CARE OF PATIENTS WITH GUNSHOT OR ● Penetrating chest trauma can injure vital

organs such as the heart and lungs and can

STAB WOUNDS
interfere with breathing and circulation.
● Lung injuries that can be caused by
PENETRATING TRAUMA
penetrating trauma include pulmonary
laceration (a cut or tear) pulmonary contusion
● injuries caused by a foreign object piercing
(a bruise), hemothorax (an accumulation of
the skin, which damages the underlying
blood in the chest cavity outside of the lung),
tissues in an open wound.
pneumothorax (an accumulation of air in the
● linical features differ depending on the
chest cavity) and hemopneumothorax
injured parts of the body and the shape and
(accumulation of both blood and air)
size of the penetrating object
● A penetrating chest wound may be referred to
● Diagnosis is established based on history and
as a sucking chest wound, since air enters
imaging studies (X-rays, CT/MRI).
the pleural space through the chest wall
● Management usually involves supportive
during inspiration.
measures (hemostasis, blood transfusion,
● Penetrating trauma can also cause injuries to
respiratory support), and surgical repair of
the heart and circulatory system. When the
damaged structures and/or removal of
heart is punctured, it may bleed profusely
foreign bodies.
into the chest cavity if the membrane around
it (the pericardium) is significantly torn, or it
CLASSIFICATION DEPENDING ON SEVERITY
may cause pericardial tamponade if the
pericardium is not disrupted. In pericardial
● Puncture wound - a sharp object pierces the
tamponade, blood escapes from the heart but
skin and creates a small hole without entering
is trapped within the pericardium, so
a body cavity (e.g. bite)
pressure builds up between the pericardium
● Penetrating wound - a sharp object pierces
and the heart, compressing the latter and
the skin, creating a single open wound, AND
interfering with its pumping.
enters a tissue or body cavity (e..g knife stab)
● Abdominal trauma - typically result from
● Perforating wound - the object passes
stabbings and shootings; also known as
completely through the body, having both an
Penetrating Abdominal Trauma (PAT)
entry and exit wound (e.g. gunshot wound)
● PAT can be life-threatening because
abdominal organs, especially those in the
CLASSIFICATION ACCORDING TO LOCATION
retroperitoneal space, can bleed profusely,
and the space can hold a large volume of
● Head trauma - accounts for only a small
blood.
percentage of all traumatic brain injuries
● If the pancreas is injured, it may be further
(TBI) but is associated with a high mortality
injured by its own secretions, in a process
rate, and only a third of people with
called autodigestion
penetrating head trauma survive long enough
● Injuries of the liver, common because of the
to arrive at a hospital.
size and location of the organ, present a
● Injuries from firearms are the leading cause
serious risk for shock because the liver tissue
of TBI-related deaths.
is delicate and has a large blood supply and
● Penetrating head trauma can cause cerebral
capacity.
contusions and lacerations, intracranial
● The intestines, taking a large part of the lower
hematomas, pseudoaneurysms, and
abdomen, are also at risk of perforation.
arteriovenous fistulas.
● Chest trauma - most penetrating injuries are
chest wounds; have a death rate of under
10%
 MECHANISM OF INJURY
● Gunshot - medium-to-high velocity; damage
can extend to structures adjacent to the path
of the bullet
● In addition to causing damage to the tissues
they contact, medium- and high-velocity
projectiles cause a secondary cavitation
injury: as the object enters the body, it creates
a pressure wave which forces tissue out of the
way, creating a cavity that can be much larger
than the object itself; this is called
"temporary cavitation"
● Hollow organs such as the stomach,
intestines, skin and gallbladder tend to
absorb more energy and are injured less
frequently than are solid organs because the
organ tissue has more flexibility to withstand
the forces.
● Meanwhile organs such as the liver, spleen,
kidney, and brain, which have relatively low
tensile strength, are likely to split or shatter
because of temporary cavitation.
● Stab wound - low velocity, less than a gunshot
● They are usually propelled by a person's
hand, and usually do damage only to the area
that is directly contacted by the object.
● The space left by tissue that is destroyed by
the penetrating object as it passes through
forms a cavity; this is called “permanent
cavitation. “
ASSESSMENT: CHEST TRAUMA
The goal of system assessment is to evaluate for
traumatic injuries of the heart, lung, great vessels,
and bony thorax.
The nurse must assess for: history and risk factors,
such as age, smoking history, mechanism of injury,
and the presence of chronic lung disease. The nurse
must also assess the vital signs to watch for the ff
manifestations:
➢ RR may be increased if hypoxia is present
➢ BP may be decreased
➢ HR may increase as a result of hypoxia or
hemorrhage.
The nurse and interdisciplinary team assess
for the following common injuries.
Pneumothorax/tension pneumothorax
● indicates air in the pleural space; however, in
tension pneumothorax, air does not escape.
The increased air in the pleural space shifts
organs and increases intrathoracic pressure
● Manifested by:
○ Chest pain
○ Respiratory distress
○ Decreased chest wall excursion
○ Hypoxia
○ Decreased breath sounds on the
affected side
○ Tachycardia
○ Hyperresonance to percussion
○ Additionally, with a tension
pneumothroax, air hunger, violent
agitation, tracheal deviation away
from affected side, subcutaneous
emphysema, JVD, hypotension, and
cyanosis (late sign) may be present
Hemothorax
● indicates blood in the pleural space, which
may or may not occur in conjunction with
pneumothorax
● Manifested by:
○ Chest pain
○ Respiratory distress
○ Decreased breath sounds on the
affected side
○ Dullness to percussion
○ Decreased Hgb and other
signs/symptoms of blood loss up to
and including shock
Flail Chest
● is the fracture of two or more adjacent ribs in
two or more places with loss of chest wall
stability
● Manifested by:
○ Paradoxical chest wall movement
 ○ Pain over affected chest wall on PERCUSSION
palpation
○ Hypoxia Percuss over the lung fields to identify areas of
○ Decreased chest excursion resulting hyperresonance, indicating a collection of air in the
from pain pleural space. Dullness may indicate atelectasis or a
○ Decreased breath sounds collection of blood in the pleural space.

Cardiac Tamponade PALPATION

● blood rapidly collects in pericaridal sac, Palpate over the ribs, sternum, and scapula to identify
which compresses the myocardium because areas of tenderness and step-offs. Feel chest for
the pericarcium does not stretch, and crepitus or subcutaneous emphysema.
prevents ventricles from filling
● Manifested by: AUSCULTATION
○ Muffled, distant heart sounds
○ Hypotension, Auscultate lung fields to identify abnormal breath
○ Neck vein distention sounds. Decreased breath sounds may indicate a
○ Increased central venous pressure pneumothorax or hemothorax. Sucking sound on
Other injuries include: inspiration may indicate an open pneumothorax. Also
● Pulmonary contusion auscultate the heart to identify abnormal heart
○ Hypoxia sounds. Muffled heart sounds may indicate a
○ Respiratory distress pericardial tamponade.
● Blunt cardiac injury
○ Arrhythmias
○ Chest wall contusions
○ Chest pain
● Aortic trauma
○ hypotension/hypertension
○ Tachycardia
○ Unequal pulses, absent pulses below
the level of injury
○ Mottling below the level of injury

INSPECTION

Check the chest for signs of trauma and chest

excursion
● Bruising, abrasions, contusions, and
lacerations indicate that the thoracic area of
the body received some of the force.
● Carefully observe chest wall for signs of
penetrating injuries because the skin may
close up, masking the entry, especially with
low-velocity injuries such as stabbings.
● Logroll the patient to inspect the back of the
chest.
● Observe position of the trachea.
● Observe for neck vein distention.
DIAGNOSTIC TESTS FOR CHEST TRAUMA
(issa low quality huhu pls refer to Baird’s Manual of Critical Nursing, pg 803)

SURGICAL MANAGEMENT
➢ Surgery may be required; impaled objects are
secured into place so that they do not move
and cause further injury, and they are
removed in an operating room. If the location
of the injury is not obvious, a surgical
operation called an exploratory laparotomy
may be required to look for internal damage
to the organs in the abdomen. Foreign bodies
such as bullets may be removed, but they may
also be left in place if the surgery necessary to
get them out would cause more damage than
would leaving them. Wounds are debrided to
remove tissue that cannot survive and other
material that presents risk for infection.
➢ Surgical exploration can be undertaken in one
of two ways: a) the conventional approach
is to perform an open laparotomy, and b)
the alternate approach is to do a
diagnostic laparoscopy. The primary
purpose of the laparoscopy is to determine
the presence of diaphragmatic perforation.
If the diaphragm is intact, then there should
be no intra-abdominal injuries. In this case, a
midline incision can be avoided, and the
recovery period will be shortened
significantly. This can be beneficial to high
risk patients such as those with pulmonary
disease, cardiac disease and morbid obesity
where a long midline incision can be a source
of morbidity such as infection and respiratory
compromise
➢ Repeated spontaneous pneumothorax may
need to be treated surgically by a partial
pleurectomy, stapling, or pleurodesis to
promote adherence of the pleurae to one
another. Tension pneumothorax, if present, is
a medical emergency, requiring urgent
needle decompression followed by chest
tube insertion to water-seal drainage.
COLLABORATIVE MANAGEMENT
● Collaborative management should start with
addressing the ABCs, (which stands for
Airway, Breathing and Circulation), including
oxygen, IV fluids, and blood as indicated.
Since our patient has a hemopneumothorax,
this warrants immediate intervention.
● Emergency treatment consists of covering the
wound with an occlusive dressing that is
secured on three sides (vent dressing).
During inspiration, as negative pressure is
created in the chest, the dressing pulls
against the wound, preventing air from
entering the pleural space. During expiration,
as the pressure rises in the pleural space, the
dressing is pushed out and air escapes
through the wound and from under the
dressing. If the object that caused the open
chest wound is still in place, do not remove it
until a physician is present. Stabilize the
impaled object with a bulky dressing.
REMEMBER!
Because of the potential for hemorrhage, never
remove a penetrating object until the surgeon is
present and tests have been completed to
determine what the object has penetrated.
Instead, stabilize impaled objects with bulky
dressings.
With pulmonary injuries, interventions are directed
toward managing acute respiratory compromise
while correcting the underlying injuries that may
cause deterioration in the patient’s condition.
Intervention should be aimed at correcting and
preventing hypoxia.
1. Ensure patent airway
● When the patient is unable to maintain a
patent airway either as a result of trauma or a
decreased LOC, an artificial airway is inserted
through oral intubation or via emergent
tracheostomy.
● Intubation: Maintains patent airway,
decreases airway resistance and respiratory
effort, provides route for easy removal of
airway secretions, and allows for manual or
mechanical ventilation, as necessary.
 2. Restore intrathoracic negative pressure
● Interventions are aimed at restoring the
negative pressure in the thoracic cavity to
allow for adequate ventilation.
● Pleural decompression: Relieves
life-threatening tension pneumothorax. A
14-gauge needle or IV catheter is inserted
into the second intercostal space at the
midclavicular line to relieve the pressure in
the chest cavity.
● Tube thoracostomy can also be done, in which
chest tubes are used to remove fluid or
trapped air from the chest cavity. A thoracic
catheter is inserted, usually through the
second intercostal space, the midclavicular
line, or the fifth lateral intercostal space,
midaxillary line. Placement depends on the
location and extent of the hemothorax,
effusion, or pneumothorax. The catheter can
be connected to a one-way flutter valve (for
air evacuation only) or to a closed chest
drainage system.
● The most definitive and common treatment of
pneumothorax and hemothorax is to insert a
chest tube and connect it to water-seal
drainage, which is the evacuation of air/or
fluid from the pleural cavity through a closed
drainage system. In water-seal chest drainage,
an intrapleural drainage tube is used after
some intrathoracic procedures; one or more
chest catheters (usually No. 28 French tubes)
are held in the pleural space along the
posterior axillary line by suture to the chest
wall.
Nursing responsibilities during chest drainage
include the ff:
a. Maintain airtight system to prevent
complications and infections.
b. Relieve patient’s anxiety and discomfort.
c. Teach patient importance of turning, deep
breathing and coughing.
d. Prevent postural deformities and
contractures.
e. Record observations accurately.
f. Promote adequate air exchange
3. Enhance oxygenation and ventilation
● Oxygen therapy: Device is determined by the
patient’s response to therapy and may range
from nasal cannula to 100% nonrebreathing
mask, depending on extent of hypoxemia.
● Pulmonary toileting: Use of incentive
spirometer, chest percussion, and suctioning
to prevent atelectasis.
● Analgesia: Manages pain to minimize
splinting and improve breathing. Opioid
analgesics are used cautiously to avoid
respiratory depression. An epidural
patient-controlled analgesia pump or an
intercostal nerve block may help to relieve
local rib pain.
● Mechanical ventilation: Must be implemented
for extreme respiratory distress or ventilatory
collapse.
● Stabilization and fixation of flail chest: Most
flail chest injuries stabilize within 10 to 14
days without surgical intervention.
Stabilization of fractures is achieved using a
volume-cycled ventilator. During surgery, a
flail segment can be externally fixated by
wiring or otherwise attaching the segment to
the intact bony structures.
4. Restore perfusion and oxygen-carrying capacity
● Volume replacement: A high priority in the
victim of trauma. Blood loss is replaced with
PRBCs or whole fresh blood, if available.
Blood replacement via autotransfusion may
also be used. Use of colloid versus crystalloid
fluids for volume replacement remains
controversial. Volume is more often replaced
with crystalloid fluids (e.g., NS, LR) rather
than colloidal IV fluids (e.g., plasma, albumin).
Colloids increase the risk of developing acute
respiratory distress syndrome and acute
renal failure, and are more expensive;
furthermore, research has failed to
demonstrate a significant benefit.
● Thoracotomy is considered in patients with
penetrating injuries to the chest who arrive in
Pulseless electrical activity (PEA) or develop
PEA shortly after arrival. This procedure
should only be performed if a qualified
 surgeon is present. Opening the chest allows
the surgeon to gain control over bleeding and
restore intravascular volume to get the
patient to the operating room for more
definitive care.
● Repair of thoracic aortic injuries: If the
patient is stable, repair should be delayed
until the other injuries have been addressed
and the patient is over the critical period.
Repair may even occur on an elective basis
after the patient is discharged from the
hospital. Repair using endovascular stenting
has been shown to decrease patient
morbidity.
5. Support cardiac function
● Monitoring of hemodynamic status: If there is
major cardiac or pulmonary involvement, use
pulmonary artery monitoring and CO
determinations with direct arterial pressure
monitoring if indicated.
● Treatment of dysrhythmias: Use the ACLS
protocols of the American Heart Association.
If rhythm disturbances do not appear in the
first 5 days after trauma, they rarely occur
later.
● Immediate corrective surgical repair:
Indicated for ruptured valve, torn papillary
muscle, or torn intraventricular septum
accompanied by hemodynamic instability.
● Treatment of shock: Initially, shock should be
treated with fluid resuscitation to ensure
adequate intravascular volume. Once
intravascular volume has been restored and
the patient remains hypotensive, vasopressor
drugs (i.e., norepinephrine, epinephrine,
vasopressin) may be necessary to enhance BP.
● Treatment of myocardial failure: Oxygen,
diuretics, positive inotropic agents, and
monitoring with a pulmonary artery catheter
for right-sided and left-sided heart pressures.
NURSING CARE PLAN
Dx: Ineffective breathing pattern related to
pulmonary and diaphragmatic injury
➢ Goals/Outcomes: Within 24 hours of this
diagnosis, RR stabilizes to 12 to 20
breaths/min with normal work of breathing;
lung injuries are managed to provide
expanded lungs with minimal fluid and/or
blood accumulation in the thoracic cavity;
sources of bleeding are identified and
managed to provide adequate Hgb level for
adequate oxygenation; lost intravascular
volume is replaced to reflect a CVP of 6 to 12
mm Hg; oxygen saturation is at least 95%,
with PaO2 at least 80 mm Hg with oxygen and
Paco2 less than 45 mm Hg with (or without)
mechanical ventilation; and HR is 60 to 100
bpm with BP stable (at least 100 mm Hg
systolic and 60 mm Hg diastolic).
Responsibilities include:
Airway management
1. Monitor for sudden blood loss or persistent
bleeding.
2. Prevent blood volume loss (e.g., apply
pressure to site of bleeding).
3. Administer oxygen and/or mechanical
ventilation, as appropriate.
4. Draw ABGs and monitor tissue oxygenation.
Ventilation assistance
1. Monitor fluid status, including intake and
output, as appropriate.
2. Maintain patent IV access.
Respiratory monitoring
1. Monitor BP, pulse, temperature, and
respiratory status.
2. Note trends and wide fluctuations in BP and
auscultate BPs in both arms and compare.
3. Initiate and maintain a continuous
temperature-monitoring device.
Dx: Ineffective tissue perfusion, cardiopulmonary
related to substantial loss of blood volume.
➢ Goals/Outcomes: Within 24 hours of this
diagnosis, the patient exhibits adequate tissue
perfusion, as evidenced by BP within normal
limits for the patient, heart rate (HR) 60 to
100 beats per minute (bpm), normal sinus
rhythm on electrocardiogram (ECG),
peripheral pulses greater than 2+ on a
 0-to-4+ scale, warm and dry skin, hourly
urine output ≥0.5 mL/kg, base deficit
between −2 and +2 mmol/L, serum lactate
less than 2.2 mmol/L, measured cardiac
output (CO) 4 to 7 L/min, central venous
pressure (CVP) or
pulmonary artery wedge pressure (PAWP) 6 to 12
mm Hg, and patient awake, alert, and oriented.
Responsibilities include:
Shock management: Volume
1. Monitor for sudden blood loss or persistent
bleeding.
2. Prevent blood volume loss (e.g., apply
pressure to site of bleeding).
3. Monitor for fall in systolic BP to less than 90
mm Hg or a fall of 30 mm Hg in patients who
are hypertensive.
4. Monitor for signs/symptoms of hypovolemic
shock (e.g., increased thirst, increased HR,
increased systemic vascular resistance [SVR],
decreased urinary output [urine output],
decreased bowel sounds, decreased
peripheral perfusion, altered mental status, or
altered respirations).
5. Position the patient for optimal perfusion.
6. Insert and maintain large-bore IV access.
7. Administer warmed IV fluids, such as isotonic
crystalloids, as indicated.
8. Administer blood products (e.g., PRBCs,
platelets, plasma, and cryoprecipitate), as
appropriate.
9. Administer oxygen and/or mechanical
ventilation, as appropriate.
10. Draw ABGs and monitor tissue oxygenation.
11. Monitor Hgb/hematocrit (Hct) level.
12. Monitor coagulation studies, including INR,
PT, PTT, fibrinogen, fibrin degradation/split
products, and platelets.
13. Monitor laboratory studies (e.g., serum
lactate, acid-base balance, metabolic profiles,
and electrolytes).
14. Monitor fluid status, including intake and
output, as appropriate.
15. Monitor for clinical signs and symptoms of
overhydration/fluid excess.
Vital signs monitoring
1. Monitor BP, pulse, temperature, and
respiratory status, as appropriate.
2. Note trends and wide fluctuations in BP.
3. Auscultate BPs in both arms and compare, as
appropriate.
4. Initiate and maintain a continuous
temperature monitoring device, as
appropriate.
5. Monitor for and report signs and symptoms of
hypothermia and hyperthermia.
6. Monitor the presence and quality of pulses.
7. Monitor cardiac rate and rhythm.
Acid-base monitoring
1. Examine the pH level in conjunction with the
Paco2 and HCO3 levels to determine whether
the acidosis/alkalosis is compensated or
uncompensated.
2. Monitor for an increase in the anion gap
(greater than 14 mEq/L), signaling an
increased production or decreased excretion
of acid products.
3. Monitor base excess/base deficit levels.
4. Monitor arterial lactate levels.
5. Monitor for elevated chloride levels with large
volumes of NS.
Dx: Acute pain related to physical injury
➢ Goals/Outcomes: Within 30 minutes of
intervention, the patient’s subjective
evaluation of discomfort improves, as
documented by a pain scale. Nonverbal
indicators, such as grimacing, are absent. Vital
signs return to baseline. ECG changes present
during event resolve.
Responsibilities include:
Pain management
1. Assess and document the location and
intensity of the pain. Devise a pain scale with
the patient, rating discomfort from 0 (no
pain) to 10 or any system that assists in
objectively reporting pain level. If intubated,
use a physiologic scale such as adult
 nonverbal pain scale or the FLACC (Face, Legs, ● Kozier, B., et. al. (2012). Fundamentals of Nursing:
Activity, Cry, Consolability) scale. Concepts, Process & Practice. 9 th Edition.
2. Determine the needed frequency of making Pearson Education Inc. New Jersey 07458.
an assessment of patient comfort and ● Potter, P. & Perry, A. Fundamentals of Nursing. 5 th
Ed. Mosby. St. Louis, Missouri.
implement monitoring plan.
● SUCN Old Procedure and Checklist
3. Provide the patient with optimal pain relief
with prescribed analgesics.
4. Ensure pretreatment analgesia and/or
nonpharmacologic strategies before painful
procedures.
5. Evaluate the effectiveness of the pain control
measures used through ongoing assessment
of the pain experience.
Other dx:
➢ Impaired skin integrity
➢ Risk for infection

