[MEDICAL SURGICAL NURSING]

Compiled By: Joshua James Diao, MANc,

CRN, RN
MAN

1. Atomistic Approach Cells, Tissues,

Organs, Systems (Physiological)

2. Holistic Approach Mind and Body

Interaction (Psychological)
Natural History of Illness
1. Stage of Susceptibility
Period where client is basically
asymptomatic.
- Basis of the Incubation Period

2. Stage of Pre-Symptomatic Illness

Appearance of vague signs and symptoms

Basis of Quarantine
3. Stage of Illness
The Appearance of True Signs and
Symptoms
Pathognomonic Diagnostic Sign
4. Stage of Recovery
Direct result of a good medical and
nursing intervention.
OXYGENATION
The dynamic interaction of gases for the
purpose of supplying and transporting
essential for cellular activity.

1.
2.
3.
4.

Organ Systems that Are Essential to

Oxygenation.
Respiratory System - Oxygen/C02 Exchange
Cardiovascular System - Pumping Mechanism
Muscuskeletal System
- Protection
Nervous System
- Chief Integrator

CARDIOVASCULAR SYSTEM
Heart
1. Pulmonary Circuit
2. Vascular Circuit
Factors to Consider for a Good Heart
P Pumping Mechanism
U Unidirectional Blood Flow (R to L )
S Significant Good Patent Vessels
O Observable Electrical Activity
Pumping Mechanism
Cardiac Output Amount of Blood Ejected per
Minute
Heart Rate Beats Per Minute

Stroke Volume Amount of Blood Ejected Per

Contraction
Cardiac Output = Stroke Volume x Heart Rate
Factors that Affected Cardiac Output
1. Neural Control CNS
Medulla Oblongata > Inc/Dec HR/CR
ANS - Sympathetic
> Inc HR
PNS - Parasympathetic > Dec HR
2. Chemical Control Electrolyte
K Out Na In (Cell) Muscle Contraction
K In - Na Out (Cell) Muscle Relaxation
3. Mechanical Control
Starlings Law of the Heart
Increase Pre-Load > Increase After-load >
Increased CO
Pre-Load Amount of Blood Returning Back to
the Heart (Venous Return)
After-Load Degree of Stretch (Stretching
Potential of the Heart)
CONGESTIVE HEART FAILURE
Pump Failure MNEMONIC: RAPID FAILURE
Renal Diseases
- Anemia
- Pulmonary Embolism
- Infection
- Delivery after Pregnancy

Forgot to take Medications

Arrhythmia Abnormal Electrical
Activity
Infarction/Ischemia
Lipid Aggregation
Uncontrolled Hypertension
Rheumatic Heart Disorder
Endocarditis

Compensations:
1. Tachycardia
2. Ventricular Dilation
3. Hypertrophy
Signs and Symptoms:
Left Sided Heart Failure Pulmonary Congestion
1. Orthopnea
2. Dyspnea
3. Cough
4. Rales

5. Pink Frothy Sputum

6. Pulsus Alternan Alternating Strong
and Weak Pulse HEART FAILURE!
Right Sided Heart Failure Systemic Congestion
1. Edema
2. Ascites
3. Hepatomegaly
4. Spleenomegaly
5. Neck Vein Distention
Dx Test: CHF
BNP (Beta Type Natriuretic Peptide)
Elevation Indicates Heart Failure
Differentiate congestion from cardiac vs
respiratory
Hemodynamic Monitoring
CVP Measures Pressure on the Right
Side of the Heart (Hypervolemia)
CVP 5-10 cm/h20
Swan Ganz Catheter Measures Pressure
on the Left Side of the Heart
NSG Intervention:
H
- Hypoxia Avoidance (Reduce Cardiac
Workload) 02 Inhalation
E

- Ensure Rest
Passive ROM
Elastic Stockings
- Avoid Salty Foods
Prudent Diet (Low Sodium and Calories)
Small Frequent Feedings

- Reduce Pre-Load (Venous Return)

Limit Fluid Intake
Rotating Tourniquet

- Take Good Care of the Skin

Medications 3D
1. Diuretics
Lasix (Furosemide)
HCT2
Ethacrynic Acid
NURSING MANAGEMENT
Give Early in the Morning
Avoid Hypokalemia
A Apple
B Banana
C Cantalope
D Dragon Fruit
A Asparagus
B Broccoli
C Carrots

2. Digitalis (Increase Force of Contraction,

Lowers HR)
Digoxin / Lanoxin / Digitoxin / Quabain
Therapeutic Index - .5 2mg (Toxicity GI
Symptoms)
Check: Apical Pulse (Dont Give To Patients
with Bradycardia)
Avoid: Hypokalemia (High Risk for Digitalis
Toxicity
3. Dilators Reduce Cardiac Workload of
Patient
Ace Inhibitors Captopril (-pril) > Side
Effect: Cough
Beta Blockers Metoprolol (-olol) > Side
Effect: Bronchospasm
Calcium Channel Blockers Verapamil /
Dilthiazem Side Effect: Erectile Dysfxn
UNIDIRECTIONAL BLOOD FLOW
Please Answer My Telephone
Heart Valves ( 1 Way Flow of Blood)
Semi Lunar Valve
- Pulmonic

Aortic
Atrio Ventricular Valve Mitral
(Point of Maximum Impulse)

