Documente Academic
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INTRODUCTORY CONCEPTS
A. STRESS
A. Stress
1. Stress and Function:
- Dynamic Balance: The Steady State
2. Stress and Adaptation
- Selyes General Adaptation Syndrome Model
- Fight-Flight Model
4. Stress Appraisal Model
B. Stress: Threats to the Steady Sate
1. Types of Stress and Stressors
2. Stress as a stimulus for disease
3. Physiological and Psychological Responses to Stress
4. Maladaptive responses to stress
5. Indications of Stress
C. Stress at the Cellular levels
i.
Control of steady state
ii.
Cellular adaptation to stress
iii.
Cellular Injury
iv.
Cellular response to injury: Inflammation
v.
Cellular Healing
D. Stress Management
D1. Promoting healthy lifestyle
D2. Enhancing coping strategies
D3. Biobehavioral Interventions for stress
1. Biofeedback
2. Progressive Muscle Relaxation
3. Meditation
4. Guided Imagery
B. ILLNESS
B1. Concept of Illness
1. Cell Injury and Inflammation
1.1 Cell adaptation to injury
1.2 Body defenses against injury
1.3 Monocular phagocyte system
1.4 Inflammatory Response
B2. Chronic Illness
1. Chronicity of Illness or Disease
1.1 Definition of Chronic Conditions
1.2 Prevalence and Causes of Chronic Illness
1.3 Characteristics of Chronic Conditions
1.4 Phases of Chronic Conditions
1.5 Management of Chronic Conditions
C. PAIN
1. Types of Pain
a. Acute
b. Chronic
c. Cancer-related Pain
2. Classifications of Pain
a. Classification by location
b. Classification by etiology
3. Harmful effects of Pain
a. Effects of Acute Pain
b. Effects of Chronic Pain
4. Pain Theories
5. Pathophysiology
i. Neurophysiological transmission of Pain
ii. Factors Affecting Pain
6. Nursing Care of a Client Experiencing Pain
ASSESSMENT
1. Pain experience inventory
2. Cries Neonatal Post-operative Pain Measurement Scale
3. FLACC Pain assessment tool
4. Faces Pain Rating Scale
5. Poker Chip tool
6. Oucher Pain Rating Scale
7. Numerical or Visual analog Scale
8. Adolescent Pediatric Pain Tool
9. Logs and Diaries
PLAN / IMPLEMENTATION
Pain Management Strategies
1. Establish therapeutic relationship
2. Teach patient about pain relief
3. Reduce anxiety and fears
4. Provide comfort measure
5. Non-Pharmacologic
5.1.1 Guided Imagery
5.1.2 Thought Stopping
5.1.3 Hypnosis
5.1.4 Aromatherapy, Essential Oils
5.1.5 Magnet Therapy
5.1.6 Music Therapy
5.1.7 Yoga and Meditation
5.1.8 Acupuncture
5.1.9 Crystal or Gem stone Therapy
5.1.10 Herbal Therapies
5.1.11 Biofeedback
5.1.12 Therapeutic touch and massage
5.1.13 TENS
5.1.14 Heat and Cold Application
o Pharmacologic Interventions for Pain
o Medications for Pain Management
o Routes of Administration
7. Neurologic and Neurosurgical Approaches to Pain
Management
7.1.Surgical destruction of painful stimuli
Rhizotomy
Nerve Block
Continuous Extravascular Infusion
Neurectomy
Sympathectomy
D. PERIOPERATIVE NURSING
1. PREOPERATIVE NURSING CARE
Perioperative and Perianesthesia Nursing
Surgical Classifications
General Considerations
- Conditions Requiring Surgery
- Categories for surgical procedure as to;
Purpose
Degree of Risk to patient
Urgency
Effects of surgery on the person
For example, a positively charged H ion may be exchanged for a positively charged K and a
negatively charged bicarbonate ion may be exchanged for another negatively charged Cl ion.
It is the osmotic pressure generated by the plasma proteins that are too large to pass
through the pores of the capillary wall.
This is different from the osmotic pressure that develops at the cell membrane from the
presence of electrolytes and nonelectrolytes.
Because plasma proteins do not normally penetrate the capillary pores and because
their concentration is greater than in the interstitial fluids, it is capillary osmotic
pressure that pulls fluids back
Insterstitial Hydrostatic Pressure, which opposes the movement of water out of the capillary
Tissue Colloidal Osmotic Pressure, which pulls water out of the capillary into the interstitial
spaces.
Combination of these forces is such that only a small excess fluid remains in the interstitium. This
excess fluid is removed from the insterstitium by the lymphatic system and returned to the systemic
circulation.
Edema
Defined as palpable swelling produced by expansion of the interstitial fluid volume.
Edema does not become evident until the interstitial fluid volume has been increased by 2.5 to 3 L.
Causes of Edema:
o Increased capillary pressure:
Decreased arteriolar resistance: e.g. Calcium channel-blocking drug responses.
Venous obstruction: e.g. liver disease with portal vein obstruction; acute pulmonary
edema; venous thrombosis (thrombophlebitis)
Increased vascular volume: heart failure, kidney diseases, premenstrual sodium
retention, pregnancy, environmental heat stress.
o Decreased capillary colloidal osmotic pressure:
Increased loss of plasma proteins (albumin): protein-losing kidney diseases, extensive
burns.
Decreased production of plasma proteins: liver disease, starvation, malnutrition
o Increase capillary permeability
Inflammation
Allergic reactions
Malignancy: ascites, pleural effusion
Tissue injury and burns
o Obstruction to lymphatic flow
Malignant obstruction of lymphatic structures
Surgical removal of lymph nodes
Routes of Gains and Losses
1. Kidneys:
The usual daily urine volume in the adult is 1 to 2L. A general rule is that the output is approximately
1mL of urine per kilogram of body weight per hour in all age groups.
2. Skin:
Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The
chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from ) to
1,000 mL or more every hour, depending on the environmental temperature. Continuous water loss
by evaporation (approximately 600 ml/day) occurs through the skin as insensible perspiration, a
nonvisible form of water loss. Fever greatly increases insensible water loss through the lungs and
the skin, as does loss of the natural skin barrier (through major burns, for example).
3. Lungs:
Eliminates water vapor (insensible loss) at a rate of approximately 400 ml every day. The loss is
much greater with increased respiratory rate or depth, or in a dry climate.
4. GI Tract:
Only 100 to 200 ml daily though 8L of fluid circulates in GIT every 24 hours. Because the bulk of fluid
is reabsorbed in the small intestine, diarrhea and fistulas cause large losses. In healthy people, the
daily average intake and output of water are approximately equal .
1, 300 ml
1, 000 ml
300 ml
2, 600 ml
1, 500 ml
200 ml
Insensible
Lungs
Skin
300 ml
600 ml
Total loss
2, 600 ml
Homeostatic Mechanisms
1. Kidneys
Normally filter 170 L of plasma every day in the adult, while excreting only 1.5 L of urine.
They act both autonomously and in response to blood-borne messengers such as aldosterone and
ADH.
Major Functions to Regulate Fluid and Electrolytes:
o Regulation of ECF volume and osmolality by selective retention and excretion of body fluids.
o Regulation of electrolyte levels in the ECF by selective retention of needed substances and
excretion of unneeded substances.
o Regulation of pH of the ECF by retention of hydrogen ions
o Excretion of metabolic wastes and toxic substances.
2. Heart and Blood Vessels
Distribution of blood to the kidneys to allow for urine formation. Failure of this pump would interfere
with renal perfusion and thus with water and electrolyte regulation.
3. Lungs
Through exhalation the lungs remove approximately 300 ml of water daily in the normal adult
Role in acid-base balance through hyper and hypoventilation
4. Pituitary Gland
ADH stored in PPG as manufactured by hypothalamus
Controlling retention and excretion of water by kidneys
5. Adrenal Gland
Aldosterone which causes sodium retention and water retention and potassium loss.
Cortisol in large amount would also cause sodium and water retention.
6. Parathyroid Glands
Parathormone regulates calcium and phosphate balance by influencing bone resorption, calcium
absorption from the intestines, and calcium reabsorption from the renal tubules.
7. Baroreceptors
Detect blood pressure changes and transmit impulse to CNS
Monitoring the circulating blood volume, regulate sympathetic and parasympathetic neural activity as
well as endocrine activities.
Sympathetic stimulation and depression of parasympathetic if there is decrease in arterial pressure.
Sympathetic stimulation also constricts renal arterioles; this increases the release of aldosterone,
decreases glomerular filtration and increases sodium and water retention.
8. RAAS
ANP increase glomerular filtration rate which increases urinary excretion of sodium and water
**
Renal Regulation
Kidney provides the major route for potassium.
Potassium is filtered in the glomerulus, reabsorbed along with sodium and water in the proximal
tubule and with sodium and chloride in the ascending loop of Henle, and then secreted into the late
distal and cortical collecting tubules for elimination in the urine.
Aldosterone plays an essential role in regulating potassium elimination by the kidney. In the
presence of aldosterone, sodium is transported back into the blood and potassium is secreted into
the tubular filtrate for elimination in the urine.
There is also a potassium-hydrogen exchange system in the collecting tubules of the kidney. When
serum potassium levels are increased, potassium is secreted into the urine and hydrogen is
reabsorbed into the blood, producing a decrease in pH and metabolic acidosis.
When potassium levels are low, potassium is reabsorbed and hydrogen is secreted into the urine,
leading to metabolic alkalosis.
Extracellular-Intracellular Shifts
Normally, it takes 6-8 hours to eliminate 50% of potassium intake.
To avoid rise in extracellular potassium levels during this time, excess potassium is temporarily
shifted into RBC and other cells such as those of muscle, liver and bone. This is controlled by the
Na/K adenosine triphosphatase (ATPase) membrane pump and the permeability of the ion channels
in the cell membrane.
Only 30-50% is absorbed from the duodenum and upper jejunum, he remainder is
eliminated in the stool.
Calcium is filtered in the glomerulus of the kidney and then selectively reabsorbed back
into the blood.
60-65% of filtered calcium is passively reabsorbed in the proximal tubule, driven by the
reabsorption of sodium chloride;
15-20% is reabsorbed in the thick ascending loop of Henle, driven by the Na/K/2Clcotransport system;
5-10% is reabsorbed in the distal convoluted tubule.Thiazide diuretics enhances
reabsorption of calcium.
2. PTH: maintain the calcium concentration of the ECF by promoting the release of calcium from
bone, increasing the activation of vitamin D and stimulating calcium conservation by the
kidney while increasing phosphate excretion.
3. Calcitonin: acts on kidney and bone to remove calcium from the circulation.
4. Serum phosphate level: calcium and phosphate are reciprocally regulated. Calcium levels fall
when phosphate levels are high.
Regulation of Magnesium
It is the second most abundant intracellular cation. 50-60% is stored in the bone; 39-49% contained
in body cells; 2% is dispersed in the ECF.
20-30% of ECF magnesium is protein bound and only 15-30% is exchangeable in the ECF.
The normal serum magnesium is 1.8 to 2.7 mg/dL
Cofactor in many intracellular enzyme reactions; all reactions that require ATP, replication and
transcription of DNA; cellular energy metabolism; nerve conduction, etc.
Ingested in the diet, absorbed from the intestine and excreted by kidneys.
Contained in all green vegetables, grains, nuts, meats, and seafood.
30-40% of filtered Magnesium is reabsorbed in the proximal tubule.
50-37% is reabsorbed in the ascending loop of Henle.
The distal tubule is the major site of magnesium regulation.
Increased serum levels of Magnesium decreases reabsorption,
PTH increases reabsorption and increased calcium levels inhibits reabsorption.
The major driving force for magnesium reabsorption is the Na/K/2Cl-cotransport system in the thick
ascending loop of Henle. Since this is site of loop diuretics action, this diuretic lowers magnesium
reabsorption.
IV Fluid Administration
Purpose:
1. to provide water, electrolytes, and nutrients to meet daily requirements ;
2. to replace water and correct electrolyte deficits;
3. to administer medications and blood products.
Types of IV Solutions
1. Isotonic solution:
a. Total electrolyte content is approximately 310 mEq/L, which is closer to that of the ECF (i.e.
280-295 mEq/L).
b. Expands the ECF volume by 1L; however, it expands the plasma by only 0.25 L because it is
a crystalloid fluid and diffuses quickly into the ECF compartment.
c. For the same reason, 3L of isotonic solution is needed to replace 1L of blood loss. Because
thes fluids expand the intravascular space, patients with hypertension and heart failure should
be carefully monitored for signs of overload.
d. D5W (252 m,Eq/L) initially isotonic but disperses as hypotonic, 1/3 ECF, 2/3 intracellular.
Good is the patient is at risk of increased in intracranial pressure. D5W is not used in fluid
resuscitation because it can cause hyperglycemia. It is used mainly to supply water and to
correct an increased serum osmolality.
e. NSS (0.9% sodium chloride) has a total osmolality of 308. Since composed mainly of
electrolytes, it remains within ECF. Therefore normally to correct Extracellular volume deficit.
Used with administration of blood transfusions and to replace large sodium losses, as in burn
injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium
retention.
f. Lactated Ringers has potassium and calcium in addition to NaCl.
2. Hypotonic solutions
a. Total electrolyte content is less than 250 mEq/L.
b. Purpose of hypotonic solution is to replace cellular fluid because its hypotonic compared to
plasma. Another is to provide water for excretion of body wastes.
c. Half strength saline (0.45 NaCl with an osmolality of 154 mEq/L is frequently used.
d. Excessive infusion could lead to intravascular fluid depletion, decreased blood pressure,
cellular edema, and cell damage.
3. Hypertonic solutions
a. Total electrolyte count is more than 375 mEq/L.
b. When normal saline solution or lactated ringers contain 5% dextrose, the total osmolality
exceeds that of the ECF.
c. 50% Dextrose,
d. They draw water from the ICF to the ECF and cause cells to shrink
Choosing an IV Site:
Factors to consider:
1. Condition of the vein
2. type of fluid or medication to be infused
3. Duration of therapy
4. Patients age and size
5. Whether the patient is right or left-handed.
6. Patients age and size
7. Patients medical history and current health status
8. Skill of the person performing the venipuncture.
Systemic Complications
1. Fluid Overload:
a. Increased BP and CVP, moist crackles on auscultation of the lungs, edema, weight gain,
dyspnea, and respirations that are shallow and have an increased rate.
b. Causes: rapid infusion, hepatic, cardiac or renal disease. Common in elderly
c. Mgt: decreasing the IV rate, monitoring vital signs, assessing breath sounds, place patient in
high Fowlers position. Contact physician.
d. Complication: Heart failure and pulmonary edema.
2. Air Embolism:
a. Associated with cannulation of central veins.
b. Manifestations: dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of
consciousness; chest, shoulder, and low back pain.
c. Treatment: Clamping of cannula, place patient on the left side in the Trendelenburg position,
assess vital signs and breath sounds; administer oxygen.
d. Complications: shock and death
3. Septicemia and Other Infection
a. Pyrogenic substances can induce a febrile reaction and septicemia.
b. Signs and Symptoms: abrupt temperature elevation shortly after infusion, backache,
headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and
shaking, and general malaise
Local Complications:
1. Infiltration and Extravasation
a. Infiltration is the unintentional administration of a nonvesicant solution or medication into
surrounding tissue. It is characterized by edema around insertion site, leakage of IV fluids
from the insertion site, discomfort and coolness in the area of infiltration, and a significant
decrease in the flow rate
b. Infiltration Scale:
i. 0 no symptoms
ii. 1 skin blanched, edema less than 1 inch in any direction, cool to touch, with or
without pain.
iii. 2 skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without
pain.
iv. 3 skin blanched, translucent, gross edema greater than 6 inches in any direction,
cool to touch, mild to moderate pain, possible numbness
v. 4 skin blanched, translucent, skin tight , leaking, skin discolored, bruised, swollen,
gross edema greater than 6 inches in any direction, deep pitting tissue edema,
circulatory impairment, moderate to severe pain, infiltration of any amount of blood
products, irritant, or vesicant.
c. Extravasation:
i. Is similar to infiltration with an inadvertent administration of vesicant or irritant solution
or medication into the surrounding tissue.
ii. Medications such as dopamine, calcium preparations and chemotherapeutic agents
can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis
of tissues can occur.
iii. Infusion must be stopped and physician notified.
2. Phlebitis
a. Characterized by reddened, warm area around site or along path of vein, pain or tenderness
at the site or along the vein.
Grade
1
Clinical Criteria
no clinical symptoms
pain at access site with erythema, streak formation, palpable venous cord
(longer than 1 inch), purulent drainage.
3. hrombophlebitis
a. Presence of clot plus inflammation in the vein.
b. Localized pain, redness, warmth, and swelling around the insertion site or along the path of
the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate,
fever, malaise, and leukocytosis.
c. Discontinue infusion, cold compress, followed by warm compress, elevate extremity,
restarting the line in opposite extremity. NO Flushing .
4. Hematoma: apply pressure with a dressing, ice for 24 hours, warm compress
5. Clotting and Obstruction
2.Nursing Process
a. Assessment
A1. Subjective Data
i. ECF volume deficits loss of body weight; changes in I and O; changes in Vital Signs
ii. Other manifestations drying of the mouth and mucous membrane; tenting of the skin;
changes in urine output and urination; muscle weakness, change in consistency of the
stool; cerebral changes
A2. Objective Data
1. Physical Assessment there is no
specific physical examination to assess fluid, electrolyte, and acid-base balance.
Skin poor skin turgor; cold, clammy skin, pitting edema; flushed dry skin
a. Food Sources of
- Sodium
- Potassium
- Calcium
- Phosphate
- Magnesium
3. Client Education
respiration.
d. Palpation
1. Upper Lobe
Place the tips of thumbs at the midsternal line at the sternal notch.
Extend fingers above the clavicles.
Ask client to fully exhale then inhale deeply.
2. Middle Lobe
Place tips of thumbs at the xiphoid process.
3. Lower Lobe
Place the tips of thumbs along the clients back at the spinous processes of the lower thoracic
level.
Extend fingers around the ribs.
Ask the client to breathe in deeply.
4. Depth of excursion
Measure the girth of the chest at three levels (axilla, xiphoid, and subcostal) during inspiration
and expiration.
5. Fremitus
Vocal (tactile) fremitus: vibration felt over the chest wall as the client speaks; used to assess
the quality of underlying tissues.
o Place the palms of hands lightly on the chest wall
o Ask the client to speak a few words or repeat 99 several times.
6. Chest wall pain
Ask the client to take a deep breath and identify any painful areas of the chest wall.
7. Position of Trachea
Determine whether the trachea is palpable at midline or has shifted to the right or left.
e. Thoracic Percussion
Used to determine whether underlying tissues are filled with air, fluid, or solid material.
Estimates the size and location of certain structures within the thorax (heart, liver, diaphragm).
Dull and flat sounds: greater than normal amount of solid matter (tumor, consolidation) is
present than air.
Hyperresonance: presence of greater than normal amount of air in the area (emphysema,
asthma)
f. Auscultation
Evaluates the presence of fluid or solid obstruction in the lung structures by listening to the
breath sounds with the use of stethosocope.
C. Diagnostic Evaluation
a. Tests to Evaluate Respiratory Function
1. Pulmonary Function Test: includes measurements of lung volumes and capacities, ventilatory
functions, mechanics of breathing, and diffusion and gas exchange.
2. Pulse Oximetry: non-invasive method of monitoring subtle or sudden changes in oxygen
saturation of hemoglobin.
3. Capnography: non-invasive procedure used to measure carbon dioxide concentration exhaled by
the client who are receiving mechanical ventilation.
4. Arterial Blood Gas Analysis: measures the degree of oxygenation of the blood and adequacy of
alveolar ventilation.
5. Ventilation-Perfusion Lung Scan: painless procedure used to measure adequacy of lung
ventilation and perfusion.
b. Tests to Evaluate Anatomic Structures
1. Radiography (Chest X-Ray)
2. Magnetic Resonance Imaging
3. Ultrasonography
4. Gallium Scan
5. Bronchoscopy
6. Laryngoscopy
7. Alveolar Lavage
8. Endoscopic Thoracotomy
9. Pulmonary Angiography
c. Specimen Recovery and Analysis
1. Sputum culture: to identify organisms responsible for infection of the respiratory tract.
2. Nose and Throat Culture: to identify specific pathogenic organisms present in the nose and throat
3. Thoracentesis: to remove fluid and air in the pleural cavity.
4. Biopsy: examination of cells through excision of small amount of tissues obtained from target
structures.
B. ANALYSIS
1. Common Health Problems of the Respiratory System
A. Upper Airway Infection
i.
Rhinitis
ii. Acute and Chronic Sinusitis
iii. Acute and Chronic Pharyngitis
iv. Tonsillitis and Adenoiditis
v. Peritonsillar Abscess
vi. Laryngitis
B. Obstruction and Trauma of the Upper Respiratory Airway
i.
Obstruction during Sleep
ii. Epistaxis
iii. Nasal Obstruction
iv. Fractures of the Nose
v. Laryngeal Obstruction
vi. Cancer of the Larynx
C. Chest and Lower Respiratory Tract Disorders
i.
Atelectasis
ii. Respiratory Infections
Acute Tracheobronchitis
Pneumonia
Severe Acute Respiratory Disorders
Pulmonary Tuberculosis
Lung Abscess
D. Pleural Conditions
i.
Pleurisy
ii. Pleural Effusion
iii. Empyema
E. Pulmonary Edema
F. Severe Acute Respiratory Distress Syndrome
G. Pulmonary Hypertension
H. Pulmonary Heart Disease (Cor Pulmonale)
I. Pulmonary Embolism
J. Sarcoidosis
K. Occupational Lung Disease
i.
Silicosis
ii. Asbestosis
iii. Coal Workers Disease
L. Chest Tumors
K. Chest Trauma
i.
Blunt Trauma
ii. Penetrating Trauma
iii. Pneumothorax
iv. Cardiac Tamponade
v. Subcutaneous Emphysema
vi. Aspiration
2. Clients with Chronic Obstructive Disease
a. Bronchiectasis
b. Asthma
Status Asthmaticus
c. Chronic Obstructive Pulmonary Disorders
Emphysema
Chronic Bronchitis
d. Cystic Fibrosis
3. Potential Nursing Diagnosis
a. Ineffective Airway Clearance as evidenced by shortness of breath, dyspnea, orthopnea, retractions,
nasal flaring, altered chest excursion
b. Ineffective Breathing Pattern as evidenced by ineffective cough, diminished or abnormal breath
sounds, cyanosis, restlessness
c. Impaired Gas Exchange as evidenced by cyanosis, abnormal respiratory rate, and rhythm, nasal
flaring, tachycardia, diaphoresis and confusion
d. Impaired Spontaneous Ventilation as evidenced by dyspnea, use of accessory muscles,
tachycardia, and apprehension
e. Disturbed Sleep pattern (Sleep-Rest)
f. Anxiety
4. PLANNING
a. Planning for promotion
b. Planning for Heath Restoration and Maintenance
i.
Maintain Airway Patency
ii. Relieving Apprehension and Fear
iii. Reducing Metabolic Demand
iv. Preventing and Controlling Infection
5. IMPLEMENTATION
a. Pharmacologic Therapeutics
i.
Decongestants and Antihistamines
ii. Anti-tubercular Drugs
iii. Broad Spectrum Antibiotics
iv. Adrenergic Stimulants
v. Methylxanthines
vi. Anticholinergics
vii. Corticosteroids
viii. Mast Cell Stabilizers
ix. Leukotriene Modifiers
b. Complementary and Alternative Therapies
i.
Echinacea
ii. Golden Seal
iii. Zinc
c. Nutritional Diet Therapy
i.
Tube feedings
ii. Fluid Therapy
iii. High Protein, high Calorie supplements
d. Respiratory Care Modalities
I. Non-invasive Respiratory Therapies
i.
Oxygenation Therapy
ii. Incentive Spirometry
iii. Nebulization Therapy
iv. Intermittent Positive Pressure Breathing
v. Chest Physiotherapy
II. Airway Management
i.
Endotracheal Intubation
ii. Tracheostomy
iii. Mechanical Ventilation
iv. Chest Drainage
e. Thoracic Surgery
i.
Pneumonectomy
ii. Lobectomy
iii. Segmentectomy (Segmental Resection)
iv. Wedge Resection
EVALUATION
II.
11 Functional Patterns
ii. Objective Data
Physical Assessment
- Non-invasive tests
ECG
Echocardiogram
Ultrasound
Chest X-ray
Radionuclide studies
CT scan
CVP monitoring
- Invasive tests
Cardiac Catheterization
Arteriogram
Angiocardiogram
Venogram
Lymphography
Bone marrow aspiration
Lipid Profiles
Cholesterol levels
Triglycerides
C. ANALYSIS
1. Common Problems of the Cardiovascular and Hemato-lymphatic Systems
Cardiovascular System
a. Conduction problems of the heart
Dysrhythmias
b. Coronary vascular disorders
1.
Coronary Artery Disease
Coronary Atherosclerosis
Angina Pectoris
Myocardial Infarction
c. Structural, Infectious and Inflammatory cardiac problems
1.
Valvular Disorders
Mitral Valve Prolapse
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation
Aortic Stenosis
2.
Cardiomyopathy
3.
Infectious Disorders of the heart
Rheumatic Endocarditis
Infective Endocarditis
Myocarditis
Pericarditis
d. Complications of Heart Disease
1.Cardiac Hemodynamics
a. Heart Failure
A1. Chronic Heart Failure
A2. Acute Heart Failure
2. Other Complications
a. Cardiogenic shock
b. Thromboembolism
c. Pericardial Infusion and Cardiac Tamponade
d. Cardiac arrest
e. Hypertension
1. Types of hypertension
2. Hypertensive Crisis
f. Vascular Disorders: Problems of Peripheral Circulation
1. Arterial Disorders
Arteriosclerosis and Atherosclerosis
Peripheral Arterial Occlusive Disease
Thromboangiitis Obliterans (Buergers Disease)
Aortitis
Aortoiliac disorders
Dissecting Aorta
Arterial embolism and Arterial thrombosis
Raynauds Disease
2. Venous Disorders
Venous thrombosis
- Deep vein thrombosis
- Thrombophlebitis
- Phlebothrombosis
Chronic Venous Insufficiency
Leg ulcers
Varicose veins
3. Lymphatic Disorders
Lymphangitis and Lymphadenitis
Lymphedema and Elephantiasis
4. Cellulitis
Hematologic Problems
a. Anemia
Hypoproliferative
Aplastic anemia
Megaloblastic anemia
- Folic acid deficiency anemia
- Vitamin B12 deficiency anemia
- Pernicious anemia
- Myelodysplastic syndrome
Hemolytic
Thalassemia
Glucose-6-phosphatase-dehydrogenase deficiency
Hereditary Spherocytosis
2. Gerontologic Considerations
3. Probable Nursing Diagnosis
Decreased Cardiac Output as evidenced by increased heart rate, fatigue, shortness of
breath, decreased urine output, impaired mental processing, decreased level of
consciousness
Activity intolerance as evidenced by weakness, fatigue, vital signs, changes with activity.
Fatigue as evidenced by difficulty completing usual daily activities, frequent desire to rest.
Impaired home maintenance as evidenced by inability to maintain family roles
Risk for peripheral neurovascular dysfunction as evidenced by changes in color,
temperature, sensation of extremities
Impaired Tissue Integrity
Ineffective Therapeutic Regimen Management
Ineffective Tissue Perfusion as evidenced by cool, dusky skin, decreased urine output and
chest pain
Acute pain
D. PLANNING
1. Planning for Health Promotion
a. Risk factor and risk management
b. Promotion of circulation
c. Prevention of infection
d. Genetic Counseling
e. Role of Nutrition
2.Planning for Health Maintenance and Restoration
a. Planning for basic life support: CPR
b. Planning for advanced life support : ACLS
c. Planning for Care of clients to have Cardiac Surgery
E.
IMPLEMENTATION
1.Pharmacologic Management
a. Cholesterol lowering medications
- Statins
- Bile Sequestrants
- Nicotinic Acid
- Fibric acid derivatives
b. Antianginal Medication
- Nitroglycerin
- Beta-blockers
- Calcium Channel Blockers
c. Antidysrhythmics
- Class I Sodium Channel Blockers
- Class II Beta-Adrenergic Blockers
- Class III Prolong Repolarization
- Class IV Calcium Channel Blockers
d. Antiplatelets
e. Diuretics
f. Medications for Heart Failure
- ACE Inhibitors
- Angiotensin Receptor Blockers
- Diuretics
- Positive Inotropic Agents
- Sympathomimetic
- Phosphodiesterase Inhibitors
g. Medications for Anemia
- Iron supplement
- Vitamin B12
- Folic Acid supplement
h. Antihypertensives
Intestinal gas
Nausea and vomiting
Change in bowel habits or stool characteristics
(1) Imbalanced Nutrition less than body requirements as evidenced by decreased food intake,
weight loss 20% or more of ideal body weight, dry or brittle hair, weakness, impaired tissue
healing.
(2) Deficient Fluid and Volume as evidenced by complaints of stomach discomfort, increased
salivation, tachycardia and cold clammy skin.
(3) Impaired skin integrity as evidenced by disruption of skin integrity as evidenced by disruption
of skin surface, pain and itching
(4) Acute pain
(5) Diarrhea
c) Planning
d) Implementation
i) Pharmacologic Management
(1) Antiemetics
(2) Anticoagulants
(3) Histamine agents
(4) Laxatives
(a) Bulk forming
(b) Stool softeners
(c) Saline and osmotic solutions
(d) Stimulants
(e) Selective chloride channel activator
(f) Serotonin type 4 receptor partial agonists
(5) Antipruritis
(6) Vitamin Supplement
(7) Antacids
(8) Antihyperlipidemics
(9) Antispasmodics
(10) Antidiarrheal
(11) Antisecretory agents H2 Receptor Blockers
(12) Vasopressin
(13) Epinephrine
(14) Cholinergics
(15) Antibiotics for H. Pylori and Anti-infectives
(16) Alpha-interferon and ribavirin
(17) Pancreatic Enzyme Replacement
ii) Complimentary Therapy
(1) Ginger
(2) Milk thistle (Silymarin)
iii) Surgical Management
(1) Neck Dissection
(2) Esophagectomy
(3) Vagotomy
(4) Pyloroplasty
(5) Gastrostomy
(6) Gastrectomy
(7) Colostomy
(8) Hemorrhoidectomy
(9) Gastrointestinal Bypass
(10)
Ileostomy
(11)
Vagotomy
(12)
Pyloroplasty
(13)
Antrectomy
(a) Billroth I (Gastroduodenostomy)
(b) Billroth II (Gastrojejunostomy)
(14) Bariatric Surgery
(15) Fistulectomy
iv) Modalities of Care of the Gastrointestinal System
II.
The Nursing Process
I. Assessment
a. Subjective Data
i. Demographic Data
ii. Presence of Signs and Symptoms
b. Objective Data
i. 11 functional pattern
ii. Physical assessment
iii. Diagnostic Assessment
1. Invasive Procedures
2. Non-invasive Procedures
3. Laboratory
II. Analysis
a. Common Health Problems
b. Gerontologic Considerations
c. Potential Nursing diagnosis
III. Planning
IV. Implementation
a. Pharmacologic Management
b. Complimentary Therapy
c. Surgical Management
d. Modalities of Care
e. Special Procedures
f. Nutrition and Diet
g. Client Education
V. Evaluation
Endocrine and Metabolic Problems
I. Anatomy and Physiology of the Metabolic, Hepatic and Endocrine Systems
II. The Nursing Process
a. Assessment
i. Subjective Data
1.
Demographic Data
2.
Presence of Signs and Symptoms related to the Endocrine and Metabolic Systems
Jaundice
Malaise
Weakness
Fatigue
Pruritus
Abdominal Pain
Increasing abdominal girth (ascites)
Melena
Hematochezia
ii. Objective Data
1.
11 functional pattern
2.
Physical assessment
Abdominal Girth Measurement
Inspection
Percussion
Palpation
Auscultation
3.
f.
Diagnostic Assessment
Invasive Procedures
a.
Angiography
b.
Adrenal Venogram
c.
Portal Pressure Measurement
d.
Biopsy
e.
Paracentesis
Endoscopic Retrograde Cholangiopancreatography
Non-invasive Procedures
a.
Test of anatomic system structure and function
b.
MRI
c.
Electroencephalogram
d.
Ultrasonography
e.
CT scan
f.
Radionuclide Imaging
g.
Fine needle aspiration
h.
Achilles tendon reflex tests
i.
Radioiodine re-uptake tests
Laboratory
a.
b.
c.
d.
e.
f.
g.
Pigment Studies
Protein Studies
Serum Aminotransferase Studies
Prothrombin Time
Serum Aminotransferase Studies
Ammonia
Cholesterol
b. Analysis
i. Common Health Problems
1.
Common Problems of the Endocrine System
Disorders of the Thyroid Gland
a.
Hyperthyroidism
i. Graves disease
ii. Toxic Nodular Goiter
iii. Thyroiditis
iv. Thyroid Tumors
b.
Hypothyroidism
i. Iodine Insufficiency
ii. Hashimotos Disease
iii. Myxedema
Disorders of the Parathyroid Gland
a.
Hyperparathyroidism
b.
Hypoparathyroidism
3.
1.
2.
3.
4.
5.
6.
7.
Iodine Resources
Antithyroid
Thyroid Replacement
Cortisol Replacement
Insulin
Oral Hypoglycemics
Hormone therapy
ii. Complimentary Therapy
1.
Aloe vera
2.
Bilberry
3.
Biter Melon
4.
Fish Oil
5.
Fenugreek
6.
Garlic
7.
Ginseng
8.
Gymema
9.
Horse Chestnut Seed Extract
10.
Prickly pear
iii. Surgical Management
1.
Thyroidectomy
2.
Parathyroidectomy
3.
Unilateral and Bilateral Adrenalectomy
4.
Transsphenoidal-Hypophysectomy
5.
AK//BK Amputation
6.
Pacreatic Transplantation
7.
Liver Transplantation
8.
Surgical Bypass Procedures
9.
Revascularization and Transition
10.
Lobectomy
11.
Cryosurgery
1.
2.
3.
4.
5.
6.
7.
ANALYSIS
- Potential Nursing Diagnosis
- Anticipatory Grieving related to perceived loss of normal body image
- Anxiety related to the effects of surgical procedure
- Fear related to surgery
- Risk for infection
- Ineffective Airway Clearance
- Ineffective Individual Coping
PLAN / IMPLEMENTATION
1. Physiological / spiritual preparation for surgery
2. Legal aspects of the informed consent
3. Instructional and Preventive aspects
3.1 Deep breathing exercises
3.2 Coughing exercises
3.3 Turning exercises
3.4 Extremity exercises
4. Physical Preparations
4.1 On the night of the surgery
a. Hygiene and skin care
b. Elimination
c. Nutrition and fluid
d. Rest and sleep
4.3 On the day of the surgery
c. Pre-operative checklist
d. Pre-operative medications
EVALUATION
1.
2.
EVALUATION
a.
b.
c.
d.
e.
Vital signs
Color and temperature of the skin
Level of Consciousness
Comfort
Time of Arrival
ANALYSIS
Postoperative nursing diagnosis
b. risk for surgical site diagnosis
c. pain
d. altered family processes related to loss of economic stability
e. impaired physical mobility
f. potential complication: Hemorrhage
PLAN / IMPLEMENTATION
1. Preventing Post-operative Complications
1.1 Respiratory Complications
1.2 Circulatory Complications
1.3 Fluid and Electrolytes Imbalance
1.4 Gastrointestinal Complications
1.5 Urinary Complications
1.6 Wound Complications
2. Post-operative Discomforts
EVALUATION