References
● Amboss. (2021, June 30). Penetrating trauma.
https://www.amboss.com/us/knowledge/Penetrating_trauma/
● Ahn, J. et al. (2019) Penetrating injuries. Bone and Joint
Initiative USA.
https://www.boneandjointburden.org/fourth-edition/vb23/pene
trating-injuries
● Aihara, R. & Lamorte, W. (n.d.) Trauma case 1: Stab to left
chest. Boston School of Medicine - Surgery.
https://www.bumc.bu.edu/surgery/training/residency/teaching
-conferences-rounds/trauma-case-1-stab-to-left-chest/
● Dearden, C. & Donnell, J. (2001, June 21). Traumatic
wounds: nursing assessment and management. Nursing
Times, 97(24), p. 52.
● Shahani, R. et al. (2021, July 1). Penetrating Chest Trauma
Treatment & Management. Medscape.
● Advanced Trauma Life Support Student Course
Manual(PDF) (9th ed.). American College of
Surgeons.
● Blank-Reid C (September 2006). "A historical
review of penetrating abdominal trauma". Crit Care
Nurs Clin North Am. 18 (3): 387–401.
doi:10.1016/j.ccell.2006.05.007. PMID 16962459
● Prentice D, Ahrens T (August 1994). "Pulmonary
complications of trauma". Crit Care Nurs Q. 17 (2):
24–33. doi:10.1097/00002727-199408000-00004.
PMID 8055358. S2CID 29662985
● Fitzgerald, J.E.F.; Larvin, Mike (2009). "Chapter 15:
Management of Abdominal Trauma". In Baker,
Qassim; Aldoori, Munther (eds.). Clinical Surgery:
A Practical Guide. CRC Press. pp. 192–204. ISBN
9781444109627.
● Smith M, Ball V (1998). "Thoracic trauma".
Cardiovascular/respiratory physiotherapy. St.
Louis: Mosby. p. 220. ISBN 0-7234-2595-7.
 THE CARE OF PATIENTS WITH HEAD INJURY – SUBDURAL HEMATOMA

I. HEAD INJURIES
a. Head injury includes any injury or trauma to the scalp, skull, or brain.
b. Types of head injury: Scalp Lacerations, Skull Fracture, and Head Trauma
c. Complications of head injury: Epidural Hematoma, Subdural Hematoma, and Intracerebral
Hematoma
II. ANATOMY AND PHYSIOLOGY REVIEW
- The nervous system consists of two major parts: the Central Nervous System (CNS) which
includes the brain and spinal cord, and the Peripheral Nervous System (PNS), which includes the
cranial nerves, spinal nerves and autonomic nervous system
- The function of the nervous system is to control motor, sensory, autonomic, cognitive and
behavioral activities.
- Structures protecting the brain:
- The rigid skull which is made up of the frontal, temporal, parietal, occipital and
sphenoid bones.
- The meninges provide protection, support and nourishment.
- The layers of the meninges are the dura mater, arachnoid and pia mater.
III. SUBDURAL HEMATOMA
- A subdural hematoma is a collection of blood between the dura and the brain, a space normally
occupied by a thin cushion of fluid.
- The most common cause of a subdural hematoma is trauma but it can also occur as a result of
coagulopathies or rupture of an aneurysm.

A. Types of Subdural Hematoma

1. Acute - Presents within 48 hours after impact
2. Subacute - Presents between 48 hours and two weeks after impact
3. Chronic - Presents from two weeks to several months after injury

B. Risk Factors - Falls

- Predisposing Factors:
- Sports Injuries
- Age - Children 0-2
years and older adults - Work Injuries

- Male - Vehicular Accidents

- Ruptured Aneurysm
- Precipitating Factors:
- Head Trauma - Coagulopathy or
medical
- Physical Violence anticoagulation

C. Pathophysiology
- The usual mechanism that produces an acute subdural hematoma is a high-speed impact
to the skull. This causes the brain tissue to accelerate or decelerate relative to the fixed
dural structures, tearing blood vessels.
- Often the torn blood vessel is a vein that connects the cortical surface of the brain to a
dural sinus called a bridging vein. In elderly persons, the bridging veins may already be
stretched because of brain atrophy
- The bleeding from the bridging veins dissects the arachnoid away from the dura and the
blood layers out along the cerebral convexity. This causes increased intracranial pressure
- This increased intracranial pressure puts pressure on the blood vessels within the brain
and this causes slow blood flow to the brain
- the slow blood flow to the brain causes cerebral hypoxia and ischemia
- If the intracranial pressure continues to increase, the brain may herniate
- Cerebral blood flow then ceases which causes death.

D. Clinical Manifestations
- For Acute Subdural - Slowing respiratory
Hematoma, the following are rate
the clinical manifestations:
- For Chronic Subdural
- Changes in LOC Hematoma, the following are
the clinical manifestations:
- Pupillary signs
- Severe Headache
- Hemiparesis
- Hemiparesis
- Coma
- Personality changes
- Hypertension
- Mental deterioration
- Decreasing heart rate
- Focal seizures

E. Assessment and Diagnostic Findings

1. Glasgow Coma Scale
a) Tool for assessing a patient’s response to stimuli; ranges from score of 3 (deep
coma) to 15 (normal)
2. CT Scan – Plain and with Contrast dye
a) Highly sensitive for acute blood; assists in the decision making for location of
lesions to perform evacuation (Diagnostic)
3. MRI
a) Demonstrates the size of the acute subdural hematoma and its effect on the brain
4. PET Scan
a) More detailed descriptive image on the brain's function
5. Skull X-ray
a) Detects and assesses skull for fractures (CT Scans are clearer than X-Rays
6. Angiography
a) Detects blockages or abnormalities in the brain that could indicate a possibility for
stroke or bleeding in the brain
7. CBC/Blood Testing
 a) Accounts of the RBC level: low levels indicates significant blood loss
b) Account of Platelet level: low levels indicates poor clotting
c) Tests for Coagulopathy
F. Pharmacologic Management
1. Anticonvulsant Agents
a) Phenytoin
(1) To control tonic-clonic (grand mal) seizures, psychomotor and
nonepileptic seizures (e.g., Reye's syndrome, after head trauma). Also
used to prevent or treat seizures occurring during or after neurosurgery. Is
not effective for absence seizures
b) Levetiracetam
(1) used in combination with other medications to treat certain types of
seizures in adults and children with epilepsy; decreases abnormal
excitement in the brain.
2. Sedative Agents
a) Propofol
(1) Induction or maintenance of anesthesia as part of a balanced anesthesia
technique; conscious sedation in mechanically ventilated patients.
b) Lorazepam
(1) Management of anxiety disorders and for short-term relief of symptoms of
anxiety. Also used for preanesthetic medication to produce sedation and to
reduce anxiety and recall of events related to day of surgery; for
management of status epilepticus.
c) Midazolam
(1) Sedation before general anesthesia, induction of general anesthesia; to
impair memory of perioperative events (anterograde amnesia); for
conscious sedation prior to short diagnostic and endoscopic procedures;
and as the hypnotic supplement to nitrous oxide and oxygen (balanced
anesthesia) for short surgical procedures.

d) Barbiturates (Pentobarbital and Thiopentone)

(1) Used short-term as a sedative to treat insomnia, or to cause you to fall
asleep for surgery; used as an emergency treatment for seizures.
3. Osmotic Diuretics
a) Mannitol
(1) May reduce subarachnoid space pressure by creating an osmotic gradient
between the cerebrospinal fluid in the arachnoid space and the plasma
G. Surgical Management
1. Evacuation of Hematoma
a) Craniotomy
(1) Surgical opening of the skull to gain access to structures beneath the
cranial bones
b) Craniectomy
(1) Removal of a portion of a cranial bone in order to relieve pressure on the
brain
2. Burr Hole
a) Drilling holes (burr holes) in the skull to relieve pressure removing the clot, and
stopping the bleeding

H. Nursing Management
1. Pre-operative Care
Preoperative Nursing Responsibilities
● Ensure completeness of Preoperative Checklist
● Validate informed consent
● Validate, clarify and reinforce information patient has received from the members
of the surgical team
● Preoperative teachings to reduce patient anxiety, prevent complications and
promote compliance after surgery
● Monitor Vital Signs: BP, HR, RR, Temperature
● Assess patient for problems that increase the risk for complications during and
after surgery
● Monitor patient’s neurologic function
● Teach patient and family what to expect immediately after surgery and throughout
the recovery period
● Ensure that the patient has been on NPO status for at least 8 hours
● Check that the patient has not had alcohol, tobacco, anticoagulants or NSAIDS for
at least 5 days before surgery