Tricuspid
PMI Left 5th Intercostal Space Mid Clavicular
Line
S1 LAB (First Closure of AV Valve)
S2 DAB (Closure of SL Valve)
VALVULAR HEART DISORDERS
1. Congenital Marfan Syndrome (Soft
Muscle Tissues)
2. Acquired Infection
Regurgitation
Insufficiency (Failure of the Heart Valve to
Close Properly)
Backward Failure
S/Sx of Congestion
Aortic and Mitral Same with LSHF
Pulomary and Tricuspid Same With RSHF
Significant Signs:
1. Corrigans Pulse Water Hammer Pulse
2. DeMusset Sign Head Bobbing
3. Traubes Sign Pistol Shot Sensation at
Femoral Area
4. Quinckes Sign Capillary Pulsation
5. Heart Murmurs Abnormal Heart Sounds
S3 Ventricular Gallop
S4 Atrial Gallop

Surgery: Valvuloplasty
Stenosis Narrowing of the Opening
Forward Failure (Signs and Symptoms of
Ischemia)
Significant Symptom:
1. Chest Pain
2. Cyanosis
3. Syncope (Transient Loss of Consciousness)
lack of blood going to the brain
Diagnostic Test
1. Echocardiography Heart Ultrasound
Surgery: Valvulotomy
Dr. Christian Barnard First To Conduct a
Successful Open Heart Surgery
South Africa
Endocarditis Colonization of Bacteria in the
Heart of the Patient
Tooth Abcess
Untreated Tonsilities
Throat Infection
Hallmark Sign: Fever, Join Pains,
Subconjuctival Hemorrhage, Oslers Node
(Painful Nodules Seen on Fingers), Splinters
Hemorrhage (Longitudinal Bleeding on
Nailbed), Janeways Lessions (Patechia at
Sole of Feet)
Care Approach
C
A
R
D
I
T
I
S

Culture of Blood (Identify Microorganism)

Antibiotics
Rest
Doppler Ultrasound
Institute Pain Management
Treat Any Infections
Instill Oral Care
Surgery

SIGNIFICANT GOOD PATENT VESSELS

Maintain Patency of the Blood Vessels
Coronary Arteries Supplies Oxygen to the
Heart Cells
R Coronary Artery - Supplies the R Portion of
the Heart Arrythmia (Pacemaker Prob)
L Coronary Artery (Descending) - Death
(No Oxygen Return) Circumflex

Coronary Artery Diseases

Atherosclerosis Deposition of Fat in Blood
Vessels
Race
- Afro-Americans
Increased Blood Pressure
Stress
Know the Lifestyle of the Patient
Fatty Foods
Alcohol
Cigarette Smoking
Type A Personality
Obesity
Result of Diabetes Mellitus
Metabolism
Sex

- Altered Lipid
- Male

Arteriosclerosis Narrowing of Blood Vessels

(Age)
Atherosclerosis and Arteriosclerosis =
Decreased Blood Supply
Decreased Blood Supply > Ischemia > Pain
Coronary Artery Diseases
Chest Pain
Chronic Stable Angina
Acute Coronary Syndrome
(AP)
(MI)
Pain:
Pain:
Exertions
Thrombus
Exercise
Embolus
Excessive Eating
Atheroma
Emotions
Extremes of Temperature
Quality:
Quality:
Constriction
Excruciating
Radiation:
Substernal
Signs and Symptoms
Signs and Symptoms
Mild
Severe
Timing (Best Indicator)
Timing (Best Indicator)
3-20 Min
> 30 Min
(+) Rest and Medication
(-) Rest and Medication

Diagnostic Test
1. ECG Standard Test in the 24 Hours of
Chest Pain
3 Important ECG Changes
a) ST Segment Elevation - Injury
b) Inverted T Wave
- Ischemia
Very Large Q Wave
- Infarction
2. Stress Test Treadmill Exercise Test
3. Holter Monitoring Device

a. C-Reactive Protein:
Marker of Inflammation

Do
Give
With
Viagra:
Hypote
nsion

b. Homocysteine
causes damage to endothelium
c. Lipoprotein associated Phospholipase A2
Marker of Vascular Inflammation
Cardiac Isoenzymes
1. Troponin I and T 2 Hours Post Cardiac
Arrest
THE BEST BLOOD TEST!
2. CPK
- 4 Hours Post Cardiac Arrest
3. LDH
- 24-48 Hours Post Cardiac Arrest
Cardiac Catheterization
THE BEST DIAGNOSTIC TEST BUT VERY
INVASIVE: Standard Test
3 in 1 Exam
Identifies the Patency of the Vessel
Assess Blood Flow
Functionality of Heart Valves
NSG Priority During Cardiac Catheter
1. Psychological Preparation TELL ME
MORE
2. Allergy Selfish or Iodine
3. Check the Most Distal Pulses
Nursing Intervention
1. Facilitate the disappearance in chest
pain.
a) Drug of Choice Chronic Stable Angina
Nitroglycerine SE: Headache
Sublingual: 3x at Interval of 5 Minutes
Spray
Transdermal Patch
Do not give with Viagra: Hypotension
Myocardial Infarction
Morphine and Meperidine (Demerol)
Oxygen Inhalation
Bed Rest
Work Quietly and Systematically

