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MEDICAL-SURGICAL NURSING REVIEW

Course Outline

I. II. III.

Client in Pain Perioperative Nursing Care Alterations in Human Functioning a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions

IV. V.

Disturbances in Musculoskeletal Functions Client in Biologic Crisis: Life threatening Conditions of the Human Body - Shock Emergency & Disaster - First-aid and Cardiopulmonary Support

b. c. d. e. f. g.

Disturbances in Metabolic and Endocrine Functions Disturbances in Elimination: Gastrointestinal Problems Disturbances in Fluids and Electrolytes: Renal & Genitourinary Functions Disturbances in Cellular Functioning: Cancer and Hematologic Problems Disturbances in Auditory & Visual Functions

I.

-------------------------------------------------------------------------------------------------------------------------------------CLIENT IN PAIN

Pain the fifth vital sign an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Basic Categories of Pain: 1. Acute Pain sudden pain which is usually relieved in seconds or after a few weeks.

2. 3.

Chronic Pain (Non-Malignant) constant, intermittent pain which usually persists even after healing of the injured tissue Cancer-Related Pain- May be acute or chronic; may or may not be relieved by medications

Pain Transmission: 1. Nociceptors are called pain receptors. These are the free nerve endings in the skin that respond to intense, potentially damaging stimuli. 2. Peripheral Nervous System 3. Central Nervous System 4. Descending Control System Factors Influencing Pain Response 1. Past Experience e.g. trauma 2. Anxiety and Depression 3. Culture - beliefs

4. 5.
6.

Age infants are more sensitive Gender Placebo Effect

Characteristics of Pain 1. Intensity mild, moderate, excruciating

2.
3.

4. 5. 6. 7.

Timing morning or evening, duration may be longer or shorter Location Quality burning, aching, stabbing Personal Meaning to pain tolerance to pain may be different from one person to the other due to some personal reasons such as economic reasons, work condition, etc. Aggravating and Alleviating factors patients environment Pain Behaviors - facial expressions with pain

Pain Assessment 1. Evaluate: Cause, Location, Character and Intensity 2. Numeric Pain Scale 5-severe pain - 0 no pain 3. Descriptive Pain Scales mild, moderate, severe 4. Visual Analogue Scales 5. Faces Pain Scale Nurses Role in Pain Management 1. Identify goals for Pain management a. Decrease intensity, duration or frequency b. Factors in identifying goals: i. Severity of pain

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ii. iii. 2.

Harmful effects of pain to the client Duration of the pain

3.

Establish Nurse-Patient Relationship and Teaching a. Acknowledge the verbalization of pain by the client b. Relieve patients anxiety c. Teach measures how to relieve pain Provide Physical care a. Teach and assist in self-care b. Environmental conditions c. Application of ice/heat on painful area Manage anxiety related to Pain a. Teach about the nature of pain that may be felt by the client and reassure him/her b. Teach alternative measures to relieve pain c. Stay with the client/ frequent communication with the client Pain Medications may be administered as:

4.

5.

a.
b.

c.
d.

e.
6.

Balanced Anesthesia given to avoid experiencing pain PRN Pro Re Nata as needed Preventive taken before pain is felt Individualized Dosage Patient-Controlled Analgesia (PCA) patient takes medication if pain felt is becoming intolerable

Non-pharmacologic Interventions a. Cutaneous Simulation and Massage b. Ice and heat therapies c. Transcutaneous Electrical Nerve Stimulation d. Distraction e. Relaxation Techniques f. Guided Imagery g. Hypnosis

II.

PERIOPERATIVE CARE o Phases of Perioperative Nursing a.

b.
c. A.

Pre-operative Nursing Inraoperative Nursing Post-operative Nursing

Pre-operative Care Pre-admission and Admission Test 1. Psychological support 2. Client Education: a. Importance and practice of breathing exercises b. Location & support of wound c. Importance of early ambulation d. Inform and practice leg exercises, positioning, turning e. Anesthesia and analgesics f. Educate regarding drains and dressings to be received post-op g. Recovery room policies and procedures 3. Informed consent a. At least 18 years of age b. In sound mind- without psychologic disorder c. Not under the influence of drugs or alcohol d. Immediate relative over 18 years old Physical Assessment and preparation a. Physical Preparation NPO, remove dentures, jewelries, clothesetc.

4.

b. c. d. e. f.

Nutritional & Fluid Status should be well hydrated Drug or alcohol Use may experience delirium or intoxication to anesthetic drugs because ormal doses do not usually take effect to these patients and require heavier dose to achieve anesthetic effect. Respiratory Status - teach breathing exercises Cardiovascular Status should have controlled and stable cardiovascular functioning before operation to prevent intraoperative problems Hepatic & Renal Functions normal functioning is important in absorbing anesthetic drugs

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g. h. i. j. 5. 6.
Semi-Fowlers

Endocrine Functions- important in monitoring to hypo/hyperglycemia, thyrotoxicosis, acidosis Immune Functions allergies esp. to anesthetic drugs

prevent

Psychosocial Factors emotional and psychological preparation to ensure cooperation fom the patient with the procedures Spiritual & Cultural Beliefs - blood transfusions, transplants, ligation, etc are against other culture & religion.

Pre-operative drugs given 20-60 mins.pre-operative o Makes patient drowsy, keep siderails up Proper positioning HOB elevated at 30 degrees HOB elevated at 45 degrees Head injury, pot-op cranial surgery, post-op cataract removal, increased ICP, dyspneic patients Head injury, pot-op cranial surgery; post-op abdominal surgery; post-op thyroidectomy, post-op cataract surgery, increased ICP; dyspnea Pneumothorax, hiatus hernia Spinal cord injury, urinary catheterization Amputation of legs/feet, post lumbar puncture, post myelogram, post tonsillectomy & adenoidectomy (T&A) Post-abominal surgery, post tonsillectomy & adenoidectomy (T&A), post-liver biopsy ( right side down), post pyloric stenosis (right) Unconscious client

Fowlers

High-Fowlers Supine/ Dorsal Recumbent

HOB elevated at 90 degrees Lying on back w/ small pillow under head Lying on abdomen with head turned to the side

Lateral / Side lying

Lying on side, weight on the lateral side, the lower scapula and lower iliac. Lying on side, weight on the clavicle, humerus and anterior aspect of the iliac. Lying on back with knees and legs bent and raised on a stir up

Perineal, rectal & vaginal procedures

Trendelenburg Reverse Tredelenburg Elevate extremity

Head & body lowered, feet elevated Head elevated , feet lowered Support with pillows

Shock Cervical traction Post-op surgical procedure on extremity, cast, edema, thrombophlebitis

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Prone Supine Lateral Recumbent

Sims Position

Reverse Trendelenburg

High-Fowlers

Jack-Knife

Lithotomy

B.

Intra-operative Care

1.

Ensure sterility of all instruments and supplies at the operating field Principle: STERILE TO STERILE, CLEAN TO CLEAN
Sterile objects touches only sterile surfaces/objects Clean objects touches only clean surfaces/objects

Sterilization techniques: o Autoclave Steam, Ethyl Oxide (Gas) o Glutaraldehyde Solution- Cidex

2.
3.

Ensure safety of client in the operating table- prevent falls, drape the patient properly, provide warmth Stay with the client to relieve anxiety and support during anesthesia Anesthesia Administration:

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a. b. c. d.

General Anesthesia via Inhalation General Anestheisia via Intravenous Regional Anesthesia - local anesthesia Conduction Blocks/ Spinal Anesthesia Epidural & Spinal Block - for operation below the waist line - patient is awake during operation

4. 5. 6. 7. C.

Perform sponge count, instrument count and needle count Aseptic technique in handling and preparing all instruments and supplies Applies grounding device to prevent electrical burn during use of electrosurgical equipment Proper documentation Post-operative Care 1. Immediate assessment of VS, and Neuro VS, drainages, surgical dressing 2. Monitoring of vital signs q 15mins until stable 3. Post-operative positioning depending on the procedure performed

4.
5. 6.

Deep breathing exercises Early ambulation Health teaching for Independent (self) care upon discharge

III. ALTERATIONS IN HUMAN FUNCTIONING


1. DISTURBANCES IN OXYGENATION Arterial Blood Gas Normal Value pH pCO2 Measure of acidity or alkalinity Partial pressure of carbon dioxide parameter influenced by lungs only respiratory 7.35 7.45 35 -45

pO2

Partial pressure of oxygen; measure of amount oxygen delivered to lungs Bicarbonate, metabolic parameter influenced only by metabolic factors

80-100

HCO3

22-26

Respiratory Acidosis pH pCO2 Normal Compensation HCO3

Normal Value 7.35 7.45 35 -45 22-26

Respiratory Alkalosis

Normal Compensation

a. Administer NaHco3 b. Get rid of CO2 c. Bronchodilators d. Monitor ABG

Nursing Intervention

a. Breathe into paper bag or cupped hands b. Oxygen

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Metabolic Acidosis pH Normal Compensation pCO2 HCO3 a. Treat underlying cause (Starvation, systemic infections, renal failure, Diabetic acidosis, Keratogenic diet, diarrhea, excessive exercise) b. Promote good air exchange c. Give NAHCO3 via IV

Normal Value 7.35 7.45

Metabolic Alkalosis

Normal Compensation 35 -45 22-26 Restore fluid loss which may be cause by vomiting, gastric suction, alkali ingestion, excessive diuretic

Nursing Intervention

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

A group of conditions assoc. w/ chronic obstruction of airflow entering or leaving the lungs

Major diseases 1. Pulmonary Emphysema airway is obstructed due to destroyed alveolar walls 2. Chronic Bronchitis- increased mucus production that obstructs airway 3. Asthma Cause: 1. 2. 3. 4. Cigarette smoking Chronic respiratory infections Family history of COPD Air pollution Medical Management: 1. Bronchodilators 2. Antihistamines 3. Steroids 4. Antibiotics 5. Expectorants 6. Oxygen therapy at 2LPM use cautiously Nursing Management: 1. Administer meds and O2 as ordered 2. Promote adequate activities to enhance cardiovascular fitness 3. Adequate rests 4. Avoid allergens or other irritants 5. Psychological Support

Clinical Manifestations: Few words between breaths Pursed-lip breathing Cyanosis Distended neck veins Barrel chest increased diameter of thorax Pulsus paradoxus Clubbing of fingers Nicotine Stains Pitting edema exertional dyspnea or dyspnea at rest Enlarged pulsating liver Cough- with or without sputum production

CHRONIC BRONCHITIS Blue Bloater An inflammation of the bronchi which causes increased mucus production and chronic cough. Chronic condition is diagnosed if symptoms occur for 3 months and for 2 consecutive years.

Cause: Cigarette Smoking, infection, pollution

Clinical Manifestations: Productive cough Thicker, more tenacious mucus Slight gynecomastia Petechiae in midsternal area Dyspnea

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Decreased exercise tolerance Wheezes

Medical Management: see COPD Nursing Management: 1. Reduce or avoid irritants 2. Increase humidity 3. Administer medications as ordered 4. Chest physiotherapy 5. Postural drainage 6. Promote Breathing techniques EMPHYSEMA Pink Puffer A disorder where the alveolar walls are destroyed causing permanent distention of air spaces. (+) dead areas in the lungs that do not participate in gas or blood exchange

Cause: Cigarette smoking, Alpha-anti-trypsin deficiency (an enzyme in the alveolar walls) Clinical Manifestations: 1. Dyspnea on exertion 2. Tachypnea 3. Barrel-chest 4. Wheezes 5. Pinkish skin color 6. Shallow rapid respirations 7. Pursed lip breathing Nursing Management: Position: Sit up and lean forward Pulmonary toilet: Cough->Breathe deeply->Chest physiotherapy-> turn & position Frequent rest periods Nebulization IPPB Intermittent Positive Pressure Breathing (aerosolized inhalation) O2 @ 2LPM

Asthma -A condition where there is an increase responsiveness and/or spasm of the trachea and bronchi due to various stimuli which causes narrowing of airways Cause and Risk Factors: 1. Family history of asthma 2. Allergens: dust, pollens, 3. Secondary smoke inhalation 4. Air pollution 5. Stress Types:

1. 2.
3.

Immunologic asthma

occurs in childhood

Non-immunologic asthma occurs in adulthood and assoc w/ recurrent resp infections. usually >35 y/o Mixed, combined immunologic and non-immunologic Nursing Management:

Clinical Manifestations: Increased tightness of chest, dyspnea Tachycardia, tachypnea Dry, hacking, persistent cough (+) wheezes, crackles Pallor, cyanosis, diaphoresis

1. 2.
3.

Promote pulmonary ventilation Facilitate expectoration Health teaching Breathing techniques Stress management Avoid allergens

Chronic barrel chest, elevated shoulders distended neck veins orthopnea Tenacious, mucoid sputum

Treatment: 1. Steroids, 2. Antibiotics 3. Bronchodilators, expectorants 4. O2, nebulization, aerosol Complication: STATUS ASTHMATICUS - a life-threatening asthmatic attack in w/c symptoms of asthma continues and do not respond to treatment II. PARENCHYMAL DISORDERS:

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PNEUMONIA - An inflammatory process of lung parenchyma assoc. w/ marked increase in alveolar and interstitial fluids Etiology: 1. Bacterial / Viral streptococcus pneumoniae, pseudomonas aeruginosa, influenza 2. Aspiration 3. Inhalation of irritating fumes Risk factors: 1. Age: too young and elderly are most prone to develop 2. Smoking, air pollution 3. URTI 4. Altered conciousness 5. Tracheal intubation 6. Prolonged immobility: post-operative, bed-ridden patients Clinical Manifestations: 1. 2. 3. Chest pain, irritability, apprehensiveness, irritability, restlessness, nausea, anorexia, hx of exposure Cough- productive , rusty/ yellowish/greenish sputum, splinting of affected side, chest retration CXR, sputum culture, Blood culture, increased WBC, elevated sedimentation rate

Nursing Management: Promote adequate ventilation- positioning, Chest physiotherapy, IPPB Provide rest and comfort Prevent potential complications Health teaching: skin care, hygiene Drug therapy: o Antibiotics: penicillin, cephalosphorin, tetracycline, erythromycin o Cough suppressants o Expectorants Rest and adequate activity Proper Nutrition PULMONARY EDEMA - often occurs when the left side of the heart is distended and fails to pump adequately o Clinical Manifestation: Constant irritating cough, dyspnea, crackles, cyanosis Pathophysiology: Fluid accumulation in the alveolar sacs due to hypovolemia, fluid congestions in the lungs, alveoli are congested

Nursing Management: 1. Diuretics, low sodium diet, I&O 2. promote effective airway clearance, breathing patterns and ventilation 3. Monitor VS 4. Psychological support 5. Administer medications TUBERCULOSIS

- A chronic lung infection that leads to consumption of alveolar tissues Etiology: Mycobacterium tuberculosis.

