WHAT YOU SHOULD KNOW BEFORE THE PNLE

DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

PERIOPERATIVE NURSING Signature is obtained with the client’s complete

understanding of what to occur.
A. Major Types of Pathologic Process Requiring Surgical - adult sign their own operative permit
Intervention (OPET) - obtained before sedation
Obstruction – impairment to the flow of vital fluids For minors, parents or someone standing in their behalf,
(blood,urine,CSF,bile) gives the consent. Note: for a married emancipated minor
Perforation – rupture of an organ. parental consent is not needed anymore, spouse is accepted
Erosion – wearing off of a surface or membrane. For mentally ill and unconscious patient, consent must be
Tumors – abnormal new growths. taken from the parents or legal guardian
If the patient is unable to write, an “X” is accepted if there is a
B. Classification of Surgical Procedure witness to his mark
Secured without pressure and threat
According to PURPOSE: A witness is desirable – nurse, physician or authorized
Diagnostic – to establish the presence of a disease condition. ( persons.
e.g biopsy ) When an emergency situation exists, no consent is necessary
Exploratory – to determine the extent of disease condition ( e.g because inaction at such time may cause greater injury.
Ex-Lap ) (permission via telephone/cellphone is accepted but must be
Curative – to treat the disease condition. signed within 24hrs.)
* Ablative – removal of an organ
* Constructive – repair of congenitally D. Preoperative Meds. 5A’s
defective organ. Anxiolitics (Tranquilizers & Sedatives)
* Reconstructive – repair of damage organ * Diazepam ( Valium )
Palliative – to relieve distressing sign and symptoms, not * Lorazepam ( Ativan )
necessarily to cure the disease. * Diphenhydramine
Analgesics
According to URGENCY * Nalbuphine ( Nubain )
Anticholinergics
Classification Indication for Examples * Atropine Sulfate
Surgery Anti-Ulcer (Proton Pump Inhibitors)
Emergent – patient - severe * Omeprazole ( Losec )
requires immediate Without delay bleeding * Famotidine
attention, life threatening - gunshot/ stab Antibiotics
condition. wounds
- Fractured skull E. Preoperative Teachings
Urgent / Imperative – Within 24 to 30 - kidney /  Incentive Spirometry
patient requires prompt hours ureteral stones  Diaphragmatic Breathing
attention.  Coughing
Required – patient Plan within a - cataract  Turning
needs to have surgery. few weeks or - thyroid d/o  Foot and Leg exercise
months Teaching should be done morning/afternoon before the day of
Elective – patient should Failure to have - repair of scar surgery
have surgery. surgery not - vaginal repair Best Method: Return Demonstration
catastrophic
Optional – patient’s Personal - cosmetic F. The Surgical Team
decision. preference surgery
Surgeon
• Performance of the operative procedure according to the
C. Inform Consent
needs of the patients.
Purposes:
• The primary decision maker regarding surgical technique to
To ensure that the client understand the nature of the
use during the procedure.
treatment including the potential complications and
Assistant Surgeon
disfigurement.
• Assists with retracting, hemostasis, suturing and any other
To indicate that the client’s decision was made without
tasks requested by the surgeon to facilitate speed while
pressure.
maintaining quality during the procedure.
To protect the client against unauthorized procedure. Anesthesiologist
To protect the surgeon and hospital against legal action by a • Selects the anesthesia, administers it, intubates the client if
client who claims that an authorized procedure was necessary, manages technical problems related to the
performed. administration of anesthetic agents, and supervises the client’s
condition throughout the surgical procedure.
Essential Elements of Informed Consent Scrub Nurse
 the diagnosis and explanation of the condition. • Assists with the preparation of the room.
 a fair explanation of the procedure to be done and used and • Scrubs, gowns and gloves self and other members of the
the consequences. surgical team.
 a description of alternative treatment or procedure. • Prepares the instrument table and organizes sterile equipment
 a description of the benefits to be expected. for functional use.
 material rights if any. • Assists with the drapping procedure.
 the prognosis, if the recommended care, procedure is refused. • Passes instruments to the surgeon and assistants by
anticipating their need.
Requisites for Validity of Informed Consent • Counts sponges, needles and instruments.
Written permission is best and legally accepted. • Keeps track of irrigations used for calculations of blood loss