Maintain Hemodynamic
Stability
Most Common Cause of Death:
Ventricular Arrhythmia
a) Maintain a Patent IV Line: Access for
Emergency Medications
b) Monitor Vital Signs of the Patient
c) Monitor the Cardiac Rate of the Patient
Premature Ventricular Contraction
Precursor to Ventricular Arrhythmias >
Cause of Death
DOC: Lidocaine > Monitor for Neurotoxicity
SE: Headache, Paresthesia, Convulsion
d) Monitor the Blood Pressure of the Patient:
Decreasing : Severe Left Ventricular
Dysfunction
Maybe Developing Cardiogenic Shock
Hallmark: Low BP, Narrowing Pulse
Pressure, Oliguria, Altered LOC
Treatment:
Inotropic Drugs: Dopamine, Dobutamine >
Increase BP
Drugs:
1. Fibrinolytics - Dissolve Blood Clots
Streptokinase, Urokinase, T-PA
Fresh Blood Clots ONLY!! First 12-24 Hours
ASK: When did you last experience chest
pain?
SE: Bleeding
2. Anticoagulants Prevents Blood Clot
Formation
Heparin
Enoxaparin
PTT
= Protamine SO4
Coumadin
Subling
Warfarin
PT
= Vitamin K
ual: 3x
at
Interva NEVER GIVE GREEN LEAFY VEGETABLES:
l5
HAS VITAMIN K!
mins.
Spray
3. Antiplatelet Decrease Blood
Aggregation (Viscocity)
Transd
Aspirin
ermal
Clopidogrel (Plavix)
Patch
Ticlopidine (Ticlid)

 Dipyridamole (Persantin)
4. Antilipemic
Simvastatin
(Lipitor)
Atorvastatin
When to Give: At Bedtime > Highest
Synthesis of Cholesterol is in the Evening
Check: Liver Enzyme
SE: Photosensitivity
2. Promote Psychological and Physical
Rest of the Patient
Encourage Verbalization of Feelings
Most Common Defense Mechanism: Denial
Sedation
Limit Visitors of Patient
Maintain Quit Environment
3. Promote Proper Nutrition
Prior: NPO (First 24 Hours)
Liquid Diet (Avoid Cold and Warm Diet)
(Next 24 Hours)
Soft Diet ( Low Calorie, Low Sodium,
Low Fat)
Prevent Constipation: Straining is Bad
for the Heart
Vagal Nerve Stimulation: Bradycardia
Treatment
Diet: High Fiber Diet
Drugs: Laxative
Best: Colace
4. Promote Sexual Education
Resumption of Activity:4-6 Weeks After
Attack
Physical Manifestation: Able to Climb Flight
of Stairs without Dyspnea
Best Time
: Early in the Morning (Well
Rested)
Medications::Take All Prior To Sex
Place: Do In a Familiar Place and Familiar
Partner, Prolonged Foreplay
Position: Any Comfortable Position (OLD
Side-Lying)

5. Assist in Cardiac Rehabilation

Best Exercise: Walking
Rehabilitation: Immediately After Admission
Observable Electrical Activity
Pacemakers

1.
2.
3.
4.

SA Node
> Atrial Contraction
AV Node
Bundle of His > Ventricular Contraction
Purkinje Fibers

Properties:
P Wave : Atrial Depolarization (Contraction) SA
Node > AV Node
QRS Complex: Ventricular Depolarization
(Contraction) AV Node > Purkinje Fibers
T Wave: Ventricular Repolarization
PR Interval: Transmission of Impulses from SA
Node to Purkinje Fibers
[Arrhythmias]
- Abnormal Heart Rhythms
Basic Arrhythmias
Bradyarrythmias Heart Blocks (Slow Abnormal
Electrical Heart Activity)
Pacemaker: Device that will increase the cardiac
rate.
Nursing Management
1. Pulse Monitoring > Pulse Monitoring Right
After Waking Up Before ADLs
Pacemaker Malfunctioning: Earliest Manifestation:
Hiccups!
Dizziness
Loss of Conciousness
2.Avoid Constrictive Garment
3.Contact Sports Beware
4.Electromagnetic Field
5. Report Pace Maker Failure
Tachyarrythmias Premature Contractions,
Flutter, Fibrilation
A) Mechanical
Carotid Sinus Massage
Valsalva Maneuver
B)

Chemical Intervention
Quinidine Einchonism
Procainamide
Adenosine

C) Cardioversion
Elective
Atrial
200 Joules
Synchronized

Defibrillation
Emergency
Ventricular
200-360 Joules
Asynchronous

TAO (Thromboangitis Obliterans) Unknown

Etiology (CC: Smoking)

D) Post Mortem Care

1. Pallor
2. Poikilothermia
3. Pulse Decreased
4. Paresthesia > Earliest Sign > Lack of 02 >
Irritation of Neurons (Highly Sensitive) BINHOD!
5. Paralysis > Late Sign!
6. Pain (Anaerobic Respiration > Formation of
Lactic Acid)

Hallmark Sign:
6 Ps

Peripheral Vascular Diseases

Arterial

Venous

Severe Ischemic Pain

Dull Aching Pain

Intermittent Claudication

(+) Homans Sign

Temperature
Cool

Temperature
Warm / Same

Pulse
Reduced / Absent

Pulse
Normal

Elevation
Pale / Pallor

Elevation
Improved Color

Lower
Erythematous

Lower
Cyanosis

Position
Flat on Bed

Position
Elevate

(+) Gangrene

(-) Gangrene

Ulcer
At Distal Portion

Ulcer
Side of Leg

(-) Edema

(+) Edema

Appearance:
Shiny, Taught Skin, Sparse
Hair

Appearance:
Brown Discoloration of Leg
(Due to Pooling of Blood)

ANEURYSM Saccular Herniation of Vessel

Abdominal Aneurysm - Presence of a Pulsating
Mass on Abdomen
Bruit Sound
Raynauds Phenomenon
Vasospasm of Arteries of Fingers
Related to Cold Weather
Hallmark Sign:
Flag Color Changes Sign (Pallor >
Cyanosis > Rubor)
Severe Pain
Diagnostic Test
1) Ankle-Brachial Index
Formula:
Interpretation:
Ankle Pressure
Arm Pressure