Risk Factors: Poor living conditions, overcrowded 1. Poor nutritional intake 2. Previous infection

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Close contact with infected person 4. Inadequate treatment of primary infection Clinical Manifestations: Diagnostic Tests: 1. 2. 3. 4. 5. 6. 7. 8. 9. Productive cough Hemoptysis Dypnea Rales Malaise Night Sweats Weight loss Anorexia, vomiting Indigestion, pallor 1. 2. 3. CXR Sputum acid-fast Mantoux Test - .1 ml of PPD (Purified Protein Derivative) ; Read after 48-72 hrs. Induration: 10mm > positive exposure to TB bacillus 5 9 mm -> doubtful, may repeat the procedure > 4 mm -> Negative

3.

Treatment: 1. Ethambutol 2. Rifampicin 3. Isoniazid 4. Pyrazinamide 5. Streptomycin Client Education: 1. TB is infectious but can be cured 2. Transmitted by droplet infection and not carried on articles like clothing or eating utensils 3. Individual is generally considered not infectious after 1- 2 weeks of medication. 4. Medication regimen should be continuous and uninterrupted 5. Regimen is usually 6 months. 6. Regular check-up to monitor progress should be done. 7. Sputum samples are obtained first before drug therapy is started. 8. Advise proper handwashing and use of mask for people in contact with infected persons who are not yet under treatment. -------------------------------------------------------------------------------------------------------------------------------------------------------CARDIOVASCULAR SYSTEM THE HEART AND MAJOR VESSELS I. Diagnostic Procedure Laboratory Test Electrocardiogram Echocardiography Central Venous Pressure Pulmonary Artery Pressure/ Swan-Ganz Cardiac Catheterization II. Diseases of the Vascular System: Arterial Disorders: 1. Hypertension 2. Arteriosclerosis 3. Atherosclerosis 4. Aortic Aneurysm 5. Buergers Disease (Thromboangitis Obliterans) 6. Raynauds Disease A. DIAGNOSTIC PROCEDURES: Procedure 1. Laboratory Tests Values / Description a. Electrolytes Na, K, Ca, Chloride , Mg (see fluids & electrolytes) b. PTT 16-40 sec. c. PT 9-12 sec. d. Clotting time 10 mins. e. Cholesterol 150-250 mg/dl - determines ability of the blood to form clot or thrombus Purpose Determines hyperkalemia, Hypernatremia, etc. - determine the ability of the heart to affect circulation and regulatory functions of fluids and electrolytes. Venous Disorders: 1. 2. Thrombophlebitis Varicose Veins

Cardiac Disorders a. b. Infarction c. Failure d. e. f. Angina Pectoris Myocardial Congestive heart Valvular Stenosis AV Heart Block Pacemakers

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

- test of renal function; determines adequacy of circulation from the heart to the kidneys and its ability to excrete protein and urea

h. Enzymes: > CPK men- 55-170 - women- 30-135 ( rises 3-6 hrs after M.I.) > LDH 150-450 u/ml (rises 12 hrs after M.I.) > SGOT 5-40 u/ml i. ESR- 0-30. also rises after MI 2. Electrocardiogram P- contraction of the atrium QRS complex- contraction of the ventricles T- Resting state of the ventricles PR interval- contraction of atrium until the beginning of the contraction of ventricles ST- ventricles moves to a resting state Values / Description Ultrasound of the heart

- cardiac enzymes are present in high concentration in the myocardial tissues ; determines tissue damage in the myocardium

Determines the electrical impulse of the heart Normal impulses ensures adequate circulation to all body organs and tissues

Procedure 3. 2-Dimensional Echocardiography (2D Echo)

Purpose Determines valvular deformities, thickening of myocardium, pericardial effusion,etc Serves as guide for fluid replacement Monitor pressures in the right atrium and central veins Administer blood products, TPN, drug therapy. Obtain venous access when peripheral veins are inadequate To insert a temporary pacemaker Obtain central venous samples Monitor pressure in the ff: Right ventricle Pulmonary artery e. Distal branches of the pulmonary artery Thermodilution Obtain blood for O2 saturation d.

4. Central Venous Pressure (CVP) Normal = 5 10 cm Water

Measures the right atrial pressure or the pressure of the greater veins within the thorax by threading a catheter into a large central vein. - Subclavian - Jugular - Median - Basilic - Femoral End of catheter or Tip positioned at the right atrium or upper portion superior vena cava (for femoral insertion, tip is at the inferior vena cava)

5. Swan-Ganz Catheter / Pulmonary Artery Pressure (PAP)

Measures the level of pressure in the left atrium 4 Ports: a. Thermodilution port b. Balloon Port for inflating balloon used for placement of catheter c. Right atrium Port d. Pulmonary atrium port

c.

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6. Cardiac Catheterization

Catheter inserted into the right or left side of the heart and vessels and a dye is introduced Used to determine details on the structure and performance of the valves, heart and circulation

a. Measure O2 concentration, saturation, tension and pressure in the chambers of the heart b. Detect shunts c. To get blood samples d. Determine cardiac output & pulmonary flow e. Determine need for bypass surgery

Three types of Blood Vessels: 1. 2. 3. Arteries - carries oxygenated blood Veins - carries unoxygenated blood Capillaries allows the delivery of nutrients, oxygen and fluids to the tissues

B. DISEASES OF THE VASCULAR SYSTEM:

B. 1.ARTERIAL DISORDERS
HYPERTENSION persistent BP above 140 /90 Types of Hypertension Etiology: Essential hypertension unknown etiology - most common - may be caused by an increase in cardiac output or increase in peripheral resistance Essential hypertension Genetic Obesity Stress Loss of elastic tissues Arteriosclerosis of aorta Secondary hypertension caused by other physiologic problems

Types of Hypertension Risk Factors

Secondary hypertension Renal problems Renal Failure, Nephritis Endocrine problems Thyroid problem, DM Neurologic Disorders Brain tumors, Trauma Pregnancy-Induced HPN Many others

Signs & Symptoms Treatment

BP=140/90 ; headache, fatigue, weakness, dizziness, palpitations, flushing, blurred vision and epistaxis Non-pharmacologic:

Weight reduction Diet modification Alcohol & Smoking cessation Relaxation Techniques

Sodium restriction Exercise Caffeine Restriction

Potassium, Calcium, Magnesium supplements (to balance sodium and other electrolytes)

Pharmacologic: Calcium Agonist: Nifedipine, Verapamil Vasodilators: Hydralazine Diuretics: Aldactone, hydrochlorothizide Adrenergic inhibitors: Propanolol, Clonidine, Methyldopa Nursing Interventions BP monitoring Correct cause: obesity, diet, stress, etc Regular exercise Salt restrictions Administer medications Teach risk factors

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ARTERIOSCLEROSIS Obstruction - When the arteries become obstructed with plaque and cholesterol, they harden and constrict, and the circulation of blood through the vessels becomes difficult, forcing the blood through narrower passageways. As a result, blood pressure becomes elevated. - Arteriosclerosis occurs when lipids in the blood, including cholesterol, accumulate inside the walls of blood vessels and reduce the size of the veins or arteries through which blood flows. ATHEROSCLEROSIS Thickening - A degenerative condition of the arteries characterized by thickening due to localized accumulation of fats, mainly cholesterol. The term atherosclerosis refers to a condition in which fatty deposits build up in and on the artery walls, interfering with the normal flow of blood and oxygen throughout the body. When this happens, the heart has to work harder to pump blood through the narrowed blood vessels, and a heart attack or a stroke may result.

Predisposing factors: cigarette smoking high fat levels in the blood high cholesterol high blood pressure obesity Signs and symptoms: The symptoms of atherosclerosis depend on the part of the body where the condition is taking place. Sometimes there aren't any noticeable symptoms until the condition has advanced to a very serious stage. When the arteries of the heart are affected, one of the first symptoms is chest pain, often called angina. A person with clogged arteries of the heart may also have occasional difficulty in breathing and may experience unusual fatigue after short periods of exertion.

a. b. c. d.

e.
a. b. c. d. e.

Medical & Surgical Interventions for Athero and Arteriosclerosis: Lifestyle Modification ; Reduce Risk Factors Coronary Artery Bypass Graft (CABG Percutaneous Transluminal Coronary Angioplasty (PTCA) Directional Coronary Atherectomy (DCA) Intracoronary Stents Nursing Intervention: Health Teaching Reduce Risk Factors Restore Blood Supply Pre & Post-op Care for Surgical Patients AORTIC ANEURYSM Types of Aneurysm: Thoracic or Abdominal Aortic Aneurysm Risk Factors: Presence of Atherosclerosis, Infections or a Congenital abnormality Signs & Symptoms: Thoracic Aortic Aneurysm Dyspnea Dysphagia voice hoarseness Treatment: Thoracic/chest pain cough Abdominal Aortic Aneurysm (AAA) Abdominal Pain Low back pain Pulsating Abdominal Mass

Surgical Removal of Aneurysm a. Psychological support b. Monitor patient for signs of rupture of aneurysm

Nursing Intervention:

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Triad of manifestations for ruptured abdominal aneurysm: 1. Abdominal pain 2. Back or Flank pain (scrotal pain may also occur) 3. Shock: Bp= >100 systolic; Pulse Rate >100bpm c. Pre-operative preparation d. Post-operative care: monitor peripheral circulation BUERGERS DISEASE a.k.a. Thromboangitis Obliterans (TAO) Definition: Risk Factors: b. c. d. e. Vasculitis of the veins and arteries in the upper & lower extremities Men -20-35 y/o, Heavy smokers, hypersensitivity to intradermal injections

Signs & Symptoms: a. pain in legs relieved by immobility, numbness and tingling of toes sensitivity to cold Weak or absent pulsations at the dorsalis pedis, posterior tibial Reddish or Cyanotic extremity which may progress to ulceration or gangrene Treatment: Calcium Channel Blockers to promote vasodilation Rest, Pain Relievers, Avoid exposure to cold Surgery: Amputation of extremity is delayed until conservative treatments fail to effect. Nursing Intervention: Health teaching on lifestyle modifications, spec. smoking Ensure protection of extremities against cold Administration of medications as ordered Protect client from injury Assessment of extremities RAYNAUDS DISEASE Definition: Risk Factors: Cause: Signs & Symptoms: Vasospasm of arteries in the hands (upper extremities only) Women, heavy smokers, individuals spec. women with Systemic Lupus Erythematosus (SLE) or rheumatoid arthritis hypersensitivity of fingers to colds, congenital vasospasm, Serotonin release Cyanosis/pallor of the fingers when exposed to cold environment or emotional stimuli Numbness and occasional pain Bilateral or symmetrical involvement

Treatment: Nifedipine to decrease vasospasm Avoid exposure to cold and keep hands warm Avoid smoking Nursing Intervention Same as buergers disease

B.2.VENOUS DISORDERS:
THROMBOPHLEBITIS Definition: Risk Factors: Signs & Symptoms: Clot disorder in the vein usually at the lower extremity Trauma of the blood vessels, stasis, Increased coagulability Edema of the extremity, redness, pain, local induration, (+) Homans sign - calf pain upon dorsiflexion of foot

Nursing Intervention: a. Use of thromboembolytic (TED) stockings

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b. Elevate legs c. Heparin therapy, as ordered d. Bed rest e. Warm compress VARICOSE VEINS Definition: Cause: Risk Factors: Signs & Symptoms: Treatment: Aching Heaviness Moderate swelling Enlarged, tortuous veins in the legs distention, lengthening and totuosity of veins loss of valvular competence and constant elevation of venous pressure most commonly in the veins of the legs. Prolonged standing, obesity, pregnancy

Surgical Management: Sclerotherapy (injection of sclerosing agent to the vein. Not a treatment, hence, for cosmetic purpose only)

Nursing Intervention Elevate legs at least 30 mins. After prolonged standing Wear thromoembolic stockings Teach client o avoid prolong sitting or standing Avoid cross-legs while sitting Post-op Care after Sclerotherapy: a. Maintain firm elastic pressure over the whole limb b. Regular but careful exercise of the legs to promote circulation ambulate for short periods 24-48 hrs post-op c. Assessfor complications such as bleeding, infection, nerve damage

IV.CARDIAC DISORDERS
ANGINA PECTORIS Chest pain insufficient coronary blood flow inadequate oxygen exchange in the heart causing intermittent chest pain can be relieved with rest. It lasts only for 1-5 minutes and taking up of nitroglycerine will be beneficial for the client.

Signs and symptoms: Patient experiences retrosternal chest discomfort Pressing, heaviness, squeezing, burning and choking sensation. Pain in the epigastrium, back neck jaw or in the shoulders. Radiation of pain in the arms, shoulders and the neck.

Precipitating factor: over exertion eating exposure to cold emotional stress Classification of Symptoms: Class I no limitations of physical activity (ordinary physical activity does not cause symptoms). Class II slight limitation of physical activity (ordinary physical activity does cause symptoms). Class III moderate limitation of activity (patient is comfortable at rest, but less than ordinary activity can cause symptoms). Class IV unable to perform any physical activity without discomfort, therefore severe limitations (patient may be symptomatic even at rest).

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Nursing Interventions: a. Assess pain location, character, ECG (ST elevation), precipitating factors b. c. Help client to adjust lifestyle to prevemt angina attack avoid excessive activity in cold weather, avoid overeating, avoid constipation, rest after meals, exercise

Teach patient how to cope with angina attack nitroglycerin every 5 mins upto 3x, if still not relieved go to the hospital Diagnostic Assessment: a. ECG b. Stress Test c. Radioisotope Imaging d. Coronary Angiography Medical Management: a. b. c. Opiate Analgesic MoSo4 Vasidilators Nitroglygcerin, Isosorbide Mononitrate/Dinitrate Calcium Channel Blockers Dlitiazem, Nifedipine Beta Blocking Agents Propanolol MYOCARDIAL INFARCTION

d.

Destruction of myocardial tissue due to reduced coronary blood flow. The rapid development of myocardial necrosis caused by imbalance between the oxygen supply and demand of the myocardium. Results from plaque rupture with thrombus formation in a coronaryvessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Causes: 1. Atherosclerotic heart 2. Coronary Artery Embolism Signs and symptoms: 1. chest pain heavy (viselike, crushing, squeezing) usually across the anterior pericardium typically is described as tightness, pressure, or squeezing.

Pain may radiate to the jaw, neck, arms, back, and epigastrium. The left arm is
affected more frequently; however, a patient may experience pain in both arms.

2. 3. 4.
5.

Dyspnea, Orthopnea sense of suffocation Nausea and/or abdominal pain- gas pains around the heart Anxiety, Apprehension Light headedness with or without syncope Cough , Wheezing Nausea with or without vomiting Cold diaphoresis, gray facial color, Weakness and altered mental status common in elderly patients.

6.
7.

8.
9.

