Medical Surgical Nursing Review 1

ROWENA ESCOLAR CHUA, RN, MAN
Perioperative Nursing
3 phases:
Pre-operative
Intra-operative
Post-operative
Pre-operative Period
Used to physically and psychologically
prepare the patient for surgery
Nursing Diagnosis:
Anxiety
knowledge Deficit
UST COLLEGE OF NURSING
Pre-operative Period
Diagnostic evaluation:
- CBC, Urinalysis (standard)
RBC, WBC, platelets

To determine any pre-existing infection
- ECG, CXR (Cardiopulmonary Clearance)
- Blood chemistries
Electrolyte levels (cardiac arrhythmias)
Nursing Responsibilities
- Encourage the patient to verbalize feelings
- Encourage to participate in decision
making- help maintain sense of control

- Provide teaching (DBCE, splinting, use of
IS, leg exercises)- decrease complications
- Provide the necessary information needed
by the client
- Informed consent (disclosure,
understanding, competence)
Nursing Considerations
(Informed Consent)
Patient signs own consent if he or she is
of age (18 yrs or older), mentally

capable, or is an emancipated minor
(<18 yrs but independent from parents)
In emergency where client is unable to
sign or there is immediate threat to life,
effort should be made to contact family
and 2 surgeons to sign the consent
Blood Products consent
Pre-op Nursing Care

Physical
GI NPO, laxatives, enema
Rest and sleep
Night before surgery:
- Barbiturates- to help them go to sleep

(pentobarbital- Nembutal)
- Quiet environment: eliminate noises,
distractions
- Position: reduce muscle tension
- Back rub
Pre-op Nursing Care

Pre-operative medications
Sedatives, hypnotics to decrease anxiety and
provide sedation (e.g. valium)
Anticholinergics to decrease secretion of saliva
and gastric juices (e.g. atropine sulfate)
Narcotics and analgesics to relieve pain and
discomfort (e.g. nalbuphine hydrochloride)
Given 45-75mins before anesthetic induction
Side rails up
Antibiotics on call to OR
Sample Question
The nurses signature as a witness on an
informed consent indicates that the

patient:
a. has been informed regarding the
procedure
b. was medicated for pain before the
consent was signed
c. can describe how the surgical
procedure will be done
d. voluntarily agreed to have the
procedure performed
Skin Preparation
Scrub with antimicrobial agent
Hair should remain unless it
interferes with surgical procedure

- note any nicks, cuts or irritations
- depilatory creams or clipping of hair
is preferred to shaving with a razor;
NICKS may result to cancellation of
surgery
- Skin prep may be done in surgery
Day of Surgery
AM care
Pre-operative checklist
Remove nail polish, jewelry, contact
lenses, dentures
Give valuable items
Chart disposition of items
Proper identification: Check band for
secureness and legibility; surgical site
may be marked to prevent error
Surgical team
Surgeon
- the captain
- specialized in surgery
Anesthesiologist
- administer anesthesia
- alleviates pain and
promote relaxation/
homeostasis
Assistants
- 1st assistant rt hand of

surgeon
- 2nd assistant - intern
Circulating nurse
- senior nurse
- errand person
Scrub nurse
junior in OR
participates directly
supply instruments
maintain asepsis
depends on the
circulating nurse
When the anesthesiologist

administers the anesthesia
Intra-operative Period
Types of Anesthesia
- Regional anesthesia
- General Anesthesia
- Local Anesthesia
Types of Anesthesia
Regional- intact consciousness; loss of
motor and sensory perception to a

particular area of the body
- Spinal- local anesthetic to subarachnoid
space in lumbar area
*CSF might leak
- Epidural- epidural space
Regional Anesthesia
- Uses: Lower legs, abdominal or
-
perineal area
Nursing Responsibilities:
Assess VS
Assess for return of sensation and
motor function
Keep FOB at least 3-4hrs
Provide adequate hydration
Types of Anesthesia
General anesthesia- produces
unconsciousness; blocks motor and

sensory pathway to major nerve
and muscle groups
Inhalation gas or IV injection or
rectal
Ex: Inhalation anesthetics:
Nitrous oxide
Halothane (Fluothane)
Enflurane (Ethrane)
Isoflurane ( forane )
Nursing Responsibilities
- Monitor safety of the patient
- Have resuscitative equipment nearby
at all times (respiratory depression)

- Avoid stimulating the patient
(Ketalar)
- To prevent impaired circulation, make
sure the feet are not crossed
(improper positioning)
Sample Question
Which nursing action is the highest
priority for a client under general

anesthesia?
a. Ensure that the surgeon is handed
the correct instrument
b. Focus lights to enhance visualization
c. Monitor urinary output
d. Position the client to avoid injury
Post-anesthesia Care
Unit
Monitor ABC
Airway and Breathing- O2 saturation,
prevent aspiration, lateral position

Circulation- Monitor for bleeding, BP,
HR
Return of sensation and motor
function
Post-operative
Complications
Altered Respiratory Function
- Causes: airway obstruction, anesthesia,
atelectasis, COPD, pain

- Assessment:
- dyspnea, tachycardia (hypoxia),
decreased breath sounds (alveolar

collapse), crackles, rhonchi and noisy
respirations, pallor and anxiety and
restlessness
- Temperature greater than 38C-
atelectasis
* Atelectasis is the most
common cause of increased
body temperature during the
1st 24hrs of surgery
Post-operative
Complications
Maintain patent airway
- DBCE, use of IS ( ventilate distal
alveoli) and changing of positions

(increased chest expansion)
Splinting of incision
Ambulate as soon as possible
Administer analgesics as ordered
Administer ATB as ordered
Post-operative
Complications
Altered Cardiac Output
- May lead to shock due to fluid volume
deficit, hemorrhage or vasodilation

Assessment:
- decreased BP, UO, weak, thready
pulse, pallor, restlessness, rapid deep
respirations
- Monitor for hemorrhage- GREATEST
risk during the 1st 48hrs of surgery
Altered Cardiac Output

- Inspect the wound for bleeding-
reinforce dressing; check drains

(JP, Hemovac)
- Provide O2
- Replace fluids, blood transfusions
and drugs to keep VS stable
(vasoconstrictors- epinephrine,
norepinephrine, dopamine )
Post-operative
Complications
Altered
Mental Status
- Monitor LOC- GCS
- Observe for decreased reflexes
(gag, cough, swallow and DTR)

- Observe for pupillary response
(brisk or sluggish)
- Observe patients safety at all times
- Be careful in giving narcotics
Discomfort and Pain

- Usually comes during the 2nd day
- Narcotics (Codeine, Morphine, Demerol,
Nalbuphine)
- Reposition every 2hrs
- Reduce anxiety and teach relaxation
techniques
- Medicate as ordered (RTC); if too much
narcotics
Antidote: ______
Post-operative
Complications
Altered GI function
- Causes: Anesthesia, bowel manipulation,
-
paralytic ileus
Observe for n/v due to decreased peristalsis
Observe for absent bowel sounds- withhold
food and fluids until bowel sounds return
Maintain IV access and administer fluids and
electrolytes
Monitor for abdominal distention and
discomfort
NGT drainage as needed
Gradually change the diet of the patient
Ambulate as soon as possible
Post-operative
Complications
Decreased
UO
- Monitor UO- should resume after
6-10hrs after surgery

- Encourage to increase fluid
intake
- Promote urination
- Insert indwelling catheter or
straight catheterization
Impaired skin Integrity

- Keep incision clean and dry
- Encourage ambulation (movement
stimulates vascular perfusion)
- Splint incision to prevent dehiscence
or evisceration
- If dehiscence or evisceration occurs,
cover wound with dressing with
sterile saline solution and notify MD.
Do not cough or move
Sample Question
Which statement by a client indicates a
need for further teaching after surgery?

a. Im looking forward to going home and
walking around in our subdivision
b. I will clean my incision every morning
and pat it dry with a clean towel
c. I will call the MD if I notice drainage
from my incision and if I have a fever
d. I cant wait to go home and pick up my
18-month old baby
Post-operative
Complications
Impaired Circulation
- Observe for Homans sign (do not elicit)

- Assess for warmth, pain and tenderness
-
in calf muscles
Provide anti-embolic stockings to
compress superficial veins and increase
blood flow to deep veins and prevent
venous pooling
Dont put pressure on popliteal area
Dont massage the patients legs
Promote ambulation ASAP
Treat thrombophlebitis by bedrest,
anticoagulant drugs
Cardiovascular System Disorders
Assessment
Risk Factors
Non-modifiable
Age
Gender
Race
Heredity
Modifiable
Stress
Diet
Exercise
Cigarette
smoking
Alcohol
HPN
Hyperlipidemia
DM
Obesity
Diagnostic Tests
Cardiac enzymes
- CK-MB- elevation indicates myocardial
damage- elevates within 4-6hrs; peaks in
18-24hrs
- LDH- occurs in 24 hrs and peaks in 48-72
hrs
- Troponin I- most accurate
Complete blood count- WBC, RBC, H&H
Electrolytes- K, Na, Ca, Phosphorous, Mg
BUN and creatinine
CXR
Sample Question
If the client asks the nurse to explain
what the physician meant by saying,

Your enzymes are elevated, the best
response is that it is:
a. a normal finding associated with tissue
healing
b. an abnormal finding associated with cell
damage
c. a normal finding associated with aging
process
d. an abnormal finding associated with infection
Blood Coagulation Tests

Prothrombin time
Coumadin tx
Partial Thromboplastin Time

Best single screening test for coagulation
d/o
Heparin tx
Activated Partial Thromboplastin
Time
Most specific for heparin tx
Diagnostic Tests:
1.ECG- a common non-invasive
procedure that records the electrical
activity of the heart
Cardiac Catheterization/
Angiography
Coronary artery visualization-
to check if any occlusion or

narrowing
Assess for allergies to
iodine/dye
L sided heart catheterization brachial
or femoral artery
Assess for bleeding
Pressure dressing and sandbag
Monitor distal pulses (pedal pulses)
Cardiac catheterization
Coronary artery plaque
ANGINA
Chest pain that results from myocardial
ischemia- most common symptom of

CAD- demands exceed supply
Types:
Stable- pain relieved by rest and
nitroglycerine
Unstable- increased severity, duration
and frequency
Variant- Vasospastic, Prinzmetal- may
occur at rest (usually secondary to
vasoconstriction)
Angina: Causes
- Activity that increases metabolic
demands
- ANY INCREASE IN HR
INCREASE
OXYGEN DEMAND
Vigorous exercise
over-eating- INCREASE METABOLISM
INCREASE HR
Stress
Sex
- Atherosclerosis, thromboembolism
Sample Question
A client with angina complains that
the anginal pain is prolonged and

severe and occurs at the same time
each day. On further assessment, a
nurse notes that the pain occurs in
the absence of precipitating factors.
This type of anginal pain is best
described as:
a. stable angina
c. prinzmetals angina
b. unstable angina d. non-anginal pain
ANGINA
Assessment:
- Pain- substernal, crushing or
compressing; may radiate to

arms, jaw or back; usually after
exertion, excitement or
exposure to cold
- Anxiety, diaphoresis, dyspnea,
tachycardia, palpitations,
epigastric distress
Angina
- Diagnostic evaluation:
- Increased cholesterol, LDL and
triglycerides
- Cardiac enzymes usually WNL
- Coronary arteriography shows
narrowing of coronary arteries
- ECG- ST segment depression, T-wave
inversion
Nursing Management
- Encourage to adhere to diet
-
restrictions- low fat, low cholesterol,

SFF
Monitor I & O
Administer O2 to increase O2 supply
Maintain bed rest (BRP) and semifowlers position- reduce cardiac
workload
Encourage weight reduction and
smoking cessation
Medications
- Administer medications as ordered
* Anticoagulants- prevents new clots from

forming
- Heparin (APTT, Protamine sulfate)
- Coumadin (PT, Vitamin K)
* Beta-blockers (Metoprolol, Atenolol)
* Calcium channel blockers
(Verapamil, Nifedipine, Diltiazem)
reduce heart rate to reduce O2 demand
* Nitrates- Nitroglycerin- Vasodilator
- dose: ____ SL (do not chew, swallow)
- burning sensation, 3-6mos storage, HA,
hypotension
Angina Pectoris
Treatment
Percutaneous Transluminal Coronary
Angioplasty (PTCA)
Intravascular Stenting
Done to prevent restenosis after PTCA
Given coumadin, ASA (prevent clotting)
Percutaneous Transluminal Coronary

Angioplasty
Stent
Myocardial Infarction
Thrombus
Emboli
Atherosclerosis
Reduced blood flow in one of the
coronary arteries > ischemia, injury and
necrosis
Possible Causes:
- Coronary artery occlusion, spasm,
stenosis
Risk factors:
- Same risk factors as in Angina
Assessment:
Crushing substernal pain (radiate to jaw,

back and arms; unrelieved by rest and
nitroglycerine)
Dyspnea, diaphoresis
Hypoxia causes arrhythmias (V.
fibrillation- most common cause of
death)
tachycardia, anxiety, pallor,
hypotension, n/v, elevated temperature
MI
Diagnostic evaluation:
ECG shows deep, wide Q wave,
elevated or depressed ST segment, T
wave inversion
Increased Cardiac Enzymes
Treatment:
Bedrest with BSC

Bleeding precautions (if thrombolytic
therapy used)
CABG; Angioplasty
Low calorie, low cholesterol, low fat diet
Monitor labs (ABG, CK, electrolyte and
troponin)
O2
CPR if pt becomes unconscious and
defibrillate when ECG shows V. fibrillation
CPR
1st action: ______________
CPR: ABC
A open airway
B - breaths
C - circulation
If ECG shows ventricular fibrillation,
defibrillate
Defibrillation: Clear, Energy setting
DEFIBRILLATOR
Paddle Placement for

Defibrillation
Medications
MONA
Morphine- vasodilator, analgesic
(reduces myocardial O2 demand)

Oxygen
Nitroglycerine IV
Aspirin- anti-platelet
Beta-blockers and Ca channel blockers
Thrombolytics- given 3-4hours after
onset of symptoms
Anti-coagulants (Heparin/ Coumadin)
Coronary Artery By pass

Graft
SAPHENOUS VEINS
Conduction system and

ECG
CARDIAC ARRYTHMIAS
- Abnormal electrical conduction or
automaticity that changes cardiac

rhythm and rate
- Too fast or too slow- decrease
perfusion to different organs
- Possible Causes:
congenital, drug toxicity,
electrolyte imbalances, heart
disease, MI
Electrocardiogram (ECG)
P wave atrial activation (depolarization)
QRS complex ventricular depolarization

ST segment beginning of ventricular
relaxation (repolarization)
T wave ventricular relaxation
Cardiac Arrhythmias
AF- feeling faint, irregular pulse,
palpitations
Asystole- no pulse, BP, apnea,
cyanosis
VF- no pulse, no palpable BP,
apnea
VT- chest pain, diaphoresis,
dizziness, hypotension, weak pulse,
possible loss of consciousness
ATRIAL DYSRHYTHMIAS
PAC
Ectopic Atrial
Beat
Atrial Tachycardia
Atrial Flutter
Atrial Fibrillation
150-250
250-350
>350
*VENTRICULAR DYSRHYTHMIAS
severely reduces diastolic filling &
CO
absence of
pulse and BP
PVC Ectopic Focus
Ventricular Tahcycardia 101-250
Ventricular Fibrillation Chaotic
Asystole No electrical activity
Ventricular
Fibrillation:
Ventricular fibrillation is seen in dying
hearts.
No true QRS complexes >> cardiac
perfusion & whole body perfusion
stopped.
Cardiopulmonary resuscitation (CPR)
and electrical defibrillation must be
performed STAT
CARDIAC ARRYTHMIAS
Treatment:
- Anti-arrythmics
Atrial- Quinidine
Ventricular- Lidocaine
Beta-blockers, Calcium channel blockers
synchronized cardioversion
CPR, defibrillation
ICD (Implanted cardiac defibrillator)
transcutaneous pacing
*HEART BLOCK:
First Degree: Impulse
slow to go thru AV
node
Second Degree: Some
impulse go thru AV
node, some do not
Third Degree: No
impulse get thru AV
node
PACEMAKERS:
- Types: Fixed
Demand
- Check basal HR
- Avoid sources of
electricity
(microwave, CP)
- No contact sports
Pace maker
Double Chamber Pacemaker

usually has two leads,
with the tip of one lead

located in the right
atrium and the tip of the
other in the right
ventricle
can monitor and deliver
impulses to either or
both of the heart
chambers
CONGESTIVE HEART FAILURE

-inability of the heart
to pump adequate
blood into the
systemic circulation
to meet metabolic
demands
CONGESTION
Heart Failure
Occurs when the heart cant
pump enough blood to meet

the metabolic demands of the
body.
Possible Causes:
Atherosclerosis, MI, COPD,
HTN, fluid overload, pulmonary
HTN, valvular insufficiency
Ride side
HF
Hepatomegaly
Edema
Ascites
Distended
jugular veins
Weight Gain
Fatigue
Left-side CHF
Dyspnea
Orthopnea
Cough
Crackles
Frothy sputum
Heart Failure
Assess CV status and VS to detect decreased
cardiac output
Assess respiratory status
Keep in semi-fowlers position
Administer medications to reduce fluids and
enhance cardiac functioning
Analgesics (Morphine sulfate for pulmonary
edema)
beta-blockers
diuretics (Furosemide)- Nursing considerations
inotropic agents (Digitalis-Digoxin; normal
level, SE, signs of toxicity)
HIGH POTASSIUM DIET
Heart Failure
Monitor I& O, labs and weight
Provide suctioning as needed,
assist with turning and encourage

coughing and deep breathing to
prevent pulmonary complications
Measure and record the patients
abdominal girth
Restrict fluids
Valvular Heart Disease

3 types of mechanical disruption from VHD
- stenosis or narrowing
- insufficiency- incomplete closure of the
valve
- prolapse of the valve- protrudes into the LA
- can result from endocarditis and
inflammation > HF
Forms:
Aortic insufficiency
Mitral insufficiency
Mitral stenosis
Mitral valve prolapse Tricuspid insufficiency
Endocarditis
Rheumatic heart fever

( valve )
Mitral valve prolapse
Prosthetic valves
Hancoc
Mitral
Mitral
Mitral
Risk Factors for

Hypertension
Nonmodifiable risk factors
Family history
Age and gender
Ethnicity
Modifiable risk factors

Stress
Obesity and nutrients
Substance abuse
Hypertension
Asymptomatic
Elevated BP
Dizziness
Headache
L ventricular
hypertrophy
Cerebral ischemia
Renal failure
Visual disturbances
including blindness
Epistaxis
Diagnostic Elevation:
Increased BUN,
creatinine, Na and
cholesterol levels
Sustained BP
readings of 140/90
mm Hg
CXR show
cardiomegaly
ECG shows LVH
Hypertension
Treatment:
Regular exercise to reduce weight

Low sodium diet and limitation of
alcohol
Medications:
- ACE inhibitors (Enalapril, Captopril)
- Angiotensin II receptor blockers
(Losartan, Valsartan)
- beta-blockers, vasodilators, Ca
channel blockers, diuretics
ANTILIPEMIC AGENTS
Cholyestyramine (Questran)
Reduces absorption of fats from GI
Tract
Atorastatin (Lipitor)
Simvastatin (Zocor)
Lovastatin (Mevacor)
Check Liver enzymes
Nursing Management
Assess CV status and VS; Take an
average of 2 or more readings to
establish HTN
Assess neurologic disorders and
observe for changes that may
indicate an alteration in cerebral
perfusion (CVA)
Monitor I & O and weight
Maintain a quiet environment to
reduce stress
When performing discharge teaching for

a client with chronic heart failure, the
nurse should stress which topic?
1. The need for high-impact aerobic
exercise program
2. A high sodium, low potassium diet
3. The signs and symptoms of pulmonary
edema
4. The possibility of the need for surgical
procedures
When performing discharge teaching for

a client with chronic heart failure, the
nurse should stress which topic?
1. The need for high-impact aerobic
exercise program
2. A high sodium, low potassium diet
3. The signs and symptoms of pulmonary
edema
4. The possibility of the need for surgical
procedures
A medical emergency situation requiring
prompt attention.
Sample Question
A client with angina pectoris has a
12 lead ECG taken during an episode

of chest pain. Which ECG change is
caused by myocardial ischemia?
a. prolonged QT interval
b. ST segment depression
c. widened QRS complex
d. tall, peaked T waves
Sample Question
Which of the following will not be included
in the treatment of a client with an acute

MI?
a. Beta-blockers to slow the heart rate
and increase myocardial perfusion
b. Nitroglycerin IV to produce vasodilation
and increase myocardial perfusion
c. Demerol to relieve chest discomfort
that is unresponsive to Nitroglycerin
d. Oxygen @ 2-4 L/min by nasal cannula
Sample Question
Because a client with MI can develop left
ventricular failure, the nurse should assess this

client for:
a. distended neck veins
b. paroxysmal nocturnal dyspnea
c. anorexia and weight loss
d. right upper quadrant tenderness
If a client reports all of the following, which one is
most indicative that the client is hypertensive?
a. client says that he has had unexplained
nosebleeds
b. client says he has difficulty sleeping all night
c. client says he has observed blood in his urine
d. client says he experiences abdominal fullness
Diagnostic Tests
Skin testing : mantoux test
Chest X-ray
Sputum examination
Lung biopsy - percutaneous,
bronchoscopic and open lung
Arterial blood gases
Thoracentesis
Common Respiratory Interventions
Oxygen therapy
tracheobronchial suctioning
chest physiotherapy
incentive spirometry
closed chest drainage (thoracostomy
tube)
EPISTAXIS
Sample Question
The patient is experiencing epistaxis
after removal of an NGT. Which of the

following nursing actions is most
appropriate to control the bleeding?
a. apply pressure by pinching the
anterior nose for about 5-10minutes
b. place the patient in a sitting position
with the neck hyperextended
c. pack the nostrils with gauze for about
5-7days
d. apply ice compress to the patients
forehead and back of the neck
Epistaxis
sit-up lean forward and head tilted
down
pressure over the soft tissue of the
nose
cold compress
Avoid nose blowing
nasal pack with neosynephrine (3-5
days)
Sinusitis
Rest
increase fluid intake
hot wet packs
anti-infectives or antihistamines
depending on the cause of sinusitis

nasal decongestants
irrigation with warm NSS
Laryngitis
Inflammation and swelling of mucous
membrane of larynx
Cause: Infection, improper use of voice,
smoking
Manifestations:
Hoarse voice, throat irritation, dry, nonproductive cough
Treatment:
ATB
Stop smoking
Removal of cause
Tonsillitis
Inflammation of the tonsils
Sore throat, difficulty or pain in swallowing,
fever
ATB, anti-pyretics, saline gargles
Surgery: Tonsillectomy
Post-op Care:
- HOB to 45 elevated to reduce edema
- Monitor for frequent swallowing
- Avoid carbonated and citrus juices- irritate the
incision
- Ice chips, small sips of cold fluid, popsicles (1 st
day)
- Soft foods on 2nd day
TONSILITIS
COPD : Chronic
bronchitis
Persistent cough for at least a month
edema of the mucous membranes
hypersecretion of mucus
blue bloaters
fluid and cellular exudation
cigarette smoking is predisposing
factor
Bacterial infection
COPD : Emphysema
Over distended and non functional
alveoli leading to rupture

retention of CO2 and hypoxia leading
to respiratory acidosis
pink puffers
the stimulus to breathe is a low pO2
instead of an increased pCO2
cigarette smoking is predisposing
factor
Asthma
Obstructive pulmonary disease

reversible
hypersensitivity reaction
bronchoconstriction, mucosal edema,
hypersecretion of mucus is the triad
retention of CO2 and air trapping
hypoxia and respiratory acidosis
Management is similar to COPD
avoidance of triggers (allergens)
multifactorial in cause
COPD
Assessment:
Anatomic changes: barrel chest and

clubbing
Cor pulmonale (R sided HF)
Cough (character, frequency, time of
day) exertional dyspnea
Wheezing and crackles
Weight loss
Sputum production (amount, color
consistency)
COPD
Use of accessory muscles for
breathing
Posturing (leaning forward)
Prolonged expiration
Pursed lip breathing
Diagnostic Exams:
CXR- congestion and hyperinflation
ABG- respiratory acidosis and
hypoxemia
COPD
Treatment:
CPT, Postural drainage, IS

Fluid intake to 3L/day if not
contraindicated (What condition?)
O2 @ 2-3L/min
Diet high in CHON, vitamin C,
calories, nitrogen
Nursing Management
Monitor VS and respiratory status.
Administer low flow O2 (24-28%).
Monitor pulse oximetry
Monitor CV status to detect
arrhythmias related to hypoxia
Encourage to drink plenty of fluids if
not contraindicated
Instruct in diaphragmatic or abdominal
and pursed lip breathing techniques
Suction if necessary to clear airway of
secretions
COPD
Position in high fowlers position and
leaning forward to aid in breathing
Encourage small, frequent feedings to
prevent dyspnea
Encourage activity as tolerated to
prevent fatigue
Encourage to stop smoking
Avoid exposure to persons with
infections
Avoid allergens and pollution
Receive immunizations: influenza (flu
shot)
Medications
- Bronchodilators- Salbutamol and
theophylline- Instruct on the use of
both oral and inhalant medications
- Steroids- to reduce inflammation
- Anti-leukotrienes
(montelukast- Singulair), mast cell
stabilizers (Cromolyn Na)
- Mucolytics- to thin secretions
- Expectorants- Guaifenesin
(Robitussin)
The nurse enters the room of the client
with COPD. The clients oxygen is running

at 6L/min his color is pink and his
respiration is 9/min. What is the best
initial action?
A. take the vital signs
B. call the physician
C. lower the oxygen rate
D. put the client in fowlers position
Status asthmaticus
High-fowlers position
Monitor VS
Monitor respiratory status
Epinephrine/ Aminophylline IV
Emotional support
Complications of COPD
Cor pulmonale
Definition: right ventricular
hypertrophy, secondary to disease
of the lungs; may or may not be
accompanied by heart failure.
Pneumonia
Refers to bacterial, viral, parasitic or fungal
infection that causes inflammation of
alveolar spaces & increase in alveolar fluid.
Ventilations decreases as secretion thicken
The edema associated with inflammation
stiffens the lungs, decreases lung
compliance and vital capacity and causes
hypoxemia
Causes:
Aspiration (NGT feedings) , chemical
irritants, bacteria, viruses
Assessment
- Chills, fever SOB, tachypnea,
accessory muscle use
- sputum (rusty, green or bloody
with pneumococcal pneumonia
and yellow green with
bronchopneumonia)
- crackles, rhonchi, pleural
friction rub on auscultation
- cough, malaise
- restlessness (hypoxia)
Pneumonia
Diagnostic exam:
- CXR shows diffuse patches
throughout the lungs or
consolidation in a lobe
- Sputum culture identifies
the organism
Pneumonia
-
Treatment:
CPT, PD, IS
Diet: High CHON, high calorie (to offset
hypermetabolic state) , force fluids
Administer O2 and respiratory
treatments
Position in semi-fowlers position to
facilitate breathing and lung expansion
Change position frequently and
ambulate as tolerated to mobilize
secretions
Pleural Effusion
Pleural effusion- excess of
fluid in the pleural space
Normally the pleural space
contains small amount of
extracellular fluid to
lubricate it- increased
production or inadequate
removal results in effusion
Pleural Effusion
Assessment:
- Pleuritic chest pain that is
sharp and increases with
inspiration
- Dyspnea, decreased breath
sounds, fever, malaise
- Dry, non-productive cough
caused by bronchial irritation
or mediastinal shift to
unaffected side
Pleural Effusion
Treatment:
- Thoracentesis
- Thoracotomy
-
Nursing Management:
Explain thoracentesis to patient.
Instruct to report difficulty breathing
during the procedure. May indicate
pneumothorax
Remind to breathe normally and to avoid
sudden movements such as coughing to
prevent improper placement of needle
Monitor breath sounds
Pneumothorax
Pneumothorax- loss of negative intrapleural
pressure > increased intrathoracic pressure and
reduced vital capacity
Types:
- Spontaneous- rupture of a bleb (bullae)
- Open opening thru the chest wall allows air to flow
between pleural space and outside of the body
- Tension-buildup of air in pleural space that cant
escape
In all cases, there is decreased surface area for gas
exchange resulting to hypoxia and hypercapnia
Pneumothorax
Assessment:
Dyspnea, diminished or absent breath
sounds unilaterally
sharp pain that increases with exertion,
dullness on percussion
tracheal shift to unaffected side
(tension)
decreased chest expansion unilaterally,
diaphoresis, subcutaneous emphysema,
sucking sound with open chest wound
Open Pneumothorax and

Tension Pneumothorax
Pneumothorax/ Hemothorax
Nursing Management:
Apply dressing over open chest wound
Position in high fowlers position
Prepare for chest tube placement until the
lung has fully expanded
Monitor for hypotension, tachycardia and
tachypnea
Assess for pain and medicate as ordered
Administer O2
Assist in turning, coughing, deep
breathing and IS to prevent atelectasis
and mobilize secretions
Monitor chest tube drainage system
Chest Tubes
Returns negative pressure to intrapleural
space
Used to remove abnormal accumulations of
air and fluid from pleural space
Collection chamber drainage
Water seal chamber- tip of tube is
underwater allowing fluid and air to drain
and prevents air from entering the pleural
space
Water oscillates (moves up when patient
inhales and moves down as patient exhales)
Suction control chamber- gentle continuous
bubbling normal
BETWEEN 2-3 ICS
BETWEEN 5-6 ICS
Nursing Management
- Monitor for drainage (amount,
-
color)
Keep tubes free of obstruction
Change position frequently
Do not strip or milk tubes
Maintain the drainage system
below chest level to maintain
water seal and prevent reflux
Care of a chest tube

If drainage bottle accidentally breaks,
immerse tube in sterile water , remove
broken system and replace with new
one
If chest tube accidentally pulled out,
pinch skin together, apply sterile
occlusive dressing and CALL MD
When chest tube is removed, patient
asked to take a deep breath and hold it
and tube is removed; a petrolatum
dressing or dry dressing is placed
15 CM (STRENGTH OF SUCTION)
-2CM (T.IMMERSION)
______
13 CM
15 CM
(PRESSURE APPLIED)
2 CM
Lung Cancer
Malignant tumor of the lungs
(primary/ metastatic)
Causes:
- Smoking, exposure to environmental
and occupational pollutants
Assessment:
Cough, dyspnea, hoarseness,
hemoptysis, chest pain, anorexia and
weight loss, weakness
- Pack year history- # of packs/day x #
years smoked
Lung Cancer
Nursing Management:
Assess for tracheal deviation

Place in fowlers position for ease
in breathing
Administer O2 and humidification
to moisten and loosen secretions
Administer corticosteroids and
bronchodilators
Provide high calorie, high CHON,
high vitamin diet
Lung Cancer
Provide activity with rest periods
Radiation therapy
Chemotherapy
No PERCUSION AND VIBRATION IF
BRONCHOGENIC CA
Post-op care for lung resection:
Pneumonectomy
removal of the entire lung
reasons: CA, abscess
Post op: Dorsal recumbent of semiFowlers on AFFECTED SIDE
ROM to shoulder
NO CHEST TUBE
Lobectomy
removal of a lobe
reasons: TB or abscess
Post-op: Chest tube
Segmentectomy
removal of a lobe segment
reason: infection in localized area
post-op: chest tube
Wedge resection
removal of a small portion of the
lung tissue
reason: small localized area of
disease near the surface of the lung.
Post-op: chest tube
Tuberculosis
Airborne, infectious, communicable
disease
Poor nutrition, overworked,
overcrowded places with poor
ventilation, immunosuppressed
Assessment :
cough, hemoptysis, dyspnea, low
grade fever, night sweats, fatigue,
malaise, anorexia, weight loss
Tuberculosis
Diagnostic exam:
Mantoux test, Sputum culture for AFB
Nursing management:
Standard airborne precautions
Diet high in CHO, CHON, B6, C and
calories
CPT, PD and IS
Provide negative pressure room to
prevent spread of infection
TB Medications
- Administer medications (MDT)
- Rifampicin- reddish orange secretions
- INH- peripheral neuritis- paresthesia
* Both hepatotoxic- avoid ALCOHOL!

- PZA
- Ethambutol
- Streptomycin- ototoxic and
nephrotoxic
Sample Questions
Which of the following findings in a client with lung

resection would require immediate intervention?
a. Decreased cough
c. absent breath sounds
b. Pain on inspiration
d. drainage from chest tubes
c.
While assisting a client in changing positions, the tube

is accidentally pulled out. What should the nurse do
1st?
d. Check breath sounds

e. Place the end in a cup of water
f.
Place the client in trendelenburg position
g. Cover the opening in the chest with a dressing

Sample Questions
The nurse explains to the client
about the result of positive PPD:

a. You have been exposed to TB
b. You have been infected with TB
c. You are immune to TB
d. You have an increased risk of
developing TB
Sample Question
The nurse includes which information in
a.
b.
c.
d.
the teaching plan for a client being

discharged home with tuberculosis?
you are not contagious unless you stop
taking your medications
your sputum may turn rust colored as
you get better
you may stop your medications as soon
as your sputum turns negative for TB
you will have to take your medications
for at least 1year
Sample Question
In assessing a client admitted with
respiratory disease, the nurse

correlates which finding to the client
with emphysema?
a. Chronic, productive cough
b. Dyspnea on rest
c. Slow deep respirations
d. Wheezing
A COPD patient presents with edema
of legs and feet, distended neck

veins and a large palpable liver. He is
most likely suffering from
A. atelectasis
B. pumonary embolism
C. cor pulmonale
D. pleurisy
Which of the following is the most
normal in water-seal chamber within the

first 24 hrs post operatively with a twobottle water seal drainage?
A. no fluctuations in the water-seal tube
B. intermittent slight bubbling
C. bright red bloody drainage
D. orders to maintain suction at
30cmH2O
Sample Question
A patient has a chest tube to underwater
drainage that is connected to suction. A

nurse observes that there is continuous
bubbling in the suction control chamber.
This finding most likely indicates that:
a. there is a leak in the tubing
b. the system is functioning properly
c. the tube needs to be repositioned
d. additional suction should be applied to
the system
Increased Intracranial Pressure
Increased Intracranial pressure secondary

to:
MASS NO MASS
Blood - Hydrocephalus
Abscess - Meningitis
Tumor glioma
Intracranial contents:
Brain 1200 cc space - 1400 g
CSF 150 cc space
- 75 cc
Blood 100 cc space - 75 cc
Meninges 50 cc space
INCREASED INTRACRANIAL
PRESSURE
Brain Tissue
CSF
(skull)
surrounded by bone
Blood
Brain tissue, CSF, or blood =
ICP
INCREASED INTRACRANIAL
PRESSURE
Pulse: decreased
Respiration: decreased & irregular
Widening Pulse Pressure; increased SYSTOLIC BP
120/70
135/60
CUSHINGS TRIAD
Projectile Vomiting; headache
Restlessness (EARLIEST); Lethargy
LOC (Level of Consciousness)
Pupils
; dilating; non reactive
ICP: > 15 mm Hg
Nursing management
Position - Semi-fowlers, 30-45
degrees
Oxygenation
Safety
Rest- keep environment quiet
Control fever; prevent shivering
(predisposes to seizures)
Avoid factors that may increase ICP-
vasovagal responses
nausea and vomiting

sneezing/ coughing
No Valsalva maneuver
No rectal examinations, enemas
No over suctioning- limit to 10-15
seconds
No restraints
N o bending
Control HPN
Restrict fluid intake- if IV, slow
infusion
pharmacotherapy
diuretics (mannitol, furosemide)
dexamethasone
anticonvulsants (diazepam, phenytoin,
phenobarbital)
Management for Increased

ICP
Craniotomy
- Supratentorial- HOB elevated

- Infratentorial- FOB to prevent brain
herniation
Place pads loosely around ears
(otorrhea) and under nose (rhinorrhea)

to absorb leaking CSF (Halo sign)
Sample Question
A patient is admitted to the hospital with
a closed head injury. The nurses observes

a yellow ring encircling a clear moist area
on the patients pillow. The nurse should
recognize this finding as:
a. an indication of a decrease in cranial
pressure
b. an indication that the patient had an
emesis prior to admission
c. a sign of CSF fluid drainage
d. an indication of an emergency situation
requiring the physician to be notified
Sample Question
When planning for the care of a
patient with increased ICP, a nurse

should give priority to which of the
following measures?
a. limiting environmental stimuli
b. increasing fluid intake
c. suctioning nasotracheally
d. keeping the patient in a
recumbent position
Which type of seizure is frequently
preceded by an aura?
A. jacksonian (focal)
B. petit mal (absence)
C. grand mal (tonic-clonic)
D. Myoclonus
Seizures
Abnormal electrical activity of the
brain
Types
grand mal (tonic-clonic)
petit mal (absence or little sickness)
Jacksonian
Febrile
Status epilepticus one seizure after
the other
Epilepsy- chronic recurring seizure
Diagnosis
- EEG
* NO MEDS EXCEPT Rx FOR 24-48 HRS
BEFORE TEST
* NORMAL MEALS BEFORE TEST
* HAIR SHAMPOO DAY BEFORE, NO
OILS, LOTION
* No caffeine or caffeine containing
products
- LP to rule out infectious cause
Seizures
3 phases
- Prodromal phase- produces aura

(sensory signals)- flash of light, mood or
behavior changes, sudden sensation of
smell or taste
- Ictal phase- seizure itself
- postictal phase- after the seizure;
amnesia, confusion, inability to be
aroused, sleepiness
Nursing management
Promote a safe environment

padded side rails
loosen constrictive clothings

turn to sides
no restraints and no tongue blades
observe and document
characteristic and duration
Health education :
medications taken regularly
- Dilantin- gingival hyperplasia

- Barbiturates- Phenobarbital
- Benzodiazepines- IV Diazepam
(status epilepticus)
avoid alcohol
active lifestyle with adequate rest
avoid hazardous activities
The most likely cause of a comatose
condition with a history of

hypertension, headache and unequal
pupils is
A. meningitis
B. intracranial aneurysm
C. diabetic ketoacidosis
D. cerebral concussion
Cerebrovascular Accidents
Stroke
Destruction of brain cells due to sudden
decrease in cerebral blood flow (cerebral

infarct)
Cerebral anoxia lasting than 10 mins causes
cerebral infarction with irreversible damage

Transient ischemic attacks- temporary
interruption of blood supply to the brain;

symptoms disappear in 1-24hours; warning
signal that a CVA can occur
CVA
Maybe an ischemic
hemorrhagic
Causes :
thrombosis
embolism
hypertension
subarachnoid
hemorrhage
UST College of Nursing
Stages of Development:
TIA
- warning sign of impending CVA
- brief neuro-deficit:
-last 30 sec to 24 hours with complete return
to normal
Stroke in Evolution
Progressive neuro impairment over a
period of several hrs. or days

Complete Stroke
- Neuro deficit remains unchanged

HEMORRHAGIC
THROMBOTIC/
EMBOLIC
ONSET
SUDDEN
GRADUAL
Signs and
Symptoms
Severe HA
Nausea and vomiting
SX of meningeal irritation
Increased restlessness
Confusion
Early instability
Signs & Symptoms of

Cerebral Insufficiency:
blurred vision
dizziness
light headedness
speech disturbance
Focal signs (related to site of infarction):

Hemiplegia
Sensory loss
Homonymous Hemianopsia
Aphasia (common with left cerebral infarct & right
handedness)
Interventions
Hemorrhagic
Ischemic
Control HTN:
Nipride
Control hemorrhage:
Vitamin K
Cerebral Vasodilators
Control increased ICP
Platelet Deaggregators
- Aspirin
Antithrombotics
- Anticoagulants
Thrombolytics: ALTEPLASE
* THERES ONLY A 3-HR
WINDOW FOR Tx
Nursing Management
Care of client with increased ICP

promote nutrition (aspiration
precautions)- soft diet; avoid liquids

activity (rehabilitation)- PT/OT
prevent contractures and muscle
atrop
elimination- constipation
communication (alternate means)
prevent pressure ulcers
Parkinsons Disease
Decreased dopamine levels in CNS

idiopathic
acetylcholine predominates
signs
pill-rolling tremors
rigidity (cogwheel rigidity)
bradykinesia
Mask-like facies
drooling of saliva
dysphagia
Shuffling and propulsive gait
Stooped posture
diagnostic test : clinical observation
Nursing Management
Maintain adequate diet

proper positioning to prevent
contractures
Aspiration precautions
pharmacotherapy
anticholinergics (biperiden,
diphenhydramine)
dopaminergics (levodopa, carbidopa)
dopamine agonists(amantadine,
bromocriptine)
Myasthenia Gravis
Autoimmune disorder
Lack of acetylcholine
Hyperactive thymus gland that destroys
acetylcholine receptors
signs
muscle weakness (including dysphagia
and dyspnea)
easy fatigability
ptosis and diplopia
Drooling
Diagnostic test
Tensilon Test (Edrophonium Chloride
Test)
short acting acetylcholine (5-20mins)
Nursing management
Aspiration precautions
accident preventions
adequate ventilation
adequate rest periods
Medical Treatment
Pharmacologic therapy:
Cholinergic Drugs
pyridostigmine Bromide ( Mestinon )
Neostigmine Bromide ( Prostigmin )
Immunosupprresive drugs
Prednisone
Nursing Considerations:
Nursing Alert!
-Always give the medication on time
- myasthenia crisis and cholinergic crisis
- Same symptom: Extreme muscle
weakness
- To differentiate: _______________
- Have a standby antidote at the
bedside (Anti-cholinergic drug:
Atropine Sulfate)
Sample Question
The nurse is aware that the teaching
about myasthenic and cholinergic

crisis is understood when a client
with Myasthenia Gravis states that a
symptom common to both is:
a. Diarrhea
b. difficulty breathing
c. salivation
d. abdominal cramping
Sample question
The nurse should explain to the client
a.
b.
c.
d.
that the diagnosis of Myasthenia gravis

will be confirmed if the administration of
Tensilon produces a:
brief exaggeration of symptoms
prolonged symptomatic improvement
rapid but brief symptomatic
improvement
symptomatic improvement of just the
ptosis
MULTIPLE SCLEROSIS
Autoimmune
characterized by exacerbation and
remission (aggravated by fatigue and

emotional disturbances)
Demyelinating disease of the CNS inflammation and destruction of the myelin
sheath (irreversible and progressive)
sclerotic plaque (scar tissue) > irritation
of nerves and slowing down of impulses
signs
- diplopia, scotoma, blindness (optic nerve)
- muscle spasms
- paresthesia
- Dysphagia
Nursing Management
Eye patch for diplopia
force fluids
avoid hot baths
Plasmapheresis
Pharmacotherapy
muscle relaxants (baclofen)
glucocorticoids
prednisone
Steroids: prevent edema formation
at the sclerotic plaques. Most

effective Tx for acute
exacerbations.
Autoimmune: Guillain-Barr
Syndrome
An autoimmune attack of the peripheral
nerve myelin
Resolves about a month after onset of
symptoms due to regeneration of
myelin sheath
Also known as: post-infectious
polyneuritis
GUILLAIN-BARRE SYNDROME
Ascending paralysis affecting peripheral
and cranial nerves.
Follows viral infection- ?? Autoimmune ??
Supportive Nursing Care
Airway
Range of Motion
Skin
Autoimmune: Guillain-Barr
Syndrome
Nursing and Medical management

medical emergency: ICU mgt.
assess changes in motor weakness
and respiratory function

respiratory therapy / mechanical
ventilation
prevent the complications of
immobility
Steroids
plasmapheresis
Pituitary gland
anterior pituitary
growth hormone : gigantism

and acromegaly vs. dwarfism
ACTH : secondary Cushings vs
Addisons disease
TSH : hyper vs. hypothyroidism
Posterior pituitary
ADH : SIADH vs. Diabetes insipidus
ADH: Water retention
SIADH: CONGESTION- HTN, crackles,
dilutional hyponatremia
- remove tumor (hypophysectomy),
replace Na
DI: polyuria, polydipsia, dehydration
management of D. insipidus
vasopressin replacement (desmopressin)
Hyperpituitarism
caused by pituitary adenoma (tumor)
Usually excessive GH
Gigantism/ Acromegaly
Enlargement of existing bones/ internal
organs
(heart, liver, spleen)
managed by surgery (hypophysectomy),
radiation therapy and chemotherapy
PROGNATHISM- PROMINENT JAW
Gigantism
Acromegaly
Gigantism-acromegaly
Thyroid gland
triiodothyronine (T3) and thyroxine (T4)
metabolism and growth; heat production
hyperthyroidism vs. hypothyroidism
diagnostic tests
T3 and T4 levels ; RAIU (Radioactive I

uptake)
( increased in hyperthyroidism and
decreased in hypo)
TSH- inversely proportional
Hyperthyroidism (Graves Disease)

Hypermetabolism-
Increased SNS activity

Signs
restlessness,
nervousness, irritability
and agitation
fine tremors
tachycardia
hypertension
increased appetite with
weight loss
diaphoresis
Diarrhea
heat intolerance
amenorrhea
Exopthalmos
Thyroid storm-
thyrotoxicosistachycardia, HTN and

heat intolerance
becomes lifethreatening.
Nursing management
Rest
diet : high calorie and high protein
Cool environment and cold fluids
promote safety
protect the eyes
replace fluid and electrolyte losses
pharmacotherapy
beta blockers
propanolol (inderal)
Iodides : lugols solution (SSKI) -reduce size
and vascularity of the gland preoperatively

- take with straw
Thioamides- inhibits thyroid hormone
synthesis
propylthiouracil (PTU)- agranulocytosis
methimazole (Tapazole)
Ca-channel blockers- anti-hypertensives
Radiation therapy- I131

thyroidectomy : total vs. subtotal
THYROIDECTOMY
Post operative care
Semi-fowlers
Check dressing (back of neck)
Trach set (risk of resp. obstruction)
O2 for 48 hrs
Suction
Check for tetany >> laryngospasm (Ca
gluconate)
Ca at bedside
Check laryngeal nerve (hoarseness)
GOITER
COMMON PROBLEM:
RESPIRATORY OBSTRUCTION
>> UPRIGHT POSITION
Hypothyroidism (Myxedema)
Slowed physical and mental
reactions
expressionless face
anorexia and obesity
bradycardia
hyperlipidemia and atherosclerosis
cold intolerance
constipation
Myxedema
Cretinism
Nursing management
Monitor daily weights

diet : low calorie high fiber
pharmacotherapy
thyroglobulin (proloid)
levothyroxine (synthroid)
dessicated thyroid extract
liothyronine (Cytomel)
Cushings Disease and

Syndrome
Hypersecretion of ACTH or GMA
Glucocorticoids (cortisol, steroids)
Mineralocorticoids (retains Na and
water)
Androgens
- Can be secondary to administration of
steroids
- Causes: Adrenal gland / Pituitary gland
tumors
Cushings Disease
- Steroids breaks down CHO- glucose
- Fat metabolism affected- adipose
tissue accumulates in the abdomen

(trunchal obesity) and behind the
shoulders (Buffalo hump)
- Accelerated CHON metabolism leads
to muscle wasting, osteoporosis,
edema, thinning of skin, moon face
- Salt ( increased), sugar (increased),
sick (immunosuppression)
CUSHINGS DISEASE
Cushings Disease and Syndrome

Interventions:
Monitor VS and labs ; I & O

Antihypertensive drugs
Adjust insulin for diabetics
Protect from infection
Low calorie diet, high CHON
Pituitary tumors- remove by
hypophysectomy
- Adrenal cortex tumors- adrenalectomy
- Radiation
- Taper steroids- will cause addisonian crisis
Addisons Disease
Signs
fatigue, muscle weakness
anorexia, nausea and vomiting with
weight loss
hypoglycemia
hypotension, weak pulse
Bronze pigmentation
Salt, sugar and sad
management
Hormone replacement therapy (GMA)
Sample Questions
Which nursing diagnosis is most likely
for a client with an acute episode of

diabetes insipidus?
a. imbalanced nutrition
b. deficient fluid volume
c. impaired gas exchange
d. ineffective tissue perfusion
Sample Questions
For which complication of
thyroidectomy would the nurse

monitor?
a. hypercalcemia
b. respiratory obstruction
c. elevated serum T4
d. paralytic ileus
Sample Questions
A client with hypothyroidism is
admitted to the ED with T=33.4C,

P=32, BP=110/58, R=16. The 1 st action
by the nurse would be to:
a. Start 2 large bore IV access lines
b. give levothyroxine as ordered
c. draw blood to test the T3 and T4
levels
d. cover with warm blankets
Diabetes Mellitus
Chronic systemic metabolic disease

Type I- absolute lack of insulin
Type II- lack of insulin or insulin
resistance
80- 120mg/dL- normal
FBS
HgbAic- assesses compliance to
medications- >7%
Signs
hyperglycemia > glycosuria
polyuria, polydipsia and polyphagia
Fats utilized- ketones > metabolic acidosis
Ketoacidosis > Lungs compensate
Kussmauls respirations (increased rate and
depth)
Acetone (fruity odored breath)
Macroangiopathy- CAD, nephropathy
Microangiopathy- retinopathy
Neuropathy (damages nerves- prone to
diabetic foot ulcers)
Diabetic Foot Ulcers

- 2ndary to diabetic neuropathy- sensory
deficit- vascular disease contributes to the

problem
Ill-fitting shoes, cuts, punctures from foreign
objects
Prevent injury to feet. Inspect feet regularly,
consult podiatrist for any callouses or corns;
Do not go barefoot, wear shoes.
Do not expose feet to heat sources
Inspect, bathe and dry
Diabetic Foot Ulcer
Nursing management
Diet
low calorie, high fiber diet
20% CHON 30% fats 50% CHO
activity
regular exercise pattern
maintenance of ideal body weight
Pharmacotherapy
Oral Hypoglycemic agents
Can only be used in Type II
Examples : Metformin
Insulin therapy (MEMORIZE ONSET AND
PEAK)
rapid acting- Humulin R
intermediate acting- Lente, Humulin N (NPH)
long acting Ultralente
Hypoglycemia
Signs
restlessness
hunger pangs, weakness, tremors, pallor
diaphoresis, cold clammy skin
blurred vision, slurred speech and
altered LOC
management
simple sugars p.o. (conscious)
D50% IV (unconscious, hospital)
glucagon SQ, IM (unconscious,
home)
Sample Questions
When can the nurse expect a client
who is receiving NPH insulin at 7:30am

to most likely have a hypoglycemic
reaction?
a. before lunch
b. early afternoon
c. late afternoon
d. after supper
Trauma
strain (muscle) vs. sprain (joints)

Dislocation (goes out of the joint)
Fracture
Signs (injury
inflammation)
pain aggravated by motion, tenderness
loss of motion
edema
Crepitus (rubbing against another bone)
Shortening of extremity
Management:
- Immobilize (splint) the more you move
it, the more it will break
- Neck (cervical)- immobilize neck ASAP!
- Cervical collar- prevent injury to phrenic
nerve
- RICE (Rest, ICE, Compression, Elevation)
- Reduction
* Open- surgery to re-align the bone
* Close (casting/ traction)
Types of Internal Fixation Devices
CAST CARE
Allow a wet cast
to dry within 2448hrs
Handle a wet cast
with the palms of

the hands
Monitor the
extremity for
circulatory
impairment
(5PsCompartment
syndrome)
Monitor for any
signs of infection
Monitor for any
drainage on the cast
Instruct not to insert
anything in the cast
Instruct to keep the
cast clean and dry
Instruct to do
isometric exercises
isometric exercises
TRACTION- Skin/ Skeletal

- Ensure that the
weights are
hanging freely
- Maintain
continuous
traction
- There should be a
countertraction
Sample Question
A client was placed in traction to align

a fractured bone in a lower extremity.
The nurse observes the traction
weights touching the floor. The nurse
should:
a. raise the foot of the bed
b. notify the MD
c. lengthen the traction rope
d. move the client up toward the head of the
bed
Bryants Traction
Cervical traction
Pelvic traction
Crutchfield tong
NC: * No side to side motion

Change of linen: head to foot
Care of pin site:

-Clean with antiseptic
-Apply antibiotic
-NO betadine >> rust pins
-NO peroxide >>
-Aerobic infection
Measurement:
2 below axilla
6 front of foot
2 to the side of foot
elbow flexion (20 30 degrees)
Exercises to prepare for CW:
- hand muscle ex
- arm muscle ex
Gaits
Stair climbing:
UP: good leg >> crutches with bad
leg
Down: bad leg with crutches
>>good leg
CRUTCH WALKING:
Nursing Considerations:
- stand on the affected side
when
ambulating with client
- When ambulating: Instruct to

- look up and outward when
- place crutches 6-10
inches
diagonally in
front of the foot.
Cane held on
non-affected side
Cane walks
together with weak
leg
HIP FRACTURES
Common among elderly women
Total or partial hip replacement
Post-op care:
- maintain legs in abduction (place pillows

between legs)- adduction will displace
prosthesis
- avoid bending
- use trochanter roll to prevent external
rotation
- NO LOW CHAIRS
Total Hip replacement
Rheumatoid Arthritis
Autoimmune and hereditary

Can occur in children
Bilateral, symmetrical, inflammatory,
systemic
Progressive, lifetime disorder
Synovitis and bony ankylosis
(permanent)
Can cause other systemic symptoms
Painful, warm, swollen joints
with limited motion, stiff in

the morning and after
periods of inactivity
Boutonnieres deformity
Swan-neck deformity
Ulnar deviation
history of remissions and
exacerbations
Rheumatoid Arthritis
Management
Bed rest during acute pain
passive ROM exercises
splint painful joints
heat and cold applications
physical therapy
Warm shower in AM
Surgery
osteotomy, synovectomy or arthroplasty
Pharmacotherapy
Aspirin (anti-inflammatory)
NSAIDS
Ibuprofen (Motrin)
Corticosteroids
intra-articular injections
Osteoarthritis
Degeneration of articular cartilage

involves weight bearing joints
signs
joint pain aggravated by use; relieved by
rest
stiffening of the joints
Heberdens and Bouchards nodes
decreased ROM and crepitus
Pathologic Changes Seen With

Osteoarthritis
Normal
Degenerated
Management
relieve strain and further trauma to
joints
cane or walker if indicated
proper body mechanics
avoid excessive weight bearing and
standing
physical therapy
relief of pain (NSAIDS)
joint replacement as needed
Gout
Disorder of purine metabolism
uric acid crystals in the joint: Tophi
signs
joint pain, redness, heat, swelling
unilateral with ears, ankle and great
toe most commonly affected
Gout
Management
rest
Low purine diet and increase fluids
pharmacotherapy
acute attack - Colchicine and NSAIDS

prevention
uricosuric drugs: excretes uric acid
Probenecid(Benemid)
Allopurinol(Zyloprim) inhibits uric acid
formation
LOW PURINE DIET

AVOID HIGH PURINE FOODS:
MEATS
FOWL
FISH & SHELL FISH
LENTILS, DRIED PEAS & BEANS
NUTS
OATS
Gouty Arthritis
Herniated Nucleus Pulposus (HNP)
Compression of the spinal nerve
roots
L4 and L5 most commonly affected
caused by heavy lifting,
degeneration of disc
Signs
cervical disc
-shoulder pain radiating to hand
- weakness
-Paresthesia
-sensory disturbance
Lumbosacral
back pain radiating across

buttocks and down the leg
(sciatic nerve)
weakness
numbness and tingling sensation
muscle spasms in the lumbar
region
Management
Bedrest on firm mattress with bed
board
traction
local application of heat
lumbosacral corset (back brace)
prevent complications of immobility
Surgical management
Laminectomy with Discectomy
- Lamina of the vertebrae are removed
Surgical fusion (spinal fusion and rod
insertion)
- Insertion of metal plates and screws and/or
use of bone grafts
Post-op:
- Lumbar: HOB flat, supine with legs slightly
flexed
- Cervical: HOB elevated, with neck
immobilized with collar or sandbags
- Log rolling technique
Smile!
Eyes and Ears

Disorders
Glaucoma
Increased IOP resulting from inadequate drainage
or overproduction of aqueous humor (10-20 mmHg)

Damages the optic nerve and causes irreversible
blindness
Types:
- Open angle glaucoma- overproduction of AH; slow
drainage of AH
-Close angle glaucoma- obstruction of outflow of
AH
* the more dilated the pupils are, the more
obstruction to the outflow
Open-Angle Glaucoma
Closed-Angle Glaucoma
INCREASED PRESSURE IN THE EYE COMPRESSES RETINA

AND OPTIC NERVE LEADING TO NERVE DAMAGE.
Assessment for Glaucoma

Progressive loss of peripheral vision
(compression of rods) tunnel vision

Increased IOP
Halos around white lights (corneal edema)
Eye pain (most common in close angle)
Management for Glaucoma

Instruct patient about lifelong need for
medication
Avoid drugs that causes pupil dilation
Prepare for surgery
- Laser trabeculoplasty to drain AH

* avoid activities that increase IOP
Glaucoma
Care: Routine post-op care
Eye patch
Position on back or on unoperative
side
Assess for signs of increased IOP
Meds: Steroids, Antibiotics and
Miotics (Pilocarpine)
Diuretics, beta-blockers, Epinephrine
(open angle)
Cataracts
Opacity of the lens that distorts the image
projected on the retina

Causes: aging, overuse of steroids,
Cushings disease, DM, overexposure to
UV rays
Manifestations:
- painless blurring of vision
- pupillary color may change to yellow, gray
or white
- reduced visual acuity
CATARACTS
TYPES OF CATARACT
SURGERY
ECCE LENS REMOVED LEAVING

POST CAPSULE BEHIND FOR ANY
LENS IMPLANT
PHACOEMULSIFICATIONULTRASONIC VIBRATION WITH A

HOLLOW NEEDLE EMULSIFIES THE
LENS AND ASPIRATED
ICCE LENS IS TOTALLY REMOVED

WITHIN ITS CAPSULE
CATARACT SURGERY
Cataracts
Elevate HOB 30-45 ; place on non
operative side
Avoid eye straining
Protect eye from injury by wearing an eye
shield
Avoid constipation (increase IOP)
Cataract glasses magnify and objects will
appear closer
Retinal detachment
- separation of the retina from the
posterior part of the eye

trauma, age related degenerative
changes
If total detachment, blindness can
occur
Retinal Detachment
RETINAL DETACHMENT
- Separation of Retina from Choroid
Assessment:
Flashes of light
Blank areas of Vision
Floating particles (Veil-like cover of the field of vision)
Nursing Care
Preop
Bed rest; affected eye in
dependent position
Both eyes covered
Affected eye
Cycloplegics
Mydriatics
Post-op
Bed rest; flat/ low fowlers
Mydriatics
Antibiotics
Corticosteroids
No reading3 weeks
Eye patch
Surgery
a.Cryosurgery- supercooled probe
causes retinal scarring to reattach

retina
b.Photocoagulation- laser beam thru
the pupil produces a retinal burn
causing scarring
c.Scleral buckling- depressing the
sclera to force the choroid closer
to the retina
Scleral Buckling
Menieres Disease
Disease of the inner ear resulting
from dilation of the endolympathic

system and increased volume of
endolymph
characterized by recurrent and
usually progressive 4 symptoms:

vertigo
tinnitus
sensorineural hearing loss
aural fullness
MENIERES DISEASE
NORMAL MEMBRANOUS LABYRINTH
DILATED MEMBRANOUS LABYRINTH
Menieres Disease
Acute attack:
Lying down to minimize head movement and
avoiding sudden movements and reduce
dizziness
Anti-emetics and anti-histamines for n/v and
vertigo (Bonamine, Plasil, Benadryl)
Diuretics
Sodium restriction- reduce endolymph
Position: Recumbent with affected ear uppermost
Menieres disease
Surgical Interventions such as
labyrinthectomy- only done if

unresponsive to meds and with
incapacitating symptoms with
poor or no hearing- destruction of
cochlea- total loss of hearing in
affected ear
SAMPLE QUESTIONS
A patient with Menieres disease is

experiencing severe vertigo. Which
instruction would the nurse give to the
patient to assist in controlling the vertigo?
a.
b.
c.
d.
increase fluid intake to 3000mL/day c.

lie still and watch the TV
avoid sudden head movements
increase sodium in the diet
A patient is diagnosed with a disorder

involving the inner ear. Which of the
following is the most common client
complaint associated with a disorder
involving this part of the ear?
a. hearing loss
b. pruritus
c. tinnitus
d. burning in the ear
GERD
Gastric contents flow upwards to esophagus
Common in obese and pregnant women
Any activity that increase intraabdominal
pressure (overeating, bending, tight

clothing), foods that relax cardiac sphincter
(alcohol, peppermint, caffeine, high fat
diet), lying down after meals
Assessment:
dyspepsia
dysphagia
odynophagia (painful swallowing)
esophagitis
Hiatal Hernia (diaphragmatic) and

GERD
Sliding hiatal or paraesophageal
hernia
signs
heartburn due to GER

dysphagia or odynophagia
dyspnea
abdominal pain
nausea and vomiting
gastric distention, belching, flatulence
symptoms aggravated when lying flat
GERD
Management
- Avoid alcohol, peppermint, caffeine,
high fat diet

- Lose weight
- Avoid over-eating and tight fitting
clothes
- Elevate HOB during and after meals
How can gastric regurgitation best be
reduced?
A. eat small frequent feedings and avoid
overeating
B. small evening meals with bedtime
snacks
C. belch frequently
D. swallow air
The nurse is preparing a client with hiatal

hernia for discharge. Which of the
following statements made by the client
would indicate the teaching has been
effective?
A. I will join the gym and get in shape by
lifting weight
B. I know I need to eat a high fat diet to
slow down my digestion.
C. I will join a support group
D. I will take a walk after dinner each
night
PEPTIC ULCER DISEASE

Impaired GI mucosa leading to erosion and
ulceration
maybe gastric or duodenal (most
common)
predisposing factors
Stress
Food (MILK included)
cigarette smoking and alcohol
caffeine
Drugs
H. pylori (90%)
Peptic Ulcers
Manifestations:
Bloating, belching, n/v, pain (burning, gnawing
or aching) located in the upper abdomen and
occurring between mealtimes or at night,
pain associated with ingestion of specific
foods (spicy, fried, alcohol) and ASA, relief of
pain after administration of antacids and food
Diagnostics:
Barium swallow, fecal occult blood, Upper GI
series, endoscopy shows location of the ulcer
Gastric analysis: Normal gastric acidity in
gastric ulcers; increased in duodenal ulcers
A client with peptic ulcer in the

duodenum would probably describe
the associated pain as:
A. an aching pain radiating to the left side
of the abdomen
B. an intermittent colicky flank pain
C. a gnawing sensation relieved by food
D. a generalized abdominal pain intensified
by moving
NURSING MANAGEMENT
Relieve the pain
lifestyle modification
dietary modification
quit smoking
stress therapy
pharmacotherapy
antacids
Magnesium/ AlMgOH
Calcium/ aluminum
Suppress gastric acid secretions

Histamine (H2) blockers
Ranitidine (Zantac), nizatidine
(Nexium), cimetidine (Tagamet)
Proton Pump Inhibitors
Esomeprazole (Losec), lansoprazole
Coats the ulcer
Sucralfate (Carafate)
Antibiotics
Amoxicillin
Metronidazole (Flagyl)
Surgery
Vagotomy- sever the vagus nerve- inhibits
release of HCl
Billroth I and II- gastric resections
Gastrectomy (Pernicious anemia)
TOTAL/SUBTOTAL GASTRECTOMY
Billroth I and Billroth II
POST-OPERATIVE CARE AFTER GASTRIC

RESECTION
pain management
Maintain on fowlers position for comfort
and to promote drainage
Gastric drainage system managementdont reposition NGT
Monitor dressings for drainage (bleeding)
Assess bowel sounds; maintain on NPO
Nutritional support (TPN)
Dumping Syndrome
- Prevent dumping syndrome - rapid

emptying of gastric contents into the
small intestine which has been
anastomosed to the gastric stump
- Cause: Ingestion of food high in CHO
and electrolytes, which must be diluted
in the jejunum; ingestion of fluid at
mealtimes
- Sweating, weakness, nausea, flatulence
and palpitations 30mins after a meal
Complication:
Signs and Symptoms
Nsg Management:
Diarrhea (3Ds)
a. Small frequent meals
dizziness
b. Chew food thoroughly
Diaphoresis
c. Avoid high carbohydrate diet
nausea and vomiting
d. Avoid liquid within meals
palpitations
e. Lying down after mealsflat for 5-30min p.c.
Following a subtotal gastrectomy, a client

develops dumping syndrome. The nurse
understand that dumping syndrome refers
to:
A. nausea due to a full stomach
B. rapid passage of osmotic fluid into the jejunum
C. reflux of intestinal contents into the esophagus
D. buildup of feces and gas within the large
intestine
APPENDICITIS
Obstruction of vermiform appendix
signs
acute abdominal pain (RLQ) McBurneys
point
Rovsings sign- pressing the left lower
quadrant will cause pain to the RLQ
anorexia, nausea and vomiting
rigid abdomen with guarding
rebound tenderness
elevated WBC count, fever
Sudden cessation of pain means rupture
APPENDICITIS
Risk Factors:
- Men>women
- 10-30 years old
- constipation
- low fiber diet
NURSING MANAGEMENT
Bed rest
NPO
Do not give NARCOTICS initially - will
mask the pain

No enema/ laxatives can cause
perforation
antibiotic therapy
surgery : appendectomy
Crohns disease vs
Ulcerative Colitis
Autoimmune
Ileum and ascending
colon
Right lower quadrant
pain
Diarrhea
3-5 watery stools
mucoid stools with pus
Transmural involvement
Ileostomy
Steroids and Flagyl
Autoimmune
Rectosigmoid
Lower left quadrant
pain
Diarrhea
15-20 watery stools
bloody mucoid stools
with pus
Shallow ulcerations
Colostomy
Steroids and Flagyl
Ulcerative Colitis
Interventions:
Steroids, Flagyl, antidiarrheal
(Imodium, Psyllium and
antispasmodic agents),
low residue, lacto-free diet,
elemental type diet, TPN, monitor
weights, I&O, stool specimens
Avoid: milk & gas-formers,
nuts,wheat grains, raw fruits & vegs,
alcohol, caffeine-containing prods,
smoking
Ulcerative Colitis
SURGERY:
- Total Proctocolectomy w/ permanent ileostomycolon and rectum removed and anus is closed. The
terminal ileum is brought out of the abdominal wall
- Continent ileostomy or Kock pouch- a reservoir
or pouch is constructed from a loop of ileum
- with a flat stoma on the right side of the
abdomen
- Advantages:
a. no need to wear an external pouch
b. minimal skin problems
c. no flatus or leakage of stool
Colectomy with
ileostomy
Surgery
Proctocolectomy
Continent Ileostomy: Free Edges

are Sutured Together
Preop bowel prep:

reduce bacteria in the intestinal tract to
prevent postop complications or infections
antibiotics- neomycin
reduce colon content- low residue diet,
laxatives, enema
decompress gastrointestinal tract
Colorectal Cancer
malignancy of small or large intestine (most common)- low
fiber high fat diet

Adenocarcinoma arising from epithelial lining
Grows slowly (polyps); s/sx absent till extensive (anorexia,
n/v, weight loss, anemia)
Metastasis to peritoneum, lymphatics, liver and lungs
Most common symptom is change in bowel habits, rectal
bleeding; progressive constipation with change in stool
shape (flattened, ribbon shaped)
Abdominal distention and pain as tumor grow
If tumor obstructs bowel, fluid backs up causing abdominal
distention, reduced or absent bowel sounds and fecal
smelling vomitus
Colorectal Cancer
Diagnostic Procedures;
- Abdominal and rectal exam, occult blood test, barium
enema, proctosigmoidoscopy and colonoscopy
- Elevated CEA
Interventions:
ATB, analgesics, antiemetics; chemotherapy; radiation
therapy
Small bowel resection- ileotransverse colostomy
Colonic resection and anastomosis; temporary colostomy
Nutritional support
Emotional support
Monitor for tumor re-occurrence
Monitor for perforation and obstruction
Colostomy Care:
a. skin care- cleanse with mild soap and water

b. odor control- avoid foods known to cause odor; lessen
with yogurt, cranberry juice and buttermilk
c. control of gas-avoid carbonated beverages and gas
forming foods
d. diet- avoid overeating; chew food thoroughly; prevent
diarrhea or constipation
e. colostomy irrigation- to stimulate peristalsis; to establish a
regular pattern of evacuation
Stoma Care
color: pinkish, reddish in
color with slight edema

for 5-7 days
Single-Barrel Colostomy
Double-Barrel Colostomy
Liver Cirrhosis
-scaring of the liver; irreversible damage to the
liver
Causes:
a. Laennec (alcohol)
b. Post hepatitis- fibrosis
c. Biliary obstruction
d. Cardiac
GI symptoms- nausea and vomiting,

anorexia
Decreased energy- not able to metabolize
fats, CHON, CHO
Hepatomegaly (fatty liver); decreased
energy production; weight loss
Decreased albumin production- edema
and ascites; decreased production of
clotting factors- bleeding; anemia
Obstruction of bile flow-
decreased absorption of fats

Decreased conjugation of
bilirubin- acholic stools, teacolored urine

Decreased deamination of CHON-
ammonia cant be converted to

urea- hepatic encephalopathy
ASCITES
Nursing Management:
Correct electrolyte imbalance
Reduction of ammonia formation- formed in
intestines by intestinal bacteria in protein
a. NGT suction
b. Neomycin sulfate, Lactulose
c. Protein restriction
d. Tap water enema
e. Potassium sparing diuretics
f. Paracentesis
Esophageal Varices
Nursing Management:
1. IV fluids
2. Anti-emetics
3.Blakemore- Sengstaken Tube (esophageal balloon
tamponade)
Nursing Interventions:
a. Keep a pair of scissors at bedside- in the
event of acute respiratory distress cut across tubing to
deflate balloon
b. deflate esophageal balloon for 5 minutes at
8-10 hrs interval to prevent necrosis
SENGSTAKEN BLAKEMORE TUBE
Cholelithiasis- stone formation in the gall bladder

Cholecystitis- inflammation of gall bladder usually
precipitated by gallstones
Choledocholithiasis- stone formation at the common
bile duct
Incidence: (5 Fs)
a. Female
b. Forty (age- 40 years and above)
c. Fair complexion
d. Fertile
e. Fat
Nursing Management:
a.Pain control- demerol (drug of choice) Do not
give MORPHINE- causes spasm of the sphincter
of ODDI
b. Anticholinergic- atropine
c. ESWL Extracorporeal Shock Wave Lithotripsyshock waves used to disintegrate gallstones
d. Cholecystectomy
- OPEN monitor for respiratory distress
- LAPAROSCOPIC
Post operative nursing Care:
1. Maintain patency of NGT

2. Assess T-tube if common bile duct is
3.
4.
5.
6.
7.
8.
9.
manipulated
position: low to SF
monitor dressing
clamp T-tube as ordered
IVFs and vitamin supplementation
deep breathing exercise
early ambulation
Fat free diet for 6 weeks
Surgical interventions
Abdominal Cholecystectomy
Laparoscopic Cholecystectomy
Extracorporeal shock wave

(Lithotripsy)
T-TUBE
GENITOURINARY
DISORDERS
FUNCTIONS OF THE KIDNEY

Urine formation
Excretion of waste products
- urea (major)
- creatinine, phosphates
- sulfates, uric acid
Regulation of electrolytes
- sodium
- potassium
Regulation of acid base balance

FUNCTIONS OF THE KIDNEY

Control of water balance
- ADH (vasopressin)
Control of blood pressure
- renin-angiotensin system
Regulation of RBC production
- erythropoeitin
Diagnostic tests
laboratory tests
routine urinalysis
creatinine clearance
blood studies : BUN (8-25mg/dL),
Serum Creatinine (0.6-1.3mg/dL),
creatinine clearance (85-135ml/min),
serum electrolytes
cystoscopy
abdominal X-ray (KUB)
SAMPLE QUESTION
After a cystoscopy, a patient is alarmed
with the presence of pink-tinged urine. The

nurse would:
a. administer atropine suppository as
ordered
b. tell the patient this is common and
continue to observe
c. notify the physician immediately
d. decrease fluid intake
RENAL FAILURE
Types
acute - sudden loss of renal function ;
reversible
chronic - gradual progressive and
irreversible loss of renal function
causes
pre-renal
renal
post-renal
ACUTE RENAL FAILURE

Oliguria/anuric phase- 8-15 days- output
<400ml/day. Toxins accumulate- metabolic
acidosis- Increased BUN, Crea, K
- decreased ph, bicarb, Na and Ca
- azotemia (elevated serum levels of urea,
creatinine and uric acid)
Diuretic phase- extends from the time daily
output > 400ml/day- BUN stops increasing, UO
> 3-5L/day, hyponatremia, hypokalemia,
change in LOC
Recovery phase- extends from 1st day BUN falls
to the day it returns to normal
ARF INTERVENTIONS
- Dialysis, monitor f&E, acids and bases

-
observe for fluid overload

moderate protein restriction, high in
calories, CHO, low K
Monitor cardiac status, I&O, weigh daily
Monitor creatinine and BUN
Fluid restriction
Diuretic therapy to treat oliguric phase
Sodium polystyrene sulfonate
(Kayexalate)- hyperkalemia- to
exchange Na for K ions in GIT
CHRONIC RENAL FAILURE

Manifestations:
Azotemia, metabolic acidosis
Altered LOC due to accumulation of wastes
Irregular heart rate
Yellow bronze skin due to altered metabolic process
Dry, scaly skin and severe itching due to uremic
frost
Proteinuria, glycosuria
Diminished erythropoetin secretion- anemia
Renal phosphate excretion and Vit D synthesis are
diminished; K secretion increases
Heart failure, pulmonary edema
Kussmauls respirations
CRF INTERVENTIONS
Dialysis, monitor I&O, F&E
Kidney transplant
Low CHON diet- limit accumulation of
end products of CHON metabolism
Fluid restrictions
Antihypertensives, diuretics
Epogen- stimulate bone marrow to
produce RBCs
Antipruritics; good skin care
TYPES OF DIALYSIS
Hemodialysis- removes wastes

and fluids rapidly than PD
removes toxic wastes and
impurities from the blood.
Blood removed from surgically
created access site
AV fistula, AV graft, Central
venous catheter
osmosis, diffusion and filtration
Monitor venous access site for bleeding
Dont use arm for BP, IVT or
venipuncture
Auscultate for bruits and palpate for
thrills
Weigh before and after the procedure
Monitor for shock and hypovolemia
Monitor for dysequilibrium syndrometoo fast removal of wastes- confusion,
weakness
HEMODIALYSIS
Peritoneal Dialysis- introduction of specially

prepared dialysate solution into the abdominal
cavity where the peritoneum acts as a
semipermeable membrane
Nursing Interventions:
a. weigh, VS every 15 mins then every hour
b. Patient voids
c. Warm dialysate solution to body temperature
d. Inflow time, Dwell time and Drain time
e. Observe character of dialysate flow
PERITONEAL DIALYSIS
SAMPLE QUESTION
When teaching a client who has just started
peritoneal dialysis about the procedure, the

nurse should tell the client that if the drainage
of dialysate from the peritoneal cavity ceases
before the required amount has been drained
out, the client should:
a. drink 8oz of water
b. turn from side to side
c. deep breathe and cough
d. periodically rotate the catheter
SAMPLE QUESTIONS
During the oliguric stage of ARF, serum
potassium is usually:
a. normal
c. elevated
b. decreased d. absent
A client with ARF moves into the diuretic phase
after 1 week of therapy. During this phase the

client must be assessed for signs of
developing:
a. renal failure
b. hypovolemia
c. hyperkalemia
d. metabolic acidosis
SAMPLE QUESTION
In caring for a client with hypovolemic
shock related to trauma, the nurse

recognizes that he is at risk for pre-renal
failure related to:
a. decreased perfusion to kidneys
b. direct trauma to the kidneys
c. obstruction to urine flow
d. vasodilation of renal arterioles
URINARY TRACT INFECTION

Signs
frequency, urgency, dysuria
hypogastric pain
malaise
fever, chills
nausea and vomiting
low back pain
urinalysis findings
MANAGEMENT
C and S before antibiotic therapy
increase fluid intake
acidify the urine
perineal hygiene
regular bladder emptying
hot sitz bath
SAMPLE QUESTION
To help prevent recurring UTI, the nurse
should plan to instruct a female client to:

a. increase the daily intake of citrus fruits
b. douche frequently with alkaline agents
c. urinate ASAP after intercourse
d. cleanse from the vaginal orifice to the
urethra
UROLITHIASIS/
NEPHROLITHIASIS
- formation of stones in the urinary tract
Risk factors :
- diet high in calcium and protein
- Urinary stasis
- Dehydration
- Uric acid accumulation
- Prolonged immobility
URINARY CALCULI
(UROLITHIASIS)
Types of stones
- Calcium oxalates, phosphates

- Uric acid
Signs
colicky pain
nausea and vomiting
dysuria and hematuria
MANAGEMENT
Fluids
strain urine
encourage ambulation
pain control
Acid ash diet for Ca/phosphate stones
Alkaline ash- cystine and uric acid
stones
- Low purine diet for uric acid stones
surgery
Urolithotomy/ nephrolithotomy
(nephrostomy tube)
ESWL
SAMPLE QUESTION
A patient passes a urinary stone and lab

analysis of the stone indicates that it is
composed of calcium oxalate. On the basis
of this analysis, which of the following
would the nurse include in the dietary
instructions?
a. increase intake of meat, fish, plums and
cranberries
b. increase citrus fruits and juices
c. Eat more green leafy vegetables such as
spinach and bran
d. increase intake of dairy products
GLOMERULONEPHRITIS
Acute (children) vs. chronic
acute : post streptococcal infection-
common in children
chronic :gradual and progressive
destruction of glomeruli
signs
headache, weakness, fatigue
Peri-orbital edema (worse in AM) and
hypertension
nocturia
MANAGEMENT
Bed rest
relief of edema
diet
fluid restrictions
Benign Prostatic
slow enlargement of the prostate gland- 40
Hypertrophy
years and above

Interference in urination
Causes: hormonal factors, age related changes
Urethral compression occurs with signs of
urinary obstruction > urinary stasis > UTI
Manifestations: Urinary frequency, nocturia,
less forceful urinary stream, dribbling after
urination, bladder distention, hematuria,
bladder calculi
BPH
Interventions:
- Administer Finasteride (Proscar)- reduce size of
prostate
- Terazosin- Hytrin- relax the muscles and promote
urination
- ATB
-
Surgical Removal of Prostate

TURP- resectoscope or laser inserted thru urethra
Suprapubic- incision in abdomen and bladder
Retropubic- abdominal incision
Perineal- perineal incision- highest risk for
incontinence, impotence and wound
contamination
BPH
CBI (continous bladder irrigation) after
surgery to promote hemostasis and limit
clots that block the catheter
Nursing Care:
Set rate of infusion per MD order; usually
to keep drainage reddish pink
Maintain infusion continuously, observing
color, clarity and amount of drainage
Bladder spasms typical after TURP, notify
patient
PROSTATE CANCER
slow malignant change in the prostate
gland that spreads by direct invasion of
surrounding tissue and can metastasize to
bony pelvis and spine
Elevated serum acid phosphatase and
serum PSA (prostate specific antigen) and
carcinoembryonic antigen (CEA)
Biopsy- reveals malignancy , MRI, CT
PROSTATE CANCER
Interventions:
Radical prostatectomy
Radiation
Diethylstilbestrol (Estrogen)
Orchiectomy- limit production of
testosterone slowing the spread of the
disease
NEOPLASTIC DISORDERS
Pathogenesis
cellular transformation and failure of
immune response
etiology
Viruses (HPV, Epstein Barr virus)
chemical carcinogens
Food preservatives
Hormones (estrogen, androgens)
WARNING SIGNS OF CANCER

Change in bladder or bowel habits
Asore that does not heal
Unusual discharge or bleeding
Thickening or lump in any part of body
Indigestion and dysphagia
Obvious change in wart or mole
Nagging cough
Diagnostics
cytologic examination
biopsy
ultrasound
X-rays, CT Scans, MRI
laboratory tests
AFP, HCG, PSA, CEA
endoscopic examinations
Staging and Grading

TNM classification
Cancer prevention
avoid over exposure to sunlight

annual oral examination
monthly BSE
avoid cigarette smoking
DRE for GI and prostate
PAP smear
Therapeutic Modalities
surgical interventions
preventive, diagnostic, curative, reconstructive, palliative
chemotherapy
radiation therapy
immunotherapy
bone marrow transplantation
CANCER CARE: SURGICAL

MANAGEMENT
Types of surgery
Diagnostic (cytologic brushings/ tissue
biopsy with endoscopy, biopsy: needle,

excisional, incisional)
Treatment: radical/wide excision
Recurrence and metastasis: excision
Palliative, reconstructive, preventive
CANCER CARE: CHEMOTHERAPY

- PHASES OF THE CELL-CYCLE
- ACTIVELY DIVIDING CELLS ARE MORE
SENSITIVE TO Chemotherapy
CHEMOTHERAPY
Alkylating Drugs
Anti-metabolites
Antitumor Antibiotics
Vinca alkaloids
Hormones
Corticosteroids
NURSING INTERVENTIONS FOR SIDE

EFFECTS
GI system
Maintain hydration status
Diet modification
anti-emetics for nausea and vomiting
integumentary
pruritus, urticaria, stomatitis, alopecia and
skin pigmentation with nail changes

provide good skin and oral care
psychological support
Hematopoetic
anemia, neutropenia, thrombocytopenia
genito-urinary
hemorrhagic cystitis and urine color
changes
maintain adequate fluids
CANCER CARE: RADIATION

THERAPY
High-energy ionizing radiation
* Normal cells have greater ability to

repair damaged DNA than Ca cells
RADIATION THERAPY
External vs. internal radiation
sealed vs. unsealed
side effects
skin reactions
infection
hemorrhage
fatigue
weight loss
CANCER CARE: RADIATION

THERAPY
Safety standards
Time- limit to 30 mins direct care/8hr shift
Distance distance & radiation exposure
inversely related.
*Visitors 6 ft. from source; off limits to <16
y.o. & pregnant women
Shielding lead shields, lead container &
long handled forceps are musts in pts unit.
- Precautionary measures for sealed &
unsealed
Stomatitis
diarrhea
nausea and vomiting
headache
hair loss/ alopecia
cystitis
BREAST CANCER
Most common cancer in women
Risk factors:
Family history
Obesity
HTN
Exposure to radiation and carcinogens
Nulliparity
Lack of breastfeeding
Early menarche before 12, menopause
after 55
- 1st pregnancy after 30
- Use of estrogen
BREAST CANCER
Signs
breast mass
dimpling
peau de
orange
nipple
retraction
nipple
discharge
Painless, non-tender,
hard, irregularly shaped,

non-mobile masses
Breast asymmetry,
palpable lymph and

axillary nodes
Heat and erythema of
breast
Skin edema- invasion and
obstruction of dermal
lymphatics
PREVENTION: MONTHLY BSE

DIAGNOSIS:
BREAST BIOPSY
MAMMOGRAPHY
COMMON SITES OF METASTASIS:
BONES, LUNGS, BRAIN, LIVER
Management
lumpectomy
simple mastectomy
modified radical mastectomy
mastectomy (halstead)
lymphedema is a common
complication
POST- OP CARE:
1. POSITION: Fowlers position or unaffected side with arm elevated
2. CARE OF WOUND DRAIN (JP drain )
3. DBCE
4. ARM PRECAUTIONS- DO NOT LIFT HEAVY OBJECTS, WEAR
ELASTIC BANDAGE, AVOID INJURY TO ARM
5. MONITOR FOR COMPLICATIONS: INFECTION, SWELLING,
ARM EDEMA (LYMPHEDEMA)
6. ASSIST WITH POST-MASTECTOMY EXERCISES- 5-10X EACH/
3X/DAY
SAMPLE QUESTION
Which of the following is the priority
nursing intervention for a client with

radiation induced skin problem?
a. remove skin markings to minimize
skin irritation
b. apply lotion to prepare for the
procedure
c. use oil based soap to clean the skin
d. minimize skin exposure to the sun
THOSE WHO JOYFULLY LEAVE

EVERYTHING IN GODS HANDS
WILL EVENTUALLY SEE GODS
HANDS IN EVERYTHING. FAITH
ENDS WHEN WORRY BEGINS AND
WORRY ENDS WHERE FAITH
BEGINS.
LITTLE FAITH SAYSGOD CAN DO IT

BIG FAITH SAYS GOD WILL DO IT
GREAT FAITH SAYS IT IS DONE.
THANK YOU LORD.
THANK YOU VERY MUCH &

HAVE A NICE DAY !

Medical Surgical Nursing Review 1

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ROWENA ESCOLAR CHUA, RN, MAN

RBC, WBC, platelets

UST COLLEGE OF NURSING

making- help maintain sense of control

UST COLLEGE OF NURSING

of age (18 yrs or older), mentally

Pre-op Nursing Care

- Barbiturates- to help them go to sleep

Pre-op Nursing Care

informed consent indicates that the

interferes with surgical procedure

- 1st assistant rt hand of

When the anesthesiologist

UST COLLEGE OF NURSING

motor and sensory perception to a

UST COLLEGE OF NURSING

unconsciousness; blocks motor and

at all times (respiratory depression)

priority for a client under general

prevent aspiration, lateral position

UST COLLEGE OF NURSING

atelectasis, COPD, pain

decreased breath sounds (alveolar

- Temperature greater than 38C-

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alveoli) and changing of positions

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deficit, hemorrhage or vasodilation

Altered Cardiac Output

reinforce dressing; check drains

(gag, cough, swallow and DTR)

Discomfort and Pain

6-10hrs after surgery

Impaired skin Integrity

need for further teaching after surgery?

- Observe for Homans sign (do not elicit)

Cardiovascular System Disorders

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what the physician meant by saying,

Blood Coagulation Tests

Partial Thromboplastin Time

Activated Partial Thromboplastin

to check if any occlusion or

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Coronary artery plaque

UST COLLEGE OF NURSING

ischemia- most common symptom of

the anginal pain is prolonged and

compressing; may radiate to

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restrictions- low fat, low cholesterol,

* Anticoagulants- prevents new clots from

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Percutaneous Transluminal Coronary

UST COLLEGE OF NURSING

UST COLLEGE OF NURSING

UST COLLEGE OF NURSING

UST COLLEGE OF NURSING

Crushing substernal pain (radiate to jaw,

UST COLLEGE OF NURSING

Bedrest with BSC

Paddle Placement for

(reduces myocardial O2 demand)