> 0.90 Normal

0.71 - 0.90 Mild
0.41- 0.70 Moderate
0.00 0.40 Severe

100/80 Feet
__________

20/40 = = .5

120-80 Arms

Arterial Disorders
ASO (Atherosclerosis Obliterans) Inflammation
of Arteries Due To Fat

2) Doppler Ultrasound Checks the Patency

of the Vessel
3) Angriography / Arteriography Best Test
to Determine Occlusion.
4) Allens Test
Nursing Intervention

Promote Adequate Tissue Perfusion on the

Leg of the Patient.
Pulse Checking on Both Legs
Discrepancy = Problem
Measure the circumference on the thighs
Asymmetry = Problem
Position the leg of the patient flat on bed.
U Understand the Medications of the Client.
- Pentoxifylline DOC for Intermittent
Claudication
- Papaverine Vasodilator
- Isoxuprine (Vasodilan) Vasodilator
- Cilostazol Anti Platelet / Anti Thrombotic /
Vasodilator
- L-Carnitine Increases Oxygenation of Cells

BP = Cardiac Output x Systemic Vascular

Resistance
Vasocontriction > Dec Blood Supply > Dec Tissue
Perfussion > End Organ Damage
Eyes Heart Brain Kidney (5-10 Years Before
Appearance of Symptoms)
Classification:
Primary Hypertension
Elevation of BP with Unknown Etiology
Secondary Hypertension
Elevation of BP with Known Etiology

L Low Fat Diet

Limit Smoking
Limit Exposure to Cold

Isolated Systolic Hypertension

Elevated Systole / Normal Diastole
(More Prone to Stroke Aging Population )

S Safety on the Legs of the Patient

- Avoid Warm Compress on the Leg
- Warm Compress on Abdomen
- Wear Comfortable Shoes
- Wear Leather Shoes (Better Support Less
Moisture Formation)
- Avoid/Prevent Emergency Surgeries on the
Leg

Pseudohypertension
False Elevation of Blood Pressure
Focus of Care
A

Avoid Salty and Fatty Foods

(Kempner Diet) Fruits and Vegetables

BP Monitoring (White Coat Phenomenon)

False Elevation of BP
- BP Monitoring at Home Prior to Visit
Complications Monitoring

E Exercise Buerger Allen Exercise

S Surgery Femoral Popliteal Bypass Graft

1.
2.

3.
4.
5.
6.
7.
8.
9.

Amputation:
Psychological Preparation
Teach About Exercises
Gluteal Setting Exercise
Quadriceps Setting
Orient About the Phantom Limb Sensation.
(True Pain)
Monitor for Bleeding >
Bedside: Tourniquet
Position: Elevate the Foot part of the Bed
No Pillows (SE: Stump Edema)
Prone Position:
Prevents Flexion Deformity
Passive ROM on the Unaffected Leg
Prevents Thrombus Formation
Prepare Client for Ambulation
Use Prosthesis or Crutches

Hypertension Sustained Elevation of BP More

than or Equal to 140/90
Silent Killer

4Cs of Hypertension
CVA
Cerebrovascular Accident
CHF
Congestive Heart Failure
CAD Coronary Artery Disease
CRF
Chronic Renal Failure
As of Hypertension
A ACE Inhibitors (-pril)
Angiotensin Receptor Blockers (-tan)
(Best Choice)
Alpha Blockers SE: Orthostatic Hypotension
(Not Commonly Used)
B Beta Blockers

(-olol)

C- Calcium Channel Blockers

Central Acting Medication
Methyldopa / Clonidine
D Diuretics FIRST LINE OF TREATMENT!
Removal of Excess Water and Sodium
Direct Acting Medication HYPERTENSIVE CRISIS

Hydralazine

E Exercise
F Force Compliance

Venous Disorders
Thrombophlebitis
Virchows Triad
Venous Stasis
Endothelial Injury
Increased Blood Viscosity

Gas Exchange
1. Ventilation - Movement of Air In and Out of
the Lungs
2. Diffusion
Alveoli to the Blood

- Movement of Air from

3. Perfusion
Blood to the Cells

- Movement of Gasses from

A) Ventilation: Patent Airway

Hallmark Sign: (+) Homans Sign

Conducting Portion > Passageway of Air >

COPD

V
Venous Support (JOBST Stockings) JOBST
= Pre-filled Pressure

Respiration Portion > Gas Exchange

Restrictive Lung Disorders

Intermittent Compression Devices >

Improves Circulation on Legs

Rest [ Do Not Massage Leg]

Count on Elevating the Leg

H20 Intake Increase

Observe Anti Coagulant Treatment

Warm Moist Application

Varicose Veins Dilated Veins Due to

Incompetent Valves
Genetic Pre-Disposition
Hallmark Sign: Appearance of Dilated and
Tortuous Veins
Nursing Focus
V

Venous Congestion Reduction

Elevate legs of Patient

Note Color Changes Brown Discoloration of Leg

Observe Hose Application

Ulcer Treatment
Unna Paste Boot (Zinc Oxide)

Stripping / Sclerotherapy (Na Morrhuate)