10. Rales may be present in congestive heart failure. 11. Neck vein distention represents right pump failure.
12. Dysrythmias - an irregular heart beat or pulse, usually tachycardic. 13. Oliguria urine less than 30 ml/hr Risk factors:

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Age , Male gender, Smoking, DM, Family history, Sedentary lifestyle, obesity, diet, stress, hypertension, Type A personality DIAGNOSTICS: Lab studies:

Creatine kinaseMB (CK-MB) Myoglobin CBC , Trponin Potassium and magnesium level Creatinine level C Reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Serum lactate dehydrogenase (LDH)

Imaging studies: Chest radiography or chest x-ray reveals pulmonary edema secondary to heart failure. CT scan Radionuclide Imaging Positron Emission Imaging Transesophageal Echocardiography Magnetic resonance imaging (MRI) - can identify wall thinning, scar, delayed enhancement (infarction), and wall motion abnormalities (ischemia). Electrocardiogram (ECG) - ST-segment elevation greater than 1 mm. - the presence of new Q waves. intermediate probability of MI are ST-segment depression, T-wave inversion, and other nonspecific ST-T wave abnormalities. Immediate emergency intervention:

IV access thrombolytic agents e.g. heparin supplemental oxygen pulse oximetry maintain oxygen saturation at >90% Immediate administration of aspirin en route Nitroglycerin for active chest pain, given sublingually or by spray ECG

Treatment is aimed at: Restoration of balance between oxygen supply and demand to prevent further ischemia. Chest Pain relief Prevention and treatment of complications. Drug of choice for patient with MI: Antithrombotic agents - prevent the formation of thrombus and inhibit platelet function. (aspirin, -heparin) Vasodilators - Opposes coronary artery spasm, which augments coronary blood flow and reduces cardiac work by decreasing preload and afterload - can be administered sublingually by tablet or spray, topically, or IV. (nitroglycerine) Beta-adrenergic blockers - reduce blood pressure, which decreases myocardial oxygen demand. (metoprolol) Platelet aggregation inhibitors inhibits platelet aggregation clopidogrel (plavix) Analgesics reduce pain which decreases sympathetic stress (morphine sulfate)

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Angiotensin converting enzyme (ACE) inhibitors prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. -captopril(capoten) Complications of MI: Dysrhytmias Cardiogenic Shock Heart Failure Pulmonary Edema Pulmonary Embolism Recurrent MI Complications due to Necrosis VSD, rupture of the heart, ruptured papillary muscles Pericarditis Recommendations: - All MI patients should be admitted in the ICU. Patient should remain on complete bed rest during his stay in the hospital and avoid straining activities. Nursing interventions for MI 1. a. b. c. d. e. f. Early Treat arrythmias promptly lidocaine Give analgesic- morphine Provide physical rest Administer O2 via cannula Frequent VS Nifedipine Propanolol HCL Emotional Support Later

g.
h. 2. a. b. c. d. e.

Give stool softener Provide low fat, low cholesterol, low sodium diet, soft food Commode Self-care Plan for rehabilitation Exercise program Stress management Teach risk factors f. Psychological support g. Long-term drug therapy Antiarryhtmics- quinidine, lidocaine Anticoagualnt heparin, aspirin Antihypertensives propanolol, chlorathiazide

TRANSIENT ISCHEMIC ATTACK (TIA) temporary episode of neurological dysfunction lasting only a few minutes or seconds (in a day/ 24hrs) due to decreased blood flow to the brain. A warning sign of stroke especially in first 4 weeks after TIA Causes: 1. Atherosclerosis 2. Microemboli from atherosclerotic plaque Manifestations: 1. Sudden loss of visual function 2. Sudden loss of sensory function 3. Sudden loss of motor function Management: - Surgical Carotid Endarterectomy (bypass) 1. Post-op focus assess neurologic deficits; avoid flexing neck Inability to swallow, move tongue, raise arm, smile may indicate problem in the specific cranial nerve. Anticoagulant therapy: aspirin, etc. CONGESTIVE HEART FAILURE (CHF) Definition: inability of the heart to meet oxygen and metabolic needs of the body

2.

131

Causes: 1. Abnormal loading conditions - Congenital defects, ventricular / atrial septal defect, Patent Ductus Arteriosus, Valvular stenosis, HPN, High Peripheral Vascular Resistance

2. 3.

Abnormal muscle function - Myocardial Infarction, myocarditis, cardiomyopathy, ventricular aneurysm Diseases that exacerbate or precipitate heart failure Stress, dysrhythmia, infection, anemia, thyroid disorders, pregnancy, nutritional deficiency, pulmonary disease, hypervolemia

Left Ventricular Failure Signs & Symptoms Causes Pulmonary Congestion: a. pnea b. ynes Stroke Dys Che

Right Ventricular Peripheral edema Venous congestion of organs Hepatomegaly Cyanosis of the nail beds Massive swelling of the legs, genitals and trunk (Anasarca) f. Anxiety, fear and depression f.

Cou gh, Rales, wheezing d. Orth opnea e. Par oxysmal Nocturnal Dyspnea f. Pul monary Edema g. Cer ebral hypoxia h. Fati gue &muscular weakness i. Renal Changes, Nocturia

c.

Management: Positioning High fowlers position to reduce pulmonary congestion O2 Administration Pharmacology: Digitalis, Dopamine & Dobutamine, ACE inhibitors Digitalis: increases ventricular contractility Increases ventricular emptying Increase Cardiac output Watch out for Digitalis toxicity Signs of Digitalis Toxicity: a. Eyes: b. Gastrointestinal Tract: c. Cardiovascular: d. Central Nervous System: Halo around lights Diarrhea, anorexia, vomiting, abdominal cramps Bradycardia, frequent PVCs Headache , Fatigue, Lethargy

Nursing Intervention: 1. Sodium restriction 2. Reduce pain and anxiety 3. Improve oxygenation: proper positioning, O2

4.

Reduce congestion and edema: meds, positioning

132

VALVULAR STENOSIS Definition: Signs & Symptoms: Treatment: Narrowing of valve which prevents blood flow or impaired closure of the valves causing regurgitation Murmurs, decreased cardiac output, heart failure Heart valve replacement, mitral commisurotomy Pharmacology: Anti-coagulant- Coumadin Management: low sodium, low cholesterol diet Stenosed

Nursing Intervention: same as CHF

AV HEART BLOCK Definition: Altered transmission of impulse from SA node through AV node Description delayed transmission of impulse to AV node not all impulses pass through AV node No impulse pass through AV node PACEMAKERS Definition: Types: Electronic device (battery- operated) that produce electrical stimuli to the heart and controls heart rate a. Temporary Pacemakers - external, device can be held in a belt. - used for emergency purposes, temporary pacing - inserted trans thoracic, transvenous, transesophageal, transcutaneous, transesophageal b. Permanent Pacemakers internal, device, sutured within the subcutaneous tissue. Nursing Intervention: a. b. c. d. Check for signs of infection on the site: fever, heat, pain, skin breakdown Avoid high-energy radar, television, microwave: if dizziness or tachycardia occur, ask patient to move 4-6 feet away from source. Remind to wear ID-information bracelet at all times esp. when traveling Care of Site: > wear loose-fitting around pace-maker > Encourage bath tubs rather than shower to protect incision site for the first 10 days > Explain that healing takes place within 3 months Treatment None

Degree of Block First-degree AV Block

Second-degree AV Block

Atrophine Isoproterenol Ventricular Pacemaker

Third-degree AV Block

133

--- External Pacemaker Internal Pacemaker (sutured subcutaneously) Appearance of a person w/ internal pacemaker

-------------------------------------------------------------------------------------------------------------------------------------------------------------Comparison of Chest Pain Angina Pectoris Myocardial Infarction Sudden, severe, crushing, heavy, tightness Substernal, radiates to one or both arms, jaw, neck >30 mins. Oxygen, narcotics, not relieved by rest & nitroglycerin

Type Location

squeezing, pressing, burning Retrosternal, substernal, left of sternum, radiates to the left arm Usually 3-5 mins duration <30 mins rest, nitroglycerin

Duration Relief

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

134

Subjective Data: Dyspnea Palpitation Dizziness Faintness

Subjective Data: Shortness of breath Apprehens ion, fear of impending death Nausea Objective Data: Symptoms of shock Cyanosis, diaphoresis

Sudden loss of: Visual fxn Sensory fxn Motor fxn

Objective Data: Tachycardia Pallor Diaphoresis

Restless

Objective Data: Loss of functioning about and returns normal

for to

Nursing Care Management Arteriosclerosis Angina Pectoris Transient Ischemic Attack

1. 2. 3. 4.

Lifestyle Modification Diet, stress mgt, habits Restore blood supply Anti-embolic stockings, anti-coagulants Pre & post-op care CABG,PTCA, Stents Health teaching Modifications, diet,etc.

1.
2. 3.

Provide relief from pain: Rest Nitroglycerin Lifestyle modification Vital signs Assist w/ ambulation Provide emotional support Health teaching Pain differentiation Medication Dx test Diet, exercise, CABG

1. 2.

Assess neurologic status Administer meds

Nursing Care Management Myocardial Infarction

1.

Reduce pain & discomfort: Narcotics, O2, Semi-fowlers position to improve ventilation battery- operated 2. Maintain adequate circulation. Monitor VS, Urine Output & ECG Meds: Anti-arrythmics & anticoagulants Check for edema, cyanosis, dyspnea, cough, crackles CVP: normal= 5-15cm H20 ROM, anti-embolic stockings 3. Decrease oxygen demand/ Promote oxygenation O2, Bedrest (24-48 hrs), rest periods Semi-fowlers position Anticipate needs of client: call light, water Meds: vasodilators, vasopressors, Cal.C.Blockers

4.

Maintain fluid & electrolyte balance / Nutrition Keep IV open; CVP, VS, UO Lab data: Na+135-145; K 3.5-5.0 mEq/L ECG Diet: low calorie, low sodium, low cholesterol, low fat Facilitate fecal elimination stool softener, avoid Valsalva, mouth breathing, bedside commode Provide emotional support Promote sexual functioning discuss concerns include partner resume 5-8 wks after uncomplicated MI

5.
6. 7.

8. Health teaching

2. Gland

DISTURBANCES IN METABOLIC & ENDOCRINE FUNCTIONING Hormone Functions

135

Pituitary Gland Anterior Lobe

Growth Hormone Prolactin Thyrotropic hormone (TSH) Gonadotropic hormones (LH & FSH) Adrenocorticotropic hormone (ACTH) Melanocyte-stimulating Hormone (MSH) Anti-diuretic hormones (ADH, vasopressin) Oxytocin

Stimulates growth of body tissues and bones Stimulates mammary tissue growth & lactation Stimulates thyroid gland Affect growth, maturity and functioning of primary and secondary sex organs Stimulates steroid production by adrenal cortex May stimulate adrenal cortex; may affect pigmentation

Posterior lobe

Promotes reabsorption of water by the distal tubules and collecting ducts of the kidney, thus decreasing urine output Stimulates ejection of milk from mammary alveoli into the ducts: stimulates uterine contractions may possibly be involved in the transport of sperm in the reproductive tract of the female Increases metabolic activity of almost all cells; stimulates most aspects of fat, protein and carbohydrate metabolism Lowers serum calcium levels and elevates phosphate level; opposite effect from that of PTH Increases calcium levels and decreases phosphate levels; increases resorption of bones Promotes carbohydrate, protein and fat catabolism, increases tissue responsiveness to other hormones Tends to increase sodium retention and potassium excretion Governs certain secondary sex characteristics; all corticoids are important for defense against stress or injury Elevates blood pressure, converts glycogen to glucose when needed by muscles for energy; increases heart rate; increases cardiac contractility; dilates bronchioles Stimulate development of secondary sex characteristics, effect repair of the endometrium after menstruation Essential for normal functioning of male reproductive organs; stimulates development of secondary sex characteristics Promotes metabolism of carbohydrates, protein and fat thus decreasing blood glucose Mobilizes glycogen stores, thus raising blood glucose levels Decreases secretion of insulin, glucagons, growth hormone and several gastrointestinal hormones( gastrin, secretin)

Thyroid Gland

Thyroxine (T4) Triiodothyronine (T3) Thryrocalcitonin

Parathyroid Adrenal Cortex Controls SSS: SUGAR, SALT, SEX

Parathormone (PTH) Glucocorticoids (primarily cortisol) -- Sugar Mineralcorticoids (Aldosterone) -- Salt Androgens (male hormones) -- Sex

Medulla

Epinephrine (Adrenalin)-80% Norepinephrine- 20%

Ovaries

Estrogens and progesterone

Testes

Testosterone

Pancreas Islets of Langerhans

Insulin Glucagon Somatostatin

PITUITARY GLAND PROBLEMS

136

Clinical Manifestations Acromegaly Growth Hormone IN ADULTS 1. Enlarged extremities 2. Protrusion of jaw and orbit 3. No increase in height and weight but hands and feet become bigger 4. Increased perspiration 5. Visual problems 6. Hyperglycemia/calcemia

Management 1. Irradiation of pituitary with Bromocriptine to decrease secretion of growth hormone 2. Surgery: Hypophysectomy-removal of the pituitary gland 3. Post-op Care: a. Assess ICP b. Elevate head of bed (HOB) 30 degrees c. Avoid coughing, sneezing, blowing nose

Gigantism Overgrowth of all body tissues and bones Growth Hormone


In CHILDREN

Dwarfism Growth Hormone In CHILDREN

1. Retarded physical growth 2. Premature body aging 3. Slow intellectual development

1. Removal of cause : tumor 2. Human Growth Hormone Injection 3. Same as acromegaly & gigantism

Diabetes Insipidus Antidiuretic Hormone

1. Polyuria 2. Polydipsia 3. Dehyration

1. Pharmacology: a. Desmopressin Acetate nasal spray b. Vasopressin Tannate IM injections c. Hypressin Nasal Spray 2. Nursing Interventions; a. Maintain adequate fluids b. Sodium Restriction c. Intake & Output monitoring d. Teach self-injection techniques e. Daily weights f. Specific gravity

SIADH Syndrome of Inappropriate secretion of ADH

1. Hyponatremia 2. Mental confusion 3. Personality changes 4. Lethargy, weakness, headache 5. Weight gain 6. Abdominal cramping 7. Anorexia, nausea, vomiting

1. Fluid restriction 2. Treat underlying causes 3. Pharma: a. Demeclocycline administration as ordered b. Lithium Carbonate c. Butorphanol Tatrate

ADRENAL GLAND PROBLEMS

137

Clinical Manifestations Addisons Disease 1. Malaise and general weakness 2. Hypotension, hypovolemia 3. Increased pigmentation of skin 4. Anorexia, nausea, vomiting 5. Electrolyte Imbalance 6. Weight loss 7. Loss of libido 8. Hypoglycemia (60-70) 9. Personality Changes