2. Postoperative Care
Postoperative Nursing Responsibilities
● Assess neurologic and Vital signs every 15-30 minutes for the first 4-6 hours after
a craniotomy and then every hour. if the patient is stable for 24 hours, the
frequency of these checks may be decreased to every 2-4 hours
● Report immediately and document new neurologic deficits, particularly a
decreased LOC, motor weakness or paralysis, aphasia, decreased sensation and
sluggish pupil reaction to light. Personality changes such as agitation, aggression
or passivity can also indicate worsening neurologic status.
● Maintain temperature less than 38C
● Monitor ABGs to assess adequacy of ventilation
● Monitor for patent airway, altered breathing pattern and hypoxemia and
pneumonia
● Record patient’s intake and output for the first 24 hours.
● Reposition patient, making sure not to cause pressure on the operative site.
● Position the patient to avoid extreme hip or neck flexion and maintain the head in
a midline, neutral position to prevent increased ICP
● Turn the patient side to side or supine to prevent pressure injury and pneumonia
● Encourage patient to take frequent deep breaths to expand the lungs each hour
● Elevate the head of the bed 30 degrees or as tolerated to prevent venous drainage
from the bed
● Check the head dressing every 1-2 hours for signs of drainage.
● Measure the drainage every 8 hours and record the amount and color. Report to
the surgeon if the drainage is greater than 50mL/8hr
● Monitor frequently for signs of increasing ICP including headache, deteriorating
LOC, restlessness and irritability
● Monitor patient for hydrocephalus
● Monitor for signs of infection
● Suction the patient as needed
● Reduce environmental stimuli by keeping the room quiet, limiting visitors,
speaking calmly and providing frequent orientation information

3. Nursing Diagnoses
a) Risk for Ineffective Breathing Pattern related to depressive effects of anesthesia
and compression of medulla secondary to edema of the brain
b) Risk for Ineffective Tissue Perfusion (Cerebral) related to cerebral edema and
bleeding within the cranium
c) Pain related to chemicals released from traumatized tissue, swelling of cerebral
tissue, irritation of meninges
d) Risk for Infection related to impaired skin integrity and suppressed inflammatory
response.
e) Risk for Hyperthermia related to hypothalamic dysfunction or infection
f) Disturbed Thought Processes related to cognitive deficits secondary to structural
changes in brain tissue and physiology
g) Risk for Injury related to confusion and poor judgment
h) Risk for Ineffective Coping related to multiple stressors involving physical losses,
lengthy rehabilitation, and compromised finances
4. Nursing Interventions
a) Risk for Ineffective Breathing Pattern related to depressive effects of anesthesia
and compression of medulla secondary to edema of the brain
(1) Monitor SpO2 with pulse oximeter
(2) Maintain a patent airway by keeping the head erect and in mid-line,
inserting an oral or nasopharyngeal airway if necessary, and suctioning
secretions
(3) Encourage client to deep breathe at least 10x each hour or to use a bedside
spirometer
(4) Avoid administering narcotic analgesia
(5) Elevate the head of the bed
(6) Report signs of hypoxemia; be prepared to administer supplemental
oxygen or provide mechanical ventilation
b) Risk for Ineffective Tissue Perfusion (Cerebral) related to cerebral edema and
bleeding within the cranium
c) Pain related to chemicals released from traumatized tissue, swelling of cerebral
tissue, irritation of meninges
(1) Assess presence, type, and level of pain whenever you assess vital signs
and as needed
(2) Reduce bright lights and noise
(3) Minimize activity when pain is acute
(4) Administer prescribed analgesia
d) Risk for Infection related to impaired skin integrity and suppressed inflammatory
response
(1) Assess temperature, PR, lung sounds, and characteristics of urine. Note the
presence of a cough
(2) Inspect the dressing and wound for evidence of purulent drainage
(3) Follow principles of asepsis when assessing the incision and changing the
dressing
(4) Administer prescribed antibiotics
e) Risk for Hyperthermia related to hypothalamic dysfunction or infection
(1) Measure body temperature every 4 hours
(2) Help client maintain an adequate oral fluid intake
(3) Remove heavy blankets if client develops a fever
(4) Administer a prescribed antipyretic when fever does not respond to heat
reduction methods
f) Disturbed Thought Processes related to cognitive deficits secondary to structural
changes in brain tissue and physiology
 (1) Orient client at frequent intervals
(2) Provide environmental clues such as a calendar with large numbers
(3) Investigate contributing causes of disorientation and restlessness (e.g. full
bladder, pain) and intervene as appropriate
(4) Share current events, and turn on newsworthy television or radio programs
(5) Repeat explanation of answers to questions as needed
g) Risk for Injury related to confusion and poor judgment
(1) Locate client near nursing station
(2) Place a signal cord within the client's reach; remind client to use it when
he or she needs assistance
(3) Place a bed/chair alarm that sounds if the client attempts to get out of bed
without assistance
h) Risk for Ineffective Coping related to multiple stressors involving physical losses,
lengthy rehabilitation, and compromised finances
(1) Consult with the physician about the client's prognosis
(2) Concur with physician's explanations if client or family raises questions
(3) Keep client and family informed of progress or changes as they occur
(4) Accept client's and family's behavior under stress in a nonjudgmental
manner
(5) Encourage problem-solving techniques and acknowledge positive
outcomes
IV. REHABILITATION
● A rehabilitation program may include:

Physical Medicine - A physiatrist can identify what’s causing pain and

help a person manage and treat the issue, with the goal of recovering
mobility and functional well-being.
Physiotherapy - Physiotherapists will help with movement problems such
as muscle weakness or poor coordination
Physical Therapy - Physical therapists will assess the patient’s ability to
walk safely and climb stairs before being released from the hospital. They
may also help the patient improve strength and balance.
Occupational Therapy - Occupational therapists will assess the patient’s
ability to perform activities of daily living such as getting dressed, using
the toilet and getting in and out of the shower. Occupational therapists also
test the patient’s vision and thinking skills to determine whether the
patient can return to work, driving or other challenging tasks.
Speech Language Therapy - Speech language pathologists: If the patient’s
brain tumor affects speech, speech language pathologists will evaluate
problems with speech, language or thinking. They may also evaluate the
patient for swallowing disorders.
 V. COMPLICATIONS

Without treatment, large hematomas can lead to coma and death. Other complications include:

• Brain herniation: Increased pressure can squeeze and push brain tissue so it moves from its normal
position. A brain herniation often leads to death.
• Repeated bleeding: Older adults who are recovering from a hematoma have a higher risk of another
hemorrhage. Older brains don’t recover as quickly as younger brains. Also, as we age, our brains shrink
and the space between the skull and brain widens. This further stretches the tiny thin veins between the
outer membrane layers of the brain and skull and makes the older brain more vulnerable to future
bleeding if another head injuries occur.
• Seizures: Seizures may develop even after a hematoma has been treated
 COLLEGE OF NURSING
SILLIMAN UNIVERSITY
DUMAGUETE CITY

Care of Patients with Cancer of the Colon (for APR)

Submitted to : Asst. Prof. Veveca Bustamante

Submitted by: Alexis Kamille Perez

S.Y 2021-2022
 Topic : Care of patients with Colon Cancer (For APR)
Topic Description: This topic deals with
Central Objective:

Specific Objectives Content

Definition of terms

Colorectal Cancer - Colorectal cancer is cancer that occurs in the colon or rectum. Sometimes it is called
colon cancer, for short.

Stage 0
Abnormal cells in the mucosa layers that will keep dividing thatd develop to polyps…

Stage 1
Tumor has spread to muscle layer

Stage 2
Tumor Spread to colon wall towards serosa
Stage 3
Tumor has spread to nearby lymph nodes

Stage 4 terminal stage

Metastasis… cancer cells have metastasized… began invading tissue and organs...by travelling to the blood
or lymphatics… can invade other organs like lungs liver and bones

https://www.youtube.com/watch?v=ASv9fhAPmiw&ab_channel=ArmandoHasudungan

Abdominal Perineal Resection ( APR ) - Surgery to remove the anus, the rectum, and part of the sigmoid
colon through an incision made in the abdomen.

The end of the intestine is attached to an opening in the surface of the abdomen and body waste is collected
in a disposable bag outside of the body. This opening is called a colostomy. Lymph nodes that contain cancer
may also be removed during this operation.

The exact cause/s of the colorectal cancer is unknown..

Predisposing and Precipitating factors of Colorectal Cancer

● older than 50 years,

● Genetic predisposition, personal or family history of cancer, and/ or diseases that predispose the
patient to cancer such as familial adenomatous polyposis (FAP)
● Familial adenomatous polyposis is a rare autosomal dominant trait linked to a mutation in the long
arm of chromosome 5. Persons with the disorder develop multiple adenomatous polyps of the colon at
an early age.
● History IBDs Crohn’s disease, and ulcerative colitis
● The role of infectious agents in the development of colorectal and anal cancer continues to be
investigated.
● Some lower GI cancers are related to Helicobacter pylori, Streptococcus bovis, JC virus, and human
papilloma virus (HPV) infections.
● long-term smoking,
● increased body fat,
● physical inactivity, and
 ● heavy alcohol consumption
● high-fat diet, particularly animal fat from red meats, increases bile acid secretion and anaerobic
bacteria, which are thought to be carcinogenic within the bowel.
● Diets with large amounts of refined carbohydrates that lack fiber decrease bowel transit time.

Pathophysiology or the disease process

Clinical Manifestations
- Insidious onset = meaning in a gradual, subtle way, but with harmful effects.

Rectal bleeding
Anemia
Change ins tool consistency or shape

Cancer of the colon is often asymptomatic in the early stages: the tumour may grow for years before
diagnosis, by which time it may be incurable.

Symptoms are usually caused by tumours that have

reached an advanced stage.

Patients may experience abdominal discomfort, change in bowel habits

or pain.

Advanced tumours are also responsible for fatigue, anorexia and weight loss.

Less frequently, patients will present with acute symptoms such as nausea, vomiting, pain and fever related to
either obstruction or perforation, following which problems of infection by resident bacteria quickly
develop.

When symptoms arise, they may be related to the location of the tumour.

For example, a rectal cancer can cause blood to appear in the stool; however, bleeding in the ascending
colon is not obvious and may only come to light because of the anaemia that results.

Diagnostic Tests

The single most important prognostic indicator of colorectal cancer is the extent (stage) of the tumor at time
of diagnosis.Therefore, the challenge is to discover the tumors at their earliest stages.

Among the methods used for the detection of colorectal cancers are the
 ● digital rectal examination -are most helpful in detecting neoplasms of the rectum.
● fecal occult blood test, usually done during routine physical examinations...A positive test result for
occult blood in the stool indicates bleeding in the GI tract.
● x-ray studies using barium (e.g., barium enema); SEARCH BARIUM ENEMA RESPONSIBILITIES
● and flexible sigmoidoscopy and colonoscopy ..Sigmoidoscopy and colonoscopy are generally the
primary diagnostic interventions where colorectal cancer is suspected. Where possible, biopsies will
be taken to identify the cancer type, differentiation and staging
● CT scanning, positron emission tomography (PET) and MRI scanning may be used to stage the
cancer and identify metastases
● Full blood examination and relevant chemical pathology testing will be performed to identify associated
problems. If anaemia and electrolyte imbalances are found, they should be corrected prior to surgery.
● CRC that has metastasized to the liver causes liver function tests to be elevated

Pharmacologic Interventions

The stage of the cancer at diagnosis will determine the nature of management.
If surgery is indicated, the extent of the cancer will dictate whether colectomy or colostomy is
required. Surgery may be indicated even in palliative care situations to manage blood loss or assist
with pain control.

Chemotherapy is a principal management intervention and may be used in almost all stages of
colon cancer, both before and after surgery.

In addition to cytotoxic drugs, the use of immune modifying agents is becoming more common in the
treatment of colon cancer. These include angiogenesis inhibitors, which block the new blood vessel
formation by the tumour.

Radiotherapy may be used for rectal cancer but it is not used as a matter of course in the management of
colon cancer.

Other considerations in colon cancer include the evidence that diet influences the occurrence
and recurrence of the cancer.

Despite the absence of evidence for specific carcinogens from the diet that act on the intestine, a diet that is
high in fresh fruit, vegetables and white meat may be preferable to one rich in red meat and highly
processed foods.

Reducing smoking and alcohol intake, and maintaining a healthy waist:hip ratio might also be beneficial

CASE SCENARIO

Dam is a 66 year-old male who went for a colonoscopy after experiencing frequent episodes of rectal bleeding
and constipation. Colonoscopy reveals positive for adenocarcinoma on the rectum. Dam is the second sibling
to have colon cancer. His social history is significant for smoking one pack per day for 35 years and eats red
meat almost once a day. Dam had a consultation with a medical oncologist and did a lot of diagnostic tests
before he was advised to have an APR as treatment for his stage 3 rectal cancer.

TREATMENT
Surgical Removal --- For APR

APR INDICATIONS

APR is performed in patients with lower-third rectal cancers. APR should be performed in patients in
whom negative margin resection (see Table 2, below) will result in loss of anal sphincter function.

In APR, both the tumor and the entire rectum are removed and the person has a permanent colostomy. The
perineal wound may be closed around a drain or left open with packing to allow healing by granulation.

Complications of APR

Delayed wound healing

Hemorrhage
Persistent perineal sinus tracts
Infection
Urinary tract and sexual dysfunctions.
Preop and Post op

- Chemotherapy can be used to shrink the tumor before surgery, as an adjuvant therapy after colon
resection, and as palliative treatment for unresectable cancer. Adjuvant chemotherapy is
recommended for patients with stage III tumors and high-risk stage II tumors.
- Colostomy care (post op)
- Jackson pratt drain (post op)

NURSING DX
● Diarrhea or constipation related to altered bowel elimination patterns
● Ineffective coping related to diagnosis of cancer and side effects of treatment
● Infection
● Fatigue related to decreased oxygen-carrying capacity of the blood occurring with anemia(caused by
some chemotherapeutic drugs, radiation therapy, chronic disease such as renal failure, or surgery
● Abdominal discomfort related to tissue injury from tumor invasion and the surgical incision

Complications of CRC

bowel obstruction or perforation with resultant peritonitis, abscess formation, and fistula formation to the
urinary bladder or the vagina. The tumor may invade neighboring blood vessels and cause frank bleeding.
Tumors growing into the bowel lumen can gradually obstruct the intestine and eventually block it completely.
Those extending beyond the bowel wall may place pressure on neighboring organs (uterus, urinary bladder,
and ureters) and cause symptoms that mask those of the cancer

Prevention
Early screening - Teach people about the need for early diagnostic screening especially those who are at risk.