> Hardens Blood Vessels
Respiratory System

>

Conducting System
Protective Devices
1. Filtration of Nasal Hair Vibrissae
(Nasal Hair)
2. Mucociliary Clearance
3. Cough Reflex > Watchdog of the
Lungs
4. Reflex Broncho Constriction
5. Alveolar Macrophage System >
Phagocytosis
Chronic Obstructive Pulmonary Disease
(COPD)
group of disorders > obstruction in gas
entry
COPD = CAL (Chronic Airflow Limitatioon)
Common Cause: Smoking
Asthma > Best Prototype of An Allergic Reaction
Antigen Antibody Reaction > Release of
Chemical Mediators
Histamine
SRS-A
ECF-A

> Bronchoconstriction
> Increase Secretion
> Mucosal Edema

Signs and Symptoms

1. Wheezing
2. Use of Accessory Muscles
3. Shortness of Breath
Gadget: Peak Expiratory Flow Meter > Only Use
When Patient is Stable
Peak Flow Codes:

Green (80-100%)
Good Control
Yellow (50-79%)
Caution: Asthma Getting
Worse
Red (Below 50%) MEDICAL ALERT

Chronic Bronchitis - Increase in

Mucocyliary Clearance Activity
Increased Secretions > Obstruction of 02
and Rention of C02
Decrease in 02 and Increased C02

Nursing Care
A

Sign and Symptoms

1. Cough
2. Increased Secretions (1/2 1L of
Phlegm / 24 Hours)
3. Cyanosis Blue Bloaters

Allergen Avoidance and Identification

S
Steroids (MDI vs DPI) Prednisone /
Fluticasone
T

Treat the Dyspnea

(Broncho Dilator, Chemical Mediator)
a) Bronchodilators
- Sympathomimetic - SNS Effect
Terbutaline, Salbutamol, Epinephrine
Xanthine Derivatives Aminophiline,
Teophiline SE: Toxicity
(Tachycardia, Headache, Convulsions)
Give: Iced Tea
Anticholinergic Ipratropium Bromide
b) Chemical Mediator Inhibitors > Asthma
Prophylaxis SE: Hepatotoxicity
Montelukast
Zafirlukast
Zileuton

High Fowlers Position / Orthopnic >

Maximum Use of Muscles of Respiration

Manage Early Infection

Assure Rest, Nutrition and Fluids

Bronchiectasis
repeated bacterial infection
Signs and Symptoms
1. Layering of Sputum
Diagnostic Test
Assessment of Oxygenation
1. Pulmonary Function Test
Spirometer > Measure Lung Volume /
Capacity
2. Pulse Oximetry
N 95 100%
With COPD 90-100%
3. ABG Best Test to Measure ABG Reading
D
Y
S

Percussion

Diet: High Caloric Diet > More Caloric

Expenditure
Best Mucolytic: Water

Vibration
Postural Drainage

Smoking > COPD

Emphysema > Loss of Elastic Recoil > Inc
Residual Lung Volume
Increased Carbon Dioxide, Decreased Oxygen
Signs and Symptoms
1. Dyspnea
2. Inc AP Diameter (Barrel Chest) >
Retention of C02
3. Clubbing of Fingers > Peripheral Hypoxia
4. Erythematous Appearance (Pink
Puffer)

Nursing Intervention
Dyspnea Reduction
Complete Bed Rest
Yank on Trigger Factors
Stop Smoking
Sputum Expectoration
Chest Physiotherapy

Postural Drainage
1. Auscultate Lungs > Determine Location of
Congestions
Lots of Phlegm on Base of Lungs >
Trendelenberg
Lots of Phlegm on Apex of Lugs > Semi
Fowlers
Lots of Phlegm on Right Middle Lobe >
Left Side Lying
2. Oral Care
P
N

Promote Adequate Oxygenation

Do Not Give High Level of O2 (2-3L)
Nutritional Support
High Caloric Diet (Small Freq Feeding)

Exercise
Pursed Lip Breathing (Removes C02)

Spirometer
IPPB (intermittent positive pressure breathing)
(prevents collapse of alveoli)
A

Administer Drugs
Bronchodilators
Influenza Vaccinations

Drugs:
1. Mucolytics -Acetylceysteine
3. Saturated Solution of Potassium Iodide
(KISS) > Bitter Taste
Combine With Orange Juice
4. Antitussive Inhibits Cough
Codeine
DIFFUSION Movement of 02 from Alveoli into
Blood
Restrictive Lung Disorders Problem in the Gas
Exchange
Lung Infection
Chest Injuries
Space Occupying Lesion
Chest
1.
I
P
P
A
2.
I
P
P
A

Injury
Hemothorax - Chest Lag > Unequal Chest Expansion
- Reduction of Tactile Frimitus
- Dull Sound
- Reduced Breath Sounds
Pneumothorax -PRIORITY PROBELEM
- Dyspnea
- Increase in the Tactile Fremitus
- Hyperresonant Sound
- Reduced Breath Sounds

Tension Pneumothorax > Lung Shifting to

Opposite Side > Mediastinal Shift
Twisting of the Aorta and Vena Cavas
Hallmark Sign: Tracheal Deviation to the
Opposite Side
Neck Vein Distention
Muffled Heart Sounds
3. Rib Fracture
- Multiple Rib Fracture > Flail Chest
> Paradoxical Chest Expansion

