I.

INTRODUCTORY CONCEPTS
A. STRESS
A. Stress
1. Stress and Function:
- Dynamic Balance: The Steady State
2. Stress and Adaptation
- Selyes General Adaptation Syndrome Model
- Fight-Flight Model
4. Stress Appraisal Model
B. Stress: Threats to the Steady Sate
1. Types of Stress and Stressors
2. Stress as a stimulus for disease
3. Physiological and Psychological Responses to Stress
4. Maladaptive responses to stress
5. Indications of Stress
C. Stress at the Cellular levels
i.
Control of steady state
ii.
Cellular adaptation to stress
iii.
Cellular Injury
iv.
Cellular response to injury: Inflammation
v.
Cellular Healing
D. Stress Management
D1. Promoting healthy lifestyle
D2. Enhancing coping strategies
D3. Biobehavioral Interventions for stress
1. Biofeedback
2. Progressive Muscle Relaxation
3. Meditation
4. Guided Imagery
B. ILLNESS
B1. Concept of Illness
1. Cell Injury and Inflammation
1.1 Cell adaptation to injury
1.2 Body defenses against injury
1.3 Monocular phagocyte system
1.4 Inflammatory Response
B2. Chronic Illness
1. Chronicity of Illness or Disease
1.1 Definition of Chronic Conditions
1.2 Prevalence and Causes of Chronic Illness
1.3 Characteristics of Chronic Conditions
1.4 Phases of Chronic Conditions
1.5 Management of Chronic Conditions
C. PAIN
1. Types of Pain
a. Acute
b. Chronic
c. Cancer-related Pain
2. Classifications of Pain
a. Classification by location
b. Classification by etiology
3. Harmful effects of Pain
a. Effects of Acute Pain
b. Effects of Chronic Pain
4. Pain Theories
5. Pathophysiology
i. Neurophysiological transmission of Pain
ii. Factors Affecting Pain
6. Nursing Care of a Client Experiencing Pain

ASSESSMENT
1. Pain experience inventory
2. Cries Neonatal Post-operative Pain Measurement Scale
3. FLACC Pain assessment tool
4. Faces Pain Rating Scale
5. Poker Chip tool
6. Oucher Pain Rating Scale
7. Numerical or Visual analog Scale
8. Adolescent Pediatric Pain Tool
9. Logs and Diaries
PLAN / IMPLEMENTATION
Pain Management Strategies
1. Establish therapeutic relationship
2. Teach patient about pain relief
3. Reduce anxiety and fears
4. Provide comfort measure
5. Non-Pharmacologic
5.1.1 Guided Imagery
5.1.2 Thought Stopping
5.1.3 Hypnosis
5.1.4 Aromatherapy, Essential Oils
5.1.5 Magnet Therapy
5.1.6 Music Therapy
5.1.7 Yoga and Meditation
5.1.8 Acupuncture
5.1.9 Crystal or Gem stone Therapy
5.1.10 Herbal Therapies
5.1.11 Biofeedback
5.1.12 Therapeutic touch and massage
5.1.13 TENS
5.1.14 Heat and Cold Application
o Pharmacologic Interventions for Pain
o Medications for Pain Management
o Routes of Administration
7. Neurologic and Neurosurgical Approaches to Pain
Management
7.1.Surgical destruction of painful stimuli
Rhizotomy
Nerve Block
Continuous Extravascular Infusion
Neurectomy
Sympathectomy

D. PERIOPERATIVE NURSING
1. PREOPERATIVE NURSING CARE
Perioperative and Perianesthesia Nursing
Surgical Classifications
General Considerations
- Conditions Requiring Surgery
- Categories for surgical procedure as to;
Purpose
Degree of Risk to patient
Urgency
Effects of surgery on the person

 Factors in the estimation of surgical risks

- Preparation for Surgery
- Preoperative Nursing Considerations
ASSESSMENT
1. Nursing History
2. Health History
- development consideration
- medical history
- medications
- occupation
3. Life-style
- nutrition
- use of alcohol
- illicit drugs or nicotine
- ADL
- occupation
4. Coping patterns and support system
5. Pre-operative physical assessment
6. Pre-surgical screening tests
- chest x-ray
- ECG
- CBC
- Electrolyte levels and urinalysis
ANALYSIS
- Potential Nursing Diagnosis
- Anticipatory Grieving related to perceived loss of normal body image
- Anxiety related to the effects of surgical procedure
- Fear related to surgery
- Risk for infection
- Ineffective Airway Clearance
- Ineffective Individual Coping
PLAN / IMPLEMENTATION
1. Physiological / spiritual preparation for surgery
2. Legal aspects of the informed consent
3. Instructional and Preventive aspects
3.1 Deep breathing exercises
3.2 Coughing exercises
3.3 Turning exercises
3.4 Extremity exercises
4. Physical Preparations
4.1 On the night of the surgery
a.Hygiene and skin care
b.Elimination
c. Nutrition and fluid
d.Rest and sleep
4.2 On the day of the surgery
a. Pre-operative checklist
b. Pre-operative medications
2. INTRAOPERATIVE NURSING CARE
ASSESSMENT
1. Identify surgical client
2. Assess the emotional and physical status
3. Verify information in the pre-operative checklist
ANALYSIS
1. Impaired Skin Integrity related to Incision

2. Risk of Fluid Volume deficit

3. Risk for Injury related to position
PLAN / IMPLEMENTATION
1. The surgical team
Duties and responsibilities of the circulating nurse; scrub nurse; RN
first assistants
2. The surgical environment
A. Principles of surgical asepsis
B. Environmental controls
C. Maintaining surgical asepsis
D. The surgical Experience
a. Positioning
b. draping
c. types of anesthesia and sedation
d. stages of anesthesia
E. Potential Intra-operative complication
- Bleeding
- Nausea and vomiting
- Anaphylaxis
- Hypoxia and other respiratory complications
- Hyperthermia
- DIC
3.
Documentation
4.
Transferring to the PCU
3. POSTOPERATIVE NURSING CARE
A. Immediate Post-operative Care in the PACU
B. Nursing responsibilities in the PACU
a. assessing the post-operative client
b. maintenance of pulmonary ventilation
c. maintenance of circulation
d. protection from injury
e. promotion of comfort
C. Aldrete post-anesthesia recovery scoring system
D. Ongoing post-operative Care
E. Immediate post-operative care in the PACU
ASSESSMENT
a. Vital signs
b. Color and temperature of the skin
c. Level of Consciousness
d. Comfort
e. Time of Arrival
ANALYSIS
Postoperative nursing diagnosis
b. risk for surgical site diagnosis
c. pain
d. altered family processes related to loss of economic stability
e. impaired physical mobility
f. potential complication: Hemorrhage
PLAN / IMPLEMENTATION
1. Preventing Post-operative Complications
1.1 Respiratory Complications
1.2 Circulatory Complications
1.3 Fluid and Electrolytes Imbalance
1.4 Gastrointestinal Complications
1.5 Urinary Complications
1.6 Wound Complications
2. Post-operative Discomforts

E. Fluid and Electrolyte: Balance and Disturbances

1.Fundamental concepts of fluid and electrolyte balance
Fluid:
The main constituent of the body and is comprised of water and dissolved substances in the form of
electrolytes, gases and nonelectrolytes. Therefore, the bodys fluid balance is extremely important.
Homeostasis of water accounts for approximately 50% to 60% of a persons body weight.
Water:
The most important nutrient of life. Humans can survive only few days without water.
Functions of water:
o Provide a medium for transporting nutrients to cells and wastes from cells, and for
transporting substances such as hormones, enzymes, blood platelets, and red and white
blood cells.
o Facilitate cellular metabolism and proper cellular chemical functioning.
o Act as solvent for electrolytes and nonelectrolytes.
o Help maintain normal body temperature.
o Facilitate digestion and promote elimination.
o Act as a tissue lubricant.
Body Fluid Compartments:
Two main compartments or spaces:
1. Intracellular Fluid
Fluid within the cells, constituting about 40% of an adults body weight or 70% of TBW.
2. Extracellular Fluid
The fluid outside the cells, constituting about 20% of an adults body weight or 30% of
TBW.
Includes intravascular and interstitial fluids.
Intravascular fluid or plasma is the liquid component of the blood.
Interstitial fluid is the fluid that surrounds tissue cells and includes lymph. It acts as a
transport vehicle for gases, nutrients, wastes, and other materials that move between
the vascular compartment and body cells.
A tissue gel which is spongelike material composed of large quantities of
mucopolysaccharides, fills the tissue spaces and aids in even distribution of
interstitial fluid. Normally most of the fluid in the interstitium is in gel form. The
tissue gel, which has a firmer consistency than water, opposes the outflow of
water from the capillaries and prevents the accumulation of free water in the
interstitial spaces.
Transcellular Compartment (usually minor) includes the CSF and fluid contained in the
various body spaces, such as the peritoneal, pleural, and pericardial cavities, and joint
spaces.
o Normally only about 1% of ECF is in the transcellular space.
o This amount can increase considerably in conditions such as ascites, in which
large amounts of fluid are sequestered in the peritoneal cavity.
o When the transcellular fluid compartment becomes considerably enlarged, it is
referred to as a third space, because this fluid is not readily available for
exchange with the rest of the ECF.
Electrolytes
Dissociation of Electrolytes:
Body fluids contain water and electrolytes.
Electrolytes are substances that dissociate in solution to form charged particles, or ions.
For example Sodium chloride dissociates to form a positively charged Na and negatively charged Cl
ion.
Particles that do not dissociate into ions such as glucose and urea are called nonelectrolytes.
The distribution of electrolytes between body compartment is influenced by their electrical charge.

