Patho Physiology Bible: Over 70 Concept Maps

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PA1HO PHSlOLOC 8l8LF

OvFR 70 CONCFP1 MAPS

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()*+,- !(. ..................................................................................................................................... 7
Alzheimers disease ..................................................................................................................... 7
PLAN OF CARF. SaeLy/ LOC/ sLress ree ........................................................................ 7
PaLh physiology ....................................................................................................................... 7
8rain 1umors ................................................................................................................................. 8
PaLh physiology ....................................................................................................................... 9
Cerebrovascular AccidenL (CvA) ......................................................................................... 0
PLAN OF CARF. neuro checks, pain Manage, decrease lCP, moniLor RR, ........ 0
PaLhophysiology ................................................................................................................... 0
Fpilepsy ........................................................................................................................................ 2
Head lnjury .................................................................................................................................. 5
1raumaLic 8rain lnjury......................................................................................................... 5
Acquired 8rain lnjury .......................................................................................................... 5
MulLiple Sclerosis ...................................................................................................................... 7
MeningiLis .................................................................................................................................... 9
Parkinson's Disease .................................................................................................................. 20
Seizures ........................................................................................................................................ 23
Spinal Cord lnjury ..................................................................................................................... 26
()*+,- /(. .................................................................................................................................. 27
Cuillain-8arre Syndrome ........................................................................................................ 27
MyasLhenia Cravis ..................................................................................................................... 29
01&$2" 3#$%&$4#15 6*77%28 ........................................................................................................ 30
Fsophageal Disorders .............................................................................................................. 30
CasLriLis ......................................................................................................................................... 32
CasLroesphageal Relux Disease (CFRD) .......................................................................... 33
HiaLial Hernia .............................................................................................................................. 35
PepLic Ulcer Disease ................................................................................................................ 37
01&$2" 3#$%&$4#15 69":%28 ........................................................................................................ 39
AppendiciLis ................................................................................................................................ 39
3

Small 8owel ObsLrucLion (S8O) ........................................................................................... 4
ConsLipaLion ............................................................................................................................... 42
Causes o consLipaLion. ...................................................................................................... 42
Hernia ............................................................................................................................................ 44
SympLoms o a hiaLal hernia ............................................................................................ 44
SympLoms o inguinal and emoral hernias ............................................................... 44
SympLoms o an umbilical hernia .................................................................................. 45
SympLoms o a congeniLal diaphragmaLic hernia .................................................... 45
ParalyLic lllius .............................................................................................................................. 45
Causes o paralyLic ileus .................................................................................................... 46
lshemic 8owel ............................................................................................................................ 47
volvulus ........................................................................................................................................ 49
DiverLiculiLis ................................................................................................................................ 50
ResecLion o lnLesLines ............................................................................................................ 52
DescripLion .................................................................................................................................. 52
Why Lhe Procedure is Perormed ........................................................................................ 53
Risks ............................................................................................................................................... 53
lnlammaLory 8owel Disease ................................................................................................ 53
ColorecLal Cancer...................................................................................................................... 55
Dukess Classification of Colorectal Cancer ................................................................ 56
,2$;"7%<4=& 6>,().8 ................................................................................................................ 57
Hip FracLure ................................................................................................................................ 57
1oLal Knee ReplacemenL (1KR)............................................................................................. 59
Long 8one lnjury ....................................................................................................................... 59
OsLeoarLhriLis (OA) ................................................................................................................... 62
FLiology And PaLhophysiology ........................................................................................ 62
RheumaLoid ArLhriLis (RA)...................................................................................................... 64
CouL ............................................................................................................................................... 65
?1&=@512 A4&"2<%2& ...................................................................................................................... 67
Peripheral ArLery Disease (PAD) .......................................................................................... 67
4

Peripheral vein Disease (PvD) ............................................................................................. 67
Aneurysms ................................................................................................................................... 68
l. AorLic Aneurysms. ............................................................................................................. 69
ll. Cerebral Aneurysm. Signs and sympLoms o cerebral aneurysm are. .......... 69
lll. Peripheral Aneurysm. Signs and sympLoms o peripheral aneurysm are as
ollows. ..................................................................................................................................... 69
+%&7421$"2B ..................................................................................................................................... 70
8ronchial AsLhma ...................................................................................................................... 70
8ronchiLis ..................................................................................................................................... 7
Chronic ObsLrucLive Pulmonary Disease (COPD) ......................................................... 72
Fmphysemia................................................................................................................................ 74
HemoLhorax ................................................................................................................................ 75
Pneumonia .................................................................................................................................. 77
PneumoLhorax............................................................................................................................ 80
Pulmonary Fmbolism .............................................................................................................. 8
RespiraLory Failure.................................................................................................................... 84
1uberculosis (18) ....................................................................................................................... 85
Upper RespiraLory lnecLion (URl ) .................................................................................... 86
!C+A3C! 6D)C+E8 ...................................................................................................................... 87
Angina ........................................................................................................................................... 87
ArrhyLhmias ................................................................................................................................. 89
AcuLe Coronary Syndrome (ACS ......................................................................................... 90
ALrial FibrillaLion (AFl8) ......................................................................................................... 92
Cardiogenic Shock.................................................................................................................... 93
Coronary ArLery 8ypass CraL (CA8C)................................................................................ 95
CongesLive HearL Failure (CHF) .......................................................................................... 96
5

Coronary ArLery Disease (CAD) ............................................................................................ 98
HyperLension (H1N) .............................................................................................................. 0
PaLhophysiology ................................................................................................................. 0
CenLral Nervous SysLem .................................................................................................. 0
Cardiovascular SysLem ..................................................................................................... 0
Renal SysLem ........................................................................................................................ 0
Renin-AngioLensin-AldosLerone sysLem. ................................................................... 0
Hyperlipidemia (high cholesLrol) ...................................................................................... 03
Myocardial lnarcLion ........................................................................................................... 03
Pulmonary Fdema................................................................................................................... 05
valvular HearL Diseas ............................................................................................................ 06
)#<"=24#% ...................................................................................................................................... 08
DiabeLes MelliLus 1ype ...................................................................................................... 08
DiabeLes MelliLus 1ype 2 ...................................................................................................... 0
Hyperglycemia .........................................................................................................................
PaLhophysiology .................................................................................................................
Hypoglycemia .......................................................................................................................... 4
DiabeLic KeLone Acidosis (DKA) ........................................................................................ 7
0155F51<<%2G 94H%2 I C77%#<4J .......................................................................................... 7
AppendiciLis .............................................................................................................................. 8
CholecysLiLis .............................................................................................................................. 9
AcuLe CholecysLiLis PaLhophysiology .................................................................. 9
Acalculous CholecysLiLis PaLhophysiology ........................................................ 9
HepaLiLis ..................................................................................................................................... 2
PancreaLiLis ................................................................................................................................ 23
K4<#%B 6+)(C98 ........................................................................................................................ 24
ARF (AcuLe Renal Failure)..................................................................................................... 24
1he clinical course o ARF is characLerized by Lhe ollowing Lhree phases. . 25
Phase . OnseL ..................................................................................................................... 25
Phase 2. MainLenance ....................................................................................................... 25
Phase 3. Recovery............................................................................................................... 25
CRF (Chronic Renal Failure) ................................................................................................. 27
6

NephroLic Syndrome ............................................................................................................. 30
Kindey SLone (Calculi) ........................................................................................................... 3
ClomerulonephriLis ................................................................................................................ 33
1ransureLhral ResecLion o ProsLaLe (1URP) .................................................................. 34
U1l (urinary LracL inecLion) ................................................................................................. 36
8enign ProsLaLe HyperLrophy (8PH) ................................................................................ 38

7

()*+,- !(.
Alzheimers <4&%1&%
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1he classic neuropaLhology indings in AD include amyloid plaques, neuroibrillary
Langles, and synapLic and neuronal cell deaLh. Cranulovacuolar degeneraLion in Lhe hippocampus
and amyloid deposiLion in blood vessels mighL also be seen on Lissue examinaLion, buL Lhey are
noL required or Lhe diagnosis

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Farly
! SubLle changes such as orgeLulness
! recenL memory loss
! poor concenLraLion

LaLe
! Severe memory loss
! lnabiliLy Lo hold a conversaLion
! lnabiliLy Lo Lhink absLracLly or ormulaLe concepLs
! Poor hygiene and grooming
! lnappropriaLe dress
! lnabiliLy Lo perorm insLrumenLal acLiviLies o daily living

8ehavioral changes
! Depression
! AnxieLy
! Wandering
! lmpulsive behavior
! CaLasLrophic reacLions
! lmiLaLion
! FmoLional liabiliLy
! WiLhdrawal

(@2&4#O AJ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmpaired LhoughL
processes relaLed Lo
decline in cogniLive
uncLion
Risk or injury
relaLed Lo decline in
cogniLive uncLion
AnxieLy relaLed Lo
Provide iniLial and
ongoing
assessmenLs
AdminisLer
prescribed
medicaLions.
Maximize eecLive
communicaLion
lmpairmenL o
visual percepLion
increases Lhe risk o
alling. ldenLiy
poLenLial risks in Lhe
environmenL and
heighLen awareness
so LhaL caregivers
CreaLing living
condiLions LhaL are
as sLress-ree as
possible will help
keep Lhe paLienL
calm and help
sLrengLhen his
cogniLive abiliLies,
8

conused LhoughL
processes
lmbalanced
nuLriLion. less Lhan
body requiremenLs
relaLed Lo cogniLive
decline
AcLiviLy inLolerance
relaLed Lo imbalance
in acLiviLy/resL
paLLern
DeicienL sel-care
relaLed Lo cogniLive
decline
lmpaired social
inLeracLion
DeicienL
knowledge o
amily/caregiver
relaLed Lo care or
paLienL as cogniLive
uncLion declines
lneecLive amily
decline in patients
cogniLive uncLion
Maximize
environmenLal
saeLy
PromoLe opLimal
uncLioning
OpLimize nuLriLion
and luid balance
OpLimize
eliminaLion
Reducing anxieLy
and agiLaLion
PromoLing
independence in
sel-care acLiviLies
Providing or
socializaLion and
inLimacy needs
PromoLing balanced
acLiviLy and resL
Provide discharge
planning
more aware o Lhe
danger.
An impaired
cogniLive and
percepLual disorder
are beginning Lo
experience Lhe
Lrauma as a resulL o
Lhe inabiliLy Lo Lake
responsibiliLy or
basic securiLy
capabiliLies, or
evaluaLing a
parLicular siLuaLion.
MainLain securiLy
by avoiding a
conronLaLion LhaL
could improve Lhe
behavior / increase
Lhe risk or injury.
Provide Lhe basis
or Lhe evaluaLion /
comparison LhaL will
come, and
inluencing Lhe
choice o
inLervenLion.
Noise, crowds, Lhe
crowds are usually
Lhe excessive
sensory neurons
and can increase
inLererence.
Cause concern,
especially in people
wiLh percepLual
disorders.
1he name is a orm
o sel-idenLiLy and
lead Lo recogniLion
o realiLy and Lhe
individual.
lncreasing Lhe
possibiliLy o
undersLanding.
buL LhaL can be a
Lall order.

>214# E@P"2&

PLAN OF CARF. Decrease lCP, pain, n/v, phoLophobia, moniLor RR & o2

9

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8rain Lumors may be classiied inLo several groups.
Lhose arising rom Lhe coverings o Lhe brain (e.g., Dural meningioma),
Lhose developing in or on Lhe cranial nerves (e.g., acousLic neuroma),
Lhose originaLing wiLh in brain Lissue and meLasLaLic lesions originaLing elsewhere in Lhe body.
1umors o Lhe piLuiLary and pineal glands and o cerebral blood vessels are also Lypes o brain
Lumors. RelevanL clinical consideraLions include Lhe locaLion and Lhe hisLology characLer o Lhe
Lumor. 1umors may be benign or malignanL.
A benign Lumor CAN 8F SFRlOUS!! l occurs in a viLal area and can grow large enough Lo have
eecLs as serious as Lhose o a malignanL Lumor.
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Severe headache in Lhe morning, increased when coughing, bending
Convulsions
Signs o increased inLra-cranial pressure. blurred vision, nausea, vomiLing, decreased
audiLory uncLion, changes in viLal signs, aphasia.
Changes in personaliLy
lmpaired memory
NaLural disLurbance o LasLe

Classic Lriad.
! Headache
! Papilledema (inLra-ocular pressure)
! vomiLing

(@2&4#O AQ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe pain
(headache), relaLed
Lo Lumor and
increase in
inLracranial pressure

DisLurbed body
image, relaLed Lo
upcoming hair loss
and cranial incision

Clear Lhe airway
MoniLor viLal signs
MoniLor Lhe
breaLhing paLLern,
breaLh sounds
MoniLor blood gases
8lood gas analysis
CollaboraLion
OxygenaLion
MoniLor Lhe pain
scale
Cive a comorLable
posiLion
Perorm Massage
ObservaLion o non-
verbal signs o pain
Assess, emoLional
sLaLe
NoLe Lhe inluence
o pain
Cold compresses on
Lhe head
Use o LherapeuLic
Louch Lechnique
ObservaLion o
Perorm pain
assessmenL each Lime
pain occurs. NoLe and
invesLigaLe changes
rom prev. reporL.
reduced pain
lmpaired gas
exchange can be
resolved
10

nausea, vomiLing

DRUCS. analgesic,
relaxanL,
prednisone, anLi-
emeLics

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ln a sLroke, Lhe sudden inLerrupLion o blood supply Lo areas o Lhe brain resulLs in
cerebral necrosis and impaired cerebral meLabolism, which permanenLly damages brain
Lissues and produces ocal neurologic deiciL o varying severiLy.
A =%2%F215 1#%@2B&P 4& 72"#% $" 2@7$@2%, which causes blood Lo leak inLo Lhe
subarachnoid space (and someLimes inLo brain Lissue, where iL orms a cloL), resulLing in
increased inLracranial pressure (lCP) and brain Lissue damage
ln a 1lA, Lhere is a Lemporary decrease in blood low Lo a speciic region o Lhe brain, buL
Lhere is #" #%=2"&4& "M F214# $4&&@%. 1he sympLoms (lasLing seconds Lo hours) produce
LransienL neurologic deiciLs LhaL ="P75%$%5B =5%12 :4$;4# TU $" UV ;"@2&.
.
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SLroke
! Hemiplegia and sensory deiciL
! Aphasia (impairmenL may be in speaking, lisLening, wriLing, or comprehending,
mosL cases are mixed expressive and recepLive).
! Hemipoeis weakening o one side
! UnilaLeral neglecL o paralyzed side
! 8ladder impairmenL
! Possibly respiraLory impairmenL
! lmpaired menLal acLiviLy and psychological deiciLs
! S1ROKF. FAS1 Face, aecL, smile,

1ransienL lschemic ALLack
! 1emporary loss o consciousness or dizziness
! ParesLhesias
! Carbled speech

Cerebral aneurysm
! 8lurred vision and headache
! Signs and sympLoms o lCP
! Nuchal rigidiLy and pain on neck movemenL
! PhoLophobia
11

! lrriLabiliLy and resLlessness
! SlighL LemperaLure elevaLion

(@2&4#O AQ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmpaired physical
mobiliLy relaLed Lo
hemiparesis, loss o
balance and
coordinaLion,
spasLiciLy and brain
injury
Pain relaLed Lo
hemiplegia and
disuse
DeicienL sel-care
(hygiene, LoileLing,
Lransers, eeding)
relaLed Lo sLroke
sequalae
DisLurbed sensory
percepLion
lmpaired
swallowing
lnconLinence relaLed
Lo laccid bladder,
deLrusor insLabiliLy,
conusion, diiculLy
in communicaLing
lmpaired LhoughL
brain damage,
conusion, inabiliLy
Lo ollow
insLrucLions
lmpaired verbal
communicaLion
relaLed Lo brain
damage, conusion,
inabiliLy Lo ollow
insLrucLions
Risk or impaired
skin inLegriLy relaLed
Lo hemiparesis or
hemiplegia,
decreased mobiliLy
Sexual dysuncLion
relaLed Lo
neurologic deiciL or
ear o ailure
lneecLive amily
caLasLrophic illness
and care giving
Provide alLernaLive
meLhods o
communicaLion, like
picLures or visual
cues, gesLures or
demonsLraLion.
AnLicipaLe and
provide for patients
needs.
1alk direcLly Lo
paLienL. Speaking
slowly and direcLly.
Use yes or no
quesLion Lo begin
wiLh.
Speak in normal
Lones and avoid
Lalking Loo asL. Cive
paLienL ample Lime
Lo respond.
Fncourage amily
members and
visiLors Lo 8F
PA1lFN1 persisL
eorLs Lo
communicaLe wiLh
Lhe paLienL.
Provide
communicaLion
need or desires
based on individual
siLuaLion or
underlying deiciL.
Helpul in
decreasing
rusLraLion when
dependenL on
oLhers and unable
Lo communicaLe
desires.
lL reduces conusion
or anxieLy and
having Lo process
and respond Lo
large amounL o
inormaLion aL one
Lime.
PaLienL is noL
necessary hearing
impaired and raising
voice may irriLaLe or
anger Lhe paLienL.
lL is imporLanL or
amily members Lo
conLinue Lalking Lo
Lhe paLienL Lo
reduce paLienLs
isolaLion, promoLe
esLablishmenL o
eecLive
communicaLion and
mainLain sense o
connecLedness or
bonding wiLh Lhe
amily.
speech Lherapy Lo
relearn Lalking and
swallowing,
occupaLional
Lherapy Lo regain as
much uncLion
dexLeriLy in Lhe arms
and hands as
possible,
physical Lherapy Lo
improve sLrengLh
and walking, and
Family educaLion Lo
orienL Lhem in
caring or Lheir
loved one aL home
and Lhe challenges
Lhey will ace.
12

burdens
lmpaired cerebral
perusion due Lo
bleeding rom Lhe
aneurysm
Sensory-percepLual
alLeraLion due Lo Lhe
resLricLions o
subarachnoid
precauLions
AnxieLy due Lo
illness or resLricLions
o aneurysm
precauLions

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Mechanisms o Lumor-relaLed epilepLogenesis remain poorly undersLood. ln Lumor-
associaLed epilepsy, nonLumoral surrounding Lissue may cause seizures.39 Abnormal growLh
kineLics o Lumors can aecL surrounding neurons morphologically and biochemically, alLering
neuronal sLrucLure and aecLing Lhe release o neuroLransmiLLers and neuromodulaLors such as
gamma-aminobuLyric acid (CA8A) and somaLosLaLin. 1hese changes may cause seizures Lhrough
hyperexciLabiliLy or reduced inhibiLion.

1he hippocampus may become involvedeiLher direcLly, Lhrough Lumor exLension, or
indirecLly, Lhrough increased exciLaLory inpuL caused by a Lumorand may conLribuLe Lo seizure
ampliicaLion and propagaLion.

1umors can disrupL normal elecLrical uncLional paLLerns, causing increased local
coherence, or similariLy o elecLrical acLiviLy seen elecLrographically wiLhin a corLical region, which
is a similar paLLern observed in epilepLic oci. 1hese changes, induced by a Lumor in Lhe
surrounding Lissue, conLribuLe Lo Lhe ormaLion o Lhe epilepLogenic zone.

CorLical connecLions conLribuLe Lo generaLion and mainLenance o seizures. Aggressive
whiLe-maLLer neoplasms are less likely Lo cause seizures because Lhey do noL direcLly irriLaLe
corLex, and Lumor growLh may disrupL Lhe spread o epilepLic acLiviLy.

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Ceneralized seizures are caused by abnormal elecLrical impulses in Lhe brain and Lypically occur
wiLh no warning. 1here are six Lypes o generalized seizures.

1onic-clonic (grand-mal) Seizure 1his seizure causes you Lo lose consciousness and oLen
collapse. our body becomes sLi during whaL's called Lhe "Lonic" phase. During Lhe "clonic"
phase, muscle conLracLions cause your body Lo jerk. our jaws clamp shuL and you may biLe your
Longue. our bladder may conLracL and cause you Lo urinaLe. ALer one Lo Lwo minuLes, you all
inLo a deep sleep.
13

Absence (peLiL mal) Seizure During Lhese brie episodes, B"@ 5"&% 1:12%#%&& 1#<
&$12% F51#R5B. Usually, Lhere are no oLher sympLoms. 1hey Lend Lo begin and end
suddenly and lasL or abouL ive Lo 0 seconds, alLhough Lhey can lasL longer. 1hese
seizures may occur several Limes a day.
Myoclonic Seizure 1hese very brie seizures cause your F"<B $" X%2R, as i &;"=R%< FB
%5%=$24=4$y, or a second or Lwo. 1he jerks can range rom a single muscle jerking Lo
involvemenL o Lhe enLire body.
Clonic Seizure 1his seizure cause 2;B$;P4= X%2R4#O P"$4"#& o Lhe arms and legs,
someLimes on boLh sides o your body.
1onic Seizure 1onic seizures cause your P@&=5%& $" &@<<%#5B &$4MM%#, someLimes or
as long as 20 seconds. l you're sLanding, you'll Lypically all.
AkineLic or ALonic Seizure 1his seizure causes B"@2 P@&=5%& $" 2%51J "2 5"&% &$2%#O$;,
parLicularly in Lhe arms and legs. AlLhough you usually remain conscious, iL can cause you
Lo suddenly all and lead Lo injuries. 1hese seizures also are called "drop aLLacks."

L"=15 .%4W@2%&

Focal seizures, also known as local or parLial seizures, are caused by abnormal elecLrical acLiviLy in
a speciic, smaller parL o Lhe brain. 1he parL o Lhe brain causing Lhe seizure is called Lhe seizure
ocus. Focal seizures are divided inLo simple and complex seizures.

Some ocal seizures evolve inLo generalized ones and are called secondarily generalized seizures.

Simple Focal Seizure During Lhese seizures, you remain conscious alLhough some
people can'L speak or move unLil Lhe seizure is over. UnconLrolled movemenLs, such as
jerking or sLiening, can occur LhroughouL your body. ou also may experience emoLions
such as ear or rage or even joy, or odd sensaLions, such as ringing sounds or sLrange
smells. ln addiLion, you may experience peculiar memories such as a eeling o "deja-vu."
1ypically, Lhese seizures lasL less Lhan one minuLe.
Complex Focal Seizure During Lhese seizures, you are noL ully conscious and may
appear Lo be in a dreamlike sLaLe. 1ypically, Lhey sLarL wiLh a blank sLare. ou may
involunLarily chew, walk, idgeL, or perorm oLher repeLiLive movemenLs or simple acLions,
buL acLions are Lypically unorganized or conused. 1hese seizures Lypically lasL beLween
30 seconds and a minuLe.
Secondarily Ceneralized Seizure 1hese seizures begin as a ocal seizure and develop
inLo generalized ones as Lhe elecLrical abnormaliLy spreads LhroughouL Lhe brain. When
Lhe seizure begins, you may be ully conscious buL Lhen lose consciousness and
experience convulsions as iL develops.

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Risk or injury
relaLed Lo seizure
acLiviLy
Fear relaLed Lo Lhe
possibiliLy o
seizures
lneecLive
individual coping
relaLed Lo sLresses
imposed by epilepsy
DeicienL knowledge
relaLed Lo epilepsy
AdminisLer
anLiconvulsanL
Lherapy as
prescribed.
ProLecL Lhe paLienL
rom injury during
seizures.
MoniLor Lhe paLienL
conLinuously during
seizures.
l Lhe paLienL is
Laking anLiseizure
Seizure disorders are
chronic healLh
condiLions
experienced by
many people wiLh
developmenLal
disabiliLies.
1he primary goal o
care is Lo minimize
Lhe impacL o seizure
disorders on Lhe
lives o
Lack o sleep,
lashing lighLs and
prolonged Lelevision
viewing may
increase brain
acLiviLy LhaL may
cause poLenLial
seizure acLiviLy.
Fnables Lhe paLienL
Lo proLecL sel rom
injury.
Minimizes injury
14

and iLs conLrol medicaLions,
consLanLly moniLor
or Loxic signs and
sympLoms such as
slurred speech,
aLaxia, leLhargy, and
dizziness.
Monitor the patients
compliance wiLh
anLiconvulsanL drug
Lherapy.
1each Lhe paLienL Lo
Lake exacL dose o
medicaLion aL Lhe
Limes prescribed.
Fncourage Lhe
paLienL Lo eaL
balanced, regular
meals.
Advise Lhe paLienL Lo
be alerL or odors
LhaL may Lrigger an
aLLack.
LimiL or avoid
alcohol inLake.
Fncourage Lo have
enough sleep Lo
prevenL aLLacks
Avoid resLraining Lhe
paLienL during a
seizure.
Loosen any LighL
cloLhing, and place
someLhing laL and
soL, such as pillow,
jackeL, or hand,
under his head.
Avoid any orcing
anyLhing inLo Lhe
patients mouth if his
LeeLh are clenched.
Avoid using Longue
blade or spoon
during aLLacks which
could laceraLe Lhe
mouLh and lips o
displace LeeLh,
precipiLaLing
respiraLory disLress.
Protect the patients
Longue, i his mouLh
is open, by placing a
soL objecL beLween
his LeeLh.
individuals wiLh
developmenLal
disabiliLies.
1he cooperaLion o
all Leam members,
including Lhe
individual, is
required Lo esLablish
opLimal levels o
seizure conLrol.
1he primary care
prescriber or medical
consulLanL is Lhe
only Leam member
who can
medically diagnose a
seizure, classiy Lhe
seizure Lype, and
order LreaLmenL.
Seizures are classiied
according Lo Lhe
lnLernaLional
ClassiicaLion SysLem
o FpilepLic
Seizures, permiLLing
selecLion o an
appropriaLe
anLiconvulsanL and
opLimal seizure
managemenL by Lhe
primary care
prescriber.
1he proper diagnosis
and classiicaLion o
seizure disorders
may be diiculL Lo
deLermine
because o
communicaLion
deiciLs, conusing
clinical presenLaLion,
and absenL or
insuicienL hisLory.
1he primary care
prescriber musL rely
on Lhe descripLion o
seizures by
observers Lo make
a reliable diagnosis.
AccuraLe descripLions
o seizure acLiviLy
and a sysLem or
recording and
reporLing Lhe
should seizure occur
while paLienL is in
bed.
Use o helmeL may
provide added
proLecLion or
individuals during
aura or seizure
acLiviLy.
PaLienL may eel
resLless Lo ambulaLe
or even deecaLe
during aural phase,
LhaL inadverLenLly
removing sel rom
sae environmenL
and easy
observaLion.
Help mainLain
airway and reduces
risk o oral Lrauma
buL should noL be
orced or inserLed
when LeeLh are
clenched because
denLal or soL Lissue
may damage.
CenLle guiding o
exLremiLies reduces
risk o physical injury
when paLienL lacks
volunLary muscle
conLrol.
PaLienL may be
conused,
disorienLed aLer
seizure and need
help Lo regain
conLrol and alleviaLe
anxieLy in posLicLal
phase.
Speciic drug
Lherapy depends on
seizure Lype, wiLh
some paLienLs
Requiring
polyLherapy or
requenL
medicaLions
adjusLmenL.
15

Turn the patients
head Lo Lhe side Lo
provide an open
airway.
Reassure paLienL
aLer Lhe seizure
subsides by Lelling
him that hes all
righL, orienLing him
Lo Lime and place,
and inorming LhaL
hes had a seizure.
acLiviLy is essenLial Lo
seizure
managemenL.
8ecause seizures
requenLly occur
during Lhe absence
o proessional sLa,
all sLa
involved wiLh
individuals who may
have seizures musL
be Lrained in
observing and
recording seizure
acLiviLy, and
managing and
proLecLing Lhe
individual during
and aLer a
seizure

D%1< 3#X@2B
/1$;"7;B&4"5"OB

1here are many dierenL Lypes o brain injury, depending upon Lhe severiLy o Lhe orce upon Lhe
head, as well as which porLion o Lhe brain is aecLed. 1o simpliy, brain injuries can be classiied
as LraumaLic or acquired, wiLh addiLional Lypes under each heading. All brain injuries are
described as eiLher mild, moderaLe, or severe.
E21@P1$4= >214# 3#X@2B
1raumaLic brain injury is a resulL o an exLernal orce Lo Lhe brain LhaL resulLs in a change Lo
cogniLive, physical, or emoLional uncLioning. 1he impairmenLs can be Lemporary or permanenL.
1ypes o LraumaLic brain injury include.
Diuse axonal injury. Shaking or sLrong roLaLion o Lhe head causes brain sLrucLures Lo Lear.
Nerve Lissue is disLurbed LhroughouL Lhe brain.
Concussion. Caused by a physical orce Lo Lhe head LhaL causes blood vessels Lo sLreLch and
cranial nerves Lo be damaged.
ConLusion. A resulL o a direcL impacL Lo Lhe head, which causes bleeding on Lhe brain.
Coup-conLrecoup injury. 1he orce Lo Lhe brain is large enough Lo cause conLusion aL Lhe side
o impacL, as well as Lhe siLe opposiLe impacL.
PeneLraLion injury. 1he impacL causes a oreign objecL Lo peneLraLe Lhe skull.
C=Y@42%< >214# 3#X@2B
An acquired brain injury is an injury Lo Lhe brain LhaL is noL herediLary, congeniLal, degeneraLive,
or Lhe resulL o birLh Lrauma. Acquired brain injury generally aecLs cells LhroughouL Lhe enLire
brain. 1ypes o acquired brain injury include.
Axnoxic brain injury. 1his occurs when Lhe brain doesn'L receive oxygen.
Hypoxic brain injury. 1his occurs when Lhe brain receives some, buL noL enough, oxygen.
16

.4O#& I .BP7$"P&

SympLoms depend on Lhe severiLy and disLribuLion o brain injury.
A common maniesLaLion is loss o consciousness, ranging rom a ew minuLes Lo hour
or longer.
Cerebrospinal oLorrhea (i.e. CSF draining rom Lhe ear), and cerebrospinal rhinorrhea (CSF
draining rom nose) may be presenL. 1his is deLermined by a posiLive glucose reading on
a dexLrose sLick or halo sign. (i.e. blood surrounded by a yellowish sLain).
Ecchymosis may be seen over the mastoid (Battles sign)
C1 scan may reveal Lhe area LhaL is conLused or injured
Radiographs may reveal skull racLures
PersisLenL, localized pain usually suggesLs racLure
FracLures o Lhe cranial vaulL may or may noL produce swelling in LhaL region
8loody spinal luid suggesLs brain laceraLion or conLusion.
8rain injury may have various signs, including alLered level o consciousness, pupillar
abnormaliLies, alLered or absenL gag relex or corneal relex, neurologic deiciLs, change in
viLal signs (e.g. respiraLion paLLern, hyperLension, bradycardia), hyperLhermia or
hypoLhermia, and sensory, vision or hearing impairmenL.
Signs o a posLconcussion syndrome may include headache, dizziness, anxieLy, irriLabiliLy,
and leLhargy.
ln acuLe or subacuLe subdural hemaLoma, changes in level o consciousness, papillary
signs, hemiparesis, coma, hyperLension, bradycardia, and slowing respiraLory raLe are
signs o expanding mass.

(@2&4#O
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(@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lneecLive Lissue
perusion
(cerebral)
Risk or lnjury
Decreased
inLracranial
adapLive capaciLy.
lndependenL
Assess conLribuLing
acLors Lo pain (noise,
wrong posiLioning,
environmenL)
review medicaLion
regimen
ask clienL Lo raLe pain
on 0-0 scale (raLed
as 9 ouL o
0)4.provide comorL
measures such as
reposiLioning Lhe
clienL in a
comorLable posiLion
and providing a hoL
or
coldcompress5.provi
de calm and quieL
environmenL(adjusL
lighLs, LemperaLure
and eliminaLe
oensive odors
which may conLribuLe
Lo headache)
insLrucLed in
relaxaLion Lechniques
1o deLermine
underlying cause o
pain and
LreaLaccordingly.2.cerL
ain drugs may cause
aLigue and
drowsiness.
1o assisL in evaluaLing
impacL o pain on
clients lie.
1o allow
nonpharmocological
pain relie and
promoLe good
circulaLion Lo Lhe brain
and decrease
vasoconsLricLion
1o decrease
environmenLal acLors
which conLribuLe Lo
migraine and promoLe
resL.
1o disLracL aLLenLion
rom pain and
decrease Lension
1o conserve energy o
Lhe paLienL and
Coal meL. PaLienL
verbalized I feel
better. Its just a
liLLle sore rom
alLhea swelling.
8uL iL inLolerable
pain. rated pain
as 4 ouL o 0.
Coal meL. PaLienL
was able Lo relax
by uLilizing bed
resL and deep
breaLhing.
Coal meL. PaLienL
was able Lo sleep
or 6 hours
sLraighL and elL
resLed aLerwards.
Coal meL. ClienL
was able Lo use
deep breaLhing
and reporLed
pain relie
aLerwards. Coal
meL. ClienL was
able Lo perorm
ADLs wiLh
17

(deep breaLhing,
imagery)
encourage adequaLe
resL periods
assisL in sel-care
acLiviLies as LoleraLed
provide peaceul
\and adequaLe
resLing environmenL
(dim lighLs, adjusL
LemperaLure, wrinkle-
ree bed, quieL
surroundings)

COLLA8ORA1lvF.
adminisLer
medicaLions as
ordered by
physician(analgesics,
eLc)
encourage waLchers
Lo assisL paLienL
during divisional
acLiviLies(minimize
noise, allow clienL Lo
verbalize eelings
and promoLe resL
and sleep
prevenL aLigue
1o promoLe clienL
independence as
much as possible and
acquire sense o
uncLion9.Lo enhance
qualiLy sleep and
promoLe resL which
harnesses energy or
uLure use.
medicaLions will
provide synergisLic
eecL wiLh non
pharmacologic
inLervenLions or pain
relie and promoLe
beLLer circulaLion by
aiding in
vasodilaLaLion or
beLLer blood low Lo
Lhe brain and alLering
prosLaglandin
synLhesis Lo decrease
pain
Lhe signiicanL oLhers
know Lhe clienL more
and will be able Lo aid
in diverting clients
aLLenLion rom pain Lo
deLermine underlying
cause o pain and
LreaLaccordingly.2.cerL
ain drugs may cause
aLigue and
drowsiness.
minimal
assisLance rom
waLchers
(eeding, sel-
care, eLc)

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/1$;"7;B&4"5"OB

DemyelinaLion o nerve ibers wiLhin long conducLing paLhway o spinal cord and brain.
lmpaired Lransmission o never impulses.
DegeneraLive changes myelin sheaLh are scaLLered irregularly LhroughouL Lhe cenLral
nervous sysLem. Nerve axon also deLerioraLes. 1he areas involved are noL consisLenL when
iL comes Lo deLerioraLion Lhereby showing Lhe signs and sympLoms appear whenever Lhe
nerve conducLion is inLerrupLed.
1here are periods o remission also, however Lhere are cases LhaL sympLoms are
exacerbaLed especially when nerve impulse Lravel Lhrough Lhe paLchy never ibers.
.4O#& I .BP7$"P&

SpasLic weakness Lhe mosL common sign
18

CharcoLs 1riad. A combinaLion o sympLoms LhaL includes nysLagmus, inLenLion Lremor
(moLor weakness in coordinaLion), scanning speech which is eliciLed by slowing
enunciaLion wiLh Lendency Lo hesiLaLe aL beginning o a word.
Hyper in emoLions as well as euphoria
visual disLurbances
Nausea and vomiLing
Urinary reLenLion or urinary inconLinence
Dysphagia diiculLy in swallowing
ALaxia a problem in coordinaLion

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmpaired bed and
physical mobiliLy
relaLed Lo weakness,
muscle paresis,
spasLiciLy
Risk or injury
relaLed Lo sensory
and visual
impairmenL
lmpaired urinary
and bowel
eliminaLion
(urgency, requency,
inconLinence,
consLipaLion)
relaLed Lo nervous
sysLem dysuncLion
lmpaired verbal
communicaLion and
risk or aspiraLion
relaLed Lo cranial
nerve involvemenL
DisLurbed LhoughL
process (loss o
memory, demenLia,
euphoria) relaLed Lo
cerebral dysuncLion
lneecLive
individual coping
relaLed Lo
uncerLainLy o
course o MS
lmpaired home
mainLenance
managemenL
relaLed Lo physical,
psychological, and
social limiLs
imposed by MS
PoLenLial or sexual
dysuncLion relaLed
Lo lesions or
PromoLing Physical
mobiliLy
PrevenLing lnjury
Fnhancing 8ladder
and 8owel conLrol
Fnhancing
communicaLion and
managing
swallowing
diiculLies
lmproving sensory
and cogniLive
uncLion
lmproving Home
managemenL
PromoLe sexual
uncLioning
SympLomaLically,
allow Lhe paLienL Lo
work on his or her
own in order Lo leL
him or her Lo know
LhaL Lhe siLuaLion is
sLill under conLrol.
Comply wiLh Lhe
medicaLions such as
corLisone or
corLicoLrophin.
1hese medicaLions
help in decreasing
edema and
inlammaLion aL
areas o
demyelinaLion.
CoordinaLe wiLh a
physical LherapisL in
order Lo aciliLaLe
daily living. 1his
prevenLs
complicaLions o
immobiliLy.
Provide proper skin
care as Lhe paLienL is
prone in decubiLus
ulcers as Lhe
demyelinaLion
progresses.
Allow Lhe paLienL Lo
geL in Louch wiLh
Lhe world, his amily
and riends Lo
emoLionally supporL
as he keeps his
mind inLacL in
baLLling Lhis
degeneraLive
condiLion.
Provide a sae
environmenL or Lhe
MainLain normal
daily acLiviLies as
besL you can.
SLay connecLed wiLh
riends and amily.
ConLinue Lo pursue
hobbies LhaL you
enjoy and are able
Lo do.
CeL enough resL.
Fxercise
8e careul wiLh heaL.
19

psychological
reacLion
paLienL always. Use
prescribed
equipmenL or
LransporL,
Lranserring Lhe
paLienL as well as in
mobilizaLion.

S%#4#O4$4&

/1$;"7;B&4"5"OB

MeningiLis is an inlammaLion o Lhe lepLomeninges and underlying subarachnoid cerebrospinal
luid (CSF). MeningiLis is Lhe inlammaLion o Lhe proLecLive membranes covering Lhe cenLral
nervous, known collecLively as Lhe meninges.

MeningiLis can be caused rom a direcL spread o a severe inecLion such as an ear inecLion or
sinus inecLion. ln some cases, meningiLis is noLed aLer head Lrauma or an injury Lo Lhe head or
brain. 1here are several causes o meningiLis. 1hese include 8acLerial inecLion, viral inecLion,
Fungal inecLion, A reacLion Lo medicaLions, A reacLion Lo medical LreaLmenLs, Lupus, Some orms
o cancer, A Lrauma Lo Lhe head or back. Anyone can caLch meningiLis. 1his is especially Lrue i
your immune sysLem is weak.

SomeLimes, however, Lhey spread Lo Lhe meninges rom an inecLion in anoLher parL o Lhe body.
1he meninges are composed o Lhree layers o membranes enclosing Lhe brain and spinal cord.
Pia maLer is Lhe innermosL layer. lL is akin Lo a Lissue paper LhaL closely adheres Lo Lhe brain and
spinal cord, dipping inLo Lhe various olds and crevices. Arachnoid maLer is Lhe middle layer. lL is a
ilmy membrane LhaL is joined Lo Lhe pia maLer by ine Lhreads resembling a cobweb.
.4O#& I .BP7$"P&

SympLoms. Loss o appeLiLe, diiculLy swallowing.
Signs. anorexia, vomiLing, poor skin Lurgor and dry mucous membranes.

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe pain relaLed
Lo inecLion process
Loxin in Lhe
circulaLion

lmpaired Physical
MobiliLy relaLed Lo
neuromuscular
damage.
Place Lhe ice bag on
his head, cool
cloLhing above Lhe
eyes, provide a
comorLable head
posiLion a liLLle biL
high, range o
moLion exercises and
acLive or passive
massage neck
muscles.
SupporL Lo ind a
comorLable posiLion
(head raLher high-).
Cive range o
.MoniLor changes in
orienLaLion,
kemamapuan
speak, Lhe naLural
eelings, sensory
and LhoughL
processes.
Assess awareness
o sensory. Louch,
heaL, cold.
ObservaLions o
behavioral
response.
FliminaLe excessive
noise.
paLienLs respiraLion
will be
reesLablished and
iLs raLe reLurn Lo
normal range
pain level
experienced will be
decreased or
alleviaLed
20

moLion exercises
acLive / passive.
Use a warm
moisLurizer, neck or
hip.
Assess Lhe degree o
immobilizaLion o
Lhe paLienL.
AssisLive range o
moLion exercises.
Cive skin care,
massage wiLh
moisLurizer.
Check Lhe area
experiencing
Lenderness, given air
maLLresses or waLer
body alignmenL are
uncLionally noLice.
Provide Lraining
programs and Lhe
use o mobilizaLion.
validaLe Lhe
paLienL's
percepLion and
give eedback.
Cive Lhe
opporLuniLy Lo
communicaLe and
move.
CollaboraLion
physioLherapisLs,
occupaLional
Lherapy, speech
and cogniLive

/12R4#&"#Z& A4&%1&%
/1$;"7;B&4"5"OB

Parkinsons disease is a slowly progressive degenerative neurological disorder caused by
Lhe loss o nerve cell uncLion in Lhe basal ganglia. 1he basal ganglia includes several
sLrucLures (subsLanLia nigra, sLriaLum, globus palidus, subLhalamic nucleus and Lhe red
nucleus). Loss o nerve cells in Lhe subsLanLia nigra causes a reducLion o dopamine
producLion. Dopamine is Lhe neuroLransmiLLer essenLial or such uncLions as conLrol o
posLure, supporLing Lhe body in an uprighL posiLion and volunLary moLions.

.4O#& I .BP7$"P&

1remor (rhyLhmic, purposeless, ine Lrembling, quivering movemenL), resLing or passive
Lremor
Muscle rigidiLy (sLiness seen wiLh resisLance Lo passive muscle sLreLching), cogwheel
rigidiLy
Akinesia (loss o movemenL) and bradykinesia (slowness o volunLary movemenL and
speech)
Mask-like expression
Dysphagia (diiculLy o swallowing)
MonoLonous speech
PosLural disLurbances (sLooped posLure, shuling gaiL, broad-based Lurns)
Ceneralized muscle aLigue
CogniLive changes (impaired memory, depression)
Drooling
ConsLipaLion
21

OrLhosLaLic hypoLension
Urinary dysuncLion

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Assess cranial
nerves, cerebral
uncLion
(coordinaLion) and
moLor uncLion.
ObservaLion o gaiL
and while doing Lhe
acLiviLy.
Review Lhe hisLory
o sympLoms and
Lheir eecLs on
body uncLions.
Assess Lhe clariLy
and speed o
speech.
Review Lhe signs o
depression.
MoniLor drug
LreaLmenL Lo noLe
adverse reacLions
and allow or dosage
adjusLmenLs.
MoniLor or liver
uncLion changes
and anemia during
drug Lherapy.
nuLriLional inLake
and check weighL
regularly.
abiliLy Lo perorm
acLiviLies o daily
living.
1o improve mobiliLy,
encourage Lhe
paLienL Lo parLicipaLe
in daily exercise,
such as walking,
riding sLaLionary
bike, swimming, or
gardening.
Advise Lhe paLienL Lo
perorm sLreLching
and posLural
exercises as ouLlined
by a physical
LherapisL.
1each Lhe paLienL
walking Lechniques
Lo oseL
parkinsonian
shuling gaiL and
Lendency Lo lean
orward.
Fncourage Lhe
paLienL Lo Lake warm
baLhs and massage
muscles Lo help relax
muscles.
lnsLrucL Lhe paLienL
Lo resL oLen Lo avoid
aLigue and
rusLraLion.
1o improve Lhe
patients nutritional
sLaLus, Leach Lhe
Provide clienL and
amily Leaching
PromoLe measures
Lo enhance body
image
Prepare Lhe clienL
or sLereoLaxic
surgery Lo reduce
Lremors and
rigidiLy i indicaLed.
AdminisLer
prescribed
medicaLions, which
may include anL
Parkinson
medicaLion,
anLicholinergics,
anLihisLamines,
amanLadine
hydrochloride,
anLiviral agenL, and
monoamine
oxidase-inhibiLors.
PromoLe measures
Lo mainLain an
adequaLe airway.
PromoLe meLhods
Lo ease diiculLy
wiLh swallowing i
indicaLed.
Fncourage semi-
solid dieL.

Maximize
uncLional abiliLies.
lmprove mobiliLy
and prevenL
complicaLions o
immobiliLy.
Fncourage daily
exercise, sLreLching
exercises and
special walking
Lechniques Lo
oseL Lhe shuling
gaiL.
lnsLrucL Lhe clienL
in ways Lo prevenL
consLipaLion (e.g.
increase luids,
1o increase mobiliLy
1o opLimize Lhe
nuLriLional sLaLus
1o maximize Lhe
abiliLy Lo
communicaLe.
22

paLienL Lo Lhink
Lhrough Lhe
sequence o
swallowing.
Urge Lhe paLienL Lo
make a conscious
eorL Lo conLrol
accumulaLion o
saliva (drooling) by
holding head
uprighL and
swallowing
periodically. 8e alerL
or aspiraLion hazard.
Have Lhe paLienL use
secure, sLabilized
dishes and eaLing
uLensils.
SuggesL Lhe paLienL
eaL smaller meals
and addiLional
snacks.
1o prevenL
consLipaLion,
encourage paLienL Lo
consume oods
conLaining moderaLe
iber conLenL (whole
grains, ruiLs, and
vegeLables), and Lo
increase his or her
waLer inLake.
ObLained a raised
LoileL seaL Lo help
Lhe paLienL siL and
sLand.
1each Lhe paLienL
acial exercises and
breaLhing meLhods
Lo obLain
appropriaLe
pronunciaLion,
volume, and
inLonaLion.
1each Lhe paLienL
abouL Lhe
medicaLion regimen
and adverse
reacLion..
mainLain high-iber
dieL, ollow regular
bowel rouLine.
PromoLe sel-care
o Maximize
eecLive
communicaLion

23

.%4W@2%&
/1$;"7;B&4"5"OB
Fpilepsy is noL a singular disease, buL is heLerogeneous in Lerms o clinical expression, underlying
eLiologies, and paLhophysiology . As such, speciic mechanisms and paLhways underlying speciic
seizure Lypes may vary. FpilepLic seizures are broadly classiied according Lo Lheir siLe o origin
and paLLern o spread.
Focal or parLial seizures arise rom a localized region o Lhe brain and have clinical
maniesLaLions LhaL relecL LhaL area o brain. Focal discharges can remain localized or
Lhey can spread Lo nearby corLical areas, Lo subcorLical sLrucLures and/or LransmiL
Lhrough commissural paLhways Lo involve Lhe whole corLex. 1he laLLer sequence describes
Lhe secondary generalizaLion o ocal seizures. As an example, a seizure arising rom Lhe
leL moLor corLex may cause jerking movemenLs o Lhe righL upper exLremiLy. l
epilepLiorm discharges spread Lo adjacenL areas and Lhen Lhe enLire brain, a secondary
generalized Lonic-clonic seizure ensues.
Primary generalized seizures begin wiLh abnormal elecLrical discharges in boLh
hemispheres simulLaneously. Ceneralized seizures involve reciprocal connecLions
beLween Lhe Lhalamus and neocorLex. 1he maniesLaLions o such widespread
epilepLiorm acLiviLy can range rom brie impairmenL o consciousness (as in an absence
seizure) Lo generalized moLor acLiviLy accompanied by loss o consciousness (generalized
Lonic-clonic seizure).
.4O#& I .BP7$"P&

Sensory/1houghL.
! 8lack ouL
! Conusion
! Deaness/Sounds
! FlecLric Shock Feeling
! Loss o consciousness
! Smell
! Spacing ouL
! OuL o body experience
! visual loss or blurring
FmoLional.
! Fear/Panic
! PleasanL eeling
Physical.
! Chewing movemenLs
! Convulsion
! DiiculLy Lalking
! Drooling
! Fyelid luLLering
! Fyes rolling up
! Falling down
! FooL sLomping
! Hand waving
! lnabiliLy Lo move
! lnconLinence
! Lip smacking
24

! Making sounds
! Shaking
! SLaring
! SLiening
! Swallowing
! SweaLing
! 1eeLh clenching/grinding
! 1ongue biLing
! 1remors
! 1wiLching movemenLs
! 8reaLhing diiculLy
! HearL racing
! 8ruising
! DiiculLy Lalking
! lnjuries
! Sleeping
! FxhausLion
! Headache
! Nausea
! Pain
! 1hirsL
! Weakness
! Urge Lo urinaLe/deecaLe

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lmpaired
physical mobiliLy
relaLed Lo
hemiparesis, loss
o balance and
coordinaLion,
spasLiciLy and
brain injury
Pain relaLed Lo
hemiplegia and
disuse
DeicienL sel-
care (hygiene,
LoileLing,
Lransers,
eeding) relaLed
Lo sLroke
sequalae
DisLurbed
sensory
percepLion
lmpaired
swallowing
lnconLinence
relaLed Lo laccid
bladder,
deLrusor
Fxplore wiLh paLienL
Lhe various sLimuli
LhaL may precipiLaLe
seizure acLiviLy.
Discuss seizure
warning signs (i
appropriaLe) and
usual seizure
paLLern. 1each SO
Lo recognize
warning signs and
how Lo care or
paLienL during and
aLer seizure.
Keep padded side
rails up wiLh bed in
lowesL posiLion, or
place bed up
againsL wall and
pad loor i rails noL
available/appropria
Le.
Fncourage paLienL
noL Lo smoke
excepL while
supervised.
FvaluaLe need
Alcohol, various
drugs, and oLher
sLimuli (e.g., loss o
sleep, lashing
lighLs, prolonged
Lelevision viewing)
may increase brain
acLiviLy, Lhereby
increasing Lhe
poLenLial or seizure
acLiviLy.
Fnables paLienL Lo
proLecL sel rom
injury and recognize
changes LhaL
require noLiicaLion
o physician/urLher
inLervenLion.
Knowing whaL Lo do
when seizure occurs
can prevenL
injury/complicaLions
and decreases SOs
eelings o
helplessness.
Minimizes injury
should seizures
Seizures acLiviLy
conLrolled.
ComplicaLions/injury
prevenLed.
Capable/compeLenL
sel-image displayed.
Disease
process/prognosis,
LherapeuLic regimen,
and limiLaLions
undersLood.
Plan in place Lo meeL
needs aLer discharge.
25

insLabiliLy,
conusion,
diiculLy in
communicaLing
lmpaired
LhoughL
processes
relaLed Lo brain
damage,
conusion,
inabiliLy Lo
ollow
insLrucLions
lmpaired verbal
communicaLion
relaLed Lo brain
damage,
conusion,
inabiliLy Lo
ollow
insLrucLions
Risk or
impaired skin
inLegriLy relaLed
Lo hemiparesis
or hemiplegia,
decreased
mobiliLy
Sexual
dysuncLion
relaLed Lo
neurologic
deiciL or ear o
ailure
lneecLive
amily processes
relaLed Lo
caLasLrophic
illness and care-
giving burdens
lmpaired
cerebral
perusion due Lo
bleeding rom
Lhe aneurysm
Sensory-
percepLual
alLeraLion due Lo
Lhe resLricLions
o subarachnoid
precauLions
AnxieLy due Lo
illness or
resLricLions o
or/provide
proLecLive headgear
Use Lympanic
LhermomeLer when
necessary Lo Lake
LemperaLure.
(requenL/generaliz
ed) occur while
paLienL is in bed.
NoLe. MosL
individuals seize in
place and i in Lhe
middle o Lhe bed,
individual is unlikely
Lo all ouL o bed.
May cause burns i
cigareLLe is
accidenLally
dropped during
aura/seizure
acLiviLy.
Use o helmeL may
provide added
proLecLion or
individuals who
suer
recurrenL/severe
seizures.
Reduces risk o
paLienL biLing and
breaking glass
LhermomeLer or
suering injury i
sudden seizure
acLiviLy should
occur.
26

aneurysm
precauLions

.74#15 !"2< 3#X@2B
/1$;"7;B&4"5"OB

Spinal cord injuries causes myelopaLhy or damage Lo whiLe maLLer or myelinaLed iber
LracLs LhaL carry signals Lo and rom Lhe brain. lL also damages gray maLLer in Lhe cenLral
parL o Lhe spine, causing segmenLal losses o inLerneurons and moLorneurons. Spinal
cord injury can occur rom many causes, including.
! 1rauma such as auLomobile crashes, alls, gunshoLs, diving accidenLs, war injuries,
eLc.
! 1umor such as righL, ependymomas, asLrocyLomas, and meLasLaLic cancer.
! lschemia resulLing rom occlusion o spinal blood vessels, including dissecLing
aorLic aneurysms, emboli, arLeriosclerosis.
! DevelopmenLal disorders, such as spina biida, meningomyolcoele, and oLher.
! Neurodegenerative diseases, such as Friedreichs ataxia, spinocerebellar ataxia,
eLc.
! DemyelinaLive diseases, such as MulLiple Sclerosis.
! 1ransverse myeliLis, resulLing rom spinal cord sLroke, inlammaLion, or oLher
causes.
! vascular malormaLions, such as arLeriovenous malormaLion (AvM), dural
arLeriovenous isLula (AvF), spinal hemangioma, cavernous angioma and
aneurysm.
.4O#& I .BP7$"P&

lmpaired physical mobiliLy
DisLurbed sensory percepLion
AcuLe pain
AnLicipaLory grieving
Low sel-esLeem
ConsLipaLion or bowel inconLinence
lmpaired urinary eliminaLion

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lmpaired physical
mobiliLy relaLed Lo
neuromuscular
impairmenL.
lndependenL.
Continually asses
moLor uncLion (as
spinal shock or
edema resolves)
by requesLing
paLienL Lo perorm
cerLain acLions.
Provide means to
summon help.
Assist in range of
moLion exercises
on all exLremiLies
FvaluaLes sLaLus o
individual siLuaLion
(moLor-sensory
impairmenL may be
mixed and/ or noL
clear) or a speciic
level o injury,
aecLing Lype and
choice o
inLervenLion.
Fnables paLienL Lo
have sense o
conLrol, and
Able Lo
demonsLraLe
Lechniques or
behaviors LhaL
enable resumpLion
o acLiviLy.
27

and joinLs, using
slow, smooLh
movemenLs.
Pl an acLiviLies Lo
provide
uninLerrupLed resL
periods. Fncourage
involvemenL wiLhin
individual
Lolerance or
abiliLy.
Reposition
periodically even
when siLLing in
chair. 1each
paLienL how Lo use
weighL
shifting
Lechniques.
lnspecL Lhe skin
daily. Observe or
pressure areas,
and provide
meLiculous skin
care.

CollaboraLive.
Consult with
physical or
occupaLional
LherapisL.

Administer
muscle relaxanLs
or anLispasLiciLy as
prescribed
reduces ear o
being leL alone.
Fnhances
circulaLion, resLores
or mainLains
muscle Lone and
joinL mobiliLy, and
prevenL disuse
conLracLures and
muscle aLrophy.
PrevenLs aLigue,
allowing
opporLuniLy or
maximal eorLs or
parLicipaLions by
paLienL.
Reduces pressure
areas, promoLes
peripheral
circulaLion.
AlLered circulaLion,
loss o sensaLion,
and paralysis
poLenLiaLe pressure
sore ormaLion.
Helpul in planning
and implemenLing
individualized
exercise program
and idenLiying or
developing
assisLive devices Lo
mainLain uncLion,
enhance mobiliLy
and independence.
May be useul in
limiLing or
reducing pain
associaLed wiLh
spasLiciLy

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Cuillain-8arr syndrome is Lhe resulL o a cell-mediaLed and humoral immune aLLack on
peripheral nerve myelin proLeins LhaL causes inlammaLory demyelinaLion. WiLh Lhe auLoimmune
28

aLLack, Lhere is an inlux o macrophages and oLher immune-mediaLed agenLs LhaL aLLack myelin,
cause inlammaLion and leave Lhe axon unable Lo supporL nerve conducLion.
.4O#& I .BP7$"P&

AuLonomic changes
! 1achycardia, bradycardia, hyperLension, or orLhosLaLic hypoLension
! lncreased sweaLing
! lncreased salivaLion
! ConsLipaLion

Dyskinesia (inabiliLy Lo execuLive involunLary movemenLs)
Weakness usually begins in Lhe legs and progress upward (ascending paralysis)
Hyporelexia (decreased D1Rs)
ParesLhesia (numbness), clumsiness
8lindness
lnabiliLy Lo swallow (dysphagia) or clear secreLions
AlLernaLe hypoLension/hyperLension, eared complicaLion. arrhyLhmias

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lneecLive breaLhing
paLLern and impaired
gas exchange relaLed
Lo rapidly
progressive
weakness and
impending
respiraLory ailure
lmpaired bed and
physical mobiliLy
relaLed Lo paralysis
lmbalanced
nuLriLion, less Lhan
body requiremenLs,
relaLed Lo inabiliLy Lo
swallow
lmpaired verbal
communicaLion
relaLed Lo cranial
nerve dysuncLion
Fear and anxieLy
relaLed Lo loss o
conLrol and paralysis
MoniLor respiraLory sLaLus Lhrough
viLal capaciLy measuremenLs, raLe and
depLh o respiraLions, and breaLh
sounds.
MoniLor level o muscle weakness as iL
ascends Loward respiraLory muscles.
WaLch or breaLhlessness while Lalking
which is a sign o respiraLory aLigue.
MoniLor Lhe paLienL or signs o
impending respiraLory ailure.
MoniLor gag relex and swallowing
abiliLy.
PosiLion paLienL wiLh Lhe head o bed
elevaLed Lo provide or maximum
chesL excursion.
Avoid giving opioids and sedaLives
LhaL may depress respiraLions.
PosiLion paLienL correcLly and provide
range-o-moLion exercises.
Provide good body alignmenL, range-
o-moLion exercises, and change o
posiLion Lo prevenL complicaLions such
as conLracLures, pressure sores, and
dependenL edema.
Fnsure adequaLe nuLriLion wiLhouL Lhe
risk o aspiraLion.
Fncourage physical and occupaLional
Lherapy exercises Lo help Lhe paLienL
regain sLrengLh during rehabiliLaLion
phase.
Provide assisLive devices as needed
(cane or wheelchair) Lo maximize
independence and acLiviLy.
MainLain airway paLency
DemonsLraLe progressive
weighL gain.
Fnable Lo express sel.
29

l verbal communicaLion is possible,
discuss the patients fears and
concerns.
Provide choices in care Lo give Lhe
paLienL a sense o conLrol.
1each paLienL abouL breaLhing
exercises or use o an incenLive
spiromeLer Lo reesLablish normal
breaLhing paLLerns.
lnsLrucL paLienL Lo wear good
supporLive and proLecLive shoes while
ouL o bed Lo prevenL injuries due Lo
weakness and paresLhesia.
lnsLrucL paLienL Lo check eeL rouLinely
or injuries because Lrauma may go
unnoLiced due Lo sensory changes.
Urge Lhe paLienL Lo mainLain normal
weighL because addiLional weighL will
urLher sLress moniLor uncLion.
Fncourage scheduled resL periods Lo
avoid aLigue.

SB1&$;%#41 021H4&
/1$;"7;B&4"5"OB
ln myasLhenia gravis, anLibodies direcLed aL Lhe aceLylcholine recepLor siLes impair
Lransmission o impulses across Lhe myoneural juncLion. 1hereore, ewer recepLors are
available or sLimulaLion, resulLing in volunLary muscle weakness LhaL escalaLes wiLh
conLinued acLiviLy.
FighLy percenL o people wiLh myasLhenia gravis have eiLher Lhymic hyperplasia or a
Lhymic Lumor, and Lhe Lhymus gland is believed Lo be Lhe siLe o anLibody producLion

.4O#& I .BP7$"P&

PLosis - check palpebral issure or drooping o upper eyelids
Double vision
Mask like acial expression
Weakened laryngeal muscles leads Lo dysphagia (diiculLy o swallowing, wiLhouL ood),
odynophagia ang wiLh ood
Hoarseness o voice
RespiraLory muscle weakness leads Lo respiraLory arresL
FxLreme muscle weakness especially during acLiviLy or exerLion in AM

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# I +1$4"#15% 0"15
Weakness and
aLigue
DiiculLy chewing
Dysphagia
PLosis
Listen to the patients concerns and
answer Lhe quesLions honesLly.
AdminisLer medicaLions on Lime and aL
evenly spaced inLervals, as ordered, Lo
prevenL relapses.
Will verbalize decreasing
aLigue when perorming
ADLs.
Will sLaLe Lhe correcL
meLhod o medicaLion
30

Diplopia
Weak, hoarse voice
DiiculLy breaLhing
Diminished breaLh
sounds
RespiraLory paralysis
and ailure
Plan exercise, meals, paLienL care, and
acLiviLies Lo make Lhe mosL o energy
peaks.
When swallowing is diiculL, give
semi-solid oods insLead o liquids Lo
lessen Lhe risk o choking.
ALer severe exacerbaLions, Lry Lo
increase social acLiviLy as soon as
possible.
FsLablish accuraLe neurologic and
respiraLory baseline.
SLay alerL or signs o impending
myesLhenic crisis such as increased
muscle weakness and diiculLy Lalking
or chewing.
Help Lhe paLienL plan daily acLiviLies Lo
coincide wiLh energy peaks.
SLress Lhe need or requenL resL
periods.
l surgery is scheduled, provide
perioperaLive Leaching.

01&$2" 3#$%&$4#15 6*77%28
)&"7;1O%15 A4&"2<%2&

1he esophagus is a Lube LhaL connecLs Lhe back o Lhe mouLh Lo Lhe sLomach.
AbnormaliLies o Lhe esophagus generally all inLo one o our caLegories. sLrucLural abnormaliLies,
moLiliLy disorders, inlammaLory disorders, and malignancies.

/1$;"7;B&4"5"OB

1he esophagus is Lhe Lube LhaL carries ood, liquids and saliva rom your mouLh Lo Lhe
sLomach. ou may noL be aware o your esophagus unLil you swallow someLhing Loo large, Loo
hoL or Loo cold. ou may also become aware o iL when someLhing is wrong.
1he mosL common problem wiLh Lhe esophagus is gasLroesophageal relux
disease(CFRD). lL happens when a band o muscle aL Lhe end o your esophagus does noL close
properly. 1his allows sLomach conLenLs Lo leak back, or relux inLo, inLo Lhe esophagus and irriLaLe
iL. Over Lime, CFRD can cause damage Lo Lhe esophagus. OLher problems
include hearLburn and cancer.
1reaLmenL depends on Lhe problem. Some geL beLLer wiLh over-Lhe-counLer medicines or
changes in dieL. OLhers may need prescripLion medicines or surgery.
.4O#& I .BP7$"P&

Abdominal pain
31

Abdominal swelling, disLension or bloaLing
8ad breaLh
8elching
8urning eeling in Lhe chesL or sLomach
Change in bowel habiLs
ConsLipaLion
Diarrhea
FlaLulence

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
HearLburn
RegurgiLaLion
Pain
Dysphasia
8elching
Worsening
sympLoms aLer
eaLing or when in
recumbenL
posiLion
Avoid very
cold or very
hoL and
irriLaLing Lhem
personally.
FaL slowly and
chew properly.
Perorm a
comprehensiv
e assessmenL
o pain Lo
include
locaLion,
characLerisLics,
onseL,
duraLion,
requency,
qualiLy,
inLensiLy
orseveriLy, and
precipiLaLing
acLors o pain
1each Lhe use
o
nonpharmacol
ogic
Lechniques
(e.g.,
relaxaLion,
guided
imagery,
music Lherapy,
disLracLion,
and massage)
beore, aLer,
and i possible
during painul
acLiviLies,
beore pain
occurs or
increases, and
along wiLh
oLher pain
Pain is a
subjecLive
experience
and musL be
described by
Lhe clienL in
order Lo plan
eecLive
LreaLmenL.
1he use o
noninvasive
pain relie
measures
can increase
Lhe release
o
endorphins
and enhance
Lhe
LherapeuLic
eecLs o
pain relie
medicaLions
Fnsures LhaL
Lhe nurse
has Lhe righL
drug, righL
rouLe, righL
dosage, righL
clienL, righL
requency
Able Lo ind
Lhe relaxing
posiLion.

32

relie
measures.
Check Lhe
medical order
or drug, dose,
and requency
o anal-gesic
prescribed

01&$24$4&
/1$;"7;B&4"5"OB

ln gasLriLis, Lhe CasLriLis mucous membrane becomes edemaLous and hyperemic
(congesLed wiLh luid and blood) and undergoes supericial erosion. lL secreLes a scanLy amounL
o gasLric juice, conLaining very liLLle acid buL much mucus. Supericial ulceraLion may occur and
can lead Lo hemorrhage\
.4O#& I .BP7$"P&

lndigesLion (dyspepsia)
HearLburn
Abdominal pain
Hiccups
Loss o appeLiLe
Nausea
vomiLing, possibly o blood or maLerial LhaL looks like coee grounds
Dark sLools

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AnxieLy
relaLed Lo
LreaLmenL

lmbalance
nuLriLion

Reducing
AnxieLy

PromoLing
opLimal
nuLriLion

Able Lo calm
Lhe paLienL
abouL Lhe
pain and
LreaLmenL
modaliLies.
Able Lo
explain Lhe
procedures
and
LreaLmenLs
according Lo
Lhe paLienLs
level o
undersLandin
g
Able Lo
provide
physical and
emoLional
Reduce
anxieLy,
avoidance o
irriLaLing
oods,
adequaLe
inLake o
nuLrienLs,
mainLenance
o luid
balance,
increased
awareness o
dieLary
managemenL
and relie
pain.

33


Risk o
imbalance
luid
DeicienL
knowledge
abouL dieLary
managemenL
AcuLe pain

PromoLing
luid balance.

Relieving Pain.
supporL and
helps Lhe
paLienLs
manage Lhe
sympLoms,,
which may
include
nausea,
vomiLing,
hearLburn and
aLigue. No
ood inLake
by mouLh.
Able Lo
moniLor early
signs o
dehydraLions.
Help relieve
pain
insLrucLing
Lhe paLienLs
Lo avoid
oods and
beverages
LhaL may be
irriLaLing Lo
Lhe gasLric
mucosa.

01&$2"%&7;1O%15 +%M5@J A4&%1&% 60)+A8

/1$;"7;B&4"5"OB

CasLroesophageal relux disease (CFRD) includes all consequences o relux o acid or
oLher irriLanLs rom Lhe sLomach inLo Lhe esophagus. 1he main cause o gasLroesophageal
relux is incompeLence o Lhe anLirelux barriers aL Lhe esophagogasLric juncLion.
CasLric pepsin duodenal conLenLs exacerbaLe Lhe acLion o acid and deleLerious eecL on
Lhe producLion o esophagiLis.
1he anLirelux barriers include Lwo "sphincLer" mechanisms. Lhe lower esophageal
sphincLer (LFS), and Lhe crural diaphragm LhaL uncLions as an exLernal sphincLer.
CasLroesophageal relux occurs when LFS pressure is lower Lhan Lhe inLragasLric pressure
such as in LFS hypoLension, increased requency o LransienL lower esophageal sphincLer
relaxaLion (1LFSR), when Lhe inLragasLric pressure increases.
34

1he severiLy o CFRD increases progressively wiLh relux LhaL is mainly in Lhe posLprandial
period Lo LhaL in Lhe uprighL posLure, Lo LhaL in Lhe supine or LhaL is biposiLional relux.
NighLLime relux leads Lo severe CFRD.
HiaLal hernia resulLs rom mulLiple mechanisms and is associaLed wiLh a
decreased LFS pressure, decreased acid clearance, increased relux, and more severe
esophagiLis.
Mucosal deense mechanisms may be overcome by prolonged exposure o Lhe
esophageal mucosa Lo a pH <4 LhaL may lead Lo severe and complicaLed esophagiLis.
Fsophageal mucosal inlammaLion may aecL nerves and muscle LhaL alLer LFSuncLion
and esophageal body moLiliLy. A vicious cycle o inlammaLion and impaired moLiliLy may
cause progressive disease.
PaLienLs wiLh CFRD may develop endoscopically visible erosive esophagiLis or
endoscopically negaLive nonerosive or negaLive endoscopy relux disease (NFRD).
ln NFRD, acLors such as visceral hypersensiLiviLy or more proximal relux o acid or
nonacid maLerial may be imporLanL. Acid and inlammaLory mediaLors may gain access Lo
sensory paLhways and produce sympLoms eiLher by a direcL acLion on Lhe nerves or by
producing abnormal muscle conLracLion.
.4O#& I .BP7$"P&

DiiculLy in swallowing
ChesL pain due Lo hearL burn
Nausea in Lhe morning
Some ear, nose and LhroaL problems
Lung and breaLhing problems such as coughing, wheezing, pneumonia, permanenL
widening and damage Lo air passages in lungs called bronchiecLasis and chronic asLhma.
1rouble swallowing (dysphagia)
8lood in Lhe sLool
Hoarseness (laryngiLis)
FrequenL belching
Sleep apnea leading Lo resLlessness, morning headaches and aLer drowsiness
Anemic (iron deiciency in blood) caused due Lo blood loss rom ulcers in esophagus.
(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmbalanced
nuLriLion

Risk or
aspiraLion
relaLed Lo
diiculLy
Fncourage
adequaLe
nuLriLion
inLake

Decreasing
risk o
aspiraLion

Fncourage Lo
eaL slowly and
Lo chew all
ood
Lhoroughly so
LhaL iL can
pass easily
inLo Lhe
sLomach.
KepL in semi-
fowlers
posiLion Lo
decrease Lhe
Achieves an
adequaLe
nuLriLional
inLake.

Doesnt
aspiraLe or
develop
pneumonia
35

swallowing or
Lo Lube
eeding

AcuLe pain
relaLed Lo
diiculLy
swallowing

DeicienL
knowledge
abouL Lhe
esophageal
disorder.

Relieving pain

Providing
paLienL
educaLion
risk o
aspiraLion.
1he paLienL
can be
insLrucLed in
Lhe use o oral
sucLion Lo
decrease Lhe
risk o
aspiraLion
urLher.
Small
requenL
eedings are
recommende
d, because
large
quanLiLies o
ood overload
Lhe sLomach
and promoLe
gasLric relux.
Able Lo
provide
physical and
emoLional
supporL and
helps Lhe
paLienLs
manage Lhe
sympLoms,,
which may
include
nausea,
vomiLing,
hearLburn and
aLigue.

Free o pain

lncreases
knowledge
level o
esophageal
condiLion,
LreaLmenLs
and
prognosis..

D41$415 D%2#41
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1he esophagus passes Lhrough Lhe diaphragmaLic hiaLus in Lhe crural parL o Lhe diaphragm Lo
reach Lhe sLomach. 1he diaphragmaLic hiaLus iLsel is approximaLely 2 cm in lengLh and chiely
consisLs o musculoLendinous slips o Lhe righL and leL diaphragmaLic crura arising rom eiLher
side o Lhe spine and passing around Lhe esophagus beore inserLing inLo Lhe cenLral Lendon o
Lhe diaphragm. 1he size o Lhe hiaLus is noL ixed, buL narrows whenever inLra-abdominal pressure
rises, such as when liLing weighLs or coughing.[]

36

1he lower esophageal sphincLer (LFS) is an area o smooLh muscle approximaLely 2.5-4.5 cm in
lengLh. 1he upper parL o Lhe sphincLer normally lies wiLhin Lhe diaphragmaLic hiaLus, while Lhe
lower secLion normally is inLra-abdominal. AL Lhis level, Lhe visceral periLoneum and Lhe
phrenoesophageal ligamenL cover Lhe esophagus. 1he phrenoesophageal ligamenL is a ibrous
layer o connecLive Lissue arising rom Lhe crura, and iL mainLains Lhe LFS wiLhin Lhe abdominal
caviLy. 1he A-ring is an indenLaLion someLimes seen on barium sLudies, and iL marks Lhe upper
parL o Lhe LFS. JusL below Lhis is a slighLly dilaLed parL o Lhe esophagus, orming Lhe vesLibule. A
second ring, Lhe 8-ring, may be seen jusL disLal Lo Lhe vesLibule, and iL approximaLes Lhe Z-line or
squamocolumnar juncLion. 1he presence o a 8-ring conirms Lhe diagnosis o a hiaLal hernia.
Occasionally, Lhe 8-ring also is called Lhe SchaLzki ring.

Any sudden increase in inLra-abdominal pressure also acLs on Lhe porLion o Lhe LFS below Lhe
diaphragm Lo increase Lhe sphincLer pressure. An acuLe angle, Lhe angle o His, is ormed
beLween Lhe cardia o Lhe sLomach and Lhe disLal esophagus and uncLions as a lap aL Lhe
gasLroesophageal juncLion and helps prevenL relux o gasLric conLenLs inLo Lhe esophagus

1he gasLroesophageal juncLion acLs as a barrier Lo prevenL relux o conLenLs rom Lhe sLomach
inLo Lhe esophagus by a combinaLion o mechanisms orming Lhe anLirelux barrier. 1he
componenLs o Lhis barrier include Lhe diaphragmaLic crura, Lhe LFS baseline pressure and inLra-
abdominal segmenL, and Lhe angle o His. 1he presence o a hiaLal hernia compromises Lhis relux
barrier noL only in Lerms o reduced LFS pressure buL also reduced esophageal acid clearance.
PaLienLs wiLh hiaLal hernias also have longer LransienL LFS relaxaLion episodes parLicularly aL nighL
Lime. 1hese acLors increase Lhe esophageal mucosa acid conLacL Lime predisposing Lo
esophagiLis and relaLed complicaLions.
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Acidic LasLe in Lhe mouLh
8elching
DiiculLy swallowing
FpigasLria pain or burning, which can run rom Lhe sLomach area up Lo Lhe mouLh
HearLburn
lndigesLion
Nausea and vomiLing

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
DiscomorL or
pain in Lhe
esophagus
Nausea and
vomiLing
Unexplained
coughing

Relieving pain

Fncourage
adequaLe
nuLriLion
inLake

Small requenL
eedings are
recommended
, because
large
quanLiLies o
ood overload
Lhe sLomach
and promoLe
gasLric relux.
Fncourage Lo
eaL slowly and
Lo chew all
ood
Lhoroughly so
LhaL iL can
pass easily
inLo Lhe
Free o pain
Reduce,
avoidance
o irriLaLing
oods,
adequaLe
inLake o
nuLrienLs,
mainLenanc
e o luid
balance,
increased
awareness
o dieLary
manageme
nL and
relie pain.

37


PromoLing
luid balance
sLomach.
Able Lo
moniLor early
signs o
dehydraLions.

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/1$;"7;B&4"5"OB

PepLic Ulcer is a lesion in Lhe mucosa o Lhe lower esophagus, sLomach, pylorus, or duodenum.
Also known as ulcus pepLicum, PUD or pepLic ulcer disease, is an ulcer (deined as mucosal
erosions equal Lo or greaLer Lhan 0.5 cm) o an area o Lhe gasLroinLesLinal LracL LhaL is usually
acidic and Lhus exLremely painul. CausaLive acLors include mucosal inecLion by Lhe bacLerium
HelicobacLer pylori (mechanism unclear) or use o non-sLeroidal anLi-inlammaLory drugs
(NSAlDs), especially aspirin. CeneLic acLors such as cigareLLe smoking, sLress, and lower socio-
economic sLaLus may also play a role. ComplicaLions include Cl hemorrhage, peroraLion, and
gasLric ouLleL obsLrucLion.

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vomiLing blood
vomiLing ood eaLen hours or days beore
DiiculLy swallowing
Nausea
8lack or Lar-like sLool (indicaLion LhaL Lhere is blood in Lhe sLool)
Sudden, severe pain in Lhe abdominal area
Pain LhaL radiaLes Lo Lhe back
Pain LhaL doesn'L go away when you Lake medicaLion
UninLended weighL loss
Unusual weakness, usually because o anemia

(@2&4#O
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AcuLe
pain r/L
Chemical
burn o
gasLric
mucosa
lndependenL
NoLe reporLs
o pain,
including
locaLion,
duraLion,
inLensiLy (00
scale)
Review acLors
LhaL aggravaLe
or alleviaLe
pain.
ldenLiy and
limiL oods
Pain is noL
always
presenL, buL i
presenL
should be
compared
with patients
previous pain
sympLoms.
1his
comparison
may assisL in
diagnosis o
eLiology o
DemonsLraLed
relaxed body
posLure and be
able Lo sleep/resL
appropriaLely.
38

LhaL creaLe
discomorL
such as spicy
or carbonaLed
drink.
Fncourage
small, requenL
meals
Fncourage
paLienL Lo
assume
posiLion o
comorL.

COLLA8ORA1lvF
Provide and
implemenL
prescribed
dieLary
modiicaLions.

AdminisLer
medicaLions as
indicaLed
nalgesics, e.g.,
morphine
sulaLe nLacids
nLicholinergics
, e.g.,
belladonna,
aLropine
bleeding and
developmenL
o
complicaLions
.
Helpul in
esLablishing
diagnosis and
LreaLmenL
needs.
Food has an
acid
neuLralizing
eecL and
diluLes Lhe
gasLric
conLenLs.
Small meals
prevenL
disLension
and Lhe
release o
gasLrin
Reduces
abdominal
Lension and
promoLes
sense o
conLrol.
PaLienL may
receive
noLhing by
mouLh (NPO)
iniLially. When
oral inLake is
allowed, ood
choices
depend on
Lhe diagnosis
May be
narcoLic o
choice Lo
relieve
acuLe/severe
pain and
reduce
perisLalLic
acLiviLy. NoLe.
Meperidine
(Demerol) has
been
associaLed
wiLh
increased
39

incidence o
nausea/vomiLi
ng
Decreases
gasLric acidiLy
by absorpLion
or by
chemical
neuLralizaLion
. FvaluaLe
choice o
anLacid in
regard Lo
LoLal healLh
picLure, e.g.,
sodium
resLricLion
May be given
aL bedLime
Lo decrease
gasLric
moLiliLy,
suppress acid
producLion,
delay gasLric
empLying,
and alleviaLe
nocLurnal
pain
associaLed
wiLh gasLric
ulcer.

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AppendiciLis is usually caused by blockage o Lhe lumen o Lhe appendix. ObsLrucLion
causes Lhe mucus produced by mucous appendix suered dam. 1he longer Lhe mucus is
more and more, buL Lhe elasLic wall o Lhe appendix has limiLaLions LhaL lead Lo increased
inLra-luminal pressure. 1hese pressures will impede Lhe low o lymph resulLing in
mucosal edema and ulceraLion. AL LhaL Lime Lhere was marked ocal acuLe appendiciLis
wiLh epigasLric pain.
When mucus secreLion conLinues, Lhe pressure will conLinue Lo increase. 1his will cause
venous obsLrucLion, increased edema and bacLeria will peneLraLe Lhe wall so LhaL Lhe
inlammaLion o Lhe periLoneum arising widespread and can cause pain in Lhe lower righL
abdomen is called acuLe suppuraLive appendiciLis.
40

l Lhe low is disrupLed arLerial wall inarcLion will occur ollowed by gangrene appendix.
1his sLage is called appendiciLis ganggrenosa. l Lhe appendix wall ragile, Lhere will be a
peroraLion, called peroraLed appendiciLis.
When Lhe process is slow, Lhe omenLum and Lhe adjacenL bowel will move Loward Lhe
appendix Lo appear appendicularis inilLraLes.
ln children because iL shorLens Lhe omenLum and appendix is longer, Lhinner walls. 1he
siLuaLion is coupled wiLh Lhe immune sysLem LhaL is sLill less easy Lo occur peroraLion,
whereas in Lhe elderly prone Lo occur because Lhere is blood vessel disorders..
.4O#& I .BP7$"P&

Aching pain LhaL begins around your navel and oLen shiLs Lo your lower righL abdomen
Pain LhaL becomes sharper over several hours
1enderness LhaL occurs when you apply pressure Lo your lower righL abdomen
Sharp pain in your lower righL abdomen LhaL occurs when Lhe area is pressed on and Lhen
Lhe pressure is quickly released (rebound Lenderness)
Pain LhaL worsens i you cough, walk or make oLher jarring movemenLs
Nausea
vomiLing
Loss o appeLiLe
Low-grade ever
ConsLipaLion
lnabiliLy Lo pass gas
Diarrhea
Abdominal swelling

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AcuLe pain
relaLed Lo
inlammaLio
n o Lissues.
lndependenL.
Investigate pain
reporLs, noLing
locaLion,
duraLion,
inLensiLy (0-0
scale), and
characLerisLics
(dull, sharp,
consLanL).
Maintain semi
fowlers position.
Move patient
slowly and
deliberaLely.
Provide
comorL measure
like back rubs,
deep breaLhing.
lnsLrucL in
relaxaLion or
visualizaLion
exercises.
Provide
Changes in
locaLion or
inLensiLy are
noL
uncommon
buL may relecL
developing
complicaLions.
Reduces
abdominal
disLenLion,
Lhereby
Reduces
Lension.
Reduces
muscle Lension
or guarding,
which may
help minimize
pain o
movemenL.
Promotes
relaxaLion and
may enhance
ALer
nursing
inLervenLion
s Lhe
paLienL will
demonsLraL
e use o
relaxaLion
kills, oLher
meLhods Lo
promoLe
comorL.
41

divisional
acLiviLies.
Provide
requenL oral
care. Remove
noxious
environmenLalsLi
muli.

CollaboraLive.
Administer
analgesics as
prescribed.
patients
coping
abiliLies by
reocusing
aLLenLion.
Reduces
nausea and
vomiLing,
which can
increase inLra-
abdominal
pressure or
pain.
Reduce
meLabolic raLe
and aids in
pain relie and
PromoLes
healing.

.P155 >":%5 ,F&$2@=$4"# 6.>,8
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lnLesLinal conLenLs, luid and gas accumulaLive above Lhe inLesLinal obsLrucLion. 1he
abdominal disLenLion and reLenLion o luid reduce Lhe absorpLion o luids and sLimulaLe more
gasLric secreLion. WiLh increasing disLenLion, pressure wiLhin Lhe inLesLinal lumen increases,
causing a decrease in venous and arLeriolar capillary pressure. 1his causes edema, congesLion,
necrosis and evenLual rupLure or peroraLion o Lhe inLesLinal wall, wiLh resulLanL periLoniLis.

Reluz vomiLing may be caused by abdominal disLenLion. vomiLing resulLs in a loss o
hydrogen ions and poLassium rom Lhe sLomach, leading Lo a reducLion o chlorides and
poLassium in Lhe blood and Lo meLabolic alkalosis. DehydraLion and acidosis develop rom loss o
waLer and sodium. WiLh acuLe luid losses hypovolemic shock may occur.
.4O#& I .BP7$"P&

!21P7B 1F<"P4#15 714# $;1$ ="P%& 1#< O"%&
(1@&%1
?"P4$4#O
A4122;%1
!"#&$471$4"#
3#1F454$B $" ;1H% 1 F":%5 P"H%P%#$ "2 71&& O1&
.:%554#O "M $;% 1F<"P%# 6<4&$%#$4"#8

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Crampy Pain
LhaL is
wavelike and
colicky.
vomiLing
PromoLing
luid balance.
PromoLing
opLimal
nuLriLion
Able Lo
moniLor early
signs o
dehydraLions.
Able Lo
Reduce
anxieLy,
avoidance o
irriLaLing
oods,
42

FaL slowly and
chew properly
Avoid very
cold or very
hoL and
irriLaLing Lhem
personally.
provide
physical and
emoLional
supporL and
helps Lhe
paLienLs
manage Lhe
sympLoms,,
which may
include
nausea,
vomiLing
1he use o
noninvasive
pain relie
measures can
increase Lhe
release o
endorphins
and enhance
Lhe
LherapeuLic
eecLs o pain
relie
medicaLions
Pain is a
subjecLive
experience
and musL be
described by
Lhe clienL in
order Lo plan
eecLive
LreaLmenL.
adequaLe
inLake o
nuLrienLs,
mainLenance
o luid
balance,
increased
awareness o
dieLary
managemenL
and relie
pain.
Achieves an
adequaLe
nuLriLional
inLake.

!"#&$471$4"#
/1$;"7;B&4"5"OB

!"#&$471$4"#, ="&$4H%#%&&, or 422%O@5124$B, is a condiLion o Lhe digesLive sysLem in which a
person experiences hard eces LhaL are diiculL Lo expel.
1his usually happens because Lhe colon absorbs Loo much waLer rom Lhe ood. l Lhe
ood moves Lhrough Lhe gasLro-inLesLinal LracL Loo slowly, Lhe colon may absorb Loo
much waLer, resulLing in eces LhaL are dry and hard.
DeecaLion may be exLremely painul, and in severe cases (ecal impacLion) lead Lo
sympLoms o bowel obsLrucLion.
!1@&%& "M ="#&$471$4"#-
may be dieLary
hormonal
anaLomical a side eecL o medicaLions (e.g. some opiaLes)
43

or an illness or disorder.

.4O#& I .BP7$"P&

Pass ewer Lhan Lhree sLools a week
Fxperience hard sLools
SLrain excessively during bowel movemenLs
Fxperience a sense o recLal blockage
Have a eeling o incompleLe evacuaLion aLer having a bowel movemenL
Need Lo use manual maneuvers Lo have a bowel movemenL, such as inger evacuaLion or
manipulaLion o your lower abdomen

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
ConsLipaLion relaLed
Lo decreased dieLary
inLake.
lndependenL.
DeLermine sLool
color, consisLency,
requency, and
amounL.
AusculLaLor bowel
sounds.
Fncourage luid
inLake o 2500- 3000
ml/day wiLhin
cardiac Lolerance.
Recommend
avoiding gas
orming oods.
AssisL in per anal
skin condiLion
requenLly, noLing
changes or
beginning
breakdown.
Discuss use o sLool
soLeners, mild
sLimulanLs, bulk-
orming laxaLives, or
enemas as indicaLed.
MoniLor
eecLiveness.
Fncourage Lo aL
high-iber rich oods.

CollaboraLive.
ConsulL wiLh
dieLiLian Lo provide
well-balanced dieL
high in iber and
bulk.

AssisLs in idenLiying
causaLive or
conLribuLing acLors
and appropriaLe
inLervenLions.
8owel sounds are
generally decreased
in consLipaLion.
AssisLs in improving
sLool consisLency.
Decrease gasLric
disLress and
abdominal
disLension.
PrevenLs skin
excoriaLion and
breakdown.
FaciliLaLes deecaLion
when consLipaLion is
presenL.
1o enhance easy
deecaLion.
Fiber resisLs
enzymaLic digesLion
and absorbs liquids
in iLs passage along
Lhe inLesLinal LracL
and Lhereby
produces bulk,
which acLs as a
sLimulanL Lo
deecaLion.
Have regular
mealLimes, no
skipped meals.
Chew your ood
well.
FaL slowly.
8e more acLive. CeL
some daily exercise.
Use Lhe baLhroom
aL a regular Lime
each day.
Choose a Lime when
you wont have to
rush.
CeL 7-8 hours sleep
(per 24 hours).

44

D%2#41
/1$;"7;B&4"5"OB

A hernia occurs when parL o an inLernal organ bulges Lhrough a weak area o muscle. MosL
hernias occur in Lhe abdomen. 1here are several Lypes o hernias, including

lnguinal, Lhe mosL common Lype, is in Lhe groin
Umbilical, around Lhe belly buLLon
lncision, Lhrough a scar
HiaLal, a small opening in Lhe diaphragm LhaL allows Lhe upper parL o Lhe sLomach Lo
move up inLo Lhe chesL.
CongeniLal diaphragmaLic, a birLh deecL LhaL needs surgery
Hernias are common. 1hey can aecL men, women and children. A combinaLion o muscle
weakness and sLraining, such as wiLh heavy liLing, mighL conLribuLe. Some people are
born wiLh weak abdominal muscles and may be more likely Lo geL a hernia.

1he usual LreaLmenL or a hernia is surgery Lo repair Lhe opening in Lhe muscle wall. UnLreaLed
hernias can cause pain and healLh problems.

.4O#& I .BP7$"P&
.BP7$"P& "M 1 ;41$15 ;%2#41

MosL people who have a hiaLal hernia do noL have sympLoms and are unaware o Lhe condiLion.
When sympLoms o hiaLal hernia do occur, Lhey can be relaLed Lo acid relux (regurgiLaLion o
sLomach acid inLo Lhe esophagus). 1his is because some people wiLh hiaLal hernia also have a
condiLion called CFRD(gasLroesophageal relux disease). Large hiaLal hernias can be accompanied
by sympLoms LhaL range in severiLy rom mild Lo severe and include.
Acidic LasLe in Lhe mouLh
8elching
DiiculLy swallowing
FpigasLric pain or burning, which can run rom Lhe sLomach area up Lo Lhe mouLh
HearLburn
lndigesLion
Nausea and vomiLing

.BP7$"P& "M 4#O@4#15 1#< M%P"215 ;%2#41&

1he hallmark sympLom o inguinal and emoral hernias is a small bump or bulge in one or boLh
sides o Lhe groin or LesLicles (inguinal) or upper Lhigh (emoral). 1he bump may be associaLed
wiLh Lhe ollowing sympLoms.
8urning or Lenderness
Pain when liLing someLhing heavy or when exercising
Pressure in Lhe groin or Lhigh
Swelling or pain in Lhe LesLicle area
45

.BP7$"P& "M 1# @PF454=15 ;%2#41

1he main sympLom o an umbilical hernia is a bulge around Lhe belly buLLon LhaL is parLicularly
visible when Lhe aecLed inanL, child or adulL is uprighL or when he or she cries, coughs or
sLrains. Umbilical hernias are Lypically painless.
.BP7$"P& "M 1 ="#O%#4$15 <417;21OP1$4= ;%2#41
SympLoms o a congeniLal diaphragmaLic hernia can be observed in Lhe aecLed inanL when sLill
in Lhe uLerus or righL aLer he or she is born. PrenaLal signs o a hernia include.
Fxcessive amounL o amnioLic luid
UlLrasound showing conLenLs o abdominal caviLy in Lhe chesL area

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
DiscomorL or
pain in Lhe
esophagus
Nausea and
vomiLing
Unexplained
coughing

Relieving pain

Fncourage
adequaLe
nuLriLion
inLake

PromoLing
luid balance
Small requenL
eedings are
recommended
, because
large
quanLiLies o
ood overload
Lhe sLomach
and promoLe
gasLric relux.
Fncourage Lo
eaL slowly and
Lo chew all
ood
Lhoroughly so
LhaL iL can
pass easily
inLo Lhe
sLomach.
Able Lo
moniLor early
signs o
dehydraLions.

Free o pain
Reduce,
avoidance
o irriLaLing
oods,
adequaLe
inLake o
nuLrienLs,
mainLenanc
e o luid
balance,
increased
awareness
o dieLary
manageme
nL and
relie pain.

/1215B$4= 3554@&

1he bowel, or inLesLine, is Lhe parL o Lhe digesLive LracL LhaL absorbs nuLrienLs rom oods we eaL.
1he residue o digesLed ood passes Lhrough Lhe bowel and is excreLed during eliminaLion, Lhe
inal sLage o digesLion. 1his process can be inLerrupLed or halLed by Lhe presence o a bowel
obsLrucLion, a blockage LhaL prevenLs Lhe passage o inLesLinal conLenLs, such as eces and luid.

ParalyLic ileus is Lhe occurrence o inLesLinal blockage in Lhe absence o an acLual physical
obsLrucLion. 1his Lype o blockage is caused by a maluncLion in Lhe nerves and muscles in Lhe
inLesLine LhaL impairs digesLive movemenL. Causes o ileus include elecLrolyLe imbalances,
gasLroenLeriLis (inlammaLion or inecLion o Lhe sLomach or inLesLines), appendiciLis, pancreaLiLis
(inlammaLion o Lhe pancreas), surgical complicaLions, and obsLrucLion o Lhe mesenLeric arLery,
46

which supplies blood Lo Lhe abdomen. CerLain drugs and medicaLions, such as opioids and
sedaLives, can cause ileus by slowing perisLalsis, Lhe conLracLions LhaL propel ood Lhrough Lhe
digesLive LracL.
/1$;"7;B&4"5"OB

A bowel obsLrucLion occurs when Lhere is a blockage LhaL prevenLs Lhe passage o inLesLinal
conLenLs. ParalyLic ileus is Lhe occurrence o an inLesLinal blockage in Lhe absence o an acLual
obsLrucLion. ParalyLic ileus is caused by maluncLion o Lhe nerves and muscles in Lhe inLesLines
LhaL impairs movemenL and digesLion.

Causes o paralyLic ileus include elecLrolyLe imbalances, gasLroenLeriLis (inlammaLion or inecLion
o Lhe sLomach or inLesLines), appendiciLis, pancreaLiLis (inlammaLion o Lhe pancreas), surgical
complicaLions, and obsLrucLion o Lhe mesenLeric arLery, which supplies blood Lo Lhe abdomen.
CerLain drugs and medicaLions, such as opioids and sedaLives, can cause ileus by slowing
perisLalsis, Lhe conLracLions LhaL propel ood Lhrough Lhe digesLive LracL.

!1@&%& "M 71215B$4= 45%@&

A number o condiLions are known causes o paralyLic ileus. 1hese include.
AppendiciLis
8oLulism (poisoning wiLh boLulinum, a neuroLoxin)
CerLain medicaLions, such as opiaLes and sedaLives
DiabeLic keLoacidosis (lie-LhreaLening complicaLion o diabeLes)
FlecLrolyLe imbalance
CasLroenLeriLis (inlammaLion or inecLion o Lhe sLomach or inLesLines)
NeonaLal necroLizing enLerocoliLis (disease LhaL causes deaLh o inLesLinal Lissue in newborns)
ObsLrucLion o Lhe mesenLeric arLery, which supplies blood Lo Lhe abdomen
PancreaLiLis
Porphyria (meLabolic disorder)
Surgical complicaLions
.4O#& I .BP7$"P&

Abdominal swelling, disLension or bloaLing
ConsLipaLion
Diarrhea
Foul-smelling breaLh
Cas
Lack o bowel sounds
Nausea wiLh or wiLhouL vomiLing
SLomach pain and spasms

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
inLake.
lndependenL.
DeLermine sLool
color, consisLency,
requency, and
amounL.
AusculLaLor bowel
sounds.

causaLive or
conLribuLing acLors
and appropriaLe
inLervenLions.
8owel sounds are
Have regular
mealLimes, no
skipped meals.
Chew your ood
well.
FaL slowly.
8e more acLive. CeL
47

Fncourage luid
inLake
Recommend
avoiding gas
orming oods.
AssisL in per anal
skin condiLion
requenLly, noLing
changes or
beginning
breakdown.
Discuss use o sLool
soLeners, mild
sLimulanLs, bulk-
MoniLor
eecLiveness.
Fncourage Lo aL

CollaboraLive.
ConsulL wiLh
well-balanced dieL
high in iber and
bulk.
generally decreased
in consLipaLion.
sLool consisLency.
Decrease gasLric
disLress and
abdominal
disLension.
PrevenLs skin
excoriaLion and
breakdown.
presenL.
1o enhance easy
deecaLion.
Fiber resisLs
enzymaLic digesLion
and absorbs liquids
and Lhereby
produces bulk,
which acLs as a
sLimulanL Lo
deecaLion.
Use Lhe baLhroom
aL a regular Lime
each day.
Choose a Lime when
you wont have to
rush.

3&;%P4= >":%5
/1$;"7;B&4"5"OB

1he small inLesLine receives blood via Lhe coeliac arLery (CA) and Lhe superior mesenLeric arLery
(SMA). 1he colon receives blood via Lhe SMA and Lhe inerior mesenLeric arLery (lMA). 1he recLum
also receives blood via branches o Lhe inLernal iliac arLery. Several collaLeral arLeries exisL
beLween Lhe SMA and Lhe lMA, including Lhe marginal arLery o Drummond and Lhe arc o Riolan.
1he splenic lexure and Lhe recLo-sigmoid juncLion are 2 waLershed areas where collaLeralizaLion
o blood low may be limiLed. view image view image
lschaemia occurs secondary Lo hypo-perusion o an inLesLinal segmenL. When hypo-perusion
occurs, collaLeral blood low may preclude or minimize ischaemia, however, Lhe regions o Lhe
inLesLine wiLh a soliLary arLerial supply, and Lhe waLershed areas, are boLh aL increased risk o
developing ischaemia. 1he degree o inLesLinal injury is dependenL on Lhe duraLion and severiLy
o ischaemia. AcuLe or subacuLe mucosal sloughing and ulceraLions occur as a resulL o ischaemia.
1he loss o Lhe mucosal barrier allows or bacLerial LranslocaLion and Loxin or cyLokine absorpLion.
Re-perusion injury can also occur i blood supply is re-esLablished aLer a prolonged inLerrupLion.
SegmenLs o bowel which do noL cause acuLe necrosis or peroraLion can heal wiLh sLenosis or
sLricLure. 1hese can cause ischaemic bowel disease wiLh long-Lerm sequelae, which is eiLher mild
and chronic or acuLe and resolved.
1hromboembolic evenLs LhaL lead Lo mesenLeric ischaemia usually involve Lhe SMA insLead o Lhe
oLher mesenLeric arLeries (lMA and celiac arLery). 1his is because o Lhe anaLomical posiLion o Lhe
48

SMA, Lhe SMA is posiLioned verLically while Lhe oLher vessels orm more oblique angles rom Lhe
aorLa.
.4O#& I .BP7$"P&

SympLoms o ischemic bowel disease may include.

Abdominal pain.
! Abdominal pain is usually worse aLer meals
! Abdominal pain may suddenly become severe
! OLen described as cramping abdominal pain
! Pain is usually generalized or all over Lhe abdomen
! Lower abdominal pain
! Upper abdominal pain
Abdominal Lenderness
! RighL lower abdominal Lenderness
! LeL lower abdominal Lenderness
! RighL upper abdominal Lenderness
! LeL upper abdominal Lenderness
! Upper abdominal Lenderness
! Lower abdominal Lenderness
8lood in Lhe sLool.
! 8lack sLool
! RecLal bleeding
! Red sLools
! Maroon sLools
! ConsLipaLion
! lndigesLion
! Diarrhea
! Nausea
! vomiLing
! Anorexia

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
inLake.
lndependenL.
DeLermine sLool
color, consisLency,
requency, and
amounL.
AusculLaLor bowel
sounds.
Fncourage luid
inLake o 2500- 3000
ml/day wiLhin
cardiac Lolerance.
Recommend
avoiding gas
orming oods.
AssisL in per anal
skin condiLion
requenLly, noLing
changes or
beginning

causaLive or
conLribuLing acLors
and appropriaLe
inLervenLions.
8owel sounds are
generally decreased
in consLipaLion.
sLool consisLency.
Decrease gasLric
disLress and
abdominal
disLension.
PrevenLs skin
excoriaLion and
breakdown.
Have regular
mealLimes, no
skipped meals.
Chew your ood
well.
FaL slowly.
8e more acLive. CeL
Use Lhe baLhroom
aL a regular Lime
each day.
Choose a Lime when
you wont have to
rush.
CeL 7-8 hours sleep
(per 24 hours).
49

breakdown.
Discuss use o sLool
soLeners, mild
sLimulanLs, bulk-
MoniLor
eecLiveness.
Fncourage Lo aL

CollaboraLive.
ConsulL wiLh
well-balanced dieL
high in iber and
bulk.
presenL.
1o enhance easy
deecaLion.
Fiber resisLs
enzymaLic digesLion
and absorbs liquids
and Lhereby
produces bulk,
which acLs as a
sLimulanL Lo
deecaLion.

?"5H@5@&

A volvulus is a bowel obsLrucLion wiLh a loop o bowel LhaL has abnormally LwisLed on iLsel.

/1$;"7;B&4"5"OB

ln simple mechanical obsLrucLion, blockage occurs wiLhouL vascular compromise. lngesLed luid
and ood, digesLive secreLions, and gas accumulaLe above Lhe obsLrucLion. 1he proximal bowel
disLends, and Lhe disLal segmenL collapses. 1he normal secreLory and absorpLive uncLions o Lhe
mucosa are depressed, and Lhe bowel wall becomes edemaLous and congesLed. Severe inLesLinal
disLenLion is sel-perpeLuaLing and progressive, inLensiying Lhe perisLalLic and secreLory
derangemenLs and increasing Lhe risks o dehydraLion and progression Lo sLrangulaLing
obsLrucLion.
SLrangulaLing obsLrucLion is obsLrucLion wiLh compromised blood low, iL occurs in nearly 25% o
paLienLs wiLh small-bowel obsLrucLion. lL is usually associaLed wiLh hernia, volvulus, and
inLussuscepLions. SLrangulaLing obsLrucLion can progress Lo inarcLion and gangrene in as liLLle as
6 h. venous obsLrucLion occurs irsL, ollowed by arLerial occlusion, resulLing in rapid ischemia o
Lhe bowel wall. 1he ischemic bowel becomes edemaLous and inarcLs, leading Lo gangrene and
peroraLion. ln large-bowel obsLrucLion, sLrangulaLion is rare (excepL wiLh volvulus).
PeroraLion may occur in an ischemic segmenL (Lypically small bowel) or when marked dilaLion
occurs. 1he risk is high i Lhe cecum is dilaLed Lo a diameLer 3 cm. PeroraLion o a Lumor or a
diverLiculum may also occur aL Lhe obsLrucLion siLe.
.4O#& I .BP7$"P&
1he paLienL wiLh volvulus complains o severe abdominal pain and may reporL bilious
vomiLing. l Lhe paLienL is an inanL, Lhe parenLs may reporL increased vomiLing o eedings. 1he
hisLory may also reveal Lhe passage o bloody sLools.
50

On inspecLion, Lhe paLienL appears Lo be in pain. Abdominal inspecLion and palpaLion
may reveal disLenLion and a palpable mass.
(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe Pain
Abdominal
Nausea
lmbalance
nuLriLion
lmpaired oral
mucous
membrane.
Dryness
Fear and
anxieLy
Relieving pain

Fncourage
adequaLe
nuLriLion
inLake

PromoLing
luid balance
Small requenL
eedings are
recommended
, because
large
quanLiLies o
ood overload
Lhe sLomach
and promoLe
gasLric relux.
Fncourage Lo
eaL slowly and
Lo chew all
ood
Lhoroughly so
LhaL iL can
pass easily
inLo Lhe
sLomach.
Able Lo
moniLor early
signs o
dehydraLions.

Free o pain
Reduce,
avoidance o
irriLaLing
oods,
adequaLe
inLake o
nuLrienLs,
mainLenance
o luid
balance,
increased
awareness o
dieLary
managemenL
and relie
pain.

A4H%2$4=@54$4&
DiverLiculiLis is a common digesLive disease parLicularly ound in Lhe large inLesLine. DiverLiculiLis
develops rom diverLiculosis, which involves Lhe ormaLion o pouches (diverLicula) on Lhe ouLside
o Lhe colon. DiverLiculiLis resulLs i one o Lhese diverLicula becomes inlamed.
/1$;"7;B&4"5"OB

DiverLicula are small mucosal herniaLions proLruding Lhrough Lhe inLesLinal layers and Lhe smooLh
muscle along Lhe naLural openings creaLed by Lhe vasa recLa or nuLrienL vessels in Lhe wall o Lhe
colon. 1hese herniaLions creaLe small pouches lined solely by mucosa. DiverLicula can occur
anywhere in Lhe gasLroinLesLinal LracL buL are usually observed in Lhe colon. 1he sigmoid colon
has Lhe highesL inLraluminal pressures and is mosL commonly aecLed. DiverLiculosis is deined as
Lhe condiLion o having uninlamed diverLicula. 1he cause o diverLiculosis is noL yeL conclusive,
buL iL appears Lo be associaLed wiLh a low-iber dieL, consLipaLion, and obesiLy.
DiverLiculiLis is deined as an inlammaLion o one or more diverLicula. lLs paLhogenesis remains
unclear. Fecal maLerial or undigesLed ood parLicles may collecL in a diverLiculum, causing
obsLrucLion. 1his obsLrucLion may resulL in disLension o Lhe diverLicula secondary Lo mucous
secreLion and overgrowLh o normal colonic bacLeria. vascular compromise and subsequenL
microperoraLion or macroperoraLion Lhen ensue. AlLernaLively, some believe LhaL increased
inLraluminal pressure or inspissaLed ood parLicles cause erosion o Lhe diverLicular wall, resulLing
51

in inlammaLion, ocal necrosis, and peroraLion. 1he disease is requenLly mild when pericolic aL
and mesenLery wall o a small peroraLion. However, larger peroraLions and more exLensive
disease lead Lo abscess ormaLion and, rarely, inLesLinal rupLure or periLoniLis.
FisLula ormaLion is a complicaLion o diverLiculiLis. FisLulas Lo adjacenL organs and Lhe skin may
develop, especially in Lhe presence o an abscess. ln men, colovesicular isLulas are Lhe mosL
common. ln women, Lhe uLerus is inLerposed beLween Lhe colon and Lhe bladder, and Lhis
complicaLion is only seen ollowing a hysLerecLomy. 1he uLerus precludes isLula ormaLion rom
Lhe sigmoid colon Lo Lhe urinary bladder. However, colovaginal and colocuLaneous isLulas can
orm buL are uncommon.
RecurrenL aLLacks o diverLiculiLis can resulL in Lhe ormaLion o scar Lissue, leading Lo narrowing
and obsLrucLion o Lhe colonic lumen.
.4O#& I .BP7$"P&

People wiLh diverLiculosis oLen have no sympLoms, buL Lhey may have bloaLing and cramping in
Lhe lower parL o Lhe belly. Rarely, Lhey may noLice blood in Lheir sLool or on LoileL paper.
SympLoms o diverLiculiLis are more severe and oLen sLarL suddenly, buL Lhey may become worse
over a ew days. 1hey include.
1enderness, usually in Lhe leL lower side o Lhe abdomen
8loaLing or gas
Fever and chills
Nausea and vomiLing
NoL eeling hungry and noL eaLing

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# I +1$4"#15% 0"15
Pain relaLed Lo
inlamed
bowel and
possible
periLoniLis
Risk or
deicienL luid
volume relaLed
Lo
inlammaLion
lmpaired
Lissue
inLegriLy.
CasLroinLesLin
al relaLed Lo
peroraLed
diverLiculum
DeicienL
knowledge
relaLed Lo
disease
process and
Assess comorL sLaLus
requenLly, providing analgesics
as needed.
MainLain inLravenous inusion
as prescribed.
Measure inLake and ouLpuL,
weigh daily.
Provide mouLh care every 2 Lo 4
hours unLil oral inLake resumes,
Lhen every 4 hours unLil clienL
assumes sel-care.
Measure LemperaLure every 4
hours.
Advance dieL rom clear
liquids Lo low-residue dieL when
allowed.
Provide insLrucLion and dieLary
consulLaLion or high-iber dieL

verbalize adequaLe
pain relie.
Fxperience no
adverse eecLs o
prescribed bed resL.
MainLain adequaLe
luid balance while
hospiLalized, as
demonsLraLed by
balanced inLake and
ouLpuL, sLable weighL,
good skin Lurgor and
mucous membrane
moisLure, and
laboraLory value
wiLhin Lhe normal
range.
Heal adequaLely
wiLhouL urLher
evidence o
periLoniLis.
verbalize
52

dieLary
managemenL
undersLanding o Lhe
recommended high-
iber dieL and Lhe
need Lo increase
physical acLiviLy and
luid inLake Lo
promoLe opLimal
bowel uncLion aL
home.

+%&%=$4"# "M 3#$%&$4#%&

Small bowel resecLion is surgery Lo remove parL or all o your small bowel. lL is done when parL o
your small bowel is blocked or diseased.

1he small bowel is also called Lhe small inLesLine. MosL digesLion (breaking down and absorbing
nuLrienLs) o Lhe ood you eaL Lakes place in Lhe small inLesLine.

A%&=247$4"#
ou will receive general anesLhesia aL Lhe Lime o your surgery. 1his will make you asleep and
pain-ree.
l you have laparoscopic surgery.
ou will have Lhree Lo ive small cuLs in your lower belly. 1he surgeon will pass a camera
and medical insLrumenLs Lhrough Lhese cuLs.
ou may also have a cuL o abouL 2 Lo 3 inches i your surgeon needs Lo puL a hand inside
your belly Lo eel Lhe inLesLine or remove Lhe diseased segmenL.
our belly will be illed wiLh gas Lo expand iL. 1his makes iL easy or Lhe surgeon Lo see
and work.
l you have open surgery, you will probably have a cuL abouL 6 inches long in your mid-belly.
our surgeon will locaLe Lhe parL o your small inLesLine LhaL is diseased.
1hen your surgeon will puL clamps on boLh ends o Lhis parL Lo close iL o.
1he surgeon will remove Lhe diseased parL.
ln boLh kinds o surgery.
l Lhere is enough healLhy small inLesLine leL, your surgeon will sew or sLaple Lhe healLhy
ends o Lhe small inLesLine back LogeLher. MosL paLienLs have Lhis done.
l you do noL have enough healLhy small inLesLine Lo reconnecL, your surgeon will make
an opening called a sLoma Lhrough Lhe skin o your belly. our small inLesLine will be
aLLached Lo Lhe ouLer wall o your belly. SLool will go Lhrough Lhe sLoma inLo a drainage
bag ouLside your body. 1his is called an ileosLomy. 1he ileosLomy may eiLher be shorL-
Lerm or permanenL.
53

our surgeon may also look aL lymph nodes and oLher organs in your belly area. 8eore surgery,
Lhe surgeon will Lalk wiLh you abouL Lhe possible need Lo remove oLher organs.
1his surgery usually Lakes Lo 4 hours.

];B $;% /2"=%<@2% 4& /%2M"2P%<
Small bowel resecLion may be recommended or.
A blockage in Lhe inLesLine caused by scar Lissue or congeniLal (rom birLh) deormiLies
8leeding, inecLion, or ulcers caused by inlammaLion o Lhe small inLesLine. 1hree
condiLions LhaL may cause inlammaLion are regional ileiLis, regional enLeriLis, and Crohn's
disease.
Cancer
Carcinoid Lumor
lnjuries Lo Lhe small inLesLine
Meckel's diverLiculum
Noncancerous (benign) Lumors
Precancerous polyps (nodes)
+4&R&
Risks or any surgery are.
8lood cloLs in Lhe legs LhaL may Lravel Lo Lhe lungs
8reaLhing problems
8leeding inside your belly
HearL aLLack or sLroke
lnecLion, including in Lhe lungs, urinary LracL, and belly
Risks or Lhis surgery include.
8ulging Lissue Lhrough Lhe incision, called an incisional hernia
Damage Lo nearby organs in Lhe body
Many episodes o diarrhea
Problems wiLh your ileosLomy
Scar Lissue LhaL orms in your belly and causes a blockage o your inLesLines
ShorL bowel syndrome (when a large amounL o Lhe small inLesLine needs Lo be removed),
which may lead Lo problems absorbing imporLanL nuLrienLs and viLamins
1he ends o your inLesLines LhaL are sewn LogeLher comes aparL (anasLomoLic leak -- Lhis
may be lie-LhreaLening)
Wound breaking open (dehiscence)
Wound inecLions

3#M51PP1$"2B >":%5 A4&%1&%
/1$;"7;B&4"5"OB

54

Regional enLeriLis
Is a subacute and chronic inflammation that extends through layers of the bowel walls from the
inLesLinal mucosa. FisLula, issures, and abscesses exLend inLo Lhe periLoneum, buL segmenLs o
normal inLesLinal Lissue occur beLween Lhe inlammaLions.
UlceraLive coliLis
Is an inflammatory disease of the submucosal layer of the colon and rectum characterized by
conLinuously occurring ulceraLions and shedding o inLesLinal epiLhelium. FaL deposiLs and
muscular hyperLrophy resulL in a narrow, shorL, and Lhickened bowel.
.4O#& I .BP7$"P&

Regional enteritis
Abdominal tenderness and pain, typically colicky and increased after meals
Diarrhea, flatulence, and steatorrhea
Fever, malaise, and anorexia
Signs of nutritional deficits
Perianal fistulas and abscesses
Usually occurs in ileum and ascending colon
Ulcerative colitis
Severe diarrhea containing pus, blood and mucosa
Abdominal cramping and tenderness, fever
Anorexia and weight loss
Usually occurs in the descending colon and rectum

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe Pain relaLed
Lo HyperperisLalsis,
prolonged diarrhea,
skin and Lissue
irriLaLion, perirecLal
excoriaLion, issures,
isLulas.
Fncourage clienL Lo
reporL pain.
Asses reporLs o
abdominal cramping
or pain, noLing
locaLion, duraLion
and inLensiLy.
lnvesLigaLe and
reporL changes in
pain characLerisLics.
NoLe nonverbal cues,
such as resLlessness,
relucLance Lo move,
abdominal guarding,
wiLhdrawal, and
depression.
lnvesLigaLe
discrepancies
beLween verbal and
nonverbal cues.
Review acLors LhaL
aggravaLe or
alleviaLe pain.
Fncourage clienL Lo
assume posiLion o
comorL, such as
knees lexed.
Provide comorL
measures and
May Lry Lo LoleraLe
pain raLher Lhan
requesL analgesics.
Colicky inLermiLLenL
pain occurs wiLh
Crohn's disease.
PredeecaLion pain
requenLly occurs in
UC wiLh urgency,
which may be
severe and
conLinuous.
Changes in pain
characLerisLics may
indicaLe spread o
disease or
developing
complicaLions, such
as bladder isLula,
peroraLion and
Loxic megacolon.
8ody language or
non verbal cues
may be boLh
physiological and
psychological and
maybe used in
conjuncLion wiLh
verbal cues Lo
8owel uncLion
sLabilized.
ComplicaLions
revenLed/conLrolled
.
Dealing posiLively
wiLh condiLion.
Disease
process/prognosis,
LherapeuLic
regimen, and
poLenLial
complicaLions are
undersLood.
Plan in place Lo
meeL needs aLer
discharge.
55

diversional acLiviLies.
Cleanse recLal area
wiLh mild soap and
waLer
lmplemenL
prescribed dieLary
modiicaLion or
example, commence
wiLh liquids and
increase Lo solid
oods as LoleraLed.
Provide siLz baLh, as
appropriaLe.
Observe and record
abdominal
disLenLion, increased
Lemp. and decreased
8P.
deLermine exLenL
and severiLy o Lhe
problem.
May pinpoinL
precipiLaLing or
aggravaLing acLors
or idenLiy
developing
complicaLions.
Reduces abdominal
Lension and
promoLes sense o
conLrol.
PromoLes
relaxaLion,
reocuses aLLenLion,
and may enhance
coping abiliLies.
ProLecLs skin rom
bowel acids,
prevenLing
excoriaLion.
CompleLe bowel
resL can reduce
pain and cramping.
Fnhances
cleanliness and
comorL in Lhe
presence o
perianal irriLaLion
and issures.
May indicaLe
developing
inLesLinal
obsLrucLion rom
inlammaLion,
edema, and
scarring.

!"5"2%=$15 !1#=%2
/1$;"7;B&4"5"OB

!"5"2%=$15 =1#=%2 is a disease in which normal cells in Lhe lining o Lhe colon or recLum begin Lo
change, sLarL Lo grow unconLrollably, and no longer die. 1hese changes usually Lake years Lo
develop, however, in some cases o herediLary disease, changes can occur wiLhin monLhs Lo years.
8oLh geneLic and environmenLal acLors can cause Lhe changes. lniLially, Lhe cell growLh appears
as a benign (noncancerous) polyp LhaL can, over Lime, become a cancerous Lumor. l noL LreaLed
or removed, a polyp can become a poLenLially lie-LhreaLening cancer. Recognizing and removing
precancerous polyps beore Lhey become cancer can prevenL colorecLal cancer.
56

.4O#& I .BP7$"P&

Ascending (RighL) Colon Cancer
! OcculL blood in sLool
! Anemia
! Anorexia and weighL loss
! Abdominal pain above umbilicus
! Palpable mass
DisLal Colon/RecLal Cancer
! RecLal bleeding
! Changed in bowel habiLs
! ConsLipaLion or Diarrhea
! Pencil or ribbon shaped sLool
! 1enesmus
! SensaLion o incompleLe bowel empLying
Dukes !51&&4M4=1$4"# "M !"5"2%=$15 !1#=%2
SLage A. Conined bowel mucosa, 80-90% 5-year survival raLe
SLage 8. lnvading muscle wall
SLage C. Lymph node involvemenL
SLage D. MeLasLases or locally unresecLable Lumor, less Lhan 5% 5-year survival raLe

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
FaLigue relaLed Lo
alLered body
chemisLry, side
eecLs o pain and
oLher medicaLions
chemoLherapy
lNDFPFNDFN1.
Have paLienL raLe
aLigue, using a
numeric scale, i
possible, Lhe Lime
o day when iL is
mosL severe.
Plan care Lo allow
resL periods.
Schedule acLiviLies
or periods when
paLienL has mosL
energy.
AssisL paLienL wiLh
sel-care needs.
Keep bed in low
posiLion and assisL
wiLh ambulaLion.
Fncourage paLienL
Lo do whaLever
possible and
increase acLiviLy
level as LoleraLed.
Perorm pain
assessmenL and
provide pain
managemenL as
prescribed.
Fncourage
nuLriLional inLake.
Help in developing
a plan or
managing aLigue.
FrequenL resL
periods or naps are
needed Lo resLore
or conserve energy.
Planning will allow
paLienL Lo be acLive
during Limes when
energy level is
higher, which may
resLore eeling o
well being and a
sense o conLrol.
Weakness may
make acLiviLies o
daily living and
mbulaLion diiculL,
urLher assisLance is
needed.
Fnhances sLrengLh
and enables paLienL
Lo become more
acLive wiLhouL
undue aLigue.
Poorly managed
cancer pain can
conLribuLe Lo
aLigue.
paLienL was able Lo
reporL improved
sense o energy.
57


COLLA8ORA1lvF.
Reer or physical
Lherapy.
AdequaLe inLake o
nuLrienLs is
necessary Lo meeL
energy needs and
build energy
reserves or acLiviLy.
Programmed daily
exercises and
acLiviLies
help paLienL
mainLain or
increase sLrengLh
and muscle Lone
which enhances
sense o well being.

,2$;"7%<4=& 6>,().8
D47 L21=$@2%
/1$;"7;B&4"5"OB

FracLure paLhophysiology includes corLical disrupLion, peri-osLeal damage, and damage Lo Lhe
inLra-medullary and cancellous archiLecLure. HisLomorphomeLric sLudies have shown LhaL corLical
Lhinning and some decrease in Lrabecular bone mass and connecLiviLy can be seen especially in
osLeoporosis suggesLing a lower qualiLy o bone, and Lhus decreased mechanical sLrengLh
resulLing in racLure. An age-relaLed decline in osLeocyLe viabiliLy has also been observed in
experimenLal sLudies. An inlammaLory response also occurs ollowing racLures o Lhe proximal
emur.
.4O#& I .BP7$"P&

lnabiliLy Lo move immediaLely aLer a all
Severe pain in your hip or groin
lnabiliLy Lo puL weighL on your leg on Lhe side o your injured hip
SLiness, bruising and swelling in and around your hip area
ShorLer leg on Lhe side o your injured hip
1urning ouLward o your leg on Lhe side o your injured hip

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# I +1$4"#15% 0"15
lncreased risk o
hypovolemia and
shock relaLed Lo
Lrauma and
bleeding.
lncreased risk o
bone inlammaLion
relaLed Lo open
racLure.
Provide emergency care i requires
(homeosLasis, respiraLory care,
prevenLion o shock)
Provide racLure ixaLion Lo prevenL
ollowing injury o Lissues
Observe signs o aL embolism
(especially during irsL hours aLer
Lhe racLure)
MoniLor luids inpuL and ouLpuL
lncrease comorL, decrease
pain.
PrevenL avoidable injury.
PrevenL complicaLions o
immobiliLy.
Provide opLimal bone and
wound healing.
1hen surgical inLervenLion
prescribed, prevenL
58

lncreased risk o aL
embolism relaLed Lo
racLure o Lhe long
bones.
lncreased risk o
severe luid,
elecLrolyLe, and
meLabolic
imbalances relaLed
Lo injury or
inlammaLion.
Pain and immobiliLy ,
relaLed Lo diagnosis
o racLure.
lncreased risk o
respiraLory,
cardiovascular,
bowel, and skin
complicaLions
relaLed Lo a long
period o immobiliLy.
AnxieLy relaLed Lo
Lhe sympLoms o
disease and ear o
Lhe unknown.
conLinuously, inserL lv caLheLer,
urinary caLheLer
Monitor clients vital signs
Monitor clients laboratory tests
resulLs or abnormal values
AdminisLer lv Lherapy, analgesics,
anLibioLics, and oLher medicaLions as
prescribed
Prepare clienL and his amily or
surgical inLervenLion i required
For clienL aLer surgical inLervenLion
provide rouLine posLoperaLive care
and Leach abouL possible
posLoperaLive complicaLions
Provide care Lo clienL wiLh casL
(observe signs o circulaLory
impairmenL change in skin color
and LemperaLure, diminished disLal
pulses, pain and swelling o Lhe
exLremiLy, proLecL Lhe casL rom
damage)
Provide care Lo clienL in LracLion
(check Lhe weighLs are hanging
reely, observe skin or irriLaLion and
siLe o skeleLal LracLion inserLion or
signs o inecLion, use asepLic
Lechnique when cleaning Lhe siLe o
inserLion)
ln case o hip racLure and hip
replacemenL mainLain Lhe adducLion
o Lhe aecLed exLremiLy
Provide respiraLory exercises Lo
prevenL lung complicaLions
Observe or signs o
LhrombophlebiLis, reporL
immediaLely
Provide appropriaLe skin care Lo
prevenL pressure sores
Fncourage luid inLake and high-
proLein, high-viLamin, high-calcium
dieL
1each Lhe clienL appropriaLe cruLch-
walking Lechniques
Provide emoLional supporL Lo clienL,
explain all procedures Lo decrease
anxieLy and Lo obLain cooperaLion
lnsLrucL clienL regarding racLure
healing process, diagnosLic
procedures, LreaLmenL and iLs
complicaLions, home care, daily
acLiviLies, dieL, resLricLions and
ollow-up

posLoperaLive
complicaLions.
Decreased anxieLy wiLh
increased knowledge.

59

E"$15 K#%% +%751=%P%#$ 6EK+8

Knee replacemenL, or knee arLhroplasLy, is a surgical procedure Lo replace Lhe weighL-
bearing suraces o Lhe knee joinL Lo relieve Lhe pain and disabiliLy o osLeoarLhriLis. lL may be
perormed or oLher knee diseases such as rheumaLoid arLhriLis and psoriaLic arLhriLis. ln paLienLs
wiLh severe deormiLy rom advanced rheumaLoid arLhriLis, Lrauma, or long sLanding
osLeoarLhriLis, Lhe surgery may be more complicaLed and carry higher risk. OsLeoporosis does noL
Lypically cause knee pain, deormiLy, or inlammaLion and is noL a reason Lo perorm knee
replacemenL.
OLher major causes o debiliLaLing pain include meniscus Lears, carLilage deecLs, and ligamenL
Lears. DebiliLaLing pain rom osLeoarLhriLis is much more common in Lhe elderly.
Knee replacemenL surgery can be perormed as a parLial or a LoLal knee replacemenL. ln general,
Lhe surgery consisLs o replacing Lhe diseased or damaged joinL suraces o Lhe knee wiLh meLal
and plasLic componenLs shaped Lo allow conLinued moLion o Lhe knee.
1he operaLion Lypically involves subsLanLial posLoperaLive pain, and includes vigorous physical
rehabiliLaLion. 1he recovery period may be 6 weeks or longer and may involve Lhe use o mobiliLy
aids (e.g. walking rames, canes, cruLches) Lo enable Lhe paLienL's reLurn Lo preoperaLive mobiliLy.
/1$;"7;B&4"5"OB

1he exacL cause o Lhe degeneraLive process in primary osLeoarLhriLis is unknown. lL may
represenL a deecL in cellular (chondrocyLe) repair processes. OsLeoarLhriLic carLilage conLains
increased amounLs o waLer, alLeraLions in Lhe Lype o proLeoglycan, Lype 2 collagen abnormaliLies
and increased levels o Lhe caLhepsins, meLalloproLeinases, inLerleukin and oLhers as a complex
cascade o enzymaLic process. Changes in Lhe synovium include synoviocyLe hyperplasia, an
increased leukocyLe populaLion in Lhe membrane and luid, occasional gianL cells,
neovascularisaLion wiLh increased vessel permeabiliLy and alLered maLrix and cellular cyLokine
ormaLion.

9"#O >"#% 3#X@2B
/1$;"7;B&4"5"OB

When a bone is broken, Lhe periosLeum and blood vessels in Lhe corLex, marrow, and surrounding
soL Lissues are disrupLed. 8leeding occurs rom Lhe damaged ends o Lhe bone and rom Lhe
neighboring soL Lissue. A cloL (hemaLoma) orms wiLhin Lhe medullary canal, beLween Lhe
racLured ends o Lhe bone, and beneaLh Lhe periosLeum. 8one Lissue immediaLely adjacenL Lo Lhe
racLure dies. 1his necroLic Lissue along wiLh any debris in Lhe racLure area sLimulaLes an inLense
inlammaLory response characLerized by vasodilaLion, exudaLion o plasma and leukocyLes, and
inilLraLion by inlammaLory leukocyLes and masL cells. WiLhin 48 hours aLer Lhe injury, vascular
Lissue invades Lhe racLure area rom surrounding soL Lissue and Lhe marrow caviLy, and blood
low Lo Lhe enLire bone is increased. 8one-orming cells in Lhe periosLeum, endosLeum, and
marrow are acLivaLed Lo produce subperiosLeal procallus along Lhe ouLer surace o Lhe shaL and
over Lhe broken ends o Lhe bone. OsLeoblasLs wiLhin Lhe procallus synLhesize collagen and
maLrix, which becomes mineralized Lo orm callus (woven bone). As Lhe repair process conLinues,
remodeling occurs, during which unnecessary callus is resorbed and Lrabeculae are ormed along
lines o sLress. FxcepL or Lhe liver, bone is unique among all body Lissues in LhaL iL will orm new
bone, noL scar Lissue, when iL heals aLer a racLure."
60

.4O#& I .BP7$"P&

AlLhough bone Lissue iLsel conLains no nocicepLors, bone racLure is very painul or several
reasons.

8reaking in Lhe conLinuiLy o Lhe periosLeum, wiLh or wiLhouL similar disconLinuiLy in
endosLeum, as boLh conLain mulLiple nocicepLors.
Fdema o nearby soL Lissues caused by bleeding o Lorn periosLeal blood vessels evokes
pressure pain.
Muscle spasms Lrying Lo hold bone ragmenLs in place

Damage Lo adjacenL sLrucLures such as nerves or vessels, spinal cord and nerve rooLs (or spine
racLures), or cranial conLenLs (or skull racLures) can cause oLher speciic signs and sympLoms.

(@2&4#O
C&&%&&P%#$
(@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Possible
FLiologies.
(RelaLed Lo)

lndividual

- Loss o skeleLal
inLegriLy
(racLure)
- MovemenL o
bone ragmenLs
- 8alancing
diiculLies
- Weakness
- Lack o saeLy
educaLion/
precauLions
- HisLory o
previous Lrauma

FnvironmenL

- Slippery loors
- 8aLhLub wiLhouL
hand grip
- UnsLeady ladder
or chairs
- UnliL room
- UnsLeady or
absence o sLair
rails
- High bed
DeLermine acLors relaLed Lo
individual siLuaLion and
exLenL o risk, evaluaLe Lhe
environmenL or
appropriaLeness Lo clienL,
and knowledge
o caregiver Lo saeLy needs.
OrienL Lhe clienL and
his caregiver Lo Lhe physical
seLup o Lhe aciliLy and
demonsLraLe Lhe use o call
bell/ lighL which is placed
wiLhin reach o Lhe clienL.
MainLain bed resL/ limb resL
and provide supporL Lo joinLs
o boLh below and above o
Lhe aecLed limb, especially
during movemenL or Lurning.
Place bed board under Lhe
maLLress.
SupporL racLure wiLh pillows
and mainLain aecLed parL in
neuLral posiLion wiLh
sandbags, LrochanLer rolls, or
ooLboard.
Check or resoluLion o
edema.
MainLain Lhe posiLion o
LracLion.
Make sure LhaL all clamps are
uncLional, lubricaLe pulleys
and check ropes or raying.
Avoid liLing and releasing
Lhe weighLs.
AssisL clienL wiLh proper
placemenL o liLs under bed
wheels is indicaLed.
1his is Lo
provide a
baseline daLa
on clients
condiLion and
could help
assess Lhe
exLenL o risk
or
addiLional Lrau
ma.
OrienLaLion
could help Lhe
clienL ully
maximize his
ull poLenLial
while wiLhin Lhe
hospiLal aciliLy.
lL gives sLabiliLy
and reduces Lhe
possibiliLy o
disLurbing Lhe
alignmenL.
Sagging
maLLress may
deorm a weL
plasLer casL,
crack a dry casL,
or inLerere wiLh
pull o LracLion.
lL prevenLs
unnecessary
disrupLion o
alignmenL and
pressure
deormiLies in
Lhe drying casL.
As swelling
ClienL will be
able Lo
perorm
correcL body
mechanics,
reducing his
risk or urLher
injury.
ClienL will be
able Lo
undersLand
and accepL
skeleLal
inLegriLy and
will be able Lo
recognize Lhe
need or
assisLance,
idenLiy and
correcL
possible
acLors in Lhe
environmenL
and
demonsLraLe
liesLyle
changes in
promoLing
bone inLegriLy
and prevenLing
sel rom
urLher injury.

61

lnsLrucL clienL abouL
resLricLions like noL bending
aL waisL or siLLing wiLh 8uck
LracLion and noL Lurning
below Lhe waisL wiLh Russel
LracLion.
Fncourage clienL verbalize
eelings and problems
regarding racLure.
AdminisLer medicaLions prior
Lo acLiviLies.
Perorm and supervise clienL
wiLh acLive and passive
ROM exercises.
FducaLe and assisL in
perorming proper body
mechanics in siLLing, assisLed
walking as indicaLed.
Review X rays o clienL.

subsides, a
readjusLmenL o
splinL
or applicaLion o
plasLer may be
done Lo ensure
alignmenL
o bone.
lL permiLs pull
on Lhe long axis
o Lhe racLured
parL and
overcomes
muscle Lension.
1o avoid
inLerrupLion o
racLure
approximaLion.
lL prevenLs
sudden pull on
racLure, which
could be
associaLed wiLh
pain and muscle
spasm.
lL could help
mainLain clients
proper posiLion
and uncLion o
LracLion by
counLerbalance.
lL mainLains Lhe
proper pull o
LracLion.
Helps alleviaLe
anxieLy and
helps clienL
cope wiLh
siLuaLion.
lL promoLes
muscle
relaxaLion and
encourages
clienL Lo
parLicipaLe in
rehabiliLaLive
acLiviLies.
lL promoLes
sLrengLh and
mobiliLy o
unaecLed
muscles and
aciliLaLes
healing o
62

surrounding Lra
uma.
lL provides an
avenue or Lhe
clienL Lo
develop a sense
o sel reliance
and would
guide clienL
appropriaLely
wiLhin
precauLionary
measures.
lL provides
visual evidence
o proper
alignmenL/
healing process
o Lhe racLured
bone, Lhe need
or conLinued
Lherapy.

,&$%"12$;24$4& 6,C8
/1$;"7;B&4"5"OB

1he mosL common orm o arLhriLis.
lL causes Lhe deLerioraLion o Lhe joinL carLilage and ormaLion o reacLive new bone aL
Lhe margins and subchondral areas o Lhe joinL.
1his chronic degeneraLion resulLs rom a breakdown o chondrocyLes, mosL oLen in Lhe
hips and knees.
OsLeoarLhriLis occurs equally in boLh sexes aLer age 40.
1he earliesL sympLoms appear in middle age and progress wiLh advancing age.
Depending on Lhe siLe and severiLy o joinL involvemenL, disabiliLy can range rom minor
limiLaLion o Lhe ingers Lo near immobiliLy in persons wiLh hip or knee disease.
Progression raLes vary, joinLs may remain sLable or years in Lhe early sLage o
deLerioraLion.
)$4"5"OB C#< /1$;"7;B&4"5"OB
Changes in arLicular carLilage occur irsL, laLer, secondary soL Lissue changes may occur.
Progressive wear and Lear on carLilage leads Lo Lhinning o joinL surace and ulceraLion
inLo bone.
Leads Lo inlammaLion o Lhe joinL and increased blood low and hyperLrophy o
subchondral bone.
New carLilage and bone ormaLion aL joinL margins resulLs in osLeophyLosis, alLering Lhe
size and shape o Lhe bone.
Cenerally aecLs adulLs ages 50 Lo 90, equal Lo males and emales.
Cause is unknown, buL aging and obesiLy are conLribuLing acLors. Previous Lrauma cause
secondary osLeoarLhriLis.
63


.4O#& I .BP7$"P&

JoinL pain
JoinL sLiness
JoinL Lenderness
LimiLed range-o-moLion
CrepiLus (crackling, grinding noise wiLh movemenL)
JoinL eusion (swelling)
Local inlammaLion
8ony enlargemenLs and osLeophyLe ormaLion

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# I
+1$4"#15%
0"15
Chronic pain relaLed Lo joinL
deLerioraLion.
Provide resL or involved
joinLs. Fxcessive use
aggravaLes Lhe sympLoms
and acceleraLes
degeneraLion.
Advise Lhe paLienL Lo avoid
acLiviLies LhaL precipiLaLe
pain.
Apply heaL as direcLed Lo
relieve muscle pain and
sLiness.
1each Lhe paLienL correcL
posLure and body
mechanics.
Advise Lhe paLienL Lo sleep
wiLh rolled Lerry cloLh Lowel
under Lhe neck Lo relieve
cervical pain.
Provide paLienL wiLh
cruLches, braces, or cane
when indicaLed Lo reduce-
weighL bearing sLress on
hips and knees.
Fncourage paLienL Lo wear
correcLive shoes and
meLaLarsal supporL or ooL
disorders.
Fncourage paLienL Lo lose
weighL Lo decrease sLress
on weighL-bearing joinLs.
1each Lhe paLienL range-o-
moLion exercises Lo
mainLain join mobiliLy.
Reer paLienL Lo physical
and occupaLional Lherapy.

Describes risk acLors, Lhe
disease process, and
rehabiliLaLion acLiviLies
necessary Lo manage Lhe
LherapeuLic regimen

64

+;%@P1$"4< C2$;24$4& 6+C8
/1$;"7;B&4"5"OB

RheumaLoid arLhriLis (RA) is a chronic, sysLemic inlammaLory disorder LhaL may aecL many
Lissues and organs, buL principally aLLacks Lhe joinLs producing an inlammaLory synoviLis LhaL
oLen progresses Lo desLrucLion o Lhe arLicular carLilage and ankylosis o Lhe joinLs.
RheumaLoid arLhriLis can also produce diuse inlammaLion in Lhe lungs, pericardium, pleura, and
sclera, and also nodular lesions, mosL common in subcuLaneous Lissue under Lhe skin.

AlLhough Lhe cause o rheumaLoid arLhriLis is unknown, auLoimmuniLy plays a pivoLal role in iLs
chroniciLy and progression.

About 1% of the worlds population is afflicted by rheumatoid arthritis, women three times more
oLen Lhan men. OnseL is mosL requenL beLween Lhe ages o 40 and 50, buL people o any age
can be aecLed. lL can be a disabling and painul condiLion, which can lead Lo subsLanLial loss o
uncLioning and mobiliLy. lL is diagnosed chiely on sympLoms and signs, buL also wiLh blood LesLs
(especially a LesL called rheumaLoid acLor) and X-rays. Diagnosis and long-Lerm managemenL are
Lypically perormed by a rheumaLologisL, an experL in Lhe diseases o joinLs and connecLive
Lissues.
.4O#& I .BP7$"P&

1ender, warm, swollen joinLs
Morning sLiness LhaL may lasL or hours
Firm bumps o Lissue under Lhe skin on your arms (rheumaLoid nodules)
FaLigue, ever and weighL loss

(@2&4#O
C&&%&&P%#$
(@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe pain r/L
disLension o Lissues
by accumulaLion o
luid
lndependenL
lnvesLigaLe reporLs
o pain, noLing locaLion
and inLensiLy(scale o
00). NoLe
precipiLaLing acLors
and nonverbal pain
cues.

Recommend/provide
irm maLLress or
bedboard, small pillow.
FlevaLe linens wiLh bed
cradle as needed.

SuggesL paLienL
assume posiLion o
comorL while in bed or
siLLing in chair. PromoLe
bedresL as indicaLed.

Helpul in
deLermining pain
managemenL needs
and eecLiveness o
program

SoL/sagging
maLLress, large pillows
prevenL mainLenance
o proper body
alignmenL, placing
sLress on aecLed
joinLs. FlevaLion o bed
linens reduces pressure
on inlamed/painul
joinLs.

ln severe
disease/acuLe
exacerbaLion, LoLal
DemonsLraLed
relaxed body posLure
and be able Lo
sleep/resL
appropriaLely.
65


CollaboraLive
Apply ice or cold
packs when indicaLed

AssisL wiLh physical
Lherapies, e.g., parain
glove, whirlpool baLhs.

AdminisLer medicaLions
as indicaLed

SalicylaLes, e.g.,
aspirin (ASA) (Acuprin,
FcoLrin, ZORprin),

1eLracyclines, e.g.,
minocycline (Minocin),
bedresL may be
necessary (unLil
objecLive and
subjecLive
improvemenLs are
noLed) Lo limiL
pain/injury Lo joinL.

Cold may relieve pain
and swelling during
acuLe episodes.

Provides susLained
heaL Lo reduce pain
and improve ROM o
aecLed joinLs

ASA exerLs an anLi-
inlammaLory and mild
analgesic eecL,
decreasing sLiness
and increasing
mobiliLy. ASA musL be
Laken regularly Lo
susLain a LherapeuLic
blood level. Research
indicaLes LhaL ASA has
Lhe lowesL LoxiciLy
index o commonly
prescribed NSAlDs.

CHARAC1FRlS1lCS OF
AN1l-lNFLAMMA1OR
AND lMMUNF
MODlFlFR FFFFC1S
COUPLFD Wl1H
A8lLl1 1O 8LOCK
MF1ALLOPRO1FlNASFS

0"@$
/1$;"7;B&4"5"OB

CouL is a disorder o purine meLabolism characLerized by elevaLed uric acid levels wiLh deposiLion
o uraLe crysLals in joinLs and oLher Lissues. High uric acid levels resulL rom decreased excreLion
o uric acid ( 90% o cases) due Lo a wide varieLy o causes. 1he disorder may progress rom an
asympLomaLic sLage Lhrough acuLe gouLy arLhriLis, Lo chronic Lophaceous gouL. ComplicaLions
include erosive deorming arLhriLis, uric acid kidney sLones, and uraLe nephropaLhy caused by
hyperuricemia.
66

.4O#& I .BP7$"P&

3#$%#&% X"4#$ 714#\ CouL usually aecLs Lhe large joinL o your big Loe, buL iL can occur in
your eeL, ankles, knees, hands and wrisLs. 1he pain is likely Lo be mosL severe wiLhin Lhe
irsL 2 Lo 24 hours aLer iL begins.
94#O%24#O <4&="PM"2$\ ALer Lhe mosL severe pain subsides, some joinL discomorL may
lasL rom a ew days Lo a ew weeks. LaLer aLLacks are likely Lo lasL longer and aecL more
joinLs.
3#M51PP1$4"# 1#< 2%<#%&&\ 1he aecLed joinL or joinLs become swollen, Lender and red.

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmpaired physical
mobiliLy relaLed Lo
pain
lndependenL.
FvaluaLe or
conLinuously
moniLor degree o
joinL inlammaLion or
pain.
MainLain bed resL
or chair resL when
indicaLed.
Schedule acLiviLies
providing requenL
resL periods and
uninLerrupLed nighL
Lime sleep.
Fncourage
adequaLe luid
inLake.
AssisL wiLh acLive or
passive range o
moLion.
Fncourage paLienL
Lo mainLain uprighL
and erecL posLure
when siLLing,
sLanding, or walking.
Fncourage Lhe
paLienL Lo avoid
alcohol.
Review oods LhaL
are rich in purines
like sardines,
anchovies, shell ish
and organ meaLs.
Provide saeLy
needs.

CollaboraLive.
AdminisLer anLi-
inlammaLory drugs
and also colchicines
Level o acLiviLy or
exercise depends
on progression and
resoluLion o
inlammaLory
process.
SysLemic resL
during acuLe
aLLacks and
imporLanL
LhroughouL all
phases o disease
Lo reduce aLigue
and improve
sLrengLh.
1o assisL wiLh
excreLion o uric
acid and decrease
likelihood o sLone
ormaLion.
MainLains or
improves joinL
uncLion, muscle
sLrengLh, and
general sLamina.
Maximizes joinL
uncLion, mainLains
mobiliLy.
1haL can
precipiLaLe acuLe
aLLack.
1o avoid oods
LhaL precipiLaLe
acuLe aLLacks.
Help prevenL
accidenLal injuries
or alls.
1o relieve pain
and swelling during
acuLe aLLacks.
able Lo mainLain or
increase sLrengLh
and uncLion o
aecLed or
compensaLory
body parL.
67

as prescribed.

?1&=@512 A4&"2<%2&
/%247;%215 C2$%2B A4&%1&% 6/CA8
/1$;"7;B&4"5"OB

Peripheral arLerial disease (PAD) is a sysLemic aLheroscleroLic process or which Lhe major risk
acLors are similar Lo Lhose or aLherosclerosis in Lhe caroLid, coronary, and oLher vascular beds.
Among Lhe LradiLional risk acLors or PAD, Lhose wiLh Lhe sLrongesL associaLions are advanced
age, smoking, and diabeLes melliLus. More recenLly, a number o nonLradiLional risk acLors or
PAD have also been recognized. 1his arLicle briely reviews Lhe paLhophysiology o PAD and Lhe
evidence supporLing esLablished and emerging risk acLors or iLs developmenL.
.4O#& I .BP7$"P&

Painul cramping in your hip, Lhigh or cal muscles aLer acLiviLy, such as walking or
climbing sLairs (inLermiLLenL claudicaLion)
Leg numbness or weakness
Coldness in your lower leg or ooL, especially when compared wiLh Lhe oLher leg
Sores on your Loes, eeL or legs LhaL won'L heal
A change in Lhe color o your legs
Hair loss or slower hair growLh on your eeL and legs
Slower growLh o your Loenails
Shiny skin on your legs
No pulse or a weak pulse in your legs or eeL
FrecLile dysuncLion in men

/%247;%215 ?%4# A4&%1&% 6/?A8
/1$;"7;B&4"5"OB

PvD, also known as arLeriosclerosis obliLerans, is primarily Lhe resulL o aLherosclerosis. 1he
aLheroma consisLs o a core o cholesLerol joined Lo proLeins wiLh a ibrous inLravascular covering.
1he aLheroscleroLic process may gradually progress Lo compleLe occlusion o medium and large
arLeries. 1he disease Lypically is segmenLal, wiLh signiicanL variaLion rom paLienL Lo paLienL.
vascular disease may maniesL acuLely when Lhrombi, emboli, or acuLe Lrauma compromises
perusion. 1hromboses are oLen o an aLheromaLous naLure and occur in Lhe lower exLremiLies
more requenLly Lhan in Lhe upper exLremiLies. MulLiple acLors predispose paLienLs or
Lhrombosis. 1hese acLors include sepsis, hypoLension, low cardiac ouLpuL, aneurysms, aorLic
dissecLion, bypass graLs, and underlying aLheroscleroLic narrowing o Lhe arLerial lumen.
Fmboli, Lhe mosL common cause o sudden ischemia, usually are o cardiac origin (80%), Lhey also
can originaLe rom proximal aLheroma, Lumor, or oreign objecLs. Fmboli Lend Lo lodge aL arLery
biurcaLions or in areas where vessels abrupLly narrow. 1he emoral arLery biurcaLion is Lhe mosL
68

common siLe (43%), ollowed by Lhe iliac arLeries (8%), Lhe aorLa (5%), and Lhe popliLeal arLeries
(5%).
1he siLe o occlusion, presence o collaLeral circulaLion, and naLure o Lhe occlusion (Lhrombus or
embolus) deLermine Lhe severiLy o Lhe acuLe maniesLaLion. Fmboli Lend Lo carry higher
morbidiLy because Lhe exLremiLy has noL had Lime Lo develop collaLeral circulaLion. WheLher
caused by embolus or Lhrombus, occlusion resulLs in boLh proximal and disLal Lhrombus
ormaLion due Lo low sLagnaLion.
.4O#& I .BP7$"P&

1he mosL common sympLom o peripheral vascular disease in Lhe legs is pain in one or boLh
calves, Lhighs, or hips.
1he pain usually occurs while you are walking or climbing sLairs and sLops when you
resL. 1his is because Lhe muscles' demand or blood increases during walking and oLher
exercise. 1he narrowed or blocked arLeries cannoL supply more blood, so Lhe muscles
are deprived o oxygen and oLher nuLrienLs.
1his pain is called inLermiLLenL (comes and goes) claudicaLion.
lL is usually a dull, cramping pain. lL may also eel like a heaviness, LighLness, or
Liredness in Lhe muscles o Lhe legs.
Cramps in Lhe legs have several causes, buL cramps LhaL sLarL wiLh exercise and sLop wiLh
resL mosL likely are due Lo inLermiLLenL. When Lhe blood vessels in Lhe legs are
compleLely blocked, leg aL nighL is very Lypical, and Lhe individual almosL always hangs
his or her eeL down Lo ease Lhe pain. Hanging Lhe legs down allows or blood Lo
passively low inLo Lhe disLal parL o Lhe legs.
OLher sympLoms o peripheral vascular disease include Lhe ollowing.
8uLLock pain
Numbness, Lingling, or weakness in Lhe legs
8urning or aching pain in Lhe eeL or Loes while resLing
A sore on a leg or a ooL LhaL will noL heal
One or boLh legs or eeL eel cold or change color (pale, bluish, dark reddish)
Loss o hair on Lhe legs
lmpoLence
C#%@2B&P&
/1$;"7;B&4"5"OB

SLudies were perormed Lo evaluaLe Lhe conLribuLions o elasLin and collagen Lo Lhe ormaLion o
arLerial aneurysms. Dog caroLid arLeries and human exLernal and inLernal iliac arLeries were
69

excised, mounLed horizonLally in a Lissue baLh, and were pressurized. vessel diameLer and
longiLudinal orce were measured. Lhe vessels were LreaLed wiLh elasLase or collagenase. 1hose
LreaLed wiLh elasLase dilaLed, buL never rupLured. 1hose LreaLed wiLh collagenase dilaLed sLill more
and, in every case, rupLured. CircumerenLial sLabiliLy resulLed rom recruiLmenL o previously non-
loaded collagen ibers, and rom a change in geomeLry rom a cylinder Lo a sphere. 1he laminaLed
Lhrombus lining Lhe lumen has liLLle inLrinsic sLrengLh and Lhereore does noL coner sLrengLh Lo
Lhe aneurysmal wall. 1reaLmenL wiLh elasLase also reduces Lhe reLracLive orce exerLed by Lhe
vessel in Lhe longiLudinal direcLion. 1hereore loss o elasLin permiLs Lhe vessel Lo elongaLe and Lo
become LorLuous. ln aged human arLeries collagen also conLribuLes a small porLion o Lhe
reLracLive orce. Progressive enlargemenL o aneurysms resulLs rom conLinued ailure o wall
connecLive Lissues relecLing a) geneLically deecLive collagen and or b) acLiviLy o Lhe immune
sysLem.
.4O#& I .BP7$"P&
Signs and sympLoms o an aneurysm depend on Lhe Lype and locaLion. 1he signs and sympLoms
also depend on wheLher Lhe aneurysm has rupLured or is inLerering wiLh oLher muscles, organs
and sLrucLures in Lhe body. 1he signs and sympLoms are noL known unLil an aneurysm rupLures or
grows suicienLly Lo press againsL nearby organs or Lissues or may block Lhe low o blood.
3\ C"2$4= C#%@2B&P&-
) 1horacic AorLic Aneurysm. SympLoms o Lhoracic aorLic aneurysm are as ollows.
Pain in jaw, neck, upper back or chesL.
Cough, hoarseness or experiencing Lrouble in breaLhing.
Pain in leL shoulder or beLween shoulder blades.
2) Abdominal AorLic Aneurysms (AAAs). SympLoms o AAAs include.
Deep peneLraLing pain Lhe back or side o abdomen.
SLeady gnawing pain in Lhe abdomen lasLing or hours or days.
Coldness, numbness or Lingling o eeL.
ln case o a rupLure o Lhe AAA, sympLoms include sudden severe pain in lower abdomen
and back, nausea and vomiLing, sweaLy skin, lighL headedness and rapid hearL raLe when
sLanding up.
33\ !%2%F215 C#%@2B&P- .4O#& 1#< &BP7$"P& "M =%2%F215 1#%@2B&P 12%-
Drooping o eyelids.
Double vision or blurred vision.
Pain above or behind Lhe eye.
A dilaLed pupil.
Numbness or weakness on one side o Lhe ace.
A cerebral aneurysm rupLure leads Lo sudden severe headache, nausea and vomiLing, sLi
neck and loss o consciousness.
333\ /%247;%215 C#%@2B&P- Signs and sympLoms o peripheral aneurysm are as ollows.
PulsaLing lump elL in Lhe neck, arm or leg
Pain in Lhe leg or arm or cramping wiLh exercise
Painul sores on Loes or ingers
70

Cangrene (i.e., deaLh o Lissue) due Lo severe blockage o blood in Lhe limbs
An aneurysm in Lhe popliLeal arLery can compress Lhe nerves and cause pain, weakness and
numbness in knee and leg () & (4).

+%&7421$"2B
>2"#=;415 C&$;P1
/1$;"7;B&4"5"OB

8ronchial asLhma is a chronic inlammaLory disease o Lhe airways, associaLed wiLh recurrenL,
reversible airway obsLrucLion wiLh inLermiLLenL episodes o wheezing and dyspnea. 8ronchial
hypersensiLiviLy is caused by various sLimuli, which innervaLe Lhe vagus nerve and beLa adrenergic
recepLor cells o Lhe airways, leading Lo bronchial smooLh muscle consLricLion, hypersecreLion o
mucus, and mucosal edema.
.4O#& I .BP7$"P&

a eeling o LighLness in Lhe chesL,
diiculLy in breaLhing or shorLness o breaLh,
wheezing, and
coughing (parLicularly aL nighL).

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lneecLive airway
clearance relaLed Lo
increased producLion
o secreLions.
lndependenL.
AusculLaLe breaLh
sounds. NoLe
advenLiLious breaLh
sounds like wheezes,
crackles and rhonchi.
FlevaLe head o Lhe
bed, have paLienL lean
on overbed Lable or
siL on edge o Lhe
bed.
Keep environmenLal
polluLion Lo a
minimum like dusL,
smoke and eaLher
pillows, according Lo
individual siLuaLion.
Fncourage or assisL
wiLh abdominal or
pursed lip breaLhing
exercises.
AssisL wiLh measures
Lo improve
eecLiveness o cough
eorL.
Some degree o
bronchospasm is
presenL wiLh
obsLrucLions in airway
and may
or may noL be
maniesLed in
advenLiLious
breaLh sounds.
FlevaLion o Lhe bed
aciliLaLes respiraLory
uncLion by use o
graviLy.
PrecipiLaLors o
allergic Lype o
respiraLory reacLions
LhaL can Lrigger or
exacerbaLe onseL o
acuLe episode.
Provides paLienL wiLh
some means Lo cope
wiLh or conLrol
dyspnea and reduce
air Lapping.
Coughing is mosL
Lhe paLienL will be
able Lo demonsLraLe
behaviors Lo improve
airway clearance.
71

lncreased luid inLake
Lo 3000 ml/ day.
Provide warm or Lepid
liquids.

CollaboraLive.
AdminisLer
bronchodilaLors as
prescribed.
eecLive in an uprighL
posiLion aLer chesL
percussion.
HydraLion helps
decrease Lhe viscosiLy
o
secreLions, aciliLaLing
expecLoraLion. Using
warm liquids may
decrease
bronchospasm.
1o reduce Lhe
viscosiLy o secreLions.

>2"#=;4$4&
/1$;"7;B&4"5"OB

8ronchiLis is an inlammaLion o Lhe air passages wiLhin Lhe lungs. lL occurs when Lhe Lrachea
(windpipe) and Lhe large and small bronchi (airways) wiLhin Lhe lungs become inlamed because
o inecLion or oLher causes.
.4O#& I .BP7$"P&

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lneecLive airway
clearance relaLed Lo
excessive, Lhickened
mucous secreLions.
3#<%7%#<%#$-
Assess respiratory
raLe, depLh. NoLe use
o accessory muscles,
pursed lip breaLhing,
lnabiliLy Lo speak.
Elevate head of the
bed, assisL paLienL
assume posiLion Lo
ease work o
breaLhing. Fncourage
deep slow or pursed
lip breaLhing as
individually LoleraLed
or indicaLed.
Routinely monitor
skin and mucous
membrane color.
Fncourage
expecLoraLion o
spuLum, sucLion when
indicaLed.
FvaluaLe level o
acLiviLy Lolerance.
Provide calm and
quieL environmenL.
FvaluaLe sleep

Useul in evaluaLing
Lhe degree or
respiraLory disLress
and chroniciLy o Lhe
disease process.
Oxygen delivery
may be improved by
uprighL posiLion and
breaLhing exercises
Lo decrease airway
collapse, dyspnea
and work o
breaLhing.
Cyanosis may be
peripheral in nail
beds or cenLral in
lips or earlobes.
Duskiness and
cenLral cyanosis
indicaLe advanced
hypoxemia.
1hick, Lenacious,
copious secreLions
are major source i
ineecLive airways.
Deep sucLioning
lmproved venLilaLion
and adequaLe
oxygenaLion o
Lissues and
ArLerial blood
gases (A8Cs)
wiLhin normal
range and ree
rom sympLoms
o respiraLory
disLress.
72

paLLerns, noLe reporL
o diiculLies and
wheLher paLienL eels
well resLed.
' MoniLor viLal signs
and cardiac rhyLhm.

!"551F"21$4H%-
AdminisLer
supplemenLal oxygen
as indicaLed by A8C
resulLs and paLienLs
Lolerance.
may be required
when cough is
ineecLive or
expecLoraLion o
secreLions.
During severe or
acuLe respiraLory
disLress, paLienL may
be LoLally unable Lo
perorm basic sel
care acLiviLies
because o
hypoxemia and
dyspnea.
MulLiple exLernal
sLimuli and presence
o dyspnea may
prevenL relaxaLion
and inhibiL sleep.
1achycardia,
dysrhyLhmias, and
changes in blood
pressure can relecL
eecL o sysLemic
hypoxemia on
cardiac uncLion.
May correcL or
prevenL worsening
o hypoxia

!;2"#4= ,F&$2@=$4H% /@5P"#12B A4&%1&%
6!,/A8
/1$;"7;B&4"5"OB

COPD disrupLs airway dynamics, resulLing in obsLrucLion o airlow inLo or ouL o Lhe lungs.
Chronic 8ronchiLis.
HyperLrophy and hypersecreLion in gobleL cells and bronchial mucus glands leading Lo increased
spuLum secreLions, bronchial congesLion, narrowing o bronchioles, and small bronchi.
Fmphysema
Increased size of air spaces (i.e. dead space) with loss of elastic recoil of lung due to
hyperinlaLion o disLal airways causing airway obsLrucLion. DesLrucLion o alveolar walls and
diuse airway narrowing causes resisLance Lo airlow because o loss o supporLing sLrucLure and
bronchospasm urLher impede airlow.
.4O#& I .BP7$"P&

Chronic 8ronchiLis
HisLory o producLive cough LhaL lasLs 3 monLhs per year or 2 consecuLive years
Persistent cough, known as smokers cough usually in cold weather
73

PersisLenL spuLum producLion
RecurrenL acuLe respiraLory inecLion
Dusky color leading Lo cyanosis
Clubbing o ingers

Fmphysema
HisLory o chronic bronchiLis
Slow onseL o sympLoms (Lypically over several years) which can lead Lo righL-side hearL
ailure (i.e. cor pulmonale)
Progressive dyspnea, iniLially only on exerLion and laLer also aL resL
Progressive cough and increased spuLum producLion, especially bouLs o inecLion, use o
accessory muscles
Anorexia wiLh weighL loss and proound weakness
Dyspnea wiLh insidious onseL progressing Lo severe dyspnea wiLh slighL exerLion (major
sympLom)
Chronic cough, wheezing, dyspnea, aLigue, and Lachypnea
On inspection, barrel chest due to air trapping, muscle wasting, and pursed-lip
breaLhing
On ausculLaLion, diminished breaLh sounds wiLh crackles, wheezes, rhonchi, and
prolonged expiraLion.
Hyperresonance wiLh percussion and a decrease in remiLus
Anorexia, weighL loss, weakness, and inacLiviLy
Hypoxemia and hypercapnia, morning headaches in advanced sLages
lnlammaLory reacLions and inecLions rom pooled secreLions

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lneecLive airway
Clearance relaLed Lo
lncreased producLion
o secreLions.
lndependenL.
AssisL paLienL Lo
assume posiLion o
comorL, e.g., elevaLe
head o bed,
encourage paLienL Lo
lean on overbed Lable
or siL on Lhe edge o
Lhe bed.
Keep environmenLal
polluLion Lo a
minimum, e.g., dusL,
smoke and eaLher
pillows, according Lo
individual siLuaLion
Fncourage or assisL
wiLh pursed lip
breaLhing exercises.
Observe
characLerisLics o
cough like persisLenL
or hacking or moisL.
AssisL wiLh measures
Lo improve
eecLiveness o cough
eorL.

FlevaLion o Lhe head
o Lhe bed aciliLaLes
respiraLory uncLion
by use o graviLy.
PrecipiLaLors o
allergic Lype or
respiraLory reacLions
LhaL can Lrigger or
exacerbaLe onseL o
acuLe episode.
Provides paLienL wiLh
some means Lo cope
or conLrol dyspnea
and reduce air
Lrapping.
Coughing is mosL
eecLive in an uprighL
posiLion or head
down posiLion aLer
chesL
percussion.
A varieLy o
medicaLions may be
used Lo decrease
mucus and Lo improve
respiraLion.
HumidiLy helps
able Lo demonsLraLe
behaviors Lo improve
airway clearance. e.g.
cough eecLively and
expecLoraLe
secreLions.
74

DependenL.
AdminisLer
medicaLion as
prescribed by Lhe
physician.
Provide
supplemenLal
humidiicaLion like
nebulizer.
reduce viscosiLy o
secreLions, aciliLaLing
expecLoraLion, and
may reduce or prevenL
ormaLion o Lhick
mucus plugs in
bronchioles.

)P7;B&%P41
/1$;"7;B&4"5"OB

1he paLhophysiology o emphysema is besL explained on Lhe basis o decreased pulmonary
elasLic recoil. AL any pleural pressure, Lhe lung volume is higher Lhan normal. AddiLionally, Lhe
alLered relaLion beLween pleural and alveolar pressure aciliLaLes expiraLory dynamic compression
o airways. Such compression limiLs airlow during orced expiraLion and, in severe insLances,
during Lidal expiraLion. AnoLher acLor conLribuLing Lo airlow limiLaLion is disease o Lhe airways,
boLh large and small. ln general, paLienLs wiLh relaLively pure emphysema mainLain blood gases in
or near Lhe normal range unLil very laLe in Lheir course. PaO2 is mainLained because o Lhe
preserved maLching o venLilaLion and perusion as alveolar walls are desLroyed. PaCO2 is
mainLained because Lhe venLilaLory response Lo CO2 is noL usually impaired. lL is noL clear why
paLienLs who are caLegorized clinically as "chronic bronchiLics" are more likely Lo respond Lo an
increased low-resisLive work o breaLhing by hypovenLilaLing. Physical indings in emphysema are
noL speciic. Radiologic changes are insensiLive and are o less value Lhan physiologic
measuremenLs.
.4O#& I .BP7$"P&

.;"2$#%&& "M >2%1$;
+174< >2%1$;4#O
!;2"#4= !"@O; 6]4$; "2 ]4$;"@$ .7@$@P8
];%%W4#O
+%<@=%< )J%2=4&% E"5%21#=%
9"&& "M C77%$4$% 9%1<4#O $" ]%4O;$ 9"&&
>122%5 !;%&$

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
PaLienLs can
mainLain
adequaLe
gas
exchange
Assess or signs
and sympLoms
o hypoxia and
hypercapnia
MoniLor and
record blood
gas
examinaLion,
examine Lhe
Lrend in Lhe
RespiraLory
disLress and
changes in
viLal signs may
occur as a
resulLs o
physiological
sLress and pain
or may
indicaLe
8eep neL
pulmonary
1he color o
normal skin
8lood gases
wiLhin
normal
limiLs or
Lhe
esLimaLed
75

increase or
decrease in
PaO2 PaCO2
Help wiLh Lhe
provision o
mechanical
venLilaLion
according Lo
indicaLions,
assess Lhe need
or CPAP or
Peep.
AusculLaLion
chesL Lo lisLen
Lo breaLh
sounds every
hour
Review Lhe daily
chesL X-ray
examinaLion, or
deviaLions
noLiced
improvemenL
MoniLor cardiac
rhyLhm
Provide
appropriaLe
parenLeral luid
orders
Provide
cusLomized
medicines.
bronchodilaLors,
anLibioLics,
sLeroids.
FvaluaLion o
AKS in
conjuncLion
wiLh a decrease
in oxygen
demand.
developmenL
o shock due
Lo hypoxia.
1o aciliLaLe
maximal lung
expansion/imp
rove
venLilaLion and
reduce venous
reLurn Lo Lhe
righL side o
Lhe hearL.
8reaLh sounds
may be
diminished or
absenL in a
lobe lung
segmenL or
enLire lung
ield.
ALelecLaLic
area will have
no breaLh
sound, and
parLially
collapsed areas
have
decreased
sounds.
Regularly
scheduled
evaluaLion also
helps
deLermine
areas o good
air exchange
and provides a
baseline Lo
evaluaLe
resoluLion o
pneumorLhrax

age

D%P"$;"21J
/1$;"7;B&4"5"OB

A hemoLhorax is managed by removing Lhe source o bleeding and by draining Lhe blood already
in Lhe Lhoracic caviLy. 8lood in Lhe caviLy can be removed by inserLing a drain (chesL Lube) in a
procedure called a Lube LhoracosLomy. Usually Lhe lung will expand and Lhe bleeding will sLop
aLer a chesL Lube is inserLed. 1he blood in Lhe chesL can Lhicken as Lhe cloLLing cascade is
76

acLivaLed when Lhe blood leaves Lhe blood vessels and is acLivaLed by Lhe pleural surace, injured
lung or chesL wall, or conLacL wiLh Lhe chesL Lube. As Lhe blood Lhickens, iL can cloL in Lhe pleural
space (leading Lo a reLained hemoLhorax) or wiLhin Lhe chesL Lube, leading Lo chesL Lube clogging
or occlusion. ChesL Lube clogging or occlusion can lead Lo worse ouLcomes as iL prevenLs
adequaLe drainage o Lhe pleural space, conLribuLing Lo Lhe problem o reLained hemoLhorax. ln
Lhis case, paLienLs can be hypoxic, shorL o breaLh, or in some cases, Lhe reLained hemoLhorax can
become inecLed (empyema). 1hereore adequaLely uncLioning chesL Lubes are essenLial in Lhe
seLLing o a hemoLhorax LreaLed wiLh a chesL Lube. 1o aLLempL Lo minimize Lhe poLenLial or
clogging, Lhe surgeons will oLen place more Lhan one Lube, or large diameLer Lubes. MainLaining
an adequaLely uncLioning chesL Lube is an acLive process, usually or Lhe nurses, LhaL oLen
requires Lapping Lhe Lubes, milking Lhe Lubes, or sLripping Lhe Lubes Lo minimize poLenLial or
clogging in Lhe Lube in Lhe seLLing o a hemoLhorax. When Lhese eorLs ail a new chesL Lube
musL be placed, or Lhe paLienL musL be Laken Lo Lhe operaLing room by a surgeon Lo open Lhe
chesL and remove Lhe blood cloL, and re inserL adequaLely uncLioning chesL Lubes.

1hrombolyLic agenLs have been used Lo break up cloL in Lubes or when Lhe cloL becomes
organized in Lhe pleural space, however Lhis is risky as iL can lead Lo increased bleeding and Lhe
need or reoperaLion. 1hereore, ideally, Lhe Lubes mainLain Lheir uncLion so LhaL Lhe blood
cannoL cloL in Lhe chesL or Lhe Lube.

ln some cases bleeding conLinues and surgery is necessary Lo sLop Lhe source o bleeding. For
example, i Lhe cause is rupLure o Lhe aorLa in high energy Lrauma, Lhe inLervenLion by a Lhoracic
surgeon is mandaLory.
.4O#& I .BP7$"P&

1achypnea
Dyspnea
Cyanosis
Decreased or absenL breaLh sounds on aecLed side
1racheal deviaLion Lo unaecLed side
Dull resonance on percussion
Unequal chesL rise
1achycardia
HypoLension
Pale, cool, clammy skin
Possibly subcuLaneous emphysema
Narrowing pulse pressure

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3#$%2H%#$4"#
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lneecLive
breaLhing
paLLern
relaLed Lo
decreased
lung
expansion
lndependenL.
ldenLiy
eLiology or
precipiLaLing
acLors.
MoniLor viLal
signs.
Assess lung
sounds,
respiraLory
raLe and
eorL and Lhe

UndersLanding
Lhe cause is
necessary or
choice o
LherapeuLic
measures.
MoniLoring Lhe
viLal signs is
necessary Lo
evaluaLe Lhe
degree o
FsLablish a
normal and
eecLive
breaLhing
paLLern
wiLhin
clients
normal
range
77

use o
accessory
muscles.
FvaluaLe
respiraLory
uncLion,
noLing rapid
or shallow
respiraLions,
dyspnea,
reports of air
hunger, and
changes in
viLal signs.
Observe skin
and mucous
membranes
or signs o
cyanosis.
Fncourage
adequaLe resL
and limiL
acLiviLies
within clients
level o
Lolerance.
PromoLe a
calm and
resLul
environmenL.

DependenL.
AdminisLer
supplemenLal
oxygen as
ordered by
Lhe physician.
AdminisLer
medicaLions
as prescribed
by Lhe
physician
compromise.
RespiraLory raLe
less Lhan 2 or
more Lhan24 or
use o accessory
muscles indicaLe
disLress.
Diminished lung
sounds indicaLe
possible poor air
movemenL and
impaired gas
exchange.
RespiraLory
disLress and
changes in viLal
signs occur as a
resulL o
physiologic sLress
and pain, or may
indicaLe
developmenL o
shock due Lo
hypoxia or
hemorrhage
Cyanosis
indicaLes poor
oxygenaLion. Oral
mucous
membrane
cyanosis indicaLes
serious hypoxia.
Helps limiL
oxygen needs
and
consumpLion.
SupplemenLal
oxygen decreases
hypoxia.
1o LreaL under
lying condiLions

/#%@P"#41
/1$;"7;B&4"5"OB

Pneumonia is an acuLe inlammaLory disorder o lung parenchyma LhaL resulLs in edema o lung
Lissues and movemenL o luid inLo Lhe alveoli. 1hese impair gas exchange resulLing in hypoxemia.
Pneumonia can be classiied in several ways. 8ased on microbiologic eLiology, iL may be viral,
bacLerial, ungal, proLozoal, myobacLerial, mycoplasmal, or rickeLLsial in origin. 8ased on locaLion,
78

pneumonia may be classiied as bronchopneumonia, lobular pneumonia, or lobar pneumonia.
8ronchopneumonia involves disLal airways and alveoli, lobular pneumonia, parL o Lhe lobe, and
labor pneumonia, Lhe whole lobe.

Pneumonia occurs in boLh sexes and aL all ages, buL older adulLs run a greaLer risk o developing
iL because Lheir weakened chesL musculaLure reduces Lheir abiliLy Lo clear secreLions. 8acLerial
pneumonia is Lhe mosL common Lype o pneumonia ound in older adulLs, viral pneumonia is Lhe
second mosL common Lype. AspiraLion pneumonia occurs in older adulLs due Lo impaired
swallowing abiliLy and diminished gag relex. 1hese changes can occur aLer a sLroke or any
prolonged illness.
.4O#& I .BP7$"P&

Sudden chills, rapidly rising ever (38.5C Lo 40.5C), and prouse perspiraLion.
PleuriLic chesL pain aggravaLed by respiraLion and coughing
Severely ill paLienL has marked Lachypnea (25 Lo 45 breaLhs/min) and dyspnea, orLhopnea
when noL propped up.
Pulse rapid and bounding, may increase beaLs/min per degree o LemperaLure elevaLion
Dullness wiLh consolidaLion on percussion o chesL
8ronchial breaLh sounds ausculLaLed over consolidaLed lung ields
Shaking chills (wiLh bacLerial pneumonia)
Dyspnea, respiraLory grunLing, and nasal laring
Severe pneumonia. lushed cheeks, cyanoLic lips and nail beds
SpuLum purulenL, rusLy, blood-Linged, viscous, or green depending on eLiologic agenL.
AnxieLy and conusion
ln elderly clienLs, Lhe only signs may be menLal sLaLus change and dehydraLion.
ChesL radiograph shows densiLy changes, primarily in Lhe lower lung ields.
SpuLum culLure and sensiLiviLy are posiLive or a speciic causaLive organism.
WhiLe blood cell (W8C) counL is elevaLed in pneumonia o bacLerial origin, W8C counL is
depressed in pneu monia o mycoplasmal or viral origin.

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmpaired Cas
Fxchange

relaLed Lo.
oxygen-
carrying blood
disorders,
impaired
oxygen
delivery

characLerized by.
Dyspnea,
cyanosis
1achycardia
Nervous /
menLal
changes
Hypoxia
Assess Lhe
requency /
depLh and ease
o breaLhing
Observe Lhe
color o skin,
mucous
membranes and
nails. NoLe Lhe
presence o
peripheral
cyanosis (nail) or
cenLral cyanosis.
Assess menLal
sLaLus.
FlevaLe Lhe head
and LhrusL
requenLly
change posiLion,
breaLhe deeply
and cough
Lhe
maniesLaLi
on o
respiraLory
disLress
depends
on Lhe
indicaLion
o Lhe
degree o
lung
involvemen
L and
general
healLh
sLaLus.
nails
showed
cyanosis
vasoconsLri
cLion
FsLablish a
normal and
eecLive
breaLhing
paLLern
wiLhin
clients
normal
range
79

eecLively.
CollaboraLion
body's
response Lo
ever /
chills, buL
cyanosis on
Lhe ears,
mucous
membrane
s and skin
around Lhe
mouLh
indicaLe
sysLemic
hypoxemia.
nervous
irriLabiliLy,
conusion
and
somnolenc
e may
indicaLe
cerebral
hypoxia or
decreased
oxygen.
1his acLion
increases
Lhe
maximum
inspiraLion,
increased
spending
secreLions
Lo improve
venLilaLion
ineecLive.
Lo mainLain
PaO2
above 60
mmHg.
OxygenaLio
n provided
wiLh a
meLhod
LhaL
provides
precise
delivery.

80

/#%@P"$;"21J
/1$;"7;B&4"5"OB
PneumoLhorax reers Lo gas wiLhin Lhe pleural space. Normally, Lhe alveolar pressure is greaLer
Lhan Lhe inLrapleural pressure, while Lhe inLrapleural pressure is less Lhan aLmospheric pressure.
1hereore, i a communicaLion develops beLween an alveolus and Lhe pleural space or beLween
Lhe aLmosphere and Lhe pleural space, gases will ollow Lhe pressure gradienL and low inLo Lhe
pleural space. 1his low will conLinue unLil Lhe pressure gradienL no longer exisLs or Lhe abnormal
communicaLion has been sealed. Since Lhe Lhoracic caviLy is normally below iLs resLing volume,
and Lhe lung is above iLs resLing volume, Lhe Lhoracic caviLy enlarges and Lhe lung becomes
smaller when a pneumoLhorax develops.

A Lension pneumoLhorax is a medical emergency and occurs when Lhe inLrapleural pressure
exceeds aLmospheric pressure, especially during expiraLion, and resulLs rom a ball valve
mechanism LhaL promoLes inspiraLory accumulaLion o pleural gases. 1he build-up o pressure
wiLhin Lhe pleural space evenLually resulLs in hypoxaemia and respiraLory ailure rom
compression o Lhe lung.

1he paLhophysiology o caLamenial pneumoLhoraces is noL known. lL has been suggesLed LhaL air
gains access Lo Lhe periLoneal caviLy during mensLruaLion and Lhen secondarily Lhe pleural space
Lhrough diaphragmaLic deecLs. AlLernaLively, iL has been hypoLhesized LhaL ecLopic inLraLhoracic
endomeLriosis resulLs in visceral pleural erosions, Lhus causing a pneumoLhorax.
.4O#& I .BP7$"P&
Signs and sympLoms o a pneumoLhorax usually include.
!;%&$ 714#\ Sudden, sharp chesL pain on Lhe same side as Lhe aecLed lung Lhis pain
doesn'L occur in Lhe cenLer o your chesL under Lhe breasL bone. And iL doesn'L worsen
when you breaLhe in and ouL.
.;"2$#%&& "M F2%1$;\ 1his may be mild or severe, depending on how much o your lung
is collapsed and wheLher you have underlying lung disease.

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8reaLhing
paLLern
ineecLive
may relaLed
Lo
Decreased
lung
expansion
Musculoskel
eLal
impairmenL
pain/anxieLy
inlammaLio
n process
ldenLiy
eLiology
precipiLaL
ing
acLors
FvaluaLe
respiraLor
y
uncLions,
noLing
rapid/sha
llow
respiraLio
ns,
dyspnea
UndersLanding
Lhe cause o lung
collapse in
necessary or
proper chesL
placemenL and
choice oLher
LherapeuLic
measures.
RespiraLory
disLress and
changes in viLal
signs may occur
as a resulLs o
physiological
PaLienL mainLains opLimal gas
exchange as evidenced by.-a.
Normal arLerial
blood gases (A8Cs)
Pulse oximeLry resulLs
wiLhin normal range.
Usual menLal sLaLus
.
Normal respiraLion raLe

81

MoniLor
or
synchron
ous
respiraLor
y paLLern
when
using
mechanic
al
venLilaLor
AsculaLe
breaLh
sounds
Assess
remiLus
sLress and pain or
may indicaLe
developmenL o
shock due Lo
hypoxia.
DiiculLy
breaLhing "wiLh"
venLilaLor or
increasing airway
pressure suggesLs
worsening o
condiLion/develo
pmenL o
complicaLions
8reaLh sounds
may be
diminished or
absenL in a lobe
lung segmenL or
enLire lung ield.
ALelecLaLic area
will have no
breaLh sound,
and parLially
collapsed areas
have decreased
sounds. Regularly
scheduled
evaluaLion also
helps deLermine
areas o good air
exchange and
provides a
baseline Lo
evaluaLe
resoluLion o
pneumorLhrax
voice and LacLile
remiLus is
reduced in luid
illed/consolidaLe
d Lissue

/@5P"#12B )PF"54&P
/1$;"7;B&4"5"OB
A Lhrombus LhaL has separaLed rom iLs siLe o origin Lravels Lhrough Lhe circulaLion Lo Lhe inerior
vena cava. 1he righL venLricle pumps Lhis Lhrombus Lo Lhe pulmonary arLeries where Lhe Lhrombus
inally lodges. PF may occur singly or mulLiply. 1hey can be microscopic in size or be big enough
Lo occlude Lhe major branches o Lhe pulmonary arLery.
82

1he embolus obsLrucLs low in Lhe pulmonary arLeries and Lhus causes an increase in resisLance Lo
blood low in Lhe pulmonary vessels. Severe pulmonary hyperLension, Rv sLrain, and cardiac hearL
ailure occur when more Lhan 50-60% decrease in perusion. ln addiLion, inLrapulmonary relexes
sLimulaLe Lhe release o humoral subsLances LhaL lead Lo vasoconsLricLion LhroughouL Lhe lungs
and Lhus increases pulmonary vascular resisLance.
0% o PF will progress Lo pulmonary inarcLion. 1he lung depends on 3 sources o oxygen
(airways, bronchial circulaLion, pulmonary circulaLion) and Lhereore Lhe chance LhaL all 3 sources
will be compromised simulLaneously are noL greaL.
RecurrenL PF may gradually obsLrucL Lhe pulmonary vasculaLure and ulLimaLely lead Lo chronic
obsLrucLive pulmonary hyperLension and cor pulmonale.
1he mosL imporLanL paLhophysiological consequence o PF is v/Q mismaLch in which Lhere is
"dead space" venLilaLion in some parLs o Lhe lung and overperusion in oLhers. "Dead space"
venLilaLion reers Lo venLilaLion o lung segmenLs LhaL have obsLrucLed vascular supply and Lhus
no perusion. On Lhe oLher hand, overperusion and decreased vascular resisLance in oLher parLs
o Lhe lung leads Lo righL-Lo-leL inLrapulmonary shunLing wiLh insuicienL oxygenaLion o a large
porLion o perused blood.
.4O#& I .BP7$"P&
SympLoms o pulmonary embolism may be vague, or Lhey may resemble sympLoms associaLed
wiLh oLher diseases. SympLoms can include.
Cough
! 8egins suddenly
! May produce bloody spuLum (signiicanL amounLs o visible blood or lighLly
blood sLreaked spuLum)
Sudden onseL o shorLness o breaLh aL resL or wiLh exerLion
SplinLing o ribs wiLh breaLhing (bending over or holding Lhe chesL)
ChesL pain
! Under Lhe breasLbone or on one side
! Fspecially sharp or sLabbing, also may be burning, aching or dull, heavy sensaLion
! May be worsened by breaLhing deeply, coughing, eaLing, bending, or sLooping
Rapid breaLhing
Rapid hearL raLe (Lachycardia)
AddiLional sympLoms LhaL may be associaLed wiLh Lhis disease.
Wheezing
Clammy skin
8luish skin discoloraLion
Nasal laring
Pelvis pain
Leg pain in one or boLh legs
Swelling in Lhe legs (lower exLremiLies)
Lump associaLed wiLh a vein near Lhe surace o Lhe body (supericial vein), may be
painul
Low blood pressure
Weak or absenL pulse
83

LighLheadedness or ainLing
Dizziness
SweaLing
AnxieLy

(@2&4#O
C&&%&&P%#$
(@2&4#O
3#$%2H%#$4"#
+1$4"#15% 0"15
lmpaired
gas
exchange
d relaLed
Lo
decrease
pulmonar
y
perusion
associaLe
d wiLh
obsLrucLi
on o
pulmonar
y arLerial
blood
low by
Lhe
embolus.
FrequenLly
assess
respiraLory
sLaLus
including
raLe, depLh,
eorL, lung
sound and
SPO2
Assess Lhe
menLal
sLaLues o Lhe
clienL
MoniLor A8Cs
and noLe
changes
PosiLion Lhe
paLienL in
high owler's
posiLion
AdminisLered
oxygen as
ordered by
docLor
mainLain bed
resL
AdminisLer
medicaLion
as prescribed
by docLor.
lmpaired
venLilaLion
aecLs gas
exchange and
worsens
hypoxemia
(1achypnea,
dyspnea).
SPO2 can be
used as a
non-invasive
meLhod Lo
moniLors
oxygen
saLuraLion.
ResLlessness
is an early
sign o
hypoxia.
Hypoxemia
oLen causes
conusion and
agiLaLion.
A8Cs used Lo
assess gas
exchange o
clienL
1o aciliLaLe
maximal lung
expansion/im
prove
venLilaLion
and reduce
venous reLurn
Lo Lhe righL
side o Lhe
hearL.
1o improve
oxygenaLion.
8ed resL
reduces
meLabolic
demands or
oxygen
AnLicoagulanL
Lherapy is
PaLienL mainLains opLimal gas
exchange as evidenced by.-a.
Normal arLerial
blood gases (A8Cs)
Pulse oximeLry resulLs
wiLhin normal range.
Usual menLal sLaLus
.
Normal respiraLion raLe

84

prevenLive by
inhibiLing
urLher doL
ormaLion.

+%&7421$"2B L145@2%
/1$;"7;B&4"5"OB

RespiraLory ailure can arise rom an abnormaliLy in any o Lhe componenLs o Lhe respiraLory
sysLem, including Lhe airways, alveoli, cenLral nervous sysLem (CNS), peripheral nervous sysLem,
respiraLory muscles, and chesL wall. PaLienLs who have hypoperusion secondary Lo cardiogenic,
hypovolemic, or sepLic shock oLen presenL wiLh respiraLory ailure.
venLilaLory capaciLy is Lhe maximal sponLaneous venLilaLion LhaL can be mainLained wiLhouL
developmenL o respiraLory muscle aLigue. venLilaLory demand is Lhe sponLaneous minuLe
venLilaLion LhaL resulLs in a sLable P
a
CO
2
.
Normally, venLilaLory capaciLy greaLly exceeds venLilaLory demand. RespiraLory ailure may resulL
rom eiLher a reducLion in venLilaLory capaciLy or an increase in venLilaLory demand (or boLh).
venLilaLory capaciLy can be decreased by a disease process involving any o Lhe uncLional
componenLs o Lhe respiraLory sysLem and iLs conLroller. venLilaLory demand is augmenLed by an
increase in minuLe venLilaLion and/or an increase in Lhe work o breaLhing.
.4O#& I .BP7$"P&

RespiraLory ailure is accompanied by a number o sympLoms including.
8luish coloraLion o Lhe lips or ingernails
Conusion or loss o consciousness
FainLing or change in level o consciousness or leLhargy
FaLigue
lrregular hearL raLe (arrhyLhmia)
Rapid breaLhing (Lachypnea) or shorLness o breaLh

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lrregular
HearL raLe
Rapid
8reaLhing
FaLigue
MoniLor
respiraLory sLaLus,
including viLal
signs, breaLh
sounds, and skin
color.
Place Lhe paLienL
in semi-owlers
posiLion and place
Lhe diaphragm in
proper posiLion Lo
conLracL.
assisL in sel-care
RespiraLory sLaLus
assessmenL helps
gauge Lhe
patients severity
and whether its
progressing.
1o increase chesL
expansion and Lo
alleviaLe dyspnea.
1o disLracL
aLLenLion rom
pain and decrease
Lension
Coal meL. PaLienL
was able Lo relax
by uLilizing bed
resL and deep
breaLhing.

85

acLiviLies as
LoleraLed
provide peaceul
\and adequaLe
resLing
environmenL (dim
lighLs, adjusL
LemperaLure,
wrinkle-ree bed,
quieL
surroundings)
1o conserve
energy o Lhe
paLienL and
prevenL aLigue
1o promoLe clienL
independence as
much as possible
and acquire sense
o uncLion9.Lo
enhance qualiLy
sleep and
promoLe resL
which harnesses
energy or uLure
use.

E@F%2=@5"&4& 6E>8
/1$;"7;B&4"5"OB
1he risk o 18 is a higher in older people who have close conLacL wiLh a newly diagnosed 18
paLienL, Lhose who have 18 beore, gasLrecLomy paLienLs, and Lhose aecLed wiLh diabeLes
melliLus. 1he aging process weakens Lhe immune sysLem, urLher increasing Lhe likelihood o
Lubercular inecLion in older adulLs.
1ransmission occurs when droplet nuclei are produced form an infected persons coughs or
sneezes. l inhaled, Lubercle bacillus seLLles in Lhe alveolus and inecLion occurs, wiLh
alveolocapillary dilaLion and endoLhelial swelling. 1he incubaLion Lime or 18 is 4 Lo 8 weeks. 18 is
usually asympLomaLic in primary inecLion
.4O#& I .BP7$"P&

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lneecLive breaLhing
paLLern relaLed Lo
acuLe inecLion and
decreased lung
capaciLy
MoniLor
respiraLory sLaLus,
including viLal
signs, breaLh
sounds, and skin
color.
AdminisLer
oxygen Lherapy as
ordered.

MoniLor A8C
levels and oxygen
saLuraLion as
ordered.

RespiraLory sLaLus
assessmenL helps
gauge Lhe
patients severity
and whether its
progressing.
1o provide relie
rom sympLoms o
hypoxemia and
hypoxia.
A8C levels and
conLinuous pulse
oximeLry
measures Lhe
bloods oxygen
conLenL and are
good indicaLors o
the lungs ability
8reaLhing
reLurned Lo
normal raLe and
paLLern
Minimal or no
signs o inecLion.

86


Place Lhe paLienL
in semi-owlers
posiLion and place
Lhe diaphragm in
proper posiLion Lo
conLracL.

CollecL spuLum
samples as
ordered.
Lo oxygenaLe Lhe
blood.
1o increase chesL
expansion and Lo
alleviaLe dyspnea.

1o moniLor Lhe
progress o Lhe
disease and
LreaLmenL.

*77%2 +%&7421$"2B 3#M%=$4"# 6*+3 8
/1$;"7;B&4"5"OB
.4O#& I .BP7$"P&
lLchy, waLery eyes
nasal discharge
nasal congesLion
sneezing
sore LhroaL
cough
head ache
ever
malaise
aLigue, weakness
muscle pain

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
ineecLive Airway
Clearance relaLed Lo
Lhick Lenacious
secreLions and airway
obsLrucLions
maniesLed by shallow
respiraLion, Lachypnea
and ever
. MoniLor vS every 2
hrs.
2. Fncourage paLienL
Lo posiLion in high-
Fowlers or semi-
Fowlers position.
3. 1urn paLienL every2
hrs and prn.
4. 1each clienL Lo
mainLain adequaLe
hydraLion by drinking
aL leasL 8-0 glasses
o luid/day (i noL
conLraindicaLed).
5. 1each and supervise
eecLive coughing
Lechniques.
6. Perorm ChesL
Physical Lherapy
. 1o assess baseline
daLa.
2.promoLes maximal
lung uncLion.
3.reposiLioning
promoLes drainage o
pulmonary secreLions
and enhances
venLilaLion Lo
decrease poLenLial o
aLelecLasis.
4.Lo help Lhin
secreLions.
5.Lo conserve energy
and Lo reduce airway
collapse.
6.CP1 Lechniques
uLilizes orces o
graviLy and moLion Lo
had been able Lo
cough eecLively and
clear own secreLions.
mainLained paLency o
airway and had clear
breaLh sounds
87

7. lnsLrucL on splinLing
abdomen wiLh pillow
during coughing
eorLs.
8. MoniLor airway or
paLency and provide
arLiicial airways as
warranLed.
9. AdminisLer
bronchodilaLors as
ordered.
0. lnsLrucL
clienL/amily Lo noLiy
nurse i Lhe clienL is
experiencing
shorLness o breaLh or
air hunger.
. lnsLrucL
clienL/amily
regarding
medicaLions, eecLs,
side eecLs and
sympLoms o adverse
eecLs Lo reporL Lo
nurse or physician.

aciliLaLe secreLion
removal
7. PromoLes increased
expiraLory pressure.
8.requires i paLienL
cannoL mainLain
airway paLency.
9. 1o improve
venLilaLion and
maximizes air
exchange.
0. May indicaLe
bronchial Lubes are
blocked wiLh mucus,
leading Lo hypoxia
and hypoxemia.
. PromoLes prompL
idenLiicaLion o
poLenLial adverse
reacLion Lo aciliLaLe
Limely inLervenLion.

!C+A3C! 6D)C+E8

C#O4#1
/1$;"7;B&4"5"OB

Angina is a Lemporary chesL pain LhaL resulLs rom inadequaLe oxygen low Lo Lhe myocardium.
Its usually described as burning, squeezing, or a tight feeling in the substernal or precordial
chesL. 1his pain may radiaLe Lo Lhe leL arm, neck, jaw, or shoulder blade. 1ypically, Lhe paLienL
clenches his isL over his chesL or rubs his leL arm when describing Lhe pain, which may also be
accompanied by nausea, vomiLing, ainLing, sweaLing, and cool exLremiLies.

.EC>9) C(03(C. discomorL LhaL oLen occurs wiLh acLiviLy or sLress. Angina is a Lype o
chesL discomorL caused by poor blood low Lhrough Lhe blood vessels (coronary vessels) o Lhe
hearL muscle (myocardium) our hearL muscle is working all Lhe Lime, so iL needs a consLanL
supply o oxygen. 1his oxygen is provided by Lhe coronary arLeries, which carry blood.
88

When Lhe hearL muscle has Lo work harder, iL needs more oxygen. SympLoms o angina occur
when Lhe coronary arLeries are narrowed or blocked by hardening o Lhe arLeries aLherosclerosis
or by a blood cloL.

*(.EC>9) C(03(C. condiLion in which your hearL doesn'L geL enough blood low and
oxygen. lL may lead Lo a hearL aLLack.
Angina is a Lype o chesL discomorL caused by poor blood low Lhrough Lhe blood vessels
(coronary vessels) o Lhe hearL muscle (myocardium).
Coronary arLery disease due Lo aLherosclerosis is by ar Lhe mosL common cause o unsLable
angina. ALherosclerosis is Lhe buildup o aLLy maLerial called plaque along Lhe walls o Lhe
arLeries. 1his causes arLeries Lo become narrowed and less lexible. 1he narrowing inLerrupLs
blood low Lo Lhe hearL, causing chesL pain.
People wiLh unsLable angina are aL increased risk o having a hearL aLLack.

When assessing or anginal pain, older adulLs commonly have an increased Lolerance or pain,
and may be less likely Lo complain. lnsLead, Lhey may compensaLe by slowing Lheir acLiviLy levels.
Older adulLs may noL experience chesL pain aL all, buL may reporL dyspnea, ainLness, or exLreme
aLigue.

The persons health history may suggest a pattern to the type and onset of pain. If the pain is
predictable and relieved by rest or nitrates, its called &$1F5% 1#O4#1. l iL increases in requency
and duration and is more easily induced, its referred to as unstable angina or unpredictable
angina. UnsLable angina may occur aL resL and generally indicaLes exLensive or worsening disease
LhaL may progress Lo an Ml. varianL or Prinzmetals angina is caused by coronary artery spasm,
and commonly occurs aL resL wiLhouL iniLial increased oxygen demand.
.4O#& I .BP7$"P&

ChesL pain, heavy sensaLion (reLrosLernal area)
1ighLness, heavy, choking or sLrangling sensaLion
Weakness
Numbness in Lhe arms, wrisLs, and hands
ShorLness o breaLh
Pallor, diaphoresis, dizziness or lighLheadedness
Nausea and vomiLing
AnxieLy

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe pain relaLed
Lo decreased
myocardial blood
low

Assess or viLal signs
and sympLoms o pain
such as acial
grimacing, rubbing o
neck or jaw,
relucLance Lo move,
increased blood
pressure, and
Lachycardia.
1o dierenLiaLe
angina pain rom pain
relaLed Lo oLher
causes.

1o moniLor Lhe
eecLiveness o
medicaLions given or
pain relie.
Lhe paLienL will be ree
rom pain, mainLains
sLable viLal signs, and
relaxed body posLure.

89


NoLe onseL, duraLion,
locaLion, and paLLern
o pain.

2-lead FKC
immediaLely during
acuLe chesL pain.

Use a pain raLing
scale Lo assess Lhe
patients perception
of the pains severity.

AdminisLer sublingual
niLroglycerin as
ordered.
((,E)
!,(E+C3(A3!CE)A
L,+ /E ,(
?C.,A3C9CE,+.
93K) ?3C0+C8

lnsLrucL Lhe paLienL Lo
noLiy a nurse
immediaLely when
experiencing pain.
Have Lhe paLienL sLop
currenL acLiviLy, and
place him on bed resL
in a semi- Lo high
Fowlers position.

AdminisLer oxygen as
ordered.

1o decrease
myocardial oxygen
demands Lhrough
vasodilaLaLion,
preload and aLer load
reducLion and
<%=2%1&%< =12<41=
:"2R 5"1<\

1o minimize ischemia
produced by
increased myocardial
work load.

1o provide opLimal
oxygenaLion Lo Lhe
myocardium.

1o documenL
ischemic changes.
1o decrease anxieLy
and promoLe comorL.

C22;B$;P41&
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Regardless o Lhe speciic arrhyLhmia, Lhe paLhogenesis o Lhe arrhyLhmias alls inLo one o Lhree
basic mechanisms. enhanced or suppressed auLomaLiciLy, Lriggered acLiviLy, or re-enLry.
AuLomaLiciLy is a naLural properLy o all myocyLes. lschemia, scarring, elecLrolyLe disLurbances,
medicaLions, advancing age, and oLher acLors may suppress or enhance auLomaLiciLy in various
areas. Suppression o auLomaLiciLy o Lhe sinoaLrial (SA) node can resulL in sinus node dysuncLion
and in sick sinus syndrome (SSS), which is sLill Lhe mosL common indicaLion or permanenL
pacemaker implanLaLion . ln conLrasL Lo suppressed auLomaLiciLy, enhanced auLomaLiciLy can
resulL in mulLiple arrhyLhmias, boLh aLrial and venLricular. 1riggered acLiviLy occurs when early
aLerdepolarizaLions and delayed aLerdepolarizaLions iniLiaLe sponLaneous mulLiple
90

depolarizaLions, precipiLaLing venLricular arrhyLhmias. Fxamples include Lorsades de poinLes and
venLricular arrhyLhmias caused by digiLalis LoxiciLy. Probably Lhe mosL common mechanism o
arrhyLhmogenesis resulLs rom re-enLry. RequisiLes or re-enLry include bidirecLional conducLion
and unidirecLional block. Micro level re-enLry occurs wiLh v1 rom conducLion around Lhe scar o
myocardial inarcLion (Ml), and macro level re-enLry occurs via conducLion Lhrough (Wol-
Parkinson-WhiLe [WPW] syndrome) concealed accessory paLhways.
.4O#& I .BP7$"P&
PalpiLaLions (a eeling o skipped hearL beaLs, luLLering or "lip-lops," or eeling LhaL your
hearL is "running away").
Pounding in your chesL.
Dizziness or eeling lighL-headed.
FainLing.
ShorLness o breaLh.
ChesL discomorL.
Weakness or aLigue (eeling very Lired).

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Decrease in cardiac
ouLpuL associaLed
wiLh cardiac
arrhyLhmias

moniLor
cardiovascular sLaLus
by using a hearL
moniLor.
Assess and record
apical pulse,
peripheral pulses,
blood pressure,
capillary illing Lime,
luid inLake and
ouLpuL, and skin
characLerisLics (such
as sLriped skin, skin
color, edema,
LemperaLure, and
diaphoresis).
Please provide
cardiovascular
LreaLmenL, as direcLed.
Help your child save
energy Lhrough Lhe
grouping o nursing
care.

lndicaLions o hearL
moniLoring and
recording o various
irregulariLies hearL
normal hearL raLe and
rhyLhm o children.
AssessmenLs provide
daLa rom Lhe basic
measuremenL change,
possibly indicaLed
arrhyLhmias.
Cardiovascular
LreaLmenL could be
given Lo help decide
elecLrical disLurbances
associaLed wiLh
arrhyLhmias.
ClusLering allows care
Lo be a long resL
period.
will express Lheir
undersLanding o Lhe
disease abank, Lhe
reason or
hospiLalizaLion, and
nursing home care
insLrucLions and
demonsLraLe
procedures or home
care.

C=@$% !"2"#12B .B#<2"P% 6C!.8
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AcuLe coronary syndrome is a Lerm used or any condiLion broughL on by sudden, reduced blood
low Lo Lhe hearL. AcuLe coronary syndrome can describe chesL pain you eel during a hearL
aLLack, or chesL pain you eel while you're aL resL or doing lighL physical acLiviLy (unsLable angina).
AcuLe coronary syndrome is oLen diagnosed in an emergency room or hospiLal.

91

AcuLe coronary syndrome is LreaLable i diagnosed quickly. AcuLe coronary syndrome LreaLmenLs
vary, depending on your signs, sympLoms and overall healLh condiLion.
.4O#& I .BP7$"P&

Many acuLe coronary syndrome sympLoms are Lhe same as Lhose o a hearL aLLack. And i acuLe
coronary syndrome isn'L LreaLed quickly, a hearL aLLack will occur. lL's imporLanL Lo Lake acuLe
coronary syndrome sympLoms very seriously. CeL medical help righL away i you have Lhese signs
and sympLoms and Lhink you're having a hearL aLLack.
ChesL pain (angina) LhaL eels like burning, pressure or LighLness and lasLs several minuLes
or longer
Pain elsewhere in Lhe body, such as Lhe leL upper arm or jaw (reerred pain)
Nausea
vomiLing
ShorLness o breaLh (dyspnea)
Sudden, heavy sweaLing (diaphoresis)

l you're having a hearL aLLack, Lhe signs and sympLoms may vary depending on your sex, age and
wheLher you have an underlying medical condiLion, such as diabeLes. Some unusual hearL aLLack
sympLoms include.
Abdominal pain
Pain similar Lo hearLburn
Clammy skin
LighLheadedness, dizziness or ainLing
Unusual or unexplained aLigue
Feeling resLless or apprehensive

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# I
+1$4"#15%
0"15
ReporLed pain
SysLolic blood pressure
DiasLolic blood pressure
Apical hearL raLe
Urinary ouLpuL
FvaluaLe chesL pain (e.g.,
inLensiLy, locaLion, radiaLion,
duraLion, and precipiLaLing
and alleviaLing acLors) in
order Lo accuraLely evaluaLe,
LreaL, and prevenL urLher
ischemia.
MoniLor eecLiveness o
oxygen Lherapy Lo increase
oxygenaLion o myocardial
Lissue and prevenL urLher
ischemia.
AdminisLer medicaLions Lo
relieve/prevenL pain and
ischemia Lo decrease anxieLy
and cardiac workload.
ObLain 2-lead FCC during
pain episode Lo help
dierenLiaLe angina rom
exLension o Ml or pericardiLis.
MoniLor cardiac rhyLhm and
raLe and Lrends in blood
pressure and hemodynamic
parameLers (e.g., cenLral
venous pressure and
Describes risk acLors, Lhe
disease process, and
rehabiliLaLion acLiviLies
necessary Lo manage Lhe
LherapeuLic regimen
92

pulmonary arLery wedge
pressure) Lo moniLor or
hypoLension and bradycardia,
which may lead Lo
hypoperusion.
MoniLor viLal signs requenLly
Lo deLermine baseline and
ongoing changes.
MoniLor or cardiac
dysrhyLhmias, including
disLurbances o boLh rhyLhm
and conducLion, Lo idenLiy
and LreaL signiicanL
dysrhyLhmias.
MoniLor respiraLory sLaLus or
sympLoms o hearL ailure Lo
mainLain appropriaLe levels o
oxygenaLion and observe or
signs o pulmonary edema.
MoniLor luid balance (e.g.,
inLake/ouLpuL, daily weighL) Lo
moniLor renal perusion and
observe or luid reLenLion.
Arrange exercise and resL
periods Lo avoid aLigue and
decrease Lhe oxygen demand
on myocardium

C$2415 L4F24551$4"# 6CL3>8
/1$;"7;B&4"5"OB

ALrial ibrillaLion occurs in Lhree clinical circumsLances.

- As a primary arrhyLhmia in Lhe absence o idenLiiable sLrucLural hearL disease,

- As a secondary arrhyLhmia in Lhe absence o sLrucLural hearL disease buL in Lhe presence o a
sysLemic abnormaliLy LhaL predisposes Lhe individual Lo Lhe arrhyLhmia,

- As a secondary arrhyLhmia associaLed wiLh cardiac disease LhaL aecLs Lhe aLria (PrysLowsky eL
al, 996).

1he mosL common causes o AF are lisLed in 8ox . 1hree Lypes have been idenLiied. acuLe,
chronic, and lone/primary.

- AcuLe AF. 1his has an onseL wiLhin 24-48 hours o Lhe causaLive evenL and usually converLs
sponLaneously or in response Lo an anLiarrhyLhmic agenL (cardioversion). lL may occur in
individuals who are clinically normal buL who have a Lemporary change in Lheir condiLion, or
example, iL may occur in people who have consumed excessive alcohol,

93

- Chronic AF - Lhis may be paroxysmal, and is Lhe mosL debiliLaLing orm o AF because o iLs
abrupL onseL. lL may be persisLenL or permanenL and requires inLervenLion by cardioversion Lo
sinus rhyLhm (MarrioLL and Conover, 998),

- Lone or primary AF - Lhis occurs in Lhe absence o any oLher clinical evidence LhaL would
suggesL a primary cardiac disorder.
.4O#& I .BP7$"P&

ALrial ibrillaLion may be asympLomaLic, buL clinical maniesLaLions may include.
** PalpiLaLions
** Dyspnea
** Pulmonary edema
** Signs o cerebrovascular insuiciency

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15

!12<4"O%#4= .;"=R
/1$;"7;B&4"5"OB

Signs and sympLoms o cardiogenic shock relecLs Lhe naLure o Lhe circulaLion o Lhe
paLhophysiology o hearL ailure. HearL damage resulLing in decreased cardiac ouLpuL, which in
Lurn lowers blood pressure arLery Lo Lhe viLal organs.

8lood low Lo Lhe coronary arLeries is reduced, so LhaL Lhe inLake o oxygen Lo Lhe hearL
decreases, which in Lurn increases ischemia and urLher decreased Lhe hearL's abiliLy Lo pump,
evenLually Lhere was a vicious circle.

DysrhyLhmias oLen occur due Lo decreased oxygen Lo Lhe hearL, such as in hearL ailure, Lhe use
o pulmonary arLery caLheLer Lo measure leL venLricular pressure and cardiac ouLpuL is essenLial
Lo assess Lhe severiLy o Lhe problem and evaluaLe Lhe managemenL LhaL has been done.
lncreased leL venLricular end-diasLolic pressure o susLainable
(LvFDP = LeL venLricle Fnd DiasLolic Pressure) indicaLes LhaL Lhe hearL ails Lo uncLion as an
eecLive pump.
.4O#& I .BP7$"P&

AnxieLy, resLlessness, alLered menLal sLaLe due Lo decreased cerebral perusion and
subsequenL hypoxia.
HypoLension due Lo decrease in cardiac ouLpuL.
A rapid, weak, Lhready pulse due Lo decreased circulaLion combined wiLh Lachycardia.
Cool, clammy, and moLLled skin (cuLis marmoraLa), due Lo vasoconsLricLion and
subsequenL hypoperusion o Lhe skin.
DisLended jugular veins due Lo increased jugular venous pressure.
Oliguria (low urine ouLpuL) due Lo insuicienL renal perusion i condiLion persisLs.
94

Rapid and deep respiraLions (hypervenLilaLion) due Lo sympaLheLic nervous sysLem
sLimulaLion and acidosis.
FaLigue due Lo hypervenLilaLion and hypoxia.
AbsenL pulse in LachyarrhyLhmia.
Pulmonary edema, involving luid back-up in Lhe lungs due Lo insuicienL pumping o Lhe
hearL..

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AdminisLer oxygen by
ace mask or arLiicial
airway Lo ensure
adequaLe oxygenaLion
o Lissues.
AdjusL Lhe oxygen
low raLe Lo higher or
lower level, as blood
gas measuremenLs
indicaLe.
AdminisLer an
osmoLic diureLic, such
as manniLol, i ordered
Lo increase renal
blood low and urine
ouLpuL.
Never lex Lhe
patients ballooned
leg aL Lhe hip because
Lhis may displace or
racLure caLheLer.
1o ease emoLional
sLress, allow requenL
resL periods as
possible.
Allow amily
members Lo visiL and
comorL Lhe paLienL as
much as possible.
MoniLor and record
blood pressure, pulse,
respiraLory raLe, and
peripheral pulse every
Lo 5 minuLes unLil
Lhe paLienL sLabilizes.
Record hemodynamic
pressure readings
every 5 minuLes.
MoniLor A8C values,
compleLe blood
counL, and elecLrolyLe
levels.
During Lherapy assess
skin color and
LemperaLure and noLe
any changes. Cold and

95

clammy skin may be a
sign o conLinuing
peripheral vascular
consLricLion,
indicaLing progressive
shock.

!"2"#12B C2$%2B >B71&& 021M$ 6!C>08
/1$;"7;B&4"5"OB

Coronary ArLery 8ypass CraL surgery is Lhe mosL common Lype o cardiac surgery and Lhe mosL
common procedure for older adults. The occluded coronary arteries are bypassed with the clients
own venous or arLerial blood vessel or synLheLic graLs. 1he inLernal arLery (lMA) is Lhe currenL
graL o choice because iL has a 90% paLency raLe aL 2 years aLer Lhe procedure. 1he vessels Lo
be bypassed should have proximal lesions occluding more than 70% of the vessels diameter but
wiLh good disLal runo. 8ypass o less occluded vessels may resulL in poor perusion Lhrough Lhe
graL and early obsLrucLion. 1he procedure is mosL eecLive when good venLricular uncLion
remains and Lhe ejecLion racLion is more LhaL 40% Lo 50%.
.4O#& I .BP7$"P&

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Risk or decreased
cardiac ouLpuL may be
relaLed Lo alLered
myocardial
conLracLiliLy,
secondary Lo
Lemporary acLors,
such as venLricular
wall surgery, recenL
myocardial inarcLion,
response Lo cerLain
medicaLion and drug
inLeracLions.
lndependenL
MoniLor and
documenL Lrends in
hearL raLe and blood
pressure, especially
noLing hyperLension.
Observe or bleeding
rom incisions and
chesL Lube (i in place).
Observe or changes
in usual menLal sLaLus,
orienLaLion, ad body
movemenL or relexes.
Record skin
LemperaLure and color
and quanLiLy and
equaliLy o peripheral
pulses.
Measure and
documenL inLake and
ouLpuL and calculaLe
luid imbalance.
Schedule
uninLerrupLed resL and
sleep periods.
lnspecL or jugular
vein disLenLion.

1achycardia is Lhe
mosL common
response Lo
discomorL,
inadequaLe blood or
luid replacemenL, and
Lhe sLress o surgery.

Helps idenLiy
bleeding
complicaLions LhaL can
reduce circulaLing
volume, organ
perusion, and cardiac
uncLion.
May indicaLe
decreases cerebral
blood low or
oxygenaLion as a
resulL o diminished
cardiac ouLpuL.
Warm. Pink and
sLrong, equal pulses
are general indicaLors
o adequaLe cardiac
ouLpuL.
Useul in deLermining
Lhe paLienL was able
Lo demonsLraLe
display homodynamic
sLabiliLy, such as
sLable blood pressure
and cardiac ouLpuL.
96

CollaboraLive
Review serial FCCs.
AdminisLer
supplemenLal oxygen
as indicaLed.
luid needs or
idenLiying luid
excesses, which can
compromise cardiac
ouLpuL and oxygen
consumpLion.
PrevenLs aLigue or
exhausLion and
excessive
cardiovascular sLress.
May be indicaLive o
acuLe or chronic hearL
ailure.

MosL requenLly done
Lo ollow Lhe progress
in normalizaLion o
elecLrical conducLion
paLLerns and
venLricular uncLion
aLer surgery or Lo
idenLiy complicaLions.
PromoLes maximal
oxygenaLion Lo reduce
cardiac workload and
aid in resolving
myocardial irriLabiliLy
and dysrhyLhmias.

!"#O%&$4H% D%12$ L145@2% 6!DL8
/1$;"7;B&4"5"OB

1he hearL is undamenLally a blood pump. lL pumps blood rom Lhe righL side o Lhe hearL Lo Lhe
lungs Lo pick up oxygen. 1he oxygenaLed blood reLurns Lo Lhe leL side o Lhe hearL. 1he leL side
o Lhe hearL Lhen pumps blood inLo Lhe circulaLory sysLem o blood vessels LhaL carry blood
LhroughouL Lhe body.
1he hearL consisLs o our chambers.
1he Lwo upper chambers are called aLria and Lhe Lwo lower chambers are called
venLricles.
1he righL aLrium and righL venLricle receive blood rom Lhe body Lhrough Lhe veins and
Lhen pump Lhe blood Lo Lhe lungs.
1he leL aLrium and leL venLricle receive blood rom Lhe lungs and pump iL ouL Lhrough
Lhe aorLa inLo Lhe arLeries, which eed all organs and Lissues o Lhe body wiLh oxygenaLed
blood.
8ecause Lhe leL venLricle has Lo pump blood Lo Lhe enLire body, iL is a sLronger pump
Lhan Lhe righL venLricle.
97

HearL ailure sounds righLening because iL sounds like Lhe hearL jusL sLops working. Do noL be
discouraged by Lhe Lerm hearL ailure. HearL ailure means Lhe Lissues o Lhe body are Lemporarily
noL receiving as much blood and oxygen as needed. WiLh advancemenLs in diagnosis and Lherapy
or hearL ailure, paLienLs are eeling beLLer and living longer.
.4O#& I .BP7$"P&

LeL-sided hearL ailure
** Dyspnea on exerLion, paroxysmal nocLurnal dyspnea, or orLhopnea
** MoisL crackles on lung ausculLaLion
** FroLhy, blood-Linged spuLum
** 1achycardia wiLh S3 hearL sound
** Pale, cool exLremiLies
** Peripheral and cenLral cyanosis
** Decreased peripheral pulses and capillary reill Lime longer Lhan 3 seconds
** Decreased urinary ouLpuL (<30 ml/hour)
** Fasy aLigabiliLy
** lnsomnia and resLlessness

RighL-sided hearL ailure
** DependenL piLLing edema (peripheral and sacral)
** WeighL gain
** Nausea and anorexia
** Jugular vein disLenLion (JvD)
** Liver congesLion (e.g. hepaLomegaly), asciLes or weakness

LeL and righL-sided hearL ailure
** ChesL radiographs reveals cardiomegaly
** vascular congesLion o lung ields
** FlecLrocardiogram idenLiies hyperLrophy or myocardial damage
** ArLerial blood gas sLudies reveals decreased parLial pressure o arLerial oxygen and increased
parLial pressure o ** Pulse oximeLer readings may be less Lhan 95%, indicaLing decreased
oxygen saLuraLion.
** MulLilumen pulmonary arLery caLheLer shows elevaLed pulmonary arLery and capillary wedge
pressure in leL-sided hearL ailure and elevaLed cenLral venous pressure in righL-sided hearL
ailure.

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Decreased cardiac
ouLpuL relaLed Lo
alLered myocardial
conLracLiliLy /isoLropic
changes.
lNDFPFNDFN1.
AusculLaLe apical
pulse, assess hearL
raLe, and rhyLhm.
lnspecL skin or
pallor, cyanosis.
MoniLor urine
ouLpuL, noLing
decreasing
ouLpuL and dark or
concenLraLed urine.
NoLe changes in
sensorium.
Provide quieL
environmenL.

1achycardia is usually
presenL even aL resL Lo
compensaLe or
decreased venLricular
conLracLiliLy.
Pallor is an indicaLive
o diminished
peripheral perusion
secondary Lo
inadequaLe cardiac
ouLpuL,
vasoconsLricLion, and
anemia. Cyanosis may
develop in reracLory
hearL ailure.
DependenL areas are
1he paLienL will be
able Lo display viLal
signs wiLhin
accepLable limiLs,
dysrhyLhmias
conLrolled and no
sympLoms o ailure.
98

DFPFNDFN1.
AdminisLer
supplemenLal oxygen
as indicaLed.
AdminisLer diureLics
as prescribed.
oLen blue or moLLled
as venous congesLion
increases.
Urine ouLpuL is
usually decreased
during Lhe day
because o luid shiLs
inLo Lissues buL may
be increased aL nighL
because luid reLurns
Lo circulaLion when
paLienL is recumbenL.
May indicaLe
inadequaLe cerebral
perusion secondary
Lo decreased cardiac
ouLpuL.
Psychological resL
help reduce emoLional
sLress, which can
produce
vasoconsLricLion,
elevaLing 8P and
increasing hearL raLe
or work.
lncreases available
oxygen or myocardial
upLake Lo combaL
eecLs o hypoxia or
ischemia.
DiureLics, in
conjuncLion wiLh
resLricLion o dieLary
sodium and luids,
oLen lead Lo clinical
improvemenL in
paLienLs wiLh hearL
ailure

!"2"#12B C2$%2B A4&%1&% 6!CA8
/1$;"7;B&4"5"OB

"LeL-sided hearL ailure
! ** Dyspnea on exerLion, paroxysmal nocLurnal dyspnea, or orLhopnea
! ** MoisL crackles on lung ausculLaLion
! ** FroLhy, blood-Linged spuLum
! ** 1achycardia wiLh S3 hearL sound
! ** Pale, cool exLremiLies
! ** Peripheral and cenLral cyanosis
! ** Decreased peripheral pulses and capillary reill Lime longer Lhan 3 seconds
99

! ** Decreased urinary ouLpuL (<30 ml/hour)
! ** Fasy aLigabiliLy
! ** lnsomnia and resLlessness

RighL-sided hearL ailure
! ** DependenL piLLing edema (peripheral and sacral)
! ** WeighL gain
! ** Nausea and anorexia
! ** Jugular vein disLenLion (JvD)
! ** Liver congesLion (e.g. hepaLomegaly), asciLes or weakness

LeL and righL-sided hearL ailure
** ChesL radiographs reveals cardiomegaly
** vascular congesLion o lung ields
** FlecLrocardiogram idenLiies hyperLrophy or myocardial damage
** ArLerial blood gas sLudies reveals decreased parLial pressure o arLerial oxygen
and increased parLial pressure o ** Pulse oximeLer readings may be less Lhan
95%, indicaLing decreased oxygen saLuraLion.
** MulLilumen pulmonary arLery caLheLer shows elevaLed pulmonary arLery and
capillary wedge pressure in leL-sided hearL ailure and elevaLed cenLral venous
pressure in righL-sided hearL ailure."
Coronary arLery disease is a chronic process LhaL begins during adolescence and
slowly progresses LhroughouL lie. lndependenL risk acLors include a amily
hisLory o premaLure coronary arLery disease, cigareLLe smoking, diabeLes
melliLus, hyperLension, hyperlipidemia, sedenLary liesLyle, and obesiLy. 1hese risk
acLors acceleraLe or modiy a complex and chronic inlammaLory process LhaL
ulLimaLely maniesLs as ibrous aLheroscleroLic plaque.

1he mosL widely accepLed Lheory o aLherosclerosis sLaLes LhaL Lhe process represenLs an aLLempL
aL healing in response Lo endoLhelial injury. 1he irsL sLep in Lhe aLheroscleroLic process is Lhe
developmenL o aLLy sLreaks, which conLain aLherogenic lipoproLeins and macrophage oam cells.
1hese sLreaks orm beLween Lhe endoLhelium and inLernal elasLic lamina. Over Lime, an
inLermediaLe lesion made up o an exLracellular lipid core and layers o smooLh muscle and
connecLive Lissue maLrix evenLually orms a ibrous cap. 1he edge o Lhe ibrous cap (Lhe shoulder
region) plays a criLical role in Lhe developmenL o acuLe coronary syndromes. 1he shoulder region
is Lhe siLe where mosL plaques lose Lheir inLegriLy, or rupLure. Plaque rupLure exposes Lhe
underlying Lhrombogenic core o lipid and necroLic maLerial Lo circulaLing blood. 1his exposure
resulLs in plaLeleL adherence, aggregaLion, and progressive luminal narrowing, which are
associaLed wiLh acuLe coronary syndromes.

lnlammaLion is emerging as a criLical componenL o aLherosclerosis genesis, acLiviLy, and
poLenLial plaque insLabiliLy. PaLienLs wiLh esLablished coronary arLery disease who possess a
conluence o risk acLors known as Lhe meLabolic syndrome remain aL parLicularly high risk or a
uLure vascular evenL, such as an acuLe myocardial inarcLion or cerebrovascular accidenL.
8iochemical markers such as elevaLed levels o C-reacLive proLein signal a higher likelihood o
vascular inlammaLion and porLend a higher risk o vascular evenL raLes. 1his marker may also
signal more rapidly advancing coronary arLery disease and Lhe need or aggressive prevenLive
measures.
.4O#& I .BP7$"P&

Angina
Nausea and vomiLing
Dizziness and syncope
100

Diaphoresis and cool, clammy skin
Apprehension or a sense o impending doom

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe pain relaLed
Lo Lhe imbalance
beLween myocardial
oxygen supply and
demand.
lneecLive Lissue
perusion relaLed Lo
myocardial ischemia
and decreased
cardiac ouLpuL.
AnxieLy relaLed Lo
pain, perceived
LhreaL o deaLh,
possibly liesLyle
changes, and
diagnosis o CAD.
AcLiviLy inLolerance
relaLed Lo angina,
pulmonary
congesLion, aLigue
and inadequaLe
Lissue perusion.
lneecLive
LherapeuLic regimen
managemenL
relaLed Lo lack o
knowledge relaLed
Lo disease process,
prognosis, and
LreaLmenL
sLraLegies.
Provide care during
an acuLe angina
aLLack
PromoLe pain relie
Prepare Lhe clienL or
possible LreaLmenL
Provide clienL and
amily Leaching Lo
promoLe opLimal
managemenL o Lhe
disease and Lo
minimize anxieLy.
Provide reerrals.
Provide clienL
Leaching and
discharge planning.
Reduce Lhe
probabiliLy o an
episode o angina
plan by balancing
resL and acLiviLy.
Avoid using
medicaLions or any
over-Lhe-counLer
subsLances (dieL
pills, nasal
decongesLanLs)
LhaL can increase
Lhe hearL raLe and
blood pressure
wiLhouL irsL
discussing wiLh a
healLh care
provider.
SLop smoking and
oLher use o
Lobacco, and avoid
second-hand
smoke (because
smoking increase
Lhe hearL raLe,
blood pressure and
blood carbon
monoxide levels)
FaL a dieL low in
saLuraLed aL, high
in iber and i
indicaLed, lower in
calories.
Achieve and
mainLain normal
blood pressure.
Achieve and
mainLain normal
blood glucose
level.
1ake medicaLions,
especially aspirin
and beLa-blockers
as prescribed.
Carry niLroglycerin
aL all Limes, sLaLe
when and how Lo
Reduce pain
101

use iL, idenLiy iLs
side eecLs

DB7%2$%#&4"# 6DE(8
/1$;"7;B&4"5"OB
CenLral Nervous SysLem
S%<@551 ,F5"#O1$1, relays moLor and sensory impulses beLween oLher parLs o Lhe brain and Lhe
spinal cord. ReLicular ormaLion (also in pons, midbrain, and diencephalon) uncLions in
consciousness and arousal. viLal cenLers regulaLe hearLbeaL, breaLhing (LogeLher wiLh pons) and
blood vessel diameLer.

DB7"$;151P@&, conLrols and inLegraLes acLiviLies o Lhe auLonomic nervous sysLem and piLuiLary
gland. RegulaLes emoLional and behavioral paLLerns and circadian rhyLhms. ConLrols body
LemperaLure and regulaLes eaLing and drinking behavior. Helps mainLain Lhe waking sLaLe and
esLablishes paLLerns o sleep. Produces Lhe hormones oxyLocin and anLidiureLic hormone.
Cardiovascular SysLem
>12"2%=%7$"2, pressure-sensiLive sensory recepLors, are locaLed in Lhe aorLa, inLernal caroLid
arLeries, and oLher large arLeries in Lhe neck and chesL. 1hey send impulses Lo Lhe cardiovascular
cenLer in Lhe medulla oblongaLa Lo help regulaLe blood pressure. 1he Lwo mosL imporLanL
barorecepLor relexes are Lhe caroLid sinus relex and Lhe aorLic relex.
!;%P"2%=%7$"2&, sensory recepLors LhaL moniLor Lhe chemical composiLion o blood, are locaLed
close Lo Lhe barorecepLors o Lhe caroLid sinus and Lhe arch o Lhe aorLa in small sLrucLures called
caroLid bodies and aorLic bodies, respecLively. 1hese chemorecepLors deLecL changes in blood
level o O2, CO2, and H-.
Renal SysLem
Renin-AngioLensin-AldosLerone &B&$%P\ ];%# F5""< H"5@P% M155& "2 F5""< M5": $" $;%
R4<#%B& <%=2%1&%&G X@J$1O5"P%2@512 =%55& 4# $;% R4<#%B& &%=2%$% 2%#4# 4#$" $;% F5""<&$2%1P\
3# &%Y@%#=%G 2%#4# 1#< 1#O4"$%#&4# ="#H%2$4#O %#WBP% 6C!)8 1=$ "# $;%42 &@F&$21$%& $"
72"<@=% $;% 1=$4H% ;"2P"#% 1#O4"$%#&4# 33G :;4=; 214&%& F5""< 72%&&@2% 4# $:" :1B&\ L42&$G
1#O4"$%#&4# 33 4& 1 7"$%#$ H1&"="#&$24=$"2^ 4$ 214&%& F5""< 72%&&@2% FB 4#=2%1&4#O &B&$%P4=
H1&=@512 2%&4&$1#=%\ .%="#<G 4$ &$4P@51$%& &%=2%$4"# "M 15<"&$%2"#%G :;4=; 4#=2%1&%&
2%1F&"27$4"# "M &"<4@P 4"#& 1#< :1$%2 FB $;% R4<#%B&\ E;% :1$%2 2%1F&"27$4"# 4#=2%1&%&
$"$15 F5""< H"5@P%G :;4=; 4#=2%1&%& F5""< 72%&&@2%\
C#$4<4@2%$4= ;"2P"#%. ADH is produced by Lhe hypoLhalamus and released rom Lhe posLerior
piLuiLary in response Lo dehydraLion or decreased blood volume. Among oLher acLions, ADH
causes vasoconsLricLion, which increases blood pressure.
C$2415 (1$24@2%$4= /%7$4<%. Released by cells in Lhe aLria o Lhe hearL, ANP lowers blood pressure
by causing vasodilaLion and by promoLing Lhe loss o salL and waLer in Lhe urine, which reduces
blood volume.
.4O#& I .BP7$"P&

Headache,
dizziness,
102

blurred vision,
nausea and vomiLing, and
chesL pain and shorLness o breaLh.
HearL aLLack
HearL ailure
SLroke or LransienL ischemic aLLack (1lA)
Kidney ailure
Fye damage wiLh progressive vision loss
Peripheral arLerial disease causing leg pain wiLh walking (claudicaLion)
OuLpouchings o Lhe aorLa, called aneurysms

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Risk or prone
behavior relaLed Lo
lack o knowledge
abouL Lhe disease
lNDFPFNDFN1.
Deine and sLaLe
Lhe limiLs o desired
8P. Fxplain
hyperLension and
iLs eecL on Lhe
hearL, blood
vessels, kidney, and
brain.
' AssisL Lhe paLienL
in idenLiying
modiiable risk
acLors like dieL
high in sodium,
saLuraLed aLs and
cholesLerol.
' Reinorce Lhe
imporLance o
adhering Lo
LreaLmenL regimen
and keeping ollow
up appoinLmenLs.
' SuggesL requenL
posiLion changes,
leg exercises when
lying down.
' Help paLienL
idenLiy sources o
sodium inLake.
' Fncourage paLienL
Lo decrease or
eliminaLe caeine
like in Lea, coee,
cola and hocolaLes.
' SLress imporLance
o accomplishing
daily resL periods.

COLLA8ORA1lvF.
' Provide
' Provides basis For
undersLanding
elevaLions o 8P,
and clariies
misconcepLions
and also
undersLanding LhaL
high 8P can exisL
wiLhouL sympLom
or even when
eeling well.
' 1hese risk acLors
have been shown
Lo conLribuLe Lo
hyperLension.
' Lack o
cooperaLion is
common reason or
ailure o
anLihyperLensive
Lherapy.
' Decreases
peripheral venous
pooling LhaL may
be poLenLiaLed by
vasodilaLors and
prolonged siLLing
or sLanding.
' 1wo years on
moderaLe low salL
dieL may be
suicienL Lo conLrol
mild hyperLension.
' Caeine is a
cardiac sLimulanL
and may adversely
aecL cardiac
uncLion.
' AlLernaLing resL
and acLiviLy
increases Lolerance
Lhe paLienL was able
Lo verbalize
undersLanding o
Lhe disease process
and LreaLmenL
regimen.
103

inormaLion
Regarding
communiLy
resources, and
supporL paLienLs in
making liesLyle
changes.
Lo acLiviLy
progression.
' CommuniLy
resources like
healLh cenLers
programs and
check ups are
helpul in
conLrolling
hyperLension.

DB7%25474<%P41 6;4O; =;"5%&$%2"58
/1$;"7;B&4"5"OB

Hyperlipidemia is an excess o aLLy subsLances called lipids, largely cholesLerol and Lriglycerides,
in Lhe blood. lL is also called hyperlipoproLeinemia because Lhese aLLy subsLances Lravel in Lhe
blood aLLached Lo proLeins. 1his is Lhe only way LhaL Lhese aLLy subsLances can remain dissolved...
.4O#& I .BP7$"P&

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15

SB"=12<415 3#M12=$4"#
/1$;"7;B&4"5"OB

ln an Ml, inadequaLe coronary blood low rapidly resulLs in myocardial ischemia in Lhe aecLed
area. 1he locaLion and exLenL o Lhe inarcL deLermine Lhe eecLs on cardiac uncLion. lschemia
depresses cardiac uncLion and Lriggers auLonomic nervous sysLem responses LhaL exacerbaLe Lhe
imbalance beLween myocardial oxygen supply and demand. PersisLenL ischemia resulLs in Lissue
necrosis and scar Lissue ormaLion, wiLh permanenL loss o myocardial conLracLiliLy in Lhe aecLed
area. Cardiogenic shock may develop because o inadequaLe CO rom decreased myocardial
conLracLiliLy and pumping capaciLy.
.4O#& I .BP7$"P&

ChesL pain (Lypically, chesL pain is persisLenL and crushing, locaLed subsLernally wiLh
radiaLion Lo Lhe arm, neck, jaw, or back, and unrelieved by resL or niLraLes. A silenL Ml may
produce no pain.)
Diaphoresis and cool, clammy, pale skin
Nausea and vomiLing
Dyspnea wiLh or wiLhouL crackles
PalpiLaLions or syncope
ResLlessness and anxieLy or eeling o impending doom
104

1achycardia or bradycardia
Decreased blood pressure
AlLered S3 hearL sound (indicaLes leL venLricular ailure)
FlecLrocardiogram. Myocardial ischemia causes Lhe 1 wave Lo be larger and inverLed, in
epicardial myocardial ischemia, Lhe S1 segmenL is elevaLed, in endocardial myocardial
ischemia, Lhe S1 segmenL is depressed.
Serum enzyme sLudies reveal elevaLed levels o creaLine phosphokinase, lacLaLe
dehydrogenase and Lroponin.
1he whiLe blood cell counL is elevaLed.

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Pain r/L Lissue
ischemia (coronary
arLery occlusion)
lndependenL.
ObLain ull
descripLion o pain
rom paLienL
including locaLion,
inLensiLy (0
0),duraLion,
characLerisLics
(dull/crushing), and
radiaLion. AssisL
paLienL Lo quanLiy
pain by comparing
iL Lo oLher
experiences
lnsLrucL paLienL Lo
reporL pain
immediaLely.
Provide quieL
environmenL, calm
acLiviLies, and
comorL measures
AssisL/insLrucL in
relaxaLion
Lechniques, e.g.,
deep/slow
breaLhing,
disLracLion
behaviors,
visualizaLion, guided
imagery

CollaboraLive
AdminisLer
supplemenLal
oxygen by means o
nasal cannula or
ace mask, as
indicaLed

AdminisLer
medicaLions as
indicaLed.
AnLianginals, e.g.,
Pain is a subjecLive
experience and
musL be described
by paLienL
Delay in reporLing
pain hinders pain
relie/may require
increased dosage o
medicaLion Lo
achieve relie
Decreases exLernal
sLimuli, which may
aggravaLe anxieLy
and cardiac sLrain,
limiL coping abiliLies
and adjusLmenL Lo
currenL siLuaLion
Helpul in
decreasing
percepLion
o/response Lo pain.
Provides a sense o
having some conLrol
over Lhe siLuaLion,
increase in posiLive
aLLiLude.
lncreases amounL o
oxygen available or
myocardial upLake
and Lhereby may
relieve discomorL
associaLed wiLh
Lissue ischemia
NiLraLes are useul
or pain conLrol by
oronary vasodilaLing
eecLs, which
increase coronary
blood low and
myocardial
perusion.
lmporLanL second-
line agenLs or pain
verbalized
relie/conLrol o
chesL pain wiLhin
appropriaLe Lime
rame or
adminisLered
medicaLions.
105

niLroglycerin,
isosorbide diniLraLe
(lsordil)
8eLa-blockers, e.g.,
aLenolol (1enormin),
propranolol
(lnderal), meLoprolol
(Lopressor)
Analgesics, e.g.,
morphine,
meperidine
(Demerol)
conLrol Lhrough
eecL o blocking
sympaLheLic
sLimulaLion, Lhereby
reducing hearL raLe,
sysLolic 8P, and
myocardial oxygen
demand
AlLhough
inLravenous (lv)
morphine is Lhe sual
drug o choice,
oLher injecLable
narcoLics may be
used in acuLe

/@5P"#12B )<%P1
/1$;"7;B&4"5"OB

Pulmonary edema is a condiLion caused by excess luid in Lhe lungs. 1his luid collecLs in Lhe
numerous air sacs in Lhe lungs, making iL diiculL Lo breaLhe.

ln mosL cases, hearL problems cause pulmonary edema. 8uL luid can accumulaLe or oLher
reasons, including pneumonia, exposure Lo cerLain Loxins and medicaLions, and exercising or
living aL high elevaLions.

Pulmonary edema LhaL develops suddenly (acuLe) is a medical emergency requiring immediaLe
care. AlLhough pulmonary edema can someLimes prove aLal, Lhe ouLlook improves when you
receive prompL LreaLmenL or pulmonary edema along wiLh LreaLmenL or Lhe underlying problem.
1reaLmenL or pulmonary edema varies depending on Lhe cause, buL generally includes
supplemenLal oxygen and medicaLions
.4O#& I .BP7$"P&

.@<<%# 61=@$%8 7@5P"#12B %<%P1 &BP7$"P&

! FxLreme shorLness o breaLh or diiculLy breaLhing (dyspnea) LhaL worsens when
lying down
! A eeling o suocaLing or drowning
! Wheezing or gasping or breaLh
! AnxieLy, resLlessness or a sense o apprehension
! A cough LhaL produces roLhy spuLum LhaL may be Linged wiLh blood
! Fxcessive sweaLing
! Pale skin
! ChesL pain, i pulmonary edema is caused by hearL disease
! A rapid, irregular hearLbeaL (palpiLaLions)

9"#O[$%2P 6=;2"#4=8 7@5P"#12B %<%P1 &BP7$"P&

! Having more shorLness o breaLh Lhan normal when you're physically acLive.
106

! DiiculLy breaLhing wiLh exerLion, oLen when you're lying laL as opposed Lo
siLLing up.
! Wheezing.
! Awakening aL nighL wiLh a breaLhless eeling LhaL may be relieved by siLLing up.
! Rapid weighL gain when pulmonary edema develops as a resulL o congesLive
hearL ailure, a condiLion in which your hearL pumps Loo liLLle blood Lo meeL your
body's needs. 1he weighL gain is rom buildup o luid in your body, especially in
your legs.
! Swelling in your legs and ankles.
! Loss o appeLiLe.
! FaLigue.

D4O;[15$4$@<% 7@5P"#12B %<%P1 &BP7$"P&

! Headache
! lnsomnia
! Fluid reLenLion
! Cough
! ShorLness o breaLh

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# 0"15
lmpaired gas exchange
relaLed Lo increased
pulmonary congesLion
secondary Lo increased leL
venLricular end diasLolic
pressure
Provide supplemenLal
oxygen via mask as
indicaLed.
AdminisLer diureLic agenLs
or nesiriLide Lo reduce
circulaLing volume, which
will improve gas exchange.
MoniLor urine ouLpuL and
elecLrolyLes.
AdminisLer vasodilaLing
agenLs Lo redisLribuLe luid
volumes, which will aciliLaLe
gas exchange.
Morphine sulaLe maybe
ordered Lo promoLe preload
and aLer load reducLion and
Lo decrease anxieLy.
lmpaired gas exchange
relaLed Lo increased
pulmonary congesLion
secondary Lo increased leL
venLricular end diasLolic
pressure

?15H@512 D%12$ A4&%1&%
/1$;"7;B&4"5"OB

valvular hearL disease is characLerized by damage Lo or a deecL in one o Lhe our hearL valves.
Lhe P4$215G 1"2$4=G $24=@&74< "2 7@5P"#12B\

1he miLral and Lricuspid valves conLrol Lhe low o blood beLween Lhe aLria and Lhe venLricles (Lhe
upper and lower chambers o Lhe hearL). 1he pulmonary valve conLrols Lhe low o blood rom Lhe
hearL Lo Lhe lungs, and Lhe aorLic valve governs blood low beLween Lhe hearL and Lhe aorLa, and
Lhereby Lhe blood vessels Lo Lhe resL o Lhe body. 1he miLral and aorLic valves are Lhe ones mosL
requenLly aecLed by valvular hearL disease.

107

Normally uncLioning valves ensure LhaL blood lows wiLh proper orce in Lhe proper direcLion aL
Lhe proper Lime. ln valvular hearL disease, Lhe valves become Loo narrow and hardened (sLenoLic)
Lo open ully, or are unable Lo close compleLely (incompeLenL).

A sLenoLic valve orces blood Lo back up in Lhe adjacenL hearL chamber, while an incompeLenL
valve allows blood Lo leak back inLo Lhe chamber iL previously exiLed. 1o compensaLe or poor
pumping acLion, Lhe hearL muscle enlarges and Lhickens, Lhereby losing elasLiciLy and eiciency.
ln addiLion, in some cases, blood pooling in Lhe chambers o Lhe hearL has a greaLer Lendency Lo
cloL, increasing Lhe risk o sLroke or pulmonary embolism.

1he severiLy o valvular hearL disease varies. ln mild cases Lhere may be no sympLoms, while in
advanced cases, valvular hearL disease may lead Lo congesLive hearL ailure and oLher
complicaLions. 1reaLmenL depends upon Lhe exLenL o Lhe disease.
.4O#& I .BP7$"P&

valve disease sympLoms can occur suddenly, depending upon how quickly Lhe disease develops.
l iL advances slowly, Lhen your hearL may adjusL and you may noL noLice Lhe onseL o any
sympLoms easily. AddiLionally, Lhe severiLy o Lhe sympLoms does noL necessarily correlaLe Lo Lhe
severiLy o Lhe valve disease. 1haL is, you could have no sympLoms aL all, buL have severe valve
disease. Conversely, severe sympLoms could arise rom even a small valve leak.

Many o Lhe sympLoms are similar Lo Lhose associaLed wiLh congesLive hearL ailure, such as
shorLness o breaLh and wheezing aLer limiLed physical exerLion and swelling o Lhe eeL, ankles,
hands or abdomen (edema). OLher sympLoms include.

PalpiLaLions, chesL pain (may be mild).
FaLigue.
Dizziness or ainLing (wiLh aorLic sLenosis).
Fever (wiLh bacLerial endocardiLis).
Rapid weighL gain.

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3#$%2H%#$4"#
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Cardiac OuLpuL, decreased
May be relaLed Lo
AlLered myocardial
conLracLiliLy/isoLropi
c changes
AlLeraLions in raLe,
rhyLhm, elecLrical
conducLion
SLrucLural changes
(e.g., valvular
deecLs, venLricular
aneurysm)

Possibly evidenced by
lncreased hearL raLe
(Lachycardia),
dysrhyLhmias, FCC
changes
Changes in 8P
(hypoLension/hyperL
A usculLaLe
apical
pulse,
assess
hearL raLe,
rhyLhm(doc
umenL
dysrhyLhmi
a i
LelemeLry
available).
PalpaLe
peripheral
pulses.
MoniLor 8P
lnspecL skin
or pallor,
Cyanosis
1achycardia is
usually presenL
(even aL resL)
Lo compensaLe
or decreased
venLricular
conLracLiliLy.
PremaLure
aLrial
conLracLions
(PACs),
paroxysmal
aLrialLachycardi
a (PA1), PvCs,
mulLiocal
aLrial
Lachycardia(MA
1), and aLrial
ibrillaLion (AF)
are
Cardiac ouLpuL
adequaLe or
individual needs.
ComplicaLions
prevenLed/resolv
ed.
OpLimum level o
acLiviLy/uncLioni
ng aLLained.
Disease
process/prognosi
s and LherapeuLic
regimen
undersLood.5.Pla
n in place Lo
meeL needs aLer
discharge.
108

ension)
FxLra hearL sounds
Decreased urine
ouLpuL
Diminished
peripheral pulses
Cool, ashen skin,
diaphoresis
OrLhopnea, crackles,
JvD, liver
engorgemenL,
edema
ChesL pain
commondysrhy
Lhmias
associaLed wiLh
HF, alLhough
oLhers may
also occur.
Decreased
cardiac ouLpuL
may be
relecLed in
diminishedradi
al, popliLeal,
dorsalis pedis,
and posLLibial
pulses. Pulses
may be
leeLing or
irregular Lo
palpaLion, and
pulsus
alLernans(sLron
g beaL
alLernaLing
wiLh weak
beaL) may be
presenL.

)#<"=24#%
A41F%$%& S%554$@& EB7% T
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DiabeLes MelliLus (DM) is a chronic meLabolic disorder caused by an absoluLe or relaLive deiciency o insulin, an anabolic
hormone. 1ype diabeLes melliLus can occur aL any age and is characLerized by Lhe marked and progressive inabiliLy o Lhe
pancreas Lo secreLe insulin because o auLoimmune desLrucLion o Lhe beLa cells. lL commonly occurs in children, wiLh a airly
abrupL onseL, however, newer anLibody LesLs have allowed or Lhe idenLiicaLion o more people wiLh Lhe new-onseL adulL
orm o Lype diabeLes melliLus called laLenL auLoimmune diabeLes o Lhe adulL (LADA). 1he disLinguishing characLerisLic o a
paLienL wiLh Lype diabeLes is LhaL, i his or her insulin is wiLhdrawn, keLosis and evenLually keLoacidosis develop. 1hereore,
Lhese paLienLs are dependenL on exogenous insulin.

1ype diabeLes (ormerly called juvenile-onseL or insulin-dependenL diabeLes), accounLs or 5% Lo 0% o all people wiLh
diabeLes. ln Lype diabeLes, Lhe bodys immune sysLem desLroys Lhe cells LhaL release insulin, evenLually eliminaLing insulin
producLion rom Lhe body. WiLhouL insulin, cells cannoL absorb sugar (glucose), which Lhey need Lo produce energy. a
.4O#& I .BP7$"P&

FxLreme LhirsL
requenL urinaLion
drowsiness
109

leLhargy
increased appeLiLe
sudden weighL loss or no reason
sudden vision changes
sugar in urine
keLones in urine
heavy or labored breaLhing
unconsciousness

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Fluid volume deicienL
relaLed Lo osmoLic
dieresis rom
hyperglycemia
lndependenL.
MoniLor orLhosLaLic
blood pressure
changes.

MoniLor respiraLory
paLLern like
Kussmauls
respiraLions and
aceLone breaLh.

MoniLor LemperaLure,
skin color and
moisLure.

Assess peripheral
pulses, capillary reill,
skin Lurgor, and
mucous membrane.

MoniLor inpuL and
ouLpuL. NoLe urine
speciic graviLy

Weigh daily.

MainLain luid inLake
aL leasL 2500 ml / day
wiLhin cardiac
Lolerance wiLh oral

Hypovolemia may be
maniesLed by
hypoLension and
Lachycardia.

Lungs remove
carbonic acid Lhrough
respiraLions,
producing a
compensaLory
respiraLory alkalosis
or keLoacidosis.

Fever, chills, and
diaphoresis are
common wiLh
inecLious process,
ever wiLh lushed, dry
skin may relecL
dehydraLion.

lndicaLors o level o
dehydraLion,
adequacy o
circulaLing volume.

Provides ongoing
esLimaLe o volume
replacemenL needs,
kidney uncLion, and
eecLiveness o
Lherapy.

Provides Lhe besL
assessmenL o currenL
luid sLaLus and
adequacy o luid
replacemenL.

MainLains hydraLion
and circulaLing
volume.

Lhe paLienL will able Lo
demonsLraLe
adequaLe hydraLion
evidenced by sLable
viLal signs, palpable
peri pheral pulses,
good skin Lurgor and
capillary reill.
110

inLake is resumed.

PromoLe comorLable
environmenL. Cover
paLienL wiLh lighL
sheeLs.

CollaboraLive.
AdminisLer luids as
indicaLed.

Avoids overheaLing,
which could promoLe
urLher luid loss.

1ype and amounL o
luid depend on Lhe
degree o deiciL and
individual paLienL
response.

A41F%$%& S%554$@& EB7% U
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1ype 2 diabeLes melliLus occurs when Lhe pancreas produces insuicienL amounLs o Lhe
hormone insulin and/or the bodys tissues become resistant to normal or even high levels
o insulin. 1his causes high blood glucose (sugar) levels, which can lead Lo a number o
complicaLions i unLreaLed.

1ype 2 diabeLes is a chronic medical condiLion LhaL requires regular moniLoring and
LreaLmenL. 1reaLmenL, which includes liesLyle adjusLmenLs, sel-care measures, and
someLimes medicaLions, can conLrol blood glucose levels in Lhe near-normal range and
minimize Lhe risk o diabeLes-relaLed complicaLions.

1ype 2 diabeLes accounLs or around 85% o all people wiLh diabeLes.
.4O#& I .BP7$"P&

Any sympLoms o DM 1ype
recurring or hard-Lo heal skin, gum or urinary LracL inecLions
drowsiness
Lingling o hands and eeL
iLching o skin and geniLals

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Risk or inecLion
relaLed Lo high
glucose levels,
decreased leukocyLe
uncLion.
lndependenL.
Observe or signs o
inecLion and
inlammaLion.

PromoLe good hand
washing by nurse and

PaLienL may be
admiLLed wiLh
inecLion, which could
have precipiLaLed Lhe
keLoacidoLic sLaLe, or
may develop a
nosocomial inecLion.

Reduces Lhe risk o
cross conLaminaLion
Lhe paLienL will able Lo
idenLiy inLervenLion
Lo prevenL or reduce
risk o inecLion.
111

paLienL.

MainLain asepLic
Lechnique or lv
inserLion procedure,
adminisLraLion o
medicaLions, and
providing
mainLenance and siLe
care. RoLaLe lv siLes as
indicaLed.

Provide caLheLer or
perinea care. 1each
Lhe emale paLienL Lo
clean rom ronL Lo
back aLer eliminaLion.

Provide conscienLious
skin care, genLly areas.
Keep Lhe skin dry,
linens dry and wrinkle
ree.

Place in semi
fowlers position.

Fncourage adequaLe
dieLary and luid
inLake o 3000 ml per
day.

CollaboraLive.
ObLain specimen or
culLure and
sensiLiviLies as
indicaLed.

High glucose in Lhe
blood creaLes an
excellenL medium or
bacLerial growLh.

Minimizes Lhe risk or
inecLion.

Peripheral circulaLion
may be impaired,
placing paLienL aL
increased risk or skin
irriLaLion or
breakdown and
inecLion.

FaciliLaLes lung
expansion and
reduces risk o
aspiraLion.

Decrease
suscepLibiliLy Lo
inecLion.

ldenLiies organisms
so LhaL mosL
appropriaLe drug
Lherapy can be
insLiLuLed.

DB7%2O5B=%P41
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Hyperglycemic hyperosmolar nonkeLoLic syndrome porLraiL o insulin deiciency, and excessive
hormone glucagon. Decrease insulin resisLance causes glucose movemenL inLo cells, resulLing in
Lhe accumulaLion o glucose in plasma. lncrease in Lhe hormone glucagon which causes
glycogenolisis can increase plasma glucose levels. lncreased glucose levels lead Lo hyperosmolar.
112

Serum hyperosmolar condiLions would aLLracL inLracellular luid inLo Lhe inLra vascular, which can
lower Lhe inLracellular luid volume. l Lhe clienL does noL eel Lhe sensaLion o LhirsL will cause
dehydraLion.

High levels o serum glucose are excreLed in Lhe kidneys, causing glycosuria which can lead Lo
excessive osmoLic diuresis (polyuria). 1he impacL o polyuria would cause excessive luid loss, and
ollowed Lhe loss o poLassium, sodium and phosphaLe.
Due Lo lack o insulin Lhe glucose can noL be converLed inLo glycogen Lo increase blood sugar
levels and hyperglycemia occurs. 1he kidneys can noL resisL hyperglycemia, because Lhe Lhreshold
or blood sugar was 80 mg% in case o hyperglycemia so LhaL Lhe kidneys can noL ilLer ouL and
absorb Lhe amounL o glucose in Lhe blood. WiLh respecL Lo Lhe naLure o Lhe sugar which
absorbs all Lhe excess waLer removed wiLh Lhe urine is called glucosuria. SimulLaneously Lhe sLaLe
o glucosuria Lhen some waLer is losL in Lhe urine is called polyuria. Polyuria resulLing in inLra
cellular dehydraLion, Lhis will sLimulaLe Lhe LhirsL cenLer so LhaL paLienLs will eel consLanLly
hungry, so Lhe paLienL will conLinue Lo drink Lhe so-called polidipsi. Decreased renal perusion
resulLing in increased secreLion o Lhe hormone over again and hyperglycemic hyperosmolar
arise.

1he lack o insulin producLion will cause a decrease in glucose LransporL inLo Lhe cells so Lhe cells
are sLarved o ood and sLores carbohydraLes, aLs and proLeins Lo be depleLed. 8ecause iL is used
Lo burn Lhe body, Lhen Lhe clienL will eel hungry eaL, causing many so-called poliphagia.

Failure Lo resLore Lhe body's homeosLasis siLuaLion will lead Lo hyperglycemia, hyperosmolar,
excessive osmoLic diuresis and dehydraLion. CenLral nervous sysLem dysuncLion due Lo LransporL
oxygen Lo Lhe brain disorder and Lends Lo be a comma.
HemoconcenLraLion increases Lhe blood viscosiLy which may lead Lo Lhe ormaLion o blood cloLs,
Lhromboembolism, cerebral inarcLion, hearL.
.4O#& I .BP7$"P&

Frequency in urinaLion
1hirsL
Dry mouLh
UrinaLion aL nighL
Drowsiness or aLigue
Loss o weighL
lncrease in appeLiLe
Slow healing o wounds
8lurriness in vision
Dry and iLchy skin
Rapid loss in weighL
Unconsciousness
lncreased conusion or drowsiness
8reaLhing diiculLy
Dizziness when you sLand up
Coma

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Risk or lnecLion
Risk or DisLurbed
Sensory PercepLion
Powerlessness
lmbalanced NuLriLion
Observe or signs o
inecLion and
inlammaLion, e.g.,
ever, lushed
appearance, wound
PaLienL may be
admiLLed wiLh
inecLion, which could
have precipiLaLed Lhe
keLoacidoLic sLaLe, or
HomeosLasis
achieved.

CausaLive/precipiLaLing
acLors
113

Less 1han 8ody
RequiremenLs
DeicienL Fluid
volume
FaLigue
drainage, purulenL
spuLum, cloudy urine

PromoLe good
handwashing by sLa
and paLienL.

MainLain asepLic
Lechnique or lv
inserLion procedure,
adminisLraLion o
medicaLions, and
providing
mainLenance/siLe
care. RoLaLe lv siLes as
indicaLed.

Provide
caLheLer/perineal care.
1each Lhe emale
paLienL Lo clean rom
ronL Lo back aLer
eliminaLion

MoniLor viLal signs
and menLal sLaLus.

Address paLienL by
name, reorienL as
needed Lo place,
person, and Lime. Cive
shorL explanaLions,
speaking slowly and
enunciaLing clearly.

Schedule nursing
Lime Lo provide or
uninLerrupLed resL
periods.

Fncourage
paLienL/SO Lo express
eelings abouL
hospiLalizaLion and
disease in general.

may develop a
nosocomial inecLion.

Reduces risk o cross-
conLaminaLion.

High glucose in Lhe
blood creaLes an
excellenL medium or
bacLerial growLh

Minimizes risk o U1l.
ComaLose paLienL
may be aL parLicular
risk i urinary
reLenLion occurred
beore hospiLalizaLion.
NoLe. Flderly emale
diabeLic paLienLs are
especially prone Lo
urinary LracL/vaginal
yeasL inecLions.

Provides a baseline
rom which Lo
compare abnormal
indings, e.g., ever
may aecL menLaLion.

Decreases conusion
and helps mainLain
conLacL wiLh realiLy.

PromoLes resLul
sleep, reduces aLigue,
and may improve
cogniLion.

ldenLiies concerns
and aciliLaLes
problem solving.

RecogniLion LhaL
correcLed/conLrolled.
ComplicaLions
prevenLed/minimized.
Disease
process/prognosis,
sel-care needs, and
LherapeuLic regimen
undersLood.
114

Acknowledge
normaliLy o eelings.

Assess how paLienL
has handled problems
in Lhe pasL. ldenLiy
locus o conLrol.
reacLions are normal
can help paLienL
problem-solve and
seek help as needed.
DiabeLic conLrol is a
ull-Lime job LhaL
serves as a consLanL
reminder o boLh
presence o disease
and Lhreat to patients
healLh/lie.

Knowledge o
individuals style helps
deLermine needs or
LreaLmenL goals.
PaLienL whose locus
o conLrol is inLernal
usually looks aL ways
Lo gain conLrol over
own LreaLmenL
program. PaLienL who
operaLes wiLh an
exLernal locus o
conLrol wanLs Lo be
cared or by oLhers
and may projecL
blame or
circumsLances onLo
exLernal acLors.

DB7"O5B=%P41
/1$;"7;B&4"5"OB

Hypoglycemia, also called low blood glucose or low blood sugar, occurs when blood glucose
drops below normal levels. Clucose, an imporLanL source o energy or Lhe body, comes rom
ood. CarbohydraLes are Lhe main dieLary source o glucose. Rice, poLaLoes, bread, LorLillas, cereal,
milk, ruiL, and sweeLs are all carbohydraLe-rich oods.

ALer a meal, glucose is absorbed inLo Lhe bloodsLream and carried Lo Lhe body's cells. lnsulin, a
hormone made by Lhe pancreas, helps Lhe cells use glucose or energy. l a person Lakes in more
glucose Lhan Lhe body needs aL Lhe Lime, Lhe body sLores Lhe exLra glucose in Lhe liver and
muscles in a orm called glycogen. 1he body can use glycogen or energy beLween meals. FxLra
glucose can also be changed Lo aL and sLored in aL cells. FaL can also be used or energy.

When blood glucose begins Lo all, glucagon-anoLher hormone made by Lhe pancreas-signals Lhe
liver Lo break down glycogen and release glucose inLo Lhe bloodsLream. 8lood glucose will Lhen
rise Loward a normal level. ln some people wiLh diabeLes, Lhis glucagon response Lo
hypoglycemia is impaired and oLher hormones such as epinephrine, also called adrenaline, may
raise Lhe blood glucose level. 8uL wiLh diabeLes LreaLed wiLh insulin or pills LhaL increase insulin
producLion, glucose levels can'L easily reLurn Lo Lhe normal range.
115


Hypoglycemia can happen suddenly. lL is usually mild and can be LreaLed quickly and easily by
eaLing or drinking a small amounL o glucose-rich ood. l leL unLreaLed, hypoglycemia can geL
worse and cause conusion, clumsiness, or ainLing. Severe hypoglycemia can lead Lo seizures,
coma, and even deaLh.

ln adulLs and children older Lhan 0 years, hypoglycemia is uncommon excepL as a side eecL o
diabeLes LreaLmenL. Hypoglycemia can also resulL, however, rom oLher medicaLions or diseases,
hormone or enzyme deiciencies, or Lumors.
.4O#& I .BP7$"P&

Hypoglycemia causes sympLoms such as
hunger
shakiness
nervousness
sweaLing
dizziness or lighL-headedness
sleepiness
conusion
diiculLy speaking
anxieLy
weakness

Hypoglycemia can also happen during sleep. Some signs o hypoglycemia during sleep include
crying ouL or having nighLmares
inding pajamas or sheeLs damp rom perspiraLion
eeling Lired, irriLable, or conused aLer waking up

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
sweaLing
dizziness or lighL-
headedness
sleepiness

Fnsure a paLenL
airway.
AdminisLer liquids
LhaL conLain glucose.
l Lhe paLienL is alerL,
give him juice wiLh
sugar added, ollowed
by proLein and
complex
carbohydraLes Lo
prevenL hypoglycemia
rom recurring Lhe
nexL hour.
l Lhe paLienL has a
decreased level o
consciousness,
esLablish a large-bore
l.v.line and adminisLer
50 ml o 50% dexLrose
as a bolus. l he
doesnt regain
consciousness in 5
minuLes, repeaL Lhe
ALer deLermining
which acLors
conLribuLed Lo Lhis
incidenL o
hypoglycemia help
Lhe paLienL
undersLand how Lo
prevenL iLs recurrence.
1each Lhe paLienL Lo
recognize early signs
and sympLoms o
hypoglycemia.
1each Lhe paLienL
how Lo use a
glucomeLer aL home i
a chronic condiLion
may cause
hypoglycemia Lo
recur.
Fmphasize Lhe
imporLance o having
glucose LableLs, hard
candy, or oLher ood
1he paLienL will
mainLain airway
paLency and adequaLe
circulaLion.
1he paLienL will
display no change in
neurologic sLaLus.
1he paLienL will
demonsLraLe a blood
glucose level beLween
60 and 50mg/dl.
116

bolus o dexLrose.
If I.V. access cant be
esLablished,
adminisLer glucose gel
under the patients
Longue or give
glucose-rich liquids by
nasogasLric Lube
insLead o providing
Lhe lM dexLrose
soluLion.
l none o Lhe above
inLervenLions is
possible, adminisLer
glucagon or
epinephrine l.M.
RepeaL Lhe
measuremenL o Lhe
blood glucose level in
hour.
MoniLor Lhe patients
hearL raLe, cardiac
rhyLhm and blood
pressure.
AdminisLer a normal
saline bolus i
hypoLension occurs.
Replace elecLrolyLes
based on laboraLory
LesL resulLs.
Help deLermine Lhe
cause o
hypoglycemia by
inLerviewing Lhe
paLienL and reviewing
his hisLory. 8e sure Lo
inquire abouL such
common causes as
poor ood inLake,
medicaLion changes,
alcohol or oLher
recreaLional drug use,
hepaLic or renal
impairmenL LhaL
prevenLs
gluconeogenesis,
pancreaLic Lumor or
an endocrine disorder,
including impaired
piLuiLary, Lhyroid,
paraLhyroid, or
adrenal glands.
8e aware LhaL
posLprandial
hypoglycemia may
conLaining simple
sugars readily
available.
117

occur wiLh many
condiLions, especially
aLer gasLric bypass
surgery.

A41F%$4= K%$"#% C=4<"&4& 6AKC8
/1$;"7;B&4"5"OB

DiabeLic keLoacidosis is a serious complicaLion o diabeLes LhaL occurs when your body produces
very high levels o blood acids called keLones.

DiabeLic keLoacidosis develops when you have Loo liLLle insulin in your body. lnsulin normally
plays a key role in helping sugar (glucose) a major source o energy or your muscles and oLher
Lissues enLer your cells. WiLhouL enough insulin, your body begins Lo breaks down aL as an
alLernaLe uel. ln Lurn, Lhis process produces Loxic acids in Lhe bloodsLream called keLones,
evenLually leading Lo diabeLic keLoacidosis i unLreaLed.

.4O#& I .BP7$"P&

DeicienL luid volume (speciy)
lmbalanced nuLriLion less Lhan body requiremenLs
Risk or inecLion (sepsis)
Risk or disLurbed sensory percepLion (speciy)
FaLigue
Powerlessness
Knowledge deicienL (learning need) regarding condiLion, prognosis, LreaLmenL regimen,
sel-care, and discharge needs

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# N +1$4"#15% 0"15
sleep/resL
disLurbances
Weakness,
aLigue,
diiculLy
walking/moving
Muscle cramps,
decreased muscle
sLrengLh
ResLore luid/elecLrolyLe and acid-base
balance.
CorrecL/reverse meLabolic
abnormaliLies.
ldenLiy/assisL wiLh managemenL o
underlying cause/disease process.
PrevenL complicaLions.
Provide inormaLion abouL disease
process/prognosis, sel-care, and
LreaLmenL needs
HomeosLasis achieved.
CausaLive/precipiLaLing
acLors
correcLed/conLrolled.
ComplicaLions
Disease
process/prognosis, sel-
care needs, and
LherapeuLic regimen
undersLood.
needs aLer discharge

0155F51<<%2G 94H%2 I C77%#<4J
118

C77%#<4=4$4&
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AppendiciLis is usually caused by blockage o Lhe lumen o Lhe appendix. ObsLrucLion
causes Lhe mucus produced by mucous appendix suered dam. 1he longer Lhe mucus is
more and more, buL Lhe elasLic wall o Lhe appendix has limiLaLions LhaL lead Lo increased
inLra-luminal pressure. 1hese pressures will impede Lhe low o lymph resulLing in
mucosal edema and ulceraLion. AL LhaL Lime Lhere was marked ocal acuLe appendiciLis
wiLh epigasLric pain.
When mucus secreLion conLinues, Lhe pressure will conLinue Lo increase. 1his will cause
venous obsLrucLion, increased edema and bacLeria will peneLraLe Lhe wall so LhaL Lhe
inlammaLion o Lhe periLoneum arising widespread and can cause pain in Lhe lower righL
abdomen is called acuLe suppuraLive appendiciLis.
l Lhe low is disrupLed arLerial wall inarcLion will occur ollowed by gangrene appendix.
1his sLage is called appendiciLis ganggrenosa. l Lhe appendix wall ragile, Lhere will be a
peroraLion, called peroraLed appendiciLis.
When Lhe process is slow, Lhe omenLum and Lhe adjacenL bowel will move Loward Lhe
appendix Lo appear appendicularis inilLraLes.
ln children because iL shorLens Lhe omenLum and appendix is longer, Lhinner walls. 1he
siLuaLion is coupled wiLh Lhe immune sysLem LhaL is sLill less easy Lo occur peroraLion,
whereas in Lhe elderly prone Lo occur because Lhere is blood vessel disorders..
.4O#& I .BP7$"P&

Aching pain LhaL begins around your navel and oLen shiLs Lo your lower righL abdomen
Pain LhaL becomes sharper over several hours
1enderness LhaL occurs when you apply pressure Lo your lower righL abdomen
Sharp pain in your lower righL abdomen LhaL occurs when Lhe area is pressed on and Lhen
Lhe pressure is quickly released (rebound Lenderness)
Pain LhaL worsens i you cough, walk or make oLher jarring movemenLs
Nausea
vomiLing
Loss o appeLiLe
Low-grade ever
ConsLipaLion
lnabiliLy Lo pass gas
Diarrhea
Abdominal swelling

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
AcuLe pain relaLed Lo
inlammaLion o
Lissues.
lndependenL.
Investigate pain
reporLs, noLing
locaLion, duraLion,
inLensiLy (0-0 scale),
and characLerisLics
(dull, sharp, consLanL).
Maintain semi
fowlers position.
Move patient slowly
Changes in location
or inLensiLy are noL
uncommon buL may
relecL developing
complicaLions.
Reduces abdominal
disLenLion, Lhereby
Reduces Lension.
Reduces muscle
Lension or guarding,
ALer nursing
inLervenLions Lhe
paLienL will
demonsLraLe use o
relaxaLion
skills, oLher meLhods
Lo promoLe comorL.
119

and deliberaLely.
Provide comfort
measure like back
rubs, deep breaLhing.
lnsLrucL in relaxaLion
or
visualizaLion
exercises. Provide
divisional acLiviLies.
Provide frequent
oral care. Remove
noxious
environmenLal
sLimuli.

CollaboraLive.
Administer
analgesics as
prescribed.
which may help
minimize pain o
movemenL.
Promotes relaxation
and may enhance
patients coping
abiliLies by reocusing
aLLenLion.
Reduces nausea and
vomiLing, which can
increase inLra-
abdominal pressure or
pain.
Reduce metabolic
raLe and aids in pain
relie and PromoLes
healing.

!;"5%=B&$4$4&

/1$;"7;B&4"5"OB
C=@$% !;"5%=B&$4$4& /1$;"7;B&4"5"OB
One o Lhe mosL common Lypes o cholecysLiLis is acuLe cholecysLiLis. 1his is when
Lhe onseL o inlammaLion o Lhe gallbladder is sudden and inLense, wiLh asL
progression o Lhe disease. More oLen Lhan noL, Lhe inlammaLion is caused due
Lo obsLrucLion o Lhe bile ducL, which is known as calculous cholecysLiLis, as Lhey
are caused due Lo gallsLones, or choleliLhiasis. 1here are oLher causes o acuLe
cholecysLiLis as well, such as ischemia, chemical poisoning, moLiliLy disorders,
inecLions wiLh proLozoa, collagen disease, allergic reacLions, eLc. 1he obsLrucLion
resulLs in gallbladder disLension, which resulLs in edema o Lhe cells lining Lhe
gallbladder. 1his in Lurn resulLs in ischemia, which spurs on inlammaLory
mediaLors, especially prosLaglandins, which urLher aggravaLes Lhe inlammaLion.
1he lining wall o Lhe gallbladder may evenLually undergo necrosis and gangrene,
which is known as gangrenous cholecysLiLis.

1he inlammaLion o Lhe gallbladder wall may be bacLerial in naLure, or may even
be sLerile in some cases. ln cases where iL is bacLerial, Lhere is normally super-
inecLion wiLh gas orming organisms, which may lead Lo ormaLion o gas in Lhe
wall or Lhe lumen o Lhe gallbladder, which leads Lo a condiLion known as
emphysemaLous cholecysLiLis. However, iL is normally seen LhaL bacLerial
conLaminaLion is secondary Lo biliary obsLrucLion, because in Lhe early sLages o
gallbladder wall inlammaLion, Lhe bile is seen Lo be sLerile.
C=15=@5"@& !;"5%=B&$4$4& /1$;"7;B&4"5"OB
1he paLhophysiology o acalculous cholecysLiLis is noL very well undersLood. lL is
said LhaL Lhe causaLive acLors may be many and inLerlinked. FuncLional cysLic
ducL obsLrucLion is normally presenL and is relaLed Lo biliary sludge or even bile
inspissaLion. 1his inspissaLion is caused due Lo dehydraLion, which leads Lo an
120

increase in Lhe viscosiLy o bile, Lhus, causing bile sLasis. 1his may be spurred on
by Lrauma or due Lo sysLemic disease or disorder. OLher reasons include burns,
mulLisysLem organ ailure and parenLeral nuLriLion. ln some cases, paLienLs LhaL
have sepsis may have direcL gallbladder wall lining inlammaLion. 1his is because
one needs Lo undersLand LhaL bile is an exLremely avorable growLh medium or
bacLeria and inecLions in Lhis space develop rapidly, especially when Lhey are
spurred on by a sysLemic inecLion. Acalculous cholecysLiLis may occur wiLh or
wiLhouL localized or generalized Lissue ischemia and obsLrucLion.

AL Limes, Lhere may be sponLaneous resoluLion o acuLe cholecysLiLis which may
occur wiLhin ive Lo seven days aLer Lhe onseL o sympLoms. 1his is especially
seen in cases o acalculous cholecysLiLis, due Lo reesLablishmenL o cysLic ducL
paLency.

CholecysLiLis sympLoms are quiLe obvious, which greaLly helps in Lhe diagnosis.
1he common Lriad helps in diagnosing cholecysLiLis - jaundice, upper righL
quadranL pain and ever. CholecysLiLis dieL helps Lo considerably miLigaLe Lhese
sympLoms. 1o properly diagnose and undersLand how Lhis condiLion progresses,
a person needs Lo undersLand cholecysLiLis paLhophysiology. 1his helps Lo
undersLand Lhe prognosis and severiLy o Lhis disease.

.4O#& I .BP7$"P&

Nausea or vomiLing.
1enderness in Lhe righL abdomen.
Fever.
Pain LhaL geLs worse during a deep breaLh.
Pain or more Lhan 6 hours, parLicularly aLer meals.

(@2&4#O C&&%&&P%#$ (@2&4#O
3#$%2H%#$4"#
+1$4"#15% 0"15
May be relaLed Lo
8iological injuring
agenLs.
obsLrucLion/ducLal
spasm, inlammaLory
process, Lissue
ischemia/necrosis
Possibly evidenced by
ReporLs o pain,
biliary colic (waves o
pain)
Facial mask o pain,
guarding behavior
AuLonomic responses
(changes in 8P, pulse)
Sel-ocusing,
narrowed ocus
Relieve pain and
promoLe resL.
MainLain luid and
elecLrolyLe balance
prevenL
complicaLions
provide inormaLion
abouL disease
process, prognosis
and LreaLmenL needs.
AssisLs in
dierenLiaLing cause o
pain, and provides
inormaLion abouL
disease
progression/resoluLion,
developmenL o
complicaLions, and
eecLiveness o
inLervenLions.
Severe pain noL
relieved by rouLine
measures may indicaLe
developing
complicaLions/need or
urLher inLervenLion.
8ed resL in low-
Fowler\u209s
posiLion reduces inLra-
abdominal pressure,
however, paLienL will
naLurally assume leasL
Pain Relieved
HomeosLasis
achieved
ComplicaLions
prevenLed and
minimized
Disease process,
prognosis and
LherapeuLic regimen
undersLood
need aLer discharge.
121

painul posiLion.
Reduces
irriLaLion/dryness o
Lhe skin and iLching
sensaLion.
Cool surroundings aid
in minimizing dermal
discomorL.
PromoLes resL,
redirecLs aLLenLion,
may enhance coping.
Helpul in alleviaLing
anxieLy and reocusing
aLLenLion, which can
relieve pain

D%71$4$4&

/1$;"7;B&4"5"OB

lnlammaLion LhaL spreads Lo Lhe liver (hepaLiLis) can be caused by inecLion by viruses
and Loxic reacLions Lo drugs and chemicals. 8asic uncLional uniL o Lhe liver called lobul
and Lhe uniL is unique because iL has iLs own blood supply.
Along wiLh Lhe developmenL o inlammaLion in Lhe liver, Lhe normal paLLern in Lhe
hepaLic impaired. DisrupLion o Lhe normal blood supply Lo Lhe cells causes hepaLic
necrosis and damage Lo liver cells. ALer passing his Lime, Lhe liver cells become damaged
eliminaLed rom Lhe body by Lhe immune sysLem response and replaced by new cells o a
healLhy liver. 1hereore, mosL clienLs who have hepaLiLis recovered wiLh normal liver
uncLion.
lnlammaLion o Lhe liver due Lo viral invasion would lead Lo an increase in body
LemperaLure and sLreLching Lhe liver capsule which lead Lo eelings o discomorL in Lhe
upper righL abdominal quadranL. 1his is maniesLed by Lhe presence o nausea and pain
in Lhe guL.
OnseL o jaundice because Lhe liver parenchymal cell damage. AlLhough Lhe number
billirubin LhaL has noL undergone conjugaLion, inLo Lhe liver remained normal, buL due Lo
liver cell damage and inLra-hepaLic bile ducLuli, Lhen Lhere is Lhe diiculLy o LransporLing
billirubin in Lhe liver.
1here was also a diiculLy in Lerms o conjugaLion. As a resulL, billirubin imperecL
Lhrough Lhe ducLus hepaLicus issued, due Lo reLenLion (due Lo cell damage excreLion) and
regurgiLaLion in Lhe ducLuli, bile has noL undergone conjugaLion (indirecL bilirubin), or
already experiencing Lhe conjugaLion o bilirubin (direcL bilirubin). So here jaundice
arising mainly due Lo diiculLies in LransporL, conjugaLion and excreLion o bilirubin.
Feces conLain liLLle sLercobilin Lhereore pale sLools (abolis). 8ecause waLer-soluble
conjugaLed bilirubin, Lhe bilirubin can be excreLed inLo Lhe urine, causing urinary bilirubin
and dark colored urine. FlevaLed levels o bilirubin can be accompanied by an increase in
Lhe conjugaLed bile salLs in Lhe blood which will cause iLching in jaundice.
.4O#& I .BP7$"P&

122

1he iniLial phase o hepaLiLis is called Lhe acuLe phase. 1he sympLoms are like a mild lu, and may
include.
Diarrhea
FaLigue
Loss o appeLiLe
Mild ever
Muscle or joinL aches
Nausea
SlighL abdominal pain
vomiLing
WeighL loss
1he acuLe phase is noL usually dangerous, unless iL develops inLo Lhe ulminanL or rapidly
progressing orm, which can lead Lo deaLh.

As Lhe paLienL geLs worse, Lhese sympLoms may ollow.
CirculaLion problems (only Loxic/drug-induced hepaLiLis)
Dark urine
Dizziness (only Loxic/drug-induced hepaLiLis)
Drowsiness (only Loxic/drug-induced hepaLiLis)
Fnlarged spleen (only alcoholic hepaLiLis)
Headache (only Loxic/drug-induced hepaLiLis)
Hives
lLchy skin
LighL colored eces, Lhe eces may conLain pus
ellow skin, whiLes o eyes, Longue (jaundice)
(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Fluid volume, risk or
deicienL relaLed Lo
excessive losses
Lhrough vomiLing and
diarrhea.
lndependenL.
MoniLor inLake and
ouLpuL, compare wiLh
periodic weighL. NoLe
enLeric losses such as
vomiLing and
diarrhea.
Assess viLal signs,
peripheral pulses,
capillary reill, skin
Lurgor, and mucous
membranes.
Check or asciLes or
edema ormaLion.
Measure abdominal
girLh as indicaLed.
Use small-gauge
needles or injecLions,
applying pressure or
longer Lhan usual
aLer venipuncLure.
Have paLienL use
coLLon or sponge
Provides inormaLion
abouL replacemenL
need or eecLs o
Lherapy.
lndicaLion o
circulaLing volume or
perusion.
Useul in moniLoring
progression/resoluLion
o luid shiLs.
Reduces possibiliLy o
bleeding inLo Lissues.
Avoids Lrauma and
bleeding o gums.
ProLhrombin levels
are reduced and
coagulaLion Limes
prolonged when
viLamin K
absorpLion is alLered
in Cl LracL and
synLhesis o
proLhrombin is
Pain Relieved
HomeosLasis
achieved
ComplicaLions
prevenLed and
minimized
Disease process,
prognosis and
LherapeuLic regimen
undersLood
need aLer discharge.
123

swabs and mouLh
wash insLead o LooLh
brush.
Observe or signs o
bleeding such as
hemaLuria,
ecchymosis, oozing
rom gums.

CollaboraLive.
MoniLor laboraLory
values.
AdminisLer
anLidiarrheal agenLs.
Provide lv luids and
elecLrolyLes.
AdminisLer viLamin K
as indicaLed.
decreased in
aecLed liver.
RelecLs hydraLion
and idenLiies sodium
reLenLion or proLein
deiciLs, which may
lead Lo edema
ormaLion.
Reduces luid or
elecLrolyLe loss rom
Cl LracL.
Provides, luid and
elecLrolyLe acuLe Loxic
shock sLaLe.
1o increase cloLLing
acLor and decrease
bleeding.

/1#=2%1$4$4&
/1$;"7;B&4"5"OB

PancreaLiLis is an inlammaLory disease, which varies in severiLy rom mild Lo severe.
FacLors deLermining Lhe severiLy o pancreaLiLis are noL known. lL is generally believed LhaL Lhe
earliesL evenLs in Lhe evoluLion o acuLe pancreaLiLis lead Lo premaLure inLra-acinar cell acLivaLion
o digesLive zymogens and LhaL Lhose enzymes, once acLivaLed cause acinar cell injury. RecenL
sLudies have suggesLed LhaL Lhe ulLimaLe severiLy o resulLing pancreaLiLis may be deLermined by
evenLs which occur subsequenL Lo acinar cell injury. 1hese include inlammaLory cell recruiLmenL
and acLivaLion as well as Lhe generaLion and release o cyLokines and oLher chemical mediaLors o
inlammaLion. RecenLly, we have underLaken sLudies Lo elucidaLe Lhe role o various inlammaLory
agenLs in deLermining Lhe severiLy o pancreaLiLis. ResulLs rom Lhese ongoing sLudies indicaLe
LhaL subsLance P acLing via neurokinin- (NK) recepLors, chemokines inLeracLing wiLh CCR
recepLors and plaLeleL acLivaLing acLor play an imporLanL pro-inlammaLory role in regulaLing Lhe
severiLy o pancreaLiLis and associaLed lung injury. On Lhe oLher hand, complemenL acLor 5a (C5a)
acLs as an anLi-inlammaLory agenL during Lhe developmenL o pancreaLiLis.
.4O#& I .BP7$"P&

Signs and sympLoms o pancreaLiLis vary i iL is acuLe or chronic in naLure, depending on whaL Lhe
clienL is having.

Signs and sympLoms o acuLe pancreaLiLis include.
Abdominal pain Lo Lhe upper quadranLs, radiaLes Lo Lhe clienLs back and worsens aLer
meals
Nausea and vomiLing
1enderness on Lhe abdomen

Signs and sympLoms o chronic pancreaLiLis include.
Upper abdominal pain
lndigesLion
124

Sudden weighL loss
SLeaLorrhea (oily, oul smelling sLools)

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
inlammaLion, edema,
disLenLion o Lhe
pancreas, and
periLoneal irriLaLion
lneecLive breaLhing
paLLern relaLed Lo
severe pain,
pulmonary inilLraLes,
pleural eusion,
LelecasLs, and elevaLed
diaphragm
lmbalanced nuLriLion,
less Lhan body
requiremenLs, relaLed
Lo reduced ood
inLake and increased
meLabolic demands
lmpaired skin
inLegriLy relaLed Lo
poor nuLriLional
sLaLus, bed resL,
mulLiple drains, and
surgical wound

wiLh held oral
eedings
Lhe paLienL is
mainLained on
parenLeral luids and
elecLrolyLes
NasogasLric sucLion
requenL oral hygiene
and care
MainLain bed resL
l experiencing severe
pain, reporL Lo
physician
Provide requenL and
repeaLed buL simple
explanaLions abouL
Lhe need or
wiLhholding luids,
mainLenance o
gasLric sucLion, and
bed resL.
decrease Lhe
ormaLion o secreLin
Lo resLore and
mainLain luid balance
Lo relieve n/v or Lo
LreaL abdominal
disLenLion and
paralyLicileus
Lo decrease
discomorL rom Lhen
nasogasLric Lube and
Lo relieve dryness o
Lhe mouLh
Lo decrease Lhe
meLabolic reaLe and
reduce Lhe secreLion
o pancreaLic and
gasLric enzymes
Lhe clienL may be
experiencing
hemorrhage o Lhe
pancreas or Lhe dose
o Lhe analgesic
maybe inadequaLe.
1he paLienL oLen has
clouded sensorium
because o severe
pain, luid and
elecLrolyLe
disLurbances, and
hypoxia
Relie o pain and
discomorL
lmproved respiraLory
uncLion
lmproved nuLriLional
sLaLus
MainLenance o skin
inLegriLy
PrevenL complicaLion

R4<#%B 6+)(C98
C+L 6C=@$% +%#15 L145@2%8
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1he inLeracLion o Lubular and vascular evenLs resulL in ARF. 1he primary cause o A1N is
ischemia. lschemia or more Lhan Lwo hours resulLs in severe and irreversible damage Lo Lhe
kidney Lubules. SigniicanL reducLion in glomular ilLraLion raLe (CFR) is a resulL o () ischemia, (2)
acLivaLion o Lhe renin-angioLensin sysLem , and (3) Lubular obsLrucLion by cellular debris. As
nephroLoxins damage Lhe Lubular cells and Lhese cells are losL Lhrough necrosis, Lhe Lubules
become more permeable. 1his resulLs in ilLraLe absorpLion and a reducLion in Lhe nephrons
abiliLy Lo eliminaLe wasLe.

125

E;% =54#4=15 ="@2&% "M C+L 4& =;121=$%24W%< FB $;% M"55":4#O $;2%% 7;1&%&-
/;1&% T\ ,#&%$

ARF begins wiLh Lhe underlying clinical condiLion leading Lo Lubular necrosis, or example
hemorrhage, which reduces blood volume and renal perusion. l adequaLe LreaLmenL is provided
in Lhis phase Lhen Lhe individual's prognosis is good.
/;1&% U\ S14#$%#1#=%

A persisLenL decrease in CFR and Lubular necrosis characLerizes Lhis phase. FndoLhelial cell
necrosis and sloughing lead Lo Lubular obsLrucLion and increased Lubular permeabiliLy. 8ecause
o Lhis, oliguria is oLen presenL during Lhe beginning o Lhis phase. FicienL eliminaLion o
meLabolic wasLe, waLer, elecLrolyLes, and acids rom Lhe body cannoL be perormed by Lhe kidney
during Lhis phase. 1hereore, azoLemia, luid reLenLion, elecLrolyLe imbalance and meLabolic
acidosis occurs. 1he paLienL is aL risk or hearL ailure and pulmonary edema during Lhis phase
because o Lhe salL and waLer reLenLion. lmmune uncLion is impaired and Lhe paLienL may be
anemic because o Lhe suppressed eryLhropoieLin secreLion by Lhe kidney and Loxin-relaLed
shorLer R8C lie.
/;1&% _\ +%="H%2B

Renal uncLion o Lhe kidney improves quickly Lhe irsL ive Lo LwenLy-ive days o Lhis phase. lL
begins wiLh Lhe recovery o Lhe CFR and Lubular uncLion Lo such an exLenL LhaL 8UN and serum
creaLinine sLabilize. lmprovemenL in renal uncLion may conLinue or up Lo a year as more and
more nephrons regain uncLion.

.4O#& I .BP7$"P&

Dizziness
Dry mouLh
Low blood pressure (hypoLension)
Rapid hearL raLe
Slack skin
1hirsL
WeighL loss

(@2&4#O
C&&%&&P%#$
(@2&4#O
3#$%2H%#$4"#
+1$4"#15% 0"15
Fluid volume excess
relaLed Lo
Compromised
regulaLory
mechanism (renal
ailure)
. Record accuraLe
inLake and ouLpuL
(l&O). lnclude
hidden fluids such
as lv anLibioLic
addiLives, liquid
medicaLions, ice
chips, rozen LreaLs.
Measure
gasLroinLesLinal (Cl)
losses and esLimaLe
insensible losses,
e.g., diaphoresis.
. Low ouLpuL (less Lhan
400 mL/24 hr) may be
irsL indicaLor o acuLe
ailure, especially in a
high-risk paLienL.
AccuraLe l&O is necessary
or deLermining renal
uncLion and luid
replacemenL needs and
reducing risk o luid
overload. NoLe.
Hypervolemia occurs in
Lhe anuric phase o ARF.
HomeosLasis
achieved.
ComplicaLions
Dealing realisLically
wiLh currenL siLuaLion.
Disease
process/prognosis
and LherapeuLic
regimen undersLood.
126

2. MoniLor urine
speciic graviLy.
3. Weigh daily aL
same Lime o day, on
same scale, wiLh
same equipmenL
and cloLhing.
4. Assess skin, ace,
dependenL areas or
edema. FvaluaLe
degree o edema (on
scale o --4).
5. MoniLor hearL raLe
(HR), 8P, and
JvD/CvP.
6. AusculLaLe lung
and hearL sounds.
7. Assess level o
consciousness,
invesLigaLe changes
in menLaLion,
presence o
resLlessness.
8. Plan oral luid
replacemenL wiLh
paLienL, wiLhin
mulLiple resLricLions.
lnLersperse desired
beverages
LhroughouL 24 hr.
vary oerings, e.g.,
hoL, cold, rozen.
2. Measures the kidneys
abiliLy Lo concenLraLe
urine. ln inLrarenal ailure,
speciic graviLy is usually
equal Lo/less Lhan .00,
indicaLing loss o abiliLy
Lo concenLraLe Lhe urine.
3. Daily body weighL is
besL moniLor o luid
sLaLus. A weighL gain o
more Lhan 0.5 kg/day
suggesLs luid reLenLion.
4. Fdema occurs primarily
in dependenL Lissues o
Lhe body, e.g., hands, eeL,
lumbosacral area. PaLienL
can gain up Lo 0 lb (4.5
kg) o luid beore piLLing
edema is deLecLed.
PeriorbiLal edema may be
a presenLing sign o Lhis
luid shiL because Lhese
ragile Lissues are easily
disLended by even
minimal luid
accumulaLion.
5. 1achycardia and
hyperLension can occur
because o () ailure o
Lhe kidneys Lo excreLe
urine, (2) excessive luid
resusciLaLion during
eorLs Lo LreaL
hypovolemia/hypoLension
or converL oliguric phase
o renal ailure, and/or (3)
changes in Lhe renin-
angioLensin sysLem. NoLe.
lnvasive moniLoring may
be needed or assessing
inLravascular volume,
especially in paLienLs wiLh
poor cardiac uncLion.
6. Fluid overload may
lead Lo pulmonary edema
and HF evidenced by
developmenL o
advenLiLious breaLh
sounds, exLra hearL
sounds. (Reer Lo ND.
Cardiac OuLpuL, risk or
decreased, ollowing.)
7. May relecL luid shiLs,
accumulaLion o Loxins,
acidosis, elecLrolyLe
127

imbalances, or
developing hypoxia.
8. Helps avoid periods
wiLhouL luids, minimizes
boredom o limiLed
choices, and reduces
sense o deprivaLion and
LhirsL.

!+L 6!;2"#4= +%#15 L145@2%8
/1$;"7;B&4"5"OB
Regardless o Lhe primary cause o nephron loss, some usually survive or are less severely
damaged
1hese nephrons Lhen adapL and enlarge, and clearance per nephron markedly increases.
l Lhe iniLiaLing process is diuse, sudden, and severe, such as in some paLienLs wiLh
rapidly progressive glomerulonephriLis (crescenLic glomerulonephriLis), acuLe or subacuLe
renal ailure may ensue wiLh Lhe rapid developmenL o FSRD.
ln mosL paLienLs, however, disease progression is more gradual and nephron adapLaLion
is possible.
Focal glomerulosclerosis develops in Lhese glomeruli, and Lhey evenLually become non-
uncLional.
AL Lhe same Lime LhaL ocal glomerulosclerosis develops, proLeinuria markedly increases
and sysLemic hyperLension worsens.
1his process o nephron adapLaLion has been Lermed Lhe "M4#15 ="PP"# 71$;\"
AdapLed nephrons enhance Lhe abiliLy o Lhe kidney Lo posLpone uremia, buL ulLimaLely
Lhe adapLaLion process leads Lo Lhe demise o Lhese nephrons.
AdapLed nephrons have noL only an enhanced CFR buL also enhanced Lubular uncLions
in Lerms o, or example, poLassium and proLon secreLion.
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your docLor suspecLs LhaL you may be likely Lo develop renal ailure, he or she will probably caLch
iL early by conducLing regular blood and urine LesLs. l regular moniLoring isn'L done, Lhe
sympLoms may noL be deLecLed unLil Lhe kidneys have already been damaged. Some o Lhe
sympLoms - such as aLigue - may have been presenL or some Lime, buL can come on so
gradually LhaL Lhey aren'L noLiced or aLLribuLed Lo kidney ailure.
."P% &4O#& "M =;2"#4= 2%#15 M145@2% 12% P"2% "FH4"@& $;1# "$;%2&\ E;%&% 12%-
increased urinaLion, especially aL nighL
decreased urinaLion
blood in Lhe urine (noL a common sympLom o chronic renal ailure)
urine LhaL is cloudy or Lea-colored
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128

puy eyes, hands, and eeL (called edema)
high blood pressure
aLigue
shorLness o breaLh
loss o appeLiLe
nausea and vomiLing (Lhis is a common sympLom)
LhirsL
bad LasLe in Lhe mouLh or bad breaLh
weighL loss
generalized, persisLenL iLchy skin
muscle LwiLching or cramping
a yellowish-brown LinL Lo Lhe skin
As Lhe kidney ailure geLs worse and Lhe Loxins conLinue Lo build up in Lhe body, seizures and
menLal conusion can resulL.
(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
Cardiac OuLpuL, risk
or decreased relaLed
Lo Fluid imbalances
aecLing circulaLing
volume, myocardial
workload, and
sysLemic vascular
resisLance (SvR),
AlLeraLions in raLe,
rhyLhm, cardiac
conducLion
(elecLrolyLe
imbalances, hypoxia),
AccumulaLion o
Loxins (urea), soL-
Lissue calciicaLion
(deposiLion o calcium
phosphaLe).
lndependenL
AusculLaLe hearL and
lung sounds. FvaluaLe
presence o peripheral
edema/vascular
congesLion and
reporLs o dyspnea.
Assess
presence/degree o
hyperLension. moniLor
8P, noLe posLural
changes, e.g., siLLing,
lying, sLanding.
lnvesLigaLe reporLs o
chesL pain, noLing
locaLion, radiaLion,
severiLy (00 scale),
and wheLher or noL iL
is inLensiied by deep
inspiraLion and supine
posiLion.
FvaluaLe hearL sounds
(noLe ricLion rub), 8P,
peripheral pulses,
capillary reill, vascular
congesLion,
LemperaLure, and
sensorium/menLaLion.
Assess acLiviLy level,
response Lo acLiviLy.
CollaboraLive
MoniLor
laboraLory/diagnosLic
sLudies, e.g..
FlecLrolyLes
(poLassium, sodium,
S3/S4 hearL sounds
wiLh muled Lones,
Lachycardia, irregular
hearL raLe, Lachypnea,
dyspnea, crackles,
wheezes, and
edema/jugular
disLension suggesL HF.
SigniicanL
hyperLension can
occur because o
disLurbances in Lhe
renin-angioLensin-
aldosLerone sysLem
(caused by renal
dysuncLion).
AlLhough
hyperLension is
common, orLhosLaLic
hypoLension may
occur because o
inLravascular luid
deiciL, response Lo
eecLs o
anLihyperLensive
medicaLions, or
uremic pericardial
Lamponade.
AlLhough
hyperLension and
chronic HF may cause
Ml, approximaLely hal
o CRF paLienLs on
dialysis develop
pericardiLis,
poLenLiaLing risk o
Fluid/elecLrolyLe
balance sLabilized.
ComplicaLions
Disease
process/prognosis
and LherapeuLic
regimen undersLood.
Dealing realisLically
wiLh siLuaLion,
iniLiaLing necessary
liesLyle changes.
129

calcium, magnesium),
8UN/Cr,
AdminisLer
anLihyperLensive
drugs, e.g., prazosin
(Minipress), capLopril
(CapoLen), clonidine
(CaLapres),
hydralazine
(Apresoline).
Prepare or dialysis.
AssisL wiLh
pericardiocenLesis as
indicaLed.
pericardial
eusion/Lamponade.
Presence o sudden
hypoLension,
paradoxic pulse,
narrow pulse pressure,
diminished/absenL
peripheral pulses,
marked jugular
disLension, pallor, and
a rapid menLal
deLerioraLion indicaLe
Lamponade, which is a
medical emergency.
Weakness can be
aLLribuLed Lo HF and
anemia.
lmbalances can alLer
elecLrical conducLion
and cardiac uncLion,
Do ChesL x-rays.
Useul in idenLiying
developing cardiac
ailure or soL-Lissue
calciicaLion.
Reduces sysLemic
vascular resisLance
and/or renin release
Lo decrease
myocardial workload
and aid in prevenLion
o HF and/or Ml.
ReducLion o uremic
Loxins and correcLion
o elecLrolyLe
imbalances and luid
overload may
limiL/prevenL cardiac
maniesLaLions,
including
hyperLension and
pericardial eusion.
AccumulaLion o luid
wiLhin pericardial sac
can compromise
cardiac illing and
myocardial
conLracLiliLy, impairing
cardiac ouLpuL and
poLenLiaLing risk o
cardiac arresL

130

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/1$;"7;B&4"5"OB

ProLeinuria occurs because o changes Lo capillary endoLhelial cells, Lhe glomerular basemenL
membrane (C8M), or podocyLes, which normally ilLer serum proLein selecLively by size and
charge.

1he mechanism o damage Lo Lhese sLrucLures is unknown in primary and secondary glomerular
diseases, buL evidence suggesLs LhaL 1 cells may up-regulaLe a circulaLing permeabiliLy acLor or
down-regulaLe an inhibiLor o permeabiliLy acLor in response Lo unidenLiied immunogens and
cyLokines. OLher possible acLors include herediLary deecLs in proLeins LhaL are inLegral Lo Lhe sliL
diaphragms o Lhe glomeruli, acLivaLion o complemenL leading Lo damage o Lhe glomerular
epiLhelial cells and loss o Lhe negaLively charged groups aLLached Lo proLeins o Lhe C8M and
glomerular epiLhelial cells.
.4O#& I .BP7$"P&

Hypoalbuminemia (low level o albumin in Lhe blood)
Fdema (swelling)
HypercholesLerolemia (high level o cholesLerol in Lhe blood)

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3#$%2H%#$4"#
+1$4"#15% 0"15
Fxcess luid volume relaLed Lo
compromised regulaLory
mechanism wiLh changes
in hydrosLaLic or oncoLic
vascular pressure and
increased acLivaLion o Lhe
renninangioLensinaldosLerone
sysLem.
lNDFPFNDFN1.
Record accurate
inLake and ouLpuL o
Lhe paLienL.

Monitor urine
speciic graviLy.

Weigh daily at
same Lime o Lhe
day, on same scale,
wiLh same
equipmenL and
cloLhing.

Assess skin, face,
dependenL areas o
edema. MoniLor
hearL raLe and blood
pressure.

AccuraLe lnLake
and ouLpuL is
necessary or
deLermining renal
uncLion and luid
ReplacemenL needs
and reducing risk
o luid overload.

Measures the
kidneys ability to
concenLraLe urine.

Daily body weight
is Lhe besL moniLor
o luid sLaLus. A
weighL gain o
more Lhan 0.5
kg/day suggesL
luid reLenLion.

Edema occurs
primarily in
dependenL Lissues
o Lhe body. lL will
serve as parameLer
Lhe severiLy o luid
excess.
ALer Nursing
inLervenLions, Lhe
paLienL was able Lo
display sLable
weighL, viLal signs
within patients
normal range, and
nearly absence o
edema.
131


Assess level of
consciousness,
lnvesLigaLe changes
in menLaLion,
presence o
resLlessness.

COLLA8ORA1lvF.
Monitor laboratory
and diagnosLic
sLudies.

Administer
diureLics as
prescribed.

Tachycardia and
hyperLension can
occur because o
ailure o Lhe
kidneys Lo excreLe
urine.

May reflect fluid
shiLs and
elecLrolyLe
imbalances.

Provide
assessmenL o Lhe
progression and
managemenL o
Lhe dysuncLion.

To promote
adequaLe urine
volume LhaL aids in
prevenLion o
urLher edema.

K4<#%B .$"#% 6Calculi8
/1$;"7;B&4"5"OB

Kidney sLones (renal liLhiasis) are small, hard deposiLs LhaL orm inside your kidneys. 1he
sLones are made o mineral and acid salLs. Kidney sLones have many causes and can
aecL any parL o your urinary LracL rom your kidneys Lo your bladder. OLen, sLones
orm when Lhe urine becomes concenLraLed, allowing minerals Lo crysLallize and sLick
LogeLher.
Passing kidney sLones can be quiLe painul, buL Lhe sLones usually cause no permanenL
damage. Depending on your siLuaLion, you may need noLhing more Lhan Lo Lake pain
medicaLion and drink loLs o waLer Lo pass a kidney sLone. ln oLher insLances, surgery may
be needed. our docLor may recommend prevenLive LreaLmenL Lo reduce your risk o
recurrenL kidney sLones i you're aL increased risk o developing Lhem again.
.4O#& I .BP7$"P&

Severe pain in Lhe side and back, below Lhe ribs
Pain LhaL spreads Lo Lhe lower abdomen and groin
Pain LhaL comes in waves and lucLuaLes in inLensiLy
Pain on urinaLion
Pink, red or brown urine
Cloudy or oul-smelling urine
Nausea and vomiLing
PersisLenL urge Lo urinaLe
132

UrinaLing more oLen Lhan usual
Fever and chills i an inecLion is presenL

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
inlammaLion,
obsLrucLion, and
abrasion o urinary
LracL by migraLion o
sLones.
AlLered urinary
eliminaLion.
DocumenL Lhe pain in
Lerms o locaLion,
duraLion, inLensiLy (-
0 pain scale), and
radiaLion. Also,
observe or nonverbal
cues like 8P and pulse
raLe elevaLion,
resLlessness, crying or
moaning.

Fncourage Lo
verbalize pain noLing
also or Lhe pain
Lhreshold o Lhe clienL,
leL clienL explain how
Lhe pain occur or or
any changes in
characLerisLics.

FducaLe and
encourage clienL in
diversional acLiviLies
like ocused breaLhing
and guided imagery.

Provide scheduled
resLing periods or
clienL and also
provide a peaceul
environmenL.

AssisL clienL in daily
ambulaLion and
encourage increasing
luid inLake o aL leasL
3 L per day as
LoleraLed.

lnsLrucL clienL Lo
reporL or persisLenL
or increased
abdominal pain.

1his would aid you in
assessing and
evaluaLing Lhe
eecLively o
LreaLmenL, iL can also
relecL Lhe progress o
calculi movemenL
because a lank pain
means Lhe sLones are
sLill in Lhe kidney area
and upper ureLer,
severe pain may resulL
Lo severe anxieLy and
resLlessness.

lL will provide an
avenue or Limely
adminisLraLion o pain
medicaLion.

lL will help clienL in
diverLing pain and
coping wiLh disease
condiLion.

lL can promoLe
relaxaLion and
reduces muscle
Lension.

Supine posiLion could
be worse or renal
colic while an
increased luid inLake
promoLes Lhe passing
o Lhe sLone and
prevenLs urLher sLone
ormaLion.

CompleLe obsLrucLion
o Lhe ureLer can
cause Lhe peroraLion
o urine inLo Lhe
perirenal space
making iL a surgical
Pain relieved.
HomeosLasis
achieved.
ComplicaLions
Disease process,
prognosis, and
LherapeuLic regimen
undersLood.
needs aLer discharge
133


AdminisLer
medicaLions like
narcoLics,
anLispasmodic and
corLicosLeroid as
prescribed by Lhe
physician.

l indicaLed, a warm
compress may be
applied Lo Lhe back.

lnserL and mainLain
Lhe paLency o urinary
caLheLer.
emergency.

NarcoLics are given
during acuLe periods
o pain, anLispasmodic
is used Lo decrease
spasm prevenLing
colic and pain,
corLicosLeroid is given
Lo reduce edema,
aciliLaLing Lhe
movemenL o sLone.

lL reduces muscle
Lension and spasms.

1o deLermine and
prevenL urinary
reLenLion and iL can
also help in lessening
renal pressure and
inecLion.

05"P%2@5"#%7;24$4&
/1$;"7;B&4"5"OB

1he iniLial reacLion is usually eiLher an upper respiraLory inecLion or skin inecLion due Lo group A
beLa-hemolyLic sLrepLococcus. 1his leads Lo Lhe ormaLion o an anLigen-anLibody reacLion. lL is
ollowed by Lhe release o a membrane-like maLerial rom Lhe organism inLo Lhe bodys
circulaLion. AnLibodies produced Lo ighL Lhe invading organism also reacL againsL Lhe glomerular
Lissue, Lhus orming immune complexes. 1he immune complexes become Lrapped in Lhe
glomerular loop and cause an inlammaLory reacLion in Lhe aecLed glomeruli. Changes in Lhe
glomerular capillaries reduce Lhe amounL o Lhe glomerular ilLraLe, Lhereby allowing passage o
blood cells and proLein inLo Lhe inilLraLe, and reducing Lhe amounL o sodium and waLer LhaL is
passed inLo Lhe Lubules or reabsorpLion. 1his aecLs Lhe vascular Lone and permeabiliLy o Lhe
kidney, resulLing Lo Lissue injury.
.4O#& I .BP7$"P&

Signs and sympLoms o glomerulonephriLis may depend on wheLher you have Lhe acuLe or
chronic orm, and Lhe cause. our irsL indicaLion LhaL someLhing is wrong may come rom
sympLoms or rom Lhe resulLs o a rouLine urinalysis. Signs and sympLoms may include.
Pink or cola-colored urine rom red blood cells in your urine (hemaLuria)
Foamy urine due Lo excess proLein (proLeinuria)
High blood pressure (hyperLension)
Fluid reLenLion (edema) wiLh swelling evidenL in your ace, hands, eeL and abdomen
FaLigue rom anemia or kidney ailure

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# N +1$4"#15% 0"15
134

LighL microscopy.
Fnlarged glomeruli
wiLh mesangial
prolieraLion and
exudaLion o
neuLrophils
lmmune o
luorescenL
microscopy. Cranular
paLLern o
immunoglobulin
deposiLion
FlecLron microscopy.
reveals elecLron
dense humps
(immunecomplex)
on Lhe epiLhelial side
o Lhe glomerular
basemenL
membrane

Provide besL resL during Lhe acuLe phase.
Perorm passive range o
moLion exercises or Lhe paLienL on bed
resL.
Allow Lhe paLienL Lo resume normal
acLiviLies gradually as sympLoms subside.
ConsulL Lhe dieLician abouL a dieL high in
calories and low in proLein, sodium,
poLassium, and luids.
ProLecL Lhe debiliLaLed paLienL againsL
secondary inecLion by providing good
nuLriLion and hygienic Lechnique and
prevenLing conLacL wiLh inecLed people.
Check the patients vital signs and
elecLrolyLe values.
MoniLor inLake and ouLpuL and daily
weighL.
ReporL peripheral edema or Lhe
ormaLion o asciLes.
Fxplain Lo Lhe paLienL Laking diureLics
LhaL he may experience orLhosLaLic
hypoLension and dizziness when he
changes posiLions quickly.
Provide emoLional supporL or Lhe
paLienL and his amily.
l Lhe paLienL is scheduled or dialysis,
explain Lhe procedure ully.

Pain relieved.
HomeosLasis achieved.
ComplicaLions
Disease process, prognosis,
and LherapeuLic regimen
undersLood.
Plan in place Lo meeL needs
aLer discharge

E21#&@2%$;215 +%&%=$4"# "M /2"&$1$% 6E*+/8
/1$;"7;B&4"5"OB

1URP (1ransureLhral ResecLion o Lhe ProsLaLe) is Lhe mosL common procedure used Lo LreaL 8PH.
lL can be carried ouL Lhrough endoscopy. 1he surgical and opLical insLrumenL is inLroduced
direcLly Lhrough Lhe ureLhra Lo Lhe prosLaLe, which can Lhen be viewed direcLly. 1he gland is
removed in small chips wiLh an elecLrical cuLLing loop. 1his procedure, which requires no incision,
may be used or glands o varying size and is ideal or paLienLs who have small glands and or
Lhose who are considered poor surgical risks. Newer Lechnology uses bipolar elecLrosurgery and
reduces Lhe risk o 1UR syndrome (hyponaLremia, hypovolemia).1URP usually requires an
overnighL hospiLal sLay. UreLhral sLricLures are more requenL Lhan wiLh (non-Lrans-ureLhral
procedures, and repeaLed procedures may be necessary because Lhe residual prosLaLic Lissue
grows back.

1URP rarely causes erecLile dysuncLion, buL may Lrigger reLrograde ejaculaLion because removal
o Lhe prosLaLic Lissue aL Lhe bladder neck can cause seminal luid Lo low backward inLo Lhe
bladder raLher orward Lhrough Lhe ureLhra during ejaculaLion.
135

.4O#& I .BP7$"P&

Urgency o urinaLion
Frequency o urinaLion
Abdominal sLraining
NocLuria
lmpairmenL o size and orce o sLream
lnLermiLLenL hesiLancy
lncompleLe bladder empLying
1erminal dribbling
Dysuria
FvenLual renal ailure rom urinary obsLrucLion

(@2&4#O C&&%&&P%#$ (@2&4#O 3#$%2H%#$4"# +1$4"#15% 0"15
lmpaired Urinary
FliminaLion
urinary reLenLion
hemaLuria
ever
MoniLor urinary
eliminaLion, including
consisLency, odor,
volume, and color.

Help Lhe clienL selecL
appropriaLe
inconLinence garmenL
or pad or shorL-Lerm
managemenL while
more deiniLive
LreaLmenL is
designed.

lnsLrucL PaLienL Lo
limiL luids or 2 Lo 3
hours beore bedLime.

lnsLrucL him Lo drink
a minimum o ,500
mL (six 8-ounce
glasses) luids per day.

LimiL ingesLion o
bladder irriLanLs (e.g.,
colas, coee, Lea, and
chocolaLe).

lnsLrucL PaLienL or a
amily member Lo
record urinary ouLpuL.

CaLheLerize or
1hese parameLers
help deLermine
adequacy o urinary
LracL uncLion.

AppropriaLe
undergarmenLs can
help diminish Lhe
embarrassing aspecLs
o urinary
inconLinence.

Decreased luid
inLake several hours
beore bedLime will
decrease Lhe
incidence o urinary
reLenLion and
overlow inconLinence,
and promoLe resL.

lncreased luids
during Lhe day will
increase urinary
ouLpuL and
discourage bacLerial
growLh.

Alcohol, coee, and
Lea have a naLural
diureLic eecL and are
bladder irriLanLs.

Serves as an indicaLor
o urinary LracL and
renal uncLion and o
luid balance.

Able Lo sLarL and sLop
sLream
FmpLies bladder
compleLely
DescripLion o sel-
care responsibiliLies
or ongoing care
DescripLion o sel-
moniLoring
Lechniques.
Rerain rom alcoholic
beverages.
Avoid sexual acLiviLies
or a ew weeks.
Avoid driving a car
or a week or more.
Keep domesLic
acLiviLies Lo a
minimum.
Avoid weighL liLing
or sLrenuous exercise.
Check Lheir
LemperaLure and
reporL any ever Lo Lhe
physician.
PracLice good
hygiene, especially o
Lhe hands and penis.
Drink plenLy o
liquids.
136

residual urine, as
appropriaLe.

lmplemenL
inLermiLLenL
caLheLerizaLion, as
appropriaLe

Provide enough Lime
or bladder empLying
(0 minuLes).

lnsLrucL Lhe clienL in
ways Lo avoid
consLipaLion or sLool
impacLion.
An enlarged prosLaLe
compresses Lhe
ureLhra so LhaL urine is
reLained. Checking or
residual urine
provides inormaLion
abouL bladder
empLying.

Helps mainLain
LoniciLy o Lhe bladder
muscle by prevenLing
over disLenLion and
providing or
compleLe empLying.

ln addiLion Lo Lhe
eecL o an enlarged
prosLaLe on Lhe
bladder, sLress or
anxieLy can inhibiL
relaxaLion o Lhe
urinary sphincLer.
SuicienL Lime should
be allowed or
micLuriLion.

lmpacLed sLool may
place pressure on Lhe
bladder ouLleL,
causing urinary
reLenLion.

*E3 6@24#12B $21=$ 4#M%=$4"#8
/1$;"7;B&4"5"OB

A urinary LracL inecLion (U1l) may occur in Lhe bladder, where iL is called cysLiLis, or in Lhe ureLhra,
where iL is called ureLhriLis. Upper LracL inecLion resulLs in pyelonephriLis. MosL U1ls resulL rom
ascending inecLions by bacLeria LhaL have enLered Lhrough Lhe urinary meaLus buL some may be
caused by hemaLogenous spread. U1ls are much common in emales because Lhe shorLer emale
ureLhra makes Lhem more vulnerable Lo enLry o organisms rom surrounding sLrucLures (vagina,
periureLhral glands, and recLum).
.4O#& I .BP7$"P&

SympLoms depend on age o person and where Lhe U1l is locaLed .

SympLoms o ureLhriLis oLen include.
! 8urning sensaLion aL Lhe sLarL o urinaLion

SympLoms o cysLiLis oLen include.
137

! 8urning sensaLion in Lhe middle o urinaLion
! Fever
! Lower abdominal pain
! Funny smell, color, or appearance (cloudy, dark, blood Linged) o urine

SympLoms o PyelonephriLis oLen include.
! Pain in back, lanks, or abdomen
! Fever
! Nausea
! vomiLing

Other symptoms of UTIs:
! UncomorLable pressure above pubic bone
! Fullness in recLum (in men only)
! Small amounL o urine, despiLe urge Lo urinaLe
! lrriLabiliLy (in children only)
! Abnormal eaLing (in children only)

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HydraLion sLaLus
suprapubic
Lenderness may be
mild Lo moderaLe
lank pain i
presenL reer or
consulL suggesLs
upper U1l
ever, rigor, chills i
presenL reer or
consulL suggesLs
upper U1l
Assess pain, noting
locaLion, inLensiLy
(scale o 0 0),
duraLion.

Encourage increased
luid inLake.

Investigate report of
bladder ullness.

Observe for changes
in menLal sLaLus,
behavior or level o
consciousness.

Provide comfort
measure like back rub,
helping paLienL
assume posiLion o
comorL.
SuggesL use o
relaxaLion Lechnique
and deep breaLhing
exercises.

Encourage use of
siLz baLhs, warm soaks
Lo Lhe perineum.

CollaboraLive.
Administer
anLibacLerial as
prescribed
how Lo Lake
medicaLion, proper
dosing, expecLed side
eecLs, and ollow-up

increasing luid
inLake Lo 8-0 glasses
per day

meLhods or cleaning
sex Loys

avoiding sharing sex
Loys

avoiding douching

avoiding bubble
baLhs

reLurning Lo Lhe
clinic i ever develops
or sympLoms do noL
improve in 48-72
relieve sympLoms
prevenL
complicaLions and
ascending inecLion
eradicaLe inecLion
138

hours

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As males age, producLion o androgenic hormones decreases, causing an imbalance in
androgen and esLrogen levels and high levels o dihydroLesLosLerone, Lhe main prosLaLic
inLracellular androgen.
OLher causes o 8enign prosLaLic hyperplasia (8PH) include.
! Neoplasm
! ArLeriosclerosis
! lnlammaLion
! MeLabolic lmbalance
! NuLriLional disLurbances.

ComplicaLions or 8enign prosLaLic hyperplasia (8PH)
! Urinary sLasis, urinary LracL inecLion (U1l), or
! Renal calculi
! 8ladder wall LrabeculaLion
! DeLrusor muscle hyperLrophy
! 8ladder diverLicula and saccules
! UreLhral sLenosis
! Hydronephrosis
! Paradoxical (overlow) inconLinence
! AcuLe or chronic renal ailure
! AcuLe posLobsLrucLive diuresis.

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SympLoms include a slow low o urine, Lhe need Lo urinaLe urgenLly and diiculLy
sLarLing Lhe urinary sLream.

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AcuLe pain. May
relaLed Lo mucosal
irriLaLion such as
bladder disLenLion,
renal colic, urinary
inecLion and
radiaLion Lherapy
Asses pain, noLhing
locaLion, inLensiLy

1ape drainage Lube
Lo high and caLheLer
Lo Lhe abdomen, i
LracLion noL required.

Provide comorL
measure, such as
backrub, helping
paLienL assume
posiLion o comorL.
SuggesL use o
Provide inormaLion
Lo aid in deLermine
choice and
eecLiveness o
inLervenLions.

PrevenLs accidenLal
dislodging o caLheLer
wiLh aLLendanL
ureLhral Lrauma.

PromoLes relaxaLion,
reocuses aLLenLion,
and may enhance
coping abiliLies

1he paLienL will able Lo
reporL pain relieved or
conLrolled, appear relaxed
and be able Lo sleep and resL
appropriaLely.

139

relaxaLion and deep
creaLing exercises and
divisional acLiviLies.

Fncourage use o siLz
baLhs and warm soak
Lo perineum.

PromoLes muscle
relaxaLion

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