Chest Drainage
Principle:
1. Gravity
2. Water-Seal = Vacuum that Creates
Negative Pressure
Purpose:
1. Remove and Air and Water from the
Pleura.
2. Facilitate re-expansion of the Lungs.
3. Maintain the Negative Pressure.
S = Observe the Site of Insertion > SQ
Emphysema
- Accumulation of Air Under the Tissues
- Crepitus on Palpation > Chicharon Sound
- Air Will Rise Up Into Face
- Assure Patient this will not cause Death :
Not An Emergency Situation
T = Observe the Tube Blood Clots
Milk Tube Only With Doctors Orders
Kinking Straighten Tube
O = Oscillations (Fluctuations)
Absence Due to Kinking, Blood Clot
Re-Expansion of Lungs > Equal Breath Sounds
P = Problems - Breakage of Bottle (Dip in a
Water Bottle/Glass of Water)
Accidental Removal Cover with Vasilinized
Gauze
Chest Surgeries
1. Pneumonectomy Removal of a Lung
Post Op = Position the patient on the
affected side
No Chest Tube Insertion
2. Lobectomy Removal of A Lung Lobe
3. Segmental Resection Removal of a Lung
Segment
4. Wedge Resection Removal of a Lung
Portion
Post Op = Position the patient on the
unaffected side
With Chest Tube
5. Thoracoplasty Repair of the Lung
Space Occupying Lesions
Cancer Abnormal Proliferation of Cells
Defect in Cellular Proliferation
>
Tumor
Loss of Contact Inhibition

Benign
Soft and Moveable
Encapsulated
Growth By Expansion
Well Differentiated
No Metastasis

Malignant
Hard and Fixed
Without Capsule
Growth by Depth
Poorly Differentiated
Metastasis

Epithelial

Carcinoma

Connective Tissue

Sarcoma

Lymphoid

Lymphoma

Blood

- Leukemia

Defect in Cellular Differentiation

Hyperplasia
Herpertrophy
Atrophy
Anaplasia
Metaplasia
Metaplasia Transformation of 1 Cell into
another Cell
Anaplasia Loss of Cellular Differentiation
Multifactorial Causation
Virus

Genetics
Foods

Early Warning Signs of Cancer

Early Detection and Health Promotion
C
A
U
T
I
O
N

Change in Bowel / Bladder Habits

A Sore that does not Heal
Unusual Bleeding / Discharge
Thickening / A Lump on Breast
Indigestion
Obvious Change in Wart or Mole
Nagging Cough or Hoarseness

Client

Factors:
Self Breast Examination
Pap Smear
DRE
Guaiac Test
Testicular Self Examination

Tumor Cell Markers

Purposes
A) To Screen and Identify High Risk
Population
B) To Help Diagnose Specific Type of Tumor
C) To Follow the Clinical Course of Cancer
1. PSA Prostatic Specific Antigen >
Prostate Cancer
2. CA-125 Ovarian Cancer
3. Alpha-Fetoprotein Liver Testicular
Cancer
4. Carcinoembryonic Antigen
Colorectal Cancer
5. HCG - Germ Cell
6. Bence Jones Protein Multiple Myeloma
7. Vanillymandelic Acid - Neuroblastoma
Breast Cancer
Risk Factors:
1. Nulliparity
2. Genetics / Heredity
3. Prolonged Exposure to Estrogen Early
Menarche Late Menopause
4. Obesity
Hallmark Signs:
1. Abnormal Discharges Maybe Blood /
Puss / Fluid
2. Edema
3. Lymph Adenopathy
4. Abnormal Dimpling > Orange Peel
Appearance
Diagnostic Test
Biopsy
Mamogram 35 Y.O and Above
Stage 1 and 2 = Lumpectomy (Removal of Mass)
Total / Simple Mastectomy = Tumor and Breast
Tissue
Modified Radical Mastectomy = Tumor Breast
Tissue and Pectoralis Minor
Radical Mastectomy = Lymph Nodes, Breast
Tissue, and Tumor
NSG Intervention: Post Mastectomy
1. Bleeding Monitoring Inspect the Back of
the Patient
Reinforce the
Dressing and Call the
Doctor
2. Reduce the Injury No BP Taking, IM
Injection, No IV Line on the Affected Side
No Gardening, Cross-stitch,

Dont Give Roses, Cactus

3. Elevate the Affected Arm
4. Avoid Flexion Contractures Exercise
( Brushing Hair)
5. Self-Breast Examination Continue on
Opposite Side
6. To Help Psychologically
Lung Infection
Pneumonia - Inflammation of the Lung
Parenchyma.
C
R
A
C
K
L
E
S

Calories Increased
Rest
Antibiotic
Chest Tapping
Keep Moving
Limit Going to Public Places
Encourage Fluids
Smoking Avoidance

White Blood Cells Fights Infection

Red Blood Cells Carry Oxygen
Platelets Control Clotting
Hypoxia Best Stimulus for RBC Production
Erythropoietin > Bone Marrow > Stem Cell >
Rubriblast (Immature RBC)
Reticulocyte > RBC (80-120 days Life
Span)

RBC
Heme
Protoporphyrin

Globin
Fe

Fat Soluble Bile (Unconjugated)

Water Soluble Bile (Conjugated)
Stercobilin (Gives Feces Its Golden Yellow Color)

PERFUSSION
2

97% Combined in Hemoglobin

3% Dissolved in Plasma

C02 Protein Forming Carbamino Compounds

As Bicarbonate
Dissolved in Plasma
dependent on the circulating blood

Blood Plasma Cells

Plasma
55%
Water
Protein

Fe Def.