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

Circulating Nurse Thrombophlebitis Early ambulation

• Responsible and accountable for all activities occurring during Anti embolic stocking
a surgical procedure including the management of personnel Encourage leg exercise
equipment, supplies and the environment during a surgical Hydrate adequately
procedure. Avoid any restricting devices
• Ensure all equipment is working properly. that impaired circulation
• Guarantees sterility of instruments and supplies. Avoid massage on the calf of
• Monitor the room and team members for breaks in the sterile the leg
technique. Initiate anticoagulant therapy
• Handles specimens.
URINARY
• Coordinates activities with other departments, such as
Urinary Retention Monitor I & O
radiology and pathology.
Interventions to facilitate
voiding
G. Principles of Surgical Asepsis Urinary Catheterization as
needed
 Sterile object remains sterile only when touched by another
Urinary Monitor I & O
sterile object
Incontinence
 Only sterile objects may be placed on a sterile field
Urinary Tract Adequate fluid intake
 A sterile object or field out of range of vision or an object held
Infection Early ambulation
below a person’s waist is contaminated
 When a sterile surface comes in contact with a wet, Aseptic catheterization as
contaminated surface, the sterile object or field becomes needed
contaminated by capillary action Good perineal hygiene
 Fluid flows in the direction of gravity GASTRO-INTESTINAL
 The edges of a sterile field or container are considered to be Nausea and IV fluids until peristalsis
contaminated (1 inch) Vomiting returns
Progressive diet ( clear liquid
H. PACU/RR Care then full fluids, soft then
regular diet)
 Maintaining a Patent Airway Anti emetics as ordered
 Assessing Status of Circulatory System Hiccups NGT insertion as needed
 Maintaining Adequate Respiratory Function Hold breath while taking a
 Assessing Thermoregulatory Status large swallow of water
 Maintaining Adequate Fluid Volume Breath in and out on a paper
 Minimizing Complications of Skin Impairment bag
 Maintaining Safety Anti emetics as ordered
 Promoting Comfort Intestinal NGT insertion as needed
Obstruction Administered IVF as ordered
I. Parameter for Discharge from PACU/RR ( 3rd-5th day postop) Prepare for possible surgery
Constipation Adequate hydration
Activity. Able to obey commands
High fiber diet
Respiratory. Easy, noiseless breathing
Encourage early ambulation
Circulation. BP within 20mmHg of preop level
Paralytic Ileus Encourage early ambulation
Consciousness. Responsive
WOUND
Color. Pinkish skin and mucus membrane
Wound Infection Keep wound clean and dry
J. Post Operative Complications Surgical aseptic technique
when changing dressing
Problem Nursing Intervention Antibiotic therapy
Wound Dehiscence
RESPIRATORY Apply abdominal binders
Encourage high protein diet
Pneumonia Deep breathing exercises and Vit.C intake
Coughing exercise Keep in bed rest
Early ambulation Wound Evisceration Semi-Fowlers, bend knees to
Atelectasis Deep breathing exercises relieve tension on the
Coughing exercise abdominal muscles
Early ambulation Splinting on coughing
Pulmonary Turning Cover exposed organ with
Embolism Ambulation sterile , moist saline dressing
Anti embolic stockings Reassure, keep him/her quite
Compression devises and relaxed
Prevent massaging the lower Prepare for surgery and repair
extremities of wound
CIRCULATION
Hypovolemia Fluid and blood replacement
Hemorrhage Fluid and blood replacement
Vit.k and hemostat
Ligation of bleeders
Pressure dressing
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

ONCOLOGY NURSING  Yearly papanicolao (Pap) smear for sexually active females and
any female over age 18
A. Benign VS Malignant Neoplasm  At menopause, high-risk women should have an endometrial
tissue sample
Characteristic Benign Neoplasm Malignant Neoplasm
Speed Growth Grows slowly Usually grows rapidly 4. For detection of prostate cancer
Usually continues Tends to grow relentlessly  At age 50, have a yearly digital rectal examination
to grow throughout throughout life  At age 50, have a yearly prostate-specific antigen (PSA) test
life unless
surgically removed C. American Cancer Society’s seven warning signs of cancer
Mode of Grows by enlarging Grows by infiltrating (uses acronym CAUTION US):
Growth and expanding surrounding tissues 1. Change in bowel or bladder habits
Always remains May remain localized (in 2. A sore that does not heal
localized; never situ) but usually infiltrates 3. Unusual bleeding or discharge
infiltrates other tissues 4. Thickening or lump in breast or elsewhere
surrounding 5. Indigestions or difficulty in swallowing
tissues 6. Obvious change in wart or mole
Capsule Almost always Never contained within a 7. Nagging cough or hoarseness
contained within a capsule
fibrous capsule Absence of capsule allows 8. Unexplained Anemia
Capsule neoplastic cells to invade 9. Sudden loss of weight
advantageous surrounding tissues
because Surgical removal of tumor D. Internal Radiation Therapy (Brachytheraphy)
encapsulated difficult
tumor can be Sources of Internal Radiation
removed surgically  Implanted into affected tissue or body cavity
Cell Usually well Usually poorly  Ingested as a solution
characteristics differentiated differentiated  Injected as a solution into the bloodstream or body cavity
 Introduced through a catheter into the tumor
Recurrence Unusual when Common following surgery
Side Effects
surgically removed because tumor cells spread
 Fatigue
into surrounding tissues
 Anorexia
Metastasis Never occur Very common  Immunosuppression
Effect of Not harmful to host Always harmful to host  Other side effects similar to external radiation
Neoplasm unless located in Causes disfigurement,
area where it disrupted organ function, Client Education
compresses tissue nutritional imbalances  Avoid close contact with others until treatment is completed
or obstructs vital May result in ulcerations,  Maintain daily activities unless contraindicated, allowing for extra
organs sepsis, perforations, rest periods as needed
Prognosis Very good Depends on cell type and  Maintain balanced diet
Tumor generally speed of diagnosis  Maintain fluid intake ensure adequate hydration (2-3 liters/day)
removed surgically Poor prognosis if cells are  If implant is temporary, maintain bedrest to avoid dislodging the
poorly differentiated and implant.
evidence of metastatic  Excreted body fluids may be radioactive; double-flush toilets after
spread exists use
Good prognosis indicated if  Radiation therapy may lead to bone marrow suppression
cells still resemble normal
cells and there is no Nursing Management
evidence of metastasis  Exposure to small amounts of radiation is possible during close
contact with persons receiving internal radiation: understand the
principles of protection from exposure to radiation: time, distance,
B. Recommendations of the American Cancer Society for Early and shielding
Cancer Detection  Time: minimize time spent in close proximity to the
1. For detection of breast cancer radiation source; a common standard is to limit contact time
 Beginning at age 20, routinely perform monthly breast self- to 30 minutes total per 8-hour shift;
examination  Distance: maintain the maximum distance 6 feet possible
 Women ages 20-39 should have breast examination by a from the radiation source
healthcare provider every 3 years  Shielding: use lead shields and other precautions to reduce
 Women age 40 and older should have a yearly mammogram exposure to radiation
and breast self-examination by a healthcare provider  Place client in private room
 Instruct visitors to maintain at least a distance of 6 feet from the
2. For detection of colon and rectal cancer client and limit visitors to 10-30 minutes
 All persons age 50 and older should have a yearly fecal occult  Ensure proper handling and disposal of body fluids, assuring the
blood test containers are marked appropriately
 Digital rectal examination and flexible sigmoidoscopy should  Ensure proper handling of bed linens and clothing
be done every 5 years  In the event of a dislodged implant, use long-handled forceps and
 Colonoscopy with barium enema should be done every 10 place the implant into a lead container; never directly touch the
years implant
 Do not allow pregnant woman to come into any contact with
3. For detection of uterine cancer radiation