Management 1. Pharmacology: Steroids (Prednisone, dexamethasone) 2. Diet: high CHO, CHON diet 3. Observe side effects of hormone replacement Cushingoid Appearance 4. Monitor fluid & electrolyte 5. Teach importance of lifelong medications 4. WOF Signs of Addisonian Crisis: Addisonian Crisis: Sudden profound weakness Severe abdominal, back and leg pain Hyperpyrexia followed by hypothermia Peripheral vascular collapse Shock Renal Shutdown -> Death

Glucocorticoids Mineralcorticoids Sex Hormones

Cushings Syndrome

Glucocorticoids

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Thin scalp Moon Face Acne Increased body hair Buffalo hump Obesity Hyperpigmentation Thin extremities Easy Bruising Mood swings, male characteristics appear in women 11. Hypokalemia, Hyperglycemia, HPN 12. Amenorrhea 13. Osteoporosis

1. Surgical Mgt: Adrenalectomy 2. Chemotherapy: Bromocriptine 3. Diet: high CHON, low CHO, low Na diet , potassium supplement 4. Nursing Mgt: > protect from infection > protect from accidents > health teaching on self-medication

STEROIDS: Purpose: Anti-inflammatory and anti-allergy; Stress Tolerance Medication: a. Take at the same time everyday b. Follow regime and do not stop abruptly c. Causes gastric upset Side effects: Cushingoid Appearance Conns Syndrome / Aldosteronism 1. HPN 2. Hypokalemia 1. Surgery: Removal of tumor 2. Potassium replacement 3. Treatment of hypertension 4. Nursing Mgt: Monitor BP, administer meds, provide quiet environment

Mineralcorticoids (Aldosterone)

Pheochromocytoma

Epinephrine/ Norepinephrine

1. HPN 2. Increase Perspiration 3.Apprehension 4.Palpitations 5. Nausea, Vomiting, Headache 6. Tachycardia 7. Hyperglycema

1. Surgical Mgt: Removal o tumor 2. Medical Management: Symptomatic (Treat symptoms as it occurs) 3. Nursing Mgt: > High caloric diet > Adequate Rest

THYROID GLAND PROBLEMS

138

Clinical Manifestations Graves Disease / Hyperthyroidism/ Thyrotoxicosis 1. Exopthalmos- protrusion of eyes 2. Enlargement of the thyroid gland 3. Increase metabolism: weight loss, diarrhea, diaphoresis 4. Personality changes 5. Cardiac Arrythmias 6. Easy fatigability 7. Muscle weakness 8. HPN 9. Anxiety, Insomnia

Management 1. Surgery: Thyroidectomy 2. Drug Therapy: a. Methimazole b. Propyl- Thyracil c. Iodides: Lugols solution strains teeth, drink w/ straw Saturated Solution of Potassium Iodide (SSKI) d. Propanolol 3. Radioiodine therapy 4. Nursing Mgt: a. Adequate Rest b. High caloric, high protein, carbohydrate, vitamins without stimulants c. Measure daily weights d. Eye protection for xopthalmos e. WOF: Thyroid Storm

T3, T4, Thyrocalcitonin

THYROID STORM: a. Fever b. Tachycardia c. Delirium d. Irritability

Cretinism
T3, T4, Thyrocalcitonin INFANTS

1. Physical & mental retardation 2. Sensitive to cold 3. Dry skin 4. Poor appetite and constipated Treatment: Hormone Replacement

Myxedema
T3, T4, Thyrocalcitonin ADULT

1. anorexia and constipation 2. intolerance to cold 3. Slow metabolism: decreased sweating, edema 4. Dry skin 5. Enlarged thyroid

1. Drug Therapy: a. Levothyroxine b. Thyroid Replacement (Desiccated thyroid) ** taken in empty stomach ** heart rate less than 100 bpm -ok

PARATHYROID GLAND PROBLEMS Clinical Manifestations Hypoparathyroid


Parathormone

Management 1. Drug therapy: Levothyroxine, Liothyronine Sodium 2. Avoid stimulus

Bradycardia , Fluid retention, Dry, coarse skin, Decreased libido, irregular menses

Easy bruising Constipation Fatigue, lethargy Menorrhagia,

139

Hyperthyroid

Parathormone

Tachycardia Palpitations Increased persitalsis weight loss Heat intolerance Decreased libido Amenorrhea

1. Drug therapy: Prophylthiuracil Methimazole, Saturated solution of Potassium Iodide, Radioactive Iodine 2. Diet: low calcium, high fiber 3. Force fluid

PANCREATIC PROBLEMS DIABETES MELLITUS

Type I Insulin Dependent DM (IDDM) Other Name Age of Onset Before 30 years old but may occur at any age Onset Abrupt Incidence 10% Insulin production Little or none Insulin Injections Required Ketosis May occur Body weight at onset Ideal body weight or thin Management Diet, exercise and insulin Juvenile DM

Type II Non-Insulin Dependent DM (NIDDM) Adult DM >35 y/o but can occur in children Insidious 85-90% Below normal Normal or Above normal Necessary for only 20-30% of clients Unlikely to occur Usually Obese Diet, exercise, hypoglycemic agent or insulin

Cardinal Signs & Symptoms: 1. Polydipsia

- excessive thirst - frequent urination

2. 3.
4. Treatment: 1. Oral hypoglycemics: a. Glipizide b. Glyburide c. Tolbutamide d. Tolazamide e. Acetohexamide f. Chlorpropamide

Polyuria

Polyphagia - excessive hunger Weight Loss - for IDDM

Side effects: a. Hypoglycemia b. Skin rashes c. GI disturbances d. Flushing e. Nausea, vomiting Administration: > usually administered 30 mins. before meals to promote faster absorption of the meds

140

2. Insulin Injections: Action Appearance- Preparation Onset of Effect Short-Acting Clear Cloudy Intermediate Acting Long-Acting Cloudy Cloudy Cloudy Cloudy Pre-Mixed - Regular Insulin - Semilente - NPH - Lente - Protamine zinc - Ultralente 30 mins. 1 hr. 30 mins. 1 hr. 1 2 hrs. 1 3 hrs. 4 6 hrs. 4 6 hrs. 30 mins. Peak 2 4 hrs. 2 8 hrs. 6 12 hrs. 6 12 hrs. 18 24 hrs. 14 24 hrs. 2 -12 hrs. Duration of Effect 6 8 hrs. 8 16 hrs 18 -26 hrs. 18 -26 hrs. 28 36 hrs. 36 hrs. 18- 24 hrs.

Cloudy - 70% NPH - 30% regular

Complications of DM: a. Hypoglycemia Cause: Signs & Symptoms: Nursing Interventions: Hunger, less dietary intake, excessive insulin Diaphoresis, Tachycardia, tremors, weakness, irritability, confusion Give candy, juice or softdrinks, let the patient eat Check sugar level

b.

Diabetic Ketoacidosis Cause: Signs & Symptoms: Lack of insulin , Infection, Stress Polyuria, thirst, Nausea, vomiting, dry mucous membranes, Kussmaul resp, Coma, sunken eyesballs, acetone odor of breath, hypotension, abdominal rigidity Give regular insulin

Nursing Interventions: c. Lipodystrophy Cause: Signs & Symptoms: Nursing Interventions: d.

Indurated areas on skin due to injections Skin indurations Teach client to rotate sites of injection

Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) Cause: Signs & Symptoms: Extremely high glucose, no ketosis Polyphagia, polydipsia, polyuria, glucosuria, dehydration, abdominal discomfort, hyperpyrexia, hyperventilation, changes in sensorium, coma, hypotension, shock Fluid & electroluyte replacement, Insulin

Nursing Interventions:

141

4.

DISTURBANCES IN ELIMINATION 3.1. Inflammatory and Neoplastic Disorders a. Acute Gastritis b. Chronic Gastritis c. Duodenal Ulcer d. Gastric Ulcer e. Gastric Cancer Acute Gastritis Chronic Gastritis o Same in Acute Gastritis Treatment Medical Management: a. Antacids b. Small frequent meals c. Bland diet d. May prescribe anticholinergics in chronic gastritis Nursing Interventions/ Health Teaching: -Avoid spicy foods -Avoid alcohol intake -Frequent small meals

Incidence:

o Common in age 50-60 years


old o Frequent in male than female o Greater incidents in heavy drinkers and smokers

Cause:

Helicobacter Pylori Medicines: Aspirin, NSAIDS, chemo drugs, steroids Food: Alcohol, coffee, spicy foods

o History of or presence of peptic ulcer disease o Previous gastric surgery o Same as acute gastritis

Prolonged o May be asymptomatic o Other symptoms include: o Dyspepsia, belching, vague epigastric pain, N/V, intolerance to spicy or fatty foods No increase in hydrochloric acid

Duration: Clinical Manifestations:

Short Epigastric discomfort, Abdominal pain, cramping, severe nausea, vomiting and sometimes hematemesis Increased hydrochloric acid.

Acid production:

Duodenal Ulcer Occurrence: o 25-50 yrs. old o Type A personality (leaders, executives); o Usually in a wellnourished individual

Gastric Ulcer Nursing Intervention: > 50 yrs. old a. Relaxation techniques

Most common in persons like farmers, construction workers o Usually affects malnourished individuals Excessive smoking, salicylates intake Normal to hyposecretion Lesser curvature o Experienced to 1 hour after meal o Ingestion of FOOD DOES NOT RELIEVE PAIN

b. Eliminate caffeine, cigarette smoking, alcohol intake and spicy foods c. High fat, high carbohydrate Medical Treatment: Antacids - avoid administration within 1-2 hr of other oral meds - frequent administration ac, pc, hs H2 Antagonists - with meals/pc Anticholinergics Prostaglandin Analogs **misoprostol** & ACID PUMP INHIBITORS - **inhibits the enzyme that produces gastric acid H Pylori Metronidazole Omeprazole Tetraycline/Clarithromycin Cytoprotective binds with

Cause: Acid production: Location of Ulcer Pain:

Stress, Poor food habit Hypersecretion Pylorus o Experienced 2-3 hrs after meal o Ingestion of FOOD RELIEVES PAIN

142

Bleeding

Melena is more common than hematemesis Not possible

diseased tissue and provides a protective barrier to acid Hematemesis is more common than melena Surgical Treatment 1. Vagotomy 2. Gastric ResectionGastroduodenostomy; Gastrojejunostomy

Malignancy:

Possible

GASTRIC CANCER Incidence: f. g. h. i. j. Common in men than women History or presence of Pernicious Anemia Often develops with the occurrence of atrophic gastritis Low-socio economic status; live in urban area Exposure to radiation or trace metals in soil

Cause: Helicobacter Pylori Clinical Manifestations: a. Palpable mass b. Ascites c. Weight loss d. Dysphagia e. Indigestion and anorexia f. (+) high lactate dehydrogenase level in gastric juice Diagnosis: GIT x-ray, gastroscopy Treatment: Chemotherapy, radiation therapy, gastric resection Nursing Intervention: Same as with patients with ulcer, emotional support, pre and post-operative health teaching 3.2. Disorders of the Large and Small Bowel VIRAL AND BACTERIAL GASTROENTERITIS/ DYSENTERY Gastroenteritis Inflammation of stomach and intestine usually the small bowel. S/S: abdominal cramps, diarrhea, vomiting, fever, severe fluid and electrolyte loss, mild to severe temperature Cause: Viral Dysentery Inflammation in the colon S/S: severe bloody diarrhea and abdominal cramping, severe fluid and electrolyte loss, mild to severe temperature Cause: Bacterial ( E.coli nd/or shigella, salmonella, Clostriduum difficile from antibiotics) o o o o Risk Factors: Poor food handling Poor sanitary conditions Overcrowding Food remaining on high temperature making organisms incubate and colonize easily.

Management: o Replace fluid loss o Anti-infective Agent (e.g. Metronidazole spec for amoebiasis, Bactrim) Nursing Intervention: o Measure intake and output o Administer medications o Replace fluids APPENDICITIS o Inflammation of the vermiform appendix Incidence: Common between 20-30 yrs. old

143

Cause:

Fecalith (stone or calculus in the appendix) Fibrous condition in the bowel wall

.-> Kinking of the appendix -> Bowel adhesion

S/S: Pain starts in the epigastriium the shifts to the the right lower quadrant Guarding of painful area Keeps legs bent to relieve tension May have vomiting, loss of apetite, low grade fever, coated tongue and halitosis Diagnosis: Increased WBC, (+) pain at Mc Burneys point (RLQ) Treatment: Appendectomy Nursing intervention: Assess the VS and pain scale carefully Observe for symptoms of peritonitis , Pre & post-operative care PERITONITIS o o Inflammation of the peritoneal membrane Cause: Gangrenous cholecystitis Ruptured gallbladder Perforated gastric cancer Perforated Peptic ulcer Ruptured spleen Acute pancreatitis Penetrating wound Ulcerative colitis Gangrenous obstruction of the bowel Perforated diverticulum o

Ileitis Appendicitis with perforation Ruptured retroperitoneal abscess Strangulated hernia Salpingitis Septic Abortion Ruptured bladder Puerperal infection Iatrogenic Cause

Signs and Symptoms: Localized pain Abdominal rigidity Increased pain upon movement Nausea, vomiting (N/V) Absence of bowel sounds Shallow respirations Increased WBC , dilation and edema of intestines revealed in GIT x-ray Medical Management: NGT: Lavage to relieve pressure in the abdomen Fluid & electrolyte replacement Surgical Treatment: Appendectomy or Exploration of the abdomen with drainage Nursing intervention: Careful assessment of history, V/S, fluid & electrolytes Pre & Post-operative Care

o o

c. Inflammatory Bowel Disease: ULCERATIVE COLITIS & CHRONS DISEASE CHRONS DISEASE Pathology & Anatomy Involves primarily the ileum & right colon Distribution of dse is segmental Malignancy is rare May be genetic Usually in the 30s Remissions and relapses Course of Disease Slowly progressive Common ULCERATIVE COLITIS Mucosal ulceration of lower colon and rectum Distribution of dse is continuous Malignancy may occur after 10 years May be caused by infection or alteration in immunity Young adults (20-40) Onset

Etiology

144

Rectal bleeding Anorectal fistula Other S/S:

Occasional Rare Common Abdominal pain Weight loss Diarrhea soft or semi-liquid Pain in RLQ, cramping, tenderness, flatulence, nausea (mimics Appendicitis) Replacement of fluid loss Anti-diarrheal: Diphenoxylate HCL (Lomotil) ; Loperamide HCL (Imodium) Total Parenteral Nutrition Bowel Resection, Ileostomy Rectal bleeding, diarrhea (20 stools/day or more); Stools may occur with blood or pus, weight loss Urgency, cramping, Pain LLQ, abdominal distention, emotional stress. Same as Chrons Dse

Medical Treatment

Surgical Treatment Nursing interventions:

Bowel Resection, Ileostomy Assess Intake and output, weight Emotionla support Client teaching regarding surgery Post-op intervention: Observation of the stoma Teach client re: self-care Same as Chrons Dse

HERNIA -An abnormal protrusion of an organ or tissue through the structure that contains it. - Frequently a congenital occurrence or acquired weakness of the abdominal muscles Types: Indirect Inguinal Hernia 2. Direct Inguinal Hernia 3. Femoral Hernia 4. Umbilical Hernia 5. Incisional Hernia Medical Treatment: Use of TRUSS if hernia is not strangulated or incarcerated. Surgical Treatment: Herniorrhaphy

1.

Nursing Intervention: Pre & Post-operative Care Post-op Care: a. Make sure the client voids after surgery, urinary retention is common after herniorrhaphy b. Resume diet as tolerated by the patient c. Ice pack over the incisional site to control pain and swelling d. Instruct patient to avoid heavy lifting from 4-6 weeks post surgery

DIVERTICULUM Diverticulum an outpouching of intestinal mucosa through the muscular coat of the large intestine (most commonly the sigmoid colon) Diverticulosis refers to the presence of non-inflamed out pouching of the intestine Diverticulitis inflammation of a diverticulum Incidence: Etiology: > 45 yrs. old ; Male & Female Lower fiber diet which causes bulk in stools which may cause intraluminal pressure in the bowel causing diverticula Chronic Constipation Anorexia Low grade fever

Risk factors: S/S:

Left Quadrant Pain Increased flatus

145

(+) rectal mass on digital rectal examination Medical Intervention: High-fiber diet and laxatives NGT insertion to relieve pressure Control inflammation through antibiotics and advise patient to: a. Avoid activities that may increase abdominal pressure (bending, lifting, etc) b. Intake of 6-8 glasses of water a day c. Reduce weight if obese Indicated for those who developed complications as manifested by hemorrhage, abscess, perforation and obstruction. o Colon resection with colostomy Indications Colostomy o Involves the large bowel (colon) o stool is semi-formed Inflammatory / obstructive process of the lower intestinal tract Trauma Rectal or sigmoid cancer Diverticulum o Chrons Disease Ulcerative Colitis Nursing Intervention 1. Emotional support 2. Psychological Support 3. Heath Education regarding: a.surgery (ileostomy/colostomy) b. Self-care

Surgical Intervention:

Ileostomy o Involves the small bowel (ileum) o stool is in liquid form

o o

d.

Hirschprungs Disease and Megacolon Congenital absence of parasympathetic ganglion Clinical Manifestations: o NB fail to pass meconium 24 hrs after birth o Older child recurrent abdominal distention, chronic constipation, ribbon-like stool, diarrhea, emesis w/ bile stain Treatment: a. Colostomy b. Bowel Resection c. Cleansing Enema Post-op Nursing Intervention; a. Teach colostomy care- check color of stoma (should be bright leg) b. Check dressing c. Monitor intake & output d. Avoid incision by keeping diapers low e. 10-11 yr. old child can already take care of his/her own stoma.

e. Hemorrhoids o Peri-anal varicosities which is either internal or external

Types: a. Internal varicosities above the mucocutaneous border covered by the mucous membrane.

146

b. External Hemorrhoids- varicosities below the mucocutaneous border covered by the anal skin. Incidence: Risk factors: S/S: Both male and female aged 20-50 y/o. Pregnancy, CHF, Prolonged sitting or standing, portal hypertension Increased abdominal pressure, constipation, straining during bowel Movement Internal bleeding and renal prolapse, bleeding and rectal itching External enlarged mass at the anus

Present symptoms in both internal & external: Bright red (blood) stain in stool or tissue, Pain Medical Intervention: a. Treat constipation b. Relieve pain through heat application / Siths bath Surgical Intervention: Hemorrhoidectomy, Sclerotheraphy, Rubber band ligation, Laser Surgery, cryosurgery

f. Fistula-in-ano Tiny, tubular fibrous tract that extends into the anal canal May develop from trauma, fissures or regional enteritis Fistulectomy is recommended. .3.3. Abdominal Trauma :

a. b.
5.

Blunt Trauma injury like vehicular accident Penetrating Abdominal Trauma stab wound

DISTURBANCES IN FLUIDS AND ELECTROLYTES Fluid Content in the Human Body : a. Women b. Men c. Infant d. Elderly Electrolytes in the Human Body: a. Sodium (Na) b. Potassium (K) c. Chloride (Cl) d. Bicarbonate (HCO3 ) 50-55% of body weight is water 60-70% of body weight is water 75- 80% of body weight is water 47% of body weight is water -

135-145 mEq/L 3.5 5.5 mEq/L 85-115 mEq/L 22-29 mEq/L

Functions of the Fluid & Electrolytes in the Human Body: a. Regulates acid-base balance in the body b. Maintains fluid volume c. Regulates exchange of water between fluid compartments a. b. c. Actions of the Fluids & Electrolytes Diffusion fluids move from area of higher concentration to an area of lower concentration Osmosis - fluids move from an area of lesser concentration to a higher concentration Filtration fluids and substances moves from higher hydrostatic pressure to lesser hydrostatic pressure. Intravenous Solutions Used to correct imbalance: e. Isotonic 0.9 NSS, D5W f. Hypertonic has greater concentration of solis substances than the fluid substances e.g.Total Parenteral Nutrition, D50 g. Hypotonic has fewer solid and has higher fluid content, e.g. 0.45 NaCl System of Fluid Balance in the body: a. Kidneys responsible in controlling the balance of fluid & electrolytes b. Lungs- controls the Carbondioxide levels in the body and water vapor c. Skin means of elimination of fluid in the body through perspiration d. Endocrine Controls hormones which regulates normal functioning of systems Imbalances in Fluids & Electrolytes Fluid Volume Excess Cause fluids exceeds the normal volume the body needs - physiologic or over hydration as Fluid Volume Deficit fluids and/or electrolytes are loss physiologic or dehydration

147

in IV therapy Illness: Renal Disease Neurologic Diseases Congestive Heart Failure Addisons Disease Renal Disease Diarrhea Post-operative conditions Burns Trauma GIT Suction/Drainage Weight loss Dry skin and mucous Membrane Tachycardia (same w/ excess) Poor skin turgor Decreased urine output Decreased Central Venous Pressure Increased hematocrit Urine output: < 30 cc/hr
( Normal Urine Output =30 cc/hr)

Clinical Manifestations

Weight gain Edema Flushed skin Tachycardia Increased BP, RR Rales Neck Vein distention Increased Central Venous Pressure Decreased Hct Urine output: > 1,500 ml/day Monitor vital signs Monitor I & O Fluid restriction Low sodium diet Weight daily Prevent skin breakdown- skin is fragile Keep client in Semi-fowlers position to establish good gas exhange Administer Diuretics as orderedLasix (Furosemide)

Nursing Interventions

Monitor vital signs Monitor I & O Replace fluids, Rehydration Weight daily Administer medications as ordered ( depending on electrolytes loss) Encourage proper nutrition an fluid intake

Sources of Electrolytes: Electrolyte Potassium Sodium Magnesium Calcium Food source Bananas, peaches, melon, prunes, raisins, apricots, tomato, nuts & vegetables, red meat, turkey Iodized or table Salt Peas, beans, nuts, fruits Milk, cheese, sardines, fish

4.1

Genitourinary & Renal Problems Renal Function Tests Normal Values: a. Blood Urea Nitrogen (BUN) 10-20 mg/dl b. Serum Creatinine- 0-1 mg/dL c. Creatinine Clearance 100-120 ml/ minute (24 hr. urine collection) d. Serum Uric Acid -3.5 -7.8 mg/dL e. Urine Uric Acid 250-750 mg/ 24 hrs. (24 hr. urine collection) 4.1.2. Cystitis / Urethritis/ Urinary Tract Infection usually caused by E.Coli Signs & Symptoms a. Frequency & Urgency of urination b. Dysuria c. Suprapubic pain d. Hematuria e. Fever, chills f. Cloudy urine Nursing Considerations: a. Collect urine for testing b. Antibiotic treatment, as ordered c. Force fluids d. Good hygiene

4.1.3.

Glomerulonephritis inflammatory damage of the glomeruli usually Streptococcus

Signs & Symptoms: Hematuria, proteinuria, fever, chills, weakness, nausea, vomiting Edema Oliguria

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HPN Headache Increased Urea Nitrogen Flank Pain Anemia Nursing Considerations: a. Penicillin, as ordered b. Proper dietary intake c. Sodium & fluid restriction d. Bed rest 4.1.4. Nephrotic Sydrome glomeruli disorder due to other diseases like DM, SLE, etc. Signs & Sypmtoms: a. Proteinuria b. Hypoalbunimemia c. Hyperbilirubinemia d. Edema Nursing Considerations: a. bed rest b. high calorie, high protein, low sodium c. Monitor I & O d. Protect from infection e. Administer meds as ordered: Diuretics, Steroids, Immunosuppresiove agents, anticoagulants 4.1.5. Urolithiasis - stones in the urinary system Signs & Symptoms: a. Dull aching pain b. Nausea, vomiting, diarrhea c. Hematuria d. UTI symptoms Nursing Considerations: a. Force fluids: at least 3L of water in a day b. Strain Urine for stones c. Administer meds as ordered 4.1.6. Acute Renal Failure sudden and reversible malfunction of the kidney due to trauma, allergies, stones or benign Prostatic hyperplasia Signs & Symptoms: 3 Phases a. Oliguric Phase sudden , (+) edema - urine is less than 400 cc in 24 hrs. b. Period of Diuresis urine is 1000 ml in 24 hrs and is diluted c. Recovery Period Nursing Intervention: a. Treat cause of sudden occurrence b. Maintain Fluid & electrolyte balance c. Prevent hypokalemia d. Administer insulin or IV glucose as ordered to promote potassium absorption e. Proper diet : Oliguric low CHON, High CHO, high fat, less potassium Diuresis high CHON, high calorie, less fluid f. Weigh daily g. Monitor I & O h. Dialysis if indicated i. Psychological & emotional support 4.1.7. Chronic Renal Failure progressive failure of kidney function which may result to death, caused by chronic gomerulonephritis (CGN), pyelopnephritis, DM, uncontrolled HPN Signs & Symptoms: a. fatigue b. Headache c. Gastrointestinal symptoms d. HPN e. Irritability f. Convulsions

149

g. Anemia h. Elevated BUN, crea, sodium, potassium Treatment: Dialysis Renal Transplant a. b. c. d. Nursing Considerations: Maintain fluid & electrolyte balance Bedrest Diet: low protein, low sodium, high CHO and vitamins Control HPN WOF cerebral irritation

e. 4.1.8.

Benign Prostatic Hyperplasia enlargement of the prostate with unknown etiology usually in older males Signs & Symptoms: Difficulty in urinating Nocturia, hematuria, dribbling sensation

Surgical Treatment: Prostatectomy Post-operative Nursing Consideration: a. Observe for shock and hemorrhage b. Bladder Drainage; monitor bladder irrigation c. Avoid lifting heavy objects x 6 weeks and avoid strenuous activities d. Increase fluid intake e. Decrease pain, administer meds as odered TREATMENT FOR GENITOURINARY PROBLEMS: 1. Dialysis a. Hemodialysis Process of cleansing the blood of waste products which the GUT is unable to eliminate Cathether inserted via a small incision on the neck (intrajugular), arms or at the femoral area. b. Peritoneal Dialysis Use of peritoneum via a catheter for proper exchange of fluids and electrolytes and drainage of fluids Catheter inserted just below the umbilicus with small incision Continuous Ambulatory Peritoneal Dialysis

c. a. b. c. d. e. 2.

Nursing Interventions: Weigh daily Monitor vital signs Maintain asepsis at all times Record intake and output Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel perforation Urinary Tract Surgery a. Transurethral Removal of the Prostate b. Prostatectomy Nursing Interventions: Weigh daily , monitor I&O Monitor vital signs Maintain asepsis at all times Monitor for complications: Bleeding, peritonitis, abdominal pain, dyspnea, bowel Replace fluids Proper irrigation

3.

Kidney Transplant

KIDNEY DISEASE IN THE PHILIPPINE HEALTH SITUATION 6,000 new cases of renal disease per year Affects all ages Adult: End-Stage Renal Disease (ESRD)

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Children and young: Chronic Glomrulonephritis Causes: 1. Chronic Glomerulonephritis 47% 2. Chronic Pyelopnephritis 17% 3. Diabetes Mellitus- 13% 4. Hypertensive Nephrosclerosis- 5% Kidney Disease Prevention: Good Nutrition Clean Environment Early detection of of the disease Thorough urinary screening of asymptomatic children Increase casefinding and treatment for chronic glomerulonephritis Good glycemic control (w/ DM) Optimum Blood Pressure Control Nursing Health Education: 1. Increase awareness and prevent renal disease: Adequate water intake Balanced diet Good personal hygiene Regular exercise Regular BP check-up Complete immunization for infants and children Proper management of throat and skin infections Yearly urinalysis 2. Increase awareness of signs & symptoms of kidney disease as edema and HPN 6. 6.1. 3. Routine screening for UTI, diabetes and kidney disease DISTURBANCES IN CELLULAR FUNCTIONING

CANCER o Abnormal growth of tissues a. Carcinoma - epithelial cells lining the internal and external surfaces of the body. b. Leukemia - cancer from blood-forming organs c. Lymphoma cancer from reticulo-endothelial lymph node organs d. Sacrcoma- cancer from connective tissues

o o

Cancer in the Philippines: Ranks third in leading cause of morbidity and mortality 75% of cancers occur at age 50 y/o Staging of Tumors a. Extent of tumor T= primary tumor N= regional nodes M= metastasis b. Extent of Malignancy T0 = no evidence of primary tumor TIS= Carcinoma in Situ T1, T2, T3, T4 = progressive tumor in size and involvement TX = tumor cannot be assessed Involvement of Regional Nodes NO = regional lymph nodes not abnormal N1, N2,N3, N4 = increasing degree of abnormal regional lymph nodes Metastatic Development MO= no evidence of distant metastasis M1, M2, M3 = increasing degree of distant metastasis

c.

d.

Clinical Manifestations of Tumor Presence (based on Community Health Nursing Services in the Philippines by the DOH) C A U T I Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in Ex. Gastric Ca, Colon Ca, Rectal Ca , Renal Ca, Prostate Ca Ex. Laryngeal Ca Ex. Uterine Ca Ex. Breast Ca, Hodgkins Lymphoma Ex. Esophageal Ca

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O N U S

swallowing Obvious change in wart or mole Nagging cough or hoarseness Unexplained Anemia Sudden uexplained weight loss

Ex. Melanoma, Squamous cell Ca Ex. Lung Ca Most Ca conditions

Risk Factors Age Health Habits Sex Family History Race Socio-Economic Status Occupation Lifestyle Cancer Therapy a. Surgery b. Chemotherapy chemical/ medication

c.
d.

Radiation Therapy electromagnetic rays destroys cancer cells Palliative/ Supportive Care- for end-stage or terminal stage - given if chemo, surgery or radiation therapy cannot assure treatment of the patient ; it is a holistic care for the patient and family - management o f care is geared towards a symptom-free individual with psychologic and spiritual support

Cancer Prevention & Early Detection Type of Cancer Oral Cancer Early Prevention Avoid Smoking tobacco, Betel quid Nganga chewing, Proper cavity and dental chewing No conclusive evidence for early prevention Early Detection Thorough dental check-up each year

Breast

Monthly self-exam and annual exam with physician; Mammography: o Initially at age 40 and then 1-2 yrs thereafter o High risk women- should consult a doctor before age 40

Lung Uterine / Cervix

Avoid smoking Clean, safe sex Single partner reduces risk Hepa. vaccine, Minimal alcohol intake, Avoid moldy foods Maintenance of a high fiber and low fat diet Avoid excessive sun exposure No conclusive evidence for early prevention

Annual check-up Regular pap smear: Once sexually active then every 3 years if findings are normal None

Liver

Colon and Rectum Skin Prostate

Regular medical check-up after 40 years, yearly occult blood tests in stools, rectal exams and sigmoidoscopy Self skin assessment Rectal Exam

Nursing Intervention a. b. c. d. e. Assist the patient in maintaining self-dignity and integrity by continued and sustained communication and contact Allow patient to ventilate feelings such as fear, anger, indifference Make arrangements for spiritual consolation Assist in rehabilitation even before treatment and until she recovers and adjust to the society Collaborate with other health workers for the patients holistic needs

152

f.

Home visits and education about the clients condition, course of treatment and alternatives

Priorities for Health Supervision: a. Newly diagnosed cases b. Post-operative Cases c. Indigent Cases d. Terminal Cases 6.2. HEMATOLOGIC PROBLEMS Normal Values to Remember: Blood Component RBC red blood cells Hgb - hemoglobin Hct - hematocrit Female: Male: Female: Male: Female: Male: Normal Values 4.2 5.4 x 106 4.7 6.1 x 106 11.5 15.5 g/dL 13.5 17.5 g/dL 36 48% 40 -52%

WBC white blood cells PC6.2.1. a. b. ANEMIA Platelet count

4,500 11,000/ mm3 150, 000 400,000 / mm3

Causes: Sudden or Chronic blood loss Abnormal bone marrow function c. RBC fails to mature adequately Signs & Symptoms: Fatigue, Weakness, Dizziness, Pallor, Decreased RBC, hemoglobin & hematocrit Types of Anemia:

a.

Hypoproliferation Anemia bone marrow fails to produce adequate blood cells a. Iron Deficiency Anemia nutritional deficiency, blood loss

b.
c.

Aplastic Anemia - due to radiation, drugs, toxin Anemia due to Renal Disease

Clinical Manifestations: Hypoxia Prone to infection Fatigue Easy bruising Nursing Intervention: Proper nutrition Psychological support Protect against infection and injury

b.
or atrophy of the

Megaloblastic Anemia due to previous gastric surgery, malabsorption gastric mucosa

Pernicious Anemia Vit. B12 and Folic acid deficiency in gastric juice Clinical Manifestations: Paresthesia Tingling or numbness of extremities Gait disturbances Behavioral Disturbances Nursing Intervention: Intake of Vit. B12 following this regimen: o 3x a week for 2 weeks, then

153

c.

o 2 x a week for 2 weeks, then o Once a month Protect lower extremities Rest in non-stimulating environment

Hemolytic Anemia Sickle Cell Anemia- defective hemoglobin, turns to sickle cell when oxygen in venous blood is low Thalassemia Glucose-6 Phosphate Dehydrogenase Deficiency Clinical Manifestations: Thalassemia & G6PD usually asymptomatic Sickle Cell Anemia: o Severe Pain o Swelling o Fever o Jaundice o Prone to infection Nursing Intervention: Proper oxygenation Hydration Analgesics Adequate Rest Refer to genetic counseling Avoid cold places to prevent sickle cell proliferation

6.2.2.

LEUKOCYTOSIS & LEUKEMIA Leukocytosis Leukemia increase level of WBC, persistent increased can be malignant - proliferation of neoplastic white blood cells in the bone marrow affecting the different tissues and organs in the body Acute & Chronic Myeloid Leukemia (AML / CML) Acute & Chronic Lymphocytic Leukemia (ALL / CML) Angiogenic Myeloid Metaplasia (AMM)

Clinical Manifestations: Fever Prone to Infection Pain Weight Loss Fatigue Nursing Interventions: Energy conservation Reverse Isolation Blood Transfusion

6.2.3.

POLYCYTHEMIA neoplasm of myeloid cells Clinical Manifestations: Dizziness, headache, tinnitus, fatige, paresthesia, blurred vision, atherosclerosis THROMBOCYTOPHENIA - Increased Bleeding Tendencies LYMPHOMAS neoplasm of lymphatic cells Hodgkins Lymphoma Non-Hodgkins Lymphoma

6.2.4. 6.2.5.

Multiple Myeloma Thrombocytophenia low platelet , bleeding

Management: Chemotherapy, Blood Transfusions, Reverse Isolation, Radiation therapy, Steroids Nursing Interventions: Emotional Support Reverse isolation Adequate Rest and Nutrition Strict Medication Regimen

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5.2.6. BLOOD TRANSFUSION 1. 2. 3. Types of Blood Components Transfused Whole Blood Packed Red Blood Cells Fresh Frozen Plasma/ Plasma Concentrate Transfusion Complications Non-hemolytic reaction- Fever Hemolytic Reaction- life threatening: fear, chills, backpain, nausea, chest tightness, dyspnea and anxiety Allergic reaction urticaria, flushing, itching Hypervolemia neck vein distention, dyspnea, orthopnea, tachycardia, sudden anxiety Diseases Transmitted through Blood Transfusion Hepatitis B or C , AIDS / HIV, Cytomegalovirus Nursing Interventions: 1. 2. 3. 4. Check name, ID, blood type, expiration, serial # Take baseline vitals signs Blood pack should be at room temperature Monitor for transfusion reaction Allergic (pruritus, respiratory distress, urticaria) Hemolytic (low back pain, fever, chills) Treat transfusion reaction, if present symptomatic treatment

5.

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7.

NEUROLOGIC DISTURBANCES I. Central Nervous System:

Brain Spinal Cord II. Peripheral Nervous System a. b. Cranial Nerves 12 pairs Spinal Nerves 31 pairs Cervical 8 Thoracic 12 Lumbar 5 Sacral 5 Coccygeal - 1 c. Autonomic Nervous System Sympathetic Nervous System Parasympathetic Nervous System The Cranial Nerves:

Oh, Oh, Oh, To Touch And Feel A Girls Veil So Heaven


I II III IV V VI VII VIII IX X XI XII

Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Auditory Glossopharyngeal Vagus Spinal Accessory Hypoglossal

Smell Visual Acuity Pupil constriction and dilation Eye movement: Inferior and medial Jaw muscles Eye movement: Lateral directions Symmetrical facial movement, Client identifies taste, Eyelid reaction to stimulus Hearing Acuity Gag Response Ability to speak clearly Shoulders ability to resist against pressure Tongue at midline

Neurologic Status: a.

b. c. d.

Conscious- alert, attentive, and follows command Lethargic- drowsy but awakens; follows command, but slowly and inattentively Stuporous - arouses to vigorous and continuous stimulation -response may be an attempt to remove the painful stimulus. Coma. no sounds, no movement
THE GLASGOW COMA SCALE

An assessment tool measuring the individuals neurologic status specifically the spontaneity of the clients eye movement , speaking ability and motor abilities in response to a stimuli. Perfect score is 15 points - Spontaneous/ Normal eye, motor and verbal response Lowest score is 3 points - No response

Eye Opening Response

a. Spontaneous b. To speech c. To pain d. No response a. Obeys verbal commands b. Localizes pain c. Flexion: no withdrawal d. Flexion: abnormal (decorticate) e. Extension: abnormal (decerebrate) f. No response to pain on any limb

Points 4 3 2 1 6 5 4 3 2 1

Moto r Response

156

Best verbal response

a. Oriented b. Able to Converse c. Inappropriate speech d. Makes incomprehensible sound e. No response

5 4 3 2 1

Example:

Patient s conscious, coherent. Can tell where he is, can look at surroundings, can raise hands when asked to, and can express self through words, answer questions appropriately. GCS Scoring: Eye opening Motor Response Verbal Response GCS Score = 4 = 6 = 5 = 15

Eye slightly opens when name is called ; No movement/response when skin is Pinched ; When calling the nurse: can only say ne.ee. sound GCS Scoring: Eye opening Motor Response Verbal Response GCS Score = 3 = 1 = 2 = 6

CEREBROVASCULAR ACCIDENT (CVA) Stroke

A sudden disruption of blood supply to the brain which may lead to temporary or permanent dysfunction. HPN, Obesity, peripheral vascular disease, obesity, aneurysm Signs & Syptoms: a. Speech problem / Aphasia - a loss or impairment of the ability to produce and/or comprehend language b. Hemiparesis- weakness of one side of the body c. Hemiplegia - total paralysis of the arm, leg and trunk on the same side f the body. d. Decreased awareness of body space

Risks Factors:

Types of stroke: 1. Transient Ischaemic Attack (TIA) short-term stroke that lasts for less than 24 hours ( seconds or minutes in a day) oxygen supply to the brain is restored quickly transient stroke needs prompt medical attention as it is a warning of serious risk of a major stroke. 2. Cerebral thrombosis - a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain. - brain cells are starved of oxygen. 3. Cerebral embolism - blood clot that forms and then travel to the brain. 4. Cerebral hemorrhage - occurs when a blood vessel bursts inside the brain and bleeds (haemorrhages). With a hemorrhage, extra damage is done to the brain tissue by the blood that seeps into it. Nursing Interventions: 1. Maintain adequate airway 2. Monitor neuro vital signs: Vital signs and Glasgow coma scale including intake and output 3. Maintain fluid & electrolyte balance

157

SPINAL CORD INJURY

Definition: A damage in the nerve structure causing dysfunction resulting to paralysis, sensory loss and altered activity. Cause: Vehicular accidents, Violence, Falls, Sports, Infection, Tumor The Spinal Nerves: 1. Cervical Nerve 2. Thoracic Nerve 3. Lumbar Nerve 4. Sacral Nerve Etiology: 1. Spinal Shock (Areflexia) 2. Autonomic Hyperreflexia Injury in T6 and above Life-threatening Nursing Interventions: 1. Immobilization specially after injury or trauma 2. Maintain respiratory function, ABC 3. Bladder & bowel management 4. Rehabilitation

Nerves

Level C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

Body part affected Head & Neck

Spinal Cord Injury Effect Paralysis below neck; impaired breathing, bowel & bladder incontinence, sexual dysfunction

Cervical Nerve Injury causes Quadriplegia/ Tetraplegia

Diaphragm Deltoid, biceps Wrist Extenders Triceps Hand

Shoulder elevation possible, ventilation support Elbow, upper arm, wrist movement

Thoracic Nerve Injury causes Paraplegia

Loss of hand control, Paralysis below waist

Chest Muscles Abdominal Muscles Trunk and Abdominal control

Lumbar Nerve Paralysis of legs; loss of bladder and bowel control Sacral Nerve Sexual, Bladder & Bowel conrol

Hip adduction impaired Leg muscles Knee and ankle movement impaired

Bladder & Bowel control Sexual Control

Bladder/Bowel Incontinence,etc Decrease sensation in the peineum

158

PARKINSONS DISEASE

Definition:

A disorder affecting control and regulation of movement Unilateral flexion of arms, shuffling gait, difficulty in walking, weakness, disability

Clinical Manifestations: Rigidity Involuntary body tremors Hips and knees flexion Masklike facial expression Slurred speech Drooling Constipation Depression Retropulsion, propulsion Medical Management: Surgical Management: Nursing Interventions: a. b. c. d. e. Rehabiltation exercise Speech therapy Diet: Low CHIN in am, high CHON in PM High fiber foods to promote bowel elimination Prevent Injury fall, etc Anti-parkinsonian Agent: Anti-cholinergic: Levodopa Cogentin

Stereotaxic Thalamotomy surgery of the thalamus to treat disorder

MYASTHENIA GRAVIS Definition: Severe weakness of one or ore groups of skeletal muscles; Severe weakness of the neuro functions most commonly affecting the Seventh cranial nerve- Facial Nerve Clinical Manifestation: 1. Mask-like facial expression 2. Diplopia- double-vision 3. Ptosis- difficulty opening of the eye 4. Dyphagia Management: b. c. d. a. Pyridostigmine Bromine (mestinon) Ambenomium Chloride Steroids Prednisone Atrophine Sulfate

Nursing Interventions: Avoid fatigue Administer meds as ordered Avoi neomycin and morphine CATARACT Definition: - the eye lenses becomes thick and unclear or yellowish. Clinical Manifestations: 2. 3. Gradual visual loss. Hazy vision / Yellowish haze Whitish to yellowish eyelense.

4.
Surgical Treatment:

Cataract extraction

Drug: 1. Mydriatrics - causes dilation of pupils; increases intraocular pressure (IOP) a. Atrophine Sulfate b. Phenylephrine Hydrochloride

Vision w/ Cataract Vision w/ Cataract

159

2. Cyclopegics decreases ciliary muscle accomodation Side effects: blurred vision, increase BP Nursing Intervention:

2.
3. 4.

Monitor BP; avoid use to patients with HPN Teach client that blurring of vision may be experienced. Post-op intervention: keep eye covered head of bed elevated at 30-45 degreed, supine position

Avoid bending or lifting heavy objects, coughing and sneezing as it may further increase IOP

GLAUCOMA non-curable condition of the eye due to increase in intraocular pressure causing deterioration of the optic nerve. 2 types of Glaucoma: 1. Acute or Closed- Angle Glaucoma a. Rainbow around lights b. Pain around the eye c. Cloudy and blurred vision d. Nausea & vomiting e. Dilation of pupils 2. Chronic or Open-Angle Glaucoma a. Halo around lights b. Progressive loss of vision c. Tired feeling in the eye d. Slowly diminishing peripheral vision Surgical Management: 1. Trabeculectomy 2. Thermosclerectomy 3. Iridenclesis Drugs: Miotics causes constriction of pupils

-A

Vision w/ Glaucoma

1.
2. 3. 4.

Pilocarpine hydrochloride - Drains aqueous humor Acetazolamide decreases production of aqueous humor Mannitol reduces IOP Isosorbid also decreases production of aqueous humor

Nursing Intervention: 1. Administer drugs as ordered 2. Teach client that glaucoma can be controlled but not curable (even surgery cant cure the disease) 3. Encourage moderate exercise 4. Avoid straining of bowel 5. Encourage low residue, high fiber diet 8. MUSCULOSKELETAL DISTURBANCES RHEUMATOID ARTHRITIS A systemic inflammatory disorder of connective tissues and/ or joints characterized by exacerbation & remission. Cervical, finger joints, ulnar, can also be involved:heart and lung (as in rheumatic heart disease) Chronic disease; early to mid-adulthood, common in women OSTEOARTHRITIS Degeneration of the articular cartilage Wear & Tear of joints Weight-bearing joints: knees, hips, spine

JOINT DISORDERS Definition

Kinds of Joints

Incidence Clinical Manifestations

Older women Pain felt after activity

Synovitis Pain relieved with rest

160

Intermittent bone pain, swelling, redness, warm feeling due to vasodialtion and increased blood flow Pannus formation- granulation of tissue causing destruction of adjacent cartilage, joints and bones fatigue, anorexia, malaise, weight loss Management Rest, exercise, ASA, NSAIDs, Steroids, heat Balanced rest and activity, heat packs, steroids in joist only Drug: Steroid, ASA, Indomethacin, Phenylbutazone Nursing Intervention Maintain body alignment, Balance rest and exercise, proper diet

Gout / Gouty Arthritis


Defintion: Risk Factors: Clinical Manifestations painful metabolic disorder due to inflammation of the joints due to high uric acid Hereditary, most common in men A salt of uric acid (Urate) crystallizes in soft and bony tissues causing local inflammation and irritation. Severe pain, usually in great toe Red, painful and swollen joints Tophi (crystal formation in joints) are palapated around great toes, fingers, earlobes Allopurinol NSAIDs Ibubrofen , Indomethacin Probenecid Colchicine Sulfinpyrazone

Drugs:

Nursing Management: a. Bedrest during attacks b. Heat or cold compress c. Increase fluid intake to flush out uric acid d. Avoid eating organ meats, shellfish, sardines - - - food with high purine / uric acid content Systemic Lupous Erythematosus (SLE)

Definition: Risk factors:

Diffuse connective tissue disease affecting skin, joints, kidney, serous membranes of the heart and lungs, lymph nodes and GI tract. Children, middle-aged and elderly; hereditary

Clinical Manifestations: Butterfly rash in the face ( across both cheeks and nose) Manifests symptoms same as that of arthritis and Raynauds Management: NSAIDs Steroids Cytotoxic drugs a. b. c.

- Azathioprine, Cyclophosphamide

Nursing Intervenions: Avoid exposure to sunlight because symptoms aggravate symptoms or wear hats, umbrella or sunscreen Adequate nutrition, rest and exercise Stress management, if possible avoid stress

Fractures Definition: A break in the continuity of the bones

Clinical Manifestations:

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Pain Loss of function Deformity False motion

Edema Spasm Crepitus Hematoma around skin Breaks for penetrating bone fragments

Management: First Aid 1. 2. 3. Maintain airway and circulation Immobilize joints that may be affected; Splint limb Bring to nearest hospital/medical institution

Traction Closed Reduction

-balanced pulling of the musculoskeletal structure to align bones; requires countertraction - external manipulation such as manually aligning bones by pulling. For patients who have lower pain tolerance (elderly, children) reduction may be done under sedation anesthesia. - internal manipulation of bones requiring surgical operation - surgically applying screws, plates, pins, nails to align bones (opening of the skin and exposing bones affected); skin is closed after the procedure. - applying nails and metal screws to bones through the skin surface

Open Reduction Internal Fixation External Fixation Casts

-a rigid mold used to immobilize an injured structure to promote healing

Nursing Management: 1. 2. 3. 4. Mainatin positioning For tractionL maintaing weights and countertraction Clean wounds to prevent infection Assess for VASCULAR OCCLUSION

5 Ps:

5 signs of Vascular Occlusion due to extremely tight casts / traction a. Pain b. Pallor c. Pulselessness d. PAresthesia e. Paralysis

9.

INTEGUMENTARY DISTURBANCES Burn

Depth of Injury First-degree Second-degree

Manifestation Painful, pink to reddish, subsides quickly Pain, pink to red, with blisters (fluid formation) Reddish, brownish or whitish, painless, eschar formation (Leather-like skin)

Level of Skin Affected Epidermis and part of dermis Epidermis and dermis hair follicle intact Epidermis, dermis, subcutaneous tissue Epidermis, dermis, subcutaneous tissue; fat, fascia, muscle and bone Superficial Superficial partial thickness; Deep partial thickness Full thickness

Third- degree

Fourth-degree Rule of Nines: a. Head and Neck b. Anterior Truck

Full thickness

9% 18%

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c. Posterior Trunk d. Arms e. Legs f. Perineum

18% 9% each = 18% 18% each = 36% 1% 100%

Management: First-Aid: 1.

Rule of Nines
Burning person: Ask person to stop, drop and roll ( lie down and roll) Burning person: Stop burning process such as wrapping the burning part with wet towel or blanket Check airway First-degree burn: Run cool water to affected area for 10 minutes

2. 3.
4.

Hospital Interventions: 1. Check ABC, give oxygen and IV fluids 2. Assess clients data, history of injury (time, cause,etc) 3. Maintain asepsis- burn patients are very prone to infections 4. Medical Surgical Management: a. Tetanus toxoid b. Topical Anti-microbial agent: Silver Nitrate, Silver Sulfadiazine, Gentamicin Sulfate, Mafenide acetate c. Debridement

SHOCK

Failure of the circulatory system to maintain adequate perfusion of vital organs. Critically severe deficiency in nutrients, oxygen and electrolytes delivered to body tissues, plus deficiency in removal of cellular wastes, resulting to cardiac failure I. Stages of Shock Non- progressive Stage - Cardiac output is slightly decreased - Body compensates Progressive Stage - Compensatory mechanism is not adequate - blood flow to the heart is not adequate thus heart begins to deteriorate 3. Irreversible Stage - Inadequate tissue perfusion - Cellular ischemia & necrosis lead to organ failure II. Types of Shock Cause Etiology

Hypovolemic Shock

due to inadequate circulating blood volume

Blood loss: Massive Trauma, GI Bleeding, Ruptured Aortic Aneurysm, Surgery, Erosion of Vessesl due to lesion, tubes or other devices, Disseminated Intravascular Coaguation Plasma loss: Burns, Accumulation of intraabdominal fluid, malnutrition, severe dermatitis, DIC Crystalloid loss: Dehydration, Protracted Vomiting, Diarrhea, nasogastric suction

Cardiogenic Shock

due to inadequate pumping action of the heart because of primary cardiac muscle dysfunction or mechanical obstruction of blood flow caused by MI or valvular insufficiency

Myocardial disease: Acute MI, Myocardial Contusion Cardiomypathies Valvular Disease or injury: Ruptured Aortic Cusp, Ruptured Papillary muscle, Ball thrombus

163

External Pressure on the Heart interferes with heart filling or emptying: Pericardial Tamponade due to Trauma, aneurysm, cardiac surgery, pericarditis, massive pulmonary embolus, tension pneumothorax Cardiac Dysrhtymias: Tachyarrhythmias, Bradyarrythmias, Electromechanical dissociation 3. Distributive Shock a. Neurogenic Shock

interference with nervous system control of the blood vessels

Spinal:

Spinal anesthesia, spinal cord injury Vaso-vagal reaction: Severe pain, severe emotional stress Allergy to food, medicines, dye, insect bites or stings

b.

Anaphylactic Shock

-severe hypersensitivity reaction resulting in massive systemic vasodilation

c.

Septic Shock

systemic reaction vasodilation due to infection

Gram-negative septicemia but also caused by other organisms

III. Signs of Shock Anxiety Restlessness Dizziness Thirst Fainting Pale skin, urticaria in anaphylactic shock Oliguria, Slow capillary refill BP- hypotension Pulse tachycardia, thready, irregular (Cardio.Shock) Respiration: increased depth, tachypnea, wheezing (anaphylactic shock) Temperature: cold clammy skin, elevated in anaphylactic LOC - could be alert, oriented, unresponsive CVP below 5 cm H20 (hypovolemic) - above 15 cms (cardio & septic)

IV. Nursing Care Management GOAL: Promote venous return, circulatory perfusion Position: Feet elevated with head slightly elevated also Ventilation: loosen restrictive clothing, O2, monitor respiration Fluids: IV, administer blood/plasma as ordered ( stop blood immediately in anaphylactic s.) Vital signs: CVP, ECG, U.O.,Swan Ganz Medications (depends on type) Antihypotensive (epinephrine, norepinephrine, dopamine) Anti-arrythmics, Cardiac Glycosides, Antibiotics, Adrenocorticoids Vasodilators (nitroprusside), Beta-adrenergic (dobutamine) Mechanical support : Military Anti-shock Trousers(MAST)

Effects of Shock in Different Organs

Respiratory System Cardiovascular System Neuroendocrine System

Hypoxia Lactic acid accumulates tissue necrosis Myocardial deterioration Disseminated Intravascular Coagulation Stage of resistance o ADH is released causing kidneys to retain sodium and water o Increase in adrenocorticoid mineralcorticoid hormones

164

Immune System

Macrophages in bloodstream and tissues are depressed Increased susceptibility to shock GIT vagal stimulation stops/slow down no peristalsis Liver ability to detoxify is lost; blood is pooled in the liver or portal bed Altered capillary blood pressure and glomerular filtration Renal ischemia

GI System

Renal System

IV.

FIRST AID *** FIRST AID: Details from www.redcross.org Dislocation: First aid***

1. Get medical help immediately.

2. Don't move the joint. Splint the affected joint into its fixed position. Don't try to move a dislocated
joint or force it back into place. This can damage the joint and its surrounding muscles, ligaments, nerves or blood vessels.

3. Put ice on the injured joint. This can help reduce swelling by controlling internal bleeding and the
buildup of fluids in and around the injured joint. Cuts and scrapes: First aid***

Minor cuts and scrapes usually don't require a trip to the emergency room. Yet proper care is essential to avoid infection or other complications. These guidelines can help you care for simple wounds:

1. Stop the bleeding. Minor cuts and scrapes usually stop bleeding on their own. If they don't, apply
gentle pressure with a clean cloth or bandage. Hold the pressure continuously for 20 to 30 minutes. Don't keep checking to see if the bleeding has stopped because this may damage or dislodge the fresh clot that's forming and cause bleeding to resume. If the blood spurts or continues to flow after continuous pressure, seek medical assistance.

2. Clean the wound. Rinse out the wound with clear water. Soap can irritate the wound, so try to
keep it out of the actual wound. If dirt or debris remains in the wound after washing, use tweezers cleaned with alcohol to remove the particles. If debris remains embedded in the wound after cleaning, see your doctor. Thorough wound cleaning reduces the risk of tetanus. To clean the area around the wound, use soap and a washcloth. There's no need to use hydrogen peroxide, iodine or an iodine-containing cleanser. These substances irritate living cells. If you choose to use them, don't apply them directly on the wound.

3. Apply an antibiotic. After you clean the wound, apply a thin layer of an antibiotic cream or
ointment such as Neosporin or Polysporin to help keep the surface moist. The products don't make the wound heal faster, but they can discourage infection and allow your body's healing process to close the wound more efficiently. Certain ingredients in some ointments can cause a mild rash in some people. If a rash appears, stop using the ointment.

4. Cover the wound. Bandages can help keep the wound clean and keep harmful bacteria out. After
the wound has healed enough to make infection unlikely, exposure to the air will speed wound healing.

5. Change the dressing. Change the dressing at least daily or whenever it becomes wet or dirty. If
you're allergic to the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze held in place with paper tape, gauze roll or a loosely applied elastic bandage. These supplies generally are available at pharmacies.

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6. Get stitches for deep wounds. A wound that cuts deeply through the skin or is gaping or jaggededged and has fat or muscle protruding usually requires stitches. A strip or two of surgical tape may hold a minor cut together, but if you can't easily close the mouth of the wound, see your doctor as soon as possible. Proper closure within a few hours minimizes the risk of infection.

7. Watch for signs of infection. See your doctor if the wound isn't healing or you notice any redness,
drainage, warmth or swelling.

8. Get a tetanus shot. Doctors recommend you get a tetanus shot every 10 years. If your wound is
deep or dirty and your last shot was more than five years ago, your doctor may recommend a tetanus shot booster. Get the booster within 48 hours of the injury Burns: First aid*** For minor burns, including second-degree burns limited to an area no larger than 2 to 3 inches in diameter, take the following action: Cool the burn. Hold the burned area under cold running water for at least 5 minutes, or until the pain subsides. If this is impractical, immerse the burn in cold water or cool it with cold compresses. Cooling the burn reduces swelling by conducting heat away from the skin. Don't put ice on the burn. Cover the burn with a sterile gauze bandage. Don't use fluffy cotton, which may irritate the skin. Wrap the gauze loosely to avoid putting pressure on burned skin. Bandaging keeps air off the burned skin, reduces pain and protects blistered skin. Take an over-the-counter pain reliever. These include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) or acetaminophen (Tylenol, others). Never give aspirin to children or teenagers. Minor burns usually heal without further treatment. They may heal with pigment changes, meaning the healed area may be a different color from the surrounding skin. Watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, seek medical help. Avoid re-injuring or tanning if the burns are less than a year old doing so may cause more extensive pigmentation changes. Use sunscreen on the area for at least a year. Caution Don't use ice. Putting ice directly on a burn can cause frostbite, further damaging your skin. Don't break blisters. Broken blisters are vulnerable to infection. Third-degree burn The most serious burns are painless and involve all layers of the skin. Fat, muscle and even bone may be affected. Areas may be charred black or appear dry and white. Difficulty inhaling and exhaling, carbon monoxide poisoning or other toxic effects may occur if smoke inhalation accompanies the burn. For major burns, dial 911 or call for emergency medical assistance. Until an emergency unit arrives, follow these steps:

1. Don't remove burnt clothing. However, do make sure the victim is no longer in contact with
smoldering materials or exposed to smoke or heat.

2. Don't immerse severe large burns in cold water. Doing so could cause shock. 3. Check for signs of circulation (breathing, coughing or movement). If there is no breathing or
other sign of circulation, begin cardiopulmonary resuscitation (CPR).

4. Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist towels.
If a Chemical burns: First aid*** chemical burns the skin, follow these steps:

1. Remove the cause of the burn by flushing the chemicals off the skin surface with cool, running
water for 15 minutes or more. If the burning chemical is a powder-like substance such as lime, brush it off the skin before flushing.

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2. Remove clothing or jewelry that has been contaminated by the chemical. 3. Wrap the burned area loosely with a dry, sterile dressing or a clean cloth.
Minor chemical burns usually heal without further treatment.

Seek emergency medical assistance if: The victim has signs of shock, such as fainting, pale complexion or breathing in a notably shallow manner. The chemical burn penetrated through the first layer of skin, and the resulting second-degree burn covers an area more than 2 to 3 inches in diameter. The chemical burn occurred on the eye, hands, feet, face, groin or buttocks, or over a major joint. If you're unsure whether a substance is toxic, call the poison center. Electrical burns: First aid***

An electrical burn may appear minor or not show on the skin at all, but the damage can extend deep into the tissues beneath your skin. If a strong electrical current passes through your body, internal damage, such as a heart rhythm disturbance or cardiac arrest, can occur. Sometimes the jolt associated with the electrical burn can cause you to be thrown or to fall, resulting in fractures or other associated injuries. Dial 911 or call for emergency medical assistance if the person who has been burned is in pain, is confused, or is experiencing changes in his or her breathing, heartbeat or consciousness. While helping someone with an electrical burn and waiting for medical help, follow these steps:

1. Look first. Don't touch. The person may still be in contact with the electrical source. Touching the
person may pass the current through you.

2. Turn off the source of electricity if possible. If not, move the source away from both you and the
injured person using a nonconducting object made of cardboard, plastic or wood.

3. Check for signs of circulation (breathing, coughing or movement). If absent, begin


cardiopulmonary resuscitation (CPR) immediately.

4. Prevent shock. Lay the person down with the head slightly lower than the trunk and the legs
elevated.

5. Cover the affected areas. If the person is breathing, cover any burned areas with a sterile gauze
bandage, if available, or a clean cloth. Don't use a blanket or towel. Loose fibers can stick to the burns. Animal bites: First aid*** Domestic pets cause most animal bites. Dogs are more likely to bite than cats. Cat bites, however, are more likely to cause infection. Bites from nonimmunized domestic animals and wild animals carry the risk of rabies. Rabies is more common in raccoons, skunks, bats and foxes than in cats and dogs. Rabbits, squirrels and other rodents rarely carry rabies. If an animal bites you or your child, follow these guidelines: For minor wounds. If the bite barely breaks the skin and there is no danger of rabies, treat it as a minor wound. Wash the wound thoroughly with soap and water. Apply an antibiotic cream to prevent infection and cover the bite with a clean bandage. For deep wounds. If the animal bite creates a deep puncture of the skin or the skin is badly torn and bleeding, apply pressure with a clean, dry cloth to stop the bleeding and see your doctor. For infection. If you notice signs of infection such as swelling, redness, increased pain or oozing, see your doctor immediately.

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For suspected rabies. If you suspect the bite was caused by an animal that might carry rabies any bite from a wild or domestic animal of unknown immunization status see your doctor immediately. Doctors recommend getting a tetanus shot every 10 years. If your last one was more than five years ago and your wound is deep or dirty, your doctor may recommend a booster. You should have the booster within 48 hours of the injury. Fall prevention: 6 ways to reduce your falling risk*** Falls put you at risk of serious injury. Prevent falls with these fall-prevention measures. Your odds of falling each year after age 65 are about one in three. Fortunately, most of these falls aren't serious. Still, falls are the leading cause of injury and injury-related death among older adults. You're more likely to fall as you get older because of common, age-related physical changes and medical conditions and the medications you take to treat such conditions. You needn't let the fear of falling rule your life. Many falls and fall-related injuries are preventable with fallprevention measures. Here's a look at six fall-prevention approaches that can help you avoid falls. Fall-prevention step 1: Make an appointment with your doctor Begin your fall-prevention plan by making an appointment with your doctor. You and your doctor can take a comprehensive look at your environment, your health and your medications to identify situations when you're vulnerable to falling. In order to devise a fall-prevention plan, your doctor will want to know: What medications are you taking? Include all the prescription and over-the-counter medications you take, along with the dosages. Or bring them all with you. Your doctor can review your medications for side effects and interactions that may increase your risk of falling. To help with fall prevention, he or she may decide to wean you off certain medications, especially those used to treat anxiety and insomnia. Have you fallen before? Write down the details, including when, where and how you fell. Be prepared to discuss instances when you almost fell but managed to grab hold of something just in time or were caught by someone. Could your health conditions cause a fall? Your doctor likely wants to know about eye and ear disorders that may increase your risk of falls. Be prepared to discuss these and to tell him or her how you walk describe any dizziness, joint pain, numbness or shortness of breath that affects your walk. Your doctor may then evaluate your muscle strength, balance and individual walking style (gait). Fall-prevention step 2: Keep moving If you aren't already getting regular physical activity, consider starting a general exercise program as part of your fall-prevention plan. Consider activities such as walking, water workouts or tai chi a gentle exercise that involves slow and graceful dance-like movements. Such activities reduce your risk of falls by improving your strength, balance, coordination and flexibility. Be sure to get your doctor's OK first, though. If you avoid exercise because you're afraid it will make a fall more likely, bring this concern to your doctor. He or she may recommend carefully monitored exercise programs or give you a referral to a physical therapist who can devise a custom exercise program aimed at improving your balance, muscle strength and gait. To improve your flexibility, the physical therapist may use techniques such as electrical stimulation, massage or ultrasound. If you have inner ear problems that affect your balance, he or she may also teach you balance retraining exercises (vestibular rehabilitation) which involve specific head and body movements to correct loss of balance. Fall-prevention step 3: Wear sensible shoes Consider changing your footwear as part of your fall-prevention plan. High heels, floppy slippers and shoes with slick soles can make you slip, stumble and fall. So can walking in your stocking feet. Instead: Have your feet measured each time you buy shoes, since your size can change. Buy properly fitting, sturdy shoes with nonskid soles.

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Avoid shoes with extra-thick soles. Choose lace-up shoes instead of slip-ons, and keep the laces tied. Select footwear with fabric fasteners if you have trouble tying laces. Shop in the men's department if you're a woman who can't find wide enough shoes.

If bending over to put on your shoes puts you off balance, consider a long shoehorn that helps you slip your shoes on without bending over.

Fall-prevention step 4: Remove home hazards As part of your fall-prevention measures, take a look around you your living room, kitchen, bedroom, bathroom, hallways and stairways may be filled with booby traps. Clutter can get in your way, but so can the decorative accents you add to your home. To make your home safer, you might try these tips: Remove boxes, newspapers, electrical cords and phone cords from walkways. Move coffee tables, magazine racks and plant stands from high-traffic areas. Secure loose rugs with double-faced tape, tacks or a slip-resistant backing. Repair loose, wooden floorboards and carpeting right away. Store clothing, dishes, food and other household necessities within easy reach. Immediately clean spilled liquids, grease or food. Use nonskid floor wax. Use nonslip mats in your bathtub or shower. Fall-prevention step 5: Light up your living space As you get older, less light reaches the back of your eyes where you sense color and motion. So keep your home brightly lit with 100-watt bulbs or higher to avoid tripping on objects that are hard to see. Don't use bulbs that exceed the wattage rating on lamps and lighting fixtures, however, since this can present a fire hazard. Also: Place a lamp near your bed and within reach so that you can use it if you get up at night. Make light switches more easily accessible in rooms. Make a clear path to the switch if it isn't right near the room entrance. Consider installing glow-in-the-dark or illuminated switches. Place night lights in your bedroom, bathroom and hallways. Turn on the lights before going up or down stairs. This might require installing switches at the top and bottom of stairs. Store flashlights in easy-to-find places in case of power outages. Fall-prevention step 6: Use assistive devices Your doctor might recommend using a cane or walker to keep you steady. Other assistive devices can help, too. All sorts of gadgets have been invented to make everyday tasks easier. Some you might consider: Grab bars mounted inside and just outside your shower or bathtub. A raised toilet seat or one with armrests to stabilize yourself. A sturdy plastic seat placed in your shower or tub so that you can sit down if you need to. Buy a hand-held shower nozzle so that you can shower sitting down. Handrails on both sides of stairways. Nonslip treads on bare-wood steps. Ask your doctor for a referral to an occupational therapist who can help you devise other ways to prevent falls in your home. Some solutions are easily installed and relatively inexpensive. Others may require

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professional help and more of an investment. If you plan on staying in your home for many more years, an investment in safety and fall prevention now may make that possible. Insect bites and stings: First aid***

Signs and symptoms of an insect bite result from the injection of venom or other substances into your skin. The venom triggers an allergic reaction. The severity of your reaction depends on your sensitivity to the insect venom or substance. Most reactions to insect bites are mild, causing little more than an annoying itching or stinging sensation and mild swelling that disappear within a day or so. A delayed reaction may cause fever, hives, painful joints and swollen glands. You might experience both the immediate and the delayed reactions from the same insect bite or sting. Only a small percentage of people develop severe reactions (anaphylaxis) to insect venom. Signs and symptoms of a severe reaction include facial swelling, difficulty breathing and shock. Bites from bees, wasps, hornets, yellow jackets and fire ants are typically the most troublesome. Bites from mosquitoes, ticks, biting flies and some spiders also can cause reactions, but these are generally milder. For mild reactions: Move to a safe area to avoid more stings. Scrape or brush off the stinger with a straight-edged object, such as a credit card or the back of a knife. Wash the affected area with soap and water. Don't try to pull out the stinger; doing so may release more venom. To reduce pain and swelling, apply a cold pack or cloth filled with ice. Apply 0.5 percent or 1 percent hydrocortisone cream, calamine lotion or a baking soda paste with a ratio of 3 teaspoons baking soda to 1 teaspoon water to the bite or sting several times a day until your symptoms subside. Take an antihistamine containing diphenhydramine (Benadryl, Tylenol Severe Allergy) or chlorpheniramine maleate (Chlor-Trimeton, Teldrin). Allergic reactions may include mild nausea and intestinal cramps, diarrhea or swelling larger than 2 inches in diameter at the site. See your doctor promptly if you experience any of these signs and symptoms. For severe reactions: Severe reactions may progress rapidly. Dial 911 or call for emergency medical assistance if the following signs or symptoms occur: Difficulty breathing Swelling of your lips or throat Faintness Dizziness Confusion Rapid heartbeat Hives Nausea, cramps and vomiting

Take these actions immediately while waiting with an affected person for medical help: 1. Check for special medications that the person might be carrying to treat an allergic attack, such as an auto-injector of epinephrine (for example, EpiPen). Administer the drug as directed usually by pressing the auto-injector against the person's thigh and holding it in place for several seconds. Massage the injection site for 10 seconds to enhance absorption. 2. After administering epinephrine, have the person take an antihistamine pill if he or she is able to do so without choking. 3. Have the person lie still on his or her back with feet higher than the head.

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4. Loosen tight clothing and cover the person with a blanket. Don't give anything to drink. 5. If there's vomiting or bleeding from the mouth, turn the person on his or her side to prevent choking. 6. If there are no signs of circulation (breathing, coughing or movement), begin CPR.

http://www.redcross.org

RESPIRATORY ARREST
Respiratory Arrest (-) RR (+) PR.

A condition of the victim wherein there is no breathing but pulse continues

CAUSES: 1. 2. 3. 4. 5. 6. Strangulation Poisoning-Injection, Ingestion, Inhalation Injection- Snakebite, Rabies, Scorpions, bees, jellyfish, spiders Severe Bleeding Drowning Electrocution Suffocation Choking: Universal Sign of Choking- palms guarding throat Disease

7.
8.

THREE (3) KINDS OF AIRWAY OBSTRUCTION Kind OF Airway Obstruction With Good Air Exchange With Poor Air Exchange Total Airway Obstruction with No Air Exchange Signs Victim can still TALK Victim produces wheezing sound Unconscious First Aid Observe the victim as he cough out obstruction Abdominal Thrust / Heimlich Maneuver 1. Abdominal Thrust 10X Blind Finger sweep for adults 2. Artificial Respiration (AR) 2X 3. Check if Air is going backLook, Listen & Feel (LLF) 4. Repeat blind finger sweep 5. Artificial Respiration 2X if effective First Aid: Artificial Respiration (AR) Giving of artificial air only either through a blow or ambubag - chest compression not indicated because there is pulse rate METHODS IN GIVING ARTIFICIAL RESPIRATION

1. 2. 3. 4.
5. 6.

Mouth to Mouth - usual method Mouth to Nose - if mouth is obstructed Mouth to Mouth & Nose used in infants Mouth to Stoma - like for patients with tracheostomy Mouth to Mask Ambu Bag to Mouth & Nose Ambu Bag- a device used for artificial mechanical breathing unit

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ADULT METHOD Manner of Breathing Rate of Blows Mouth TO Mouth Full and Slow 1 Blow every 5 secs 12 blows per min

CHILD Mouth TO Mouth Regulated 1 Blow every 4 secs 15 blows per min

INFANT Mouth TO Mouth & Nose Puff 1 Blow every 3 seconds 20 blows per min

START WITH A BLOW AND END WITH A BLOW WHEN TO STOP 1. 2. 3. When the rescuer is exhausted When the victim is breathing on his own When the service of the physician is available When the pulse disappears; artificial respiration is stopped and cardiopulmonary rescucitation begins When another first aider takes over

4.
5.

CARDIAC ARREST
Condition of the victim when the pulse and breathing is absent.

Intervention for Cardiac Arrest: CPR CPR- Cardio Pulmonary Resuscitation - A combination of external chest compression and artificial ventilations to revive the heart and the lungs CAUSES All causes of Respiratory Arrest, Heart Attack, Stroke Location Of Chest Compressions Danger of Failure to revive Patient: 1. CLINICAL DEATH- may occur if heart rate is not revived within 4-6 minutes 2. BIOLOGICAL DEATH- usually occurs after 4-6 mins of cardiac arrest

1.
2.

ADULT- 3 fingers above mid xiphoid INFANT- along nipple line

ADULT Method Depth Rate Speed 2 Heels of 2 Hands 1 - 2 15 ECC/2 blows 4X/min 60-80 ECC/min 12X/min 2 RESCUERS DONTS IN CPR: 1. 2. 3. 4. 5. 6. Dont be a double crosser Dont be a rocker Dont be a jerker Dont be a render Dont be a bouncer Dont be a massager

CHILD 1 Heel of 1 hand 1- 1 5ECC/1 blow 15X/min 80-100 ECC/min

INFANT 2 Fingers (ring and mid finger) 1 5ECC/1 blow 20X/min 100-120 ECC/min

5 ECC/1 blow

CPR- start with 2 blows end with 2 blows

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SEQUENCE: 1. 2. 3. 4. 5. 6. 7. 8. Survey the scene the scene is safe Check for responsiveness Hey 2X, R U Okay Position the victim Open and Clear the airway (head tilt chin lift) Mouth is clear Check breathing for 3-5 seconds (LLF) 1001, 1002, etc. Breathless If Breathless, give 2 blows Check for Pulse: Carotid 5-10 seconds State the condition of the victim Victim is breathless with pulse or Victim is breathless & pulse less 9. Activate medical assistance Arrange transfer facilities and Ill doAR or CPR 10. After each cycle, check pulse for 5 sec. then deliberate 11. Recovery Position

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