Rubriblast Requirements to Become Mature

RBC
Amino Acids
- structure
Iron and Copper
- color
Folic Acid, Vitamin B6, Vitamin B12
- enzymatic activity
Iron Deficiency Anemia

Cells
45%
(Hematocrit)
RBC, WBC, Platelet

Anemia Reduction of the Oxygen Carrying

Capacity of the Blood

Etiology

Hallmark

Cells

Nutritional
Paracitism

Koilonychia
(Spoon S. Fingers)

Microcytic (Small)
Hypochromic (Pale)

Pica
(Crave to Eat Inedible
Food)
Plummer Vinson Syndrome
- Cheilitis (Crack in Oral Mucosa)
- Dysphagia
- Glossitis
MGT: Dietary Management
Liver

Ampalaya

Test
Hemoglobin
(hgb)
Serum Ferritin
RBC Index

Malunggay
Kangkong
Iron Supplementation
Fumarate
> Highest Source of Iron > Give with Vitamin C
Sulfate
Gluconate

Aplastic
Bone Marrow
(Bleeding Tendencies)Depression

Pancytopenia
(All Cells are Low)

Normocytic
Normochromic

BM Biopsy

Nursing Consideration
1. Protect Patient from Infection (Dec WBC) (Immunocompromised)
Reverse Isolation

2.

3.

No Fresh Fruits and Vegetables

Protect Patient from Injury
No Traumatic Procedures
Prepare Patient from Bone Marrow Transplantation

Pernicious Anemia
(Vit B12 Def)
Only with
Neurologic
Symptoms
NSG:
1.

Malabsorption

Sore Beefy Tongue

Ataxia
Paresthesia

Macrocytic
Hyperchromic

Schillings Test
(VitB12 Absorb)

24 Urine Sample

Schilling:
1. Injection of Nonradioactive Vitamin B12 Given
2. Radioactive B12 Ingested

Hemolytic Anemia
G6PD Anemia

Genetics

Jaundice
Splenomegaly
Hepatomegaly

NSG MGT:
1. Genetic Counseling

Nursing Focus
A
N
E
M
I
A

Assess the causes of anemia

Nutritional Supplement
Encourage Rest
Monitor Laboratory Values
Institute Infection Precaution
Avail of Blood Transfusion
Kidney

K
Keeps Us Clean
I
Institute Acid Base
D
D Regulation (Vit D)
Vit D Calcium and Phosphate Regulation
N
No To Electrolyte Imbalance
E
Erythropoietin Controls
Y
Your BP is Regulated (RAAS)

Normocytic
Normochromic

Osmotic Fragility

Urine Formation
Glomerular Filtration
Tubular Reabsroption
Tubular Excretion
Obstructive Pathology
Nephrolithiasis
Genetics
Diet
Dehydration
Infection

Signs and Symptoms

Urinary Difficulties
Renal Colic (Severe Flank Pain)
Dysuria
Hematuria

Diagnostic Tests
1. Urinary Analysis
(+) RBC

2. Ultrasound
3. KUB X-Ray (Kidney, Ureter, Bladder)
4. IVP Intravenous Pyelography > NSG
MGT: NPO, Allergy to Dye
Benign Prostatic Hypertrophy
Etiology
Unknown

Nursing Management

Signs and Symptoms

1.Nocturia
2. Urinary Dribling
3. Urinary Retention

S = Strain Urine of Patient (Collect the Stone)

- Acid Stone > Give Alkaline Ash Diet
* Fish Without Scales
* Dairy Products
* All Fruits and Vegetables Except Cranberry,
Plum, Plunes

Diagnostic Test
1. Digital Rectal Exam - 40 y.o above
2. PSA Prostatic Specific Antigen > R/O
Cancer
3. Cystoscopy
Surgical Correction:
1. Prostatectomy
Transurethral Resection of the Prostate
Suprapubic Prostatectomy > Bladder >
Prostate
Retropubic Prostatectomy > Direct to
Prostate
Perineal Prostatectmy > Perinium >
Bladder

-Alkaline Stone > Acid Ash Diet

* Cranberry, Plum, Prunes
* All Meat Products
* All Poultry Products
T = Take Plenty of Fluids
* 3-4 Liters of Water Per Day
O = Observe for Infection / Observe for
Hematuria
* Urinary Antiseptics Inhibit Growth of Bacteria
- nitrofurantoin
- nalidixic acid
- Pyridium
- Mandelamine
SE: Orange Discoloration of Urine : Abstain from
Wearing White Undergarments

Nursing Management Post Operative

P
Prevent Bleeding
- Cystoclysis
(Continuous Bladder Irrigation)
> Prevent Bleeding and Blood Clot Formation
> First 24 Hours Bloody, Next 24 Pink > Next 24
Colorless
R

N = Narcotic Analgesics
- Morphine Sulfate
- Demerol
- Nubain
E = Encourage Ambulation
ESWL (Extracorporeal Shock-Wave
Lithotripsy) P72,000
S = Surgery (Nephrolithotomy)

Record Urine Output

Observe for Bladder Spasm > No

Prolonged Sitting / Avoid Straining
Antispasmodic Drug : Buscopan

S
Sexuality Concerns: Damage to Perineal
Nerve > Impotence
T

Take Time to Ambulate

Avoid Tea and Coffee Bladder Irritant

To Increase Fluids

Emotional Support

Inflammatory
More Common in Females

 Anatomical Predisposition
E-Coli, Proteus, Enterobacter

Pyelonephritis
Flank Pain
Fever

Acute
Sudden Onset
Reversible
Etiology
Pre-Renal
Renal
Post-Renal

Urethritis
Dysuria
Abnormal Discharges
Diagnostic Test
1. Urine Culture
Focus of Care:
A

Acidify Urine of Patient

> Foods and Drinks Rich in Vitamin C

- Bubble Bath Beware

- Cotton Panty

- Drugs

- Encourage Fluids

> Floroquinolones / (-xin)

Basement Membrane Disorder

Glomerolonephritis

Nephrotic Syndrome

GABHS

Autoimmune

Signs and Symptoms

Tea Colored Urine
Edema
Hypertension

Signs and Symptoms

Edema
Proteinuria
Increased
Cholesterol

Diagnostic Test
Urinalysis (+) RBC
Anti-Streptolycin O
Titer
Increased BUN
Increased Creatinine

Diagnostic Test
Urinalysis (+)
Albumin
Low Serum Albumin
High Lipid Profile

Common Nursing Interventions

Monitor Weight of Patient
Intake and Output Monitoring
Skin Care
Complete Bed Rest

Diet
Low Protein

Drugs
Antibiotics
Anti
Hypertensives
Diuretics (Edema)

Drugs
Steroids
Diuretics

Renal Failure

Cystitis (Urinary Bladder)

Suprapubic Tenderness
Dysuria

Low Sodium

Diet
High Protein

Chronic
Progressive
Irreversible
Etiology
Diabetes Mellitus
Hypertension
Infections

Acute Renal Failure

Pre-Renal Reduction of Blood Flow to the
Kidney
Hypovolemic Shock
Burns
Diarrhea / LBM
Renal - Conditions which Cause Direct
Injury to the Kidney
Pyelonephritis
Glomerolonephritis
Post-Renal - Conditions which obstruct the
flow of Urine
BPH
Nephrolithiasis
Oliguric Phase
Diuretic Phase
Recovery Phase
Chronic Renal Failure
Diminished Renal Reserve (40% of
Kidney Damage) Asymptomatic
Renal Insufficiency Period (60% of
Kidney Damage)
Isosthenuria Fixed Specific Gravity of
Urine
Anemia > Delineates ARF and CRF
*End Stage Renal Disorder (80% of Kidney
Damage)
- Azothemia Retention of Waste Products
in Blood
- Uremia Signs and Symptoms Associated
With Azomethia (Complaints)

Uremia

Excretion
Edema
(Uremic Frost)
Pruritus
Electrolyte Imbalance
Altered Level of Conciousness
Secretory
Weight Gain
Pallor
> No Erythropoietin
Fracture > Vit D Synthesis: Hypocalcaemia
BP Regulation
Headache
Dizziness
Renal Function Test
1. BUN
8-24 mg/dl
2. Creatinine
.6 1.3 mg/dl
3. Creatinine Clearance 100-120 ml/min
BEST TEST!
4. Uric Acid
2.5 8 mg / dl
Specimen: 24 Hour Urine Collection

- Calcium Carbonate, Milk Diet

(Sippy or Karrell Diet)
6
4 G of Milk
Hyperphosphatemia
- Aluminum Hydrozide (Amphojel)
Y Your Blood Counts
Tx: Synthetic Erythropoietin (Eprex)
> Stimulate RBC Production Injected
2-3 X Week
Dialysis
A
E
I
O
U

Acidosis
Electrolyte Imbalance
Ingestion of Poison
Overload
Uremic Symptoms

Peritoneal Dialysis
Artificial Kidney
Peritoneum
Vascular Access
Tenckhoft Catheter

Hemodialysis
Artificial Kidney
Dialyzer
Vascular Access
AV Shunt / Fistula

Dialyzing Solution
Impersol

Note:
Protect Arm From
Injury
NO BP Taking
NO IM Injections
NO IV Insertion
Dialyzing Solution
No Need (In Machine)

Nursing Considerations
K Keeping Fluid Balance
Monitor Intake and Output
Limit Oral Fluid Intake (500-1000ml / day)
Treatment: Diuretic
I

Inspect the Skin (Pruritus)

Colloidal Bath
Cetaphil
Oatmeal Bath
Cornstarch Bath

D Dietary Instructions
Low Protein Diet
Giordano Giovanetti Diet (Low Protein)
Tx: Ketosteril - Non-Ketogenic Amino Acid
N No To Acidosis
Na HCO3
E Electrolyte Balance Maintenance (Because
of Hyperkalemia)
Monitor ECG of Patient Tall T Wave
Avoid Giving Fruits to Patient
Tx: Sorbitol (Laxative)
Kayexalate (Rectal Via Enema)
Glucose + Insulin Treatment
Hyperkalemia
- Sorbitol, Kayexalate, Glucose + Insulin
Hypocalcemia

Nursing Responsibility
Peritoneal Dialysis
1. Get the Weight of the Patient
2. Warm the Dialysate Solution
Reduce Abdominal Cramping
Vasodilation
3. Instill Solution in Patients Abdomen
and Allow to Settle for 1 Hour
4. Drain Out the Solution : Measure
Intake and Output I = O
Turn Patient from Side to Side to Facilitate
Release of Water
Watch for Complications:
1. Monitor for Signs of Infection
Fever
Abnormal Color in the Dialysate Solution
Hemodialysis
1. Get the Weight of the Patient
2. Position the Patient Comfortably on Bed
3. Vital Signs qH

Complication:
1. Dialysis Disequilibrium Syndrome
Rapid Ultra Filtration of the Blood >
Cerebral Edema
Headache
Vomiting
Convulsions
Nursing Management
Slow Down the Filtration Rate
Kidney Transplantation
1. Best Donor: Twin Brother / Sibling
2. First Come First Serve : Drivers License
Diagnostic Test
1. Imuran
2. Cyclosporine
3. Prednisone
Nursing Management
Monitor for Signs and Symptoms of Rejection
Decreased Urine Output
Edema
Generalized Body Malaise
Rise in Serum Creatinine
Abnormal Temperature
Dull Pain on Site
Manifestation
Elevated BP

> Late Manifestation

> Earliest