December 2012 Pnle Pearls of Success Part 6: Medical and Surgical Health Nursing (A)

WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
PERIOPERATIVE NURSING
A. Major Types of Pathologic Process Requiring Surgical
Intervention (OPET)
Obstruction impairment to the flow of vital fluids
(blood,urine,CSF,bile)
Perforation rupture of an organ.
Erosion wearing off of a surface or membrane.
Tumors abnormal new growths.
B. Classification of Surgical Procedure
According to PURPOSE:
Diagnostic to establish the presence of a disease condition. (
e.g biopsy )
Exploratory to determine the extent of disease condition ( e.g
Ex-Lap )
Curative to treat the disease condition.
* Ablative removal of an organ
* Constructive repair of congenitally
defective organ.
* Reconstructive repair of damage organ
Palliative to relieve distressing sign and symptoms, not
necessarily to cure the disease.
According to URGENCY
Classification
Emergent patient
requires immediate
attention, life threatening
condition.
Urgent / Imperative
patient requires prompt
attention.
Required patient
needs to have surgery.
Elective patient should
have surgery.
Optional patients
decision.
Indication for
Surgery
Without delay
Within 24 to 30
hours
Plan within a
few weeks or
months
Failure to have
surgery not
catastrophic
Personal
preference
Examples
- severe
bleeding
- gunshot/ stab
wounds
- Fractured skull
kidney
/
ureteral stones
- cataract
- thyroid d/o
- repair of scar
- vaginal repair
- cosmetic
surgery
C. Inform Consent
Purposes:
To ensure that the client understand the nature of the
treatment including the potential complications and
disfigurement.
To indicate that the clients decision was made without
pressure.
To protect the client against unauthorized procedure.
To protect the surgeon and hospital against legal action by a
client who claims that an authorized procedure was
performed.
Essential Elements of Informed Consent
the diagnosis and explanation of the condition.
a fair explanation of the procedure to be done and used and
the consequences.
a description of alternative treatment or procedure.
a description of the benefits to be expected.
material rights if any.
the prognosis, if the recommended care, procedure is refused.
Requisites for Validity of Informed Consent
Written permission is best and legally accepted.
Signature is obtained with the clients complete

understanding of what to occur.
- adult sign their own operative permit
- obtained before sedation
For minors, parents or someone standing in their behalf,
gives the consent. Note: for a married emancipated minor
parental consent is not needed anymore, spouse is accepted
For mentally ill and unconscious patient, consent must be
taken from the parents or legal guardian
If the patient is unable to write, an X is accepted if there is a
witness to his mark
Secured without pressure and threat
A witness is desirable nurse, physician or authorized
persons.
When an emergency situation exists, no consent is necessary
because inaction at such time may cause greater injury.
(permission via telephone/cellphone is accepted but must be
signed within 24hrs.)
D. Preoperative Meds. 5As
Anxiolitics (Tranquilizers & Sedatives)
* Diazepam ( Valium )
* Lorazepam ( Ativan )
* Diphenhydramine
Analgesics
* Nalbuphine ( Nubain )
Anticholinergics
* Atropine Sulfate
Anti-Ulcer (Proton Pump Inhibitors)
* Omeprazole ( Losec )
* Famotidine
Antibiotics
E. Preoperative Teachings
Incentive Spirometry
Diaphragmatic Breathing
Coughing
Turning
Foot and Leg exercise
Teaching should be done morning/afternoon before the day of
surgery
Best Method: Return Demonstration
F. The Surgical Team
Surgeon
Performance of the operative procedure according to the

needs of the patients.
The primary decision maker regarding surgical technique to

use during the procedure.
Assistant Surgeon
Assists with retracting, hemostasis, suturing and any other

tasks requested by the surgeon to facilitate speed while
maintaining quality during the procedure.
Anesthesiologist
Selects the anesthesia, administers it, intubates the client if

necessary, manages technical problems related to the
administration of anesthetic agents, and supervises the clients
condition throughout the surgical procedure.
Scrub Nurse
Assists with the preparation of the room.
Scrubs, gowns and gloves self and other members of the

surgical team.
Prepares the instrument table and organizes sterile equipment

for functional use.
Assists with the drapping procedure.
Passes instruments to the surgeon and assistants by

anticipating their need.
Counts sponges, needles and instruments.
Keeps track of irrigations used for calculations of blood loss
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 July 2012 the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE

Circulating Nurse
Responsible and accountable for all activities occurring during

a surgical procedure including the management of personnel
equipment, supplies and the environment during a surgical
procedure.
Ensure all equipment is working properly.
Guarantees sterility of instruments and supplies.
Monitor the room and team members for breaks in the sterile
technique.
Handles specimens.
Coordinates activities with other departments, such as

radiology and pathology.
Thrombophlebitis
URINARY
Urinary Retention
G. Principles of Surgical Asepsis
Sterile object remains sterile only when touched by another

sterile object
Only sterile objects may be placed on a sterile field
A sterile object or field out of range of vision or an object held
below a persons waist is contaminated
When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
Fluid flows in the direction of gravity
The edges of a sterile field or container are considered to be
contaminated (1 inch)
Urinary
Incontinence
Urinary Tract
Infection
GASTRO-INTESTINAL
Nausea and
Vomiting
H. PACU/RR Care
Maintaining a Patent Airway

Assessing Status of Circulatory System
Maintaining Adequate Respiratory Function
Assessing Thermoregulatory Status
Maintaining Adequate Fluid Volume
Minimizing Complications of Skin Impairment
Maintaining Safety
Promoting Comfort
I. Parameter for Discharge from PACU/RR

Activity. Able to obey commands
Respiratory. Easy, noiseless breathing
Circulation. BP within 20mmHg of preop level
Consciousness. Responsive
Color. Pinkish skin and mucus membrane
Hiccups
Intestinal
Obstruction
( 3rd-5th day postop)
Constipation
Paralytic Ileus
WOUND
Wound Infection
J. Post Operative Complications

Problem
Nursing Intervention
Atelectasis
Pulmonary
Embolism
CIRCULATION
Hypovolemia
Hemorrhage
Deep breathing exercises

Coughing exercise
Early ambulation
Deep breathing exercises
Coughing exercise
Early ambulation
Turning
Ambulation
Anti embolic stockings
Compression devises
Prevent massaging the lower
extremities
Monitor I & O
Interventions to facilitate
voiding
Urinary Catheterization as
needed
Monitor I & O
Adequate fluid intake
Early ambulation
Aseptic catheterization as
needed
Good perineal hygiene
IV fluids until peristalsis
returns
Progressive diet ( clear liquid
then full fluids, soft then
regular diet)
Anti emetics as ordered
NGT insertion as needed
Hold breath while taking a
large swallow of water
Breath in and out on a paper
bag
Anti emetics as ordered
NGT insertion as needed
Administered IVF as ordered
Prepare for possible surgery
Adequate hydration
High fiber diet
Encourage early ambulation
Encourage early ambulation
Keep wound clean and dry
Surgical aseptic technique
when changing dressing
Antibiotic therapy
Wound Dehiscence
RESPIRATORY
Pneumonia
Early ambulation
Anti embolic stocking
Encourage leg exercise
Hydrate adequately
Avoid any restricting devices
that impaired circulation
Avoid massage on the calf of
the leg
Initiate anticoagulant therapy
Wound Evisceration
Apply abdominal binders

Encourage high protein diet
and Vit.C intake
Keep in bed rest
Semi-Fowlers, bend knees to
relieve tension on the
abdominal muscles
Splinting on coughing
Cover exposed organ with
sterile , moist saline dressing
Reassure, keep him/her quite
and relaxed
Prepare for surgery and repair
of wound
Fluid and blood replacement

Fluid and blood replacement
Vit.k and hemostat
Ligation of bleeders
Pressure dressing

ONCOLOGY NURSING
A. Benign VS Malignant Neoplasm
Characteristic
Speed Growth
Benign Neoplasm
Grows slowly
Usually continues
to grow throughout
life unless
surgically removed
Grows by enlarging
and expanding
Always remains
localized; never
infiltrates
surrounding
tissues
Almost always
contained within a
fibrous capsule
Capsule
advantageous
because
encapsulated
tumor can be
removed surgically
Usually well
differentiated
Malignant Neoplasm
Usually grows rapidly
Tends to grow relentlessly
throughout life
Recurrence
Unusual when
surgically removed
Metastasis
Effect of
Neoplasm
Never occur
Not harmful to host
unless located in
area where it
compresses tissue
or obstructs vital
organs
Very good
Tumor generally
removed surgically
Common following surgery

because tumor cells spread
into surrounding tissues
Very common
Always harmful to host
Causes disfigurement,
disrupted organ function,
nutritional imbalances
May result in ulcerations,
sepsis, perforations,
Depends on cell type and
speed of diagnosis
Poor prognosis if cells are
poorly differentiated and
evidence of metastatic
spread exists
Good prognosis indicated if
cells still resemble normal
cells and there is no
evidence of metastasis
Mode of
Growth
Capsule
Cell
characteristics
Prognosis
Grows by infiltrating
surrounding tissues
May remain localized (in
situ) but usually infiltrates
other tissues
Never contained within a
capsule
Absence of capsule allows
neoplastic cells to invade
surrounding tissues
Surgical removal of tumor
difficult
Usually poorly
differentiated
B. Recommendations of the American Cancer Society for Early

Cancer Detection
1. For detection of breast cancer
Beginning at age 20, routinely perform monthly breast selfexamination
Women ages 20-39 should have breast examination by a
healthcare provider every 3 years
Women age 40 and older should have a yearly mammogram
and breast self-examination by a healthcare provider
2. For detection of colon and rectal cancer
All persons age 50 and older should have a yearly fecal occult
blood test
Digital rectal examination and flexible sigmoidoscopy should
be done every 5 years
Colonoscopy with barium enema should be done every 10
years
3. For detection of uterine cancer
Yearly papanicolao (Pap) smear for sexually active females and

any female over age 18
At menopause, high-risk women should have an endometrial
tissue sample
4. For detection of prostate cancer

At age 50, have a yearly digital rectal examination
At age 50, have a yearly prostate-specific antigen (PSA) test
C. American Cancer Societys seven warning signs of cancer
(uses acronym CAUTION US):
1. Change in bowel or bladder habits
2. A sore that does not heal
3. Unusual bleeding or discharge
4. Thickening or lump in breast or elsewhere
5. Indigestions or difficulty in swallowing
6. Obvious change in wart or mole
7. Nagging cough or hoarseness
8. Unexplained Anemia
9. Sudden loss of weight
D. Internal Radiation Therapy (Brachytheraphy)
Sources of Internal Radiation
Implanted into affected tissue or body cavity
Ingested as a solution
Injected as a solution into the bloodstream or body cavity
Introduced through a catheter into the tumor
Side Effects
Fatigue
Anorexia
Immunosuppression
Other side effects similar to external radiation

Client Education
Avoid close contact with others until treatment is completed
Maintain daily activities unless contraindicated, allowing for extra
rest periods as needed
Maintain balanced diet
Maintain fluid intake ensure adequate hydration (2-3 liters/day)
If implant is temporary, maintain bedrest to avoid dislodging the
implant.
Excreted body fluids may be radioactive; double-flush toilets after
use
Radiation therapy may lead to bone marrow suppression
Nursing Management
Exposure to small amounts of radiation is possible during close
contact with persons receiving internal radiation: understand the
principles of protection from exposure to radiation: time, distance,
and shielding
Time: minimize time spent in close proximity to the
radiation source; a common standard is to limit contact time
to 30 minutes total per 8-hour shift;
Distance: maintain the maximum distance 6 feet possible

from the radiation source
Shielding: use lead shields and other precautions to reduce
exposure to radiation
Place client in private room
Instruct visitors to maintain at least a distance of 6 feet from the
client and limit visitors to 10-30 minutes
Ensure proper handling and disposal of body fluids, assuring the
containers are marked appropriately
Ensure proper handling of bed linens and clothing
In the event of a dislodged implant, use long-handled forceps and
place the implant into a lead container; never directly touch the
implant
Do not allow pregnant woman to come into any contact with
radiation

If working routinely near radiation sources, wear a monitoring

device to measure exposure
Educate client in all safety measures
E. External Radiation Therapy (Teletheraphy)
The radiation oncologist marks specific locations for radiation

treatment using a semipermanent type of ink
Treatment is usually given 15-30 minutes per day, 5 day per
week, for 2-7 weeks
The client does not pose a risk for radiation exposure to other
people
Side Effects
Tissue damage to target area (erythema, sloughing, hemorrhage)
Ulcerations of oral mucous membranes
GIT effects such as nausea, vomiting, and diarrhea
Immunosuppression
Client Education
Wash the marked area of the skin with plain water only and pat
skin dry; do not use soaps, deodorants, lotions, perfumes, powders
or medications on the site during the duration of the treatment; do
not wash off the treatment site marks
Avoid rubbing, scratching, or scrubbing the treatment site; do
not apply extreme temperatures (Heat or Cold) to the
treatment site ; if shaving, use only an electric razor
Wear soft, loose-fitting over the treatment area
Protect skin from sun exposure during the treatment and for at
least 1 year after the treatment is completed; when going
outdoors, use sun-blocking agents with sun protector factor
(SPF) of at least 15
Maintain proper rest, diet, and fluid intake as essential to
promoting health and repair of normal tissues
Nursing Management
Monitor for adverse side effects of radiation
Monitor for significant decreases in white blood cell counts

and platelet counts
Client teaching (refer to later sections for management of
immunosuppression, thrombocytopenia
B. Heart Sound
Tricuspid valve (lub) - RT 5th intercostal, medial
Mitral valve (lub) - LT 5th intercostal, lateral
Aortic semilunar valve (dub) - RT 2nd intercostal
Pulmonary semilunar valve (dub) - LT 2nd intercostals
S1 - due to closure of the AV(mitral/tricuspid) valves
S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves
S3 Ventricular Diastolic Gallop
Mechanism: vibration resulting from resistance to rapid
ventricular filling secondary to poor compliance
S4 - Atrial Diastolic Gallop
Mechanism: vibration resulting from resistance to late
ventricular filling during atrial systole
Heart Murmurs
Incompetent / Stenotic Valve
Pericardial Friction Rub
It is an extra heart sound originating from the pericardial sac
Mechanism: Originates from the pericardial sac as it moves
Timing: with each heartbeat
C. ECG
Cardiac Action Potential

Depolarization/Contraction/Systole - electrical activation of
a cell caused by the influx of sodium into the cell while
potassium exits the cell
Repolarization/Resting/Diastole - return of the cell to the
resting state caused by re-entry of potassium into the cell
while sodium exits
D. CARDIAC Proteins and enzymes
a.
CARDIOVASCULAR NURSING
A. Heart Circulation
b.
c.
d.
CK- MB ( creatine kinase)

Most cardiac specific enzymes
Accurate indicator of myocardial dammage
Elevates in MI within 4 hours, peaks in 18 hours and
then declines till 3 days
Normal value is 0-7 U/L or males 50-325 mu/ml
Female 50-250 mu/ml
Lactic Dehydrogenase (LDH)
Most sensitive indicator of myocardial damage
Elevates in MI in 24 hours, peaks in 48-72 hours
Return to normal in 10-14 days
Normally LDH1 is greater than LDH2
Troponin I and T
Troponin I is usually utilized for MI
Elevates within 3-4 hours, peaks in 4-24 hours and
persists for 7 days to 3 weeks!
Normal value for Troponin I is less than 0.6 ng/mL
REMEMBER to AVOID IM injections before obtaining
blood sample!
Early and late diagnosis can be made!
Serum Lipids
Lipid profile measures the serum cholesterol,
triglycerides and lipoprotein levels
Cholesterol= 200 mg/dL
Triglycerides- 40- 150 mg/dL
LDH- 130 mg/dL
HDL- 30-70- mg/dL
NPO post midnight (usually 12 hours)