For example, a positively charged H ion may be exchanged for a positively charged K and a
negatively charged bicarbonate ion may be exchanged for another negatively charged Cl ion.

Diffusion and Osmosis

Diffusion is the movement of charged or uncharged particles along a concentration gradient.
Because there are more molecules in constant motion in a concentrated solution, particles move
from an area of higher concentration to one of lower concentration.
The concentrations of electrolytes and solutes can be expressed in several ways, for example
mg/dL, mEq/L, or millimoles/L (mmol/L).
Osmosis is the movement of water across a semipermeable membrane (one that is permeable to
water but impermeable to most solutes.)
As with solute particles, water diffuses down its concentration gradient, moving from the side of the
membrane with the lesser number of particles and greater concentration of water to the side with
the greater number of particles and lesser concentration of water.
As water moves across the semipermeable membrane, it generates a pressure called osmotic
pressure, which represents the pressure needed to oppose the movement of water across the
membrane.
Osmolality and Osmolarity
The osmotic activity of a solution may be expressed in terms of either its osmolarity or osmolality.
Osmolarity refers to the osmolar concentration in 1L of solution (mOsm/L); usually used when
referring to fluids outside the body.
Osmolality refers to the osmolar concentration in 1 kg of water (mOsm/kg of H2O); used for
describing fluids inside the body.
Because 1kg is equal to 1L, both are used interchangeably.
Serum osmolality which is largely determined by sodium and its attendant anions (CL and HCO3)
normally ranges from 280 to 295 mOsm/L/
Tonicity
Refers to the tension or effect that the effective osmotic pressure of a solution with impermeable
solutes exerts on cell size because of water movement across the cell membrane.
Solutions to which body cells are exposed can be classified as isotonic, hypotonic, or hypertonic,
depending on whether they cause cells to swell or shrink.
Isotonic Solutions
Cells placed in isotonic solution (e.g. 0.9% sodium chloride or 5% Dextrose in water), which has the
same effective osmolality as the ICF(i.e 280 mOsm/L, neither shrink nor swell.
These solutions are important in the clinical setting because they can be infused into the blood
without danger of upsetting the osmotic equilibrium between the ICF and ECF.
Hypotonic Solutions
When cells are placed in a hypotonic solution (i.e. distilled water), which has a lower effective
osmolality than the ICF, they swell as water moves into the cell.
Hypertonic Solutions
When cells are placed in a hypertonic solution (e.g. 3% normal saline or 10% glucose), which has a
greater effective osmolality than ICF, they shrink as water is pulled out of the cell.
Capillary / Interstitial Fluid Exchange
The transfer of water between the vascular and interstitial compartment occurs at the capillary level.
Four Forces Control the Movement of Water Between the Capillary and Insterstitial Spaces:
Capillary Filtration Pressure/Capillary Hydrostatic pressure, which pushes water out of the
capillary into the interstitial spaces through mechanical rather than an osmotic pressure.
It is about 30-40 mmHg at the arterial end, 10-15 at the venous end and 25 mmHg at
the middle.
A rise in arterial or venous pressure increases capillary pressure.
The force of gravity increases capillary pressure in the dependent parts of the body.
Capillary Colloidal Osmotic Pressure/Plasma Oncotic Pressure , which pulls water back into
the capillary (about 28 mmHg).

It is the osmotic pressure generated by the plasma proteins that are too large to pass
through the pores of the capillary wall.
This is different from the osmotic pressure that develops at the cell membrane from the
presence of electrolytes and nonelectrolytes.
Because plasma proteins do not normally penetrate the capillary pores and because
their concentration is greater than in the interstitial fluids, it is capillary osmotic
pressure that pulls fluids back
Insterstitial Hydrostatic Pressure, which opposes the movement of water out of the capillary
Tissue Colloidal Osmotic Pressure, which pulls water out of the capillary into the interstitial
spaces.
Combination of these forces is such that only a small excess fluid remains in the interstitium. This
excess fluid is removed from the insterstitium by the lymphatic system and returned to the systemic
circulation.

Edema
Defined as palpable swelling produced by expansion of the interstitial fluid volume.
Edema does not become evident until the interstitial fluid volume has been increased by 2.5 to 3 L.
Causes of Edema:
o Increased capillary pressure:
Decreased arteriolar resistance: e.g. Calcium channel-blocking drug responses.
Venous obstruction: e.g. liver disease with portal vein obstruction; acute pulmonary
edema; venous thrombosis (thrombophlebitis)
Increased vascular volume: heart failure, kidney diseases, premenstrual sodium
retention, pregnancy, environmental heat stress.
o Decreased capillary colloidal osmotic pressure:
Increased loss of plasma proteins (albumin): protein-losing kidney diseases, extensive
burns.
Decreased production of plasma proteins: liver disease, starvation, malnutrition
o Increase capillary permeability
Inflammation
Allergic reactions
Malignancy: ascites, pleural effusion
Tissue injury and burns
o Obstruction to lymphatic flow
Malignant obstruction of lymphatic structures
Surgical removal of lymph nodes
Routes of Gains and Losses
1. Kidneys:
The usual daily urine volume in the adult is 1 to 2L. A general rule is that the output is approximately
1mL of urine per kilogram of body weight per hour in all age groups.
2. Skin:
Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The
chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from ) to
1,000 mL or more every hour, depending on the environmental temperature. Continuous water loss
by evaporation (approximately 600 ml/day) occurs through the skin as insensible perspiration, a
nonvisible form of water loss. Fever greatly increases insensible water loss through the lungs and
the skin, as does loss of the natural skin barrier (through major burns, for example).
3. Lungs:
Eliminates water vapor (insensible loss) at a rate of approximately 400 ml every day. The loss is
much greater with increased respiratory rate or depth, or in a dry climate.
4. GI Tract:
Only 100 to 200 ml daily though 8L of fluid circulates in GIT every 24 hours. Because the bulk of fluid
is reabsorbed in the small intestine, diarrhea and fistulas cause large losses. In healthy people, the
daily average intake and output of water are approximately equal .

Average Daily I and O in an Adult.

Intake
Oral Liquids
Water in Food
Water produced by metabolism
Total Gain
Output
Urine
Stool

1, 300 ml
1, 000 ml
300 ml
2, 600 ml
1, 500 ml
200 ml

Insensible
Lungs
Skin

300 ml
600 ml

Total loss

2, 600 ml

Homeostatic Mechanisms
1. Kidneys
Normally filter 170 L of plasma every day in the adult, while excreting only 1.5 L of urine.
They act both autonomously and in response to blood-borne messengers such as aldosterone and
ADH.
Major Functions to Regulate Fluid and Electrolytes:
o Regulation of ECF volume and osmolality by selective retention and excretion of body fluids.
o Regulation of electrolyte levels in the ECF by selective retention of needed substances and
excretion of unneeded substances.
o Regulation of pH of the ECF by retention of hydrogen ions
o Excretion of metabolic wastes and toxic substances.
2. Heart and Blood Vessels
Distribution of blood to the kidneys to allow for urine formation. Failure of this pump would interfere
with renal perfusion and thus with water and electrolyte regulation.
3. Lungs
Through exhalation the lungs remove approximately 300 ml of water daily in the normal adult
Role in acid-base balance through hyper and hypoventilation
4. Pituitary Gland
ADH stored in PPG as manufactured by hypothalamus
Controlling retention and excretion of water by kidneys
5. Adrenal Gland
Aldosterone which causes sodium retention and water retention and potassium loss.
Cortisol in large amount would also cause sodium and water retention.
6. Parathyroid Glands
Parathormone regulates calcium and phosphate balance by influencing bone resorption, calcium
absorption from the intestines, and calcium reabsorption from the renal tubules.
7. Baroreceptors
Detect blood pressure changes and transmit impulse to CNS
Monitoring the circulating blood volume, regulate sympathetic and parasympathetic neural activity as
well as endocrine activities.
Sympathetic stimulation and depression of parasympathetic if there is decrease in arterial pressure.
Sympathetic stimulation also constricts renal arterioles; this increases the release of aldosterone,
decreases glomerular filtration and increases sodium and water retention.
8. RAAS

9. ADH and Thirst

Increased osmolality of body fluids and decrease of blood volume stimulate the sensory
neurons/osmoreceptors of hypothalamus through intracellular dehydration thirst occurs fluid
intake
ADH controls urination
Thirst is a conscious sensation of the need to obtain and drink fluids high in water content
It is controlled by the thirst center in the hypothalamus.
Diabetes Insipidus: is caused by a deficiency or a decreased response to ADH. Persons with DI are
unable to concentrate their urine during periods of water restriction; they excrete large volume of
urine, usually 3 to 20 L/day. Danger arises when there is inability to secure the needed water.
Inadequate water intake leads to hypertonic dehydration and increased serum osmolality.
Syndrome of Inappropriate Secretion of ADH: results from the failure of the negative feedback
system that regulates the release and inhibition of ADH. ADH secretion continues even when serum
osmolality is decreased, causing marked water retention and dilutional hyponatremia
10. Osmoreceptors
Increase of osmotic pressure neurons dehydrated impulse toward pituitary gland increased
release of ADH
11. Release of Atrial Natriuretic Peptide
Increased BV and BPIncrease atrial pressure/atrial stretch increased ANP release from cardiac
cells in atria
ANP decreases vascular resistance by causing vasodilation decrease in BP suppression of
renin levels**decrease in vascular volume, BP and preload and after load.

ANPdecreased ADH release from PPG **

ANP increase glomerular filtration rate which increases urinary excretion of sodium and water
**

Fluid Regulation see p. 255.

Regulation of Water and Sodium Balance
It is the amount of water and its effect on sodium concentration in the ECF that serves to regulate
the distribution of fluid between the ICF and the ECF compartments.
Most of the bodys sodium (135 to 145 mEq/L) is in the ECF with only small amount (10-14 mEq/L)
located in the ICF compartment.
Sodium functions mainly in regulating extracellular fluid volume, including that in the vascular
compartment.
Sodium normally enters the body through the GIT and is eliminated by the kidneys or lost through
GIT or skin.
Kidney is efficient in sodium regulation and when sodium intake is limited or conservation of sodium
is needed, it is able to reabsorb almost all the sodium that has been filtered by the glomerulus,
which will produce essentially sodium-free urine.
The sympathetic nervous system respond to changes in arterial pressure and blood volume by
adjusting the glomerular filtration rate and the rate at which sodium is filtered from the blood (see
also RAAS).
Regulation of Potassium Balance
Potassium is the second most abundant cation in the body and major cation in the ICF compartment.
98% of body K is contained within the body cells (ICF K:140-150 mEq/L)
ECF K: 3.5 to 5.0 mEq/L
Because potassium is an intracellular ion, total body stores of potassium are related to body size
and muscle mass. Thus, total body potassium declines with age, mainly as a result of a decrease in
muscle mass.
Potassium intake is normally derived from dietary sources. Potassium balance can be maintained by
a daily intake of 50 to 100 mEq.
The kidneys are the main potassium losses occur in the urine, with the remainder being lost in stools
or sweat.

Two Mechanisms that regulate serum potassium levels:

o Renal mechanisms that conserve or eliminate potassium
o Transcellular shift of potassium between the ICF and ECF compartments.

Renal Regulation
Kidney provides the major route for potassium.
Potassium is filtered in the glomerulus, reabsorbed along with sodium and water in the proximal
tubule and with sodium and chloride in the ascending loop of Henle, and then secreted into the late
distal and cortical collecting tubules for elimination in the urine.
Aldosterone plays an essential role in regulating potassium elimination by the kidney. In the
presence of aldosterone, sodium is transported back into the blood and potassium is secreted into
the tubular filtrate for elimination in the urine.
There is also a potassium-hydrogen exchange system in the collecting tubules of the kidney. When
serum potassium levels are increased, potassium is secreted into the urine and hydrogen is
reabsorbed into the blood, producing a decrease in pH and metabolic acidosis.
When potassium levels are low, potassium is reabsorbed and hydrogen is secreted into the urine,
leading to metabolic alkalosis.
Extracellular-Intracellular Shifts
Normally, it takes 6-8 hours to eliminate 50% of potassium intake.
To avoid rise in extracellular potassium levels during this time, excess potassium is temporarily
shifted into RBC and other cells such as those of muscle, liver and bone. This is controlled by the
Na/K adenosine triphosphatase (ATPase) membrane pump and the permeability of the ion channels
in the cell membrane.

Factors that alter Intracellular/Extracelllular distribution of potassium:

o Acid-Base disorders
The hydrogen and potassium ions, which are positively charged, can be exchanged
between the ICF and ECF in a cation shift. In metabolic acidosis, for example,
hydrogen ions move into body cells for buffering, causing potassium to leave the cells
and move into the ECF.
o Serum osmolality
Acute increases in serum osmolality cause water to leave the cell. The loss of cell
water produces an increase in intracellular potassium, causing it to move out of the cell
into the ECF.
o Insulin
Both insulin and catecholamines (e.g.epinephrine) increase cellular uptake of
potassium by increasing the activity of the Na/K ATPase membrane pump.
o Beta-adrenergic stimulation
o Exercise: repeated muscle contraction causes potassium to be released into the ECF.

Regulation of Calcium and Magnesium

99% of body calcium is found in bone, where it provides the strength and stability for the skeletal
system and serves as an exchangeable source to maintain extracellular calcium levels.
Most of the remaining calcium (approx. 0.7%) is located inside the cells and only 0.1% to 0.3% is
present in the ECF.

Extracellular calcium exists in three forms:

o Protein bound: with albumin
o Complexed: with substances such as citrate, phosphate, and sulfate.
o Ionized: free to leave intravascular and participate in cellular functions; participates in enzyme
reactions, membrane potentials and neuronal excitability , contraction in skeletal, cardiac,
smooth muscle, etc.

Factors that Regulate Calcium

1. Vitamin D: influential in the absorption of calcium from the intestine. It is then stored in the
bone then excreted by the kidneys.

Only 30-50% is absorbed from the duodenum and upper jejunum, he remainder is
eliminated in the stool.
Calcium is filtered in the glomerulus of the kidney and then selectively reabsorbed back
into the blood.
60-65% of filtered calcium is passively reabsorbed in the proximal tubule, driven by the
reabsorption of sodium chloride;
15-20% is reabsorbed in the thick ascending loop of Henle, driven by the Na/K/2Clcotransport system;
5-10% is reabsorbed in the distal convoluted tubule.Thiazide diuretics enhances
reabsorption of calcium.

2. PTH: maintain the calcium concentration of the ECF by promoting the release of calcium from
bone, increasing the activation of vitamin D and stimulating calcium conservation by the
kidney while increasing phosphate excretion.
3. Calcitonin: acts on kidney and bone to remove calcium from the circulation.
4. Serum phosphate level: calcium and phosphate are reciprocally regulated. Calcium levels fall
when phosphate levels are high.
Regulation of Magnesium
It is the second most abundant intracellular cation. 50-60% is stored in the bone; 39-49% contained
in body cells; 2% is dispersed in the ECF.
20-30% of ECF magnesium is protein bound and only 15-30% is exchangeable in the ECF.
The normal serum magnesium is 1.8 to 2.7 mg/dL
Cofactor in many intracellular enzyme reactions; all reactions that require ATP, replication and
transcription of DNA; cellular energy metabolism; nerve conduction, etc.
Ingested in the diet, absorbed from the intestine and excreted by kidneys.
Contained in all green vegetables, grains, nuts, meats, and seafood.
30-40% of filtered Magnesium is reabsorbed in the proximal tubule.
50-37% is reabsorbed in the ascending loop of Henle.
The distal tubule is the major site of magnesium regulation.
Increased serum levels of Magnesium decreases reabsorption,
PTH increases reabsorption and increased calcium levels inhibits reabsorption.
The major driving force for magnesium reabsorption is the Na/K/2Cl-cotransport system in the thick
ascending loop of Henle. Since this is site of loop diuretics action, this diuretic lowers magnesium
reabsorption.
IV Fluid Administration
Purpose:
1. to provide water, electrolytes, and nutrients to meet daily requirements ;
2. to replace water and correct electrolyte deficits;
3. to administer medications and blood products.
Types of IV Solutions
1. Isotonic solution:
a. Total electrolyte content is approximately 310 mEq/L, which is closer to that of the ECF (i.e.
280-295 mEq/L).
b. Expands the ECF volume by 1L; however, it expands the plasma by only 0.25 L because it is
a crystalloid fluid and diffuses quickly into the ECF compartment.
c. For the same reason, 3L of isotonic solution is needed to replace 1L of blood loss. Because
thes fluids expand the intravascular space, patients with hypertension and heart failure should
be carefully monitored for signs of overload.
d. D5W (252 m,Eq/L) initially isotonic but disperses as hypotonic, 1/3 ECF, 2/3 intracellular.
Good is the patient is at risk of increased in intracranial pressure. D5W is not used in fluid
resuscitation because it can cause hyperglycemia. It is used mainly to supply water and to
correct an increased serum osmolality.

e. NSS (0.9% sodium chloride) has a total osmolality of 308. Since composed mainly of
electrolytes, it remains within ECF. Therefore normally to correct Extracellular volume deficit.
Used with administration of blood transfusions and to replace large sodium losses, as in burn
injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium
retention.
f. Lactated Ringers has potassium and calcium in addition to NaCl.
2. Hypotonic solutions
a. Total electrolyte content is less than 250 mEq/L.
b. Purpose of hypotonic solution is to replace cellular fluid because its hypotonic compared to
plasma. Another is to provide water for excretion of body wastes.
c. Half strength saline (0.45 NaCl with an osmolality of 154 mEq/L is frequently used.
d. Excessive infusion could lead to intravascular fluid depletion, decreased blood pressure,
cellular edema, and cell damage.
3. Hypertonic solutions
a. Total electrolyte count is more than 375 mEq/L.
b. When normal saline solution or lactated ringers contain 5% dextrose, the total osmolality
exceeds that of the ECF.
c. 50% Dextrose,
d. They draw water from the ICF to the ECF and cause cells to shrink
Choosing an IV Site:
Factors to consider:
1. Condition of the vein
2. type of fluid or medication to be infused
3. Duration of therapy
4. Patients age and size
5. Whether the patient is right or left-handed.
6. Patients age and size
7. Patients medical history and current health status
8. Skill of the person performing the venipuncture.
Systemic Complications
1. Fluid Overload:
a. Increased BP and CVP, moist crackles on auscultation of the lungs, edema, weight gain,
dyspnea, and respirations that are shallow and have an increased rate.
b. Causes: rapid infusion, hepatic, cardiac or renal disease. Common in elderly
c. Mgt: decreasing the IV rate, monitoring vital signs, assessing breath sounds, place patient in
high Fowlers position. Contact physician.
d. Complication: Heart failure and pulmonary edema.
2. Air Embolism:
a. Associated with cannulation of central veins.
b. Manifestations: dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of
consciousness; chest, shoulder, and low back pain.
c. Treatment: Clamping of cannula, place patient on the left side in the Trendelenburg position,
assess vital signs and breath sounds; administer oxygen.
d. Complications: shock and death
3. Septicemia and Other Infection
a. Pyrogenic substances can induce a febrile reaction and septicemia.
b. Signs and Symptoms: abrupt temperature elevation shortly after infusion, backache,
headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and
shaking, and general malaise
Local Complications:
1. Infiltration and Extravasation
a. Infiltration is the unintentional administration of a nonvesicant solution or medication into
surrounding tissue. It is characterized by edema around insertion site, leakage of IV fluids
from the insertion site, discomfort and coolness in the area of infiltration, and a significant
decrease in the flow rate

b. Infiltration Scale:
i. 0 no symptoms
ii. 1 skin blanched, edema less than 1 inch in any direction, cool to touch, with or
without pain.
iii. 2 skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without
pain.
iv. 3 skin blanched, translucent, gross edema greater than 6 inches in any direction,
cool to touch, mild to moderate pain, possible numbness
v. 4 skin blanched, translucent, skin tight , leaking, skin discolored, bruised, swollen,
gross edema greater than 6 inches in any direction, deep pitting tissue edema,
circulatory impairment, moderate to severe pain, infiltration of any amount of blood
products, irritant, or vesicant.
c. Extravasation:
i. Is similar to infiltration with an inadvertent administration of vesicant or irritant solution
or medication into the surrounding tissue.
ii. Medications such as dopamine, calcium preparations and chemotherapeutic agents
can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis
of tissues can occur.
iii. Infusion must be stopped and physician notified.
2. Phlebitis
a. Characterized by reddened, warm area around site or along path of vein, pain or tenderness
at the site or along the vein.
Grade
1

Clinical Criteria
no clinical symptoms

erythema at access site with or without pain

pain at access site. Erythema, edema or both

pain at access site, erythema, edema or both, streak formation, palpable

venous cord )1 inch or shorter)

pain at access site with erythema, streak formation, palpable venous cord
(longer than 1 inch), purulent drainage.

3. hrombophlebitis
a. Presence of clot plus inflammation in the vein.
b. Localized pain, redness, warmth, and swelling around the insertion site or along the path of
the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate,
fever, malaise, and leukocytosis.
c. Discontinue infusion, cold compress, followed by warm compress, elevate extremity,
restarting the line in opposite extremity. NO Flushing .
4. Hematoma: apply pressure with a dressing, ice for 24 hours, warm compress
5. Clotting and Obstruction
2.Nursing Process
a. Assessment
A1. Subjective Data
i. ECF volume deficits loss of body weight; changes in I and O; changes in Vital Signs
ii. Other manifestations drying of the mouth and mucous membrane; tenting of the skin;
changes in urine output and urination; muscle weakness, change in consistency of the
stool; cerebral changes
A2. Objective Data
1. Physical Assessment there is no
specific physical examination to assess fluid, electrolyte, and acid-base balance.
Skin poor skin turgor; cold, clammy skin, pitting edema; flushed dry skin

 Pulse bounding; rapid, weak, thready, irregular, slow pulse

BP hypotension, hypertension
Respirations deep, rapid breathing; shallow; slow, irregular breathing; shortness of
breath, moist crackles, restricted airways
Skeletal Muscles cramping of exercised muscle; carpal spasms (Trousseaus), flabby
muscles, positive Chvosteks sign
B. ANALYSIS / NURSING DIAGNOSIS
B1. Common Problems of Fluid and Electrolyte Imbalance
1. Fluid Volume Disturbances:
- Hypovolemia
- Hypervolemia
2. Electrolyte Imbalances
a. Sodium imbalances
b. Potassium imbalances
c. Calcium imbalances
d. Magnesium imbalances
e. Phosphorus imbalances
f. Chloride imbalances
3. Acid-Base Imbalances
a. Acute and Chronic Metabolic Acidosis (Base Bicarbonate Deficit)
b. Acute and Chronic Metabolic Alkalosis (Base Bicarbonate Excess)
c. Acute and Chronic Respiratory Acidosis (Carbonic Acid Excess)
d. Acute and Chronic Respiratory Alkalosis (Carbonic Acid Deficit)
4. Mixed Acid-Base Disorders
B2. Potential Nursing Diagnosis
1. Deficient fluid volume, related to insufficient fluid intake, diarrhea, hemorrhage or third-space fluid
shift such as ascites or burns
2. Excess fluid volume related to fluid retention secondary to heart, renal, or lives failure, or excess
consumption
3. Impaired Oral Mucous membrane
4. Risk for Injury
5. Risk for Activity Intolerance
6. Risk for Decreased Cardiac Output
7. Risk for impaired skin integrity
8. Imbalanced Nutrition; Less than body requirements related to insufficient intake of foods rich in
potassium
c. PLANNING
1. Planning for Health Promotion
Preventing fluid and electrolyte loss
Planning for client hydration
Reducing risk for injury
2. Planning for Health Restoration and Maintenance
Fluid and electrolyte Management Oral and
Intravenous fluid and electrolyte replacement
D. IMPLEMENTATION
1. Pharmacological Therapy
a. IV Additives
- KCl
- CaCL
- MgSO4
- HCO3
b. Plasma Expanders
- Colloids
- Dextran
- Hexastarch
2. Nutrition and Diet Therapy

a. Food Sources of
- Sodium
- Potassium
- Calcium
- Phosphate
- Magnesium
3. Client Education

Alterations in the Respiratory System

I. CONCEPT REVIEW
A. Anatomy and Physiology of the Respiratory System
II. APPLICATION OF THE NURSING PROCESS
I.

Assessment of Respiratory Function

A. History
a. Biographical and Demographic Data
b. Present Health
b.1 Chief Complaint
1. Dyspnea
- Onset: Sudden onset indicates pneumothorax, acute respiratory obstruction or ARDS.
2. Cough
a. Results as a reaction to the irritants of the mucous membrane lining the respiratory tract.
b. Chief protection of the client from the accumulation of secretions in the bronchi and the
bronchioles.
c. May indicate serious lung disease
d. Evaluate the type, character and time.
1) Dry, irritative cough: URT infection of viral origin.
2) Irritative, high-pitched cough: Laryngotracheitis
3) Brassy cough: tracheal lesions.
4) Severe changing cough: Bronchogenic carcinoma
5) Cough accompanied by pleuritic chest pain: Pleural or chest wall involvement.
6) Cough that worsens in supine position: Sinusitis
7) Coughing at night may indicate left-sided heart failure or bronchial asthma.
8) Coughing after food intake may indicate aspiration.
3. Sputum Production
a. Discharge formation which serves as the lungs reaction to recurring irritant or may be
associated with nasal discharge.
b. The presence of an infection or disease entity and its causative organism can be
determined by its amount, color, and consistency.
c. Great amount of purulent sputum (thick and yellow, green or rust colored: Bacterial
infection.
d. Increase in amount over time: chronic bronchitis or bronchiectasis.
e. Pink- tinged mucoid sputum: Lung tumor
f. Profuse, frothy, pink-tinged discharge: Pulmonary edema
g. Foul-smelling sputum with halitosis: Lung abscess, bronchiectasis, or infection.
4. Chest Pain
a. Discomfort associated with pulmonary or cardiac disease.
b. Pain related to pulmonary conditions may be sharp, stabbing, intermittent, or it may be dull,
aching and persistent.
c. May occur with pneumonia, pulmonary embolism with lung infarction, and pleurisy.
d. Late symptom of bronchogenic carcinoma.
5. Wheezing

a. High-pitched, musical sound heard mainly on expiration.

b. Indicates obstruction or increased resistance of the air passages.
6. Clubbing of the Fingers
a. Manifested as sponginess of the nailbed and loss of the nailbed angle.
b. Observed in clients with chronic hypoxic conditions, infections, and malignancies.
7. Hemoptysis
a. Expectoration of blood from the respiratory tract.
b. Signifies lung or cardiac disorder.
8. Cyanosis
a. A very late indicator of hypoxia
b. Central cyanosis is typified by bluish discoloration of the lips and tongue .
c. Peripheral cyanosis results from decreased blood flow to distal structures (i.e. nail beds
and ear lobes)
c. Past Health History: clients previous hospitalization, illnesses, childhood diseases,
medications, and allergies.
d. Family Health History: previous health history and present health status of every member of
the family.
B. Physical Examination
a. Upper and Lower Respiratory Structures
Use penlight for a routine examination and a nasal speculum for a thorough examination.
1. Nose and Sinuses
a. Inspect the external nose for lesions, asymmetry, or inflammation.
b. Examine the internal structures for any signs of swelling, exudates, bleeding or change
in color of the nasal mucosa.
c. Check nasal septum for deviation, perforation, or bleeding.
d. Inspect the inferior and middle turbinates for presence of polyps.
e. Palpate the frontal and maxillary sinuses for tenderness.
2. Pharynx and Mouth
a. Inspect the color, symmetry, and evidence of exudates, ulceration or enlargement.
3. Trachea
a. Palpate the position and mobility.
4. Thorax
a. Observe the skin over the thorax for color and turgor and evidence of loss of
subcutaneous tissue.
b. Check for asymmetry.
b. Chest configuration
- Assess shape and dimensions of the chest
1. Funnel chest (Pectus excavatum): depressed lower portion of the sternum with the lower ribs
flaring outward.
2. Pigeon chest (Pectus carinatum): sternum protrudes anteriorly.
3. Barrel chest: increased anteroposterior diameter of the thorax due to overinflation of the lungs.
4. Kyphoscoliosis: characterized by elevation of the scapula and S-shaped spine.
c. Breathing Pattern:
- Observe the rate, regularity, depth and location of

respiration.

d. Palpation
1. Upper Lobe
Place the tips of thumbs at the midsternal line at the sternal notch.
Extend fingers above the clavicles.
Ask client to fully exhale then inhale deeply.
2. Middle Lobe
Place tips of thumbs at the xiphoid process.

Extend fingers laterally around the ribs.

Ask client to breathe in deeply.

3. Lower Lobe
Place the tips of thumbs along the clients back at the spinous processes of the lower thoracic
level.
Extend fingers around the ribs.
Ask the client to breathe in deeply.
4. Depth of excursion
Measure the girth of the chest at three levels (axilla, xiphoid, and subcostal) during inspiration
and expiration.
5. Fremitus
Vocal (tactile) fremitus: vibration felt over the chest wall as the client speaks; used to assess
the quality of underlying tissues.
o Place the palms of hands lightly on the chest wall
o Ask the client to speak a few words or repeat 99 several times.
6. Chest wall pain
Ask the client to take a deep breath and identify any painful areas of the chest wall.
7. Position of Trachea
Determine whether the trachea is palpable at midline or has shifted to the right or left.
e. Thoracic Percussion
Used to determine whether underlying tissues are filled with air, fluid, or solid material.
Estimates the size and location of certain structures within the thorax (heart, liver, diaphragm).
Dull and flat sounds: greater than normal amount of solid matter (tumor, consolidation) is
present than air.
Hyperresonance: presence of greater than normal amount of air in the area (emphysema,
asthma)
f. Auscultation
Evaluates the presence of fluid or solid obstruction in the lung structures by listening to the
breath sounds with the use of stethosocope.
C. Diagnostic Evaluation
a. Tests to Evaluate Respiratory Function
1. Pulmonary Function Test: includes measurements of lung volumes and capacities, ventilatory
functions, mechanics of breathing, and diffusion and gas exchange.
2. Pulse Oximetry: non-invasive method of monitoring subtle or sudden changes in oxygen
saturation of hemoglobin.
3. Capnography: non-invasive procedure used to measure carbon dioxide concentration exhaled by
the client who are receiving mechanical ventilation.
4. Arterial Blood Gas Analysis: measures the degree of oxygenation of the blood and adequacy of
alveolar ventilation.
5. Ventilation-Perfusion Lung Scan: painless procedure used to measure adequacy of lung
ventilation and perfusion.
b. Tests to Evaluate Anatomic Structures
1. Radiography (Chest X-Ray)
2. Magnetic Resonance Imaging
3. Ultrasonography
4. Gallium Scan
5. Bronchoscopy
6. Laryngoscopy

7. Alveolar Lavage
8. Endoscopic Thoracotomy
9. Pulmonary Angiography
c. Specimen Recovery and Analysis
1. Sputum culture: to identify organisms responsible for infection of the respiratory tract.
2. Nose and Throat Culture: to identify specific pathogenic organisms present in the nose and throat
3. Thoracentesis: to remove fluid and air in the pleural cavity.
4. Biopsy: examination of cells through excision of small amount of tissues obtained from target
structures.
B. ANALYSIS
1. Common Health Problems of the Respiratory System
A. Upper Airway Infection
i.
Rhinitis
ii. Acute and Chronic Sinusitis
iii. Acute and Chronic Pharyngitis
iv. Tonsillitis and Adenoiditis
v. Peritonsillar Abscess
vi. Laryngitis
B. Obstruction and Trauma of the Upper Respiratory Airway
i.
Obstruction during Sleep
ii. Epistaxis
iii. Nasal Obstruction
iv. Fractures of the Nose
v. Laryngeal Obstruction
vi. Cancer of the Larynx
C. Chest and Lower Respiratory Tract Disorders
i.
Atelectasis
ii. Respiratory Infections
Acute Tracheobronchitis
Pneumonia
Severe Acute Respiratory Disorders
Pulmonary Tuberculosis
Lung Abscess
D. Pleural Conditions
i.
Pleurisy
ii. Pleural Effusion
iii. Empyema
E. Pulmonary Edema
F. Severe Acute Respiratory Distress Syndrome
G. Pulmonary Hypertension
H. Pulmonary Heart Disease (Cor Pulmonale)
I. Pulmonary Embolism
J. Sarcoidosis
K. Occupational Lung Disease
i.
Silicosis
ii. Asbestosis
iii. Coal Workers Disease
L. Chest Tumors
K. Chest Trauma
i.
Blunt Trauma
ii. Penetrating Trauma
iii. Pneumothorax
iv. Cardiac Tamponade
v. Subcutaneous Emphysema
vi. Aspiration
2. Clients with Chronic Obstructive Disease
a. Bronchiectasis

b. Asthma
Status Asthmaticus
c. Chronic Obstructive Pulmonary Disorders
Emphysema
Chronic Bronchitis
d. Cystic Fibrosis
3. Potential Nursing Diagnosis
a. Ineffective Airway Clearance as evidenced by shortness of breath, dyspnea, orthopnea, retractions,
nasal flaring, altered chest excursion
b. Ineffective Breathing Pattern as evidenced by ineffective cough, diminished or abnormal breath
sounds, cyanosis, restlessness
c. Impaired Gas Exchange as evidenced by cyanosis, abnormal respiratory rate, and rhythm, nasal
flaring, tachycardia, diaphoresis and confusion
d. Impaired Spontaneous Ventilation as evidenced by dyspnea, use of accessory muscles,
tachycardia, and apprehension
e. Disturbed Sleep pattern (Sleep-Rest)
f. Anxiety
4. PLANNING
a. Planning for promotion
b. Planning for Heath Restoration and Maintenance
i.
Maintain Airway Patency
ii. Relieving Apprehension and Fear
iii. Reducing Metabolic Demand
iv. Preventing and Controlling Infection
5. IMPLEMENTATION
a. Pharmacologic Therapeutics
i.
Decongestants and Antihistamines
ii. Anti-tubercular Drugs
iii. Broad Spectrum Antibiotics
iv. Adrenergic Stimulants
v. Methylxanthines
vi. Anticholinergics
vii. Corticosteroids
viii. Mast Cell Stabilizers
ix. Leukotriene Modifiers
b. Complementary and Alternative Therapies
i.
Echinacea
ii. Golden Seal
iii. Zinc
c. Nutritional Diet Therapy
i.
Tube feedings
ii. Fluid Therapy
iii. High Protein, high Calorie supplements
d. Respiratory Care Modalities
I. Non-invasive Respiratory Therapies
i.
Oxygenation Therapy
ii. Incentive Spirometry
iii. Nebulization Therapy
iv. Intermittent Positive Pressure Breathing
v. Chest Physiotherapy
II. Airway Management
i.
Endotracheal Intubation
ii. Tracheostomy
iii. Mechanical Ventilation
iv. Chest Drainage
e. Thoracic Surgery
i.
Pneumonectomy
ii. Lobectomy
iii. Segmentectomy (Segmental Resection)
iv. Wedge Resection

v. Bronchoplastic or Sleeve Resection

vi. Lung Volume Reduction
g. Client Health Teaching
6.

EVALUATION

Altered Oxygenation: Cardiac and Tissue Peripheral Perfusion and Transport

I.

Review of Anatomy and Physiology of the Cardiovascular and Hemato-lymphatic System

II.

The Nursing Process

A. ASSESSMENT
i. Subjective Data

Nursing Health History

Demographic Information regarding age, gender, and ethnic origin
Presence of signs and symptom related to cardiovascular and hemato-lymphatic problems.
- Chest pain or discomfort
- Shortness of breath or dyspnea
- Fluid retention, peripheral edema or weight gain
- Palpitations
- Fatigue or changes in level of consciousness
- Syncope
- Irregular heartbeat
- Pain extremities
- Tenderness on calf or leg
- Altered neurologic function

11 Functional Patterns
ii. Objective Data
Physical Assessment
- Non-invasive tests
ECG
Echocardiogram
Ultrasound
Chest X-ray
Radionuclide studies
CT scan
CVP monitoring
- Invasive tests
Cardiac Catheterization
Arteriogram
Angiocardiogram
Venogram
Lymphography
Bone marrow aspiration

III. The Nursing Process

B. ASSESSMENT
- Diagnostic Tests and Laboratory Procedures
Cardiac Biomarker Analysis
Blood Chemistry
Hematology
Coagulation studies

 Lipid Profiles
Cholesterol levels
Triglycerides
C. ANALYSIS
1. Common Problems of the Cardiovascular and Hemato-lymphatic Systems
Cardiovascular System
a. Conduction problems of the heart
Dysrhythmias
b. Coronary vascular disorders
1.
Coronary Artery Disease
Coronary Atherosclerosis
Angina Pectoris
Myocardial Infarction
c. Structural, Infectious and Inflammatory cardiac problems
1.
Valvular Disorders
Mitral Valve Prolapse
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation
Aortic Stenosis
2.
Cardiomyopathy
3.
Infectious Disorders of the heart
Rheumatic Endocarditis
Infective Endocarditis
Myocarditis
Pericarditis
d. Complications of Heart Disease
1.Cardiac Hemodynamics
a. Heart Failure
A1. Chronic Heart Failure
A2. Acute Heart Failure

2. Other Complications
a. Cardiogenic shock
b. Thromboembolism
c. Pericardial Infusion and Cardiac Tamponade
d. Cardiac arrest
e. Hypertension
1. Types of hypertension
2. Hypertensive Crisis
f. Vascular Disorders: Problems of Peripheral Circulation
1. Arterial Disorders
Arteriosclerosis and Atherosclerosis
Peripheral Arterial Occlusive Disease
Thromboangiitis Obliterans (Buergers Disease)
Aortitis
Aortoiliac disorders
Dissecting Aorta
Arterial embolism and Arterial thrombosis
Raynauds Disease
2. Venous Disorders
Venous thrombosis
- Deep vein thrombosis
- Thrombophlebitis
- Phlebothrombosis
Chronic Venous Insufficiency
Leg ulcers

 Varicose veins
3. Lymphatic Disorders
Lymphangitis and Lymphadenitis
Lymphedema and Elephantiasis
4. Cellulitis

Hematologic Problems
a. Anemia
Hypoproliferative

Iron deficiency anemia

Anemias in renal disease

Anemias of chronic disease

Aplastic anemia

Megaloblastic anemia
- Folic acid deficiency anemia
- Vitamin B12 deficiency anemia
- Pernicious anemia
- Myelodysplastic syndrome
Hemolytic

Sickle cell anemia

Thalassemia

Glucose-6-phosphatase-dehydrogenase deficiency

Hereditary Spherocytosis

Immune Hemolytic anemia

b. Polycythemia
Polycythemia Vera
Secondary Polycythemia
c. Leukopenia
Neutropenia
Lymphopenia
d. Leukemia
Acute Myeloid Leukemia
Chronic Myeloid Leukemia
Acute Lymphocytic Leukemia
Chronic Lymphocytic Leukemia
e. Agnogenic Myeloid Metaplasia (Lymphoma)
Hodgkins Disease
Non-Hodgkins disease
f. Multiple Myeloma
g. Bleeding Disorders
Primary Thrombocytopenia
Secondary Thrombosis
Thrombocytopenia
Idiopathic Thrombocytopenic Purpura
Platelet Defects
Hemophilia
Von Willebrands Disease
h. Acquired Coagulation Disorders
Vitamin K deficiency
Disseminated Intravascular Coagulopathy
Thrombotic Disorders
Hyperhomocysteinemia
Anti-thrombin Deficiency
Acquired Thrombophilia

2. Gerontologic Considerations
3. Probable Nursing Diagnosis
Decreased Cardiac Output as evidenced by increased heart rate, fatigue, shortness of
breath, decreased urine output, impaired mental processing, decreased level of
consciousness
Activity intolerance as evidenced by weakness, fatigue, vital signs, changes with activity.
Fatigue as evidenced by difficulty completing usual daily activities, frequent desire to rest.
Impaired home maintenance as evidenced by inability to maintain family roles
Risk for peripheral neurovascular dysfunction as evidenced by changes in color,
temperature, sensation of extremities
Impaired Tissue Integrity
Ineffective Therapeutic Regimen Management
Ineffective Tissue Perfusion as evidenced by cool, dusky skin, decreased urine output and
chest pain
Acute pain
D. PLANNING
1. Planning for Health Promotion
a. Risk factor and risk management
b. Promotion of circulation
c. Prevention of infection
d. Genetic Counseling
e. Role of Nutrition
2.Planning for Health Maintenance and Restoration
a. Planning for basic life support: CPR
b. Planning for advanced life support : ACLS
c. Planning for Care of clients to have Cardiac Surgery
E.

IMPLEMENTATION

1.Pharmacologic Management
a. Cholesterol lowering medications
- Statins
- Bile Sequestrants
- Nicotinic Acid
- Fibric acid derivatives
b. Antianginal Medication
- Nitroglycerin
- Beta-blockers
- Calcium Channel Blockers
c. Antidysrhythmics
- Class I Sodium Channel Blockers
- Class II Beta-Adrenergic Blockers
- Class III Prolong Repolarization
- Class IV Calcium Channel Blockers
d. Antiplatelets
e. Diuretics
f. Medications for Heart Failure
- ACE Inhibitors
- Angiotensin Receptor Blockers
- Diuretics
- Positive Inotropic Agents
- Sympathomimetic
- Phosphodiesterase Inhibitors
g. Medications for Anemia
- Iron supplement
- Vitamin B12
- Folic Acid supplement
h. Antihypertensives

- Alpha adrenergic blockers

- ACE Inhibitors
- Angiotensin Receptor Blockers
- Beta Adrenergic lockers
- Calcium Channel; Blockers
- Centrally acting sympatholytics
- Vasodilators
i. Anticoagulants
- Heparin
- Warfarin
2.Surgical Management
a. Invasive Coronary Artery Procedures
- Percutaneous Coronary Interventions
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Coronary Artery Stents
Atherectomy
Brachytherapy
- Coronary Artery Revascularization
Coronary Artery Bypass Graft (CABG)
b. Heart Transplantation
c. Valvular Replacement Procedures
- Valvuloplasty
- Valve Replacement Therapy
- Septal Repair
3. Complementary and Alternative Therapies
a. Fish oil / Omega 3 fatty acids
b. Hawthorn
c. Herbs that may affect clotting
d. Natural Lipid lowering agents
4.Management for Blood disorders
a. Blood Transfusion
b. Stem Cell Transfusion
- Bone marrow transplantation
- Peripheral blood stem cell transfusion
5.Adjunctive Modalities for Cardiovascular Problems
a. Cardioversion and Defibrillation
- Electrical Cardioversion
- Pacemaker Insertion
6.Nutrition and Diet Therapy
H. EVALUATION
NUTRITIONAL-METABOLIC PATTERNS
Responses to Altered Nutrition Functions
I. Anatomy and Physiology of the Gastrointestinal System
II. The Nursing Process
a) Assessment
i) Nursing History
(1) Subjective Data
(a) Demographic Data
(b) Presence of signs and symptoms related to Gastrointestinal Problems
Abdominal pain
Dyspepsia

Intestinal gas
Nausea and vomiting
Change in bowel habits or stool characteristics

(2) Objective Data

(a) 11 functional pattern
(b) Physical Assessment
(i) Anthropometric Measurement
(ii) Inspection
(iii) Auscultation
(iv) Percussion
(v) Palpation
(c) Diagnostic Assessment
(i) Non-invasive Diagnostic Procedures
1. Radiological Studies
2. Upper GI Barium Swallow
3. Lower GI or Barium Enema
4. Flat Plate of the Abdomen
5. Ultrasound
6. Magnetic Resonance Imaging
7. Computed Tomography
(ii) Invasive Diagnostic Procedures
Scintigraphy (Molecular Imaging Scan)
Anoscopy
Proctoscopy
Sigmoidoscopy
(ii) Other GI tests
1. Bernstein Tests (Esophageal Acidity, Manometry, Acid Perfusion)
2. Esophageal Manometry
3. Ambulatory Esophageal pH monitoring
4. Exfoliative Cytologic Analysis
5. Gastric Analysis
(d) Laboratory Procedures
(i) Blood Chemistries
(ii) Total Lymphocyte Count
(iii) Fecal Analysis
1. Occult Blood
2. Ova and Parasite
3. Quantitative fat Studies
4. Fecal Leukocytes
5. Stool electrolyte tests
b) Analysis
i) Common Health Problems of the Gastrointestinal Systems
(1) Disorders of the Salivary
(a) Parotitis
(b) Sialadenitis
(c) Salivary Calculus
(2) Cancer of the Oral Cavity
(3) Disorders of the esophagus
(a) Achalasia
(b) Diffuse Spasm
(c) Hiatal Hernia
(d) Diverticulum
(e) Perforation

(f) Foreign Bodies

(g) Chemical Burns
(h) Gastroesophageal reflux
(i) Barretts esophagus
(j) Benign tumors of the esophagus
(k) Cancer of the esophagus
(4) Gastric and Duodenal Disorders
(a) Gastritis
(b) Peptic Ulcer Disease
(c) Morbid Obesity
(d) Gastric Acid
(e) Duodenal Tumors
(5) Intestinal and Rectal Disorders
(a) Abnormalities of Fecal Elimination
(i) Constipation
(ii) Diarrhea
(iii) Fecal Incontinence
(iv) Irritable Bowel Syndrome
(b) Conditions of the Malabsorption, Acute Inflammatory and Intestinal Disorders
(i) Appendicitis
(ii) Diverticular disease
(iii) Peritonitis
(c) Inflammatory Bowel Disease
(i) Regional Enteritis (Crohns Disease)
(ii) Ulcerative Colitis
(iii) Diverticulosis and Diverticulitis
(iv) Hemorrhoids
(6) Intestinal Obstructions
(a) Small bowel obstruction
(b) Colorectal Cancer
(c) Polyps of the Colon and Rectum
(7) Diseases of the Anorectum
(a) Anorectal Abscess
(b) Anal Fistula
(c) Anal Fissure
(d) Hemorrhoids
(e) Sexually Transmitted Anorectal Disease
(f) Pilonidal Sinus or Cysts
(i) Cholelithiasis
(ii) Gall Bladder Cancer
(8) Disturbances of the Accessory Organs
(a) Disorders of the liver
(i) Hepatitis
(ii) Cirrhosis
(iii) Liver Cancer
(b) Disorders of the Pancreas
(i) Acute and Chronic pancreatitis
(ii) Pancreatic Cancer
(c) Disorders of the Biliary Tract
ii) Gerontologic Assessment
iii) Potential Nursing Diagnosis

(1) Imbalanced Nutrition less than body requirements as evidenced by decreased food intake,
weight loss 20% or more of ideal body weight, dry or brittle hair, weakness, impaired tissue
healing.
(2) Deficient Fluid and Volume as evidenced by complaints of stomach discomfort, increased
salivation, tachycardia and cold clammy skin.
(3) Impaired skin integrity as evidenced by disruption of skin integrity as evidenced by disruption
of skin surface, pain and itching
(4) Acute pain
(5) Diarrhea
c) Planning
d) Implementation
i) Pharmacologic Management
(1) Antiemetics
(2) Anticoagulants
(3) Histamine agents
(4) Laxatives
(a) Bulk forming
(b) Stool softeners
(c) Saline and osmotic solutions
(d) Stimulants
(e) Selective chloride channel activator
(f) Serotonin type 4 receptor partial agonists
(5) Antipruritis
(6) Vitamin Supplement
(7) Antacids
(8) Antihyperlipidemics
(9) Antispasmodics
(10) Antidiarrheal
(11) Antisecretory agents H2 Receptor Blockers
(12) Vasopressin
(13) Epinephrine
(14) Cholinergics
(15) Antibiotics for H. Pylori and Anti-infectives
(16) Alpha-interferon and ribavirin
(17) Pancreatic Enzyme Replacement
ii) Complimentary Therapy
(1) Ginger
(2) Milk thistle (Silymarin)
iii) Surgical Management
(1) Neck Dissection
(2) Esophagectomy
(3) Vagotomy
(4) Pyloroplasty
(5) Gastrostomy
(6) Gastrectomy
(7) Colostomy
(8) Hemorrhoidectomy
(9) Gastrointestinal Bypass
(10)
Ileostomy
(11)
Vagotomy
(12)
Pyloroplasty
(13)
Antrectomy
(a) Billroth I (Gastroduodenostomy)
(b) Billroth II (Gastrojejunostomy)
(14) Bariatric Surgery
(15) Fistulectomy
iv) Modalities of Care of the Gastrointestinal System

(1) Parenteral Hyperalimentation

Feeding via Nasogastric, Jejunostomy and Gastrostomy Tubes
(2) Colostomy
v) Special Procedures
(1) Colostomy care and Irrigation
(2) Hot Sitz Bath
vi) Nutrition and Diet Therapy
(1) Regular Diets
(2) Special; Diets high fiber, gluten free, low-protein, high calorie, high protein diets
vii) Client Education
e) Evaluation

Responses to Altered Metabolic and Endocrine Function

I.

Anatomy and Physiology of the Endocrine System

II.
The Nursing Process
I. Assessment
a. Subjective Data
i. Demographic Data
ii. Presence of Signs and Symptoms
b. Objective Data
i. 11 functional pattern
ii. Physical assessment
iii. Diagnostic Assessment
1. Invasive Procedures
2. Non-invasive Procedures
3. Laboratory
II. Analysis
a. Common Health Problems
b. Gerontologic Considerations
c. Potential Nursing diagnosis
III. Planning
IV. Implementation
a. Pharmacologic Management
b. Complimentary Therapy
c. Surgical Management
d. Modalities of Care
e. Special Procedures
f. Nutrition and Diet
g. Client Education
V. Evaluation
Endocrine and Metabolic Problems
I. Anatomy and Physiology of the Metabolic, Hepatic and Endocrine Systems
II. The Nursing Process
a. Assessment
i. Subjective Data
1.
Demographic Data
2.
Presence of Signs and Symptoms related to the Endocrine and Metabolic Systems
Jaundice
Malaise

 Weakness
Fatigue
Pruritus
Abdominal Pain
Increasing abdominal girth (ascites)
Melena
Hematochezia
ii. Objective Data
1.
11 functional pattern
2.
Physical assessment
Abdominal Girth Measurement
Inspection
Percussion
Palpation
Auscultation
3.

f.

Diagnostic Assessment
Invasive Procedures
a.
Angiography
b.
Adrenal Venogram
c.
Portal Pressure Measurement
d.
Biopsy
e.
Paracentesis
Endoscopic Retrograde Cholangiopancreatography
Non-invasive Procedures
a.
Test of anatomic system structure and function
b.
MRI
c.
Electroencephalogram
d.
Ultrasonography
e.
CT scan
f.
Radionuclide Imaging
g.
Fine needle aspiration
h.
Achilles tendon reflex tests
i.
Radioiodine re-uptake tests
Laboratory
a.
b.
c.
d.
e.
f.
g.

Pigment Studies
Protein Studies
Serum Aminotransferase Studies
Prothrombin Time
Serum Aminotransferase Studies
Ammonia
Cholesterol

b. Analysis
i. Common Health Problems
1.
Common Problems of the Endocrine System
Disorders of the Thyroid Gland
a.
Hyperthyroidism
i. Graves disease
ii. Toxic Nodular Goiter
iii. Thyroiditis
iv. Thyroid Tumors
b.
Hypothyroidism
i. Iodine Insufficiency
ii. Hashimotos Disease
iii. Myxedema
Disorders of the Parathyroid Gland
a.
Hyperparathyroidism
b.
Hypoparathyroidism

 Disorders of the Adrenal Gland

a.
Addisons Disease
b.
Pheochromocytoma
c.
Cushings Syndrome
Disorders of the Pituitary Gland
a.
Anterior Pituitary Gland Disorders
i. Gigantism
b.
Posterior Pituitary Gland Disorders
i. SIADH
ii. Diabetes Insipidus
2.

Common Problems of the Biliary System

Cholecystitis
Cholelithiasis
Pancreatitis
a.
Acute
b.
Chronic
Pancreatic Cysts
Hyperinsulinism
Diabetes Mellitus
a.
Types of Diabetes Mellitus
b.
Acute complications of Diabetes Mellitus
i. Hypoglycemia (Insulin Reactions)
ii. Diabetic Ketoacidosis (DKA)
iii. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)
c.
Long Term complications of Diabetes Mellitus
i. Macrovascular complications
ii. Microvascular complications
iii. Foot and leg problems
d.
Special Issues in Diabetic Care

3.

Common Problems of the Hepatic System

Viral Hepatitis
a.
Hepatitis A, B, C, D,E and G
Non-viral Hepatitis
a.
Toxic Hepatitis
b.
Drug Induced Hepatitis
Fulminant Hepatic Failure
Hepatic Cirrhosis
Cancer of the Liver

ii. Gerontologic Considerations

iii. Potential Nursing diagnosis
1.
Activity Intolerance related to fatigue and depressed cognitive process
2.
Risk for imbalance body temperature
3.
Constipation related to depressed gastrointestinal function
4.
Ineffective Breathing Pattern related to depressed ventilation
5.
Disturbed thought process related to depressed metabolism
6.
Imbalanced Nutrition: Less / More than Body requirements
7.
Deficient fluid volume as evidenced by dry mucus membranes, thirst and decreased urine
output
8.
Impaired skin integrity as evidenced by dry, rough, reddened, and edematous skin.
9.
Disturbed body image
10.
Ineffective therapeutic management
c. Planning
i. Planning for Health Restoration and Health Maintenance
d. Implementation
i. Pharmacologic Management

1.
2.
3.
4.
5.
6.
7.

Iodine Resources
Antithyroid
Thyroid Replacement
Cortisol Replacement
Insulin
Oral Hypoglycemics
Hormone therapy
ii. Complimentary Therapy
1.
Aloe vera
2.
Bilberry
3.
Biter Melon
4.
Fish Oil
5.
Fenugreek
6.
Garlic
7.
Ginseng
8.
Gymema
9.
Horse Chestnut Seed Extract
10.
Prickly pear
iii. Surgical Management
1.
Thyroidectomy
2.
Parathyroidectomy
3.
Unilateral and Bilateral Adrenalectomy
4.
Transsphenoidal-Hypophysectomy
5.
AK//BK Amputation
6.
Pacreatic Transplantation
7.
Liver Transplantation
8.
Surgical Bypass Procedures
9.
Revascularization and Transition
10.
Lobectomy
11.
Cryosurgery

1.
2.
3.
4.
5.
6.
7.

iv. Modalities of Care/Special Procedures

Balloon Tamponade
Endoscopic Therapy
Esophageal Intrahepatic Portosystemic Shunting
Radiation Therapy
Chemotherapy
Percutaneous Biliary Drainage
Laser Hyperthermia
v. Nutrition and Diet
vi. Client Education
e. Evaluation
E. Concept of Pain
E1. Types of Pain
a. acute pain
b. chronic pain
c. Cancer related pain
d. Pain classified by location
e. Pain classified by etiology
E2. Harmful effects of Pain
a. Effects of Acute pain
b. Effects of Chronic pain
E3. Pain Assessment Tools

a.Pain experience inventory

b.Cries Neonatal Postoperative Pain measurement scale
c. FLACC Pain assessment tool
d.Poker chip tool
e.Faces Pain rating Scale
f. Oucher Pain Rating Scale
g.Numerical or Visual Analog Scale
h.Adolescent Pediatric Pain tool
i. Logs and Diaries
E4. Neurophysiological transmission of pain
E5. Pain theories
E6. Factors influencing Pain response
E7. Characteristics of pain
E8. Pain Management Strategies
a. Nurses role in Pain Management
b. Pharmacologic Interventions for Pain
c. Routes of Administration
d. Non-pharmacologic Interventions
- Guided Imagery
- Thought Stopping
- Hypnosis
- Aromatherapy, Essential Oils
- Magnet therapy
- Music therapy
- Yoga and Meditation
- Acupuncture
- Crystal or Gemstone therapy
- Herbal therapies/Hot and Cold application
- Biofeedback
- Therapeutic touch and massage
- TENS
PLAN/IMPLEMENTATION
5.2. Pharmacologic Pain Relief
5.2.1 Analgesics
a. Narcotic
b. Non-narcotic analgesics
5.2.2 Method of Administration
a. Topical
b. Oral
c. IM
d. IV
e. PCA
f.Conscious Sedation
g. Intranasal
h. Local Injection
i. Epidural
5.2.3
a.
b.
c.
d.
e.
EVALUATION

Surgical destruction of painful stimuli

Rhizotomy
Nerve Block
Continuous Extravascular Infusion
Neurectomy
Sympathectomy

D. Care of Patients Requiring Surgery

1. General Considerations
1.1 Conditions Requiring Surgery
1.2 Categories for surgical procedure as to;
a. Purpose
b. Degree of Risk to patient
c. Urgency
d. Effects of surgery on the person
e. Factors in the estimation of surgical risks
2. The Surgical Experience
1.1 Pre-operative Nursing Care
ASSESSMENT
7. Nursing History
8. Health History
- development consideration
- medical history
- medications
- occupation
9. Life-style
- nutrition
- use of alcohol
- elicit drugs or nicotine
- ADL
- occupation
10. Coping patterns and support system
11. Pre-operative physical assessment
12. Pre-surgical screening tests
- chest x-ray
- ECG
- CBC
- Electrolyte levels and urinalysis

ANALYSIS
- Potential Nursing Diagnosis
- Anticipatory Grieving related to perceived loss of normal body image
- Anxiety related to the effects of surgical procedure
- Fear related to surgery
- Risk for infection
- Ineffective Airway Clearance
- Ineffective Individual Coping
PLAN / IMPLEMENTATION
1. Physiological / spiritual preparation for surgery
2. Legal aspects of the informed consent
3. Instructional and Preventive aspects
3.1 Deep breathing exercises
3.2 Coughing exercises
3.3 Turning exercises
3.4 Extremity exercises
4. Physical Preparations
4.1 On the night of the surgery
a. Hygiene and skin care
b. Elimination
c. Nutrition and fluid
d. Rest and sleep
4.3 On the day of the surgery
c. Pre-operative checklist

d. Pre-operative medications

EVALUATION

2.2 Intra-operative Nursing Care

ASSESSMENT
1. Identify surgical client
2. Assess the emotional and physical status
2. Verify information in the pre-operative checklist
ANALYSIS
1. Impaired Skin Integrity related to Incision
2. Risk of Fluid Volume deficit
3. Risk for Injury related to position
PLAN / IMPLEMENTATION
Duties and responsibilities of the circulating nurse; scrub nurse; RN first assistants
The surgical environment
- Principles of surgical asepsis
- Environmental controls
- Maintaining surgical asepsis
3. The surgical Experience
e. Positioning
f. draping
g. types of anesthesia and sedation
h. stages of anesthesia
4. Potential Intra-operative complication
- Bleeding
- Nausea and vomiting
- Anaphylaxis
- Hypoxia and other respiratory complications
- Hyperthermia
- DIC
5. Documentation
6. Transferring to the PCU

1.
2.

EVALUATION

2.3 Post-operative Nursing Care

2.3.1 Immediate Post-operative Care in the PACU
Nursing responsibilities in the PACU
a. assessing the post-operative client
b. maintenance of pulmonary ventilation
c. maintenance of circulation
d. protection from injury
e. promotion of comfort
2.3.2 Aldrete post-anesthesia recovery scoring system
2.3.3 Ongoing post-operative Care
2.3.4 Immediate post-operative care in the PACU
ASSESSMENT

a.
b.
c.
d.
e.

Vital signs
Color and temperature of the skin
Level of Consciousness
Comfort
Time of Arrival

ANALYSIS
Postoperative nursing diagnosis
b. risk for surgical site diagnosis
c. pain
d. altered family processes related to loss of economic stability
e. impaired physical mobility
f. potential complication: Hemorrhage
PLAN / IMPLEMENTATION
1. Preventing Post-operative Complications
1.1 Respiratory Complications
1.2 Circulatory Complications
1.3 Fluid and Electrolytes Imbalance
1.4 Gastrointestinal Complications
1.5 Urinary Complications
1.6 Wound Complications
2. Post-operative Discomforts
EVALUATION