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

 If working routinely near radiation sources, wear a monitoring
device to measure exposure
 Educate client in all safety measures
E. External Radiation Therapy (Teletheraphy)
B. Heart Sound
 Tricuspid valve (lub) - RT 5th intercostal, medial
 Mitral valve (lub) - LT 5th intercostal, lateral
 Aortic semilunar valve (dub) - RT 2nd intercostal
 Pulmonary semilunar valve (dub) - LT 2nd intercostals

 The radiation oncologist marks specific locations for radiation S1 - due to closure of the AV(mitral/tricuspid) valves
treatment using a semipermanent type of ink S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves
 Treatment is usually given 15-30 minutes per day, 5 day per S3 – Ventricular Diastolic Gallop
week, for 2-7 weeks Mechanism: vibration resulting from resistance to rapid
 The client does not pose a risk for radiation exposure to other ventricular filling secondary to poor compliance
people S4 - Atrial Diastolic Gallop
Mechanism: vibration resulting from resistance to late
Side Effects ventricular filling during atrial systole
 Tissue damage to target area (erythema, sloughing, hemorrhage) Heart Murmurs
 Ulcerations of oral mucous membranes  Incompetent / Stenotic Valve
 GIT effects such as nausea, vomiting, and diarrhea Pericardial Friction Rub
 Immunosuppression  It is an extra heart sound originating from the pericardial sac
 Mechanism: Originates from the pericardial sac as it moves
Client Education  Timing: with each heartbeat
 Wash the marked area of the skin with plain water only and pat
skin dry; do not use soaps, deodorants, lotions, perfumes, powders C. ECG
or medications on the site during the duration of the treatment; do
not wash off the treatment site marks
 Avoid rubbing, scratching, or scrubbing the treatment site; do
not apply extreme temperatures (Heat or Cold) to the
treatment site ; if shaving, use only an electric razor
 Wear soft, loose-fitting over the treatment area
 Protect skin from sun exposure during the treatment and for at
least 1 year after the treatment is completed; when going
outdoors, use sun-blocking agents with sun protector factor
(SPF) of at least 15
 Maintain proper rest, diet, and fluid intake as essential to Cardiac Action Potential
promoting health and repair of normal tissues  Depolarization/Contraction/Systole - electrical activation of
a cell caused by the influx of sodium into the cell while
potassium exits the cell
Nursing Management  Repolarization/Resting/Diastole - return of the cell to the
 Monitor for adverse side effects of radiation resting state caused by re-entry of potassium into the cell
 Monitor for significant decreases in white blood cell counts while sodium exits
and platelet counts
 Client teaching (refer to later sections for management of D. CARDIAC Proteins and enzymes
immunosuppression, thrombocytopenia
a. CK- MB ( creatine kinase)
 Most cardiac specific enzymes
CARDIOVASCULAR NURSING  Accurate indicator of myocardial dammage
 Elevates in MI within 4 hours, peaks in 18 hours and
A. Heart Circulation then declines till 3 days
 Normal value is 0-7 U/L or males 50-325 mu/ml
Female 50-250 mu/ml
b. Lactic Dehydrogenase (LDH)
 Most sensitive indicator of myocardial damage
 Elevates in MI in 24 hours, peaks in 48-72 hours
Return to normal in 10-14 days
 Normally LDH1 is greater than LDH2
c. Troponin I and T
 Troponin I is usually utilized for MI
 Elevates within 3-4 hours, peaks in 4-24 hours and
persists for 7 days to 3 weeks!
 Normal value for Troponin I is less than 0.6 ng/mL
 REMEMBER to AVOID IM injections before obtaining
blood sample!
 Early and late diagnosis can be made!
d. Serum Lipids
 Lipid profile measures the serum cholesterol,
triglycerides and lipoprotein levels
 Cholesterol= 200 mg/dL
 Triglycerides- 40- 150 mg/dL
 LDH- 130 mg/dL
 HDL- 30-70- mg/dL
 NPO post midnight (usually 12 hours)