Teach patients, regardless of risk, to modify their diets as needed to decrease fat, refined carbohydrates, and
low-fiber foods. Encourage baked or broiled foods, especially those high in fiber and low in animal fat. Teach
people the hazards of smoking, excessive alcohol, and physical inactivity. Refer patients as needed for
smoking- or alcohol-cessation programs, and recommend ways to increase regular physical exercise.

Is APR only the surgery for colorectal cancer?

Technically, no. There are actually other surgical procedures for your crc depending on the location of the
tumor. An AP resection is performed when rectal tumors are present. Wherein the surgeon removes the
sigmoid colon, rectum, and anus through combined abdominal and perineal incisions.

You mentioned polyethylene glycol in the preop responsibilities… what does that do?

This solution overwhelms the absorptive capacity of the small bowel and clears feces from the colon.
However, the use of bowel preps is controversial, and some surgeons do not recommend it because of patient
discomfort. Older adults may become dehydrated from this process. I

This solution overwhelms the absorptive capacity of the small bowel and clears feces from the colon.
However, the use of bowel preps is controversial, and some surgeons do not recommend it because of patient
discomfort.

You’ve mentioned angiogenesis. ..What does it have to do with cancer?

Angiogenesis is the formation of new blood vessels.. And this essential in cancer to supply cancerous growth.
Moreover, the development and the progression of the tumor and its metastases are the result of an efficient
vascular response.

Thats why patients with crc are prescribed with angiogenesis

inhibitors, which block the new blood vessel formation by the tumour. Like your angiogenesis
inhibitors..bevacizumab (Avastin) which i mentioned in the ppt

When should colostomy start functioning? What is the appearance of a healthy stoma

The colostomy should start functioning in 2 to 4 days postoperatively.

A healthy stoma should be reddish pink and moist and protrude about 3 4 inch (2 cm) from the abdominal
wall.

During the initial postoperative period, the stoma may be slightly edematous. A small amount of bleeding at
the stoma is common.
Perineal sinus is a discharging blind end track that extends from the skin to an underlying
area or abscess cavity. The commonest cause of abscess formation is the presence of underlying
infection.

What about the post op care for the perineal wound? Diba you have colostomy care for the stoma and
what about the perineal wound?

We have the sitz bath for the perineal wound….

• If prescribed, soak the wound area in a sitz bath for 10 to 20

minutes three or four times per day.
• Administer pain medication as prescribed, and assess its
effectiveness.
• Instruct the patient about permissible activities. The patient should:
• Assume a side-lying position in bed; avoid sitting for long
periods
• Use foam pads or a soft pillow to sit on whenever in a sitting
position
 Care of Patient with Cataracts
By: Freshsia Pastor
Introduction
What is Cataract?
• A cataract is a lens opacity or cloudiness. On visual
inspection, the lens appears gray or milky.
• Cataract is defined as opacity within the clear natural
crystalline lens of the eye, which gradually results in
vision deterioration.
• Cataracts are responsible for visual disability in 18
million people worldwide (Grossman & Porth, 2014).
• Cataracts are a leading cause of blindness in the world
(Prevent Blindness America, 2012).
• Cataract removal is the most common surgical
procedure in the United States.
Types of cataracts
Cataract types include:
Cataracts affecting the center of the lens (nuclear cataracts)
• A nuclear cataract may at first cause more
nearsightedness or even a temporary improvement in
your reading vision. But with time, the lens gradually
turns more densely yellow and further clouds your
vision.
• As the cataract slowly progresses, the lens may even
turn brown. Advanced yellowing or browning of the
lens can lead to difficulty distinguishing between
shades of color.
Cataracts that affect the edges of the lens (cortical
cataracts)
• A cortical cataract begins as whitish, wedge-shaped
opacities or streaks on the outer edge of the lens cortex.
As it slowly progresses, the streaks extend to the center
and interfere with light passing through the center of
the lens.
Cataracts that affect the back of the lens (posterior
subcapsular cataracts)
• A posterior subcapsular cataract starts as a small,
opaque area that usually forms near the back of the
lens, right in the path of light. A posterior subcapsular
cataract often interferes with your reading vision,
reduces your vision in bright light, and causes glare or
halos around lights at night. These types of cataracts
tend to progress faster than other types do.
Cataracts you're born with (congenital cataracts)
• Some people are born with cataracts or develop them
during childhood. These cataracts may be genetic, or
associated with an intrauterine infection or trauma.
• These cataracts also may be due to certain conditions,
such as myotonic dystrophy, galactosemia,
neurofibromatosis type 2 or rubella. Congenital
cataracts don't always affect vision, but if they do
they're usually removed soon after detection.
Epidemiology and Etiology
Most cataracts are due to age-related changes in the lens of the
eye that cause it to become cloudy or opaque. However, other
factors can contribute to cataract development, including:
• Diabetes mellitus. People with diabetes are at higher
risk for cataracts.
• Drugs. Certain medications are associated with
cataract development. These include:
• Corticosteroids.
• Chlorpromazine and other phenothiazine
related medications.
• Ultraviolet radiation. Studies show an increased
chance of cataract formation with unprotected
exposure to ultraviolet (UV) radiation.
• Smoking. There is possibly an association between
smoking and increased lens cloudiness.
• Alcohol. Several studies show increased cataract
formation in patients with higher alcohol consumption
compared with people who have lower or no alcohol
consumption.
• Nutritional deficiency. Although the results are
inconclusive, studies suggest an association between
cataract formation and low levels of antioxidants (for
example, vitamin C, vitamin E, and carotenoids).
Further studies may show that antioxidants can help
decrease cataract development.
• Family History. If a close relative has had cataracts,
there is a higher chance of developing a cataract.
Rarely, cataracts are present at birth or develop shortly after.
They may be inherited or develop due to an infection (such as
rubella) in the mother during pregnancy. A cataract may also
develop following an eye injury or surgery for another eye
problem, such as glaucoma.
Clinical Manifestation / Signs & Symptoms
• Diplopia. (Double Vision) Diplopia is when you see
two images of the same thing. You might know it as
double vision. You might have diplopia in one eye or
both. Generally, double vision in both eyes is more
serious than if you have it in just one.
• Nearsightedness (myopia) is a common vision
condition in which you can see objects near to you
clearly, but objects farther away are blurry. It occurs
when the shape of your eye causes light rays to bend
(refract) incorrectly, focusing images in front of your
retina instead of on your retina.
• Sensitivity to bright sunlight, lamps or headlights.
• Glare (seeing a halo around lights), especially when
you drive at night with oncoming headlights. Glare
 Care of Patient with Cataracts
By: Freshsia Pastor
refers to the pain felt when the patient looks directly
into the light.
• Prescription changes in glasses, including sudden
nearsightedness.
• Poor night vision. Difficulty seeing at night
• Blurred vision. Blurred vision is usually the first
symptom of cataracts.
• Halos. Halos are formed when the patient looks at a
bright light and there is still the vision of the light
after looking away.
• Astigmatism. a common and generally treatable
imperfection in the curvature of your eye that causes
blurred distance and near vision. Astigmatism occurs
when either the front surface of your eye (cornea) or
the lens, inside your eye, has mismatched curves.
Complications
• Posterior capsule opacification (PCO) - Occurs
when a cloudy layer of scar tissue forms behind your
lens implant. This may cause you to have blurry or
hazy vision, or to see a lot of glare from lights. PCO is
fairly common after cataract surgery, occurring in
about 20% of patients.
• Glaucoma - is an eye condition that can cause damage
to the optic nerve.
• Blindness
• Photopsia (perceived flashes of light)
• Ptosis (droopy eyelid)
• Corneal edema (swelling of the clear covering of the
eye)
• Hyphema (bleeding in the front of the eye). The
presence of blood within the aqueous fluid of the
anterior chamber. The most common cause of
hyphema is trauma. Postinjury accumulation of blood
in the anterior chamber is one of the most challenging
clinical problems encountered by the ophthalmologist.
• Retinal detachment (detachment of the nerve layer at
the back of the eye). Retinal detachment, or a
detached retina, is a serious eye condition. The retina,
the layer of tissue in the back of the eye, pulls away
from tissues supporting it. Sudden changes, including
eye floaters and flashes and darkening side vision, are
signs this may be happening.
• Ocular hypertension (elevated eye pressure)
• Endophthalmitis (infection in the eye)
• Cystoid macular edema (swelling of the clear
covering of the eye)
Diagnostic Test
Ophthalmoscopy
• Ophthalmoscopy (also called fundoscopy) is a test that
lets a doctor see inside the back of the eye, which is
called the fundus.
• The doctor can also see other structures in the eye. He
or she uses a magnifying tool called an
ophthalmoscope and a light source to see inside the
eye. The test is done as part of an eye exam. It may
also be done as part of a routine physical exam.
Glare testing
• Used to verify the vision loss associated with clouding
of the posterior capsule (posterior capsule
opacification or PCO) after cataract surgery. Patients
can be quickly tested with and without glare to
determine if the PCO is causing sufficient light scatter
to be debilitating for the patient.
Keratometry
• The measurement of the corneal radius of curvature.
The anterior corneal surface is treated as a specular
reflector. A ring of known size is placed in front of the
eye. Consequently, keratometry attempts to predict
the total corneal power based only on a measurement
of the anterior corneal surface.
Visual acuity test
• A visual acuity test uses an eye chart to measure how
well you can read a series of letters. Your eyes are
tested one at a time, while the other eye is covered.
Using a chart or a viewing device with progressively
smaller letters, your eye doctor determines if you have
20/20 vision or if your vision shows signs of
impairment.
Retinal Examination
• To prepare for a retinal exam, your eye doctor puts
drops in your eyes to open your pupils wide (dilate).
This makes it easier to examine the back of your eyes
(retina). Using a slit lamp or a special device called an
ophthalmoscope, your eye doctor can examine your
lens for signs of a cataract.
Slit-lamp examination.
• A slit lamp allows your eye doctor to see the structures
at the front of your eye under magnification. The
microscope is called a slit lamp because it uses an
intense line of light, a slit, to illuminate your cornea,
iris, lens, and the space between your iris and cornea.
The slit allows your doctor to view these structures in
small sections, which makes it easier to detect any tiny
abnormalities.
 Care of Patient with Cataracts
By: Freshsia Pastor
Surgical Management
a. Removal of lens
i.Phacoemulsification
Phacoemulsification is the most common procedure for
cataracts. Your ophthalmologist makes a small opening in the
eye to reach the clouded lens. Using high-frequency sound
waves (ultrasound) or a laser, your ophthalmologist breaks the
lens into pieces. Then the doctor suctions lens fragments from
your eye and puts in a new plastic lens.
Phacoemulsification with an intraocular lens (IOL) is a
procedure done for patients having cataract. The cataract-
affected lens inside the eye is removed, and an artificial lens is
inserted in its place
ii. Extracapsular extraction
In extracapsular cataract surgery, your ophthalmologist makes
a larger opening in the eye. Instead of breaking up the lens and
then removing it, your doctor removes the lens in one piece.
Then the surgeon inserts the manufactured lens.
b. Intraocular lens implantation (most frequent
type of correction)
An intraocular lens (IOL) is a clear, artificial lens implant used
to replace a cloudy natural lens in cataract surgery.
An IOL focuses light that comes into the eye through the cornea
and pupil onto the retina, the sensitive tissue at the back of the
eye that relays images through the optic nerve to the brain. Most
IOLs are made of a flexible, foldable material and are about
one-third of the size of a dime. Like the lenses of prescription
eyeglasses, the IOL will contain the appropriate prescription to
give you the best vision possible.
c. Aphakic glasses
In aphakic glasses, objects are magnified by 25%, making them
appear closer than they actually are.
d. Contact lenses
Contact lenses provide patients with almost normal vision, but
because contact lenses need to be removed occasionally, the
patient also needs a pair of aphakic glasses.
Nursing Management
Possible nursing diagnosis:
Disturbed Visual Sensory Perception related to poor visual
acuity
NURSING RESPONSIBILITIES
• Assess the patients ability to see and perform
activities.
• Encourage patient to see an ophthalmologist at least
yearly.
• Provide sufficient lighting for the patient to carry out
activities.
• Provide large print objects and visual aids for teaching
• Demonstrate/have client administer eye drops using
correct procedure
• Prepare for surgical intervention as indicated like a
cataract extraction
Risk for injury related to decreased vision
Nursing Responsibilities:
• Ascertain knowledge of safety needs/injury prevention
and motivation.
• Orient patient with the type of environment.
• Advise patient to use sunglasses to reduce glare.
• Keep patients visual aids near reach
• Ensure the environment has sufficient lighting and all
furniture moved to the walls
• Monitor environment for potentially unsafe conditions
and modify as needed and reduce risk for injury
Risk for Injury related to increased intraocular pressure
secondary to Phacoemulsification Surgery
Nursing Responsibility:
• Assess clients feelings, understanding, or thoughts
about his post-operative experience, on pain and
activity restrictions.
• Give client information about positioning and
restrictions about position.
• Instruct client to avoid coughing.
• Instruct client to limit activities e.g. moving the head,
scratching eyes, bowing down.
• Tell the client to maintain eye protection as indicated.
• Teach client of the proper way in caring for the eye by
applying eye drops and not scratching it.
Risk for infection related to trauma to the incision
NURSING RESPONSIBILITIES
• Maintain strict aseptic technique, wash hands
frequently.
• Advice to supervise and report immediately any signs
and symptoms of complications, such as: bleeding,
increased IOP or infection to avoid risk of vi
• Explain the recommended position such as elevating
head and avoiding lying on the side of the operation to
reduce the edema
• Instruct the patient to know bedrest activity
restrictions, with flexibility to the bathroom, according
to a gradual increase in activity tolerance. (speedy
healing and avoiding more damage)
• Describe the actions that should be avoided, as
prescribed by coughing, sneezing, vomiting (ask for
medication for it).
• Give medications as prescribed, according to
prescribed techniques.
• Maintain strict aseptic technique, wash hands
 Care of Patient with Cataracts
By: Freshsia Pastor

Interventions

Ambulatory and Rehabilitative Care

Include the following information in the teaching plan for the
patient
and the caregiver after eye surgery.
• Proper hygiene and eye care techniques to ensure that
medications, dressings, and/or surgical wound is not
contaminated during eye care
• Signs and symptoms of infection and when and how to
report these to allow for early recognition and
treatment of possible infection
• Importance of complying with postoperative
restrictions on head positioning, bending, coughing,
and Valsalva maneuver to optimize visual outcomes
and prevent increased intraocular pressure
• How to instill eye medications using aseptic
techniques and adherence with prescribed eye
medication routine to prevent infection
• How to monitor pain, take pain medication, and report
pain not relieved by medication
• Importance of continued follow-up as recommended
to maximize potential visual outcomes
 CARE OF PATIENT WITH BENIGN PROSTATIC HYPERPLASIA (BPH)
[NCM 71] WARDCLASS TOPIC #2 – SURGERY ROTATION

INTRODUCTION: CLINICAL MANIFESTATIONS:

•

• •
o
o
•
o
o
•
• •
•

•
DEFINITION: o Irritative symptoms

o Obstructive symptoms
INCIDENCE
•

•
o –
o –
•
o – –
o
• o
• o
o
o
ETIOLOGY & RISK FACTORS
• o
•
o
•
‘
•

•
o

o
▪
• ▪
•

PATHOPHYSIOLOGY: DIAGNOSTIC TESTS

-

•
→
−

−
→

→
→ •

→ o –
→
→ o
→
’
o
→

•
→

o –
o –

•
 • ’

’ Pharmacologic Therapy:
•
o “ ” →
”
o “ ” •
“ ”
o
o o

✓
Other Diagnostic Tests:
• ✓
✓
•
o
o
▪

o ▪
✓

✓
o

•
o o

o
• ’

o o
▪
▪

o
▪
o

MEDICAL MANAGEMENT: o
•
o
•
o

“ ” – o

o o

NURSING MANAGEMENT OF THE MEDICAL CLIENT

Assessment
o -
o
o
o o
o
o
o
-
-
o

Diagnosis, Outcomes, Interventions

•
−
−

o −
−
o
– Evaluation
✓
o
✓

o
SURGICAL MANAGEMENT
o -

-
 -

−
Minimally Invasive Therapy:

−
−
Other surgical options
•
° ° −
−
•

• −

•
• −

• −

−
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–
COMPLICATIONS AFTER TREATMENT
• •
•
•
•
•
•
’ •
•
• –

• –

• –

•
–
→

NURSING MANAGEMENT OF THE SURGICAL CLIENT

PREOPERATIVE CARE:
• •
•
•

Invasive Therapy (surgery)

’
−

•
−
−
POSTOPERATIVE CARE:
•

−
−

− –

−
−

−
 SILLIMAN UNIVERSITY
COLLEGE OF NURSING
Dumaguete City

Care of the Patient with Fractures of the Femur

Prepared by:
Anton Raymundo Y. Abiera III
Level IV C2
Submitted to:
Asst. Prof. Veveca V. Bustamante

Teaching Date: September 2 , 2021 ​Time: 8:00am - 10:00am​​

Venue: Online via Google Meet
 CARE OF PATIENT WITH FRACTURES OF THE FEMUR

● Musculoskeletal System
○ The musculoskeletal system (locomotor system) is a human body system
that provides our body with movement, stability, shape, and support. It is
subdivided into two broad systems:
○ Muscular system, which includes all types of muscles in the body. Skeletal
muscles, in particular, are the ones that act on the body joints to produce
movements. Besides muscles, the muscular system contains the tendons
which attach the muscles to the bones.
○ Skeletal system, whose main component is the bone. Bones articulate with
each other and form the joints, providing our bodies with a hard-core, yet
mobile, skeleton. The integrity and function of the bones and joints is
supported by the accessory structures of the skeletal system; articular
cartilage, ligaments, and bursae.
○ Besides its main function to provide the body with stability and mobility,
the musculoskeletal system has many other functions; the skeletal part
plays an important role in other homeostatic functions such as storage of
minerals (e.g., calcium) and hematopoiesis, while the muscular system
stores the majority of the body's carbohydrates in the form of glycogen.

What is a fracture?
● Fracture
- A fracture is a disruption or break in the continuity of the structure of
bone.
- A break or crack in a bone.
- It is a complete or incomplete disruption in the continuity of bone
structure and is defined according to its type and extent. Fractures occur
when the bone is subjected to stress greater than it can absorb

● Classifications of Fracture
○ Open - fractured bone that breaks through the skin and is also known as
compound fracture
○ Closed - fractured bone that DOES NOT penetrate through skin and is
also known as simple fracture
○ Complete fracture - the fracture completely separates the bone in two
 ○ Incomplete fracture - fracture that does not break the bone all the way
through
○ Greenstick - one side of the bone is bent while the other side is broken
and is an incomplete fracture
○ Comminuted - bone is broken into 3 or more fragments
○ Transverse fracture - fracture is straight across the bone shaft
○ Oblique - fracture is slanted across the bone shaft
○ Spiral - fracture twists around the bone shaft
○ Transverse fracture: the line of the fracture extends across the bone shaft
at a right angle to the longitudinal axis.
○ Spiral fracture: the line of the fracture extends in a spiral direction along
the bone shaft.
○ Greenstick fracture: an incomplete fracture with one side splintered and
the other side bent.
○ Comminuted fracture: a fracture with more than two fragments. The
smaller fragments appear to be floating.
○ Oblique fracture: the line of the fracture extends in an oblique direction.
○ Pathologic fracture: a spontaneous fracture at the site of a bone disease.
○ Stress fracture: occurs in normal or abnormal bone that is subject to
repeated stress, such as from jogging or running.

● Case Scenario
○ Pablo, a 22 year old active male was rushed to the emergency room crying
in pain with an immobilized leg. He was involved in a motor vehicular
accident and was taken to the emergency room immediately. DR. Tan
ordered an x-ray and he was then diagnosed with a comminuted complex
fracture of the proximal left femur diaphysis. Before his surgery, he
verbalized his fears on how he might not be able to go back to his original
lifestyle. Patient underwent open reduction, internal fixation the next
morning.

● Types of femur fracture

Femur fractures vary based on the type of injury that was sustained, the way the
bone was fractured and the location of the fracture. The femur shaft is divided
into three parts and the location of injuries may include:
○ Proximal femur fractures involve the upper portion of the bone, next to
the hip joint
○ Femoral shaft fractures involve the middle portion of the bone and are
usually very severe injuries
○ Supracondylar femur fractures involve the area just above the knee and
are considered uncommon
● Causes
○ Injury commonly occurs when a high-force blow hits the thigh bone.
■ High-speed trauma, such as a motor vehicle or motorcycle accident.
■ A fall from a high place.
■ Injury during extreme or contact sports.
■ A preexisting bone disease that weakens the bone, such as a tumor,
Paget disease, bone cyst, or osteoporosis.

● Clinical Manifestations
○ Pain - The pain is continuous and increases in severity until the bone
fragments are immobilized.
○ Loss of Function - After a fracture, the extremity cannot function properly
because normal function of the muscles depends on the integrity of the
bones to which they are attached.
○ Deformity - Displacement, angulation, or rotation of the fragments in a
fracture of the arm or leg causes a deformity that is detectable when the
limb is compared with the uninjured extremity.
○ Shortening - In fractures of long bones, there is actual shortening of the
extremity because of the compression of the fractured bone.
○ Crepitus - It is caused by the rubbing of the bone fragments against each
other.
○ Localized Edema and ecchymosis - Localized edema and ecchymosis
occur after a fracture as a result of trauma and bleeding into the tissues.
 ● Complications

Complication Clinical Manifestations Prevention and Management

Shock - · Cool, clammy skin · Treatment for shock

Hypovolemic · Low blood consists of stabilizing
shock resulting pressure the fracture to prevent
from hemorrhage · Pale or ashen skin. further hemorrhage,
is more · Bluish tinge to lips restoring blood volume
frequently noted or fingernails (or and circulation,
in trauma gray in the case of relieving the patient’s
patients with dark complexions) pain, providing proper
pelvic fractures · Rapid pulse. immobilization, and
and in patients · Rapid breathing. protecting the patient
with a displaced · Nausea or from further injury and
or open femoral vomiting. o other complications.
fracture in which Enlarged pupils.
the femoral artery · Weakness or
is torn by bone fatigue.
fragments.
Fat Embolism · Hypoxemia - The · Immediate
Syndrome - Fat typical first immobilization of
embolism manifestations are fractures, including
syndrome (FES) pulmonary and early surgical fixation,
describes the include hypoxia, minimal fracture
clinical tachypnea, and manipulation, and
manifestations dyspnea adequate support for
that occur when accompanied by fractured bones during
fat emboli enter tachycardia, turning and
circulation substernal chest positioning, and
following pain, low-grade maintenance of fluid
orthopedic fever, crackles, and and electrolyte balance
trauma, additional are measures that may
especially long manifestations of reduce the incidence of
bone (e.g., respiratory failure. fat emboli. There is no
femur) fractures. Chest x-ray may specific treatment for
At the time of show evidence of FES; the treatment is
fracture, fat acute respiratory supportive.
globules may distress syndrome Vasopressors,
diffuse from the (ARDS) or it may mechanical ventilation,
marrow into the be normal. and sometimes
vascular · Neurologic corticosteroids are used
compartment. compromise - There as supportive therapy.
The fat globules may be varying
(i.e., emboli) may degrees of
occlude the small neurologic deficits
blood vessels that can include
that supply the restlessness,
lungs, brain, agitation, seizures,
kidneys, and focal deficits, and
other organs. encephalopathy.
· Petechial rash - rash
may develop 2 to 3
days after the onset
of symptoms. This
rash is secondary to
dysfunction in the
microcirculation
and/or
thrombocytopenia
and is typically
located in
nondependent
regions (e.g., chest,
mucous
membranes) of the
body.
Compartment · The patient with · Prompt management of
Syndrome - acute compartment acute compartment
characterized by syndrome reports syndrome is essential.
the elevation of deep, throbbing, If conservative
pressure within unrelenting pain, measures do not
an anatomic which is unrelieved restore tissue perfusion
compartment by medications, and relieve pain, a
that is above seems fasciotomy (surgical
normal perfusion disproportionate to decompression with
pressure. the injury, and excision of the fascia)
Compartment intensifies with is indicated to relieve
syndrome arises passive ROM. the constrictive muscle
from an increase Frequent fascia. After
in compartment assessment of fasciotomy, the wound
volume (e.g., neurovascular is not sutured but is
from edema or function after a left open to allow the
bleeding), a fracture is essential muscle tissues to
decrease in and focuses on the expand; it is covered
compartment “five Ps”: pain, with moist, sterile
size (e.g., from a pallor, saline 3178 dressings or
restrictive cast), pulselessness, with artificial skin.
or aspects of paresthesias, and Alternatively, a
both. When the paralysis. vacuum dressing may
pressure within be used to remove
an affected fluids and hasten
compartment wound closure. The
rises above affected arm or leg is
normal, splinted in a functional
perfusion to the position and elevated
tissues is to heart level, and
impaired, prescribed intermittent
causing cell passive ROM exercises
death, which are usually performed.
may lead to In 2 to 3 days, when the
tissue necrosis swelling has resolved
and permanent and tissue perfusion
dysfunction has been restored, the
(Porth, 2015). wound is débrided and
Compartment closed (possibly with
syndrome occurs skin grafts).
more frequently
in young adults, Nursing Management
and although it · The nurse should
may take up to 48 frequently assess pain
hours for and neurovascular
symptoms to status of the affected
present, it limb and report any
typically negative changes that
develops quickly, may suggest
within 6 to 8 compartment
hours after the syndrome immediately
initial injury or to the primary
after fracture provider. The limb
repair (NAON, should be maintained
2013). in a functional position
at the level of the heart
to promote optimal
blood flow.

Pharmacologic Management
· Pain management is
essential and is
accomplished with
opioid analgesia, as
prescribed. Careful
assessment of intake
and output and
urinalysis could alert
the nurse to the
development of
rhabdomyolysis.

○ Other Complications:
■ Venous Thromboembolism - Venous thromboembolism - is a condition in which
a blood clot forms most often in the deep veins of the leg, groin or arm (known as
deep vein thrombosis) and travels in the circulation, lodging in the lungs (known
as pulmonary embolism)
■ Delayed Union, Nonunion, and Malunion
■ Avascular Necrosis of Bone (AVN; Osteonecrosis)
■ Complex Regional Pain Syndrome
■ Heterotopic Ossification

● Assessment and Diagnostic Findings

○ Checking the neurovascular status of the extremity - especially
circulatory perfusion of the lower leg and foot (popliteal, posterior tibial,
and pedal pulses and toe capillary refill time), and comparing with the
unaffected leg.
○ Doppler ultrasound - may be indicated to assess blood flow
○ X-ray - determines location and extent of fractures/trauma, may reveal
pre-existing and yet undiagnosed fracture(s).
○ CT Scan / MRI - Visualizes fractures, bleeding, and soft-tissue damage;
differentiates between stress/trauma fractures and bone neoplasms.

● Pharmacologic Management
○ IV opioid analgesic agents (Morphine) – typically given to treat pain.
○ Bone penetrating antibiotics, such as cephalosporin, are used
prophylactically before surgery
 ○ Central and peripheral muscle relaxants, such as diazepam (Valium),
eperisone, hydrochloride (Myonal), or methocarbamol (Robaxim), may be
prescribed for relief of pain associated with muscle spasms.
○ Pain relievers or analgesics may be used to reduce pain and inflammation
such as acetaminophen or ibuprofen.

● MEDICAL MANAGEMENT
○ Fracture Reduction - refers to restoration of the fracture fragments to
anatomic alignment and positioning. Either closed reduction or open
reduction may be used to reduce a fracture.
■ Closed Reduction - Closed reduction is a nonsurgical, manual
realignment of bone fragments to their previous anatomic position.
■ Open Reduction - Open reduction is the correction of bone
alignment through a surgical incision. It usually includes inter- nal
fixation of the fracture with wires, screws, pins, plates, intra-
medullary rods, or nails.
■ Traction - Traction is the application of a pulling force to an injured
or diseased part of the body or an extremity. Traction is also
indicated to (1) provide immobilization to prevent soft tissue
damage, (2) promote active and passive exer- cise, (3) expand a
joint space during arthroscopic procedures, and (4) expand a joint
space before major joint reconstruction.
○ Fracture Immobilization
■ after the fracture has been reduced, the bone fragments must be
immobilized and maintained in proper position and alignment
until union occurs.
○ Maintaining and Restoring Function
■ reduction and immobilization are maintained as prescribed to
promote bone and soft tissue healing.

● Surgical Management
○ Open reduction, and internal fixation (ORIF) - this involves a surgery to
repair the fracture-frequently, metal rods, screws or plates are used to
repair the bone, and remain in place, under the skin, after the surgery. This
procedure is recommended for complicated fractures not able to be
realigned (reduced) by casting, or in cases in which the long-term use of a
cast is undesirable. Internal fixation devices (pins, plates, intramedullary
rods, and metal and bioabsorbable screws) are surgically inserted to
realign and maintain bony fragments. These metal devices are biologically
inert and made from stainless steel, vitallium, or titanium. Proper
alignment is evaluated by x-ray studies at regular intervals.
 ○ Internal fixation refers to the method of physically reconnecting your
bones. This might involve special screws, plates, rods, wires, or nails that
your surgeon places inside your bones to fix them in the correct place.
This prevents your bones from healing abnormally. For a fracture in the
long, middle part of your femur, your surgeon may insert a long metal rod
through the middle of your bone. The entire operation usually takes place
while you are asleep under general anesthesia.

○ Open reduction, and external fixation (OREF) - this involves a surgery to

repair the fracture, and placement of an external fixation device on the
limb with the fracture. This device is an external frame which supports the
bone and holds it in the correct position while it is healing. This technique
is generally applied to complex fractures that cannot be repaired using
open reduction, and internal fixation. An external fixator is a metallic
device composed of metal pins that are inserted into the bone and
attached to external rods to stabilize the fracture while it heals. It can be
used to apply traction or to compress fracture fragments and to
immobilize reduced fragments when the use of a cast or other traction is
not appropriate. The external device holds fracture fragments in place
similar to a surgically implanted internal device. The external fixator is
attached directly to the bones by percutaneous transfixing pins or wires
External fixation is indicated in simple fractures, complex fractures with
extensive soft tissue damage, correction of bony defects (congenital),
non-union or malunion, and limb lengthening.

● If the pt fractures his/her femur, they usually need ORIF to bring their bones
back into place and help them heal. During an open reduction, orthopedic
surgeons reposition the bone pieces during surgery, so that they are back in their
proper alignment. This contrasts with a closed reduction, in which a healthcare
provider physically moves your bones back into place without surgically
exposing your bone.

● Rehabilitation
○ Physical Therapy – The physical therapist will design a specific treatment
program to restore function and help you return to activities of daily
living. Once the bone is set back into its proper place and is stable, your
doctor will most likely recommend physical therapy to strengthen the
muscles around the bone. Exercises to strengthen the thigh will also help
with the return to flexibility and normal function of the leg.
○ Physiotherapy - The treatment of disease, injury, or deformity by physical
methods such as massage, heat treatment, and exercise rather than by
 drugs or surgery; physical therapy. Examples: a.) Ambulation (Sitting,
Standing & Walking) b.) The use of assistive devices for ambulation
○ Occupational Therapy – The patient might work with an occupational
therapist to learn techniques for independence in daily life, such as using
the toilet, bathing, dressing and cooking. The occupational therapist will
determine if a walker or wheelchair might help the patient regain mobility
and independence.

PREOP NURSING DX

- Acute pain r/t movement of bone fragments, and muscle spasms

- Impaired physical mobility r/t pain
- Fear/anxiety r/t sudden change of health staus

NURSING INTERVENTIONS

● Assess and record the patient’s level of pain utilizing pain intensity rating scale
● Maintain immobilization of affected parts by means of bed rest, cast, splint,
traction.
● Medicate before care activities. Let the patient know it is important to request
medication before pain becomes severe.
● Encourage participation in diversional or recreational activities. Maintain a
stimulating environment.
● Assist with self-care activities and provide & assist with the use of mobility aids
such as wheelchair, walker, crutches, and canes.
● Encourage use of isometric exercises starting with the unaffected limb.
● Establish a therapeutic relationship with the patient.
● Provide preoperative education and provide accurate factual information.

POSTOP NURSING DX

● Acute pain r/t surgical incision

● Impaired physical mobility r/t loss of integrity of bone structures and prescribed
movement restrictions
● Risk for infection r/t post-surgical incision s/t open reduction and internal
fixation

NURSING INTERVENTIONS

● Monitor vital signs.

● Perform deep breathing exercises and relaxation techniques with the patient.
● Maintain immobilization of the affected leg.
● Elevate the affected leg with pillow.
 ● Assess signs and symptoms of infection such as skin redness, swelling, and
discharges.
● Closely monitor the WBC levels
● Teach the patient and SO the importance of keeping the wound/incision site
clean dry and intact.
● Monitor movement of the unaffected lower extremities.
● Teach patient or assist with active and passive ROM exercises of affected and
unaffected extremities
● Encourage participation in diversional or recreational activities.

NURSING RESPONSIBILITIES

● Teach people in the community to take appropriate safety precautions to prevent

injuries while at home, at work, when driving, or when participating in sports.
● Be an advocate for personal actions known to reduce injuries, such as regularly
using seat belts; driving within posted speed limits; avoiding distracted driving;
warming up muscles before exer- cise; using protective athletic equipment
(helmets and knee, wrist, and elbow pads); using safety equipment at work; and
not combining driving and drinking or the use of illicit drugs.
● Encourage individuals (especially older adults) to participate in moderate
exercise to help maintain muscle strength and balance.
● To reduce falls, they should wear adequate footwear and assess their living
environment for safety (e.g., remove scatter rugs, maintain good lighting, clear
paths to the bath- room for nighttime use). Also stress the importance of
adequate calcium and vitamin D intake.
● Patients often have reduced mobility as a result of the fracture. Plan care to
prevent the many complications associated with immobility.
● Prevent constipation by increased patient activity and maintenance of a high
fluid intake (more than 2500 mL/day unless contraindicated by the patient’s
health status) and a diet high in bulk and roughage (fresh fruits and vegetables).
● If these measures are not effective in maintaining the patient’s normal bowel
pattern, warm fluids, stool softeners, laxatives, or suppositories may be
necessary. Maintain a regular time for elimination to promote bowel regularity.

PREOPERATIVE
● If surgical intervention is required to treat a fracture, patients need preoperative
preparation.
● In addition to the usual preoperative nursing measures, inform patients of the
type of immobilization and assistive devices that will be used and the expected
activity limitations after surgery.
● Assure patients that their needs will be met by the nursing staff until they can
resume self-care. Knowing that pain medication will be available if needed is
often beneficial.
POSTOPERATIVE
● In general, postoperative nursing care and management are directed toward
monitoring vital signs and applying the general principles of postoperative
nursing care.
● Frequent neurovascular assessments of the affected extremity are necessary to
detect early and subtle neurovascular changes.
● Closely monitor any limitations of movement or activity related to turning,
positioning, and extremity support.
● Pain and discomfort can be minimized through proper alignment and
positioning.
● Carefully observe dressings or casts for any signs of bleeding or drainage.
● Report a significant increase in size of the drainage area. If a wound drainage
system is in place, regularly measure the volume of drainage and assess the
patency of the system, using aseptic technique to avoid contamination.
Bantilan
CARE OF PATIENTS WITH BURNS
Burns are tissue damage that results from heat,
overexposure to the sun or other radiation, or chemical
or electrical contact. Burns can be minor medical
problems or life-threatening emergencies.
Pathophysiology
At the time of major burn injury, there is increased
capillary permeability. All fluid components of the blood
begin to leak into the interstitium, causing edema and a
decreased blood volume. Hematocrit increases, and the
blood becomes more viscous. The combination of
decreased blood volume and increased viscosity
produces increased peripheral resistance. Burn shock, a
type of hypovolemic shock, rapidly ensues and, if not
corrected, can result in death.
Risk Factors
A. Predisposing factors
● Female - Females have slightly higher rates of
death from burns compared to males according
to the most recent data
● Age - Along with adult women, children are
particularly vulnerable to burns.
B. Precipitating factors
● occupations that increase exposure to fire
● alcohol abuse and smoking
● easy access to chemicals used for assault
● inadequate safety measures for liquefied
petroleum gas and electricity.
Types of Burn Injury
1. Thermal Burns - caused by flame, flash, scald, or
contact with hot objects, are the most common
type of burn injury.
2. Chemical Burns - are the result of contact with
acids, alkalis, and organic compounds
3. Smoke and Inhalation Injury - this is from
breathing hot air or noxious chemicals and can
cause damage to the respiratory tract.
4. Electrical Burns - result from intense heat
generated from an electric current. Direct
damage to nerves and vessels, causing tissue
anoxia and death, can also occur.
5. Cold Thermal Injury or Frostbite - it is an injury
caused by freezing of the skin and underlying
tissues. First your skin becomes very cold and
red, then numb, hard and pale.
Classification of Burn Injury
1. Depth of Burn
● First degree burn (superficial) – this affects the
outer layer of the skin, which is the epidermis.
The skin is red, dry, painful, and no blisters.
Treatment includes oral pain medications, cool
compress, and skin lubricant.
● Second degree burn (partial thickness) – this
affects the epidermis and a portion of the
dermis. The skin is blistered, red, painful, and has
a weeping surface.
● Third degree burn (full thickness) this involves
total destruction of the epidermis, dermis, and
some subcutaneous tissue. Wound color ranges
widely from pale white to red, brown, or charred,
and appears leathery and dry.
● Fourth degree burn (deep full thickness) - this
injury extends into deep tissue, muscle, or bone.
There is no feeling in the area since the nerve
endings are destroyed.
2. Extent of Burn
Two commonly used guides for determining the TBSA
affected or the extent of a burn wound are the Lund-
Browder chart and the Rule of Nines.
● Lund-Browder chart - considered more accurate
because it considers the patient’s age in
proportion to relative body-area size. By dividing
the body into very small areas and providing an
estimate of the proportion of TBSA accounted
for by each body part, clinicians can obtain a
reliable estimate of TBSA burned.
● Rule of Nines - often used for initial assessment
of a burn patient because it is easy to remember.
This system is based on anatomic regions, each
representing approximately 9% of the TBSA,
allowing clinicians to quickly obtain an estimate
of burn size.
● Example:
Bantilan
A 23 year old female patient has deep partial thickness
burns on the back of left leg, front and back of both
arms, anterior and posterior sides of the right leg, and
anterior trunk. What is the total body surface area
percentage that is burned?
Back of left leg: 9%
Front and back of both arms: 18%
Anterior and posterior of right leg: 18%
Anterior trunk: 18%
Total: 63%
3. Location of Burn
● Burns to the face and neck and circumferential
burns to the chest or back may interfere with
breathing as a result of mechanical obstruction
from edema or leathery, devitalized burn tissue
(eschar). These burns may also indicate possible
inhalation injury.
● Burns to the hands, feet, joints, and eyes are of
concern because they make self-care difficult
and may jeopardize future function.
● Burns to the ears and the nose are susceptible
to infection because of poor blood supply to the
cartilage.
● Burns to the buttocks or perineum are highly
susceptible to infection from urine or feces
contamination.
● Circumferential burns to the extremities can
cause circulation problems distal to the burn,
with possible nerve damage to the affected
extremity.
4. Patient Risk Factors
● Any patient with preexisting cardiovascular,
respiratory, or renal disease has a poorer
prognosis for recovery because of the
tremendous demands placed on the body by a
burn injury.
● Example, the patient with diabetes mellitus or
peripheral vascular disease is at high risk for
poor healing, especially with foot and leg burns.
● In addition, the burn patient who has also
sustained fractures, head injuries, or other
trauma has a more difficult time recovering.
Laboratory and Diagnostic Tests
1. Complete Blood Count (CBC)
After a burn injury, red blood cells, hematocrit, and
hemoglobin can be impacted in a number of ways.
Hematocrit levels are often increased in the early period
after a burn. This suggests the need for more fluid in the
bloodstream, and is usually corrected with adequate
fluid resuscitation.
2. Comprehensive Metabolic Panel (CMP)
Sodium levels change after burn injury with the shift of
fluid from the intravascular space into the interstitial
space. This can be corrected in part with electrolytes
found in intravenous fluid; Lactated Ringer’s (LR) solution
contains a certain amount of sodium chloride that may
be used as part of treatment and replacement of sodium
loss.
In contrast to sodium, high levels of potassium can
develop in the bloodstream as a result of muscle and
tissue breakdown with burn injuries.
3. Blood Urea Nitrogen (BUN) & Creatinine
Both levels are typically elevated after a burn injury. If
the patient does not receive enough fluids with
resuscitation, there may be low urine output, in which
case the levels of BUN and creatinine will be elevated
because they are not being excreted in the urine.
4. Arterial blood gas (ABG)
A burn patient may be more likely to develop metabolic
acidosis, particularly when fluid resuscitation is
inadequate. In other cases of metabolic acidosis,
administration of sodium bicarbonate is part of standard
treatment to regulate the blood pH and bring it back
into normal parameters.
5. Blood Type And Cross matching
It is most likely necessary in order to provide
appropriate blood products for the patient when
needed.
6. CT Scan
Bantilan
Should be obtained as indicated in the patient with
accompanying traumatic injuries or decreased mental
status.
7. Chest x-ray
Warranted in all burned patients when an inhalation
injury is possible.
Complications of Burn Injury
1. Acute Respiratory Failure & Acute Respiratory
Distress Syndrome
● The patient’s respiratory status is monitored
closely for increased difficulty in breathing,
change in respiratory pattern, or onset of
adventitious (abnormal) breath sounds.
● signs of hypoxia, diminished breath sounds,
wheezing, tachypnea, stridor, and sputum tinged
with soot are among the many possible findings
● Medical management of the patient with acute
respiratory failure requires intubation and
mechanical ventilation
2. Heart Failure & Pulmonary Edema
● If the cardiac and renal systems cannot
compensate for the excess vascular volume as
fluid shifts back to the intravascular space, heart
failure and pulmonary edema may result
● The patient is assessed for signs of heart failure,
including decreased cardiac output, oliguria,
jugular vein distention, persistent edema, and
the onset of an S3 or S4 heart sound.
3. Curling’s Ulcer
● Oftentimes a complication stemming from
severe burns to the body, or other cases of
massive trauma to the body, such as injuries
sustained during a car accident.
● May develop within 24 hours after a severe burn
injury because of reduced GI blood flow and
mucosal damage.
4. Renal failure
 Acute renal failure occurring immediately after
burns is mostly due to reduced cardiac output,
which is mainly caused by fluid loss. This is
usually caused by delayed or inadequate fluid
resuscitation.
5. Infection
 Wounds can become infected if bacteria get into
them. If your burn or scald has a blister that's
burst, it may become infected if it's not kept
clean.
6. Shock
 After a serious injury, it's possible to go into
shock. Shock is a life-threatening condition that
occurs when there's an insufficient supply of
oxygen to the body.
Signs and symptoms of shock include:
● a pale face
● cold or clammy skin
● a rapid pulse
● fast, shallow breathing
● unconsciousness
7. Contractures
 Contractures occur when the burn scar matures,
thickens, and tightens. This can prevent
movement. It usually occurs when a burn occurs
over a joint
● Burn contractures can be treated with serial
splinting, incision and skin grafting or excision
and resurfacing with skin grafts or flaps.
Management of Burn Injury
a. Emergent Phase
This is the time required to resolve the immediate, life-
threatening problems resulting from burn injury. The first
step in management is to remove the patient from the
source of injury and stop the burning process while
preventing injury to the rescuer.
Nursing and Collaborative Management:
1. Airway management - frequently involves early
endotracheal intubation. Early intubation
eliminates the need for emergency
tracheostomy after respiratory problems have
become apparent. In general, the patient with
burns to the face and neck requires intubation
within 1 to 2 hours after injury.
2. Fluid therapy - establishing IV access is critical
for fluid resuscitation and drug administration.
Fluid replacement is achieved with crystalloid
Bantilan
solutions (usually lactated Ringer’s), colloids
(albumin), or a combination of the two.
The Parkland (Baxter) formula for fluid replacement is
the most common formula used. It is used to calculate
fluid resuscitation for critical burn patients.
Formula:
4 mL lactated Ringer’s solution per kilogram (kg) of body
weight per percent of total body surface area (% TBSA)
burned = Total fluid requirements for first 24 hr after
burn
Application:
½ of total in first 8 hr
¼ of total in second 8 hr
¼ of total in third 8 hr
Example:
For a 70 kg patient with a 50% TBSA burn:
4 mL × 70 kg × 50 TBSA burned = 14,000 mL in 24 hr
½ of total in first 8 hr = 7000 mL (875 mL/hr)
¼ of total in second 8 hr = 3500 mL (437 mL/hr)
¼ of total in third 8 hr = 3500 mL (437 mL/hr)
3. Wound care - Two approaches to burn wound
treatment are (1) the open method and (2) the use of
multiple dressing changes (closed method).
- In the open method the patient’s burn is
covered with a topical antimicrobial and has no
dressing over the wound. In the multiple
dressing change, or closed method, sterile gauze
dressings are impregnated with or laid over a
topical antimicrobial. These dressings are
changed anywhere from every 12 to 24 hours to
once every 14 days.
4. Wound Debridement - it is a procedure for treating a
wound in the skin. In a debridement, the surgeon
removes damaged tissue from the body to promote
healing.
5. Drug therapy
● Analgesics and sedatives - Initially, opioids are
the drug of choice for pain control.
Sedatives/hypnotics and antidepressants can
also be given with analgesics to control the
anxiety, insomnia, or depression that patients
may experience.
- Fentanyl (Sublimaze)
- Methadone (Dolophine)
- Lorazepam (Ativan)
- Midazolam (Versed)
● Tetanus immunization - Tetanus toxoid is given
routinely to all burn patients because of the
likelihood of anaerobic burn wound
contamination.
● Antimicrobial agents - After the wound is
cleansed, topical antimicrobial agents may be
applied and covered with a light dressing.
6. Nutritional therapy - Early enteral feeding,
usually with smaller-bore tubes, preserves GI
function, increases intestinal blood flow, and
promotes optimal conditions for wound healing.
In general, begin the feedings slowly at a rate of
20 to 40 mL/hr and increase to the goal rate
within 24 to 48 hours.
b. Acute Phase
It concludes when partial-thickness wounds are healed
or full-thickness burns are covered by skin grafts. This
may take weeks or months.
Nursing and Collaborative Management:
1. Wound care - Cleanse wounds with soap and
water or normal saline-moistened gauze to
gently remove the old antimicrobial agent and
any loose necrotic tissue, scabs, or dried blood.
During the debridement phase, cover the wound
with topical antimicrobial creams.
2. Excision and Grafting - Many patients, especially
those with major burns, are taken to the OR for
wound excision on day 1 or 2. The wounds are
covered with a biologic dressing or allograft for
temporary coverage until permanent grafting
can occur. Grafting permits earlier functional
ability and reduces scar contractures.
Bantilan
Autograft - Autografts are the ideal
means of covering burn wounds
because the grafts are the patient’s own
skin and therefore are not rejected by
the patient’s immune system.
→ Cultured epithelial autograft (CEA) has emerged as an
important procedure in the management of massive
burns. In burns that cover more than 90% TBSA, CEA
may be the only option because the availability of non-
burned skin as donor sites will not be sufficient for
grafting.
 Care of the graft site
Occlusive dressings are commonly used initially after
grafting to immobilize the graft and support a humid
environment. The first dressing change is usually
performed 2 to 5 days after surgery, or earlier in the case
of clinical signs of infection or bleeding. If an extremity
has been grafted, it is elevated to minimize edema
 Care of the donor site
The donor site is a clean wound created in a surgical
environment. After the donor skin is excised, a
hemostatic agent such as thrombin or epinephrine may
be applied directly to the site to promote hemostasis. A
myriad of dressings are available to cover donor sites.
Homografts and Xenografts - also
referred to as biologic dressings and are
intended as temporary wound coverage.
Homografts are skin obtained from
recently deceased or living humans
other than the patient. Xenografts
consist of skin taken from animals
(usually pigs).
3. Pain management - (1) continuous, background
pain that might be present throughout the day
and night; and (2) treatment-induced pain
associated with dressing changes, ambulation,
and rehabilitation activities.
- With background pain, a continuous IV infusion
of an opioid (e.g., hydromorphone [Dilaudid])
allows for a steady, therapeutic level of
medication.
- For treatment-induced pain, premedicate with
an analgesic and an anxiolytic via the IV or oral
route. For patients with an IV infusion, a potent,
short-acting analgesic, such as fentanyl
(Sublimaze), is often effective.
4. Physical and occupational therapy - Passive and
active ROM should be performed on all joints.
Ensure that the patient with neck burns
continues to sleep without pillows or with the
head hanging slightly over the top of the
mattress to encourage hyperextension.
5. Nutritional therapy - The goal of nutritional
therapy during the acute burn phase is to
provide adequate calories and protein to
promote healing. The patient may benefit from
an antioxidant protocol, which includes
selenium, acetylcysteine, ascorbic acid, vitamin E,
zinc, and a multivitamin. Meeting daily caloric
requirements is crucial and should begin within
the first 1 to 2 days postburn.
c. Rehabilitation Phase
This may happen as early as 2 weeks or as long as 7 to 8
months after the burn injury.
Nursing and Collaborative Management:
1. Psychological support - During the rehabilitation
phase, encourage both the patient and the
caregiver to participate in care. Since the patient
may go home with small, unhealed wounds,
teach your patient and caregiver the skills for
dressing changes and wound care. If needed,
arrange home care nursing services to assist with
care after discharge. Water-based creams that
penetrate into the dermis should be used
routinely on healed areas to keep the skin
supple and well moisturized.
2. Promoting activity tolerance - The nurse
incorporates physical and occupational therapy
exercises in the patient’s care to prevent muscle
atrophy and to maintain the mobility required
for daily activities. The patient’s activity
tolerance, strength, and endurance gradually
increase if activity occurs over increasingly
longer periods.
3. Prevention and treatment of scars -
Compression is introduced early in burn wound
treatment. Elastic bandage wraps are used
initially to help promote adequate circulation,
Bantilan
but they can also be used as the first form of
compression for scar management. Gentle
superficial scar massage can be performed with
a moisturizer several times a day. Burn
reconstruction is a treatment option after scars
have matured and is discussed within the first
few years after injury.
Case Scenario:
Meredith Grey was cooking a meal for her husband,
Derek. She was frying bacon to add to a pasta dish when
the grease from the bacon caught fire. Meredith
panicked, grabbed the boiling pasta water on the stove,
and dumped it on the grease fire. The fire exploded into
a raging fire ball, scalding her face and hair, and catching
her shirt on fire. Luckily, her husband, Derek, walked in
right after the explosion. Grabbing Meredith, he rolled
her on the floor, quickly extinguishing the flames, and
then he called 911.
Meredith was still conscious and in a great deal of
pain. Keeping Derek on the phone, the dispatcher asked
him to gently turn Meredith on to her back and tilt her
head to one side. He then told Derek to elevate her legs
to treat for shock.
Emergency responders placed Meredith on 100%
oxygen and put her in a neck brace as a precautionary
measure. During transport, paramedics started an IV and
began administering Lactated Ringer's solution to
replace lost fluid volume. They also cut away her burnt
clothing and placed a light blanket over her to preserve
her body temperature.
Assessment:
Upon arrival, the physician, and nursing personnel
quickly assessed the extent of the burn and determined
if any other injuries were present. The patient presented
with tachypnea and tachycardia but remained conscious.
Vital signs were taken and recorded:
T = 38.5
BP = 95/60
PR = 130 bpm
RR = 24 cpm
Meredith had burns on the anterior head and neck,
anterior trunk, and both anterior thighs. Using the rule of
nines, this was approximately 40.5% of her body.
The depth of the burns were also assessed. Full-thickness
or third-degree burns were present on the right
shoulder, upper anterior right arm, and part of the
anterior trunk. Second-degree burns with blistering were
present on the remaining burn areas. She was intubated
and placed on mechanical ventilation to maintain an
open airway.
Lab tests were ordered including a CBC, chemistry panel,
urinalysis, and carboxyhemoglobin.
● Lab results:
WBC - 15, 000
RBC - 4.2 x 106/uL
Hgb - 12 g/dl
Hct - 48%
● Chemistry Panel:
Sodium -137 mEq/L
K - 3.6 mEq/L
Cl - 105 mEq/L
● Carboxyhemoglobin result: < 10%
● Results from the x-ray were negative for
respiratory damage.
Nursing Management:
Pre-operative phase:
1. Impaired gas exchange related to carbon
monoxide poisoning, smoke inhalation, and
upper airway obstruction
Interventions:
● Provide 100% humidified oxygen.
● Assess breath sounds and respiratory rate,
rhythm, depth, and symmetry of chest excursion.
Monitor patient for signs of hypoxia
● Monitor arterial blood gas values, pulse oximetry
readings, and carboxyhemoglobin levels.
● Prepare to assist with intubation and
escharotomies of chest.
2. Deficient fluid volume related to increased capillary
permeability and evaporative losses from the burn
wound
Interventions:
● Monitor vital signs, hemodynamics, and urine
output, as well as strict intake and output and
daily weight.
Bantilan
● Maintain IV lines and regulate fluids at
appropriate rates, as prescribed.
● Observe for symptoms of deficiency or excess of
serum sodium, potassium, calcium, phosphorus,
and bicarbonate.
● Elevate head of patient’s bed and burned
extremities.
● Notify physician immediately of decreased urine
output and hemodynamic changes
3. Impaired skin integrity related to disruption of skin
surface with destruction of skin layers requiring skin
grafting
Interventions:
● Assess and document size, color, depth of
wound, noting necrotic tissue and condition of
surrounding skin.
● Provide appropriate burn care and infection
control measures.
● Elevate grafted area if possible. Maintain desired
position and immobility of area when indicated.
● Keep skin free from pressure.
● Wash sites with mild soap, rinse, and lubricate
with cream several times daily after dressings are
removed and healing is accomplished.
● Prepare for/assist with surgical grafting or
biological dressings.
Post-operative phase:
1. Activity intolerance related to pain with exercise,
limited joint mobility, muscle wasting, and
limited endurance
Interventions:
● Schedule care to allow periods of uninterrupted
sleep.
● Maintain proper body alignment with supports
or splints
● Incorporate physical therapy exercises to prevent
muscular atrophy and maintain mobility required
for daily activities.
● Support positive outlook, and increase tolerance
for activity by scheduling diversion activities in
periods of increasing duration.
● Perform ROM exercises consistently, initially
passive, then active.
● Communicate plan of care to family and other
caregivers.
2. Disturbed body image related to altered physical
appearance and self-concept.
Interventions:
● Take time to listen to patient’s concerns and
provide realistic support; refer patient to a
support group to develop coping strategies to
deal with losses.
● Assess patient’s psychosocial reactions; provide
support and develop a plan to help the patient
handle feelings.
● Promote a healthy body image and self-concept
by helping patient practice responses to people
who stare or ask about the injury.
● Maintain nonjudgmental attitude while giving
care, and help client identify positive behaviors
that will aid in recovery.
3. Deficient knowledge about post-discharge home care
and recovery needs.
Interventions:
● Discuss patient’s expectations of returning
home, to work, and to normal activities.
● Review and have patient/SO demonstrate proper
burn, skin-graft, and wound care techniques.
Identify appropriate sources for outpatient care
and supplies.
● Discuss skin care. Teach proper use of
moisturizers, sunscreens, and anti-itching
medications.
● Review medications, including purpose, dosage,
route, and expected and/or reportable side
effects.
● Encourage continuation of prescribed exercise
programs and scheduled rest periods.
Other nursing dx:
● Anxiety related to fear and the emotional impact
of burn injury
● Hypothermia related to loss of skin
microcirculation and open wounds
● Acute pain related to tissue and nerve injury
● Impaired physical mobility due to contractures
or hypertrophic scarring
Burn Prevention
● Minimize sun exposure:
● Advise that matches and lighters be kept out of
the reach of children.
● Emphasize the importance of never leaving
children unattended around fire or in
bathroom/bathtub.
Bantilan
● Educate about the installation and maintenance
of smoke and carbon monoxide detectors on
every level of the home and changing batteries
● Recommend the development and practice of a
home exit fire drill with all members of the
household.
● Advocate setting the water heater temperature
no higher than 48.9°C (120°F).
● Educate about the perils of smoking in bed,
smoking while using home oxygen, or falling
asleep while smoking.
● Caution against using flammable liquids to start
fires and/or throwing flammable liquids onto an
already burning fire.
● Advise that hot irons and curling irons be kept
out of the reach of children.
● Discourage running electric cords under carpets
or rugs.
REYNALD D. ONG
BSN-IV

Overview of nephrolithiasis
• Also called Kidney stones are hard deposits made of minerals and salts that form inside
your urinary tract (Kidneys).
• Kidney stones can affect any part of your urinary tract — from your kidneys to your
bladder. Often, stones form when the urine becomes concentrated, allowing minerals to
crystallize and stick together.
• Passing kidney stones can be quite painful, but the stones usually cause no permanent
damage if they're recognized in a timely fashion.
• You may need nothing more than to take pain medication and drink lots of water to pass
a kidney stone. In other instances — for example, if stones become lodged in the urinary
tract, are associated with a urinary infection or cause complications — surgery may be
needed.
• Prevention is better than cure

Mr. Reynald, A 21-year-old patient with a 2-week with a chief complaint of pain in the left
flank presented to the ED via emergency medical services. The patient has a family history of
nephrolithiasis on his father side. He loves eating salty foods like bulad or dried fish, fast
food restaurants, and many more. He stated that while waiting for the presumed stone to pass,
the pain in her left flank worsened and she felt lightheaded and weak. Dra. Sendiong ordered
for a CT scan. Once results received by the doctor, she ordered for a surgery tomorrow.

HR: 76 bpm
BP:120/80 mmHg
RR:19
Temp: 36C
Physical Examination: pain in the left lower quadrant

Predisposing
• Family History or personal history
o If someone in your family has had kidney stones, you're more likely to develop
stones, too.
o If you've already had one or more kidney stones, you're at increased risk of
developing another.
• Gender
o Affects men twice as women
• Age
o Urinary stones predominantly occur in the third to fifth decades of life

Precipitating
• Dehydration
 o Not drinking enough water each day can increase your risk of kidney stones.
People who live in warm, dry climates and those who sweat a lot may be at higher
risk than others.
• Certain diets
o Eating a diet that's high in protein, sodium (salt) and sugar may increase your risk
of some types of kidney stones. This is especially true with a high-sodium diet.
Too much salt in your diet increases the amount of calcium your kidneys must
filter and significantly increases your risk of kidney stones.
• Obesity
o High body mass index (BMI), large waist size and weight gain have been linked
to an increased risk of kidney stones.
• Digestive diseases and surgery
o Gastric bypass surgery, inflammatory bowel disease or chronic diarrhea can cause
changes in the digestive process that affect your absorption of calcium and water,
increasing the amounts of stone-forming substances in your urine.
• Other medical conditions
o such as renal tubular acidosis, cystinuria, hyperparathyroidism and repeated
urinary tract infections also can increase your risk of kidney stones.
• Certain supplements and medications
o such as vitamin C, dietary supplements, laxatives (when used excessively),
calcium-based antacids, and certain medications used to treat migraines or
depression, can increase your risk of kidney stones.
Pathophysiology

Types of kidney stones

• Calcium stones
o Most kidney stones are calcium stones, usually in the form of calcium oxalate.
Oxalate is a substance made daily by your liver or absorbed from your diet.
Certain fruits and vegetables, as well as nuts and chocolate, have high oxalate
content
• Struvite stones
o Struvite stones form in response to a urinary tract infection. These stones can
grow quickly and become quite large, sometimes with few symptoms or little
warning.
• Uric acid stones
o Uric acid stones can form in people who lose too much fluid because of chronic
diarrhea or malabsorption, those who eat a high-protein diet, and those with
diabetes or metabolic syndrome.
• Cystine stones
o These stones form in people with a hereditary disorder called cystinuria that
causes the kidneys to excrete too much of a specific amino acid.

Symptoms/clinical manifestation
Block the flow of urine

• Severe, sharp pain in the side and back, below the ribs
 • Pain that radiates to the lower abdomen and groin
• Pain that comes in waves and fluctuates in intensity
• Pain or burning sensation while urinating
Ureteral Colic

• Pink, red or brown urine

• Cloudy or foul-smelling urine
• A persistent need to urinate, urinating more often than usual or urinating in small
amounts
• Nausea and vomiting
• Fever and chills if an infection is present

Diagnostic exams
• Blood testing
o Blood tests may reveal too much calcium or uric acid in your blood. Blood test
results help monitor the health of your kidneys and may lead your doctor to check
for other medical conditions
• Urine Testing
o The 24-hour urine collection test may show that you're excreting too many stone-
forming minerals or too few stone-preventing substances. For this test, your
doctor may request that you perform two urine collections over two consecutive
days.
• Imaging
o Imaging tests may show kidney stones in your urinary tract. High-speed or dual
energy computerized tomography (CT) may reveal even tiny stones. Simple
abdominal X-rays are used less frequently because this kind of imaging test can
miss small kidney stones.
• Analysis of passed stones
o You may be asked to urinate through a strainer to catch stones that you pass. Lab
analysis will reveal the makeup of your kidney stones. Your doctor uses this
information to determine what's causing your kidney stones and to form a plan to
prevent more kidney stones.
• History Taking
o Dietary and medication histories and family history of kidney stones are obtained
to identify factors predisposing the patient to the formation of stones.

Medical management
The goals of management are to eradicate the stone, determine the stone type, prevent
nephron destruction, control infection, and relieve any obstruction that may be present.
 Small Stones
Most small kidney stones won't require invasive treatment. You may be able to pass a small
stone by:
• Drinking water
o Drinking as much as 2 to 3 quarts (1.8 to 3.6 liters) a day will keep your urine
dilute and may prevent stones from forming. Unless your doctor tells you
otherwise, drink enough fluid — ideally mostly water — to produce clear or
nearly clear urine.
• Pain relievers
o Passing a small stone can cause some discomfort. To relieve mild pain, your
doctor may recommend pain relievers such as ibuprofen (Advil, Motrin IB,
others) or naproxen sodium (Aleve).
• Medical Therapy
o our doctor may give you a medication to help pass your kidney stone. This type of
medication, known as an alpha blocker, relaxes the muscles in your ureter,
helping you pass the kidney stone more quickly and with less pain. Examples of
alpha blockers include tamsulosin (Flomax) and the drug combination dutasteride
and tamsulosin (Jalyn).
* Hot baths or moist heat to the flank area may also be helpful.

Medications can control the amount of minerals and salts in the urine and may be helpful in
people who form certain kinds of stones. The type of medication your doctor prescribes will
depend on the kind of kidney stones you have. Here are some examples:

• Calcium stones. To help prevent calcium stones from forming, your doctor may
prescribe a thiazide diuretic or a phosphate-containing preparation.
• Uric acid stones. Your doctor may prescribe allopurinol (Zyloprim, Aloprim) to
reduce uric acid levels in your blood and urine and a medicine to keep your urine
alkaline. In some cases, allopurinol and an alkalizing agent may dissolve the uric
acid stones.
• Struvite stones. To prevent struvite stones, your doctor may recommend strategies
to keep your urine free of bacteria that cause infection, including drinking fluids to
maintain good urine flow and frequent voiding. In rare cases long-term use of
antibiotics in small or intermittent doses may help achieve this goal. For instance,
your doctor may recommend an antibiotic before and for a while after surgery to
treat your kidney stones.
• Cystine stones. Along with suggesting a diet lower in salt and protein, your doctor
may recommend that you drink more fluids so that you produce a lot more urine,. If
that alone doesn't help, your doctor may also prescribe a medication that increases
the solubility of cystine in your urine.
 Large Stones
Kidney stones that are too large to pass on their own or cause bleeding, kidney damage or
ongoing urinary tract infections may require more-extensive treatment. Procedures may include:
• Using sound waves to beak up stones
o extracorporeal shock wave lithotripsy (ESWL) uses sound waves to create strong
vibrations (shock waves) that break the stones into tiny pieces that can be passed
in your urine. The procedure lasts about 45 to 60 minutes and can cause moderate
pain, so you may be under sedation or light anesthesia to make you comfortable.
• Surgery
o procedure called percutaneous nephrolithotomy (nef-row-lih-THOT-uh-me)
involves surgically removing a kidney stone using small telescopes and
instruments inserted through a small incision in your back.
o You will receive general anesthesia during the surgery and be in the hospital for
one to two days while you recover. Your doctor may recommend this surgery
if ESWL is unsuccessful.
• Scope to remove stones
o To remove a smaller stone in your ureter or kidney, your doctor may pass a thin
lighted tube (ureteroscope) equipped with a camera through your urethra and
bladder to your ureter.
o Once the stone is located, special tools can snare the stone or break it into pieces
that will pass in your urine. Your doctor may then place a small tube (stent) in the
ureter to relieve swelling and promote healing. You may need general or local
anesthesia during this procedure.
• Parathyroid gland surgery
o Some calcium phosphate stones are caused by overactive parathyroid glands,
which are located on the four corners of your thyroid gland, just below your
Adam's apple. When these glands produce too much parathyroid hormone
(hyperparathyroidism), your calcium levels can become too high and kidney
stones may form as a result.
Prevention
• Lifestyle changes
o Drink water throughout the day
For people with a history of kidney stones, doctors usually recommend
drinking enough fluids to pass about 2.1 quarts (2 liters) of urine a day.
Your doctor may ask that you measure your urine output to make sure that
you're drinking enough water.
 If you live in a hot, dry climate or you exercise frequently, you may need
to drink even more water to produce enough urine. If your urine is light
and clear, you're likely drinking enough water.
o Eat fewer oxalate-rich foods
If you tend to form calcium oxalate stones, your doctor may recommend
restricting foods rich in oxalates. These include rhubarb, beets, okra,
spinach, Swiss chard, sweet potatoes, nuts, tea, chocolate, black pepper
and soy products.
o Choose a diet low in salt and animal protein.
Reduce the amount of salt you eat and choose nonanimal protein sources,
such as legumes. Consider using a salt substitute, such as Mrs. Dash.
o Continue eating calcium-rich foods, but use caution with calcium
supplements.
Calcium in food doesn't have an effect on your risk of kidney stones.
Continue eating calcium-rich foods unless your doctor advises otherwise.

Ask your doctor before taking calcium supplements, as these have been
linked to increased risk of kidney stones. You may reduce the risk by
taking supplements with meals. Diets low in calcium can increase kidney
stone formation in some people.

Ask your doctor for a referral to a dietitian who can help you develop an
eating plan that reduces your risk of kidney stones.
• Avoid protein intake to decrease urinary excretion of calcium and uric acid.
• Limit sodium intake to 3–4 g/day. Table salt and high-sodium foods should be reduced,
because sodium competes with calcium for reabsorption in the kidneys.
• Be aware that low-calcium diets are not generally recommended, except for true
absorptive hypercalciuria. Evidence shows that limiting calcium, especially in women,
can lead to osteoporosis and does not prevent stones.
• Avoid intake of oxalate-containing foods (e.g., spinach, strawberries, rhubarb, tea,
peanuts, wheat bran).
• Drink fluids (ideally water and one glass of cranberry juice per day) every 1–2 hours
during the day.
• Drink two glasses of water at bedtime and an additional glass at each nighttime
awakening to prevent urine from becoming too concentrated during the night.
• Avoid activities leading to sudden increases in environmental temperatures that may
cause excessive sweating and dehydration. Contact the primary provider at the first sign
of a urinary tract infection.

Nursing dx
• Acute pain related to inflammation, obstruction, and abrasion of the urinary tract
• Deficient knowledge regarding prevention of recurrence of kidney stones
 • Impaired Urinary Elimination related to Mechanical obstruction, inflammation
• Risk for Deficient Fluid Volume Nausea/vomiting
•
Nursing intervention

Relieving Pain

• Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed.

• Encourage and assist patient to assume a position of comfort.
• Assist patient to ambulate to obtain some pain relief.
• Monitor pain closely and report promptly increases in severity.
Monitoring and Managing Complications

• Encourage increased fluid intake and ambulation.

• Begin IV fluids if patient cannot take adequate oral fluids.
• Monitor total urine output and patterns of voiding.
• Encourage ambulation as a means of moving the stone through the urinary tract.
• Strain urine through gauze.
• Crush any blood clots passed in urine, and inspect sides of urinal and bedpan for
clinging stones.
• Instruct patient to report decreased urine volume, bloody or cloudy urine, fever,
and pain.
• Instruct patient to report any increase in pain.
• Monitor vital signs for early indications of infection; infections should be treated
with the appropriate antibiotic agent before efforts are made to dissolve the stone.
Teaching Points

• Explain causes of kidney stones and ways to prevent recurrence.

• Encourage patient to follow a regimen to avoid further stone formation, including
maintaining a high fluid intake.
• Encourage patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24
hours.
• Recommend that patient have urine cultures every 1 to 2 months the first year
and periodically thereafter.
• Recommend that recurrent urinary infection be treated vigorously.
• Encourage increased mobility whenever possible; discourage excessive ingestion
of vitamins (especially vitamin D) and minerals.
• If patient had surgery, instruct about the signs and symptoms of complications
that need to be reported to the physician; emphasize the importance of followup to
assess kidney function and to ensure the eradication or removal of all kidney
stones to the patient and family.
• If patient had ESWL, encourage patient to increase fluid intake to assist in the
passage of stone fragments; inform the patient to expect hematuria and possibly a
bruise on the treated side of the back; instruct patient to check his or her
 temperature daily and notify the physician if the temperature is greater than 38C
(about 101F), or the pain is unrelieved by the prescribed medication.
• Provide instructions for any necessary home care and followup.
CONTINUING CARE

• Closely monitor the patient to ensure that treatment has been effective and that no
complications have developed.
• Assess the patient’s understanding of ESWL and possible complications; assess
the patient’s understanding of factors that increase the risk of recurrence of renal
calculi and strategies to reduce those risks.
• Assess the patient’s ability to monitor urinary pH and interpret the results during
followup visits.
• Ensure that the patient understands the signs and symptoms of stone formation,
obstruction, and infection and the importance of reporting these signs promptly.
• If medications are prescribed for the prevention of stone formation, explain their
actions, importance, and side effects to the patient.

Acute Pain related to inflammation, obstruction, and abrasion of the urinary tract
(Pre-op)
• Determine and note location, duration, intensity (0–10 scale), and radiation.
• Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed.
• Implement comfort measures (back rub, restful environment).
• Positioning of patient that he is comfortable
• Assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L a
day within cardiac tolerance
• Apply warm compresses to back.
Risk for Infection related to invasive procedure
• Adhere to facility infection control, sterilization, and aseptic policies and procedures.
• Verify sterility of all manufacturers’ items.
• Prepare operative site according to specific procedures.
• Identify breaks in aseptic technique and resolve immediately on occurrence.
• Maintain dependent gravity drainage of indwelling catheters, tubes, and/or positive
pressure of parenteral or irrigation lines
• Administer antibiotics as indicated.
Deficient knowledge related to lack of exposure regarding prevention of recurrence of kidney
stones
• Review dietary regimen, as individually appropriate
• Discuss medication regimen; avoidance of OTC drugs, and reading all product or food
ingredient labels.
• Promote regular activity and exercise program.
• Identify signs and symptoms requiring medical evaluation (recurrent pain, hematuria,
oliguria)
• Demonstrate proper care of incisions and catheters if present.
• Active-listen concerns about therapeutic regimen and lifestyle changes.
 • Emphasize importance of increased fluid intake of 3–4L a day or as much as 6–8 L a day.
Encourage patient to notice dry mouth and excessive diuresis and diaphoresis and to
increase fluid intake whether or not feeling thirsty.

https://nurseslabs.com/13-surgery-perioperative-client-nursing-care-plans/5/
https://www.hindawi.com/journals/au/2018/3068365/#introduction
https://www.mayoclinic.org/diseases-conditions/kidney-stones/symptoms-causes/syc-
20355755

Jambhulkar, P., & Faustina, B. (2020, June 21). 13 surgery (Perioperative Client) nursing care
plans. Nurseslabs. https://nurseslabs.com/13-surgery-perioperative-client-nursing-care-
plans/.

Verra, M. (2019, April 11). 4 urolithiasis (renal calculi) nursing care plans. Nurseslabs.
https://nurseslabs.com/4-urolithiasis-nursing-care-plans/3/.

Mayoclinic. (2020, May 5). Kidney stones. Mayo Clinic. https://www.mayoclinic.org/diseases-

conditions/kidney-stones/symptoms-causes/syc-20355755.

Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarth's
textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins.