOSE VEINS
Definition: distention, lengthening and totuosity of veins
Cause: loss of valvular competence and constant elevation of venous pressure

most commonly in the veins of the legs.
Risk Factors: Prolonged standing, obesity, pregnancy
Signs & Symptoms:

 Aching
 Heaviness
 Moderate swelling
 Enlarged, tortuous veins in the legs
Treatment:
 Surgical Management: Sclerotherapy (injection of sclerosing agent to the
vein. Not a treatment, hence, for cosmetic purpose only)
 Elevate legs at least 30 mins. After prolonged standing
 Wear thromoembolic stockings
 Teach client o avoid prolong sitting or standing
 Avoid cross-legs while sitting
 Post-op Care after Sclerotherapy: a. Maintain firm elastic pressure over the whole limb
b. Regular but careful exercise of the legs to promote

circulation – ambulate for short periods 24-48 hrs post-op
c. Assessfor complications such as bleeding, infection, nerve

damage
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IV.CARDIAC DISORDERS
ANGINA PECTORIS
Chest pain
 insufficient coronary blood flow

 inadequate oxygen exchange in the heart causing intermittent chest pain
 can be relieved with rest.
 It lasts only for 1-5 minutes and taking up of nitroglycerine will be beneficial for the client.
Signs and symptoms:
 Patient experiences retrosternal chest discomfort

 Pressing, heaviness, squeezing, burning and choking sensation.
 Pain in the epigastrium, back neck jaw or in the shoulders.
 Radiation of pain in the arms, shoulders and the neck.
Precipitating factor:
 over exertion
 eating
 exposure to cold
 emotional stress
Classification of Symptoms:
Class I – no limitations of physical activity (ordinary physical activity does not cause symptoms).
Class II – slight limitation of physical activity (ordinary physical activity does cause symptoms).
Class III – moderate limitation of activity (patient is comfortable at rest, but less than ordinary activity can
cause symptoms).
Class IV – unable to perform any physical activity without discomfort, therefore severe limitations (patient may
be symptomatic even at rest).
Nursing Interventions:
a. Assess pain – location, character, ECG (ST elevation), precipitating factors
b. Help client to adjust lifestyle to prevemt angina attack – avoid excessive activity in cold
weather, avoid overeating, avoid constipation, rest after meals, exercise
c.
Teach patient how to cope with angina attack – nitroglycerin every 5 mins upto 3x, if still not
relieved go to the hospital
Diagnostic Assessment:
a. ECG
b. Stress Test
c. Radioisotope Imaging
d. Coronary Angiography
Medical Management:
a. Opiate Analgesic – MoSo4

b. Vasidilators – Nitroglygcerin, Isosorbide Mononitrate/Dinitrate
c. Calcium Channel Blockers – Dlitiazem, Nifedipine
d. Beta Blocking Agents –Propanolol
MYOCARDIAL INFARCTION
 Destruction of myocardial tissue due to reduced coronary blood flow.
 The rapid development of myocardial necrosis caused by imbalance between the oxygen supply and
demand of the myocardium.
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Comparison of Chest Pain
Angina Pectoris Myocardial

Infarction
Type • squeezing, pressing, • Sudden, severe, crushing,

heavy, tightness
burning
• Substernal, radiates to one

Location • Retrosternal, or both arms, jaw, neck
substernal, left of
sternum, radiates to the
left arm
• >30 mins.
• Usually 3-5 mins

duration <30 mins
Duration • Oxygen, narcotics,
• rest, nitroglycerin • not relieved by rest &

nitroglycerin
Comparison of other signs & symptoms
Angina Pectoris Myocardial Infarction Transient Ischemic

Attack
Subjective Data: Subjective Data: Sudden loss of:

 Dyspnea  Shortness of breath  Visual fxn
 Palpitation  Apprehension, fear  Sensory fxn
 Dizziness of impending death  Motor fxn
 Faintness  Nausea
Objective Data: Objective Data: Objective Data:

 Tachycardia  Symptoms of shock Loss of functioning for about and
 Pallor  Cyanosis, diaphoresis returns to normal
 Diaphoresis  Restless
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Nursing Care Management
Arteriosclerosis Angina Pectoris Transient Ischemic Attack
1. Lifestyle Modification 1. Provide relief from 1. Assess neurologic status

• Diet, stress mgt, habits pain:
• Rest 2. Administer meds
2. Restore blood supply • Nitroglycerin
• Anti-embolic stockings, • Lifestyle modification
anti-coagulants • Vital signs
• Assist w/ ambulation
3. Pre & post-op care
• CABG,PTCA, Stents 2. Provide emotional
support
4. Health teaching
• Modifications, diet,etc. 3. Health teaching
• Pain differentiation
• Medication
• Dx test
• Diet, exercise, CABG
Nursing Care Management
Myocardial Infarction
1. Reduce pain & discomfort: 4. Maintain fluid & electrolyte balance /

Nutrition
• Narcotics, O2, Semi-fowler’s position to
improve ventilation • Keep IV open; CVP, VS, UO
battery- operated • Lab data: Na+135-145; K 3.5-5.0 mEq/L
2. Maintain adequate circulation. • ECG
• Monitor VS, Urine Output & ECG • Diet: low calorie, low sodium, low
cholesterol, low fat
• Meds: Anti-arrythmics & anticoagulants
• Check for edema, cyanosis, dyspnea,
cough, crackles 5. Facilitate fecal elimination
• CVP: normal= 5-15cm H20 • stool softener, avoid Valsalva, mouth
breathing, bedside commode
• ROM, anti-embolic stockings
6. Provide emotional support

3. Decrease oxygen demand/ Promote
oxygenation
• O2, Bedrest (24-48 hrs), rest periods 7. Promote sexual functioning
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DISTURBANCES IN METABOLIC & ENDOCRINE FUNCTIONING

Gland Hormone Functions
Pituitary Gland
Anterior Lobe Growth Hormone Stimulates growth of body tissues and bones
Prolactin Stimulates mammary tissue growth & lactation
Thyrotropic hormone (TSH) Stimulates thyroid gland
Gonadotropic hormones (LH & Affect growth, maturity and functioning of primary and
FSH) secondary sex organs
Adrenocorticotropic hormone Stimulates steroid production by adrenal cortex

(ACTH)
Melanocyte-stimulating Hormone May stimulate adrenal cortex; may affect pigmentation

(MSH)
Anti-diuretic hormones (ADH, Promotes reabsorption of water by the distal tubules and
Posterior lobe vasopressin) collecting ducts of the kidney, thus decreasing urine
output
Oxytocin Stimulates ejection of milk from mammary alveoli into

the ducts: stimulates uterine contractions may possibly
be involved in the transport of sperm in the reproductive
tract of the female
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Thyroid Gland Thyroxine (T4) Increases metabolic activity of almost all cells;
stimulates most aspects of fat, protein and carbohydrate
Triiodothyronine (T3) metabolism
Thryrocalcitonin Lowers serum calcium levels and elevates phosphate

level; opposite effect from that of PTH
Parathyroid Parathormone (PTH) Increases calcium levels and decreases phosphate

levels; increases resorption of bones
Adrenal Cortex Glucocorticoids (primarily Promotes carbohydrate, protein and fat catabolism,
cortisol) -- Sugar increases tissue responsiveness to other hormones
Controls SSS:
SUGAR, SALT, Mineralcorticoids (Aldosterone) Tends to increase sodium retention and potassium
SEX -- Salt excretion
Androgens (male hormones) Governs certain secondary sex characteristics; all

-- Sex corticoids are important for defense against stress or
injury
Medulla Epinephrine (Adrenalin)-80% Elevates blood pressure, converts glycogen to glucose

when needed by muscles for energy; increases heart
Norepinephrine- 20% rate; increases cardiac contractility; dilates bronchioles
Ovaries Estrogens and progesterone Stimulate development of secondary sex

characteristics, effect repair of the endometrium after
menstruation
Testes Testosterone Essential for normal functioning of male reproductive

organs; stimulates development of secondary sex
characteristics
Pancreas Insulin Promotes metabolism of carbohydrates, protein and fat

Islets of thus decreasing blood glucose
Langerhans Glucagon Mobilizes glycogen stores, thus raising blood glucose
levels
Somatostatin Decreases secretion of insulin, glucagons, growth
hormone and several gastrointestinal hormones( gastrin,
secretin)
PITUITARY GLAND PROBLEMS
Clinical Manifestations Management
Acromegaly 1. Enlarged extremities 1. Irradiation of pituitary with Bromocriptine to

2. Protrusion of jaw and orbit decrease secretion of growth hormone
3. No increase in height and weight but
Growth hands and feet become bigger 2. Surgery: Hypophysectomy-removal of the
Hormone 4. Increased perspiration pituitary gland
5. Visual problems
6. Hyperglycemia/calcemia 3. Post-op Care:
a. Assess ICP
b. Elevate head of bed (HOB) 30 degrees
c. Avoid coughing, sneezing, blowing nose
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Gigantism
Overgrowth of all body tissues and bones
Growth
Hormone
Dwarfism 1. Retarded physical growth 1. Removal of cause : tumor

2. Premature body aging 2. Human Growth Hormone Injection
3. Slow intellectual development 3. Same as acromegaly & gigantism
Growth
Hormone
Diabetes Insipidus 1. Polyuria 1. Pharmacology:

2. Polydipsia a. Desmopressin Acetate nasal spray
Anti- 3. Dehyration b. Vasopressin Tannate – IM injections
diuretic c. Hypressin Nasal Spray
Hormone
2. Nursing Interventions;
a. Maintain adequate fluids
b. Sodium Restriction
c. Intake & Output monitoring
d. Teach self-injection techniques
e. Daily weights
f. Specific gravity
SIADH – Syndrome 1. Hyponatremia 1. Fluid restriction

of Inappropriate 2. Mental confusion 2. Treat underlying causes
secretion of ADH 3. Personality changes 3. Pharma:
4. Lethargy, weakness, headache a. Demeclocycline administration as
5. Weight gain ordered
6. Abdominal cramping b. Lithium Carbonate
7. Anorexia, nausea, vomiting c. Butorphanol Tatrate
ADRENAL GLAND PROBLEMS
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Addison’s Disease 1. Malaise and general weakness 1. Pharmacology: Steroids (Prednisone,
2. Hypotension, hypovolemia dexamethasone)
3. Increased pigmentation of skin 2. Diet: high CHO, CHON diet
4. Anorexia, nausea, vomiting 3. Observe side effects of hormone replacement –
5. Electrolyte Imbalance Cushingoid Appearance
6. Weight loss 4. Monitor fluid & electrolyte
Glucocorticoids 7. Loss of libido 5. Teach importance of lifelong medications
Mineralcorticoids
8. Hypoglycemia (60-70) 4. WOF Signs of Addisonian Crisis:
9. Personality Changes
Addisonian Crisis:
1. Sudden profound weakness

2. Severe abdominal, back and leg
pain
3. Hyperpyrexia followed by
hypothermia
Cushing’s 1. Thin scalp 1. Surgical Mgt: Adrenalectomy

Syndrome 2. Moon Face 2. Chemotherapy: Bromocriptine
3. Acne 3. Diet: high CHON, low CHO, low Na diet ,
4. Increased body hair potassium supplement
5. Buffalo hump 4. Nursing Mgt:
6. Obesity > protect from infection
7. Hyperpigmentation > protect from accidents
8. Thin extremities > health teaching on self-medication
9. Easy Bruising
10. Mood swings, male characteristics
appear in women
11. Hypokalemia, Hyperglycemia, HPN
12. Amenorrhea
13. Osteoporosis
STEROIDS:
Purpose: Anti-inflammatory and anti-allergy; Stress Tolerance
Medication:
a. Take at the same time everyday
b. Follow regime and do not stop abruptly
c. Causes gastric upset
Side effects: Cushingoid Appearance
Conn’s Syndrome / 1. HPN 1. Surgery: Removal of tumor

Aldosteronism 2. Hypokalemia 2. Potassium replacement
3. Treatment of hypertension
4. Nursing Mgt: Monitor BP, administer meds,
provide quiet environment
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Pheochromocytom 1. HPN 1. Surgical Mgt: Removal o tumor
a 2. Increase Perspiration 2. Medical Management: Symptomatic (Treat
3.Apprehension symptoms as it occurs)
4.Palpitations 3. Nursing Mgt:
5. Nausea, Vomiting, Headache > High caloric diet
6. Tachycardia > Adequate Rest
7. Hyperglycema
THYROID GLAND PROBLEMS
Grave’s Disease / Hyperthyroidism/ 1. Exopthalmos- protrusion of eyes 1. Surgery: Thyroidectomy

Thyrotoxicosis 2. Enlargement of the thyroid gland 2. Drug Therapy:
3. Increase metabolism: weight loss, a. Methimazole
diarrhea, diaphoresis b. Propyl- Thyracil
4. Personality changes c. Iodides:
5. Cardiac Arrythmias Lugol’s solution – strains teeth, drink
6. Easy fatigability w/ straw
T3, T4,
7. Muscle weakness
Thyrocalcitonin
8. HPN Saturated Solution of Potassium
9. Anxiety, Insomnia Iodide (SSKI)
d. Propanolol
THYROID STORM: 3. Radioiodine therapy
4. Nursing Mgt:
a. Fever a. Adequate Rest
b. High caloric, high protein,
b. Tachycardia carbohydrate, vitamins without
c. Delirium stimulants
c. Measure daily weights
d. Eye protection for xopthalmos
e. WOF: Thyroid Storm
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Cretinism 1. Physical & mental retardation
2. Sensitive to cold
3. Dry skin
T3, T4, 4. Poor appetite and constipated
Thyrocalcitonin
Treatment:
Hormone
Replacement
Myxedema 1. anorexia and constipation 1. Drug Therapy:

2. intolerance to cold a. Levothyroxine
3. Slow metabolism: decreased b. Thyroid Replacement (Desiccated
T3, T4, sweating, edema thyroid)
Thyrocalcitonin 4. Dry skin ** taken in empty stomach
5. Enlarged thyroid ** heart rate less than 100 bpm -ok
PARATHYROID GLAND PROBLEMS
Hypoparathyroid Bradycardia , Easy bruising 1. Drug therapy: Levothyroxine,

Fluid retention, Constipation Liothyronine Sodium
Dry, coarse skin, Fatigue, lethargy 2. Avoid stimulus
Decreased libido, Menorrhagia,
irregular menses
Hyperthyroid Tachycardia 1. Drug therapy: Prophylthiuracil

Palpitations Methimazole, Saturated solution
Increased persitalsis of Potassium Iodide, Radioactive
weight loss Iodine
Heat intolerance 2. Diet: low calcium, high fiber
Decreased libido 2. Force fluid
Amenorrhea
PANCREATIC PROBLEMS
DIABETES MELLITUS
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Type I Type II
Insulin Dependent DM Non-Insulin Dependent DM
(IDDM) (NIDDM)
Other Name Juvenile DM Adult DM
Age of Onset
Before 30 years old but may occur at >35 y/o but can occur in children
any age
Onset
Abrupt Insidious
Incidence
10% 85-90%
Insulin production
Little or none Below normal
Normal or
Above normal
Insulin Injections
Required Necessary for only 20-30% of clients
Ketosis
May occur Unlikely to occur
Body weight at onset
Ideal body weight or thin Usually Obese
Management
Diet, exercise and insulin Diet, exercise, hypoglycemic agent or
insulin
Cardinal Signs & Symptoms:

1. Polydipsia - excessive thirst
2. Polyuria - frequent urination
3. Polyphagia - excessive hunger
4. Weight Loss - for IDDM
Treatment:
1. Oral hypoglycemics: Side effects:

a. Glipizide a. Hypoglycemia
b. Glyburide
c. Tolbutamide b. Skin rashes
d. Tolazamide
c. GI disturbances
e. Acetohexamide
f. Chlorpropamide d. Flushing
e. Nausea, vomiting
Administration:
2. Insulin Injections:
Action Appearance- Preparation

Onset of Effect Peak Duration of
Effect
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Short-Acting Clear - Regular Insulin 30 mins. – 1 hr. 2 – 4 hrs. 6 – 8 hrs.
Cloudy - Semilente 30 mins. – 1 hr. 2 – 8 hrs. 8 – 16 hrs
Intermediate Cloudy - NPH 1 – 2 hrs. 6 – 12 hrs. 18 -26 hrs.

Acting
Cloudy - Lente 1 – 3 hrs. 6 – 12 hrs. 18 -26 hrs.
Long-Acting Cloudy - Protamine zinc 4 – 6 hrs. 18 – 24 hrs. 28 – 36 hrs.
Cloudy - Ultralente 4 – 6 hrs. 14 – 24 hrs. 36 hrs.
Pre-Mixed Cloudy - 70% NPH 30 mins. 2 -12 hrs. 18- 24 hrs.

- 30% regular
Complications of DM:
a. Hypoglycemia
Cause: Hunger, less dietary intake, excessive insulin
Signs & Symptoms: Diaphoresis, Tachycardia, tremors, weakness, irritability, confusion
Nursing Interventions: Give candy, juice or softdrinks, let the patient eat
Check sugar level
b. Diabetic Ketoacidosis
Cause: Lack of insulin , Infection, Stress
Signs & Symptoms: Polyuria, thirst, Nausea, vomiting, dry mucous membranes, Kussmaul resp,
Coma, sunken eyesballs, acetone odor of breath, hypotension, abdominal
rigidity
Nursing Interventions: Give regular insulin
c. Lipodystrophy
Cause: Indurated areas on skin due to injections
Signs & Symptoms: Skin indurations
Nursing Interventions: Teach client to rotate sites of injection
d. Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK)
Cause: Extremely high glucose, no ketosis
Signs & Symptoms: Polyphagia, polydipsia, polyuria, glucosuria, dehydration, abdominal

discomfort, hyperpyrexia, hyperventilation, changes in sensorium, coma,
hypotension, shock
Nursing Interventions: Fluid & electroluyte replacement, Insulin
3. DISTURBANCES IN ELIMINATION
3.1. Inflammatory and Neoplastic Disorders

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a. Acute Gastritis
b. Chronic Gastritis
c. Duodenal Ulcer
d. Gastric Ulcer
e. Gastric Cancer
Acute Gastritis Chronic Gastritis Treatment
Incidence: o Common in age 50-60 o Same in Acute Gastritis Medical Management:

years old a. Antacids
o Frequent in male than b. Small frequent
female meals
o Greater incidents in heavy c. Bland diet
drinkers and smokers d. May prescribe
anticholinergics in
Helicobacter Pylori o History of or presence chronic gastritis
Cause: of peptic ulcer disease
Medicines: o Previous gastric Nursing Interventions/
Aspirin, NSAIDS, chemo drugs, surgery Health Teaching:
steroids o Same as acute gastritis -Avoid spicy
foods
Food: -Avoid alcohol
Alcohol, coffee, spicy foods intake
Prolonged
-Frequent small
Duration: Short meals
o May be asymptomatic
o Other symptoms
Clinical Epigastric discomfort, include:
Manifestations: Abdominal pain, cramping, o Dyspepsia, belching,
severe nausea, vomiting and vague epigastric pain,
sometimes hematemesis N/V, intolerance to
spicy or fatty foods
Acid Increased hydrochloric acid.
production:
No increase in hydrochloric
acid
Duodenal Ulcer Gastric Ulcer

Occurrence: o 25-50 yrs. old > 50 yrs. old
a. Relaxation techniques
o Type A personality o Most common in
(leaders, executives); persons like b. Eliminate caffeine, cigarette
farmers, smoking, alcohol intake and
construction spicy foods
o Usually in a well- workers
nourished individual c. High fat, high carbohydrate
o Usually affects
malnourished Medical Treatment:
individuals Antacids - avoid administration
within 1-2 hr of other oral
Cause: Stress, Poor food habit Excessive smoking, meds
salicylates intake - frequent administration –
ac, pc,
Acid Hypersecretion Normal to
production: hyposecretion hs
H2 Antagonists - with meals/pc
Pylorus
Location of Lesser curvature Anticholinergics
Ulcer
o Experienced 2-3 hrs Prostaglandin Analogs -
o Experienced ½
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after meal to 1 hour after **misoprostol** & ACID PUMP
Pain: o Ingestion of FOOD meal INHIBITORS - **inhibits the
RELIEVES PAIN o Ingestion of enzyme that produces gastric
FOOD DOES acid
NOT RELIEVE
PAIN H Pylori –
 Metronidazole
 Omeprazole
 Tetraycline/Clarithromycin
Hematemesis is more  Cytoprotective – binds with
common than melena diseased tissue and
Bleeding Melena is more common provides a protective barrier
than hematemesis to acid
Possible Surgical Treatment

Malignancy: Not possible 1. Vagotomy
2. Gastric Resection-
Gastroduodenostomy;
Gastrojejunostomy
GASTRIC CANCER
Incidence:
f. Common in men than women
g. History or presence of Pernicious Anemia
h. Often develops with the occurrence of atrophic gastritis
i. Low-socio economic status; live in urban area
j. Exposure to radiation or trace metals in soil
Cause: Helicobacter Pylori
a. Palpable mass
b. Ascites
c. Weight loss
d. Dysphagia
e. Indigestion and anorexia
f. (+) high lactate dehydrogenase level in gastric juice
Diagnosis: GIT x-ray, gastroscopy
Treatment: Chemotherapy, radiation therapy, gastric resection
Nursing Intervention: Same as with patient’s with ulcer, emotional support, pre and post-operative health teaching
3.2. Disorders of the Large and Small Bowel
VIRAL AND BACTERIAL GASTROENTERITIS/ DYSENTERY
Gastroenteritis - Inflammation of stomach and intestine usually the small bowel.

S/S: abdominal cramps, diarrhea, vomiting, fever, severe fluid and electrolyte loss,
mild to severe temperature
Cause: Viral
Dysentery - Inflammation in the colon

S/S: severe bloody diarrhea and abdominal cramping, severe fluid and electrolyte loss,
mild to severe temperature
Cause: Bacterial ( E.coli nd/or shigella, salmonella, Clostriduum difficile from
antibiotics)
Risk Factors:
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o Poor food handling
o Poor sanitary conditions
o Overcrowding
o Food remaining on high temperature making organisms incubate and colonize easily.
Management:
o Replace fluid loss
o Anti-infective Agent (e.g. Metronidazole spec for amoebiasis, Bactrim)
o Measure intake and output
o Administer medications
o Replace fluids
APPENDICITIS
o Inflammation of the vermiform appendix
Incidence: Common between 20-30 yrs. old
Cause: Fecalith (stone or calculus in the appendix) .-> Kinking of the appendix
Fibrous condition in the bowel wall -> Bowel adhesion
S/S: Pain starts in the epigastriium the shifts to the the right lower quadrant
Guarding of painful area
Keeps legs bent to relieve tension
May have vomiting, loss of apetite, low grade fever, coated tongue and halitosis
Diagnosis: Increased WBC, (+) pain at Mc Burney’s point (RLQ)
Treatment: Appendectomy
Nursing intervention:
Assess the VS and pain scale carefully
Observe for symptoms of peritonitis , Pre & post-operative care
PERITONITIS
o Inflammation of the peritoneal membrane

o Cause:
Gangrenous cholecystitis Ileitis
Ruptured gallbladder Appendicitis with perforation
Perforated gastric cancer Ruptured retroperitoneal abscess
Perforated Peptic ulcer Strangulated hernia
Ruptured spleen Salpingitis
Acute pancreatitis Septic Abortion
Penetrating wound Ruptured bladder
Ulcerative colitis Puerperal infection
Gangrenous obstruction of the bowel Iatrogenic Cause
Perforated diverticulum
o Signs and Symptoms:

Localized pain
Abdominal rigidity
Increased pain upon movement
Nausea, vomiting (N/V)
Absence of bowel sounds
Shallow respirations
Increased WBC , dilation and edema of intestines revealed in GIT x-ray
o Medical Management:
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NGT: Lavage to relieve pressure in the abdomen
Fluid & electrolyte replacement
o Surgical Treatment:
Appendectomy or Exploration of the abdomen with drainage
o Nursing intervention:
Careful assessment of history, V/S, fluid & electrolytes
Pre & Post-operative Care
c. Inflammatory Bowel Disease:
ULCERATIVE COLITIS & CHRON’S DISEASE
CHRON’S DISEASE ULCERATIVE COLITIS
Pathology & Involves primarily the ileum & right Mucosal ulceration of lower colon
Anatomy colon and rectum
Distribution of d’se is segmental Distribution of d’se is continuous
Malignancy is rare Malignancy may occur after 10 years
May be caused by infection or

Etiology May be genetic alteration in immunity
Young adults (20-40)

Onset Usually in the 30’s
Remissions and relapses
Course of Disease Slowly progressive
Common
Rectal bleeding Occasional
Rare
Anorectal fistula Common
Rectal bleeding, diarrhea (20
Other S/S: Abdominal pain stools/day or more); Stools may
Weight loss occur with blood or pus, weight loss
Diarrhea – soft or semi-liquid Urgency, cramping,
Pain in RLQ, cramping, tenderness, Pain LLQ, abdominal distention,
flatulence, nausea (mimics emotional stress.
Appendicitis)
Same as Chron’s D’se

Medical Treatment Replacement of fluid loss
Anti-diarrheal: Diphenoxylate HCL
(Lomotil) ; Loperamide HCL
(Imodium)
Total Parenteral Nutrition

Bowel Resection, Ileostomy
Surgical Bowel Resection, Ileostomy
Treatment
Assess Intake and output, weight Same as Chron’s D’se

Nursing Emotionla support
interventions: Client teaching regarding surgery
Post-op intervention:
Observation of the stoma
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Teach client re: self-care
HERNIA
-An abnormal protrusion of an organ or tissue through the structure that contains it.
- Frequently a congenital occurrence or acquired weakness of the abdominal muscles
Types:
1. Indirect Inguinal Hernia
2. Direct Inguinal Hernia
3. Femoral Hernia
4. Umbilical Hernia
5. Incisional Hernia
Medical Treatment: Use of TRUSS if hernia is not strangulated or incarcerated.
Surgical Treatment: Herniorrhaphy
Nursing Intervention: Pre & Post-operative Care

Post-op Care:
a. Make sure the client voids after surgery, urinary retention is common
after herniorrhaphy
b. Resume diet as tolerated by the patient
c. Ice pack over the incisional site to control pain and swelling
d. Instruct patient to avoid heavy lifting from 4-6 weeks post surgery
DIVERTICULUM
Diverticulum – an outpouching of intestinal mucosa through the muscular coat of the large
intestine (most commonly the sigmoid colon)
Diverticulosis – refers to the presence of non-inflamed out pouching of the intestine
Diverticulitis – inflammation of a diverticulum
Incidence: > 45 yrs. old ; Male & Female
Etiology: Lower fiber diet which causes bulk in stools

which may cause intraluminal
pressure in the bowel causing diverticula
Risk factors: Chronic Constipation
S/S: Left Quadrant Pain Anorexia

Increased flatus Low grade fever
(+) rectal mass on digital rectal examination
Medical Intervention: High-fiber diet and laxatives

NGT insertion to relieve pressure
Control inflammation through antibiotics and advise patient to:
a. Avoid activities that may increase abdominal pressure (bending,
lifting, etc)
b. Intake of 6-8 glasses of water a day
c. Reduce weight if obese
Surgical Intervention: Indicated for those who developed complications as manifested

by hemorrhage, abscess, perforation and obstruction.
o Colon resection with colostomy
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Indications Nursing Intervention
Colostomy o Inflammatory / obstructive 1. Emotional support

process of the lower
o Involves the large 2. Psychological
intestinal tract
bowel (colon)
Support
o Trauma
3. Heath Education
o Rectal or sigmoid cancer
o stool is semi-
regarding:
Ileostomy
a.surgery (ileostomy/colostomy)
o Involves the small o Chron’s Disease
bowel (ileum) b. Self-care
o Ulcerative Colitis
o stool is in liquid
d. Hirschprung’s Disease and Megacolon
 Congenital absence of parasympathetic ganglion

 Clinical Manifestations:
o NB fail to pass meconium 24 hrs after birth
o Older child – recurrent abdominal
distention, chronic constipation, ribbon-like
stool, diarrhea, emesis w/ bile stain
Treatment:
a. Colostomy
b. Bowel Resection
c. Cleansing Enema
Post-op Nursing Intervention;

a. Teach colostomy care- check color of stoma
(should be bright leg)
e. Hemorrhoids
o Peri-anal varicosities which is either internal or external
o Types: a. Internal – varicosities above the mucocutaneous border covered by the

mucous membrane.
b. External Hemorrhoids- – varicosities below the mucocutaneous border

covered by the anal skin.
Incidence: Both male and female aged 20-50 y/o.

Pregnancy, CHF, Prolonged sitting or standing, portal hypertension
Risk factors: Increased abdominal pressure, constipation, straining during bowel

Movement
S/S: Internal – bleeding and renal prolapse, bleeding and rectal itching
External – enlarged mass at the anus
Present symptoms in both internal & external: Bright red (blood) stain in
stool or tissue, Pain
Medical Intervention: a. Treat constipation
b. Relieve pain through heat application / Sith’s bath
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Surgical Intervention: Hemorrhoidectomy, Sclerotheraphy, Rubber band ligation, Laser
Surgery, cryosurgery
f. Fistula-in-ano
 Tiny, tubular fibrous tract that extends into the anal canal
 May develop from trauma, fissures or regional enteritis
 Fistulectomy is recommended.
.3.3. Abdominal Trauma :
a. Blunt Trauma – injury like vehicular accident

b. Penetrating Abdominal Trauma – stab wound
4. DISTURBANCES IN FLUIDS AND ELECTROLYTES
Fluid Content in the Human Body :

a. Women - 50-55% of body weight is water
b. Men - 60-70% of body weight is water
c. Infant - 75- 80% of body weight is water
d. Elderly - 47% of body weight is water
Electrolytes in the Human Body:

a. Sodium (Na) - 135-145 mEq/L
b. Potassium (K) - 3.5 – 5.5 mEq/L
c. Chloride (Cl) - 85-115 mEq/L
d. Bicarbonate (HCO3 ) - 22-29 mEq/L
Functions of the Fluid & Electrolytes in the Human Body:

a. Regulates acid-base balance in the body
b. Maintains fluid volume
c. Regulates exchange of water between fluid compartments
Actions of the Fluids & Electrolytes

a. Diffusion – fluids move from area of higher concentration to an area of lower concentration
b. Osmosis - fluids move from an area of lesser concentration to a higher concentration
c. Filtration – fluids and substances moves from higher hydrostatic pressure to lesser hydrostatic pressure.
Intravenous Solutions Used to correct imbalance:

e. Isotonic – 0.9 NSS, D5W
f. Hypertonic – has greater concentration of solis substances than the fluid substances
e.g.Total Parenteral Nutrition, D50
g. Hypotonic – has fewer solid and has higher fluid content, e.g. 0.45 NaCl
System of Fluid Balance in the body:

a. Kidneys – responsible in controlling the balance of fluid & electrolytes
b. Lungs- controls the Carbondioxide levels in the body and water vapor
c. Skin – means of elimination of fluid in the body through perspiration
d. Endocrine –Controls hormones which regulates normal functioning of systems
Imbalances in Fluids & Electrolytes
Fluid Volume Excess Fluid Volume Deficit
Cause fluids exceeds the normal volume fluids and/or electrolytes are
the body needs loss
- physiologic or over hydration as physiologic or dehydration
in IV therapy
Illness:
Renal Disease Renal Disease
Neurologic Diseases Diarrhea
Congestive Heart Failure Post-operative conditions
Addison’s Disease Burns
Trauma
GIT Suction/Drainage
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Clinical Manifestations Weight gain Weight loss
Edema Dry skin and mucous
Flushed skin Membrane
Tachycardia Tachycardia (same w/ excess)
Increased BP, RR Poor skin turgor
Rales Decreased urine output
Neck Vein distention Decreased Central Venous
Increased Central Venous Pressure
Pressure Increased hematocrit
Decreased Hct Urine output: < 30 cc/hr
Urine output: > 1,500 ml/day ( Normal Urine Output =30 cc/hr)
Nursing Interventions Monitor vital signs Monitor vital signs

Monitor I & O Monitor I & O
Fluid restriction Replace fluids, Rehydration
Low sodium diet Weight daily
Weight daily Administer medications as
Prevent skin breakdown- skin is ordered ( depending on
fragile electrolytes loss)
Keep client in Semi-fowler’s Encourage proper nutrition an
position to establish good gas fluid intake
exhange
Administer Diuretics as ordered-
Lasix (Furosemide)
Sources of Electrolytes:
Electrolyte Food source

Potassium Bananas, peaches, melon, prunes, raisins, apricots, tomato, nuts &
vegetables, red meat, turkey
Sodium Iodized or table Salt
Magnesium Peas, beans, nuts, fruits
Calcium Milk, cheese, sardines, fish
4.1 Genitourinary & Renal Problems

Renal Function Tests Normal Values:
a. Blood Urea Nitrogen (BUN) – 10-20 mg/dl
b. Serum Creatinine- 0-1 mg/dL
c. Creatinine Clearance – 100-120 ml/ minute (24 hr. urine collection)
d. Serum Uric Acid -3.5 -7.8 mg/dL
e. Urine Uric Acid – 250-750 mg/ 24 hrs. (24 hr. urine collection)
4.1.2. Cystitis / Urethritis/ Urinary Tract Infection –usually caused by E.Coli
Signs & Symptoms

a. Frequency & Urgency of urination
b. Dysuria
c. Suprapubic pain
d. Hematuria
e. Fever, chills
f. Cloudy urine
Nursing Considerations:
a. Collect urine for testing
b. Antibiotic treatment, as ordered
c. Force fluids
d. Good hygiene
4.1.3. Glomerulonephritis – inflammatory damage of the glomeruli – usually Streptococcus
Signs & Symptoms:
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 Hematuria, proteinuria, fever, chills, weakness, nausea, vomiting
 Edema
 Oliguria
 HPN
 Headache
 Increased Urea Nitrogen
 Flank Pain
 Anemia
a. Penicillin, as ordered
b. Proper dietary intake
c. Sodium & fluid restriction
d. Bed rest
4.1.4. Nephrotic Sydrome – glomeruli disorder due to other diseases like DM, SLE, etc.
Signs & Sypmtoms:

a. Proteinuria
b. Hypoalbunimemia
c. Hyperbilirubinemia
d. Edema
a. bed rest
b. high calorie, high protein, low sodium
c. Monitor I & O
d. Protect from infection
e. Administer meds as ordered: Diuretics, Steroids, Immunosuppresiove agents,
anticoagulants
4.1.5. Urolithiasis - stones in the urinary system
Signs & Symptoms:

a. Dull aching pain
b. Nausea, vomiting, diarrhea
c. Hematuria
d. UTI symptoms
a. Force fluids: at least 3L of water in a day
b. Strain Urine for stones
c. Administer meds as ordered
4.1.6. Acute Renal Failure –sudden and reversible malfunction of the kidney due to trauma, allergies, stones or
benign Prostatic hyperplasia
Signs & Symptoms: 3 Phases

a. Oliguric Phase – sudden , (+) edema
- urine is less than 400 cc in 24 hrs.
b. Period of Diuresis – urine is 1000 ml in 24 hrs and is diluted
c. Recovery Period
a. Treat cause of sudden occurrence
b. Maintain Fluid & electrolyte balance
c. Prevent hypokalemia
d. Administer insulin or IV glucose as ordered to promote potassium absorption
e. Proper diet :
 Oliguric – low CHON, High CHO, high fat, less potassium
 Diuresis – high CHON, high calorie, less fluid
f. Weigh daily
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g. Monitor I & O
h. Dialysis if indicated
i. Psychological & emotional support
4.1.7. Chronic Renal Failure – progressive failure of kidney function which may result to death, caused
by chronic gomerulonephritis (CGN), pyelopnephritis, DM, uncontrolled HPN
Signs & Symptoms:

a. fatigue
b. Headache
c. Gastrointestinal symptoms
d. HPN
e. Irritability
f. Convulsions
g. Anemia
h. Elevated BUN, crea, sodium, potassium
Treatment:
 Dialysis
 Renal Transplant
a. Maintain fluid & electrolyte balance
b. Bedrest
c. Diet: low protein, low sodium, high CHO and vitamins
d. Control HPN
e. WOF cerebral irritation
4.1.8. Benign Prostatic Hyperplasia – enlargement of the prostate with unknown etiology usually in
older males
Signs & Symptoms:
 Difficulty in urinating
 Nocturia, hematuria, dribbling sensation
Surgical Treatment:
 Prostatectomy
Post-operative Nursing Consideration:

a. Observe for shock and hemorrhage
b. Bladder Drainage; monitor bladder irrigation
c. Avoid lifting heavy objects x 6 weeks and avoid strenuous activities
d. Increase fluid intake
e. Decrease pain, administer meds as odered
TREATMENT FOR GENITOURINARY PROBLEMS:

1. Dialysis
a. Hemodialysis
 Process of cleansing the blood of waste products which the GUT is unable to eliminate
 Cathether inserted via a small incision on the neck (intrajugular), arms or at the femoral area.
b. Peritoneal Dialysis
 Use of peritoneum via a catheter for proper exchange of fluids and electrolytes and drainage of
fluids
 Catheter inserted just below the umbilicus with small incision
c. Continuous Ambulatory Peritoneal Dialysis
a. Weigh daily
b. Monitor vital signs
c. Maintain asepsis at all times
d. Record intake and output
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e. Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel
perforation
2. Urinary Tract Surgery
a. Transurethral Removal of the Prostate
b. Prostatectomy
 Weigh daily , monitor I&O
 Monitor vital signs
 Maintain asepsis at all times
 Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel
 Replace fluids
 Proper irrigation
3. Kidney Transplant
KIDNEY DISEASE IN THE PHILIPPINE HEALTH SITUATION
 6,000 new cases of renal disease per year

 Affects all ages
 Adult: End-Stage Renal Disease (ESRD)
Children and young: Chronic Glomrulonephritis
Causes:
1. Chronic Glomerulonephritis – 47%
2. Chronic Pyelopnephritis – 17%
3. Diabetes Mellitus- 13%
4. Hypertensive Nephrosclerosis- 5%
Kidney Disease Prevention:

1. Good Nutrition
2. Clean Environment
3. Early detection of of the disease
4. Thorough urinary screening of asymptomatic children
5. Increase casefinding and treatment for chronic glomerulonephritis
6. Good glycemic control (w/ DM)
7. Optimum Blood Pressure Control
Nursing Health Education:
1. Increase awareness and prevent renal disease:

 Adequate water intake
 Balanced diet
 Good personal hygiene
 Regular exercise
 Regular BP check-up
 Complete immunization for infants and children
 Proper management of throat and skin infections
 Yearly urinalysis
2. Increase awareness of signs & symptoms of kidney disease as edema and HPN
3. Routine screening for UTI, diabetes and kidney disease

5. DISTURBANCES IN CELLULAR FUNCTIONING
5.1. CANCER
o Abnormal growth of tissues

a. Carcinoma - epithelial cells lining the internal and external surfaces of the body.
b. Leukemia - cancer from blood-forming organs
c. Lymphoma – cancer from reticulo-endothelial lymph node organs
d. Sacrcoma- cancer from connective tissues
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Cancer in the Philippines:
o Ranks third in leading cause of morbidity and mortality
o 75% of cancers occur at age 50 y/o
Staging of Tumors
a. Extent of tumor
T= primary tumor
N= regional nodes
M= metastasis
b. Extent of Malignancy
T0 = no evidence of primary tumor
TIS= Carcinoma in Situ
T1, T2, T3, T4 = progressive tumor in size and involvement
TX = tumor cannot be assessed
c. Involvement of Regional Nodes

NO = regional lymph nodes not abnormal
N1, N2,N3, N4 = increasing degree of abnormal regional lymph nodes
d. Metastatic Development
MO= no evidence of distant metastasis
M1, M2, M3 = increasing degree of distant metastasis
Clinical Manifestations of Tumor Presence

(based on Community Health Nursing Services in the Philippines by the DOH)
C Change in bowel or bladder habits Ex. Gastric Ca, Colon Ca, Rectal Ca ,
Renal Ca, Prostate Ca
A A sore that does not heal Ex. Laryngeal Ca
U Unusual bleeding or discharge Ex. Uterine Ca
T Thickening or lump in breast or Ex. Breast Ca, Hodgkin’s Lymphoma
elsewhere
I Indigestion or difficulty in Ex. Esophageal Ca
swallowing
O Obvious change in wart or mole Ex. Melanoma, Squamous cell Ca
N Nagging cough or hoarseness Ex. Lung Ca
U Unexplained Anemia
S Sudden uexplained weight loss Most Ca conditions
Risk Factors
Age Health Habits
Sex Family History
Race Socio-Economic Status
Occupation Lifestyle
Cancer Therapy
a. Surgery
b. Chemotherapy – chemical/ medication
c. Radiation Therapy – electromagnetic rays destroys cancer cells
d. Palliative/ Supportive Care- for end-stage or terminal stage
- given if chemo, surgery or radiation therapy cannot assure treatment of
the patient ; it is a holistic care for the patient and family
- management o f care is geared towards a symptom-free individual with
psychologic and spiritual support
Cancer Prevention & Early Detection
Type of Cancer Early Prevention Early Detection
Oral Cancer Avoid Smoking tobacco, Betel Thorough dental check-up each year
quid “Nganga” chewing,
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Proper cavity and dental
chewing
Breast No conclusive evidence for Monthly self-exam and annual exam with
early prevention physician;
Mammography:
o Initially at age 40 and then 1-2 yrs
thereafter
o High risk women- should consult a
doctor before age 40
Lung Avoid smoking Annual check-up
Uterine / Cervix Clean, safe sex Regular pap smear: Once sexually active then
Single partner reduces risk every 3 years if findings are normal
Liver Hepa. vaccine, Minimal None

alcohol intake, Avoid moldy
foods
Colon and Maintenance of a high fiber Regular medical check-up after 40 years,
Rectum and low fat diet yearly occult blood tests in stools, rectal exams
and sigmoidoscopy
Skin Avoid excessive sun Self skin assessment

exposure
Prostate No conclusive evidence for Rectal Exam

early prevention
a. Assist the patient in maintaining self-dignity and integrity by continued and sustained communication
and contact
b. Allow patient to ventilate feelings such as fear, anger, indifference
c. Make arrangements for spiritual consolation
d. Assist in rehabilitation even before treatment and until she recovers and adjust to the society
e. Collaborate with other health workers for the patient’s holistic needs
f. Home visits and education about the client’s condition, course of treatment and alternatives
Priorities for Health Supervision:

a. Newly diagnosed cases
b. Post-operative Cases
c. Indigent Cases
d. Terminal Cases
5.2. HEMATOLOGIC PROBLEMS
Normal Values to Remember:
Blood Component Normal Values
RBC – red blood cells Female: 4.2 – 5.4 x 106

Male: 4.7 – 6.1 x 106
Hgb - hemoglobin Female: 11.5 – 15.5 g/dL

Male: 13.5 – 17.5 g/dL
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Hct - hematocrit Female: 36 – 48%
Male: 40 -52%
WBC – white blood cells 4,500 – 11,000/ mm3
PC- Platelet count 150, 000 – 400,000 / mm3
5.2.1. ANEMIA
Causes:
a. Sudden or Chronic blood loss
b. Abnormal bone marrow function
c. RBC fails to mature adequately
Signs & Symptoms:

Fatigue, Weakness, Dizziness, Pallor, Decreased RBC, hemoglobin & hematocrit
Types of Anemia:
a. Hypoproliferation Anemia – bone marrow fails to produce adequate blood cells

a. Iron Deficiency Anemia – nutritional deficiency, blood loss
b. Aplastic Anemia - due to radiation, drugs, toxin
c. Anemia due to Renal Disease
 Hypoxia
 Prone to infection
 Fatigue
 Easy bruising
 Proper nutrition
 Psychological support
 Protect against infection and injury
b. Megaloblastic Anemia – due to previous gastric surgery, malabsorption or atrophy of the

gastric mucosa
 Pernicious Anemia – Vit. B12 and Folic acid deficiency in gastric juice
 Paresthesia
 Tingling or numbness of extremities
 Gait disturbances
 Behavioral Disturbances
 Intake of Vit. B12 following this regimen:
o 3x a week for 2 weeks, then
o 2 x a week for 2 weeks, then
o Once a month
 Protect lower extremities
 Rest in non-stimulating environment
c. Hemolytic Anemia
 Sickle Cell Anemia- defective hemoglobin, turns to sickle cell when oxygen in venous
blood is low
 Thalassemia
 Glucose-6 Phosphate Dehydrogenase Deficiency
 Thalassemia & G6PD – usually asymptomatic
 Sickle Cell Anemia:
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o Severe Pain
o Swelling
o Fever
o Jaundice
o Prone to infection
 Proper oxygenation
 Hydration
 Analgesics
 Adequate Rest
 Refer to genetic counseling
 Avoid cold places to prevent sickle cell proliferation
5.2.2. LEUKOCYTOSIS & LEUKEMIA
Leukocytosis – increase level of WBC, persistent increased can be malignant
Leukemia - proliferation of neoplastic white blood cells in the bone marrow affecting the
different tissues and organs in the body
 Acute & Chronic Myeloid Leukemia (AML / CML)

 Acute & Chronic Lymphocytic Leukemia (ALL / CML)
 Angiogenic Myeloid Metaplasia (AMM)
 Fever
 Prone to Infection
 Pain
 Weight Loss
 Fatigue
 Energy conservation
 Reverse Isolation
 Blood Transfusion
5.2.3. POLYCYTHEMIA – neoplasm of myeloid cells

 Dizziness, headache, tinnitus, fatige, paresthesia, blurred vision, atherosclerosis
5.2.4. THROMBOCYTOPHENIA - Increased Bleeding Tendencies
5.2.5. LYMPHOMAS – neoplasm of lymphatic cells

 Hodgkin’s Lymphoma
 Non-Hodgkin’s Lymphoma
 Multiple Myeloma
 Thrombocytophenia – low platelet , bleeding
Management: Chemotherapy, Blood Transfusions, Reverse Isolation, Radiation therapy,

Steroids
 Emotional Support
 Reverse isolation
 Adequate Rest and Nutrition
 Strict Medication Regimen
5.2.6. BLOOD TRANSFUSION
Types of Blood Components Transfused

1. Whole Blood
2. Packed Red Blood Cells
3. Fresh Frozen Plasma/ Plasma Concentrate
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Transfusion Complications
1. Non-hemolytic reaction- Fever
2. Hemolytic Reaction- life threatening: fear, chills, backpain, nausea, chest tightness, dyspnea and anxiety
3. Allergic reaction –urticaria, flushing, itching
4. Hypervolemia – neck vein distention, dyspnea, orthopnea, tachycardia, sudden anxiety
Diseases Transmitted through Blood Transfusion

 Hepatitis B or C , AIDS / HIV, Cytomegalovirus
1. Check name, ID, blood type, expiration, serial #

2. Take baseline vitals signs
3. Blood pack should be at room temperature
4. Monitor for transfusion reaction
 Allergic (pruritus, respiratory distress, urticaria)
 Hemolytic (low back pain, fever, chills)
5. Treat transfusion reaction, if present – symptomatic treatment
NEUROLOGIC DISTURBANCES
I. Central Nervous System:
a. Brain
b. Spinal Cord
II. Peripheral Nervous System
a. Cranial Nerves – 12 pairs

b. Spinal Nerves – 31 pairs
 Cervical – 8
 Thoracic – 12
 Lumbar – 5
 Sacral – 5
 Coccygeal - 1
c. Autonomic Nervous System
 Sympathetic Nervous System
 Parasympathetic Nervous System
The Cranial Nerves:

o Oh, Oh, Oh, To Touch And Feel A Girls Veil So Heaven
I Olfactory Smell
II Optic Visual Acuity
III Oculomotor Pupil constriction and dilation
IV Trochlear Eye movement: Inferior and medial
V Trigeminal Jaw muscles
VI Abducens Eye movement: Lateral directions
VII Facial Symmetrical facial movement, Client
identifies taste, Eyelid reaction to stimulus
VIII Auditory Hearing Acuity
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IX Glossopharyngeal Gag Response
X Vagus Ability to speak clearly
XI Spinal Accessory Shoulder’s ability to resist against
pressure
XII Hypoglossal Tongue at midline
Neurologic Status:
a. Conscious- alert, attentive, and follows command

b. Lethargic- drowsy but awakens; follows command, but slowly and inattentively
c. Stuporous - arouses to vigorous and continuous stimulation
-response may be an attempt to remove the painful stimulus.
d. Coma. – no sounds, no movement
THE GLASGOW COMA SCALE
- An assessment tool measuring the individual’s neurologic status specifically the spontaneity of the client’s eye
movement , speaking ability and motor abilities in response to a stimuli.
Perfect score is 15 points - Spontaneous/ Normal eye, motor and verbal response
Lowest score is 3 points - No response
Points
a. Spontaneous 4
Eye b. To speech 3
Opening c. To pain 2
Response d. No response 1
a. Obeys verbal commands 6

b. Localizes pain 5
c. Flexion: no withdrawal 4
Motor d. Flexion: abnormal (decorticate) 3
Response e. Extension: abnormal (decerebrate) 2
f. No response to pain on any limb 1
a. Oriented 5
Best verbal b. Able to Converse 4
response c. Inappropriate speech 3
d. Makes incomprehensible sound 2
e. No response 1
Example:
Patient s conscious, coherent. Eye slightly opens when name is called ;

Can tell where he is, can look at No movement/response when skin is
surroundings, can raise hands Pinched ;
when asked to, and can express When calling the nurse: can only say
self through words, answer “ne….e…e.” sound
questions appropriately.
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GCS Scoring: GCS Scoring:
Eye opening = 4 Eye opening = 3

Motor Response = 6 Motor Response = 1
Verbal Response = 5 Verbal Response = 2
GCS Score = 15 GCS Score = 6
CEREBROVASCULAR ACCIDENT (CVA)

“Stroke”
o
o A sudden disruption of blood supply to the brain which may lead to temporary or permanent
dysfunction.
Risks Factors: HPN, Obesity, peripheral vascular disease, obesity, aneurysm
Signs & Syptoms:

a. Speech problem / Aphasia - a loss or impairment of the ability
to produce and/or comprehend language
b. Hemiparesis- weakness of one side of the body
c. Hemiplegia - total paralysis of the arm, leg and trunk on the
same side f the body.
d. Decreased awareness of body space
Types of stroke:
1. Transient Ischaemic Attack (TIA)

- short-term stroke that lasts for less than 24 hours ( seconds or minutes in a day)
- oxygen supply to the brain is restored quickly
- transient stroke needs prompt medical attention as it is a warning of serious risk of
a major stroke.
2. Cerebral thrombosis
- a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain.
- brain cells are starved of oxygen.
3. Cerebral embolism
- blood clot that forms and then travel to the brain.
4. Cerebral hemorrhage
- occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a hemorrhage,
extra damage is done to the brain tissue by the blood that seeps into it.
1. Maintain adequate airway

2. Monitor neuro vital signs: Vital signs and Glasgow coma scale including intake and output
3. Maintain fluid & electrolyte balance
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SPINAL CORD INJURY
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Definition: A damage in the nerve structure causing dysfunction resulting to paralysis, sensory loss and altered
activity.
Cause:
Vehicular accidents, Violence, Falls,
Sports, Infection, Tumor
The Spinal Nerves:

1. Cervical Nerve
2. Thoracic Nerve
3. Lumbar Nerve
4. Sacral Nerve
Etiology:
1. Spinal Shock (Areflexia)
2. Autonomic Hyperreflexia
- Injury in T6 and above
- Life-threatening
Nerves Level Body part affected Spinal Cord

Injury Effect
C1 Head & Neck Paralysis below neck; impaired breathing, bowel & bladder
Cervical C2 incontinence, sexual dysfunction
Nerve C3
C4
Injury C5 Diaphragm Shoulder elevation possible, ventilation support
causes C6 Deltoid, biceps
Quadriplegia C7 Wrist Extenders Elbow, upper arm, wrist movement
/ Tetraplegia C8 Triceps
Thoracic T1 Hand
Nerve T2 Loss of hand control, Paralysis below waist
T3
Injury T4
causes T5 Chest Muscles
Paraplegia T6
T7
T8 Abdominal Trunk and Abdominal control
T9 Muscles
T10
T11
T12
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L1
Lumbar Nerve
L2
Paralysis of L3 Knee and ankle movement impaired

legs; loss of L4 Leg muscles
bladder and L5
S1
S2
Bladder & Bowel control Bladder/Bowel Incontinence,etc
Sacral Nerve S3
S4 Sexual Control Decrease sensation in the peineum
Sexual, Bladder
S5
& Bowel conrol
PARKINSON’S DISEASE
PARKINSON’S DISEASE
Definition: A disorder affecting control and regulation of movement
- Unilateral flexion of arms, shuffling gait, difficulty in walking, weakness, disability
a. Rigidity
b. Involuntary body tremors
c. Hips and knees flexion
d. Masklike facial expression
e. Slurred speech
f. Drooling
g. Constipation
h. Depression
i. Retropulsion, propulsion
Medical Management: Anti-parkinsonian Agent: Levodopa

Anti-cholinergic: Cogentin
Surgical Management: Stereotaxic Thalamotomy – surgery of the thalamus to treat disorder
a. Rehabiltation – exercise
b. Speech therapy
c. Diet: Low CHIN in am, high CHON in PM
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d. High fiber foods to promote bowel elimination
e. Prevent Injury – fall, etc
MYASTHENIA GRAVIS
Definition: Severe weakness of one or ore groups of skeletal muscles;

Severe weakness of the neuro functions most commonly affecting the
Seventh cranial nerve- Facial Nerve
Clinical Manifestation:
1. Mask-like facial expression
2. Diplopia- double-vision
3. Ptosis- difficulty opening of the eye
4. Dyphagia
Management:
a. Pyridostigmine Bromine (mestinon)
b. Ambenomium Chloride
c. Steroids –Prednisone
d. Atrophine Sulfate
Nursing Interventions: Avoid fatigue, Administer meds as ordered, Avoid neomycin and morphine
CATARACT
Definition: - the eye lenses becomes thick and unclear or yellowish.
2. Gradual visual loss.
3. Hazy vision / Yellowish haze
4. Whitish to yellowish eyelense.
Surgical Treatment: Cataract extraction
Drug: Vision
Vision w/
w/ Cataract
Cataract
1. Mydriatrics - causes dilation of pupils; increases intraocular pressure (IOP)
a. Atrophine Sulfate
b. Phenylephrine Hydrochloride
2. Cyclopegics – decreases ciliary muscle accomodation
Side effects: blurred vision, increase BP
1. Monitor BP; avoid use to patients with HPN
2. Teach client that blurring of vision may be experienced.
3. Post-op intervention:
 keep eye covered
 head of bed elevated at 30-45 degreed, supine position
 Avoid bending or lifting heavy objects, coughing and sneezing as it may further increase
IOP
GLAUCOMA
- A non-curable condition of the eye due to increase in intraocular pressure causing

deterioration of the optic nerve.
2 types of Glaucoma:
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1. Acute or Closed- Angle Glaucoma
a. Rainbow around lights
b. Pain around the eye
c. Cloudy and blurred vision
d. Nausea & vomiting
e. Dilation of pupils
2. Chronic or Open-Angle Glaucoma

a. Halo around lights
b. Progressive loss of vision
c. Tired feeling in the eye
d. Slowly diminishing peripheral vision
Surgical Management: Vision w/ Glaucoma

1. Trabeculectomy
2. Thermosclerectomy
3. Iridenclesis
Drugs:
Miotics – causes constriction of pupils
1. Pilocarpine hydrochloride - Drains aqueous humor

2. Acetazolamide – decreases production of aqueous humor
3. Mannitol – reduces IOP
4. Isosorbid – also decreases production of aqueous humor
1. Administer drugs as ordered
2. Teach client that glaucoma can be controlled but not curable (even surgery can’t cure the disease)
3. Encourage moderate exercise
4. Avoid straining of bowel
5. Encourage low residue, high fiber diet
6. MUSCULOSKELETAL DISTURBANCES
JOINT DISORDERS RHEUMATOID ARTHRITIS OSTEOARTHRITIS
Definition A systemic inflammatory disorder of Degeneration of the articular cartilage

connective tissues and/ or joints Wear & Tear of joints
characterized by exacerbation & remission.
Kinds of Joints Cervical, finger joints, ulnar, can also be Weight-bearing joints: knees, hips, spine
involved:heart and lung (as in rheumatic heart
disease)
Incidence Chronic disease; early to mid-adulthood, Older women

common in women
Clinical Manifestations  Synovitis Pain felt after activity

 Pain relieved with rest
 Intermittent bone pain, swelling, redness,
warm feeling due to vasodialtion and
increased blood flow
 Pannus formation- granulation of tissue
causing destruction of adjacent cartilage,
joints and bones
 fatigue, anorexia, malaise, weight loss
Management Rest, exercise, ASA, NSAIDs, Steroids, heat Balanced rest and activity, heat packs,
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steroids in joist only
Drug: Steroid, ASA, Indomethacin,

Phenylbutazone
Nursing Intervention Maintain body alignment, Balance rest and exercise, proper diet
Gout / Gouty Arthritis
Defintion: painful metabolic disorder due to inflammation of the joints due to

high uric acid
Risk Factors: Hereditary, most common in men
Clinical Manifestations A salt of uric acid (Urate) crystallizes in soft and bony tissues causing local inflammation and
irritation.
Severe pain, usually in great toe
Red, painful and swollen joints
Tophi (crystal formation in joints) are palapated around great toes, fingers,
earlobes
Drugs: Allopurinol
NSAID’s – Ibubrofen , Indomethacin
Probenecid
Colchicine
Sulfinpyrazone
Nursing Management:
a. Bedrest during attacks
b. Heat or cold compress
c. Increase fluid intake to flush out uric acid
d. Avoid eating organ meats, shellfish, sardines - - - food with high purine / uric acid content
Systemic Lupous Erythematosus (SLE)
Definition: Diffuse connective tissue disease affecting skin, joints, kidney, serous membranes of the heart and
lungs, lymph nodes and GI tract.
Risk factors: Children, middle-aged and elderly; hereditary
Clinical Manifestations: “Butterfly rash” in the face ( across both cheeks and nose)
Manifests symptoms same as that of arthritis and Raynaud’s
Management: NSAID’s
Steroids
Cytotoxic drugs - Azathioprine, Cyclophosphamide
Nursing Intervenions:
a. Avoid exposure to sunlight because symptoms aggravate symptoms or wear hats, umbrella or
sunscreen
b. Adequate nutrition, rest and exercise
c. Stress management, if possible avoid stress
Fractures
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Definition: A break in the continuity of the bones
Pain Edema
Loss of function Spasm
Deformity Crepitus
False motion Hematoma around skin
Breaks for penetrating bone fragments
Management:
First Aid 1. Maintain airway and circulation

2. Immobilize joints that may be affected; Splint limb
3. Bring to nearest hospital/medical institution
Traction -balanced pulling of the musculoskeletal structure to align bones; requires

countertraction
Closed Reduction - external manipulation such as manually aligning bones by pulling. For patients
who have lower pain tolerance (elderly, children) reduction may be done under
sedation anesthesia.
Open Reduction - internal manipulation of bones requiring surgical operation
Internal Fixation - surgically applying screws, plates, pins, nails to align bones (opening of the
skin and exposing bones affected); skin is closed after the procedure.
External Fixation - applying nails and metal screws to bones through the skin surface
Casts -a rigid mold used to immobilize an injured structure to promote healing
Nursing Management:
1. Mainatin positioning
2. For tractionL maintaing weights and countertraction
3. Clean wounds to prevent infection
4. Assess for VASCULAR OCCLUSION
5 P’s: 5 signs of Vascular Occlusion due to extremely tight casts / traction

a. Pain
b. Pallor
c. Pulselessness
d. PAresthesia
e. Paralysis
7. INTEGUMENTARY DISTURBANCES
Burn
Depth of Injury Manifestation Level of Skin Affected
First-degree Painful, pink to reddish, Epidermis and part of dermis Superficial

subsides quickly
Second-degree Pain, pink to red, with blisters Epidermis and dermis hair follicle Superficial partial
(fluid formation) intact thickness; Deep
partial thickness
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Third- degree Reddish, brownish or whitish, Epidermis, dermis, subcutaneous Full thickness
painless, eschar formation tissue
(Leather-like skin)
Fourth-degree Epidermis, dermis, subcutaneous Full thickness

tissue; fat, fascia, muscle and bone
Rule of Nines:
a. Head and Neck - 9%
b. Anterior Truck - 18%
c. Posterior Trunk - 18%
d. Arms - 9% each = 18%
e. Legs - 18% each = 36%
f. Perineum - 1%
100%
Rule of
Nine’s
Management:
First-Aid:
1. Burning person: Ask person to stop, drop and roll ( lie down and roll)
2. Burning person: Stop burning process such as wrapping the burning part with wet towel or blanket
3. Check airway
4. First-degree burn: Run cool water to affected area for 10 minutes
Hospital Interventions:
1. Check ABC, give oxygen and IV fluids
2. Assess client’s data, history of injury (time, cause,etc)
3. Maintain asepsis- burn patients are very prone to infections
4. Medical – Surgical Management:
a. Tetanus toxoid
b. Topical Anti-microbial agent: Silver Nitrate, Silver Sulfadiazine, Gentamicin Sulfate, Mafenide acetate
c. Debridement
SHOCK
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•Failure of the circulatory system to maintain adequate perfusion of vital organs.
•Critically severe deficiency in nutrients, oxygen and electrolytes delivered to body tissues, plus deficiency in removal of cellular
wastes, resulting to cardiac failure
I. Stages of Shock
1. Non- progressive Stage
- Cardiac output is slightly decreased
- Body compensates
2Progressive Stage
- Compensatory mechanism is not adequate
- blood flow to the heart is not adequate thus heart begins to deteriorate
3. Irreversible Stage
- Inadequate tissue perfusion
- Cellular ischemia & necrosis lead to organ failure
II. Types of Shock
Cause Etiology
Hypovolemic Shock due to inadequate circulating blood Blood loss: Massive Trauma, GI
volume Bleeding, Ruptured Aortic Aneurysm,
Surgery, Erosion of Vessesl due to lesion,
tubes or other devices, Disseminated
Intravascular Coaguation
Plasma loss: Burns, Accumulation of

intra-abdominal fluid, malnutrition, severe
dermatitis, DIC
Crystalloid loss: Dehydration, Protracted
Vomiting, Diarrhea, nasogastric suction
Cardiogenic Shock due to inadequate pumping action Myocardial disease:

of the heart because of primary Acute MI, Myocardial Contusion
cardiac muscle dysfunction or
mechanical obstruction of blood flow Cardiomypathies Valvular Disease or injury:
caused by MI or valvular Ruptured Aortic Cusp, Ruptured Papillary
insufficiency muscle, Ball thrombus
External Pressure on the Heart interferes with

heart filling or emptying:
Pericardial Tamponade due to Trauma,
aneurysm, cardiac surgery,
pericarditis, massive pulmonary
embolus, tension pneumothorax
Cardiac Dysrhtymias:
Tachyarrhythmias, Bradyarrythmias,
Electromechanical dissociation
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3. Distributive Shock
a. Neurogenic - interference with nervous

Shock system control of the blood
vessels Spinal: Spinal anesthesia, spinal
cord injury
Vaso-vagal reaction: Severe pain,
b. Anaphylactic -severe hypersensitivity reaction
severe emotional stress
Shock resulting in massive systemic
vasodilation Allergy to food, medicines, dye, insect bites or
stings
c. Septic Shock - systemic reaction vasodilation

due to infection
Gram-negative septicemia but also caused by

other organisms
III. Signs of Shock
Anxiety BP- hypotension

Restlessness Pulse – tachycardia, thready, irregular (Cardio.Shock)
Dizziness Respiration: increased depth, tachypnea, wheezing
Thirst (anaphylactic shock)
Fainting Temperature: cold clammy skin, elevated in anaphylactic
Pale skin, urticaria in anaphylactic shock LOC - could be alert, oriented, unresponsive
Oliguria, Slow capillary refill CVP – below 5 cm H20 (hypovolemic)
- above 15 cms (cardio & septic)
IV. Nursing Care Management
GOAL: Promote venous return, circulatory perfusion
1. Position: Feet elevated with head slightly elevated also

2. Ventilation: loosen restrictive clothing, O2, monitor respiration
3. Fluids: IV, administer blood/plasma as ordered ( stop blood immediately in anaphylactic s.)
4. Vital signs: CVP, ECG, U.O.,Swan Ganz
5. Medications (depends on type)
6. Antihypotensive (epinephrine, norepinephrine, dopamine)
7. Anti-arrythmics, Cardiac Glycosides, Antibiotics, Adrenocorticoids
8. Vasodilators (nitroprusside), Beta-adrenergic (dobutamine)
9. Mechanical support : Military Anti-shock Trousers(MAST)
IV. Effects of Shock in Different Organs
•Respiratory System Hypoxia

Lactic acid accumulates tissue necrosis
•Cardiovascular System Myocardial deterioration

Disseminated Intravascular Coagulation
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•Neuroendocrine System Stage of resistance
o ADH is released causing kidneys to retain
sodium and water
o Increase in adrenocorticoid mineralcorticoid
hormones
•Immune System Macrophages in bloodstream and tissues are depressed

Increased susceptibility to shock
•GI System GIT vagal stimulation stops/slow down

no peristalsis
Liver – ability to detoxify is lost; blood is pooled in the
liver or portal bed
•Renal System Altered capillary blood pressure and glomerular filtration

Renal ischemia
V. FIRST AID
*** FIRST AID: Details from www.redcross.org
Dislocation: First aid***
1. Get medical help immediately.
2. Don't move the joint. Splint the affected joint into its fixed position. Don't try to move a dislocated joint or force it
back into place. This can damage the joint and its surrounding muscles, ligaments, nerves or blood vessels.
3. Put ice on the injured joint. This can help reduce swelling by controlling internal bleeding and the buildup of
fluids in and around the injured joint.
Minor cuts and scrapes usually don't require a trip to the emergency room. Yet proper care is essential to avoid infection
or other complications. These guidelines can help you care for simple wounds:
1. Stop the bleeding. Minor cuts and scrapes usually stop bleeding on their own. If they don't, apply gentle
pressure with a clean cloth or bandage. Hold the pressure continuously for 20 to 30 minutes. Don't keep checking
to see if the bleeding has stopped because this may damage or dislodge the fresh clot that's forming and cause
bleeding to resume. If the blood spurts or continues to flow after continuous pressure, seek medical assistance.
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2. Clean the wound. Rinse out the wound with clear water. Soap can irritate the wound, so try to keep it out of the
actual wound. If dirt or debris remains in the wound after washing, use tweezers cleaned with alcohol to remove
the particles. If debris remains embedded in the wound after cleaning, see your doctor. Thorough wound cleaning
reduces the risk of tetanus. To clean the area around the wound, use soap and a washcloth. There's no need to
use hydrogen peroxide, iodine or an iodine-containing cleanser. These substances irritate living cells. If you
choose to use them, don't apply them directly on the wound.
3. Apply an antibiotic. After you clean the wound, apply a thin layer of an antibiotic cream or ointment such as
Neosporin or Polysporin to help keep the surface moist. The products don't make the wound heal faster, but they
can discourage infection and allow your body's healing process to close the wound more efficiently. Certain
ingredients in some ointments can cause a mild rash in some people. If a rash appears, stop using the ointment.
4. Cover the wound. Bandages can help keep the wound clean and keep harmful bacteria out. After the wound has
healed enough to make infection unlikely, exposure to the air will speed wound healing.
5. Change the dressing. Change the dressing at least daily or whenever it becomes wet or dirty. If you're allergic to
the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze held in place with paper
tape, gauze roll or a loosely applied elastic bandage. These supplies generally are available at pharmacies.
6. Get stitches for deep wounds. A wound that cuts deeply through the skin or is gaping or jagged-edged and has
fat or muscle protruding usually requires stitches. A strip or two of surgical tape may hold a minor cut together, but
if you can't easily close the mouth of the wound, see your doctor as soon as possible. Proper closure within a few
hours minimizes the risk of infection.
7. Watch for signs of infection. See your doctor if the wound isn't healing or you notice any redness, drainage,
warmth or swelling.
8. Get a tetanus shot. Doctors recommend you get a tetanus shot every 10 years. If your wound is deep or dirty
and your last shot was more than five years ago, your doctor may recommend a tetanus shot booster. Get the
booster within 48 hours of the injury
For minor burns, including second-degree burns limited to an area no larger than 2 to 3 inches in diameter, take the
following action:
 Cool the burn. Hold the burned area under cold running water for at least 5 minutes, or until the pain subsides. If
this is impractical, immerse the burn in cold water or cool it with cold compresses. Cooling the burn reduces
swelling by conducting heat away from the skin. Don't put ice on the burn.
 Cover the burn with a sterile gauze bandage. Don't use fluffy cotton, which may irritate the skin. Wrap the gauze
loosely to avoid putting pressure on burned skin. Bandaging keeps air off the burned skin, reduces pain and
protects blistered skin.
 Take an over-the-counter pain reliever. These include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve)
or acetaminophen (Tylenol, others). Never give aspirin to children or teenagers.
Minor burns usually heal without further treatment. They may heal with pigment changes, meaning the healed area may
be a different color from the surrounding skin. Watch for signs of infection, such as increased pain, redness, fever,
swelling or oozing. If infection develops, seek medical help. Avoid re-injuring or tanning if the burns are less than a year
old — doing so may cause more extensive pigmentation changes. Use sunscreen on the area for at least a year.
Caution
 Don't use ice. Putting ice directly on a burn can cause frostbite, further damaging your skin.
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 Don't break blisters. Broken blisters are vulnerable to infection.
Third-degree burn
The most serious burns are painless and involve all layers of the skin. Fat, muscle and even bone may be affected. Areas
may be charred black or appear dry and white. Difficulty inhaling and exhaling, carbon monoxide poisoning or other toxic
effects may occur if smoke inhalation accompanies the burn.
For major burns, dial 911 or call for emergency medical assistance. Until an emergency unit arrives, follow these steps:
1. Don't remove burnt clothing. However, do make sure the victim is no longer in contact with smoldering
materials or exposed to smoke or heat.
2. Don't immerse severe large burns in cold water. Doing so could cause shock.
3. Check for signs of circulation (breathing, coughing or movement). If there is no breathing or other sign of
circulation, begin cardiopulmonary resuscitation (CPR).
4. Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist towels.
Chemical burns: First aid***
If a chemical burns the skin, follow these steps:
1. Remove the cause of the burn by flushing the chemicals off the skin surface with cool, running water for 15
minutes or more. If the burning chemical is a powder-like substance such as lime, brush it off the skin before
flushing.
2. Remove clothing or jewelry that has been contaminated by the chemical.
3. Wrap the burned area loosely with a dry, sterile dressing or a clean cloth.
Minor chemical burns usually heal without further treatment.
Seek emergency medical assistance if:
 The victim has signs of shock, such as fainting, pale complexion or breathing in a notably shallow manner.
 The chemical burn penetrated through the first layer of skin, and the resulting second-degree burn covers an area
more than 2 to 3 inches in diameter.
 The chemical burn occurred on the eye, hands, feet, face, groin or buttocks, or over a major joint.
If you're unsure whether a substance is toxic, call the poison center.
An electrical burn may appear minor or not show on the skin at all, but the damage can extend deep into the tissues
beneath your skin. If a strong electrical current passes through your body, internal damage, such as a heart rhythm
disturbance or cardiac arrest, can occur. Sometimes the jolt associated with the electrical burn can cause you to be
thrown or to fall, resulting in fractures or other associated injuries.
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Dial 911 or call for emergency medical assistance if the person who has been burned is in pain, is confused, or is
experiencing changes in his or her breathing, heartbeat or consciousness.
While helping someone with an electrical burn and waiting for medical help, follow these steps:
1. Look first. Don't touch. The person may still be in contact with the electrical source. Touching the person may
pass the current through you.
2. Turn off the source of electricity if possible. If not, move the source away from both you and the injured
person using a nonconducting object made of cardboard, plastic or wood.
3. Check for signs of circulation (breathing, coughing or movement). If absent, begin cardiopulmonary
resuscitation (CPR) immediately.
4. Prevent shock. Lay the person down with the head slightly lower than the trunk and the legs elevated.
5. Cover the affected areas. If the person is breathing, cover any burned areas with a sterile gauze bandage, if
available, or a clean cloth. Don't use a blanket or towel. Loose fibers can stick to the burns.
Domestic pets cause most animal bites. Dogs are more likely to bite than cats. Cat bites, however, are more likely to
cause infection. Bites from nonimmunized domestic animals and wild animals carry the risk of rabies. Rabies is more
common in raccoons, skunks, bats and foxes than in cats and dogs. Rabbits, squirrels and other rodents rarely carry
rabies. If an animal bites you or your child, follow these guidelines:
 For minor wounds. If the bite barely breaks the skin and there is no danger of rabies, treat it as a minor wound.
Wash the wound thoroughly with soap and water. Apply an antibiotic cream to prevent infection and cover the bite
with a clean bandage.
 For deep wounds. If the animal bite creates a deep puncture of the skin or the skin is badly torn and bleeding,
apply pressure with a clean, dry cloth to stop the bleeding and see your doctor.
 For infection. If you notice signs of infection such as swelling, redness, increased pain or oozing, see your doctor
immediately.
 For suspected rabies. If you suspect the bite was caused by an animal that might carry rabies — any bite from a
wild or domestic animal of unknown immunization status — see your doctor immediately.
Doctors recommend getting a tetanus shot every 10 years. If your last one was more than five years ago and your wound
is deep or dirty, your doctor may recommend a booster. You should have the booster within 48 hours of the injury.
Fall prevention: 6 ways to reduce your falling risk***
Falls put you at risk of serious injury. Prevent falls with these fall-prevention measures.
Your odds of falling each year after age 65 are about one in three. Fortunately, most of these falls aren't serious. Still, falls
are the leading cause of injury and injury-related death among older adults. You're more likely to fall as you get older
because of common, age-related physical changes and medical conditions — and the medications you take to treat such
conditions.
You needn't let the fear of falling rule your life. Many falls and fall-related injuries are preventable with fall-prevention
measures. Here's a look at six fall-prevention approaches that can help you avoid falls.
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Fall-prevention step 1: Make an appointment with your doctor
Begin your fall-prevention plan by making an appointment with your doctor. You and your doctor can take a
comprehensive look at your environment, your health and your medications to identify situations when you're vulnerable to
falling. In order to devise a fall-prevention plan, your doctor will want to know:
 What medications are you taking? Include all the prescription and over-the-counter medications you take, along
with the dosages. Or bring them all with you. Your doctor can review your medications for side effects and
interactions that may increase your risk of falling. To help with fall prevention, he or she may decide to wean you off
certain medications, especially those used to treat anxiety and insomnia.
 Have you fallen before? Write down the details, including when, where and how you fell. Be prepared to discuss
instances when you almost fell but managed to grab hold of something just in time or were caught by someone.
 Could your health conditions cause a fall? Your doctor likely wants to know about eye and ear disorders that
may increase your risk of falls. Be prepared to discuss these and to tell him or her how you walk — describe any
dizziness, joint pain, numbness or shortness of breath that affects your walk. Your doctor may then evaluate your
muscle strength, balance and individual walking style (gait).
Fall-prevention step 2: Keep moving
If you aren't already getting regular physical activity, consider starting a general exercise program as part of your fall-
prevention plan. Consider activities such as walking, water workouts or tai chi — a gentle exercise that involves slow and
graceful dance-like movements. Such activities reduce your risk of falls by improving your strength, balance, coordination
and flexibility. Be sure to get your doctor's OK first, though.
If you avoid exercise because you're afraid it will make a fall more likely, bring this concern to your doctor. He or she may
recommend carefully monitored exercise programs or give you a referral to a physical therapist who can devise a custom
exercise program aimed at improving your balance, muscle strength and gait. To improve your flexibility, the physical
therapist may use techniques such as electrical stimulation, massage or ultrasound. If you have inner ear problems that
affect your balance, he or she may also teach you balance retraining exercises (vestibular rehabilitation) — which involve
specific head and body movements to correct loss of balance.
Fall-prevention step 3: Wear sensible shoes
Consider changing your footwear as part of your fall-prevention plan. High heels, floppy slippers and shoes with slick
soles can make you slip, stumble and fall. So can walking in your stocking feet. Instead:
 Have your feet measured each time you buy shoes, since your size can change.
 Buy properly fitting, sturdy shoes with nonskid soles.
 Avoid shoes with extra-thick soles.
 Choose lace-up shoes instead of slip-ons, and keep the laces tied.
 Select footwear with fabric fasteners if you have trouble tying laces.
 Shop in the men's department if you're a woman who can't find wide enough shoes.
If bending over to put on your shoes puts you off balance, consider a long shoehorn that helps you slip your shoes on
without bending over.
Fall-prevention step 4: Remove home hazards
As part of your fall-prevention measures, take a look around you — your living room, kitchen, bedroom, bathroom,
hallways and stairways may be filled with booby traps. Clutter can get in your way, but so can the decorative accents you
add to your home. To make your home safer, you might try these tips:
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 Remove boxes, newspapers, electrical cords and phone cords from walkways.
 Move coffee tables, magazine racks and plant stands from high-traffic areas.
 Secure loose rugs with double-faced tape, tacks or a slip-resistant backing.
 Repair loose, wooden floorboards and carpeting right away.
 Store clothing, dishes, food and other household necessities within easy reach.
 Immediately clean spilled liquids, grease or food.
 Use nonskid floor wax.
 Use nonslip mats in your bathtub or shower.
Fall-prevention step 5: Light up your living space
As you get older, less light reaches the back of your eyes where you sense color and motion. So keep your home brightly
lit with 100-watt bulbs or higher to avoid tripping on objects that are hard to see. Don't use bulbs that exceed the wattage
rating on lamps and lighting fixtures, however, since this can present a fire hazard. Also:
 Place a lamp near your bed and within reach so that you can use it if you get up at night.
 Make light switches more easily accessible in rooms. Make a clear path to the switch if it isn't right near the room
entrance. Consider installing glow-in-the-dark or illuminated switches.
 Place night lights in your bedroom, bathroom and hallways.
 Turn on the lights before going up or down stairs. This might require installing switches at the top and bottom of
stairs.
 Store flashlights in easy-to-find places in case of power outages.
Fall-prevention step 6: Use assistive devices
Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help, too. All sorts
of gadgets have been invented to make everyday tasks easier. Some you might consider:
 Grab bars mounted inside and just outside your shower or bathtub.
 A raised toilet seat or one with armrests to stabilize yourself.
 A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Buy a hand-held shower
nozzle so that you can shower sitting down.
 Handrails on both sides of stairways.
 Nonslip treads on bare-wood steps.
Ask your doctor for a referral to an occupational therapist who can help you devise other ways to prevent falls in your
home. Some solutions are easily installed and relatively inexpensive. Others may require professional help and more of
an investment. If you plan on staying in your home for many more years, an investment in safety and fall prevention now
may make that possible.
Signs and symptoms of an insect bite result from the injection of venom or other substances into your skin. The venom
triggers an allergic reaction. The severity of your reaction depends on your sensitivity to the insect venom or substance.
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Most reactions to insect bites are mild, causing little more than an annoying itching or stinging sensation and mild swelling
that disappear within a day or so. A delayed reaction may cause fever, hives, painful joints and swollen glands. You might
experience both the immediate and the delayed reactions from the same insect bite or sting. Only a small percentage of
people develop severe reactions (anaphylaxis) to insect venom. Signs and symptoms of a severe reaction include facial
swelling, difficulty breathing and shock.
Bites from bees, wasps, hornets, yellow jackets and fire ants are typically the most troublesome. Bites from mosquitoes,
ticks, biting flies and some spiders also can cause reactions, but these are generally milder.
For mild reactions:
 Move to a safe area to avoid more stings.
 Scrape or brush off the stinger with a straight-edged object, such as a credit card or the back of a knife. Wash the
affected area with soap and water. Don't try to pull out the stinger; doing so may release more venom.
 To reduce pain and swelling, apply a cold pack or cloth filled with ice.
 Apply 0.5 percent or 1 percent hydrocortisone cream, calamine lotion or a baking soda paste — with a ratio of 3
teaspoons baking soda to 1 teaspoon water — to the bite or sting several times a day until your symptoms subside.
 Take an antihistamine containing diphenhydramine (Benadryl, Tylenol Severe Allergy) or chlorpheniramine maleate
(Chlor-Trimeton, Teldrin).
Allergic reactions may include mild nausea and intestinal cramps, diarrhea or swelling larger than 2 inches in diameter at
the site. See your doctor promptly if you experience any of these signs and symptoms.
For severe reactions:
Severe reactions may progress rapidly. Dial 911 or call for emergency medical assistance if the following signs or
symptoms occur:
 Difficulty breathing
 Swelling of your lips or throat
 Faintness
 Dizziness
 Confusion
 Rapid heartbeat
 Hives
 Nausea, cramps and vomiting
Take these actions immediately while waiting with an affected person for medical help:
1. Check for special medications that the person might be carrying to treat an allergic attack, such as an auto-
injector of epinephrine (for example, EpiPen). Administer the drug as directed — usually by pressing the auto-
injector against the person's thigh and holding it in place for several seconds. Massage the injection site for 10
seconds to enhance absorption.
2. After administering epinephrine, have the person take an antihistamine pill if he or she is able to do so without
choking.
3. Have the person lie still on his or her back with feet higher than the head.
4. Loosen tight clothing and cover the person with a blanket. Don't give anything to drink.
5. If there's vomiting or bleeding from the mouth, turn the person on his or her side to prevent choking.
6. If there are no signs of circulation (breathing, coughing or movement), begin CPR.
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http://www.redcross.org
RESPIRATORY ARREST
Respiratory Arrest (-) RR (+) PR.
 A condition of the victim wherein there is no breathing but pulse continues
CAUSES:
1. Strangulation
2. Poisoning-Injection, Ingestion, Inhalation
 Injection- Snakebite, Rabies, Scorpions, bees, jellyfish, spiders
3. Severe Bleeding
4. Drowning
5. Electrocution
6. Suffocation
7. Choking: Universal Sign of Choking- palms guarding throat
8. Disease
THREE (3) KINDS OF AIRWAY OBSTRUCTION
Kind OF Airway Obstruction Signs First Aid
With Good Air Exchange Victim can still TALK Observe the victim as he cough out
obstruction
With Poor Air Exchange Victim produces wheezing sound Abdominal Thrust / Heimlich
Maneuver
Total Airway Obstruction with No Air Unconscious 1. Abdominal Thrust 10X

Exchange Blind Finger sweep for adults
2. Artificial Respiration (AR) 2X
3. Check if Air is going back-

Look, Listen & Feel (LLF)
4. Repeat blind finger sweep
5. Artificial Respiration 2X if
effective
First Aid: Artificial Respiration (AR) – Giving of artificial air only either through a blow or ambubag
- chest compression not indicated because there is pulse rate
METHODS IN GIVING ARTIFICIAL RESPIRATION
1. Mouth to Mouth - usual method

2. Mouth to Nose - if mouth is obstructed
3. Mouth to Mouth & Nose – used in infants
4. Mouth to Stoma - like for patients with tracheostomy
5. Mouth to Mask
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6. Ambu Bag to Mouth & Nose
Ambu Bag- a device used for artificial mechanical breathing unit
ADULT CHILD INFANT
METHOD Mouth TO Mouth Mouth TO Mouth Mouth TO Mouth & Nose
Manner of Breathing Full and Slow Regulated Puff
Rate of Blows 1 Blow every 5 secs 1 Blow every 4 secs 1 Blow every 3 seconds
12 blows per min 15 blows per min 20 blows per min
START WITH A BLOW AND END WITH A BLOW
WHEN TO STOP
1. When the rescuer is exhausted

2. When the victim is breathing on his own
3. When the service of the physician is available
4. When the pulse disappears; artificial respiration is stopped and cardiopulmonary rescucitation begins
5. When another first aider takes over
CARDIAC ARREST
 Condition of the victim when the pulse and breathing is absent.
Intervention for Cardiac Arrest: CPR
CPR- Cardio Pulmonary Resuscitation

- A combination of external chest compression and artificial ventilations to
revive the heart and the lungs
CAUSES
 All causes of Respiratory Arrest, Heart Attack, Stroke Danger of Failure to revive Patient:
Location Of Chest Compressions

1. CLINICAL DEATH- may occur if
heart rate is not revived within 4-6
1. ADULT- 3 fingers above mid xiphoid minutes
2. INFANT- along nipple line

2. BIOLOGICAL DEATH- usually
occurs after 4-6 mins of cardiac
ADULT CHILD INFANT
Method 2 Heels of 2 Hands 1 Heel of 1 hand 2 Fingers (ring and mid

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finger)
Depth 1 ½’- 2” 1”- 1 ½” ½” – 1”
Rate 15 ECC/2 blows 4X/min 5ECC/1 blow 15X/min 5ECC/1 blow 20X/min
Speed 60-80 ECC/min 12X/min 80-100 ECC/min 100-120 ECC/min
2 RESCUERS 5 ECC/1 blow
DON’T’S IN CPR:
1. Don’t be a double crosser

2. Don’t be a rocker
3. Don’t be a jerker
4. Don’t be a render
5. Don’t be a bouncer
6. Don’t be a massager
CPR- start with 2 blows end with 2 blows
SEQUENCE:
1. Survey the scene “ the scene is safe”

2. Check for responsiveness “ Hey 2X, R U Okay”
3. Position the victim
4. Open and Clear the airway (head tilt chin lift) “Mouth is clear”
5. Check breathing for 3-5 seconds (LLF) 1001, 1002, etc. “Breathless”
6. If Breathless, give 2 blows
7. Check for Pulse: Carotid 5-10 seconds
8. State the condition of the victim
“Victim is breathless with pulse” or
“Victim is breathless & pulse less”
9. Activate medical assistance “Arrange transfer facilities and I’ll do…AR or CPR”
10. After each cycle, check pulse for 5 sec. then deliberate
11. Recovery Position
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Nurse Licensure Examination Review

Pain – the fifth vital sign

Basic Categories of Pain:

Factors Influencing Pain Response

Nurse’s Role in Pain Management

2. Establish Nurse-Patient Relationship and Teaching

4. Manage anxiety related to Pain

5. Pain Medications may be administered as:

II. PERIOPERATIVE CARE

o Phases of Perioperative Nursing

4. Physical Assessment and preparation

5. Pre-operative drugs – given 20-60 mins.pre-operative

Semi-Fowlers HOB elevated at 30 Head injury, pot-op cranial surgery,

Fowlers HOB elevated at 45 Head injury, pot-op cranial surgery;

High-Fowler’s HOB elevated at 90 Pneumothorax, hiatus hernia

Supine/ Dorsal Lying on back w/ small Spinal cord injury, urinary

Lying on abdomen with Amputation of legs/feet, post lumbar

Lateral / Side lying Lying on side, weight Post-abominal surgery, post

Lying on side, weight Unconscious client

Lying on back with Perineal, rectal & vaginal procedures

Trendelenburg Head & body lowered, Shock

Reverse Head elevated , feet Cervical traction

Elevate extremity Support with pillows Post-op surgical procedure on

Sim’s Position Reverse High-Fowler’s

1. Ensure sterility of all instruments and supplies at the operating field

Principle: STERILE TO STERILE, CLEAN TO CLEAN

4. Perform sponge count, instrument count and needle count

III. ALTERATIONS IN HUMAN FUNCTIONING

Arterial Blood Gas

pH Measure of acidity or alkalinity 7.35 – 7.45

pCO2 Partial pressure of carbon dioxide respiratory 35 -45

pO2 Partial pressure of oxygen; measure of amount 80-100

HCO3 Bicarbonate, metabolic parameter influenced only by 22-26

Respiratory Normal Value Respiratory

Normal Compensation HCO3 22-26 Normal Compensation

a. Administer NaHco3 Nursing Intervention a. Breathe into paper

Metabolic Normal Value Metabolic

a. Treat underlying cause Restore fluid loss which may be

Diabetic acidosis, Nursing Intervention

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Cause: Medical Management:

Cause: Cigarette Smoking, infection, pollution

Medical Management: see COPD

Clinical Manifestations: Nursing Management:

Cause and Risk Factors:

Clinical Manifestations: Nursing Management:

Complication: STATUS ASTHMATICUS - a life-threatening asthmatic attack in w/c symptoms of asthma

II. PARENCHYMAL DISORDERS:

1. Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure

 Promote adequate ventilation- positioning, Chest physiotherapy, IPPB

- A chronic lung infection that leads to consumption of alveolar tissues

Etiology: Mycobacterium tuberculosis.

1. Poor living conditions, overcrowded

I. Diagnostic Procedure Venous Disorders:

II. Diseases of the Vascular System: Cardiac Disorders

Arterial Disorders: a. Angina Pectoris

Procedure Values / Description Purpose

b. PTT – 16-40 sec.

c. PT – 9-12 sec. - determines ability of the blood to form clot or

e. Cholesterol – 150-250 mg/dl

g. BUN – 6-20 mg/dl - test of renal function; determines adequacy of circulation

i. ESR- 0-30.– also rises after MI

2. Electrocardiogram P- contraction of the atrium  Determines the

Procedure Values / Description Purpose