E. Cardiac Catheterization ( Coronary Angiography /
Arteriography )
Insertion of a catheter into the heart and surrounding vessels
Is an invasive procedure during which physician injects dye
into coronary arteries and immediately takes a series of x-ray
films to assess the structures of the arteries
Pretest: Ensure Consent, assess for allergy to seafood and
iodine, NPO, document weight and height, baseline VS, blood
tests and document the peripheral pulses
Intra-test: inform patient of a fluttery feeling as the catheter
passes through the heart; inform the patient that a feeling of
warmth and metallic taste may occur when dye is
administered
Post-test: Monitor VS and cardiac rhythm
Monitor peripheral pulses, color and warmth and sensation of
the extremity distal to insertion site
Maintain sandbag to the insertion site if required to maintain
pressure
Monitor for bleeding and hematoma formation
F. CVP ( Central Venous Pressure )
Reflects the pressure of the blood in the right atrium.
Engorgement is estimated by the venous column that can be
observed as it rises from an imagined angle at the point of
manubrium ( angle of Louis).
With normal physiologic condition, the jugular venous column
rises no higher than 2-3 cm above the clavicle with the client in
a sitting position at 45 degree angle.
NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg

To Measure:
Patient should be flat with zero point of manometer at the
same level of the RA which corresponds to the mid-axillary
line of the patient or approx. 5 cm below the sternum.
Fluctuations follow patients respiratory function and will
fall on inspiration and rise on expiration due to changes in
intrapulmonary pressure.
Reading should be obtained at the highest point of
fluctuation.
ECG: may reveals

ST segment
depression
T wave inversion
Myocardial
Infarction
(MI)
Death of
myocardial
cells from
inadequate
oxygenation,
often caused
by sudden
complete
blockage of a
coronary
artery
Characterized
by localized
formation of
necrosis
(tissue
destruction)
with
subsequent
healing by
scar formation
& fibrosis
Chest pain
Usually radiates
from neck, back,
shoulder, arms,
jaw & abdominal
muscles
(abdominal
ischemia): severe
crushing
Not usually
relieved by rest or
by nitroglycerine
N/V
Dyspnea
Increase in blood
pressure & pulse
Hyperthermia:
elevated temp
Skin: cool, clammy,
ashen
Mild restlessness
& apprehension
ECG:
ST segment
elevation
T wave inversion
Widening of QRS
complexes
4 Es of
Angina
Pectoris
Excessive
physical
exertion
Exposure to
cold
environment
Extreme
emotional
response
Excessive
intake of
foods or
heavy meal
Levines Sign:
initial sign that
shows the hand
clutching the chest
Coronary artery bypass

surgery
Greater and lesser
saphenous veins are
commonly used for
bypass graft procedures
Chest pain:
characterized by
sharp stabbing
pain located at sub
sterna usually
radiates from neck,
back, arms,
shoulder and jaw
muscles
Percutaneuos
Transluminal Coronary
Angioplasty (PTCA)
Mechanical dilation of
the coronary vessel wall
by compresing the
atheromatous plaque.
Dyspnea
Tachycardia
Palpitations
Diaphoresis
NTG Tablets(sublingual)
Give 3 doses interval of 35minutes
Nursing Management:
NTG Nitrol or
Transdermal patch
Avoid placing near hairy
areas as it may decrease
drug absorption
Avoid rotating
transdermal patches.
Nursing Management
Goal: Decrease myocardial
oxygen demand
Administer narcotic
analgesic as ordered:
Morphine
Administer oxygen low
flow 2-3 L / min
Enforce CBR in semifowlers position without
bathroom privileges
Instruct client to avoid
forms of valsalva
maneuver
Monitor urinary output
& report output of less
than 30 ml / hr:
indicates decrease
cardiac output
Resumption of ADL
particularly sexual
intercourse: is 4-6 weeks
post cardiac rehab, post
CABG & instruct to:
Instruct client to assume
a non weight bearing
position
Client can resume sexual
intercourse: if can climb
or use the staircase
The Most Critical Period
6-8 hours because majority
of death occurs due to
arrhythmia leading to
premature ventricular
contractions (PVC)
*Lidocaine: DOC for
arrhythmia
G. Coronary Arterial Diseases

ANGINA
PECTORIS
Keep the drug in a dry

place, avoid moisture
and exposure to sunlight
Change stock every 6
months
Offer sips of water
before giving sublingual
nitrates,
F. Congestive Heart Failure

Inability of the heart to pump blood towards systemic circulation
I.
Left sided heart failure

90% - Mitral valve stenosis
Pulmonary Symptoms
II.
Right sided heart failure

Tricuspid valve stenosis
Venous congestion symptoms

NURSING MANAGEMENT
Goal: increase myocardial contraction
Administer medications as ordered
Cardiac glycosides
Digoxin *Antidote: Digibind
Loop diuretics
Bronchodilators
Narcotic analgesics
Morphine sulfate
Vasodilators
Anti-arrhythmic agents
Administer O2 inhalation at 3-4 L/minute
Restrict Na and fluids
Monitor strictly VS and IO and Breath SoundsWeigh pt daily and
assess for pitting edema and abdominal girth daily and notify MD
Provide meticulous skin care
Provide a dietary intake which is low in saturated fats and caffeine
5. Bronchoscopy
This is the direct inspection and observation of the
larynx, trachea and bronchi through a flexible or rigid
bronchoscope.
Passage of a lighted bronchoscope into the bronchial tree
for direct visualization of the trachea and the
tracheobronchial tree.
Diagnostic uses:
To examine tissues or collect secretions
To determine location or pathologic process and
collect specimen for biopsy
To evaluate bleeding sites
To determine if a tumor can be resected surgically
Therapeutic uses
To Remove foreign objects from tracheobronchial tree
To Excise lesions
To remove tenacious secretions obstructing the
tracheobronchial tree
To drain abscess
To treat post-operative atelectasis
RESPIRATORY NURSING
A. Diagnostic Evaluation
Nursing Interventions BEFORE Bronchoscopy

Informed consent/ permit needed
Explain procedure to the patient, tell him what to expect,
to help him cope with the unkown
Atropine (to diminish secretions) is administered one
hour before the procedure
About 30 minutes before bronchoscopy, Valium is given
to sedate patient and allay anxiety.
Topical anesthesia is sprayed followed by local
anesthesia injected into the larynx
Instruct on NPO for 6-8 hours
Remove dentures, prostheses and contact lenses
The patient is placed supine with hyperextended neck
during the procedure
1. Skin Test: Mantoux Test or Tuberculin Skin Test

This is used to determine if a person has been infected or
has been exposed to the TB bacillus.
This utilizes the PPD (Purified Protein Derivatives).
The PPD is injected intradermally usually in the inner
aspect of the lower forearm about 4 inches below the elbow.
The test is read 48 to 72 hours after injection.
(+) Mantoux Test is induration of 10 mm or more.
But for HIV positive clients, induration of about 5 mm is
considered positive
2. Pulse Oximeter
Non-invasive method of continuously monitoring he oxygen
saturation of hemoglobin
A probe or sensor is attached to the fingertip, forehead,
earlobe or bridge of the nose
Normal SpO2 = 95% - 100%
< 85% - tissues are not receiving enough O2
Nursing Interventions AFTER Bronchoscopy

Put the patient on Side lying position
Tell patient that the throat may feel sore with .
Check for the return of cough and gag reflex.
Check vasovagal response.
Watch for cyanosis, hypotension, tachycardia,
arrythmias, hemoptysis, and dyspnea. These signs and
symptoms indicate perforation of bronchial tree. Refer
the patient immediately!
3. Chest X-ray
This is a NON-invasive procedure involving the use of x-rays
with minimal radiation.
The nurse instructs the patient to practice the on cue to
hold his breath and to do deep breathing
Instruct the client to remove metals from the chest.
Rule out pregnancy first.
4 . Indirect Bronchography
A radiopaque medium is instilled directly into the trachea
and the bronchi and the outline of the entire bronchial tree
or selected areas may be visualized through x-ray.
It reveals anomalies of the bronchial tree and is
important in the diagnosis of bronchiectasis.
Nursing Interventions BEFORE Bronchogram
Secure written consent
Check for allergies to sea foods or iodine or anesthesia
NPO for 6 to 8 hours
Pre-op meds: atropine SO4 and valium, topical
anesthesia sprayed; followed by local anesthetic
injected into larynx. The nurse must have oxygen and
anti spasmodic agents ready.
Nursing Interventions AFTER Bronchogram
Side-lying position
NPO until cough and gag reflexes returned
Instruct the client to cough and deep breathe client
6. Sputum Examination
Indicated for microscopic examination of the sputum:
Gross appearance, Sputum C&S, AFB staining, and for
Cytologic examination/ Papanicolaou examination
Nursing Interventions:
Early morning sputum specimen is to be
collected (suctioning or expectoration)
Rinse mouth with plain water
Use sterile container.

Sputum specimen for C&S is collected before

the first dose of anti-microbial therapy.
For AFB staining, collect sputum specimen for
three consecutive mornings.
6. Pulmonary Function Test / Studies

Non-invasive test
Measurement of lung volume, ventilation, and diffusing
capacity
7. Arterial Blood Gas

Assessment of arterial blood for tissue oxygenation,
ventilation, and acid-base status
Arterial puncture is performed on areas where good pulses
are palpable (radial, brachial, or femoral). Radial artery
is the most common site for withdrawal of blood specimen
Nursing Interventions:
Utilize a 10-ml. Pre-heparinized syringe to prevent
clotting of specimen
Soak specimen in a container with ice to prevent
hemolysis
If ABG monitoring will be done, do Allens test to assess
for adequacy of collateral circulation of the hand (the
ulnar arteries)
8. Thoracentesis
Procedure suing needle aspiration of intrapleural fluid or air
under local anesthesia
Specimen examination or removal of pleural fluid
Nursing Intervention BEFORE Thoracentesis
Secure consent
Take initial vital signs
Instruct to remain still, avoid coughing during
insertion of the needle
Inform patient that pressure sensation will be felt on
insertion of needle
Nursing Intervention DURING the procedure:
Reassess the patient
Place the patient in the proper position:
Upright or sitting on the edge of the bed
Lying partially on the side, partially on the

back
Nursing Interventions after Thoracentesis
Assess the patients respiratory status
Monitor vital signs frequently
Position the patient on the affected side, as ordered,
for at least 1 hour to seal the puncture site
Turn on the unaffected side to prevent leakage of
fluid in the thoracic cavity
Check the puncture site for fluid leakage
Auscultate lungs to assess for pneumothorax

Monitor oxygen saturation (SaO2) levels
Bed rest
Check for expectoration of blood
C. Chronic Obstructive Pulmonary Diseases

Chronic Bronchitis
(Blue Bloaters)
Inflammation of the
bronchi due to
hypertrophy or
hyperplasia of goblet
mucous producing cells
leading to narrowing of
smaller airways
Smoking
Air
pollution
Consistent productive
cough
Dyspnea on exertion
with prolonged
expiratory grunt
Anorexia and
generalized body
malaise
Cyanosis
Scattered rales/rhonchi
Bronchial Asthma
Reversible inflammatory
lung condition caused by
hypersensitivity to
allergens leading to
narrowing of smaller
airways
Allergens
Bronchiectasis
Permanent dilation of
the bronchus due to
destruction of muscular
and elastic tissue of the
alveolar walls
Recurrent
LRTI
Congenital
disease
Presence
of tumor
Chest
trauma
Pulmonary
Emphysema
Terminal and
irreversible stage of
COPD characterized by :
Smoking
Pollution
Hereditary
Allergy
Consistent productive
cough
Dyspnea
Presence of cyanosis
Rales and crackles
Hemoptysis
Anorexia and
generalized body
malaise
Productive cough
Dyspnea at rest
Prolonged expiratory
grunt
Resonance to
hyperresonance
Decreased tactile
fremitus
Decreased breath
sounds
Barrel chest
Anorexia and
generalized body
malaise
Rales or crackles
Pursed-lip breathing
Inelasticity of alveoli
Air trapping
Maldistribution of
gasses
Overdistention of
thoracic cavity
(Barrel chest)
Cough that is productive

Dyspnea
Wheezing on expiration
Tachycardia,
palpitations and
diaphoresis
Mild apprehension,
restlessness
Cyanosis
Nursing Management:
Enforce CBR
Low inflow O2 admin; high inflow will cause respiratory arrest
* most accurate: venturi mask
Bronchodilators
Antimicrobials
Corticosteroids (5-10 minutes after bronchodilators)
Mucolytics/expectorants
Force fluids
Nebulize and suction client as needed
Provide comfortable and humid environment
Avoidance of smoking and allergens

C. PNEUMONIA
Inflammation of the lung parenchyma leading to pulmonary
consolidation because alveoli is filled with exudates
I.
II.
III.
IV.
Administer
bronchodilators
15-30
minutes before procedure
Stop if pt. cant tolerate the procedure
Provide oral care after procedure as it
may affect taste sensitivity
Contraindications:
Unstable VS
Hemoptysis
Increased ICP
Increased IOP (glaucoma)
12. Provide pt health teaching and d/c planning
Avoidance of precipitating factors
Prevention of complications
Atelectasis
Meningitis
Regular compliance to medications
Importance of ffup care
Etioilogic Agent
1. Streptococcus
pneumoniae
(pneumococcal
pneumonia)
2. Hemophilus influenzae (bronchopneumonia)
3. Klebsiella pneumoniae
4. Diplococcus pneumoniae
5. Escherichia coli
6. Pseudomonas aeruginosa
Predisposing Factor
1. Smoking
2. Air pollution
3. Immunocompromised
(+) AIDS
Kaposis Sarcoma
Pneumocystis Carinii Pneumonia
DOC: Zidovudine (Retrovir)
Bronchogenic Ca
4. Prolonged immobility (hypostatic pneumonia)
5. Aspiration of food (aspiration pneumonia)
6. Over fatigue
Signs / Symptoms
1. Productive cough, greenish to rusty
2. Dyspnea with prolong expiratory grunt
3. Fever, chills, anorexia, general body malaise
4. Cyanosis
5. Pleuritic friction rub
6. Rales/crackles on auscultation
7. Abdominal distention paralytic ileus
NURSING MANAGEMENT
1. Enforce CBR (consistent to all respi disorders)
2. Strict respiratory isolation
3. Administer medications as ordered
Broad spectrum antibiotics

Penicillin pneumococcal infections
Tetracycline
Macrolides
Anti-pyretics
Mucolytics/expectorants
4. Administer O2 inhalation as ordered
5. Force fluids to liquefy secretions
6. Institute pulmonary toilet measures to promote
expectoration of secretions
DBE,
Coughing
exercises,
CPT
(clapping/vibration),
Turning
and
repositioning
7. Nebulize and suction PRN
8. Place client of semi-fowlers to high fowlers
9. Provide a comfortable and humid environment
10. Provide a dietary intake high in CHO, CHON, Calories
and Vit C
11. Assist in postural drainage
Patient is placed in various position to drain

secretions via force of gravity
Usually, it is the upper lung areas which are

drained
Nursing management:
Monitor VS and BS
Best performed before meals/breakfast
or 2-3 hours p.c. to prevent
gastroesophageal reflux or vomiting
(pagkagising maraming secretions diba?
Nakukuha?)
Encourage DBE
HEMATOLOGY NURSING
A. Blood Cellular Components
RBC
4-6
million/mm3
* Hemoglobin
Ave. 12 - 18
g/dL
iron-containing protein of RBC,

delivers oxygen to tissue
* Hematocrit
F: 36-42%
M: 42-48%
red cell percentage in whole

blood
WBC
N = 5,00010,000/mm3
*Neutrophils
Most common
type of
leukocyte but a
short lifespan
of only 10-12
hours
First line of defense,

Helpful in localizing the
infection and in
immobilizing the
pathogens until other
WBCs arrive
*Eosinophils
Lifespan=
hours to 3 days
Allergic Reaction and

Parasitic Invasion
*Basophils
they are mediators in

inflammatory process.
*Monocytes
largest WBC
(macrophage)
Antibody response
Immunity
Anti tumor
*Lymphocytes
Platelets
B Cells
T Cells
NK Cells
N = 150-450
thousand mm3
Promotes hemostasis
prevention of blood loss
promote clotting mechanisms

B. Blood Disorder
IRON DEFICIENCY
ANEMIA (IDA)
chronic microcytic
anemia due to
inadequate
absorption of iron
leading to
hypoxemic tissue
injury
APLASTIC
ANEMIA stem
cell disorder
leading to bone
marrow
depression
pancytopenia (all
blood cells
decreased)
anemia,
leucopenia,
thrombocytopenia
PERNICIOUS
ANEMIA chronic
anemia resulting
from deficiency of
intrinsic factor
leading to
hypochlorhydria
(decreased HCl
secretion);
Monitor for signs of bleeding of all hema

test including urine, stool and GIT
Enforce CBR so as not to overtire patient
Encourage increased iron diet
Avoid tannates in tea and coffee
Oral iron preparations (300mg OD)
NURSING MANAGEMENT
1. Administer with meals to lessen
GIT irritation
2. Use straw for liquid form
3. Administer with orange juice or
vitamin C to facilitate absorption
4. Inform client of SE/monitor for
a.
Anorexia
b. Nausea and vomiting
c.
Abdominal pain
d. Diarrhea/constipation
e.
Melena
Parenteral Iron Preparations
NURSING MANAGEMENT
1. Administer using z-tract method
to prevent discomfort,
discoloration and leakage
2. Avoid massaging of injection site
instead encourage pt. to
ambulate to facilitate absorption
3. Monitor SE
a.
Pain at injection site
b. Localized abscess
c.
Lymphadenopathy
d. Fever and chills
Enforce complete BR
Administer O2 inhalation
Reverse isolation
Monitor for signs of infection
Avoid IM, SQ or any venipuncture sites
instruct: use electric razor when shaving
Medications as ordered
Immunosuppressants via central
venous catheter
Anti-lymphocyte globulin (ALG)
given within 6 days 3 weeks to
achieve maximum therapeutic effect
Headache, dizziness, dyspnea, palpitation,

cold sensitivity, pallor and generalized body
malaise
GIT changes: Mouth sores, Red beefy
tongue, Dyspepsia or indigestion, Weight
loss, Jaundice
CNS changes PA is the most dangerous
form of anemia, Tingling sensation,
Paresthesia, Ataxia, Psychosis
DIAGNOSTICS
SCHILLINGS TEST indicates decreased
reabsorption of vitamin B12; confirms
presence of pernicious anemia
NURSING MANAGEMENT
Enforce complete bed rest (consistent to
all types of anemia)
Administer Vit B12 injections at
MONTHLY intervals for lifetime as
ordered; common site: dorso and
ventrogluteal, no drug toxicity because it
is water soluble and is easily excretable;

oral forms might develop tolerance.
Increase caloric intake, CHON, CHO, Fe,
Vit C
Encourage client to use soft bristled
toothbrush and avoid irritating
mouthwashes (remember there are
mouthsores!)
Avoid heat application (there is
numbness remember?) may lead to
burns
GUT NURSING
A. Causes of Acute Renal Failure
Acute Renal Failure

Sudden inability of the
kidneys
to
excrete
nitrogenous
waste
products, leads to azotemia
STAGES
Oliguric phase passage
of urine (1-2 weeks)
UO: <400 ml/cc
Hyperkalemia
Hypernatremia
Hyperphosphatemia
HYPOCALCEMIA
Hypermagnesemia
Metabolic acidosis
Elevated BUN, Crea
Diuretic Phase (2-3
weeks)
Increased passage of
urine
Hyperkalemia
Hyponatremia
Metabolic acidosis
Chronic Renal Failure

Irreversible loss of kidney
function
PREDISPOSING FACTORS
DM and HPN (common
causes)
Recurrent pyelonephritis
Exposure to renal toxins
Tumor
STAGES
Diminished renal reserve
volume asymptomatic,
normal BUN and CREA
Renal insufficiency
End-stage renal disease
(ESRD) presence of
oliguria, azotemia
Convalescent phase (3-12

months)
Improvement in
passage of urine
Characterized by
complete diuresis

NURSING MANAGEMENT ARF/CRF
Enforce CBR
Admin oxygen inhalation as ordered
High CHO diet low CHON, fats, High vit and minerals
Provide meticulous skin care
Wash with warm water
Soap irritates and dries skin
Meds as ordered
anti-HPN agents
Hydralazine (appresoline)
SE: orthostatic hypotension
NaHCO3
Kayexelate enema
Hematinics
Antibiotics
Supplementary vitamins and minerals
Phosphate binders
Calcium gluconate
B. Nursing Management on Hemodialysis
Secure consent and explain procedure to client

Maintain strict aseptic technique
Obtain baseline data before and q30 during
procedure
VS
Wt
Blood exams secure all pre-procedure
I/O
Have client void pre-procedure
Inform pt about bleeding (blood is heparinized)
Monitor for signs of complications (BEDSSH)
Bleeding
Embolism
DISEQUILIBRIUM SYNDROME results from rapid
loss of nitrogenous waste products particularly UREA
from the brain
HPN
Disorientation initial sign
Nausea and vomiting
Anorexia
Headache
Paresthesia, peripheral
Numbness
Septicemia
Shock
Hepatitis
Avoid BP taking, phlebotomy, IV meds at the site of
fistula, blood extraction to prevent compression
Maintain patency of shunt/fistula:
Palpate for thrills, auscultate for bruits
Instruct that minimal bleeding is expected since blood
is heparinized
Avoid use vasodilators, sedatives, and tranquilizers to
prevent hypotension unless ordered
Prepare at bedside bulldog clips to prevent embolism
Auscultate for bruits and palpate for thrills (if (+)
patent)
ENDOCRINE NURSING
A. Thyroid Gland Disorders
HYPOTHYROIDISM
Decreased T3 and T4
Early Signs
1. Weakness and fatigue
2. Loss of appetite but
(+) weight gain d/t
increased lipolysis
3. Dry skin
4. Cold intolerance
5. Constipation
6. Menorrhagia
Late Signs
1. Brittleness of hair
2. Non-pitting edema
3. Hoarseness of voice
4. Decreased libido
5. Decreased VS
6. CNS changes
a.
Lethargy
b. Memory
impairment
c.
Psychosis
1. Monitor STRICTLY VS,
IO to determine
presence of
MYXEDEMA COMA a
complication of severe
hypothyroidism
characterized by:
a.
Severe
hypotension
b. Bradycardia
c.
Bradypnea
d. Hypoventilation
e.
Hypoglycemia
f.
Hyponatremia
g.
Hypothermia
2. Administer isotonic
fluids as ordered
3. Administer
medications as
ordered thyroid
hormones or agents
(may cause insomnia
and heat intolerance)
4. Provide dietary intake
low in calories to
prevent weight gain
5. Institute meticulous
skin care
6. Provide comfortable
and warm
environment
7. Forced fluids
HYPERTHYROIDSM
Increased T3 and T4
1. Hyperphagia increased
appetite
2. (+) weight loss d/t
increased metabolism
3. heat intolerance
4. moist skin
5. diarrhea
6. increased VS
7. CNS changes
a.
Irritability
b. agitation
c.
Tremors
d. Restlessness
e.
Insomnia
f.
Hallucinations
8. Goiter
9. Exophthalmos
10. Amenorrhea
1.
2.
3.
4.
5.
6.
7.
8.
Monitor VS and IO strictly

to determine presence of
THYROID STORM/Crisis
Administer medications
as ordered
a.
Anti-Thyroid Agents:
PTU toxic effects is
AGRANULOCYTOSIS
fever and chills, sore
throat (throat CS
pls!), LEUKOCYTOSIS
(CBC pls!)
b. Methimazole
(Tapazole)
High calorie diet to
correct weight loss
Provide comfortable and
cool environment
Institute meticulous skin
care
Maintain side rails
Bilateral eye patch to
prevent drying of eyes
Assist in surgical
procedure: subtotal
thyroidectomy
PRE-OP
Administer lugols solutions/
SSRI to promote decreased
vasculature and promote
atrophy of the thyroid gland to
prevent/minimize bleeding
and hemorrhage
POST-OP
WOF signs of THYROID
STORM agitation, hyperthermia, HPN. If (+) thyroid
storm: administer anti-pyretics
and beta-blockers; VS, IO and
NVS strictly, siderails up,
provide hypothermic blanket
WOF: inadvertent or
accidental removal of

parathyroid gland
hypocalcemia or tetany [(+)
trousseus signs, (+) chvosteks
Give Ca Gluc slowly to
prevent arrhythmia and
arrest
WOF accidental laryngeal
nerve damage hoarness of
voice instruct client to talk
immediately post-op if (+)
notify MD
WOF signs of bleeding (+)
feeling of fullness at incision
site, (+) soiled dressings at
back or nape area, notify MD
WOF signs of laryngeal spasm
DOB and SOB prep trache
set
9.
Hormonal Replacement
therapy for life
10. importance of FFup care
11. wearing of medic-alert
bracelet
B. Insulin Therapy
I.
Types of Insulin
A. Rapid (SAI) clear, peak: 2-4 hours , Regular insulin
B. Intermediate AI NPH (Non-Protamine Hagedorn)
cloudy, peak : 6-12 hours
C. Long AI Ultra lente cloudy, peak 12-24 hours
II.
Nursing Management
A. Administer insulin at room temp to prevent
lipodystrophy atrophy/hypertrophy of SQ tissue
B. Insulin only refrigerated once opened
C. Avoid shaking insulin, roll between palms only
D. Accuracy of administration is important
E. Rotate insulin sites to prevent lipodystrophy
F. Use short bore needle gauge 25-26
G. No need to aspirate
H. Administer insulin 45/90 degrees angle depending on
amount to pts SQ tissue
I.
Most accessible route: abdomen
J.
Aspirate CLEAR before CLOUDY to prevent
contamination and promote accurate calibration
K. Monitor for local complications:
1. Allergic reactions
2. Lipodystrophy
3. SOMOGYIS PHENOMENON rebound effect of insulin
characterized by hypoglycemia, hyperglycemia

December 2012 Pnle Pearls of Success Part 6: Medical and Surgical Health Nursing (A)

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WHAT YOU SHOULD KNOW BEFORE THE PNLE