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

E. Cardiac Catheterization ( Coronary Angiography /  Keep the drug in a dry

Arteriography ) ECG: may reveals place, avoid moisture
 Insertion of a catheter into the heart and surrounding vessels ST segment and exposure to sunlight
 Is an invasive procedure during which physician injects dye depression  Change stock every 6
into coronary arteries and immediately takes a series of x-ray T wave inversion months
films to assess the structures of the arteries  Offer sips of water
Pretest: Ensure Consent, assess for allergy to seafood and before giving sublingual
iodine, NPO, document weight and height, baseline VS, blood nitrates,
tests and document the peripheral pulses
Intra-test: inform patient of a fluttery feeling as the catheter NTG Nitrol or
passes through the heart; inform the patient that a feeling of Transdermal patch
warmth and metallic taste may occur when dye is  Avoid placing near hairy
administered areas as it may decrease
Post-test: Monitor VS and cardiac rhythm drug absorption
 Monitor peripheral pulses, color and warmth and sensation of  Avoid rotating
the extremity distal to insertion site transdermal patches.
 Maintain sandbag to the insertion site if required to maintain Myocardial Chest pain Nursing Management
pressure Infarction Usually radiates Goal: Decrease myocardial
 Monitor for bleeding and hematoma formation (MI) from neck, back, oxygen demand
shoulder, arms,
F. CVP ( Central Venous Pressure ) Death of jaw & abdominal  Administer narcotic
 Reflects the pressure of the blood in the right atrium. myocardial muscles analgesic as ordered:
 Engorgement is estimated by the venous column that can be cells from (abdominal Morphine
observed as it rises from an imagined angle at the point of inadequate ischemia): severe  Administer oxygen low
manubrium ( angle of Louis). oxygenation, crushing flow 2-3 L / min
 With normal physiologic condition, the jugular venous column often caused  Enforce CBR in semi-
rises no higher than 2-3 cm above the clavicle with the client in by sudden Not usually fowlers position without
a sitting position at 45 degree angle. complete relieved by rest or bathroom privileges
blockage of a by nitroglycerine  Instruct client to avoid
coronary forms of valsalva
artery N/V maneuver
Dyspnea  Monitor urinary output
Characterized Increase in blood & report output of less
by localized pressure & pulse than 30 ml / hr:
formation of Hyperthermia: indicates decrease
necrosis elevated temp cardiac output
(tissue Skin: cool, clammy,  Resumption of ADL
destruction) ashen particularly sexual
 NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg with Mild restlessness intercourse: is 4-6 weeks
 To Measure: subsequent & apprehension post cardiac rehab, post
 Patient should be flat with zero point of manometer at the healing by CABG & instruct to:
same level of the RA which corresponds to the mid-axillary scar formation ECG:  Instruct client to assume
line of the patient or approx. 5 cm below the sternum. & fibrosis ST segment a non weight bearing
 Fluctuations follow patients respiratory function and will elevation position
fall on inspiration and rise on expiration due to changes in T wave inversion  Client can resume sexual
intrapulmonary pressure. Widening of QRS intercourse: if can climb
 Reading should be obtained at the highest point of complexes or use the staircase
fluctuation.
The Most Critical Period
G. Coronary Arterial Diseases 6-8 hours because majority
of death occurs due to
ANGINA Coronary artery bypass arrhythmia leading to
PECTORIS Levine’s Sign: surgery premature ventricular
initial sign that  Greater and lesser contractions (PVC)
4 E’s of shows the hand saphenous veins are *Lidocaine: DOC for
Angina clutching the chest commonly used for arrhythmia
Pectoris bypass graft procedures
Chest pain:
 Excessive characterized by Percutaneuos F. Congestive Heart Failure
physical sharp stabbing Transluminal Coronary Inability of the heart to pump blood towards systemic circulation
exertion pain located at sub Angioplasty (PTCA)
 Exposure to sterna usually  Mechanical dilation of I. Left sided heart failure
cold radiates from neck, the coronary vessel wall  90% - Mitral valve stenosis
environment back, arms, by compresing the  Pulmonary Symptoms
 Extreme shoulder and jaw atheromatous plaque.
emotional muscles II. Right sided heart failure
response Nursing Management:  Tricuspid valve stenosis
 Excessive Dyspnea  Venous congestion symptoms
intake of Tachycardia NTG Tablets(sublingual)
foods or Palpitations Give 3 doses interval of 3-
heavy meal Diaphoresis 5minutes
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
NURSING MANAGEMENT
Goal: increase myocardial contraction
 Administer medications as ordered
 Cardiac glycosides
 Digoxin *Antidote: Digibind
 Loop diuretics
 Bronchodilators
 Narcotic analgesics
 Morphine sulfate
 Vasodilators
 Anti-arrhythmic agents
 Administer O2 inhalation at 3-4 L/minute
 Restrict Na and fluids
 Monitor strictly VS and IO and Breath SoundsWeigh pt daily and
assess for pitting edema and abdominal girth daily and notify MD
 Provide meticulous skin care
 Provide a dietary intake which is low in saturated fats and caffeine
RESPIRATORY NURSING
A. Diagnostic Evaluation
1. Skin Test: Mantoux Test or Tuberculin Skin Test
 This is used to determine if a person has been infected or
has been exposed to the TB bacillus.
 This utilizes the PPD (Purified Protein Derivatives).
 The PPD is injected intradermally usually in the inner
aspect of the lower forearm about 4 inches below the elbow.
 The test is read 48 to 72 hours after injection.
 (+) Mantoux Test is induration of 10 mm or more.
 But for HIV positive clients, induration of about 5 mm is
considered positive
2. Pulse Oximeter
 Non-invasive method of continuously monitoring he oxygen
saturation of hemoglobin
 A probe or sensor is attached to the fingertip, forehead,
earlobe or bridge of the nose
 Normal SpO2 = 95% - 100%
 < 85% - tissues are not receiving enough O2
3. Chest X-ray
 This is a NON-invasive procedure involving the use of x-rays
with minimal radiation.
 The nurse instructs the patient to practice the on cue to
hold his breath and to do deep breathing
 Instruct the client to remove metals from the chest.
 Rule out pregnancy first.
4 . Indirect Bronchography
 A radiopaque medium is instilled directly into the trachea
and the bronchi and the outline of the entire bronchial tree
or selected areas may be visualized through x-ray.
 It reveals anomalies of the bronchial tree and is
important in the diagnosis of bronchiectasis.
Nursing Interventions BEFORE Bronchogram
 Secure written consent
 Check for allergies to sea foods or iodine or anesthesia
 NPO for 6 to 8 hours
 Pre-op meds: atropine SO4 and valium, topical
anesthesia sprayed; followed by local anesthetic
injected into larynx. The nurse must have oxygen and
anti spasmodic agents ready.
Nursing Interventions AFTER Bronchogram
 Side-lying position
 NPO until cough and gag reflexes returned
 Instruct the client to cough and deep breathe client
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
5. Bronchoscopy
 This is the direct inspection and observation of the
larynx, trachea and bronchi through a flexible or rigid
bronchoscope.
 Passage of a lighted bronchoscope into the bronchial tree
for direct visualization of the trachea and the
tracheobronchial tree.
Diagnostic uses:
 To examine tissues or collect secretions
 To determine location or pathologic process and
collect specimen for biopsy
 To evaluate bleeding sites
 To determine if a tumor can be resected surgically
Therapeutic uses
 To Remove foreign objects from tracheobronchial tree
 To Excise lesions
 To remove tenacious secretions obstructing the
tracheobronchial tree
 To drain abscess
 To treat post-operative atelectasis
Nursing Interventions BEFORE Bronchoscopy
 Informed consent/ permit needed
 Explain procedure to the patient, tell him what to expect,
to help him cope with the unkown
 Atropine (to diminish secretions) is administered one
hour before the procedure
 About 30 minutes before bronchoscopy, Valium is given
to sedate patient and allay anxiety.
 Topical anesthesia is sprayed followed by local
anesthesia injected into the larynx
 Instruct on NPO for 6-8 hours
 Remove dentures, prostheses and contact lenses
 The patient is placed supine with hyperextended neck
during the procedure
Nursing Interventions AFTER Bronchoscopy
 Put the patient on Side lying position
 Tell patient that the throat may feel sore with .
 Check for the return of cough and gag reflex.
 Check vasovagal response.
 Watch for cyanosis, hypotension, tachycardia,
arrythmias, hemoptysis, and dyspnea. These signs and
symptoms indicate perforation of bronchial tree. Refer
the patient immediately!
6. Sputum Examination
 Indicated for microscopic examination of the sputum:
Gross appearance, Sputum C&S, AFB staining, and for
Cytologic examination/ Papanicolaou examination
 Nursing Interventions:
 Early morning sputum specimen is to be
collected (suctioning or expectoration)
 Rinse mouth with plain water
 Use sterile container.
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

 Sputum specimen for C&S is collected before  Auscultate lungs to assess for pneumothorax
the first dose of anti-microbial therapy.  Monitor oxygen saturation (SaO2) levels
 For AFB staining, collect sputum specimen for  Bed rest
three consecutive mornings.  Check for expectoration of blood

6. Pulmonary Function Test / Studies C. Chronic Obstructive Pulmonary Diseases

 Non-invasive test
 Measurement of lung volume, ventilation, and diffusing Chronic Bronchitis Smoking  Consistent productive
capacity (Blue Bloaters) Air cough
Inflammation of the pollution  Dyspnea on exertion
bronchi due to with prolonged
hypertrophy or expiratory grunt
hyperplasia of goblet  Anorexia and
mucous producing cells generalized body
leading to narrowing of malaise
smaller airways  Cyanosis
 Scattered rales/rhonchi

Bronchial Asthma Allergens  Cough that is productive

Reversible inflammatory  Dyspnea
lung condition caused by  Wheezing on expiration
hypersensitivity to  Tachycardia,
allergens leading to palpitations and
narrowing of smaller diaphoresis
airways  Mild apprehension,
restlessness
 Cyanosis

Bronchiectasis Recurrent  Consistent productive

7. Arterial Blood Gas
Permanent dilation of LRTI cough
 Assessment of arterial blood for tissue oxygenation,  Dyspnea
the bronchus due to Congenital
ventilation, and acid-base status  Presence of cyanosis
destruction of muscular disease
 Arterial puncture is performed on areas where good pulses  Rales and crackles
and elastic tissue of the Presence
are palpable (radial, brachial, or femoral). Radial artery  Hemoptysis
alveolar walls of tumor
is the most common site for withdrawal of blood specimen  Anorexia and
Chest
Nursing Interventions:
trauma generalized body
 Utilize a 10-ml. Pre-heparinized syringe to prevent malaise
clotting of specimen 
 Soak specimen in a container with ice to prevent Pulmonary Smoking  Productive cough
hemolysis Emphysema Pollution  Dyspnea at rest
 If ABG monitoring will be done, do Allen’s test to assess Terminal and Hereditary  Prolonged expiratory
for adequacy of collateral circulation of the hand (the irreversible stage of Allergy grunt
ulnar arteries) COPD characterized by :  Resonance to
hyperresonance
8. Thoracentesis Inelasticity of alveoli  Decreased tactile
 Procedure suing needle aspiration of intrapleural fluid or air Air trapping fremitus
under local anesthesia  Decreased breath
Maldistribution of
 Specimen examination or removal of pleural fluid sounds
gasses
Nursing Intervention BEFORE Thoracentesis  Barrel chest
Overdistention of
 Secure consent  Anorexia and
thoracic cavity
 Take initial vital signs generalized body
(Barrel chest)
 Instruct to remain still, avoid coughing during malaise
insertion of the needle  Rales or crackles
 Inform patient that pressure sensation will be felt on  Pursed-lip breathing
insertion of needle

Nursing Intervention DURING the procedure: Nursing Management:

 Reassess the patient
 Place the patient in the proper position:
 Upright or sitting on the edge of the bed
 Lying partially on the side, partially on the
back
Nursing Interventions after Thoracentesis
 Assess the patient’s respiratory status
 Monitor vital signs frequently
 Position the patient on the affected side, as ordered,
for at least 1 hour to seal the puncture site
 Turn on the unaffected side to prevent leakage of
fluid in the thoracic cavity
 Check the puncture site for fluid leakage
 Enforce CBR
 Low inflow O2 admin; high inflow will cause respiratory arrest
* most accurate: venturi mask
 Administer medications as ordered
Bronchodilators
Antimicrobials
Corticosteroids (5-10 minutes after bronchodilators)
Mucolytics/expectorants
 Force fluids
 Nebulize and suction client as needed
 Provide comfortable and humid environment
 Avoidance of smoking and allergens

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

C. PNEUMONIA  Administer bronchodilators 15-30

 Inflammation of the lung parenchyma leading to pulmonary minutes before procedure
consolidation because alveoli is filled with exudates  Stop if pt. can’t tolerate the procedure
 Provide oral care after procedure as it
I. Etioilogic Agent may affect taste sensitivity
1. Streptococcus pneumoniae (pneumococcal  Contraindications:
pneumonia)  Unstable VS
2. Hemophilus influenzae (bronchopneumonia)  Hemoptysis
3. Klebsiella pneumoniae  Increased ICP
4. Diplococcus pneumoniae
 Increased IOP (glaucoma)
5. Escherichia coli
12. Provide pt health teaching and d/c planning
6. Pseudomonas aeruginosa
 Avoidance of precipitating factors
 Prevention of complications
II. Predisposing Factor
 Atelectasis
1. Smoking
 Meningitis
2. Air pollution
 Regular compliance to medications
3. Immunocompromised
 Importance of ffup care
 (+) AIDS
 Kaposi’s Sarcoma
 Pneumocystis Carinii Pneumonia
HEMATOLOGY NURSING
 DOC: Zidovudine (Retrovir)
 Bronchogenic Ca A. Blood Cellular Components
4. Prolonged immobility (hypostatic pneumonia)
5. Aspiration of food (aspiration pneumonia)
RBC 4-6
6. Over fatigue
million/mm3
III. Signs / Symptoms
* Hemoglobin Ave. 12 - 18 iron-containing protein of RBC,
1. Productive cough, greenish to rusty
g/dL delivers oxygen to tissue
2. Dyspnea with prolong expiratory grunt
3. Fever, chills, anorexia, general body malaise
* Hematocrit F: 36-42% red cell percentage in whole
4. Cyanosis
M: 42-48% blood
5. Pleuritic friction rub
6. Rales/crackles on auscultation
7. Abdominal distention  paralytic ileus
WBC N = 5,000-
10,000/mm3
IV. NURSING MANAGEMENT
1. Enforce CBR (consistent to all respi disorders)
*Neutrophils Most common  First line of defense,
2. Strict respiratory isolation
type of  Helpful in localizing the
3. Administer medications as ordered
leukocyte but a infection and in
 Broad spectrum antibiotics
short lifespan immobilizing the
 Penicillin – pneumococcal infections
of only 10-12 pathogens until other
 Tetracycline
hours WBCs arrive
 Macrolides
 Anti-pyretics
 Mucolytics/expectorants
*Eosinophils Lifespan=  Allergic Reaction and
4. Administer O2 inhalation as ordered
hours to 3 days Parasitic Invasion
5. Force fluids to liquefy secretions
6. Institute pulmonary toilet – measures to promote
*Basophils  they are mediators in
expectoration of secretions
inflammatory process.
 DBE, Coughing exercises, CPT
(clapping/vibration), Turning and
*Monocytes  largest WBC
repositioning
(macrophage)
7. Nebulize and suction PRN
*Lymphocytes B Cells
8. Place client of semi-fowlers to high fowlers
T Cells  Antibody response
9. Provide a comfortable and humid environment
NK Cells  Immunity
10. Provide a dietary intake high in CHO, CHON, Calories
 Anti tumor
and Vit C
11. Assist in postural drainage
Platelets N = 150-450 Promotes hemostasis →
 Patient is placed in various position to drain
thousand mm3 prevention of blood loss →
secretions via force of gravity
promote clotting mechanisms
 Usually, it is the upper lung areas which are
drained
 Nursing management:
 Monitor VS and BS
 Best performed before meals/breakfast
or 2-3 hours p.c. to prevent
gastroesophageal reflux or vomiting
(pagkagising maraming secretions diba?
Nakukuha?)
 Encourage DBE

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

B. Blood Disorder is water soluble and is easily excretable;

oral forms might develop tolerance.
IRON DEFICIENCY  Monitor for signs of bleeding of all hema  Increase caloric intake, CHON, CHO, Fe,
ANEMIA (IDA) – test including urine, stool and GIT Vit C
chronic microcytic  Enforce CBR so as not to overtire patient  Encourage client to use soft bristled
anemia due to  Encourage increased iron diet toothbrush and avoid irritating
inadequate  Avoid tannates in tea and coffee mouthwashes (remember there are
absorption of iron  Administer medications as ordered mouthsores!)
leading to Oral iron preparations (300mg OD)  Avoid heat application (there is
hypoxemic tissue NURSING MANAGEMENT numbness remember?)  may lead to
injury 1. Administer with meals to lessen burns
GIT irritation
2. Use straw for liquid form
3. Administer with orange juice or
vitamin C to facilitate absorption GUT NURSING
4. Inform client of SE/monitor for
a. Anorexia A. Causes of Acute Renal Failure
b. Nausea and vomiting
c. Abdominal pain
d. Diarrhea/constipation
e. Melena
Parenteral Iron Preparations
NURSING MANAGEMENT
1. Administer using z-tract method
to prevent discomfort,
discoloration and leakage
2. Avoid massaging of injection site
instead encourage pt. to
ambulate to facilitate absorption
3. Monitor SE
a. Pain at injection site
b. Localized abscess
c. Lymphadenopathy
d. Fever and chills

APLASTIC  Enforce complete BR

ANEMIA – stem  Administer O2 inhalation Acute Renal Failure Chronic Renal Failure
cell disorder  Reverse isolation Sudden inability of the Irreversible loss of kidney
leading to bone  Monitor for signs of infection kidneys to excrete function
marrow  Avoid IM, SQ or any venipuncture sites nitrogenous waste
depression   instruct: use electric razor when shaving products, leads to azotemia PREDISPOSING FACTORS
pancytopenia (all  Medications as ordered DM and HPN (common
blood cells Immunosuppressants via central STAGES causes)
decreased)  venous catheter Recurrent pyelonephritis
anemia, Anti-lymphocyte globulin (ALG) – Oliguric phase – passage Exposure to renal toxins
leucopenia, given within 6 days – 3 weeks to of urine (1-2 weeks) Tumor
thrombocytopenia achieve maximum therapeutic effect  UO: <400 ml/cc
 Hyperkalemia STAGES
PERNICIOUS  Hypernatremia  Diminished renal reserve
ANEMIA – chronic  Headache, dizziness, dyspnea, palpitation,  Hyperphosphatemia volume – asymptomatic,
anemia resulting cold sensitivity, pallor and generalized body  HYPOCALCEMIA normal BUN and CREA
from deficiency of malaise  Hypermagnesemia  Renal insufficiency
intrinsic factor  GIT changes: Mouth sores, Red beefy  Metabolic acidosis  End-stage renal disease
leading to tongue, Dyspepsia or indigestion, Weight  Elevated BUN, Crea (ESRD) – presence of
hypochlorhydria loss, Jaundice oliguria, azotemia
(decreased HCl  CNS changes – PA is the most dangerous Diuretic Phase (2-3
secretion); form of anemia, Tingling sensation, weeks)
Paresthesia, Ataxia, Psychosis  Increased passage of
urine
DIAGNOSTICS  Hyperkalemia
SCHILLING’S TEST – indicates decreased  Hyponatremia
reabsorption of vitamin B12; confirms  Metabolic acidosis
presence of pernicious anemia
Convalescent phase (3-12
NURSING MANAGEMENT months)
 Enforce complete bed rest (consistent to  Improvement in
all types of anemia) passage of urine
 Administer Vit B12 injections at  Characterized by
MONTHLY intervals for lifetime as complete diuresis
ordered; common site: dorso and
ventrogluteal, no drug toxicity because it
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS
PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
NURSING MANAGEMENT ARF/CRF ENDOCRINE NURSING
 Enforce CBR
 Admin oxygen inhalation as ordered A. Thyroid Gland Disorders
 High CHO diet low CHON, fats, High vit and minerals HYPOTHYROIDISM
 Provide meticulous skin care Decreased T3 and T4
 Wash with warm water Early Signs
 Soap irritates and dries skin 1. Weakness and fatigue
 Meds as ordered 2. Loss of appetite but
 anti-HPN agents (+) weight gain d/t
 Hydralazine (appresoline) increased lipolysis
 SE: orthostatic hypotension 3. Dry skin
 NaHCO3 4. Cold intolerance
 Kayexelate enema 5. Constipation
 Hematinics 6. Menorrhagia
 Antibiotics Late Signs
 Supplementary vitamins and minerals 1. Brittleness of hair
 Phosphate binders 2. Non-pitting edema
 Calcium gluconate 3. Hoarseness of voice
4. Decreased libido
5. Decreased VS
B. Nursing Management on Hemodialysis 6. CNS changes
a. Lethargy
 Secure consent and explain procedure to client b. Memory
 Maintain strict aseptic technique impairment
 Obtain baseline data – before and q30 during c. Psychosis
procedure 1. Monitor STRICTLY VS,
 VS IO to determine
 Wt presence of
 Blood exams – secure all pre-procedure MYXEDEMA COMA a
 I/O complication of severe
hypothyroidism
 Have client void pre-procedure characterized by:
 Inform pt about bleeding (blood is heparinized) a. Severe
 Monitor for signs of complications (BEDSSH) hypotension
 Bleeding b. Bradycardia
 Embolism c. Bradypnea
 DISEQUILIBRIUM SYNDROME – results from rapid d. Hypoventilation
loss of nitrogenous waste products particularly UREA e. Hypoglycemia
from the brain f. Hyponatremia
 HPN g. Hypothermia
 Disorientation – initial sign 2. Administer isotonic
 Nausea and vomiting fluids as ordered
 Anorexia 3. Administer
 Headache medications as
ordered – thyroid
 Paresthesia, peripheral
hormones or agents
 Numbness
(may cause insomnia
 Septicemia
and heat intolerance)
 Shock 4. Provide dietary intake
 Hepatitis
low in calories to
 Avoid BP taking, phlebotomy, IV meds at the site of
prevent weight gain
fistula, blood extraction to prevent compression
5. Institute meticulous
 Maintain patency of shunt/fistula:
skin care
 Palpate for thrills, auscultate for bruits
6. Provide comfortable
 Instruct that minimal bleeding is expected since blood
and warm
is heparinized
environment
 Avoid use vasodilators, sedatives, and tranquilizers to
7. Forced fluids
prevent hypotension unless ordered
 Prepare at bedside bulldog clips to prevent embolism
 Auscultate for bruits and palpate for thrills (if (+) 
patent)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
HYPERTHYROIDSM
Increased T3 and T4
1. Hyperphagia – increased
appetite
2. (+) weight loss d/t
increased metabolism
3. heat intolerance
4. moist skin
5. diarrhea
6. increased VS
7. CNS changes
a. Irritability
b. agitation
c. Tremors
d. Restlessness
e. Insomnia
f. Hallucinations
8. Goiter
9. Exophthalmos
10. Amenorrhea
1. Monitor VS and IO strictly
to determine presence of
THYROID STORM/Crisis
2. Administer medications
as ordered
a. Anti-Thyroid Agents:
PTU  toxic effects is
AGRANULOCYTOSIS
fever and chills, sore
throat (throat CS
pls!), LEUKOCYTOSIS
(CBC pls!)
b. Methimazole
(Tapazole)
3. High calorie diet to
correct weight loss
4. Provide comfortable and
cool environment
5. Institute meticulous skin
care
6. Maintain side rails
7. Bilateral eye patch to
prevent drying of eyes
8. Assist in surgical
procedure: subtotal
thyroidectomy
PRE-OP
Administer lugol’s solutions/
SSRI to promote decreased
vasculature and promote
atrophy of the thyroid gland to
prevent/minimize bleeding
and hemorrhage
POST-OP
WOF signs of THYROID
STORM  agitation, hyper-
thermia, HPN. If (+) thyroid
storm: administer anti-pyretics
and beta-blockers; VS, IO and
NVS strictly, siderails up,
provide hypothermic blanket
WOF: inadvertent or
accidental removal of
 WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

parathyroid gland 
hypocalcemia or tetany [(+)
trousseu’s signs, (+) chvostek’s
Give Ca Gluc slowly to
prevent arrhythmia and
arrest

WOF accidental laryngeal

nerve damage  hoarness of
voice  instruct client to talk
immediately post-op  if (+)
notify MD

WOF signs of bleeding  (+)

feeling of fullness at incision
site, (+) soiled dressings at
back or nape area, notify MD

WOF signs of laryngeal spasm

 DOB and SOB  prep trache
set

9. Hormonal Replacement
therapy for life
10. importance of FFup care
11. wearing of medic-alert
bracelet

B. Insulin Therapy

I. Types of Insulin
A. Rapid (SAI) – clear, peak: 2-4 hours , Regular insulin
B. Intermediate AI – NPH (Non-Protamine Hagedorn) –
cloudy, peak : 6-12 hours
C. Long AI – Ultra lente – cloudy, peak 12-24 hours

II. Nursing Management

A. Administer insulin at room temp to prevent
lipodystrophy atrophy/hypertrophy of SQ tissue
B. Insulin only refrigerated once opened
C. Avoid shaking insulin, roll between palms only
D. Accuracy of administration is important
E. Rotate insulin sites to prevent lipodystrophy
F. Use short bore needle gauge 25-26
G. No need to aspirate
H. Administer insulin 45/90 degrees angle depending on
amount to pt’s SQ tissue
I. Most accessible route: abdomen
J. Aspirate CLEAR before CLOUDY to prevent
contamination and promote accurate calibration
K. Monitor for local complications:
1. Allergic reactions
2. Lipodystrophy
3. SOMOGYI’S PHENOMENON – rebound effect of insulin
characterized by hypoglycemia, hyperglycemia

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE