MEDICAL SURGICAL NURSING - Albumin is the protein we see in blood.

It is responsible for maintaining the

oncotic pressure.
- To simplify oncotic pressure, it is the
ADRENAL GLAND albumin that holds the water in the
blood vessels. But because of increase
capillary permeability, the albumin
goes out and makes the interstitial
compartment hypertonic. That will now
tell you what’s the movement of water.
- Osmosis is flow of fluid from lesser
which is inside capillary now. Because
the albumin went out, it accumulates
outside the capillary (interstitial
compartment). Because the water outside
Questions: How come body produces histamine? capillary is Hypertonic (concentration
is high), it will pull water from
Answer: intravascular to interstitial. If fluid
goes out it will cause Swelling or
 There is injury, so the injured tissue Edema. So that will explain what tumor
produces chemical mediators. The most is.
abundant is Histamine. Then because of
- Pain: because of swelling it will push
injury, it will release histamine that
the nerve ending underneath the skin,
causes vasodilation. Then it will enter
and will cause pain. The patient will
blood vessels and blood will go to injured
not be able to move (loss of function).
area (because of vasodilation).
That is why patient who undergo surgery
- Vasodilation is the reason there is warm are bed ridden.
to touch and redness.
- Assessing warm to touch is through
palpation. BLOOD VESSEL DYSFUNCTION
 Then histamine will increase capillary
permeability and this is because of the  Permeability
histamine released by the injured tissue, - Capillaries leak fluid
blood vessels specifically Capillaries is out their walls
affected. - Cause by severe
- Capillaries connect the veins and infection (sepsis) and
arteries. There is also an exchange of certain diseases
nutrients, gases and substances in
capillaries. Why? Because the membrane
is made up of a single layer, so that
exchange of substances can easily take
place. Also, inside there is WBC, RBC
INFLAMMATORY RESPONSE
and platelets.
 Histamine will cause the pores to be
bigger. Albumin is the blood protein. This
is one of the end products if it takes in
protein. And that albumin stays in
intravascular, because it such a big
molecule that it will not be allowed to be
in another compartment.
 Swelling: Because of the injury the
histamine will be produced, it will
increase the force of the capillary, and
this big molecule which is supposed to be FLUID COMPARTMENT
inside will now have chance to go out and
that is albumin. So it will make
interstitial compartment Hypertonic whereas
inside the capillary is Hypotonic.
What is the mechanism involved?

- Osmosis is flow of fluid from lesser to

greater concentrated solution.

What is inside and in the outside?

- The histamine produced by the injured

issues is going to make the pores in - Intravascular compartment - inside the
the capillary bigger and that will give blood vessels
chance for albumin to go out.
 - Interstitial compartment - space  Capillary permeability (2nd picture) – the
outside cell and blood vessels. The pores became bigger; it should be tight.
fluid will go out here which will cause It allows the water, albumin to go out
swelling. which cause swelling.
- Cytoplasm - is the fluid inside the
cell and have the biggest amount of RAAS in SURGERY
fluid in the body. When there is loss of blood in the body, the
body compensates through releasing the 2
INFLAMMATION catecholamines norepinephrine and epinephrine.
(Increase cardiac rate + vasoconstriction) and
Inflammation is good
sends the blood to the primary organ which is
1.) If there is inflammation the WBC will the brain.
show like monocytes and neutrophils.
Immediately it will embrace the bacteria, The kidney will detect that there is less
so that the injury is localized. It will blood flowing to the secondary organ so the
not allow bacteria to spread. If it kidney will release the hormone renin which
spreads it is already the generalized converts angiotensinogen that is found in the
manifestation of inflammation like fever, liver into angiotensin I (a mild
no appetite to eat and body weakness. vasoconstrictor) angiotensin I will then be
Inflammation will limit the injury or converted by Angiotensin converting enzyme
infection. that is found in the lungs into angiotensin II
2.) It prevents spread of damaging agent a potent vasoconstrictor which also stimulates
because of plenty WBC, it will the release of aldosterone in the adrenal
phagocytize (ingest) bacteria. cortex. The aldosterone reabsorbs sodium:
3.) It is going to digest cell debris and where sodium goes water follows. To retain
bacteria fluids in the body. The brain will also
4.) It will Repair the injured area to compensate and the posterior pituitary gland
recover. How? Because of histamine will release the hormone ADH which retains the
produced. Histamine will cause water in the kidney and decreases the
vasodilation, there will be rush of blood production of urine in the body which causes
in operated area. You will see redness, oliguria.
palpate (warm to touch).
o 1000-1500mL for 24 hours
- Repair because of the gush of blood in o 30-50cc for an hour
the injured area. The blood will o Decrease urinary output – d/t loss of
contain nutrients, oxygen, antibodies, blood during surgery -> hypothalamus
and WBC which will help wound recovery. can feel that -Posterior Pituitary
 Function of the inflammatory Response Gland will release ADH – orders kidney
- Prevents spread of damaging agents to reabsorb fluids – Aldosterone is
- Disposes of cell debris & pathogens secondary to retain sodium =
- Set the stage for repair PHYSIOLOGIC OLIGURIA.
o 4th Post-Operative day will give a
CAPILLARY PERMEABILITY Normal I&O
o 2-3 days of Post-Operative will give
you normal bowel sounds
o Dull if you percuss an organ and fluid
o 6 to 8 hours is the expected for the
patient to void after removal of Foley
Catheter.
To prevent constipation
o Early Ambulation
o Increase Fluid Intake
o Fibers in Diet

 Oncotic pressure – fluid is retained in PERIOPERATIVE CONCEPTS AND NURSING MANAGEMENTS

the blood vessel. Remove the protein and
it will cause edematous. (pp. 418-476 14th Edition)

Ex. Just like babies. Last privilege of PURPOSE OF SURGERY

Filipinos is not able to get good milk to
children. Hence, usage of condense milk. It 1. Diagnostic -confirmation of suspected
has zero nutrients. The baby will have edema diagnosis
since there is no protein and albumin. It will (ex. Biopsy, Endoscopy, Culture)
result to Anasarca (general swelling of whole - Assessment is needed, also a first step
body). in nursing process.
(ex. Your father says he has a black stool.
Assess, so ask if he ate food or take medicine
which will cause the problem. Medicine like PRE-OPERATIVE INTERVIEW
ferrous sulfate (iron prep.) will make stool
dark or there might be intestinal bleeding,  Meet the patient at eye level & introduce
peptic ulcer or cancer in the rectum. These yourself by name first & role
might give blood in stool.) - The nurse should ask the patient to
tell her full name rather than asking
2. Explorative – confirms the type and
is she is Mrs. Cruz there might be
extent of a disease process. Use what is
inside that can’t be seen by diagnostic another patient by that name on the
schedule
test. (ex. Laparotomy, Joint Exploration)
3. Reconstructive – repairs physical  Nurses should not start the physical
deformities, improves appearance (ex. assessment or ask the patient’s name
Rhinoplasty, Mammoplasty, Skin grafting) without first identifying themselves and
4. Curative – diseased, or damaged body their role
organ, or structure is removed or - To relieve the patient’s anxiety in
repaired (ex. Appendectomy, Hysterectomy, the new environment of the surgical
Fixation of fractures) experience
5. Palliative – alleviates pain, discomfort
or other disease symptoms; Slow PRE-OPERATIVE ASSESSMET
progression of disease but does not cure
(ex. Nerve blocks, Placement of feeding  History of Previous Surgery
tubes) - To avoid problems previously
encountered (ex. Pneumonectomy;
(ex. The patient cannot eat because of many respiratory complication will be
lesions in mouth or unconscious. IV will possible. Because of anesthesia, it
not be enough. On the 3rd hospitalization day, will temporarily collapse lung. Also,
patient need to eat or else it will destroy bed ridden patient mucus doesn’t move,
the permeability of colon. In the large colon so mucus might block the airway and
there is microorganism like E. Coli. It should might cause accumulation.)
only stay in colon. Or the patient might die  History of Allergies
due to septic shock)
 Chronic Disease History (Need to ask:
URGENCY OF SURGERY Diabetes Mellitus, Hypertension, Cancer
or Asthma)
1. Emergent - Diabetic patient needs to be noted
- Preserves function of body parts or because of hyperglycemia. Wound will
life of the patient not be able to heal properly. Px need
- The procedure will be carried out to stay longer.
within 1-2 hours from admission (ex.
Repair of major vessels to stop (Note: Be alert about Aspirin medication.
Because the side effect of Aspirin is
bleeding; like appendectomy, vehicular
accident) bleeding. The patient will undergo surgery. If
2. Urgent not noted, possible to bleed profusely. Need
to stop 5 – 7 days prior surgery. Other drugs
- Requires prompt attention within 24-48
to stop are anti-coagulate drugs like
hours (ex. Repair of fracture Incision Enoxaparin, Coumadin which might cause more
and drainage of wound infection.)
bleeding.)
3. Elective
- Patient is in optimal health  Smoking History
- It can wait for days, months or year - Increase risk for postoperative
- Doe before the disease affect or complications
threatens the quality of life (ex. - Smoking needs to stop 1-month prior
Inguinal Surgery) surgery
- Satisfies patient’s desires but not
needed to preserve life or function Smoking 3 effects:
(ex. Cosmetic Surgery)
1.) It decreases contraction of Cilia.
SURGICAL PROCEDURES CAN BE BROADLY CATEGORIZED Cilia are hair like structures in upper
AS: respiratory system. The environment is
not sterile like COVID. So, the Cilia
- Elective – which is planned contracts 1000times/min upwards to
- Emergency – which is unplanned bring foreign bodies inhaled out to not
reach lungs. Remove by sneezing or
cough. Smoking paralyzes Cilia, so when
PHASES OF PERIOPERATIVE NURSING foreign bodies enter, it easily goes to
lungs which might cause Pneumonia.
I. PRE-OPERATIVE PHASE 2.) You are creating another gas Carbon
- Begins when the decision for surgery Monoxide. There are 2 gases in body
is made, and ends when the patient is Oxygen and Co2. However, smoking
transferred to the operating room. accumulates huge amount of carbon
 monoxide. Hemoglobin which is in RBC When immediate medical treatment is
and carrier of Oxy. & CO2 will be 200x needed to preserve life and the patient
attracted to carbon monoxide. is incapable of giving consent,
3.) Cause Vasoconstriction. It will THE NEXT OF KIN may give consent
increase the pressure in periphery.
Hence, heart will increase workload. IF REACHING THE NEXT OF KIN IS NOT
 Current Height and Weight POSSIBLE,
- Determine drug dosage calculations THE PHYSICIAN MAY INSTITUTE TREATMENT
 Vital Signs WITHOUT WRITTEN CONSENT
However, healthcare personnel must make
- To detect abnormalities
every effort to obtain consent by:
- Provide baseline data Telephone.
(High temp. & High BP like for anxiety = Stop
Surgery) ▪ If it is a true lifesaving emergency,
consent may be obtained over the
 Current Medications telephone from the patient’s next of
- Medications that can affect kin or guardian
coagulation status ▪ The surgeon must obtain the telephone
consent
INFORMED CONSENT ▪ If it is a true lifesaving emergency,
the surgeon often is already in
• An active, share decision-making process surgery, the nurse makes the telephone
between the provider and the recipient of call & another nurse witnesses the call
care ▪ Consent can be waived in situations in
• It protects the patient, the surgeon and which no family is available
the hospital and its employees
PREOPERATIVE PROCEDURES and EXERCISES
When is it Necessary? 4 Reasons: Teaching is needed for pre-op than post-op.
 Breathing exercises
1. When it is invasive
2. When it requires anesthesia  Coughing and Splinting
3. When it involves radiation  Incentive Spirometry
4. When there is a risk of potential harm  Leg exercises
 Early Ambulation
The operative consent must be signed  Range-of-Motion Exercises
before any preoperative medication is
given. DEEP BREATHING EXERCISES
- Medications can make you sleepy like • Dilates the airways
Demerol, Valium. Signing of consent
• It expands lung tissue. It will improve
must be prior pre-operative
exchange of Oxygen and CO2
medication.
The surgeon is legally responsible for • Stimulates surfactant production
obtaining the patient’s informed • Expands the lung tissue surface THUS
consent. Nurse are only witness. IMPROVING RESPIRATORY GAS EXCHANGE
▪ It is the surgeon's responsibility • Dilated airways → increased lumen of
❖ to discuss the planned procedure bronchi → better passing of oxygen and
❖ review the risks, benefits, & carbon dioxide → stimulates surfactant
alternatives to the planned
production → decreasing surface tension
procedure
▪ If the patient verbalizes that he or → decreased attraction of water
she does not understand the molecules
procedure that is planned, it is the ▪ Surfactants: a phospholipid substance
nurse’s responsibility to notify the found only in alveoli. Alveoli has
surgeon of this lack of many water molecules. This has
understanding right away tendency to attracts towards each
▪ The nurse should not teach about the other. If surface tension is high, can
procedure; the surgeon needs to do cause collapse of alveoli. Surfactants
this. are produced by alveolar type 2 cells.
If the patient is a o Surfactant is present as early as 8
months of pregnancy
▪ MINOR
o If the surface tension is increased,
▪ UNCONSCIOUS
it results to the collapse of the
▪ MENTALLY INCOMPETENT
alveoli
✓ The written permission may be
given by a REPONSIBLE FAMILY o Surfactants decrease surface tension
MEMBER (water molecules). Meaning it will
decrease attraction of water
molecules.
 o Alveoli: 3 Million of alveoli, 150
million in each lung; comparable to
a tennis court.
- Pain after surgery → shallow
breathing (inhaling deeply = pain)
- Immobilized (bed ridden because of
pain): tendency of accumulation of
goblet cells causing mucus to
partially obstruct airways
 DIAPHRAGM
- The diaphragm is the major muscle of
respiration.
- Inhale = diaphragm descends
- Located under the lung
- Deep breathing causes it to descend,
thereby increasing the ventilating
surface
seal with the lips → breathe deeply
through the mouth → hold for
3 seconds → remove mouthpiece → exhale
normally through the mouth
LEG EXERCISES
- Prevent venous stasis and help push blood
to the right side of the heart. Venous
stasis promotes blood to clot.
- Muscle is surrounding the vein. Veins
have valve, moving the legs will squeeze
veins and that will push blood to the
right side of the heart.
- More than 3 Days bed ridden Px: prone to
clotted blood. One of the complications
is Thrombus, once dislodge can lead to
pulmonary embolism or to the brain and
cause cerebrovascular accident.

COUGHING EXERCISES EARLY AMBULATION

• Loosens mucus secretions and forces them  Ambulation will move secretions,
up into the BRONCHUS to be expectorated increase peristalsis, prevent venous
or suctioned. stasis (accumulation of blood in the
• SITTING UPRIGHT shifts abdominal organs lower extremities) that can develop
away from the lungs, enabling greater venous thrombosis, DVT.
expansion.
RANGE-of-MOTION EXERCISES
▪ Mucus accumulates and can partially
obstruct flow of oxygen and carbon  To prevent joint rigidity and muscle
dioxide contractures
 Done 3 – 4 times a day
• Patients should be asked to perform deep
breathing & incentive spirometry 10
PREOPERATIVE TEACHING
times every hour holding each breath for
o Reduces anxiety
three seconds during waking hours to
o The timing of pre-op teaching is highly
prevent:
individualized.
▪ Atelectasis (Anesthesia will
o Ideally there will be enough time for
temporarily collapse lung.
the nurse to give instructions and
Surgical pain causes shallow
answer questions
breathing, that will not expand
o Often the client is admitted on the day
lungs.)
of surgery. It is imperative that the
▪ Pneumonia (anesthesia may paralyze client receives instructions before
Cilia. Foreign bodies will easily this time so that the nurse can simply
enter your lung) reinforce instructions and answer
• Contraindications questions
▪ Cranial surgeries because of o But if the teaching is done too far in
increased Intracranial pressure advance, the client will forget the
(ICP) information
▪ Eye surgeries because of increased
intraocular pressure CLIENT PREPARATION

SPLINTING NPO STATUS

- Small pillow/rolled blanket or • To prevent aspiration
towel/hands (middle fingers should be  8-10 or 10-12 hours before surgery.
touching) Anesthesia → Decrease peristalsis →
- For the suture not to break
Increase secretions → accumulation of
- If patient has muscle weakness, use
nurse’s hand gastric secretions in the stomach →
gag reflex not active → No epiglottis
→ substances can regurgitate → Food
INCENTIVE SPIROMETRY may enter lungs → Thus aspiration and
- Promotes lung expansion & increases Pneumonia
respiratory function
- Causes maximal inspiration & increased Adults are advised to fast for:
cardiac output  8 hours after eating fatty food
- Patient is at sitting position → exhale  4 hours after ingesting milk products
normally → put mouthpiece to lips →  Clear liquids up to 2 hours before an
elective procedure
INTRAVENOUS ACCESS o For surgery, appropriate preoperative
o For fluid and replacement skin preparation is key step to
o Administering IV medications preventing SSIs.
o Providing a route for emergency o Research studies show shaving cause
medication multiple skin abrasions that later may
o Act as nutrition become infected.
o Administering blood products o Removing hair at the surgical site
▪ Profuse bleeding: route to give BT abrades the skin surface and enhances
microbial growth.
OXYGEN ▪ Destroy dermal layer of skin →
o Cannula opening pores → injury to the skin
o Mask
→ possible for microorganisms to
▪ Minimum of 5L
▪ Whenever a patient exhales, he/she enter → infection to set in
is giving out carbon dioxide. The o Hair at the surgical site should be left
pressure inside is going to push the in place, whenever possible. When hair
carbon dioxide out of the pores so removal is required, hair should be
that that patient won’t inhale it clipped with an electric clipper.
again ▪ Ex: cranial surgeries
o Venturi
o Rebreather
o A common adverse effect of sedatives is BOWEL PREPARATION
respiratory depression • For patients undergoing elective GIT
o If alveoli is collapsed, exchange of surgery to ensure that the contents of
gases will not be good and also the bowel are cleared. (Risk for
decreases hemoglobin Peritonitis)
o For the wound to recover, there must be • Enemas are not commonly prescribed
plenty of blood to the area (WBC, preoperatively unless the patient is
nutrients, antibodies) undergoing abdominal or pelvic surgery.
• At 24-48 hours prior to surgery, the
FOLEY CATHETER patient may be allowed CLEAR LIQUIDS (no
o Muscle contract → Increase Urine → milk):
Bladder enlarge. → Catheter Inserted. ▪ Water
o Prevent distention of urinary bladder ▪ black tea
especially if the operation is quite ▪ coffee no cream
long ▪ meat extracts
o Inserted at intraoperative phase ▪ consommé
o An invasive procedure (any tube ▪ glucose drinks
inserted) which is a good medium for *Full liquids contain milk like sherbet,
growth of bacteria ice cream, creamy soup*
o 90% prone to UTI • Less food intake
o Should not last inside for two days. • Laxatives/Enema: Used the evening before
Removed on second postoperative day surgery to clear the bowel of fecal
preventing UTI matter. (Induce to move bowel)
o Maintain close system of Foley catheter Examples:
o Empty bag regularly
▪ Bisacodyl (Dulcolax)
o Prone to infection – Aseptic insertion
–Perineal care ▪ Na Picosufate (Laxoberal)
o Meperidine ▪ Klean-Prep (Picolax)
• Food and water are usually withheld at
ORAL AIRWAY MIDNIGHT (no midnight snacks) of the
o Gag reflex not good, insert surgical day.
• Water may be given up to 4 hours before
HAIR REMOVAL surgery. (Depends on type of surgery)
o The main purpose is to ease visualization • Aspirin is withheld 7-10 days before
of the surgical site and to provide a surgery.
better skin surface for wound closure.
o Shaving is done as close to the time of PURPOSES OF PREANESTHETIC MEDICATIONS
incision as possible to avoid o Facilitation of anesthesia induction
contaminating the shave wound. o Lowering of the dose of the anesthetic
▪ If the wound occurred within 30 agent used.
minutes before incision time, it o Reduction of pain and anxiety
is considered a clean wound.
▪ 5 – 8 hrs negative tayo dyan boss PREOPERATIVE MEDICATIONS
baka ma-squeeze ang ating fucking 1. To reduce anxiety and induce sedation
neck. (strong sedatives)
o Diazepam (Valium)
o Lorazepam (Ativan)
 o Midazolam (Versed, Dormicum)
Note: MIDAZOLAM HYDROCHLORIDE
Causes antegrade amnesia or decreased
ability to remember events that occurred
around the time of sedation.
The patient should be encouraged to take
slow, deep breaths because midazolam is a
respiratory depressant.
2. To reduce/relieve discomfort during
preoperative procedure
o Meperidine (Demerol)
o Morphine
3. Anticholinergics to decrease the risk of
bradycardia during surgery
o Atropine + Demerol is always given
▪ Risk of Bradycardia – Common
adverse effect of anesthesia
▪ Atropine counteracts
bradycardia
▪ Atropine also decreases
mucus secretion and saliva
o Scopolamine
o Glycopyyrolate (Robinul)
NOTE: GLYCOPYRROLATE an anticholinergic
given for its ability to reduce oral and
respiratory secretions before general
anesthesia.
Adverse Effects: Increased CR and RR
4. To increase gastric pH and decrease gastric
volume
o Cimetidine (Tagamet)
o Famotidine (Pepcid)
o Ranitidine (Zantac)
NOTE:
• H2 BLOCKER: Hydrochloric Acid 60%;
increase gastric PH, gastric volume ↓
• PPI: Gastric PH 90-95; potent but
expensive
• Not always given
• Gastric PH: hydrogen content low in the
stomach for it to be acidic needed for
digestion of food. Acidity can kill
microorganisms found in food
• Reason for increasing gastric PH or
decrease gastric volume in surgery:
• The stomach has three types of cells:
mucous mast cells, parietal cells
(production of hydrochloric acid), chief
cells (pepsinogen = neutralize acidity)
→ 2400 gastric secretions in 24 hours →
production of acid is continuous but
protected by mucous mast cells or eating
on time is another → patient is going to
bleed decreasing circulation → stomach
is a secondary organ and is receiving
less blood → mucous mast cells won’t be
able to produce enough mucus to
neutralize acid → plenty of acid → acid
can eat mucosa of stomach → Gastric
ulcers
• Drugs can diminish acidity of gastric
secretions (Gastric PH of 3.5 or 4 ↑)
• Less acid for not cause auto digestion
5. Anti-Emetics
• Metoclopramide
• Droperidol
• Stop nausea
▪ Can open wound when vomiting causing
dehiscence
NOTE: Eye/brain surgery. Vomiting increase
pressure. Anti-Emetics given preop (Depends on
anesthesia, if major adverse effect is vomiting)
or postoperatively.
PREOPERATIVE MEDICATIONS
o Oral medications should be given 60-90
minutes before the patient goes to the
OR. (Esophagus-stomach-intestine-absorbed
blood-taken to liver-etc.)
▪ The patient should swallow these
meds with minimal amount of water.
o IM and SC injections should be given 30-
60 minutes before arrival at the OR
o “On Call” from operating room
▪ OR nurse call when to give meds
o The patient is kept in bed with the side
rails raised.
o Identify yourself.
o Ask the patient to void before pre-op
meds
o Inform patient of the effects of the drug
to avoid anxiousness because it can
increase BP
o Do not let patient to get out of the bed
once given with pre-op meds (tendency to
fall)
o The immediate surroundings are kept quiet
to promote relaxation. (no visitors)
o Cover the head completely with disposable
paper cap
o All patients should void immediately
before going to the OR
o The nurse should have the patient empty
the bladder BEFORE the premedication is
administered.
RATIONALE FOR WEARING A SURGICAL CAP
o To prevent dissemination of microorganism
o To protect it from being soiled.
o To prevent hair from falling into the
sterile field.
o To prevent a static spark near the
anesthesia machine.
PREOPERATIVE CHECKLIST
(NIGHT BEFORE THE SURGERY)
 Allergies
 Consent
 History/PE
 Weight
 NPO
 Pre anesthetic evaluation
 Exercises Performed
 PM Care
 Polish/Denture/Make up removed
 Sedatives as ordered. If not, ordered
call the physician
 Signature of RN
 Lab/Diagnostic
  BT/Consent for BT. Ask religion
 Jewelry, dental prosthesis and contact
lenses removed
 Voided on call
 Indwelling catheter if ordered
 Tampon Removed
 ID Checked
 Vital Signs
 Preoperative medications
 Side rails up
 Instruct the patient not to get out of
the bed
 Vital signs 30 minutes after pre-op
 Old chart sent to OR
 Time sent to surgery
NOTE: The patient must have identification
bracelet properly secured on the wrist before
being transported to the operating room to
ensure correct identification.
II. INTRAOPERATIVE PHASE
• Includes all those that occur from the time
the patient is transferred to the OR until
he or she is transferred to the RECOVERY
FACILITY.
NURSING INTERVENTIONS
1. PROVIDE EMOTIONAL SUPPORT
o Introduce yourself, addressing the
patient by name warmly and frequently
o Providing appropriate information and
explanation, answering questions to
help the patient feel secure
o Providing emotional support for the
client’s family is equally important
o The purpose of separating the public
from the restricted attire are is to:
▪ Provide an aseptic environment
▪ Prevent contamination of the
environment by organisms
o THE MAIN PURPOSE IS INFECTION CONTROL.
o LET THE FAMILY KNOW when the procedure
is completed.
o How long the client will be in the OR
o Where the client will go after
discharge from the recovery room.
2. ENSURING A SAFE ENVIRONMENT
o Proper positioning of the patient
(Circulating Nurse)
o Using safety straps, bed rails
o Not leaving the sedated patient
unattended.
COMMON SURGICAL POSITIONS
SUPINE: abdomen, thorax, face, orthopedic,
vascular surgeries
TRENDELENBURG: allows greater access to the
lower abdominal cavity and pelvic structures by
allowing gravity to retract organs
REVERSE TRENDELENBURG: surgeon requires
unobstructed access to the upper peritoneal
cavity and lower esophagus, allows clear view of
the diaphragm, cardiac sphincter and esophagus
LITHOTOMY: gynecological, obstetrical,
genitourinary procedures
SITTING (FOWLER’S): facial, cranial,
reconstructive breast surgery
LATERAL (SIMS): renal and cardiothoracic surgery
PRONE: spine, cranium, perianal region; pressure
on the abdomen restricts normal ventilation
JACKKINFE OR KRASKEE: anorectal surgery
Contraindicated: ages 60 and above. Lithotomy,
sims and lateral positions instead
URINARY CATHETERIZATION
o To prevent bladder distention during a
long procedure or after the surgical
procedure.
o For bladder decompression to avoid trauma
during a lower abdominal or pelvic
procedure.
o To facilitate output and healing after a
surgical procedure on GUT structures
o Catheterization is performed after
anesthesia is administered
o Before the patient is positioned for the
surgical procedure.
o It should be inserted before the vaginal
or abdominal skin preparation to prevent
perineal splash to the surgical site.
o Sterile technique must be maintained.
ANESTHESIA
STAGE I Analgesia Stage
STAGE II Excitement Stage
STAGE III Surgical Anesthesia
STAGE IV Medullary Paralysis
STAGE I: ANALGESIA STAGE
o Loss of pain sensation with the patient
still conscious and able to communicate
o Warmth, dizziness and feeling of
detachment
o May feel or have RINGING, ROARING,
BUZZING
o Noises are exaggerated; even low voices
or minor sounds seem loud or unreal.
STAGE II: EXCITEMENT STAGE
o Period of excitement and often combative
behavior
o Characterized by struggling, shouting,
talking, laughing, crying
o Signs of sympathetic stimulation such as
tachycardia, Increase RR and BP
o Uncontrolled movements: RESTRAIN PATIENT
STAGE III: SURGICAL ANESTHESIA
o Involves relaxation or skeletal muscles
and return of regular respiration
o Patient is unconscious
o Progressive loss of eye reflexes and
pupil dilation
o Surgery can be safely performed in Stage
III.
STAGE IV: MEDULLARY PARALYSIS ADVERSE EFFECTS
o Very deep CNS depression with loss of o Respiratory depression
respiratory and vasomotor center stimuli o Hypotension
to which, death can occur rapidly o Expensive
o Happens when too much anesthesia has been It is not associated with renal or
administered. hepatic toxicity
o Cyanosis develops and death may follow
ENFLURANE (ENDURANCE, ETHRANE)
Anesthesia may be produced in a number of ways o Induction of anesthesia is smooth and
rapid
GENERAL ANESTHESIA o Salivation is not stimulated
o Drugs that produce UNCONSCIOUSNESS and o Muscle relaxation is greater than with
lack of responsiveness to all PAINFUL halothane. However, despite the action, a
STIMULATION Neuromuscular Blocker is employed to
o Basic elements include: permit a reduction of Enflurane dosage
▪ Loss of consciousness o Suppress uterine contraction
▪ Analgesia
▪ Muscle relaxation ADVERSE EFFECTS
▪ Interference with undesirable o High dosage can induce SEIZURE
reflexes o SUBSTANTIAL DEPRESSION OF RESPIRATION
▪ Amnesia: inability to recall what
took place. NITROUS OXIDE (BLUE CYLINDER)
o “Laughing Gas”
TWO METHODS OF ADMINISTERING GENERAL ANESTHESIA o It has a VERY HIGH ANALGESIC POTENCY and
o Inhalation a VERY LOW ANESTHETIC POTENCY
o Intravenous
Analgesia: Loss of sensibility to pain
INHALATION ANESTHETICS Anesthesia: refers not only to loss of pain but
o Halothane to loss of all other sensations as well. Touch,
o Isoflurane Temperature, Taste
o Enlurane
o Nitrous Oxide o Never employed as a primary anesthesia.
o Cyclopropane It is frequently combined w/other
o Ethylene inhalational agents to enhance ANALGESIA
o Most widely used inhalation agent
HALOTHANE (FLUOTHANE) o Almost all patients undergoing general
o Induction of anesthesia is smooth and anesthesia receive nitrous oxide to
rapid supplement the analgesic effect of the
o WEAK ANALGESIC. Co-administration of a primary anesthetic
STRONG ANALGESIC (morphine, nitrous o Major concern is postop Nausea and
oxide) is usually required. Vomiting
▪ Counteract with atropine sulfate o Can cause bowel distention
o RELAXATION OF SKELETAL MUSCLE is only o There is no muscle relaxation
moderate. Concurrent use of neuromuscular
blocking agent is required (Pancuronium) CYCLOPROPANE (ORANGE) and ETHYLENE (RED
o Promote significant RELAXATION OF THE CYLINDER)
o Obsolete inhalational anesthetics
UTERINE SMOOTH MUSCLE → inhibit uterine because:
contractions → DELAYING DELIVERY ▪ They are explosives
▪ They offer no advantage over newer
ADVERSE EFFECTS less hazardous anesthetics
o HYPOTENSION:
▪ Dec myocardial contractility -> INTRAVENOUS ANESTHETICS
dec. CO by 20%- 50%. o Injected directly into the circulation
▪ Stimulate vagal tone -> dec. HR -> usually via a PERIPHERAL VEIN in the arm.
dec. CO o May be used alone or to supplement the
o RESIRATORY DEDPRESSION effects of INHALATIONAL AGENTS.
o VOMITING
THIOPENTAL (PENTOTHAL)
ISOFLURANE (FORANE) o Acts rapidly to produce UNCONSCIOUSNESS
o Most widely used inhalational anesthetic in 10-20 seconds after IV injection
o A POTENT MUSCLE RELAXANT and protects the o ANALGESIC and MUSCLE RELAXANT EFFECTS are
HEART against cathecolamine-induced weak.
dysrhythmias -> CO is not decreased o Supplement to regional anesthesia
o It depresses BRONCHOCONSTRICTION. May be o Used as a safe adjunct for intubation in
used in Asthma and COPD. HEAD INJURIES
ADVERSE EFFECTS o Anesthesia is produced by injection into
o CARDIOVASCULAR and RESPIRATORY DEPRESSION the DISTAL VEIN of an arm or leg
o APNEA, if given rapidly
TOPICAL ANESTHETICS
PROPOFOL (DIPRIVAN, DIPRIFOL)
o Used for rapid induction and maintenance BENZOCANE (Auralgan)
of anesthesia for non-invasive procedures o For ear pain
▪ Endoscopy
▪ MRI LIDOCAINE (XYLOCAINE, EPICAINE, ENDUCAINE, EMLA,
▪ Radiation Therapy EMLOCAINE)
o UNCONSCIOUSNESS develops w/in 60 secs and o For dermatological procedures
lasts for 3-5mins following a single o For painless IV insertion
injection. o Most widely used local anesthetics
o Causes death rapidly o Preparations: Cream ointment jelly patch
o MODERATE TO SEVERE PAIN may be felt at soln aerosol
the injection site
▪ Larger antecubital vein should be TATRACAINE (PONTOCAINE, NIPHANOID)
use o For surgical, dental and obstetric
▪ Site should be injected with procedures.
LIDOCAINE o Eye drop to numb the eye for various
ophthalmic procedures.
ADVERSE EFFECTS
o Profound respiratory depression Avoid application to skin that is abraded or
o Bradycardia injured. TO PREVENT SYSTEMIC TOXICITY,
BRADYCARDIA, CONVULSIONS
KETAMINE (KETAMAX, KETAZOL) ADVERSE EFFECTS Wear gloves when applying the anesthetic
o Hallucinations
o Disturbing dreams SPINAL ANESTHESIA (LUMBAR)
o Injecting local anesthetic into the
BALANCED ANESTHESIA SUBARACHNOID SPACE (Intrathecal)
Use of a COMBINATION OF DRUGS each with a o To create sensory, motor and autonomic
specific effect to achieve blockage of the nerve roots and spinal
o Analgesia cord.
o Muscle relaxation o Indicated for surgical procedures below
o Unconsciousness the diaphragm such as:
o Amnesia ▪ Prostectomy
▪ Knee Arthoscopy
The agents most commonly used to achieve these ▪ Total Joint Replacement
agents are: ▪ Urologic Procedures
SHORT ACTING NEUROMUSCULAR BLOCKING
BARBITURATES AGENTS ANESHETICS MOST COMMONLY EMPLOYED
For induction of For muscle relaxation o Bupivacaine
anesthesia o Lidocaine
o Thiopental o Vecuronium o Tetracaine
o Methohexital (Norcuron)
o Rocuronium COMPLICATIONS AND INTERVENTIONS
(Dameron) o HYPOTENSION
o SPINAL HEADACHE
OPIODS AND NITROUS PREOPERATIVE MEDICATIONS o URINARY RETENTION
OXIDE
The patient will feel sensation to the toes
For Induction of Use of ANTICHLONERGICS that before the perineal area
Analgesia decrease secretions to A spinal headache due to the loss of fluid is a
facilitate intubation and severe headache that occurs while in the upright
prevent bradycardia position but is relieved in the lying position.
o Morphine
o Demerol HYPOTENSION
o BP is decreased by venous dilation
secondary to blockade of sympathetic
NERVE BLOCK
o Injecting the anesthetic at some point nerves.
o Loss of venous tone decreases the rerun
along the nerve/nerves that run to and
from the region in which the loss of pain of blood to the heart casing a reduction
in cardiac output and corresponding fall
sensation or muscle paralysis is desired
in BP
INTRAVENOUS REGIONAL ANESTHESIA
o Employed to the anesthesia the INTERVENTION
o Elevate legs.
extremities
o Closely Monitor BP
 o IV fluids and EPHEDRINE, alpha 1 agonist o Contains nasal and oral droplets, which
that increases BP by stimulating are easily transmitted to the hands as
norepinephrine release. the mask dangles when left hanging around
the neck.
SPINAL HEADACHE o When a face mask is not worn over the
o Indicating leak of CSF thru the opening mouth and nose, it should be discarded
in the Dural sheath.
o Injected lumbar area → leak of CSF SURGICAL SCRUB
(shock absorber) → increasing pressure o A study revealed that microorganisms
o May occur from6-12hrs after spinal decrease to an estimated 50% with each
anesthesia to the 2nd postop day SIX-MINUTE SCRUB
o Signs and symptoms: o Other studies have shown that a VIGOROUS
FIVE-MINUTE scrub with a reliable
▪ Frontal/occipital headache
antiseptic agent is as effective as a
▪ Tinnitus
TEN-MINUTE SCRUB.
▪ Double vision o During and after scrubbing KEEP THE HANDS
▪ Nausea HIGHER THAN THE ELBOWS to allow water
▪ Photophobia flow from the cleanest area the HANDS, to
the marginal areas of the UPPER ARMS
INTERVENTION DRYING OF HANDS AND ARMS
o Supine position (6-8 hours): good o Hold the towel away from the body, dry
distribution of CSF only scrubbed areas, starting with the
o Large amount of IV fluids. (Well- HANDS.
regulated to replace lost CSF) o Avoid contaminating the hands or areas
o Systemic ANALGESIA distal to the ELBOWS
STERILE TECHNIQUE HAND RUB
o STERILE means absence of all o CHLORHEXIDINE GLUCONATE or
microorganisms o BETADINE SOAP 7%
∞ RUB 3-5 MINS
MAINTAINING SURGICAL ASEPSIS o STERILEUM
o Maintaining ASEPSIS to avoid
∞ CONTINUOUS RUBBING 2-5MINS, AIR
contamination of the surgical site by
DRY
microorganisms is the responsibility of
ALL OTHER MEMBERS OF THE SURGICAL TEAM.
MAINTAINING SURGICAL SEPSIS
o All materials in contact with the
o The STERILE GOWN is worn immediately
surgical wound and used w/in the sterile
AFTER THE SURGICAL SCRUB.
field must be STERILE.
o The STERILE GLOVES are worn immediately
AFTER GOWNING
PRINCIPLES OF STERILE TECHNIQUE
o Sterile drapes to create sterile field
o The edge of a sterile field and 1-2
o The MOVEMENTS of the surgical team are
inches inward is unsterile.
from are from STERILE to STERILE AREAS
o Sterile packages are labelled as sterile. and from unsterile to unsterile areas
If a package is not labelled sterile, it
o Have unscrubbed personnel stay at least
should be considered an unsterile item
ONE FOOT AWAY from the sterile field
o Sterile objects that comes in contact
o Whenever a STERILE BARRIER is breached,
with unsterile objects are considered
the area must be considered CONTAMINATED.
contaminated
o Any part of sterile field that falls of
SCRUB NURSE AND CIRCULATING NURSE
hands below the top of the table is
SCRUB NURSE CIRCULATING NURSE
unsterile.
o A sterile field that becomes WET will PREOPERATIVE
draw microorganisms from the surface The SCRUB NURSE performs SPONGE COUNTS with
underneath and contaminate the field. the CIRCULATING NURSE
o Items in a sterile package must be used READ CARD FILE TO HELP IN PREPARING
immediately once it has been opened or it VERIFY SURGEONS NEEDED SUPPLIES
considered contaminated SPECIAL REQUIREMENTS
o GOWNS of the surgical team are considered HELP SCRUB NURSE AND
sterile IN FRONT FROM THE CHEST TO THE ASSEMBLE ALL STERILE SURGEON IN GOWNINH
LEVEL OF THE STERILE FIELD. SUPPLIES NEEDED IN
o The SLEEVES are considered sterile form PROCEDURE OPENS STERILE PACKS
TWO INCHES ABOVE THE ELBOW TO THE
STOCKINETTE CUFF. WEAR MASK AND SCRUB PERFORM AND RECORD
HANDS COUNTS
SURGICAL MASK PUT GOWN AND GLOVES ADMIT PATIENT TOP
o Remove all jewelry, hair covered by IN PREPARATION FOR OPERATIVE SUITE
headgear THE PROCEDURE
o Disposable mask must fit snugly and
comfortable over the nose and mouth PREPARE STERILE
FIELD  Because if the patient vomits and is
performing Valsalva maneuver, that
MAKE SURE ALL will increase pressure in brain or
INSTRUMENTS ARE eyes can give complication bleeding.
WORKING PROPERLY In abdomen, wound might open due to
increase pressure.)
 If px is unconscious vomits while in
bed/ lying down: turn the patient’s
head to one side for them not to
swallow the vomit.
 If px is conscious while vomiting:
Semi Fowler position; 45-degree angle.
 Don’t give anything by the mouth if px
PRE INCISIONAL is vomiting.
Assist surgeon in Anticipate
DRAPING the ANESTHESIOLOGIST’S needs (Ex. Scenario: Nurse making round 3 rd post-
patient during induction of operative day, and the patient says “I’m so
anesthesia hungry. Can I eat the oatmeal that was
Pass off suction prepared by my wife?”. The doctor’s order is
cautery lines Assist with drapes; NPO.)
connect suction and
cautery Answer: Nurse can independently decide. Assess
CLOSING PHASE patient first: 3 to look for
Count with Make a tally of SPONGES
1. If patient can already swallow or has
CIRCULATING NURSE counted together with
gag reflex. Just feeling it in neck and
at frequent SCRUB NURSE
the pharynx goes up and down while
intervals
patient swallow. It is okay.
Assist surgeon in Apply tape to secure
2. Use stethoscope to assess abdomen.
SUTURES and TUBINGS and other
There are 4 quadrants, if not heard in
DRESSING attachments
one quadrant go to another. If
peristalsis is good it is okay.
TIME-OUT
 Normal Bowel Sound: 5 – 25 Bowel
When a “time-out” is called prior to surgery,
sounds/min
the surgical team must:
3. Flatus is the most reliable
o Read back all prescriptions
o Verify the correct site Note: Assessment is always first before making
o Identify the patient again an action. In nursing process first is
o Double check the echocardiogram assessment, second diagnosis, 3 rd is planning,
4th implement and 5th/last evaluate
III. POST-OPERATIVE PHASE • Peristalsis is movement. It is seen in
esophagus, stomach, small & large
Involves the period after the client is intestines.
discharged from the recovery room and ends with o Normal: 3-5 days
the resolution of all surgical consequences. 3.) Deep vein thrombosis (DVT). Px is immobile
4.) Infection. Temperature is taken q4 even in
Complications: 1st day. To look for infection (ex. UTI,
respiratory infection, wound infection)
1.) Respiratory Complication is number one
because: (Ex. Scenario: 1st operative day px tempt. is
a. Adverse effect of anesthesia 38.7 C.)
b. Pain causes shallow breathing. Not
Answer: Not normal. If it is elevated in 1st
expanding alveoli. Exchange of gas
day it is respiratory complication.
will not be good
c. Immobility because px in bed for • It would take 3-5 days post op for wound
several days. Solution: Early infection to develop. You can have high
ambulate helps prevent constipation, temperature. If wound is assessed, there
DVT will be calor, dolor, rubor and tumor.
2.) Nausea and Vomiting. Surgical pain • UTI develops 2nd post op day. That is why
triggers vomiting center in brain. If catheter is removed in 2 nd day to prevent
patient is nauseated, immediately give UTI. If needed longer, it is a must to
anti-emetic drug like Metoclopramide. keep perineal care.
 If no order, immediately refer to • Respiratory complication like Atelectasis
doctor. Not allowed to vomit if the or pneumonia develops 1st post op day
patient will undergo cosmetic surgery, 1st post-op day:
cranial surgery, abdominal surgery.
 ∞
Temp. should be lower than 38 C,
expected because there is
surgical incision.
∞ Higher than 38 C, there is
complication.
∞ Temp. is assessed every 4 hours,
after the first 24 hours of
surgery.
• To prevent UTI, doctors usually orders
to pull catheter in 2nd post op day.
Steps to pull:
a. Wash hands
b. With the syringe put in balloon
part, then aspirate 5-10 cc
c. After aspiration, gently pull out
catheter.
∞ Expect patient to void normally 6-
8 hours after removal.
(Ex. Scenario: Nurse entered the room at 8 or
9 pm. Nurse asks patient Ms. Cruz if she
voided already. The answer is no, not urinated
yet. What is the nursing intervention?)
Answer:
1. Percuss and the sound is Dull, because
it is filled with water
2. There is urinary distension. You should
not let the urinary bladder to be
distended with so much urine. You
should motivate patient to void.
Motivations that help are:
o Water sound
o Pouring perineum with tap/warm
water
o Best: Provide bedside commode, if
px can’t go to the restroom yet
(Ex. Scenario: You were making rounds 2nd post
op. Px still have foley catheter, the shift is
6 am to 2pm. As you were making rounds, px
urinary output in whole shift is 100 cc. What
will be your reaction?)
Answer: Normal because px body is
compensating. Expect physiologic oliguria the
px bled in surgery therefore body has to do
something. Hypothalamus will alert posterior
pituitary gland and will release hormone
Oxytocin & anti-diuretic hormone. Because
there is decrease in circulating blood volume,
ADH will be release. Then will be absorbed by
the blood and this will order renal tubules to
reabsorb water. So, it will order kidneys, the
body loss a lot of blood so don’t make so much
urine reabsorb water that is why urine is
less. Another hormone to release as
compensatory mechanism by adrenal cortex and
adrenal gland is Aldosterone. It compensates
and will order again renal tubules to reabsorb
because of loss of blood and where sodium is,
water follow.
• Intake & Output = equal in 4th day post
op.
• Maximum: 50 cc/hr multiply by 8 = 400c
in 8 hours.
• Minimum: 30 cc/hr multiply by 8 = 240
cc in 8 hours
ACID BASE BALANCES
Body’s line of defense in maintaining normal
pH are:
1.) Respiratory System (Lungs) - controls
acid like CO2. Responds within minutes
2.) Renal System (Kidneys) - reabsorbs or
excrete bicarbonate (HCO3). Bicarbonates
are base. Kidneys will take time to
act. 1 or 2 days to make changes. Only
system that can put pH in normal level.
3.) Buffer System
• Proteins
• Bicarbonate buffer system
• Transcellular hydrogen potassium
exchange system.
• Buffer system and respiratory
system almost the same. Quickly
responds. However, cannot bring
pH in normal level. This is where
kidneys come in. 2 kidneys will
control base in form of
bicarbonates.
• If the pH is BELOW 7.40 and PaCO2 is
GREATER than 45 mmHg = RESPIRATORY
ACIDOSIS
• If the pH is LEESS THAN 7.40 and HCO 3 is
BELOW 22mEq/L = METABOLIC ACIDOSIS
• Respiratory acidosis – accumulated CO2
in lungs probably pneumonia, asthma
where bronchi is partially obstructed.
It can be in COPD.
• Metabolic acidosis – immediately lungs
will compensate. Kidneys & lungs help
each other. But lung can’t bring pH to
normal, and kidneys are broken. Plenty
of acid due to renal failure like urea,
uric acid accumulate toxins, cannot
excrete it there is accumulation and
you can be in state of metabolic
acidosis. Px will be hyperventilating
due to so much acids in form of
Hydrogen Ions and CO2. So, lungs are
compensating, it increases RR. You are
blowing some form of acids in form of
CO2.
• Cerebrovascular vasodilation happens
when CO2 is elevated because CO2 will
elevate arteries. CO2 is not only in
lungs, there is also metabolism in
 brain and end product is CO2. Since RESPIRATORY ALKALOSIS
airway is partially obstructed not all
CO2 can be eliminated. So possible 3. Results from HYPERVENTILATION
headache, because too much CO2 can 1. Fever
dilate arteries in brain. 2. Hyperthyroidism
3. Shock
ABG IN ADULTS: NORMAL 4. Pulmonary embolism
VALUES 5. Over ingestion of salicylate
pH 7.35 – 7.45
PaCO2 35 – 45 mm Hg
PaO2 80 – 100 mm Hg
HCO3 22 – 26 mEq
SaO2 95 – 100 %

METABOLIC ACIDOSIS

1. Bodily gain of a strong acid

 Diabetic ketoacidosis
 Prolonged starvation
2. Loss of Bicarbonates
 Chronic diarrhea
3. Decreased acid excretion
 Renal Failure

METABOLIC ALKALOSIS

1. Loss of acid from the plasma

▪ Vomiting
RESPIRATORY ACIDOSIS ▪ Gastric Suctioning
2. Large intake of antacid
1. Depressed central respiratory centers
 Over sedated
 Head trauma
 General Anesthesia

Respiratory acidosis results from

HYPOVENTILATION

2. Compromised respiratory apparatus

 COPD
 Guillain-Barre’
 Asthma
 Pneumonia

Patent airways is essential. • 7.40 above ALKALOSIS

• 7.36 below ACIDOSIS
There is depress CNS

COMPENSATED

- pH within normal level. Examples: 7.38,

7.42, 7.44 (It is compensated)

UNCOMPENSATED STATUS

- Indicates that one of the body systems

Respiratory or Kidneys. Has made no
Note: Respiratory center is in pons, medulla attempt to change pH
oblongata. Above pons is Midbrain. All part of
brainstem
PARTIALLY COMPENSATED HCO3 19 Low

- It can be below or higher than 7.45 mm

Hg. But if you look at other figures, one
of figures is compensating. However, 5.) A: Uncompensated Respiratory Acidosis
failed to put pH within normal level.
pH 7.43 Normal
Sample Problems:
PaCO2 58 High
1.) A: Uncompensated Metabolic Acidosis
HCO3 25 Normal
pH 7.30 Acidosis
PaCO2 38 Normal Interpretation:

HCO3 16 Low - PaCO2 is 58 because there is plenty of CO2

Interpretation:
- Since lungs is damage, kidneys will
- pH is not normal. Lungs is not doing compensate by releasing bicarbonate. Since
anything there is plenty of acid it will neutralize it.

- 25 HCO3 is normal so it doesn’t compensate.

2.) A: Uncompensated Metabolic Alkalosis
- It is uncompensated and not partially 6.) A: Partially Compensated Respiratory
because the lungs are normal and didn’t Acidosis
compensate.
- Uncompensated because CO2 is normal pH 7.10 Acidosis
level.
PaCO2 50 High
- Lung didn’t do anything maybe aged/have
problem with lungs. Lungs react in HCO3 24 Normal
minutes but it didn’t react here.
- Lungs are normal so it is not the
problem, so it is metabolic.
7.) A: Partially Compensated Respiratory
- Alkalotic happens if vomiting → it lets
Acidosis
gastric juices (hydrochloric acid produce
by parietal cell) & chief cell produces pH 7.32 Acidosis
acid Pepsinogen → active form pepsin.
- So, for gastric juices to be potent it PaCO2 48 High
should be acidic for it to kill
microorganism in the food. While HCO3 30 High
vomiting, it releases great amount of Interpretation:
acids which will cause the Alkalotic
state. - PaCO2 is damage.
pH 7.56 Alkalosis -HCO3 is compensating. However, it didn’t
bring the pH in normal level. So partially
PaCO2 41 Normal compensated respiratory acidosis. Bicarbonate
increased to compensate due to many acids, but
HCO3 40 High
failed to normalize pH.

8.) A: Partially Compensated Metabolic

Acidosis
3.) A: Uncompensated Metabolic Acidosis
pH 7.38 Normal;
pH 7.27 Alkalosis
acidosis
PaCO2 38 High
PaCO2 28 Low
HCO3 14 Low
HCO3 18 Low

- Partially compensated because its pH is

4.) A: Compensated Respiratory Alkalosis normal. But still considered acidotic because
it is below 7.40.
pH 7.45 Normal;
Alkalosis

PaCO2 25 Low
9.) A: Uncompensated Respiratory Alkalosis A: uncompensated metabolic acidosis

pH 7.50 Alkalosis pH 7.27 Acidosis

PaCO2 30 Low PaCO2 38 High

HCO3 25 Normal HCO3 14 Low

Interpretation:

- Low PaCO2 will cause high respiratory rate A: compensated respiratory acidosis
(RR). Maybe px is in severe pain, fear,
anger, anxious pH 7.39 Normal
- Bicarbonate takes days to react PaCO2 60 High
- Fast breathing, release too much CO2
- Tachypnea is shallow breathing. While, HCO3 34 High
Hyperventilation is deep

10.) A: Combined Acidosis

A: uncompensated metabolic alkalosis
pH 7.32 Acidosis
pH 7.56 High
PaCO2 52 High
PaCO2 42 Normal
HCO3 18 Low
HCO3 40 High
Interpretation:

- Plenty of CO2. (pneumonia, asthma, COPD)

A: compensated metabolic acidosis
- 18 Bicarbonate didn’t compensate so it
may be broken (COPD, renal failure, pH 7.36 Normal
probable Diabetes)
- Diabetes & Hypertension destroy kidneys PaCO2 29 Low

11.) A: Uncompensated Metabolic Acidosis HCO3 20 Low

pH 7.27 Acidosis

PaCO2 38 Normal A: partially compensated respiratory acidosis

HCO3 14 Low pH 7.34 Low

Interpretation: PaCO2 52 High

- Uncompensated metabolic acidosis because HCO3 30 High

the CO2 didn’t do anything.

Wrong or Not Possible Case:

• ↑ CO2 = not excreted well
A: • ↑ HCO3 = kidneys are compensating
because we have plenty of carbon
pH 7.38 Normal dioxide in the body. Kidneys will
produce plenty of bicarb and able to
PaCO2 43 Normal bring pH within the normal level
• Tachypnea = cause of too much acid. To
HCO3 18 Abnormal be able to blow off some acid in the
form of CO2 (carbonic acid + water)
Interpretation

- Bicarbonates are low. So PaCO2 needs to

compensate, it should be low.
- Many acids → High RR to remove CO2 →
PaCO2 is low.
- PaCO2 is 43 so it didn’t do anything. Not
probable.
 PULMONARY EMBOLISM RIGHT VENTRICULAR HYPERTROPHY
Blood cannot pass through because of
obstruction → high afterload (right ventricle)
→ right ventricle having a hard time pushing
blood against the pressure → increasing the
work load → muscles will enlarge

Less blood supply to the lungs → less cardiac

output (amount of blood ejected by the heart
in 1 minute) → anaerobic metabolism → plenty
of lactic acid → metabolic acidosis

With hypertension/COPD (viscous blood)

Bronchoconstriction (diminishing lumen of the
blood) → high pressure in the lungs (pulmonary
hypertension) = increasing workload of right
ventricle

Cardiac muscle: less space for blood to enter

→ less blood in the lungs for oxygenation →
less blood going to the left side of the heart
→ less cardiac output → metabolic acidosis
o 90% come from lower extremities
Cannot accumulate blood in the right → blood
o Blood stopping lower extremities =
will regurgitate → going to right atrium →
blood can be viscous → forming a clot
blood from superior vena cava cannot be
To prevent:
accommodated by the right side of the heart →
▪ Contract muscles → squeeze veins flow of blood in superior and inferior vena
→ causing valves to push blood cava → Neck Vein Engorgement (vein will be
back from the heart
distended)
o Thrombus: attached to the wall of the
vein
ATRIAL FIBRILLATION
o Embolus: detached
Heart is beating too fast. Atrium is
o Can also be a fat embolism contracting 200-400 times per minute → SA node
o Decrease oxygen in the lungs (alveolar
damaged (right atrium) → tricuspid and
hypoxia)
bicuspid valves will open when atrium
▪ Lessen blood supply to the lungs contracts pouring blood into the ventricles
→ bronchoconstriction (smaller for about 2-3 seconds only (because of 200-400
lumen of bronchi) → increased beats per minute = ↑ cardiac rate) → 80-120 cc
pressure → pulmonary hypertension of blood did not enter ventricles → blood
o Obstruction (clotted blood/lipids) → accumulating in the atrium → blood becoming
obstructed airways → alveolar hypoxia viscous → opportunity to clot → clotted blood
in the atrium → ventricles → obstructing
pulmonary artery → less oxygenated blood going
through the different systems of the body →
anaerobic metabolism (mitochondria cannot
produce a good amount of ATP needed by the
cell) → body will produce lactic acid
*normal: AV valves open for about 5 seconds
for 80-120cc of blood to enter ventricles
 CHRONIC ONSTRUCTIVE PULMONARY DISEASE
It is a disorder wherein the protein alpha-1
antitrypsin is defective or absent. This
protein is a protease which inactivate
elastase that breaks down elastin. But since
there is a deficiency, the elastase cannot be
prevented from breaking down too much elastin.
This primarily affects the lungs. If there are
bacteria or foreign matter that has entered
particularly in the alveoli, the Neutrophils
usually arrive to release Neutrophil Elastase.
This elastase is going to break down the
proteins of the bacteria and as well as the
elastin - which gives the lung tissues
elasticity and strength. But before this
elastase could break down the elastin in our
lung tissue surface, the liver will release
the alpha-1 antitrypsin to inhibit
elastase. Without this alpha-1 antitrypsin
protein, the neutrophil elastase goes
unchecked causing further breakdown of the
elastin in the alveolar walls therefore also
resulting in the alveoli to lose
structural integrity and elasticity. If this
happens, there would be loss of elastic recoil
resulting in decrease in ventilation and
destruction of the alveolar wall and capillary
bed would result in decreased perfusion.
HYPOXIC DRIVE
Normal (Central Chemoreceptor)
The stimulus for respiratory center is found
in medulla oblongata and pons. (inhalation and
exhalation). The presence of carbon dioxide
(end product of metabolism = waste product)
drives us to breathe
In COPD, Peripheral Chemoreceptor
o Stimulated with low oxygen (hypoxic
drive)
o Because of destroyed airways
damaged alveoli, it damages elastin and
collagen and it will not be elastic
anymore. It completely distends alveoli
and carbon dioxide will accumulate in
the alveoli
o There is bronchoconstriction,
inflammation, and accumulation
carbon dioxide in the lungs = barrel
chest
o If 6-8L of oxygen, patient may develop
respiratory distress because it would
not stimulate hypoxic drive
o 1-2L of oxygen only because of the
damaged airways and alveoli, there is a
high level of carbon dioxide which is
not good. This will stimulate
peripheral chemoreceptors (carotid
arteries) for the stimulating hypoxic
drive (low flow of oxygen)
o Venturi mask is used to give a precise
level of oxygen
POLYCYTHEMIA = destroyed alveoli → less oxygen
in blood → kidneys being the secondary organs
will be affected → release erythropoietin →
stimulate bone marrow to produce red blood
cells.
Compensatory mechanism that makes blood
viscous. The hematocrit can be evaluated.
COR PULMONALE
According to WHO, enlargement of the right
ventricle due to respiratory disorder (but not
if pulmonary edema)
1. Kidneys compensated, releasing
erythropoietin = producing RBC = high
hematocrit (blood viscous). Muscle of
the right ventricle having a hard time
pushing a viscous blood
2. Chronic bronchitis is an inflammation,
alveoli damaged, oxygen content of
lungs diminished, less oxygen in lungs
because of damages airways and alveoli.
= bronchoconstriction. Smooth muscle
the surrounding airways will contract and
construct airway, decreasing lumen =
pulmonary hypertension (high pressure
in the lungs). High pressure in the
pulmonary arteries. Viscous blood =
its enlarge the heart
NURSING INTERVENTION
o Backslapping
o Vibration
o Postural drainage
Rebamipide (Mucosta)- Antacid
o Because of steroids (intravenously can
cause gastric ulcer)
o It is given to counteract solu-medrol
o A cytoprotective agent (protect mucosa
of stomach because patient is receiving
medication that can cause gastric
ulcer)
ASTHMA
o Hereditary, inflammatory disorder
o Swelling in airways
and o Psychological stressors (asthmatic
attack)
RISK FACTORS
o Dust (rich in cockroaches, becoming
part of the dust) = acts as an irritant
o Foods (seafoods) oyster, shrimp,
of mussels, eggs, chocolate
o Soap (ariel or tide)
o Smoke
o Weather
o Perfumes
PATHOPHYSIOLOGY
Obstruction
Airways are affected (bronchi), there are
goblet cells stimulating mucus, obstructing
the airways (complete/partial).
Passage of oxygen and carbon dioxide will not
be good. Carbon dioxide will be in the airways
and won’t be eliminated
Obstruction
Plenty of mucus
Edema
Because of inflammatory disorder
Less oxygen in lungs = bronchoconstriction
 DRUGS USED TO TREAT ASTHMA

SHORT- ACTING BRONCHODILATORS

Short – Acting beta – 2 agonists
o SALBUTAMOL – Ventolin/Asmalin
o TERBUTALINE SULFATE – Bricanyl (can
also be used in delivery room)
Bronchodilators to dilate airways (for easy
breathing; mucus will move)
Expectorant (let patient expectorate mucus)

MDI
o Put patient in sitting or semi fowlers
o Place it in front of the mouth
o Seal it with lips
o Let patient inhale exhale then push
hold breath for 10 sec (for the
Smooth muscle is going to contract, squeezing medicine to reach the deepest part of
the lumen = high pressure lungs)

If there is airway obstruction in bronchi

There will be atelectasis (collapse of part of
the lung) = ventilation/perfusion mismatch
The ventilation is affected because airways
are obstructed. Perfusion is flow of blood
that enters the right ventricle (unoxygenated)
pulmonary trunk entering the lungs for
oxygenation
If collapsed, not all blood will be oxygenated
Blood with less oxygen = quality of blood
ejected by the left ventricle to the different
systems of the body

SINGS AND SYMPTOMS

o Irritable (brain cells not oxygenated)
o Restlessness (less oxygen)
o Hypoxemia (blood going to descending BRONCHODILATORS
aorta to different systems of the body Beta-Adrenergic Drugs
= less oxygen o Albuterol – Ventolin
o Easy Fatiguability (cells not receiving o Metaproterenol – Alupent
sufficient amount of oxygen) Bronchodilators with long duration of action
o Pallor (less oxygen) Frequently administered by metered-dose
o Increased cardiac rate (because heart inhaler
has to compensate)
o Increased respiratory rate METAPROTERENOL
o Tachypnea (respiratory acidosis, lungs o Metaproterenol (Alupent)is a
compensate increasing respiratory rate) sympathetic bronchodilator
o The client should take the last dose a
UPON AUSCULTATION few hours before bedtime so that the
o Plenty of mucus = crackles medication does not produce insomnia
o Obstructed airways = reduced breath
sounds (dangerous signs) ALBUTEROL
o Rales/crackles (partially obstructed) o Albuterol (Proventil) is a
bronchodilator
HYPERINFLATION (plenty of carbon dioxide in o The patient should avoid drinking large
the lungs) obstructed airways = hypercapnia. amounts of caffeine-containing drinks
Can develop respiratory acidosis such as tea, coca and cola drinks
▪ Make brain cells alert
EX: o Sprite and 7-Up do not contain caffeine
65 years old, with pneumonia and hypertension
(less blood going to kidneys = reabsorbing ANTICHOLINERGICS
bicarbonates) = Diarrhea o Ipratropium Bromide – Atrovent/Duavent
o pH: 7.29 = decreased (acidosis) o Used to treat asthmatic conditions by
o PCO2: 48 = high(respiratory) dilating the bronchioles
o HCO3: 20 = low (combined respiratory o stopping action of parasympathetic =
and metabolic acidosis) because bicarb bronchodilator
went down
Low=compensating
Ipratropium Side Effects o If patient receiving for 3 months, it
Atrovent softens bones developing fractures
o Dryness of mouth (resulting to o Weight gain = because it causes
halitosis) reabsorption of sodium attracting
o Cough water, increased appetite, BP also
increases
Duavent ▪ Lessen sodium in diet
o Dyspnea ▪ Give food that has less
o Cough carbohydrates
o HPN
o Tremor, nervousness HEALING FOODS FOR ASTHMA
o Insomnia FOODS HIGH IN VITAMIN C
o Papaya
COMBIVENT o Guava
o The combination of ipratropium bromide o Oranges
with albuterol o Kalamansi
o Used to treat chronic bronchitis o Strawberry
o For patients who require more than a o Datiles
single bronchodilator o Melons

MDI TEACHING POINTS

o Wait 30 seconds between inhalation of
same medication
o Wait 5-10 minutes between inhalations
of different medications
o Inform the patient to start breathe in
slowly for 3 to 5 seconds, to draw in
medication
o Instruct patient to hold his breath for
10 seconds, to allow medicine to go
deeply into his lungs.
o Use BRONCHODILATOR before
CORTICOSTEROIDS (for better absorption
GLUCOCORTICOIDS
o Beclomethasone (Foster) – MDI
o Dexamethasone (Prednisone) – Tablet;
(Decadron) (IV & Tablet)
INHALED CORTICOSTEROIDS
o First line therapy for Asthma
o Used for clients with moderate to
severe Asthma
Most Common Adverse Effects
o Oropharyngeal Candidiasis
▪ Steroids can still be in the
mouth killing lysosomes prone to
mouth infection
▪ To minimize this effect, clients
should GARGLE after each
administration
▪ Nurse will let px perform mouth
wash to remove remaining steroids
o Dysphonia (voice hoarseness)
o Inflammation (-it is_
o Gastric ulcer
o If taking more than 2 weeks, it
diminishes immune system (activity of
WBC = prone to infection
o If patient has catheter, asepsis
technique
o Good personal hygiene if patient is
advised to take prednisone for 3
months (hand washing, bath, changing
underwear)
o Take after a meal because it can cause
gastric pain
NURSING INTERVENTIONS
o Loosens mucus secretion
o Backslapping
o Postural depression
o Increase fluid
o Perform coughing exercises
o Try to know the cause that triggers
asthma
o Don’t put patient in a room with
carpet, heavy curtains (it collects
dust) or many books, newspapers,
stuffed toys
o Wear masks if travelling publicly /
handkerchief or face towel, wet it and
squeeze water as a mask
o Expose pillows and mattresses once a
month
o Hypoallergenic pillows or mattresses
o Tonsillectomy: cold foods
CARDIOVASCULAR
CIRCULATION OF THE HEART
The unoxygenated blood coming from the upper
extremities will go to the superior vena cava,
while the unoxygenated blood coming from the
lower extremities will go to the inferior vena
cava → right atrium → tricuspid valve → right
ventricle → pulmonary valve → pulmonary trunk
→ pulmonary artery, going to the lungs for
oxygenation then it will go to the four
pulmonary veins → left atrium → bicuspid valve
→ left ventricle → aortic valve → ascending
and descending aorta → different parts of the
body
o 70 cc (lub-dub)
o Cardiac Output – 5-8 liters
CONDUCTION SYSTEM
Superior and inferior vena cava → SA node
(contract 60-100 bpm) → right atrium
(contracting) → Bachman’s bundle → left atrium
→ AV node (open valves and semilunar valves
close) → bundle of his (atrioventricular
valves close, ventricles contract) → purkinje
fibers (AV valves close, SV valves open) → the
right ventricle pushes unoxygenated blood
against the pulmonary valve going to the lungs
→ then the left ventricle pushes oxygenated
blood against the aortic valve → aorta →
different systems of the body
o 8 seconds – cardiac cycle

STROKE VOLUME: amount of blood ejected per

contraction (lub-dub)

CARDIAC OUTPUT: blood ejected by the heart in

one minute (5-8L)

DIASTOLE
Opening of the atrioventricular valves which
are the tricuspid and bicuspid valves and the
closing of the semilunar valves which are the
pulmonic and aortic valves. The ventricles are
in a relaxed state and the atrium contracts
filling ventricles with blood; s2 sound is
produced
SYSTOLE
Closing of the atrioventricular valves which
are the tricuspid and bicuspid valves and the
opening of the semilunar valves which are the
pulmonic and aortic valves. The right
ventricle pushes unoxygenated blood to the
pulmonic valve going to the lungs for
oxygenation and at the same time, the left
ventricle contracts and pushes oxygenated
blood to aortic valve to ascending and
descending aorta to be distributed to the
different systems of the body
The medium and big arteries are affected
(coronary arteries) arteries that supply blood
with oxygenated blood for the heart to
function as a pumping organ
Affected with lipids/plaques, obstructing
artery
Carotid arteries (vertebral arteries) = supply
the brain with oxygenated blood
Young people (as early as 2 years old) can
develop lipids in arteries especially if fat
Progressive: will take years to be big in size
and will later cause complete obstruction
ARTERIOSCLEROSIS
Small arteries are affected

PRELOAD: when chambers of the heart (atrium DEVELOPMENTAL STAGES OF CAD

ventricles) filling with blood, during
diastole, atrioventricular open, giving blood
to ventricles = distend
Place px in a semi fowler to decrease preload,
giving rest to the heart, diminishing blood
going back to the heart

AFTERLOAD: pressure that the heart must

overcome to eject the blood
Ex: BP-160/100; 60-80 in left ventricle, it
cannot eject blood = generating higher
pressure so that it can push blood towards the
different systems of the human body,
increasing workload and muscle will enlarge
(left)

Risk factors: Obesity

ATHEROSCLEROSIS Complications
o Peripheral arterial disorder
o Myocardial infarction
o CVA

Myocardium will die = less contractility;

blood remains at heart
COLLATERAL CIRCULATION ECG INTERPRETATION
o Compensatory mechanism P wave – the atrioventricular (bicuspid and
o More blood vessels formed tricuspid valve) are open during the p wave,
o Disadvantage: weak and new blood the atriums are contracting and filling the
vessels = can rupture and have bleeding ventricles with blood.

PR – the stimulus is already received by the

AV node, trying to open the valves a longer
time so that more blood will go to the
ventricles

QRS – the ventricular contraction, systole,

the stimulus is already received by the bundle
of his and purkinje fibers, the
atrioventricular valves will close (bicuspid
and tricuspid) and the semilunar valves are
open, and the right ventricle will eject the
unoxygenated blood towards the lungs for
oxygenation, and the left ventricle will also
contract pushing the oxygenated blood to the
RISK FACTORS FOR CAD aortic valve to the aorta, to the different
A. NONMODIFIABLE RISK FACTORS systems of the body
o Age: arteries not elastic, sudden
change of position causes dizziness and ST – the ventricles has ejected all the blood
fall (should be gradual and walk and is starting now to relax
slowly)
o Gender: males (stressors in life e.g., T – ventricles are contracting
fight in a family, bad relationship
with coworkers, death of a family CASE STUDY PRINCIPLES
member, jobless) = they handle it by COPD
usually smoke and drink liquor
▪ Nicotine causes vasoconstriction, DRUGS (fucking reason muna bakit ibibigay sa
increasing blood pressure, patient bago ka maglagay ng fucking mechanism
destroying intimal layer of of action)
artery = no supply of the nitric Examples:
oxide (produced by intimal o Ampicillin was ordered because cilia
layer). It dilates artery. If was paralyzed making the patient
pressure is always high, it susceptible to infection, etc.
destroys it. Artery won’t be able o Steroid is given because of chronic
to dilate bronchitis there is inflammation in
o Ethnicity: African-Americans because of order to stop the migration of WBC,
high salt intake; Koreans and etc.
Filipinos; 1 in every 4 Filipinos are o Rebamipide is given because patient is
hypertensive taking ampicillin and steroids, both
o Family history: genes; hereditary are GI irritants, a cytoprotective
agent, etc.
B. MODIFIABLE RISK FACTORS
o Elevated serum lipids: do not eat red HEALTH TEACHING (i-relate sa case ng patient;
meat (beef)/ limit (bad cholesterol) common sense)
▪ Should be lower than 200mg Examples:
o Hypertension: 140/90 1. Cessation of smoking (patient might
▪ Can be prevented by limiting food smoke again, importance of reducing
intake and exercise regularly, number of cigarette)
lessen stressors in life a. Avoid friends who are smoking
o Diabetes – high glucose levels may b. Let patient put all cigarette box
irritate the endothelial layer of the in a transparent container so
blood vessel, leading to that patient can realize just how
atherosclerosis many cigarettes did he already
stopped taking
ANGINA c. If there is an urge to smoke,
Chest pain - can be obstructed with lipids; chew bubblegum as substitute
blood cannot flow into the heart. Continuously 2. Good hydration (increase fluid intake)
beat but activity will be converted to 3. Pursed lip breathing (include how)
anaerobic metabolism (less oxygen) because of 4. Avoidance of infection
clotted blood (less blood) → body is producing a. not going to crowded places
lactic acid stimulating nerve endings at the b. avoiding people with respiratory
heart → angina or chest pain infection
c. vaccines
5. Dietary
 ▪ Decrease Carbohydrate Content: o Spasm – less blood (ischemia)triggered
The end product is CO2 by smoking or cocaine causing chest
▪ Avoid gas forming foods = pain
bloating push diaphragm o Unlike typical angina-which is often
triggered by exertion or emotional
MYOCARDIAL INFARCTION stress
o Almost always occurs when a person is
DRUGS at rest, usually between midnight and
NITROGLYCERIN – dilates coronary artery early morning
There is pain when there is less blood supply. o These attacks can be very painful
With MI, there is lipid meaning there is less o Can be severe but pain can respond to
blood supply going to the heart → aerobic medications like NTG.
changed to anaerobic → lactic acid produced → o Can occur even at rest
pain
Relieves pain by dilating coronary artery: ANGINA COMPLAINTS
pain will subside, giving plenty of blood = no o Heaviness
lactic acid produced o Pressure
o Squeezing
MORPHINE SULFATE (opiate) – for chest pain o Burning sensation/tenderness (For
Drug for chest pain (primary), relieves pain women)
and anxiety (not stimulating norepinephrine,
there will be no vasoconstriction that lessens
blood supply) and also a dilator

INTERVENTIONS IN PTCA
Stent inserted at femoral artery
Once the catheter is removed, there is wound,
and there will be clotted blood (normal
reaction) *platelets will be attracted to that
area*
1. Keep patient on bed rest and keep legs
straight for 4-6 hours (can be
dislodged and go to the lungs)
2. Put sand bag over the area to prevent
bleeding

PAIN radiates because of presence of the

nerves

Coronary artery is blocked with lipids = less

blood supply going to heart = aerobic will be
changed to anaerobic and it will be producing
lactic acid (Krebs cycle) = irritate nerve
endings at the heart = ANGINA

ANGINA PRECIPITATING FACTORS

4 E’s
o Exertion
o Eating (after heavy meal) food remain
at stomach – stomach needs a lot of
blood to digest food but if there’s
blockage, possible for patient to have
chest pain
o Emotional distress (catecholamines
cause vasoconstriction) STABLE UNSTABLE MYOCARDIAL
ANGINA
o Extreme temperatures (cold causes ANGINA ANGNA INFARCTION
vasoconstriction = less blood) More than 50% Complete
Blockage 50%
- 90% obstruction
Prinzmetal Angina Less than More than
o Vasospasm occurs Duration 15-20 minutes
10 minutes 30 minutes
▪ Narrowing of the coronaries Immediately Morphine
▪ No buildup of fatty deposits in Relief by resting NTG IV only Sulfate
the artery walls or NTG SL only
o Experienced at night, which can be Predictable
Unpredictable
disruptive to sleep (doing
o It is a medical condition in which (can occur
something
there is temporary spasm of the Onset while working
heavy →
coronary arteries causing pain and or even
inadequate
discomfort resting)
blood
 supply →
chest pain)
NITROGLYCERIN SUBLINGUAL HEALTH TEACHING
1. Take the drug sublingually (under
tongue) up to 3 doses at 5 minutes
interval
o Ex: Patient is given at 8:00,
then go back at 8:05 and ask if
the patient still has pain. If
so, give the second dose. Ask
patient again at 8:10 and if so,
give the third dose. If pain
persists, don’t give the fourth
dose and bring patient to the
hospital – possible Myocardial
Infarction
2. Once buying NTG, store it in original
container, should be colored because it
is sensitive to light
3. Store in a cool, dry place (not in the
refrigerator, because it will cause
moisture)
4. Bring NTG whether in school or office,
but do not put in pocket or glove
compartment, because it can destroy
potency of drug
5. If there is discoloration upon opening
the container, discard
NITROGLYCERIN PATCH HEALTH TEACHING
1. Apply it anywhere in the chest (no
lesion, sweat, hair)
o Do not shave if there is hair
because purpose of the drug is
slower absorption
2. Not to apply patch in the same area
everyday (cause contact dermatitis);
rotate it
3. Common side effect: headache (call
physician for medication of headache,
probably acetaminophen)
4. Wash hands after applying patch. Can
cause vasodilation of the arteries
5. Before sleeping at night, tell patient
to remove patch
Additional:
• The nurse should remove the old patch,
wash the client’s skin
• Note the date and time the new patch is
applied
• Apply it in a new area that is not
hairy
• The NTG patch should be held if the
client’s blood pressure is less than
90/60
ECG
P WAVE – atrium (left & right) are contracting
and AV (tricuspid & bicuspid) valves are open.
Atrium giving blood to ventricles (diastole)
PR INTERVAL
QRS – ventricles are contracting so that AV
valves should close and semilunar valves open.
Right ventricle is contracting unoxygenated
blood. Entering pulmonic valve → pulmonary
trunk → pulmonary arteries → lungs for
oxygenation. Left ventricle also contracting
giving out oxygenated blood entering aortic
valve to ascending aorta to different systems
of the body (occupies 1 small box)
ST SEGMENT – early ventricular
repolarization/depolarization
T WAVE – complete ventricular repolarization
o PR and ST segment should be at the same
level (normal)
o Depression of ST segment – indication
of myocardial ischemia
COMPONENTS OF A NORMAL ECG
PWAVE: <0.11 SECONDS
QRS: 0.06-0.1O SECONDS
TWAVE: 0.16 SECONDS
PR INTERVAL: 0.12-0.20 SECONDS
NON-ST-SEGMENT ELEVATION MI
o Same signs and symptoms with unstable
angina
o Occurs at rest or with exertion; limits
activity
o LONGER IN DURATION and MORE SEVERE than
in UNSTABLE ANGINA
o Cardiac Catheterization and
Percutaneous Coronary Intervention
DIAGNOSTIC FINDINGS
o ST-segment depression or T-wave
inversion on ECG
o Cardiac biomarkers are elevated
o There may be less damage to the
myocardium
ST-SEGMENT ELEVATION MI
o Thrombus fully occludes the coronary
artery
o Same signs and symptoms with ANGINA and
NSTEMI
o Occurs at rest or with exertion
o LONGER IN DURATION and MORE SEVERE than
in UNSTABLE ANGINA
DIAGNOSTIC FINDINGS
o ST-segment depression or T-wave
inversion on ECG
o Cardiac biomarkers are elevated
o There is significant damage to the
myocardium
PHASES OF MYOCARDIAL INFARCTION CLINICAL MANIFESTATIONS
o Chest pain
Myocardial Ischemia o Vomiting (can trigger vomiting center,
o less blood supply because coronary but not all patient will vomit)
artery is with lipids/plaques o Tachycardia
o depressed ST segment o increased blood pressure
o Causes ST segment Depression with or o cold, clammy, pale skin
without T wave inversion as result of o decreased cardiac output
altered repolarization. o increased respiratory rate
o hypoxemia
Myocardial Injury o body weakness
o ST elevation o low grade fever
o Causes ST segment elevation with or o leukocytosis
without loss of R wave
o can also mean other diseases like *stimulates cathecholamines epinephrine
pericarditis causing tachycardia and norepinephrine that
o inverted T wave causes vasoconstriction therefore increasing
blood pressure and giving patient cold,
Myocardial Infarction clammy, pale skin (SNS stimulation) *
o ST elevated,
o T wave inverted Interventional laboratory
o Q is deep and wide o Where angioplasty is done
o Causes deep Q waves as result of o Guided by fluoroscopes
absence of depolarization current from
dead tissue and receding current from Before PTCA:
opposite side of heart o IV line
o Death of one part of heart usually o Heart monitor
myocardium o Oral or IV sedative

*No death of tissue in ischemia and injury After PTCA

o Apply pressure bandage
CARDIAC ENZYMES o Lie on back for several hours
o released by heart whenever injured o Check for bleeding or chest pain
CK-MB o Discharged same day or stay overnight
CARDIAC TROPONIN
TROPONIN I (CREATININE
BIOMARKERS T
KINASE-MB) PERICARDITIS
Exclusively *itis-inflammation
Seen in
seen in
cardiac Most PERICARDIUM
cardiac
and reliable outer layer of the heart; followed by
muscle
skeletal before myocardium (muscle responsible in contracting
(most
muscle heart); then inner endocardium
reliable)
3-6 o Provides lubrication to decrease
3-6 hours 4-6 hours friction during systolic and diastolic
hours
Release after after heart movements
after
injury injury o Normally it contains 10 to 15 mL serous
injury
5-14 fluid
5-10 days 2-3 days o Assist in preventing in excessive
days
Elevation after after dilation of the heart during diastole
after
injury injury
injury
Sac contains fluid so that parietal will not
PTCA INDICATION: for patients with coronary come in contact with visceral. If parietal and
arteries that have at least 70% narrowing visceral touch, it causes friction and will
give severe chest pain
ANGIOPLASTY CABG
4 arteries 5-7 arteries

STENT
o a foreign body
o 2 complications
▪ Blood clots (can go to the brain
= CVA)
▪ infection
o Tissue will grow over it becoming a
part of artery holding it in place
o Can still be blocked with lipids and
undergo PTCA again
 *Sharp, stabbing chest pain is a common
symptom of pericarditis*

PERICARDIUM PALAPTION
o Apex beat (5th
intercostal
space/mid-
clavicular line)
o to feel
pulsation
o to evaluate
apical pulse
o to assess
dilation and
dynamics of RV, aorta and pulmonary
artery
Pericardial Cavity o If obese, place patient at left lateral
o 10-15 ml of water acts as a lubricant decubitus position to put heart
o Parietal layer contains plenty of nerve anteriorly for you to feel it
endings. If it comes in contact with
visceral = chest pain Can anemia give you chest pain?
o Protect heart: pericardium = parietal & - Yes, because lack RBCs → less oxygen →
visceral = pericardial sac (act as aerobic-anaerobic → lactic acid → chest
lubricant) pain

AUSCULTATION
o The most characteristic clinical
manifestation is CREAKY, or SCRTACHY,
GRATING in quality friction rub
o Heard in both the inspiratory and
expiratory phases of the respiratory
cycle

ECG

ETIOLOGY
VIRAL
o Echo virus
o Mumps
o HIV
o Hepatitis
BACTERIAL
o Pneumococci
o Streptococci o T wave initially upright and elevated
NONINFECTIOUS but then during recovery phase it
o Uremia inverts
▪ Renal failure = toxins: uric o ST segment elevated and usually flat or
acid, urea, creatinine concave
▪ Can also be azotemia
▪ Results to inflammation of the PAIN
heart o The pain is generally worse with deep
o Acute MI (because of blood) INSPIRATION and when lying supine or
o Cancer, radiation turning
o Trauma: thoracic surgery, pacemaker ▪ when lying down, parietal by
insertion gravity comes in contact with
o Dissecting aortic aneurysm visceral = chest pain
▪ pain on inspiration associated
CLASSIC TRIAD OF SYMPTOMS with pericarditis is due to
1. CHEST PAIN: with fluids, decreased contact between the inflamed
contractility of heart → less stroke pericardium, which is adjacent to
volume and cardiac output → less blood the diaphragm, and the trachea
going to coronary artery → aerobic- o It is relieved by sitting up and
anerobic = chest pain leaning forward
2. FEVER: general manifestation of patient ▪ Sitting up and leaning forward
with inflammation positions the stretched
3. PERICARDIAL FRICTION RUB: heard through pericardium away from the pleura,
stethoscope which relieves comfort
 ▪ Sitting up: allow CARDIAC TAMPONADE
pericardium to o If accumulation is rapid, as little as
hung 100 to 150 mL of blood in the
▪ Leaning forward: pericardial sac can adversely affect
to keep parietal cardiac output
layer away from o The leading cause of cardiac tamponade
the visceral is penetrating chest injuries (80% to
layer 90%) such as stab wounds
o DYSPNEA o Develops as the pericardial effusion
▪ Pain on inspiration associated increases in volume, → compression of
with pericarditis is due to the heart → restricts diastolic
contact between the inflamed ventricular filling → cardiac output
pericardium, which is adjacent to drops
the diaphragm and the trachea. o Results from a stab or gunshot wound or
▪ Sitting up and learning forward surgery = plenty of blood in
positions the stretched pericardial sac → limit contraction of
pericardium away from the pleura the heart → less cardiac output →
which relieves discomfort. hypoxemia, renin released
▪ The parietal (fibrous) o Develops as the pericardial effusion
pericardium is innervated with increases in volume → compression of
pain nerve fibers responsible for the heart → restricts diastolic volume
producing the pain experienced in
pericarditis.

MANIFESTATIONS
o PERICARDIAL FRICTION RUB at the left
sternal of the chest
o Fear and ANXIETY
o INCREASED WBC COUNT
▪ given with steroids (anti-
inflammatory) to prevent of WBC
to injured site (causes edema and
sever pain)
o ELEVATED ESR and C-REACTIVE PROTEIN
(dangerous)
o NONPRODUCTIVE COUGH or HICCUP

TWO MAJOR COMPLICATIONS

PATHOPHYSIOLOGY
PERICARDIAL EFFUSION
Less than 100cc → because of inflammation
there will be exudates → increase fluid in
pericardium (can have blood, if stabbed,
gunshot wound, or surgery entering
pericardium) → limiting space of ventricles →
less contractility (less space because of
fluid) → less stroke volume and less cardiac
output → SVC: neck vein engorgement; IVC:
hepatomegaly

SIGNS AND SYMPTOMS

o Confused, anxious, and restless
▪ More than 2L → compress heart →
plenty of fluids → hard time
contracting → cardiac output less
→ brain cells depend on blood →
less cardiac output → less oxygen
and nutrient in the brain →
confused, irritable restless
 o Tachypnea and tachycardia ▪ Decrease migration of WBC in
▪ Decreased cardiac output → injured site and decreases immune
stimulate SNS → triggering system
adrenal medulla → producing o PERICARDIOCENTESIS – performed only
catecholamines epinephrine causes for:
tachycardia (trying to ❖ Pericardial effusion with cardiac
compensate) & norepinephrine tamponade
cause vasoconstriction to ❖ Purulent pericarditis
increase blood pressure because ❖ Neoplasm
it is one way in putting more
blood to the brain HEALTH TEACHING FOR ASPIRIN
o Distended neck veins o Instruct patient to take it after a
▪ Plenty of fluids in pericardial meal because it causes gastric
sac that it is compressing the irritation that can cause ulcer
heart → unoxygenated blood from
superior and inferior vena cava HEALTH TEACHING FOR COLCHICINE/PREDNISONDE
cannot enter atrium → back flow Decreases immunity (usually after 2 weeks of
of blood taking it)
o Muffled heart sounds o Tell patient to not expose himself to
▪ S1 cannot be differentiated with crowded places and people with
S2 respiratory infections
o Advise patient to have good hygiene
❖ Although muffled heart sounds indicate (good hand washing technique)
accumulation of fluid around the heart Can cause osteoporosis if taking for more than
❖ Narrowing pulse pressure signals 3 months
cardiac tamponade o Protect patient from falls because it
▪ Pulse pressure (difference can cause fracture of bones
between systolic and diastolic For side effects, it causes weight gain due to
pressure) sodium retention. Patient becomes a voracious
▪ normal: 30-40mmHg eater and mooning of the face. Advise patient
▪ tells you pressure inside to avoid:
arteries o Salt and caloric intake
▪ Ex: 90/70 = 20 (narrowed pulse ▪ Junk foods
pressure) ▪ Cured meats (bacon, ham)
▪ Cold cuts (sweet ham, Canadian
PERICARDIOCENTESIS ham)
▪ Canned goods
▪ Boxed foods
▪ Condiments high in salt
▪ Chicken nuggets
▪ Milk and milk products (cheese,
butter, ice cream, cottage
cheese, queso de bola)

NURSING CARE
o Bed rest until fever, chest pain, and
friction rub have subsided
o Pain may be relieved with a FORWARD
LEANING or SITTING POSITION
o Providing simple, complete explanations
of all procedures and possible causes
DIAGNOSTIC STUDIES of the pain
o Widespread ST segment elevations ❖ The goal of nursing management is PAIN
o Elevated CRP and ESR RELIEF
o CT imaging – best diagnostic tool to o Reassure patient that the pericardial
determine size, shape, location pain does not indicate an MI
o MRI for visualization of the o Six meals a day; avoid gas-forming
pericardium and pericardial space foods
-Produces plenty of flatus → abdominal
MEDICAL MANAGEMENT distention → pushing diaphragm up →
o ASPIRIN, IBUPOROFEN (anti-inflammatory chest pain
▪ Given because it lessens ▪ Eggs
inflammation and therefore lessen ▪ Soft drinks
the swelling. Inhibits migration ▪ Broccoli
of WBC in the injured area ▪ Eggplants
o COLCHICINE or PREDNISONE for severe
▪ Beans (chili con carne)
pericarditis
▪ Kamote (sweet potatoes)
 *know certain dishes for beans and vulnerable in having frequent
sweet potatoes* grrr upper respiratory infection
▪ Tonsillectomy is done to prevent
VALVULAR DISORDERS rheumatic heart disease
o Congenital
CHORDAE TENDINEAE o Calcification-elderly
Valves are connected to chordae tendineae so o Ineffective endocarditis
that it will be closed then connected to MITRAL VALVE STENOSIS DEVELOPS SLOWLY OVER 10
papillary muscles to 20 YEARS

During Systole SIGNS AND SYMPTOMS

Will pull chordae tendineae to close o The first symptom is DYSPNEA ON
atrioventricular valves so that blood in the EXERTION as a result of pulmonary
ventricle will not go up (regurgitation) venous hypertension
o CLINICAL MANIFESTATIONS
INTRODUCTION ▪ Fatigue
Mitral Stenosis ▪ Palpitations
o narrowing ▪ Orthopnea
o can also be because of aging because of ▪ Paroxysmal nocturnal dyspnea
calcium deposits
o genetics DYSPNEA
During Diastole (should be open to deliver Exertional Dyspnea: whenever you increase
100-120 cc of blood to ventricles) not all activity
blood will go to ventricles → less blood →
less cardiac output → less glucose and oxygen Orthopnea: dyspnea in a lying position
to different systems of the body = body o can I have a pillow? (patient’s
weakness and easy fatigability request)
o If patient requests for 2 pillows = 2
Regurgitation pillow orthopnea
o valves cannot close completely and o Depends on the number of pillow kung
blood returns san comfortable to breathe
Mitral Insufficiency Paroxysmal Nocturnal Dyspnea: is a sensation
o valves cannot close completely of SHORTNESS OF BREATH that awakens the
patient, often after 1 to 2 hours of sleep,
MITRAL STENOSIS and is usually relieved in the upright
The heart valves can be inflamed and become position
scarred over time. This can result in
narrowing or leaking of the heart valve making DRUG TREATMENT
it harder for the heart to function normally. DIURETIC
This may take years to develop and can result o Ex: Furosemide (Lasix): removes excess
in heart failure. water from the body.
o If there is water in pulmonary bed, the
ETIOLOGY amount of blood that goes to ventricles
o Rheumatic fever – most common cause are less. Blood will accumulate in left
▪ Since there is bacteria atrium (enlarge) → cannot accommodate
(Streptococci) the body will oxygenated blood entering pulmonic
compensate, antibodies will be valves → lungs → backflow of blood in
produced (immunoglobulins), then pulmonary bed → pulmonary congestion →
antigen and antibody will react pulmonary edema
and it will produce antigen- o Used to remove excess water because it
antibody complexes which is a causes dyspnea
protein then after 15-20 years it
can destroy the valves and you DIURETIC HEALTH TEACHING
can have Rheumatic Heart Disease Ex: Taken for 1-month for twice a day
▪ The rheumatic fever can result to o Give in the morning 8:00 because it
rheumatic heart disease if there increases urinary excretion
is damage in the valves of the o 2nd dose will be given at 18:00 and not
heart like mitral valve stenosis near at retiring time of the patient.
- aortic valve is the most common Patient’s sleeping pattern will be
valve that is affected disturbed (sleep pattern dysfunction)
▪ Prevalent in congested/crowded
places o If once a day, give it at morning
▪ Ex: a one room house with five o Take weight to see effect of medication
members; if a family member is
having productive cough or DIGOXIN (LANOXIN)
sneezing without covering, o Positive inotropic: increase
children and elderly are contractility
 o Negative chronotropic: decrease cardiac
rate to open atrioventricular valves
for a longer time for more blood to go
to the ventricles to improve cardiac
output
BETA BLOCKERS/CALCIUM-CHANNEL BLOCKERS
(Metoprolol/Verapamil)
o have the same action with digoxin but
not a positive inotropic
o Good in decreasing cardiac rate
o Also, a dilator
ANTICOAGULANTS for AF (Warfarin (Coumadin))
o less blood going to the ventricle →
blood will accumulate in left atrium →
tendency to clot
HEPARIN WARFARIN
IV
SQ
Route Oral
IM (should be avoided for
this case)
Backflow of blood to the right atrium →
enlarge RA → chambers of the heart enlarge
because it cannot accommodate blood coming
from the superior and inferior vena cava →
backflow again (blood goes back) → ascites and
pitting edema
MOST COMMON SYMPTOMS
o Dyspnea/shortness of breath
o Fatigue
o Weakness
DRUG TREATMENT
ACUTE MR
o Nitroglycerin/Nitroprusside IV – to
reduce afterload (given first)
o Dobutamine – to increase force of
myocardial contraction (patient might
die from cardiogenic shock); (given
last)
o Diuretics
o ACE inhibitors – decrease afterloads

SURGICAL TREATMENTS SURGICAL TREATMENTS

o Mitral Balloon Valvuloplasty o Mitral Valve Annuloplasty
o Open Valvotomy
AORTIC STENOSIS
NURSING INTERVENTION FOR DYSPNEA o Most common cardiac valve dysfunction
o Position o More common in MEN than in women
o Alternate rest and activity o Patients with AS can be ASYMPTOMATIC
for years
MITRAL REGURGITATION o HEART MURMUR is the most common early
In regurgitation, ventricles are contracted, sign
left with oxygenated blood. Push blood toward
aortic valve. Some went to descending aorta, ETIOLOGY
some went back → less cardiac output → o Age-related degenerative calcific AS
enlarging left atrium → backflow of blood to most common cause in adults
the lungs → pulmonary congestion/edema → o Rheumatic disease
dyspnea o Congenital

ETIOLOGY Without treatment, the patient is at risk for:

o Rheumatic heart fever o Heart failure
o Coronary artery disease o Dilated cardiomyopathy
o Cardiomyopathy ▪ muscles of the heart are
o Congenital affected; accumulated blood at
o Ineffective endocarditis the left ventricle → enlarge
PATIENTS WITH CHRONIC MR MAY NOT EXPERIENCE muscle
ANY SYMPTOMS UNTIL 20 YEARS AFTER EPISODE OF o Sudden cardiac death
RF.
o In ACUTE MR, the patient may develop THREE CARDINAL SYMPTOMS
PULMONARY HYPERTENSION and RIGHT-SIDED 1. Angina
HEART FAILURE with EDEMA and ASCITES 2. Syncope
3. Exertional Dyspnea
During Systole, left ventricle should eject
blood into descending aorta but mitral valve
is open, causing the blood to go back → left
atrium enlarges because valve cannot close
completely → left atrium accumulate blood
because it is receiving blood coming from
pulmonic veins and left ventricle → cannot
accommodate blood coming from the lungs →
pulmonary bed → pulmonary congestion → lots of
fluids in the lungs → pulmonary hypertension →
pressure in pulmonary trunk increase → right
ventricle having a hard time pushing
unoxygenated blood towards a high pressure →
increasing workload → enlarge RV muscle
 HYPERTENSION CLASSIFICATION OF HYPERTENSION
Hypertension is consistently high blood
pressure of at least 140 (systolic) over 90 PRIMARY HYPERTENSION (ESSENTGIAL/IDIOPATHIC)
(diastolic) o Affects 90% of people with hypertension
CAUSES
o Hereditary
o Increased salt intake
o Stressors in life
o African-Americans due to increased salt
intake
o Asians: Koreans and Filipinos due to
increased salt intake like kimchi which
is preserved using salt
o Abnormal arteries
o Increased blood volume
o Genetic disorders

SECONDARY HYPERTENSION
o A direct result of another problem or
Lumen of artery is small compared to vein condition
because media is thick in artery making CAUSES
pressure in artery higher than the vein o Health conditions
o Thyroid gland is firing out/plenty of
Effects of Hypertension T3 an\d T4 that increases metabolism
Sluggish flow of blood → viscous → formation and therefore increases blood pressure
of clots → embolus → can go to lungs/brain ▪ Medicine that lower T3 and T4
resulting to CVA → half of body paralyzed bring blood pressure to a normal
level
o PHEOCROMOCYTOMA: Tumor in adrenal
medulla that releases catecholamines:
norepinephrine and epinephrine.
Norepinephrine causes vasoconstriction
that increases blood pressure
▪ Removing tumor lowers blood
pressure
o Hyperthyroidism
o Neurologic disorders that increase ICP
o High dose estrogen use
o Renal artery stenosis
o Pregnant (Preeclampsia)
o Certain medicines
Pressure is high in the artery → destroying o Recreational drugs
intimal layer of blood vessel → less nitric o Hormonal therapy
oxide (dilates arteries) → artery will not
dilate anymore → plaque can start forming

CAUSES
1. Hyperactivity of the sympathetic
nervous system
o Obstruction → bigger in size → causes
narrow lumen of the artery → sluggish
Plaque → left ventricle generates higher flow of blood → viscous → heart is
pressure than 160 → increasing workload of the trying to push against a high pressure
heart → contracting against pressure → bigger → less cardiac output → stimulate SNS →
in size = left ventricular hypertrophy trigger the adrenal glands above the
kidneys → adrenal medulla release
norepinephrine (vasoconstriction) and
epinephrine (tachycardia) → increased
 cardiac rate → atrioventricular MEDICAL MANAGEMENT
(bicuspid and tricuspid) valves close o All studies have shown that the
immediately (should be open for .5 majority of hypertensive patients will
seconds) → less amount of blood need two to three drugs to control
delivered in the ventricles their BP
▪ Combined 2-3 drugs are better
2. Hyperactivity of the renin-angiotensin- because complications will not
system develop and that is if patient is
o Hypertension → increased cardiac rate → taking the drugs religiously.
increased blood pressure → less stroke o Sticking to monotherapy will only delay
volume and cardiac output → kidneys are control and may cause serious
secondary organ receiving less blood → complications
will compensate → renin → angiotensin o The absence of symptoms which is
one → liver → lung converting it to usually the case in most hypertensive
angiotensin two which is a potent patients, does not mean that one is
vasoconstrictor low-risk
➢ The BP should be brought down to 120/70
3. Endothelial dysfunction mmHg to less than 140/80 mmHg
o High blood pressure → destroying
intimal layer → less production of DIURETICS
nitric oxide → arteries will not dilate o First-line therapy for hypertension
o Eliminating excess salt and water from
Enlarged left ventricle → limiting space of the body
blood that will be sent by the atrium to the o To remove excess body fluids
ventricles → increase cardiac output o Hydrochlorothiazide (Betazide, Diuzid)
o Furosemide (Lasix, Pharmix)
Hypertension is asymptomatic, slowly
destroying the eyes, heart, kidneys and brain NURSING MANAGEMENT
o Take diuretics in the morning
NOSE BLEEDING (late manifestation of HTN) o Caution patients to stand up slowly to
1. Help the patient to sit, leaning minimize the risk of orthostatic
forward, with the head tilted forward hypotension
o This position keeps the blood o Monitor the patient for signs of
from dripping down the throat, or hypokalemia such as:
being aspirated into the lungs; ▪ Muscle weakness
prevent entering pharynx ▪ Confusion and irritability
2. Apply DIRECT PRESSURE at least 15 o Weigh patients daily
minutes by PINCHING THE NOSTRILS ▪ Weigh before breakfast and let
together (might re-bleed if less than patient void first
15 minutes) o Report a significant weight gain such
3. Apply COLD COMPRESS to the bridge of as 3 pounds in 3 days
the nose o Increase potassium intake because
4. Keep the patient CALM and QUIET potassium can be removed
especially if he has HIGH BP
o Anxiety tends to increase BP ACE INHIBITORS (PRIL)
which could worsen the nosebleed o Enalapril (Renitec, Hypace)
• Stimulate SNS = o Imidapril (Norten, Vascor)
increasing BP o Cilazapril (Vascase)
o Ramipril (Ramipro, Tritace)
o Prevent conversion of angiotensin one
to angiotensin two (vasoconstriction),
preventing release of aldosterone and
reabsorption of sodium

NURSING MANAGEMENT
o Risk for hyperkalemia
*do not tilt head ▪ Do not give potassium
back* o The patient may experience persistent
dry, irritating, non-productive cough
▪ Report because it can disturb the
TO PREVENT RE-BLEEDING after the bleeding has sleep pattern of the patient
stopped: o Infrequent but dangerous adverse
o Don’t pick or blow your nose effects are agranulocytosis,
o Don’t bend down until several hours proteinuria, acute kidney failure,
after the bleeding episode glomerulonephritis
o Keep your head higher than the level of
your heart
BETA BLOCKERS (OLOL) EXERCISE REGULARLY
o Atenolol (Cardioten, Tenormin) Brisk walking for 30mins drops your systolic
o Metoprolol (Betaloc, Neobloc) BP by 4-9 points

ALPHA BLOCKERS LIMIT YOUR SODIUM INTAKE

o Doxazocin (Alfadil XL) Eating no more than 2,400mg a day of sodium
brings down your systolic pressure by 2-8
COMMON ADVERSE EFFECTS points
o Dizziness
o Bradycardia While all the above measures are important for
o Hypotension health promotion, weight reduction measures
o Fatigue will have to most immediate impact

CALCIUM CHANNEL BLOCKERS (PINE) 30 minutes of Brisk Walking benefits health

o Depresses myocardial contractility o Regulate blood pressure
o Should not be given with heart failure o Lower body fat levels
o Relaxes and dilates arteries causing a o Protection from arthritis
fall in BP and decrease in venous o Lowers stress levels
return o Weight loss
o Diltiazem (Dilzem, Filazem)
o Verapamil (Isoptin) EXERCISE
o Amlodipine (Amlodine, Amlocor) 1. Exercise helps make BV more flexible
o Nifedipine (Adalat, Calcibloc) and increases their diameter by
▪ Gel-like increasing NITRIC OXIDE levels
▪ Can be placed under the tongue 2. Forty-five minutes of moderate-
(SL) intensity exercise will raise HDL
▪ For faster absorption cholesterol level
: with a sterile needle, prick o HDL (good cholesterol) → going to
and then squeeze under the remove bad cholesterol that
tongue) = lower BP immediately obstructs artery
o SE: 2-3% edema at lower extremities o Eating peanuts, legumes, beans
increases HDL
AMLODIPINE BESYLATE (NORVASC) o High in sodium: soy sauce, patis,
o Dilate the peripheral vessels to lower ketchup
BP (results to dizziness and swelling) 3. Exercise increases an enzyme that
o Used primarily in patients with breaks down TRIGLYCERIDES so it can be
hypertension processed by the liver
o Reduce visceral fat (deep fat
NURSING MANAGEMENT that is hart to remove)
o Instruct patient to report dizziness 4. Regular exercise has an ANTI-CLOTTING
and irregular heart rate EFFECT similar to aspirin therapy
o Avoid grapefruit juice because it o Can send fats in blood that
inhibits the hepatic metabolism of CCB causes obstruction
that may lead to pharmacologic effects
o All CCBs should be used cautiously in SODIUM LANDMINES
patients with heart failure o WHOOPER with CHEESE-------------1450 mg
o PASTA SAUCE, canned, 1 cup------1025 mg
COMPLICATIONS OF HYPERTENSION o BROTH/BOUILLON, 1 packet--------1020 mg
o Aneurysm: ballooning of the artery in o SOY SAUCE, 1 tablespoon---------900 mg
the brain → ruptured → blood in the o COTTAGE CHEESE, 1 cup-----------800 mg
brain → increased ICP (80% brain o CHICKEN McNUGGETS, 6------------600 mg
tissue, 10& cerebrospinal fluid, 10% o BEEF/PORK HOTDOG----------------500 mg
blood only). Edema will also cause high o BACON, 3 strips-----------------550 mg
ICP, diminishing blood o MILK and MILK PRODUCTS (cheese, butter,
o Destroy the kidneys resulting to renal ice cream)
failure as evidenced by less urine
excretion and plenty of bubbles in the LDL: <100 mg/dL
urine which indicates protein HDL: >60 mg/dL
o Blurred vision: arteries in the eyes
are dilated CARDIOVASCULAR DISEASE
o Enlargement of the heart o Others, however, have no such innate
capability, and the excess sodium gets
LIFESTYLE MODIFICATIONS stored in the body and attracts water
causing:
LOSING EXCESS WEIGHT ▪ Edema
For every 20lbs you lose, you drop your ▪ Weight gain
systolic BP 5-20 points o The greatest amount of salt we ingest
does not come from the condiments we
use.
 o The biggest source is processed foods, o Obesity
which include: o Diabetes
▪ canned goods o Metabolic syndrome
▪ instant noodles o Physiologic states
▪ salty snacks o Homocysteine level
▪ margarine
▪ frozen meals CENTRAL OR ABDOMINAL OBESITY
▪ ketchup o Men – waist circumference is greater
▪ Dried fruits than 40 inches
o Salt reduction in all processed foods o Women – wait measures more than 35
is doable and can have a tremendous inches
impact on hypertension control, since o A healthy waist circumference is less
around 80% of salt intake really comes than 35 inches (87.5 cm) in women and
from them less than 40 inches (100 cm) in men
o Too much salt retained in the body may o The desired BMI is 18.5 to 24.9 kg/m2
lead to: for both sexes
▪ High blood pressure
SATURATED FATS
▪ Heart failure
Typically come from ANIMAL SOURCES such as:
▪ Stroke
➢ Meats
▪ Premature death
➢ Cheese
o CVD and stroke have remained the top
➢ Egg yolks
two killers in the country for the last
30 years ➢ Ice cream
o Around 200,000 Filipinos dying yearly ➢ Cream
o Increased salt intake is particularly ➢ Butter
related to the risk of developing ➢ Whole milk
stroke ➢ Lard
➢ Bacon drippings
LIFESTYLE MODIFICATION
o The primary dietary culprit in raising
FOLLOWING A DASH DIET (DIETARY APPROACHES TO blood levels of LDL CHOLESTEROL
STOP HYPERTENSION) o Saturated fats increase the risk of
Low fat diet, rich in vegetables, fruits and HEART DISEASE
low-fat dairy foods lower your SBP by 8-14 o An optimal level of LDL is <100 mg/dL
points
HIGH-DENSITY LIPOPROTEIN
STOP SMOKING o HDL leave the LIVER with very little
cholesterol, PICK UP EXCESS CHOLESTEROL
LIMIT YOUR ALCOHOL INTAKE on their route through the bloodstream
No more than 2 drinks a day for men, one for and take it back to the LIVER
women o The LIVER EXCRETES this cholesterol
into the bile and out of the body
SMOKING through the BOWELS
o TOBACCO use is the leading risk factor o Higher levels of HDL, ideally 60 mg/dL
for coronary artery disease and a OR GREATER
POTENT VASOCONSTRICTOR leading to o You get HDL from:
hypertension ▪ Nuts
▪ Beans
COMPLIANCE ▪ Legumes (green peas, garbanzos,
o Long-term compliance and adherence have monggo)
emerged as the most essential element *garbanzos with the skin has good
in reducing morbidity associated woth fiber content*
hypertension ▪ High-fiber fruits and vegetables
o Taking medications consistently and as ▪ Virgin olive oil
directed by the doctor ▪ Exercising regularly and being
more physically active
BREAKFAST
o According to research skipping TRANS FAT
breakfast increases platelet stickiness o A specific type of fat formed when
which in turn can promote clotting, liquid fats are made into solid fats by
eventually leading to a heart attack the addition of HYDROGEN atoms
o The HYDROGEN makes the fat harder which
RISK FACTORS FOR CAD is why it sticks to the arteries
Modifiable Risk Factors o gives the food a good form
o Elevated serum lipids
o Hypertension EXERCISE
o Tobacco use o Walking, jogging, bike riding that
o Physical inactivity raises your heart rate for 20 to 30
 minutes at a time maybe the most
effective way to increase HDL levels
LOSE WEIGHT
OMEGA-3 FATTY ACIDS (salmon, mackerel, trout)
PERIPHERAL ARTERY DISEASE
o PVD usually affects people in their
60’s and 70’s
o Men are more affected than women
o Having PAD puts a person 2 to 6 times
greater risk of dying of a Heart Attack
or Brain Attack
o Risk Factors for PAD are similar to
those for Atherosclerosis and CHD
▪ HTN
▪ DM: ↓ insulin produced → glucose
cannot enter the cell and stays
in the blood → viscous → high
pressure in arteries
▪ Cigarette smoking
▪ High homocysteine levels (from
meat)
o PAD interferes with Arterial Blood Flow
to the lower extremities, the risk for:
▪ Neuropathy and Paresthesias
▪ Ulcers that do not heal
▪ Necrosis, Gangrene: decrease
blood supply that damages the
nerves that results on wounds
taking time to heal = gangrene
▪ Amputation
o Sudden pain, numbness or tingling
sensation in one leg indicates possible
arterial occlusion from an embolus
o The patient’s leg becomes cold and
pale, and pain will ensue
▪ Obstruction → less blood supply →
pale in color and cold to touch,
numbness
▪ The pain is caused by lactic acid
buildup secondary to anaerobic
metabolism in the affected leg
o The absence of pulses distal to the
occlusion is an ominous sign that the
artery has been completely occluded
o Absent or diminished distal pulses
indicate that the ulcers in the
patient’s leg are due to an arterial
problem
o A patient with arterial insufficiency
will have hairless shiny skin on their
legs
▪ This is due to the lack of blood
supply that brings oxygen and
nutrients to nourish the skin and
the roots of the hair
o Peripheral arterial diseases have many
skin manifestations
o A patient with a peripheral arterial
disease would have:
▪ Dystrophic brittle toenails
▪ Bluish or pale extremities
▪ Hairless skin
THROMBOANGIITIS OBLITERANS
BUERGER'S DISEASE
o Mainly seen in young men between ages
20 and 35 years.
o Tends to occur in young men and women
who are heavy cigarette smokers.
o Affects the small and medium sized
arteries and medium- sized, mostly
superficial, veins of the extremities.
PATHOPYSIOLOGY
Prolonged periods of Tissue Hypoxia increase
the risk for:
o Tissue Ulceration
o Gangrene
INTERMITTENT CLAUDICATION
o The most common symptom is intermittent
claudication
o The leg cramping that occurs during
walking or exercise and disappears with
rest.
▪ It results from inadequate blood
flow to the legs.
o Example Scenario: in the mall with
parents, father will stop and complain
pain in the right lower leg. When he
sat down, the pain subsided. Because of
obstruction, there is less blood supply
in the lower leg, converting aerobic to
anaerobic producing lactic acid that
will stimulate nerve endings in the leg
= pain. When the father stopped
walking, sit and took a rest, there is
no anaerobic metabolism and no lactic
acid is produced = pain will subside
CLINICAL MANIFESTATIONS
Pain
o Elevation of the extremity may
aggravate rest pain; dependency may
relieve it.
Coldness
o The temperature of the feet is colder
to touch than the rest of the body.
Impaired Arterial Pulsation Pentoxifylline (Trental)
o Pulsation may improve on rest, which o ↓ Blood viscosity & ↑ Blood flow to the
indicates that some alterations in lower extremities.
blood flow may be due to Arterial o The patient should have improved
Spasm. circulation in the legs as evident by
Rubor / Cyanosis/ Pallor less pain
o Visible particularly when the extremity
is in Dependent Position NURSING INTERVENTIONS
o Pallor with extremity elevation Smoking cessation is vital.
Paresthesia
o Thin, shiny, hairless skin, thick, HEALING FOODS FOR INTERMITTENT CLAUDICATION
brittle and slow growing nails. o A blood thinning compound in ginger is
GINGEROL.
THE PAIN AND OTHER SYMPTOMS OF ARTERIAL o It slows the production of THROMBOXANE,
DISEASE CAN BE CHARACTERIZED AS THE "FIVE Ps": a compound that causes blood platelets
o PAIN to clump together and clot. (anti-
o PALLOR inflammatory)
o PULSELESSNESS o Also, pineapple
o PARESTHESIA
o PARALYSIS NURSING INTERVENTIONS
*Paresthesia and Paralysis indicate ACUTE LIMB 1. INEFFECTIVE PERIPHERAL TISSUE PERFUSION
ISCHEMIA*
Positioning:
POIKILOTHERMIA o Maintain the legs in a position of
o Ischemic tissue is pale in appearance slight dependency, so that the gravity
and cool to touch compared to other enhances tissue perfusion.
areas of the body. o If the patient experiences rest pain at
night, the head of the bed is elevated
CAPILLARY REFILL OF THE TOE PADS 4 to 6 inches.
o Return of color after more than 3 o The legs are not elevated above the
seconds indicates a slow arterial level of the heart, Impede Arterial
inflow. Flow.
o Press the distal part of a toe until it ▪ Put legs down, increased blood
blanches and then release. supply and giving oxygen and
o Normal reperfusion takes 0-5 seconds nutrients relieving pain.
o Delayed refill is an indicator of ▪ Never elevate (arterial) because
arterial ischemia. it diminishes blood supply
o Prolonged capillary refill time ▪ Elevate (vein)
indicates compromised arterial
perfusion, a problem associated with AVOID THE FOLLOWING:
cardiogenic shock and heart failure. o Crossing the legs at the knees
▪ Places pressure on the arteries
MEDICATIONS o Sitting in a slumped or slouched
posture
Aspirin or Clopidogrel ▪ Acute constriction of the
o To inhibit platelet aggregation, to arteries in the pelvis
reduce the risk of arterial thrombosis o Massage of the extremities
o AE: bleeding ▪ Promote embolus formation
Cilostazol (Pletal) ▪ Can detach clotted blood going to
o Platelet inhibitor with vasodilator brain/lungs
properties, improves claudication. o Exposure to cold. (vasoconstriction)
o Constrictive or restrictive clothing.
Clopidogrel (Plavix) is an antiplatelet
medication. ELIMINATE SMOKING
o Smoking is a major risk factor for PAD
Ginkgo, an herb, can increase bleeding when
taken with an antiplatelet medication such as Use of elastic stockings (support hose) to
aspirin or Plavix. promote circulation by preventing pooling of
o The nurse should encourage the client blood in the feet and legs.
to quit taking ginkgo. o The stocking should be applied in the
o Ginkgo has been shown to have a morning before the patient gets out of
beneficial effect of increasing blood bed
flow to the brain, but in this case, o The stockings should be applied
the risk of bleeding warrants the smoothly to avoid wrinkles, but the top
nurse's intervention. should not be rolled down to avoid
constriction of circulation
o The stocking should be removed every 8
hours and the patient should elevate
 the legs for 15 minutes and
stockings
2. RISK FOR IMPAIRED SKIN INTEGRITY
Because of decrease tissue oxygenation.
o Inspect the skin daily for:
▪ Dryness
▪ Redness
▪ Injury
o Clean feet daily using a mild soap
o Skin is gently dried & moisturizing
lotion to counteract dryness.
o Properly fitted shoes, soft leather.
o Toenails are trimmed straight across
using nail clippers
3. RISK FOR ACTIVITY INTOLERANCE
o Encourage the patient to exercise
frequently
▪ Walking
▪ Swimming
▪ Use of stationary bicycle
o Exercise should be slow & and
progressive
o Walking 30 to 45 minutes twice a day.
o Exercise is halted immediately when
pain occurs.
o The nurse should suggest that the
patient enroll in a supervised exercise
training program that will assist the
patient to gradually increase walking
distances without pain.
o The patient is instructed to avoid bed
rest as much as possible.
o Buerger - Allen exercises for patients
with advanced disease with minimal
exercise tolerance.
4. STRESS REDUCTION
5. DIET
o Adequate amounts of protein; Vitamins
A, C & E and minerals zinc for wound
healing.
STENT is longer and more expensive
GREENFIELD FILTER is inserted into inferior
vena cava to catch blood clots (150-200,000)
DEEP VEIN THROMBOSIS (DVT)
DEEP VEIN THROMBOPHLEBITIS
o DVT Usually occurs in the lower leg
o Nearly 70% of the venous ulcers recur.
o DVT is a common complication among
Asians who underwent major orthopedic
surgery of the lower limb
o Women are three times more likely than
men to have venous ulcer.
▪ Varicosity due to estrogen that
weakens wall of the veins
RISK FACTORS FOR DVT
Collectively known as Virchow's Triad
Vascular Wall Injury
o Surgery
o Infection
o Trauma - burns
o W/ drug abuse
reapply o Indwelling w/ Catheters
o Injection of irritating catheters
substances
*give antibiotics via vein in a slow manner to
prevent inflammation*
Venous Stasis
o Immobilization for more than 3 days
(bedridden)
o Obstruction or compression of the iliac
or femoral veins from
▪ Abdominal or pelvic tumors
▪ Obesity
▪ Lengthy surgery more than 30
minutes
▪ Congestive heart failure
▪ Shock
▪ Varicose veins
Hypercoagulability
o Pregnancy
o Malignancy
o Polycythemia vera
o Dehydration
o Estrogen Therapy
o Sickle cell disease
As people age, the valves inside leg veins
commonly weaken, which can lead to pooling of
blood in the periphery and may further
contribute to orthostatic hypotension.
SIGNS & SYMPTOMS OF DVT
o More than 50% of the DVT's don't cause
symptoms initially.
o Most reliable physical findings in DVT
is
▪ Unilateral edema of the affected
leg.
o Abnormal findings that are unilateral
are more indicative of an acute problem
that may be developing, and such
findings require immediate attention.
o Homans' sign: Pain that occurs in the
calf on forced dorsiflexion of the foot
is an unreliable diagnostic sign.
o Dull ache in the calf that intensifies
during walking or their leg feels heavy
or tight.
o The affected limb becomes painful, warm
and reddish.
o Cyanosis and Mottling of the skin due
to stagnant blood flow.
COMPLICATIONS OF DVT
PULMONARY EMBOLISM
o Most serious complication of DVT
o PE can be life-threatening and may
require mechanical ventilation
POSTTHROMBOTIC SYNDROME
o Caused by back flow of blood related to
faulty valves and blockage that remains
in the vessel.
Signs and Symptoms
o Pain increased swelling
o Skin ulcers
 o Hyperpigmentation Compression Therapy
Treatment o Intermittent pneumatic compression
o Anticoagulation device work by repeatedly squeezing the
o Elevating the affected extremity to legs which help empty the leg veins.
decrease Swelling and pain. o The use of elastic compression
stockings (3 to 6 months) to support
HEMOSIDEROSIS the vein walls & valves & decreasing
Fibrinogen builds up around the capillaries swelling & pain on ambulation
↓ o Remove for 30 minutes every 8 hours &
The fibrin formed interferes with the inspect the skin for irritation &
transport of OXYGEN and NUTRIENTS to breakdown.
capillaries and surrounding tissues
Elastic Compression Stockings
DRUGS USED TO TREAT DVT FALL INTO 3 GENERAL o Support hose apply external pressure on
CLASSES the veins, preventing the retrograde
Anticoagulants pressure or flow that may occur in the
o Inhibit blood coagulation and serve to standing or sitting positions
weaken already formed clots, preventing o Application before arising, prevents
further expansion. the veins from having the opportunity
o Heparin with to become engorged.
▪ low - molecular - weight heparins
▪ Enoxaparine - Clexane S.C. Perform deep breathing exercises
▪ Oral warfarin - Coumadin (3 to 6 o Help the large veins in the legs and
months) elsewhere in the body to empty by
increasing negative pressure in the
Thrombolytic Agents thorax
o Help dissolve clots
▪ For patients with hemodynamically When in bed active/passive leg exercises
unstable PE or Massive o Done after S/S have subsided.
iliofemoral thrombosis
ND: PAIN > INFLAMMATION> EDEMA
Antiplatelet Agents o Asses pain as to:
o To decrease activation of platelets & ▪ Onset
prevent new clots from being formed. ▪ Quality
o Assess a patient who's receiving ▪ Intensity
anticoagulant therapy for signs & ▪ Location
symptoms of bleeding. ▪ Duration
▪ Bleeding Gums
▪ Nose Bleeds Apply warm, moist heat at least 4x/daily as
▪ Unusual Bruising ordered.
▪ Bloody urine o warmth promotes vasodilation, allowing
▪ Black, tarry stools reabsorption of excess fluids into the
o Advise the patient not to take any circulation.
medication containing aspirin or non-
steroidal anti-inflammatory drugs. Bed Rest
o Instruct a patient on warfarin therapy o Using leg muscles during walking
to maintain a consistent intake of exacerbates the inflammatory process &
foods with high Vitamin K. increases Edema → increase pain

NURSING MANAGEMENT Caution the patient not to massage the leg or

arm.
ND: Ineffective Peripheral Tissue Perfusion o This maneuver could dislodge the clot
and cause more pain
GOAL: To reduce venous stasis
PREVENTION OF DVT
Bed Rest for 5 to 7 days thrombus formation o The simplest way to prevent DVT is
o Indicated initially to allow time for encouraging early ambulation.
clot organization or until the Thrombus ▪ Exercising the legs & engaging in
is stable and has adhered to the early ambulation activates the
intraluminal wall. calf muscle pump which can
o Bed rest is continued until S/S decrease venous stasis & increase
particularly Edema subside. venous return.
▪ if edema subsided, patient can
To reduce Edema, elevate the legs 18 cm (7 ambulate
inches) above the heart for 2 to 4 hours o Monitor for adequate fluid intake to
during the day & at night. prevent dehydration & changes in the
blood flow.
 o Avoid sitting with knees bent or SIGNS AND SYMPTOMS
crossed, and standing for long periods. o Pallor: skin, mucous membranes,
o Avoid sitting for more than 2 hours at conjunctiva and nails beds
a time. The patient should walk at o Tachycardia An attempt to increase
least 10 minutes every 1 to 2 hours if o Tachypnea CO and tissue perfusion
possible, to help prevent venous o Fatigue
stasis. o Dyspnea Due to tissue hypoxia
o Prolonged standing increase venous o Angina
pressure causes venous distention & o Headache, dizziness, dim vision due to
decrease venous return. cerebral hypoxia
o Quit SMOKING, nicotine increases o Bone pain – increase erythropoietin
viscosity of the blood. ▪ Activity → stimulates RBC
o NO SMOKING production in the bone marrow
o Weight loss can lower venous pressure Significant Blood Loss:
o Hypotension
PAD DVT o Tachycardia
Antiplatelets Anticoagulants o Decrease LOC
Never elevate Elevate o Oliguria: because of hypotension, low
BP
ANEMIA Less oxygen in the red blood cells → the heart
o An abnormally low number of circulating has to work harder to get enough oxygen
RBC’s, low hemoglobin concentration or circulating in the body → this can cause
both serious HEART PROBLEMS
o Regardless of the cause, every type of
anemia reduces oxygen–carrying of the
blood → TISSUE HYPOXIA

HEMOGLOBIN

RBC 80-130 days

RBC 4.5-5 million
Hemoglobin 12-17 g/dL
Hematocrit 38-54% IRON-DEFICIENCY ANEMIA
WBC 5,000-10,000 o Insufficient intake of iron
Platelets 300,000-400,000 o Excessive blood loss
o Pregnancy (diverts maternal iron to
fetus for erythropoiesis)
o Malabsorption

Iron-Rich Foods
o Beef liver
o Pork
o Chicken
o Fish
o Oyster
o Clams
o Green leafy veggies (kangkong, kamote
leaves)
o Potatoes with skin
o Beans
o Peas
o Dried fruits like prunes and raisins
 o Iron-fortified breads and cereals o Aging (progressive loss of vitamin B12
absorption usually beginning after age
Ferrous Sulfate 50)
o Should be taken with vitamin c ▪ Vitamin B12 is absorbed in ileum
and aging results on less
PERNICIOUS ANEMIA absorption of vitamin B12
Characterized by decreased production of HCL o Strict vegetarian diet
acid in the stomach and deficiency of
INTRINSIC FACTOR SIGNS AND SYMPTOMS
↓ o Glossitis: a smooth beefy-red tongue,
Essential for vitamin B12 absorption in the due to atrophy of papillae
ILEUM ▪ Approximately 50% of patients
↓ have a smooth tongue with loss of
Inhibits RBC cell growth deformed RBCs papillae
↓ ▪ The tongue may be painful and
POOR OXYGEN-CARRYING CAPACITY beefy red
▪ It may be associated with changes
o CNS involvement = ataxic gait, urinary in taste and loss of appetite
incontinence o Neurologic abnormalities
o No intrinsic factor ▪ Paresthesias of the hands and
o Parietal cells produce HCL and feet
intrinsic factor which is needed by the ▪ Ataxia
extrinsic factor (vitamin B12) to be ▪ Loss of bowel and bladder control
absorbed o Primary symptoms include: neuropathy
o Deficiency of vitamin B12, autoimmune with paresthesias of hands and feet
disorder
SCHILLING’S TEST
o A megaloblastic anemia, is lack of o A normal result shows at least 10% of
intrinsic factor, which results from the radiolabeled vitamin B12 in the
atrophy of the stomach wall urine over the first 24 hours
▪ Large RBCs decrease intrinsic o In patients with impaired absorption,
factor which causes inflammation less than 10% of the radiolabeled
in the stomach vitamin B12 is detected
▪ Gastritis (not eating on time) /
drinking liquor increases gastric TREATMENT
juice o Lifetime vitamin B12 via IM
▪ Infection in the stomach if not
produced APLASTIC ANEMIA
▪ Undergone partial gastrectomy o Inhalation of chemicals like benzene
▪ Strict vegetarian (3-5 years o Adverse effect of chloramphenicol which
before signs and symptoms will is an antibiotic
manifest)
➢ Vitamin B12 is stored in CAUSES
the liver for 3-5 years o Congenital
o Without the intrinsic factor, vitamin o Exposure to TOXIC SUNSTANCES
B12 cannot be absorbed in the small ▪ INDUSTRIAL CHEMICAL – BENZENES,
intestine, and folic acid needs vitamin INSECTICIDES
B12 for deoxyribonucleic acid synthesis ▪ CHEMOTHERAPY medications
of RBCs ▪ Antibiotics
VITAMIN B12 FOOD SOURCES: o Bacterial and viral infections
o Eggs ▪ Tuberculosis
o Poultry ▪ Hepatitis
o Shellfish
o Milk and milk products SIGNS AND SYMPTOMS
o Pork Ecchymosis
o Chicken Nose bleeds
o Beef Bleeding gums
Petechiae
Vitamin B12 is important for the metabolism,
the formation of red blood cells, and the ANEMIA OF CHRONIC DISEASE
maintenance of the central nervous system, o Chronic kidney disease
which includes the brain and spinal cord o Inflammatory diseases
(development of spinal cord) ▪ Rheumatoid Arthritis reduce the
bone marrow’s response to
RISK FACTORS erythropoietin leading to a
o Genetic predisposition decrease in RBC
o Partial gastrectomy o HIV, Cancer, Cirrhosis
 MEDICAL SURGICAL NURSING Renin, Angiotensin 2 will stimulate the
thirst center.
MIDTERMS
ATRIAL NATRIURETIC PEPTIDE (ANP)
FLUID AND ELECTROLYTES o A cardiac hormone, stored in the cells or
the atria
INTRACELLULAR (40%) o ANP is released when atrial pressure
Cytoplasm (organelles flow) increases
o The hormone opposes the RAAM by
EXTRACELLULAR (20%) decreasing BP and reducing intravascular
Outside the cell blood volume
o Released whenever there is increase
INTERSTITIAL COMPARTMENT (15%) 11-12L of fluids pressure in the atrium, plenty of blood
in the atrium. ANP will oppose RAAM by
INTRAVASCULAR (5%) decreasing BP
Blood and plasma
OSMOLARITY
MECHANISMS OF FLUID BALANCE o Sodium is the largest contributor of
particles to osmolality
Fetus: 100% o More sodium outside than inside
Baby: 80% o Potassium inside
Adult: 70% o Normal Serum Osmolality – 280 – 295
Elderly: 50% mOsm/kg (milliosmole)
o Swell - <280 – hypo-osmolar
The amount of water taken in must equal the o Shrink - >295 – hyperosmolar – more
amount of water lost solutes than water
o When Serum osmolality is increased (more
WATER OUTPUT solutes than water), the fluid in the
Kidneys---1,500 mL intracellular (cells) is greatly
Skin------600 mL decreased
Lungs-----300 mL o Hyper-osmolality pulls the water out of
GI tract--100 mL the cells to maintain homeostasis of the
Total-----2,500 mL body fluid and cellular dehydration
(lesser to greater; the cell will shrink)
MECHANISMS OF FLUID BALANCE
HYPOVOLEMIA (FLUID VOLUME DEFICIT)
ANTI-DIURETIC HORMONE (ADH) o severe diuresis
o Posterior pituitary gland will secrete o abnormality (SIADH, Diabetes insipidus)
ADH if you have less body fluids like o UO: 3L in one day instead of 1.5L per day
vomiting or severe diarrhea. = dehydrated
o Order renal tubules to reabsorb water for o suctioning gastric area
compensation. o sweating
o Decreasing circulating blood volume. o diuretics
o Body is compensating
HYPERVOLEMIA (plenty of water fluid overload)
ALDOSTERONE o SIADH: over secretion of ADH
RAAM o water retention = water intoxication
o Compensatory o liver disorder
o released whenever there is less blood o heart failure
circulating (stab or car accident o destroyed kidneys = edematous in the
decreasing amount of blood) lower extremities
o the brain, heart and lungs will be
perfused with blood. DIFFUSION – movement of solutes from greater to
o Kidneys are secondary organs only and lesser concentrated solution (osmolarity)
whenever there is less blood supply,
there is a release of hormone called OSMOSIS – fluid moving from lesser to greater
renin converted to angiotensin 1 to concentrated solution (edema)
angiotensin 2.
o ADH is water, where sodium is, water
follows.

THIRST MECHANISM
o Sweating a lot due to exercise or climate
o Drinking a lot of water
o Compensatory mechanism
o Decrease blood volume because of vomiting
and diarrhea, gastroenteritis, it will
decrease BP, if decrease BP there will be
less blood going to the kidneys and
kidneys will compensate, it will release
 RENAL CALCULI o Weight-bearing activities produce
o No exact etiology biomechanical stresses on the bone,
o Runs in the family initiating a cascade of events to cause
o Masses of crystals and protein bone remodeling
o Most common: calcium oxalate (70% of o Bone resorption is the process by which
people) osteoclasts break down bone and release
o Men are more affected than women the minerals, resulting in a transfer of
o Age: 40 - 50 calcium from bone fluid to the blood
o The osteoclasts are multi-nucleated cells
FUNCTIONS OF KIDNEYS that contain numerous mitochondria and
lysosomes. These are the cells
Forms urine. removing waste products of the body responsible for resorption of bone
(urea from protein, uric acid, creatinine
(muscle metabolism)) UTIs
o Ex.: inflammation in the urinary bladder
Responsible in maintaining acid base balance. > urethra becomes edematous > no good
Primarily control base in the form of flow urine because there is partial
bicarbonates. Example is with COPD and there is obstruction > urine becomes stagnant >
a destruction in alveoli, exchange of gases urine becomes super concentrated >
affected. CO2 will not be excreted and develop formation of crystals > stones
respiratory acidosis. Since there is o Urinate 2-3 hours
accumulation of CO2, the kidneys can feel this
and it will produce more bicarbonates and it FAMILY HISTORY OF STONE FORMATION
will lessen the production of hydrogen ions.
Remove excess water and electrolytes and urinate NEUROGENIC BLADDER
if kidneys are working. o cannot feel the urge to void
*Potassium can cause dysrhythmia if excessive o Destroyed spinal cord: sacral 1 – 5
(where urge to void & defecate is
Erythropoietin production. It will stimulate seen/being felt) is destroyed → leads to
bone marrow to produce red blood cells. incontinence (urge to void cannot be
controlled)
Vitamin D production. The vitamin D is taken
from early morning sunlight and food. However, A DIET HIGH IN:
the vitamin D form external environment is still o PURINES
inactive. Kidneys are responsible in activating ▪ Beer
the vitamin D from the environment. Vitamin D ▪ Sardines
is responsible in absorption of calcium in small ▪ Seafoods (tahong, shrimp)
intestine (gut) ▪ Vegetable oil
▪ Peanuts and legumes (monggo)
Stones are masses of crystals and proteins that o OXALATES
form when the urine becomes supersaturated with ▪ asparagus
a salt capable of forming solid crystals ▪ cabbage
▪ tomatoes
Hydronephrosis urine formed by the kidney cannot ▪ nuts
flow and enter urinary bladder ▪ celery
▪ parsley
RISK FACTORS FOR STONE FORMATION
▪ cola drinks
▪ instant coffee
INCLUDE ANYTHING THAT CAUSES WHETHER STASIS OR
SUPERSATURATION ▪ ovaltine
o Ex.: person on a diet doesn’t eat on time ▪ tea
→ bile stored in the gall bladder is not ▪ Worcestershire sauce
used → bile becomes super ▪ Beans
saturated/concentrated → becomes ▪ Grapes, apples
crystals → stone gall bladder calculi ▪ Peanuts and peanut butter
o Ex.: not voiding → urine becomes super o ANIMAL PROTEINS
saturated/concentrated ▪ meat

GENETIC AGE AND GENDER

o Stones are more common in men than women
DEHYDRATION, WHICH LEADS TO SUPERSATURATION o The risk peaks between the ages of 40 or
o Ex.: d/t not drinking enough water, early 50s
sweating, vomiting, diarrhea o Estrogen helps kidneys remove stones

IMMOBILITY AND A SEDENTARY LIFESTYLE/OCCUPATION OVERWEIGHT

o Releasing calcium and go to blood going o Researches show that overweight people
to kidneys excrete more calcium and oxalate in their
o Lack of physical activity increases BONE urine, which increases the risk of stones
RESORPTION (releasing calcium in blood)
STONE TYPE o URINARY TRACT OBSTRUCTION is an emergency
and must be treated immediately to
CALCIUM OXALATE preserve kidney function
o most common type of stone o NAUSEA, VOMITING: Pain will stimulate the
o small, rough, and hard vomiting center in the brain
o grayish-whitish in color o PALLOR: Pain will stimulate SNS, trigger
adrenal Medulla will release
HYPERCALCIURIA – high calcium in the urine NOREPINEPHRINE will cause
vasoconstriction, arteries will
1. A high rate of BONE RESORPTION which constrict to increase BP in order to give
liberates calcium → goes to blood → blood is lots of blood to the no. 1 organ (it will
being filtered in the kidneys → Calcium will be take the blood away from the secondary
part of the urine organ to give blood to the primary organ)
o Hyperparathyroidism → overuse of [Norepi – will redirect the blood from
parathyroid gland → release parathormone the skin to the brain].
→ Calcium is released from bone and goes o ELEVATED BP AND PR: Epinephrine – tachy
to blood o DIAPHORESIS AND ANXIETY (less blood to
o Immobility → bone resorption the brain)
- In an immobilized patient, calcium leaves o ELEVATED WBC COUNT AND TEMPERATURE (due
the bone and concentrates in the to inflammation)
extracellular fluid o BLOOD IN THE URINE, WHICH OFTEN MAKES IT
- When large amount of calcium passes LOOK PINK
through the kidneys, calcium can o PERSISTENT URGE TO URINATE
precipitate and form calculi o PAIN WITH URINATION (DYSURIA)

2. Gut absorption of abnormally large amounts HEMATURIA

of calcium According to the amount of RBC in the urine,
o Excessive intake of vitamin D hematuria can be classified as:

3. Renal leak of calcium resulting to Gross Hematuria (visible)

hypocalcemia o Tea-colored, cola-colored, pink or even
o Ex.: low Ca → stimulate PTH → PTH will red
release Parathyroid hormone Microscopic Hematuria
o Normal color with eyes
(parathormone) → bone resorption AND ᛏ
intestinal absorption of calcium
PREVENTIVE MEASURES
o Ex.: destroyed kidneys (basement
membrane) → electrolytes (Ca+) leaks out
DRINKING ENOUGH FLUID
and goes to the urine
o 12 glasses of fluid, preferably WATER a
day
STRUVITE
o Most basic kidney stone prevention step
o Made of magnesium ammonium phosphate
o This dilutes urine and decreases the risk
o Second most common type of stone
of crystal formation
o Calculi crumble easily
o Stones have a yellow color
LIMITING MEAT INTAKE
o Consuming more than 6 to 8 ounces of meat
URIC ACID STONES
daily can increase CALCIUM and URIC ACID
o due to high uric acid levels
in the urine
o high purine food
o Increase the acidity of urine
▪ seafoods o Reduce chemicals that inhibit crystal
▪ beer formation
▪ meat
o A diet rich in acid should be provided to
CYSTINE STONES keep the urine acidic, which increases
o caused by genetic defects in the renal the solubility of calcium
reabsorption of amino acids o Limiting foods rich in calcium, such as
o stones form at LOW UIRINARY pH dairy products will help prevent renal
o small, smooth, waxy stones calculi
o A liberal fluid intake
CLINICAL MANIFESTATION o Decrease intake of highly acid-ash food
o RENAL COLIC – lumbar region and radiates o Foods to avoid include:
down toward the TESTICLE in the male and ▪ Meat
BLADDER in the female ▪ Fish
o PAIN – severe, colicky, dull, or aching
▪ Poultry
o FLANK PAIN
▪ Eggs
o FREQUENCY and DYSURIA occur when a stone
reaches the bladder ▪ Cheese
o OLIGURIA or ANURIA suggest obstruction ▪ All breads
possibly at the bladder neck ▪ Crackers
▪ Macaroni/Spaghetti
▪ Nuts
GETTING CALCIUM IN THE DIET
o The calcium in food may lower the risk of
stones by binding oxalate in the GIT
o The bound oxalate is excreted in the
stool, which leaves less oxalate to be
absorbed into the blood and later
excreted in the urine
o Dairy products and supplements containing
calcium citrate are the preferred way of
getting calcium
LIMITING INTAKE OF OXALATE-CONTAINING FOODS
SUCH AS:
OTHER MEASURES
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)
o Uses high-energy shock waves to break the
stone into tiny pieces that can be more
easily passed
o Sedation or anesthesia is required
o Large stone require repeated treatments
(up to 5 treatments)
PATIENT EDUCATION AFTER ESWL
o PAIN may be experienced as the stone
fragments pass down the ureter.
ANTISPASMODICS are given
▪ Mebeverine HCL---Duspatalin
100 mg tab
▪ Pinaverium Br----Eldicet
50 mg tab
o Advised to drink 2-3L in 24 hours to help
flush out stone fragments and clear any
blood in the urine
▪ The fragments may be passed for up
to 3 months after the procedure
o Early ambulation

PERCUTANEOUS NEPHROLITHOTOMY

DON’T OVERDO VITAMIN C

o Some of the vitamin is metabolized to
oxalic acid in the body ‘
o In three studies done, those taking 2,000
mg had a higher oxalate level in their
urine

MEDICATION FOR STONES

THIAZIDE DIURETICS (HYDROCHLOROTHIAZIDE)

o Promotes calcium resorption from the
renal tubules, thereby preventing excess
calcium loads in the urine
o Thiazide diuretics are prescribed because
they decrease the amount of calcium
released by the kidneys into the urine by
favoring calcium retention in the bone
o Most kidney stones (75% to 80%) are
calcium stones, composed of calcium
o This medication will decrease calcium
levels in the bloodstream by increasing
calcium excretion in the urine

POTASSIUM CITRATE (ACALKA)

o Inhibits calcium oxalate and calcium
phosphate crystal formation in urine
o Lowers the acidity, to increase the pH of NEPHROSTOMY TUBE
urine to 6-7
o Uric acid stones form in ACIDIC URINE

ALLOPURINOL (ZYLOPRIM)
o To lower uric acid concentration
o Prescribed only if a reduced purine diet
fails and stones persist

TIOPRONIN (THILA)
o For cystine stones, which make cystine
more soluble for excretion
o Long-term ANTIBIOTICS are used to control
the infection
POSTOPERATIVE CARE
o Secure the tube to the patient’s flank to
ensure that it does not become dislodged
 o Check that the nephrostomy and drainage
tubing are not KINKED or that the patient
is not compressing the tubing
o Assess the tube insertion for BLEEDING
and DRAINAGE
o Notify the physician immediately if there
is an ABSENCE of urinary drainage
o Encourage FLUID INTAKE of 2-3 L in 24
hours (intravenous and oral fluids
initially
▪ To flush out any blood or stone
fragments that might be present
PATIENT EDUCATION
ELIMINATION
o There may still be blood present in the
urine in the initial days following
surgery. THIS IS NORMAL, but it should
decrease in the first 3-5 days
TEACH THE PATIENT SIGNS AND SYMPTOMS OF UTI:
o Urgency
o Frequency
o Dysuria
HIV – HUMAN IMMUNODEFICIENCY VIRUS
AIDS – ACQUIRED IMMUNODEFICIENCY
SYNDROME
GENDER/AGE GROUP
o Most of the cases were males (96%)
o Almost half (49%) of the cases were from
25-34 year of age
HIV RISE IN THE PHILIPPINES
o Sexual contact remains the main mode of
transmission with 863 cases
o 90% of which are from the male-having-
sex-with-male population
o Injecting drugs accounted for 16 new
cases
o 4 cases of mother-to-child transmission
o The country has the fastest growing HIV
epidemic in the Asia and the Pacific
region
o A total of 72 overseas Filipino workers
were also found to have acquired HIV/AIDS
IMMUNE SYSTEM
CD4
o CD4 + T helper cells are white blood cells
that are an essential part of the human
immune system
o There is a protein molecule on the
surface of the T-helper cells known as
CD4 hence the T-helper cells are also
known as CD4
o CD4 cell count is a key measure of the
health of the immune system
o Anyone who has less than 200 CD4 cells is
considered to have AIDS
HIV INFECTION-AIDS
o AIDS is a group of serious illnesses and
opportunistic infection that develop
after a person is infected with HIV for
a long period of time
o Even if the symptoms of AIDS develop and
then subside for a while, that virus is
still present, and the infected person
can still transmit the disease
HOW IS HIV/AIDS CONTRACTED?
The BIG Three: Exchange of Bodily Fluids
1. Sexual Contact (vaginal, oral, anal); does
not include casual kissing (unless open mouth
sores are present)
2. Sharing hypodermic needles/syringes through o Viral load: the risk of contracting HIV
IV drug use, tattooing, and body piercing is higher if the person with HIV has a
high viral load
3. Mother to infant transmission: in utero ▪ Higher viral loads increase
exchange, during birth, or through infectivity
breastfeeding after birth
VAGINA
ALSO, less commonly (and now very rarely in o Is a thin-walled tube 8 to 10 cm (3 to 4
countries where blood is screened for HIV inches)
antibodies), through transfusions of infected o Three main functions:
blood or blood cutting factors ▪ To accommodate the penis during
coitus
▪ To channel blood discharged from
the uterus during menstruation
▪ To serve as the birth canal during
child birth

HIV-MOTHER TO FETUS
An HIV+ pregnant woman can transmit HIV to her
baby 3 WAYS:
o During pregnancy
o During vaginal childbirth
o Through breastfeeding

Sharing IV drug needles of HIV positive people

HIV infected blood
ANAL SEX
o Unprotected anal sex is considered to be
a HIGH-risk factor
o HIV is present in blood, semen, pre-
seminal fluid, or vaginal fluid of a
person infected with the virus
o The individual receiving the semen has a
higher risk of contracting HIV since the
virus can penetrate the thin lining of
the rectum during anal sex
o A person who inserts his penis into an
infected partner is also at risk because
HIV can enter through the urethra or
through small cuts, abrasions, or open
sores in the penis

ORAL SEX
o Fellatio (oral-penile sex) carries some
risk, but it’s low
o Cunnilingus (oral-vaginal sex)
o Anilingus (oral-anal sex)
o If you’re giving a blowjob. Receptive
oral sex with a male partner who has HIV
is considered exceptionally low-risk HIV-AIDS
▪ A 2002 study found that the risk o A recent CDC study found that 1 in 5 gay
for HIV transmission through and bisexual men are in 21 major US cities
receptive oral sex was were infected with HIV, and nearly half
statistically zero were unaware of their infection
o If you’re receiving a blowjob. Insertive o Gay and bisexual guys have much more anal
oral sex is an unlikely method of sex than straight guys
transmission too o It has been scientifically proven that
▪ Enzymes in the saliva neutralize anal sex is riskier than vaginal sex when
viral particles. This may be true it comes to HIV. Eighteen times riskier
even if the saliva contains blood to be exact. There are two reasons for
o Risk varies based on whether the person this
with HIV is giving or receiving oral sex o First, the cells in the anus are much
▪ If the person with HIV is more susceptible to HIV than cells in the
receiving oral sex, the person vagina
giving it may have a higher risk o Second, both semen and rectal mucosa (the
o Mouths may have more openings in the skin lining of the anus) carry more HIV than
or lesions vaginal fluid
o Saliva, on the other hand, is not a ▪ Vagina is acidic because the
carrier of the virus urethra of female is short, a
protective mechanism
 o Combine this with the fact that gay and
bi guys have much more anal sex than
straight guys

HIV IN BODY FLUIDS

ELISA TEST
o A human immunodeficiency virus (HIV) test
detects antibodies to HIV or the genetic
material (DNA or RNA) of HIV in the blood
o After the original infection, it takes
between 2 weeks and 6 months for
antibodies to HIV to appear in the blood
o If antibodies to HIV are present
(positive), the test is usually repeated
to conform the diagnosis. If ELISA is
negative, other tests are not usually
BODY FLUIDS NOT INFECTIOUS needed
The following body fluids are NOT infectious o ELISA, like the Western blot test,
o Saliva detects HIV antibodies in your blood
o Tears o Antibodies are proteins your immune
o Sweat system produces in response to the
o Feces presence of foreign substances, such as
o Urine viruses
o if you test positive for HIV on the ELISA
STAGES OF HIV INFECTION test, your provider will order the
Western blot test to confirm HIV
infection

WINDOW PERIOD
o Occurs between the time of HIV infection
and the time when diagnostic tests can
detect HIV
o The length of the window period varies
depending on the type of diagnostic test
used and the method the test employs to
detect the virus

HIV TESTS
o HIV tests after the 3-month window are
STAGE 1 PRIMARY INFECTION more than 99.97% accurate. They work for
o infected with HIV until development of all types and subtypes of HIV
antibodies (6-12 weeks to develop o If the result is negative three months
antibodies) after exposure your result is interpreted
o no signs and symptoms (asymptomatic) for as negative. This assumes you have had no
years, maximum of 15 years before further risks
developing
SYMPTOMS OF HIV/AIDS INFECTION
STAGE 2 SYMPTOMATIC
o signs and symptoms appear
o CD4 less than 200
o persistent fever
o loss of appetite
o diarrhea
o infection

STAGE 3 AIDS
o no cure
o drugs control replication of virus but no
treatment
o prone to opportunistic infection (immune
system is down)
 o Facial Lipoatrophy (diarrhea and loss of
appetite)
o Swelling of lymph nodes
o Dry cough
o Night sweats
o Fatigue
o Rashes
o Thickening of nails (CD4 is down, fungi
growing)
o Clubbing and curving of the nails
o Wasting syndrome (protein catabolism)
HIV-CANDIDIASIS
o Candidiasis is a fungal infection due to
any type of Candida (a type of yeast).
When it affects the mouth, it is commonly
called thrush
o Signs and symptoms include white patches
on the tongue or other areas of the mouth
and throat
o CD4 count less than 50
KAPOSI’S SARCOMA
o Most common HIV-related malignancy
o Most often seen among men who have sex
with men
o It involves the endothelial layer of
blood and lymphatic vessels
PNEUMOCYSTIS CARINII/JIROVECI
o This pneumonia occurs in more than 80% of
AIDS patient
o Most opportunistic infection in persons
affected with HIV
HIV TREATMENT
ART – ANTIRETROVIRAL THERAPY
o NRTIs – Nucleoside Reverse Transcriptase
Inhibitors
▪ Emtriva------Emtricitabine
▪ Epivir-------3TC, Lamivudine
▪ Retrovir-----AZT, Zidovudine
▪ Videx-EC-----Didanosine
▪ Viread-------Tenofovir
▪ Zerit--------Stavudine
▪ Ziagen-------Abacavir
o PIs – Protease Inhibitors
o Fusion Inhibitor
HIV
o The DOH data showed that as of May 2019,
38,279 Filipinos with HIV were undergoing
the therapy
o As of May 2019, 3,357 patients listed in
the registry had already died
PREVENTION
o Abstain from sex before marriage
o Be faithful to your husband or wife
o Condoms are a protective barrier
▪ When used consistently and
correctly, condoms are highly
effective in preventing HIV
▪ Condom use remains inexpensive,
cost effective first line of
defense against HIV
o Avoid drugs and excess alcohol
o Early detection and treatment of STIs
o No to alcohol and drugs because it can
impair your judgement and affect your
ability to make safe choices, putting you
at greater risk for HIV
o No anal sex
o A new pill known as Truvada or pre-
exposure prophylaxis (PrEP), can reduce
the risk of transmission by more than 90%
▪ PrEP is a new HIV prevention
method in which people who do not
have HIV infection take a pill
daily to reduce their risk of
becoming infected
o Promoting sex-education among teenagers
o Safe injections: using unused syringes
will help to prevent HIV infections
o Male circumcision: it is the surgical
removal of the foreskin (prepuce) from
the human penis
▪ Removal of the inner foreskin
removes the main site of HIV entry
into the penis, resulting in a
sevenfold reduction in
susceptibility to infection
o Strict examination for blood, blood
products, organ donation for HIV before
administration
o No sharing of needles, brushes, or razors
o Proper sterilization of dental and
surgical instrument
REPUBLIC ACT NO. 8504
A.K.A. “Philippine AIDS Prevention and Control
Act of 1996”
An act promulgating policies and prescribing
measures for the prevention and control of
HIV/AIDS in the Philippines, instituting a
nationwide HIV/AIDS information and educational
program, establishing a comprehensive HIV/AIDS
monitoring system, strengthening the Philippine
National AIDS Council and for other purposes
HIV does not make people dangerous to know, so
you can shake their hands and give them a hug.
Heaven knows they need it. -Princess Diana
 PNEUMONIA
CHEMOTHERAPY cause pneumonia because of the
drug. It can destroy bone marrow – anemic and
white blood cells will be decreased in number:
leukopenic.
STEROIDS is an anti-inflammatory and if given
more than 2 weeks, it decreases the immune
system and infection can set in. Environment is
not sterile and microorganisms can enter the
lungs and cause inflammation
COMMUNITY ACQUIRED PNEUMONIA (CAP) – from
environment that can affect especially aged and
children. Patient can have pneumonia
Mechanical Ventilator – help patient breathe.
Taking in oxygen and taking out carbon dioxide.
Endotracheal tube is a tube inserted and
microorganism can easily enter.
INFECTION SEPSIS-HYPOVOLEMIC SHOCK (nawalan ng
dugo): If there are microorganisms that entered
the body (sepsis) it will cause an inflammatory
response and that will release chemical
mediators like histamine and cytokines. And this
will increase the permeability which means it
will allow the free passage of molecules or
substances in the capillary. The plasma leak in
the capillary and may enter the alveoli and
cause pulmonary edema or congestive pneumonia
and some fluids will go the interstitial space
causing hypovolemic shock (Rabino, 2020)
LUNG CONSOLIDATION: nag heal, maraming peklat
PRECAUTIONS TO IMPLEMENT INFECTIOUS PNEUMONIA
STANDARD PRECAUTION
o Private room
▪ If the patient can’t afford a
private room, place the patient in
the ward but see to it that there
is spatial separation (3-6 ft away
from another bed of patient)
o Doctors, nurses, janitors should wear
mask
o Have patient wear mask if frequently
coughing
o Handwashing technique
o Gowning, if highly infectious
DROPLET PRECAUTION
o Donning and doffing technique
NURSING MANAGEMENT
o Move patient from side to side
o Physiotherapy (vibration, backslapping)
▪ In order to move that mucoid
secretion so that patient
o Increase fluid intake if patient is
negative of pleural effusion. If
positive, no intake because it adds edema
to the patient
o IV fluid well-regulated because this is
going to thin the mucoid secretion
o Put humidifiers in the room
o Boil water and inhale the steam
CHICKEN POX/VARICELLA
The Plucky Little Virus You Ought to Know
About
CHICKENPOX/VARICELLA
• A highly contagious viral illness that
causes an itchy rash & is followed by a
vesicular eruption on the skin
• Usually occurs during childhood (normally
5-9), but you can get it at any time in
your life
• Within 1 or 2 days, the rash appears,
begins as red spots which then forms
blisters & spreads to the rest of the
body
Varicella (Chicken Pox)
• Mild, highly contagious disease chiefly
affecting children
• Mode of transmission:
o airborne droplets and direct
contact from varicella patients
o Vesicular fluid of Zoster patients
can be the source of Varicella in
susceptible children
CHICKENPOX/VARICELLA
• INFECTIOUS AGENT: Varicella Zoster Virus
• INCUBATION PERIOD: 10 to 21 days or may
be prolonged after passive immunization
against chicken pox
• Varicella zoster virus, a DNA virus and
is a member of the herpes virus group
• Primary infection causes chicken pox.
• Recurrent infection results in herpes
zoster (shingles).
INCUBATION PERIOD
• The host may become infectious (i.e. able
to transmit the pathogen to other hosts)
at any moment of the infection. This
moment will vary per pathogen.
• The starting point is the moment when a
pathogen enters the host this moment is
often referred to as blabla moment
• Immediately after this moment, the
pathogen usually will move to the blabla
tissue or target organ
• This will be the place within the host
where the pathogen can effectively
multiply
• Different pathogens may have different
target organs. Hepatitis virus will
target the liver for multiplication, for
example.
MODE OF TRANSMISSION
• AIRBORNE or spread by aerosolized
droplets from the nasopharynx of ill
individuals
• Direct contact with a patient who sheds
the virus from the vesicles
• Indirect contact, through linens or
fomites
AIRBORNE TRANSMISSION
• Small droplet nuclei, <5 microns diameter
• Stay suspended in air
• When inhaled, can reach the alveoli and
cause infection
DROPLET TRANSMISSION
• Large droplets >5 microns in diameter
• Do not remain suspended in the air, so no
special air handling or ventilation is
required
• if inhaled, do not reach alveoli
VESICLE
PERIOD OF COMMUNICABILITY
• The patient is capable of transmitting
the disease about a day before the
eruption of the first lesion up to about
5 days after the appearance of the last
crop.
TREATMENTS
• Following primary infection there is
usually lifelong protective immunity from
further episodes of chickenpox
SIGNS & SYMPTOMS
• Very itchy rashes
o Trunk - Neck, Face, Limbs (Rashes
in Crops)
• Red bumps
o Blisters, filled with clear fluid
(1-5mm or more in size) → drain →
scab
• Fever with body ache
o On the day or 1st day before rash
appears
• MOUTH, SCALP, AROUND EYES, GENITALS →
Painful
• Cycle repeats in crops
ERUPTIVE STAGE
• The rash is most dense on the trunk and
head
• Macules → Papules → Vesicles → Pustules
• PUSTULE- is a vesicle that is infected or
filled with pus.
• CRUST- is a scab or eschar. A secondary
lesion caused by the secretion of vesicle
drying on the skin.
o The scars are superficial,
depigmented, & take time to fade
out
• Blister: Filled with clear liquid
containing the virus.
• Skin lesions caused by chicken pox appear
in the form of red papule several
millimeters wide, with a blister in the
middle. The blister dries out and forms
a scab which falls off after about a week
without leaving any marks, except in the
case of secondary infections
• Chickenpox is a virus, so the physician
will not prescribe an antibiotic
▪ Virus has self-limiting disorder.
No medication can kill the virus,
only prevent multiplication of the
virus.
• Over time, the body's immune system will
clear out the virus
• Usually, those infected are instructed
to:
o Rest (to prevent skin abrasion)
o Cut their nails
o Depending on the severity of the
rash, wear gloves to prevent
further infections.
• Acyclovir, an antiviral medication, is
licensed for treatment of chickenpox.
▪ Reduce fever, body weakness,
lesion
• The medication works best if it is given
within the first 24 hours after the rash
starts.
• Other antiviral medications that may also
work against chickenpox include
valacyclovir and famciclovir.
• Acyclovir is the generic name for
Zovirax, a prescription medication used
to treat certain virus infections
• The drug works by preventing viruses from
dividing and multiplying.
 • If you are taking ACYCLOVIR to treat
chickenpox, the drug can reduce the
severity of the infection
• It's important to know that treatment
with acyclovir works best when you start
taking it as soon as possible after a
rash appears.
• This means within three days of a
shingles rash and within 24 hours of a
chicken pox rash.
VACCINATION
• MEASLES, MUMPs, RUBELLA, VARICELLA (MMRV)
o 1st dose: 12 months 12 y/o
o 2nd dose: 4-6 y/o
• 2nd dose may be administered at an
earlier age provided the interval between
the first and the second dose is at least
3 months
AIRBORNE PRECAUTIONS
• Used when patient has a known or
suspected disease that can be spread
through the air. (TB, Measles,
Chickenpox, disseminated herpes zoster,
and SARS)
• Properly fitted N95 respirators (high
filtration masks) required for people
entering room
• Room engineered with special airflow
criteria is required
• Door must remain closed
• Patients must wear a surgical mask when
outside the airborne isolation room (e.g.
for testing)
CALAMINE LOTION/CALADRYL
OATMEAL BATH to relieve itchiness
ICE CAP numbs the nerves and won’t feel pain
CARROT AND GINGER
• A soup made of carrots and coriander is
highly beneficial in the treatment of
chickenpox. It is rich in antioxidants
that help in the healing Process.
▪ Afritada
▪ Macaroni soup with plenty of diced
celery or finely chopped carrots
• Ginger can reduce the itching as they
have the anti-bacterial property.
• Pineapple can be also due to its anti-
inflammatory effects
HERPES ZOSTER/SHINGLES
• Stored at dorsal root (posterior, back)
of spinal cord and remains dormant. If
immune system went down because of
infection, surgery/transplant, cancer,
immunosuppressants, that virus will be
reactivated and result to shingles or
herpes zoster. Shingles are highly
infectious.
• ls caused by the same virus responsible
for chickenpox, the varicella zoster
virus
• It occurs in people who have had
chickenpox after several years
• After the initial exposure, herpes zoster
lies dormant in certain nerve fibers.
• Approximately 80% of cases occur in
persons older than 20 years
• Although it is most common in people over
age 50
• Anyone who has had chickenpox is at risk
for developing shingles
• Lesion will appear at the back because
virus is stored at dorsal root of spinal
cord (afferent nerves, responsible for
sensory) that’s why there is pain
• Ventral root – efferent nerves,
(front/anterior) supplying skin and
muscles in front/anteriorly
Herpes zoster may become active as a result of:
• Aging (50 and above)
• Stress
• Suppression of the immune system
o HIV-infection
o Cancer
• Certain medications
o Corticoid steroid use
o Radiation therapy
PERIOD OF COMMUNICABILITY
• A day before the appearance of the first
rash until five to six days after the
last crust disappears.
• The virus that causes shingles, VZV, can
be spread from a person with active
shingles to a person who has never had
chickenpox through direct contact with
the rash
• The person exposed would develop
chickenpox, not shingles
HERPES ZOSTER/SHINGLES
• Reactivation of latent VZV
• Uncommon in childhood
• Zoster is not caused by exposure to a
patient with varicella
• The lifetime risk for herpes zoster for
individuals with a history of varicella
is 10-20%
• 75% of cases occurring after 45 years of
age.
• Herpes zoster is very rare in healthy
children <10 year of age
PATHOPHYSIOLOGY
• After the primary infection, the
varicella zoster virus may persist in a
dormant state in the dorsal nerve root
ganglia
• The virus remains latent for decades
because of varicella-zoster virus
specific cell-mediated immunity acquired
during the primary infection.
 • The virus may later emerge from the site • Pain Control: Narcotics, gabapentin,
following a decrease in cell-mediated pregabalin, amitriptyline
immunity
• It produces localized vesicular skin NURSING MANAGEMENT
lesions, usually in a single dermatome & • Keep the patient in strict contact
pain along the involved dermatome precaution
• Apply cool, wet dressings with NSS to
SIGNS & SYMPTOMS pruritic lesions
• Pain occurs from one to five days prior • Do not puncture & open the blisters
to the development of rash
• Avoid contact with the skin lesions of
o burning or stabbing persons with known herpes zoster
o extreme pain infection
o pain is usually worse at night &
is intensified by movement.
• Encourage adequate rest (increases
activity of cell due to infection, to
• Rash starts off as red spots, which promote healing)
quickly turn into blisters
• Provide the patient with a diversionary
o They affect only one side of the activity to take his mind off the pain &
body & never cross the midline the pruritus
o This is because they come out on
the area of skin which is supplied • Prevent entrance of microorganisms into
by one particular nerve the lesions, especially if they are
broken
o Lesions may last for one to two
weeks
• Pruritus
• Fever, malaise, headache
• Paralysis of the facial nerve & vesicles
in the external auditory canal affects
the 7th CN. This condition is called
Ramsay-Hunt Syndrome

RAMSAY-HUNT SYNDROME
• Vesicular rash on external ear
• Lower motor neuron paralysis of facial
nerve
• Loss of taste sensation over anterior 2/3
of tongue
• Other manifestation
o Ramsay Hunt syndrome is an
otologic manifestation of herpes
zoster infection that results from
a reactivation of the geniculate
ganglion of CN VII. The triad of
symptoms include
▪ Ipsilateral facial
paralysis
▪ Ear pain
▪ Vesicles in the auditory
canal and auricle

HERPES ZOSTER OPTHALMICUS

ZOSTER TREATMENT
• Antivirals: Acyclovir, valacyclovir,
famciclovir
• Prednisone in certain cases
 MEASLES o The rash is typically pink or light red
Signs and Symptoms o RASH spreads in a cephalocaudal direction
o Fever of 38.3◦ C or greater to involve the entire body over the next
o Cough, runny nose and red, watery eyes 24 hours, and fades during the ensuring
o Red blotchy itch 2 or 3 days, also in a cephalocaudal
direction
GERMAN MEASLES/RUBELLA o Duration changes from < 1 day to > 5 days
o There was a pandemic of rubella between o Clears with minimal desquamation
o A pinkish rash on the soft palate,
1962 and 1965, starting in Europe and
spreading to the United States Forchheimer’s spot
o In the years 1964-65, the United States
had an estimated 12.5 million rubella FORCHHEIMER SPOT
o Forchheimer spots are a fleeting enanthem
cases. This led to 11,000 miscarriages or
therapeutic abortions and 20,000 cases of seen as small, red spots (petechiae) on
the soft palate in 20% of patients with
congenital rubella syndrome. Of these,
2,100 died as neonates, 12,000 were deaf, rubella
o They precede or accompany the skin rash
3,580 were blind, and 1,800 were mentally
of rubella. They are not diagnostic of
retarded
rubella, as similar spots can be seen in
o Three-day Measles
o Rubella is a contagious disease caused by measles and scarlet fever
a virus
GERMAN MEASLES/MEASLES
o Most people who get rubella usually have
a mild illness, with symptoms that can o Once recovered, people are immune to
future infections
include a low-grade fever, sore throat,
and a rash that starts on the face and
LABORATORY FINDINGS
spreads to the rest of the body
o 79% of all cases of rubella occurred
Rubella-specific IgM
among people ages 15 and older
o Diagnostic of acute infection
o Rubella is rare to catch, unless you are
o Usually appears within four days after
unvaccinated
o A mild self-limiting illness with rare onset of the rash
o Can persist up to 4-12 weeks
sequelae
Rubella-specific IgG
INFECTIOUS AGENT: Rubella virus
o Long-term marker of previous rubella
INCUBATION PERIOD: from exposure to the
infection
appearance of the rash, usually 14 to 21 days
o Begins to rise after the onset of the
rash, peaks about four weeks later, and
MODE OF TRANSMISSION
generally lasts for life
o Direct contact with nasopharyngeal
secretions
CONGENITAL RUBELLA
o Air droplets
o Result of in utero fetal infection
o Transplacental transmission in
o Occurs during 1st 12 weeks of pregnancy
congenital rubella
o Fetal infection may be subacute or
chronic
PERIOD OF COMMUNICABILITY
o May result in abortion, stillbirth,
o Approximately one week before and 4 days
congenital malformation
after the onset of rashes, but is at its
worst when the rash is as its peak
o Highly communicable infants with RISK OF CONGENITAL MALFORMATION
congenital rubella may shed virus for o 100% when maternal infection occurs on
the first trimester of pregnancy
more than a year after birth
o 4% in the second and third trimesters of
pregnancy
CLINICAL MANIFESTATIONS
o 90% of congenital rubella cases excrete
the virus at birth and are therefore
PRODROMAL PERIOD
o Low-grade fever infectious
o 10% of the virus remains contagious until
o Headache
the first year of age of the infected
o Malaise
o Mild coryza child
o Conjunctivitis
PATHOLOGY
o Cervical lymphadenopathy
o Maternal viremia → transplacental
infection → embolization of necrotic
ERUPTIVE PERIOD
placental vascular endothelium → fetal
o Maculopapular rash that appears first on
the face, spreading on the neck, the infection
arms, trunk and legs ▪ Placental infection does not
o The rash involves the entire body during always result in fetal infection
the first 24 hour → fades on the face particularly after the 1st
during the 2nd day → rashes disappear on trimester
the 3rd day
 o The virus crosses the placenta. Rubella
infections of pregnant women during the
first month results in birth defects:
▪ Deafness
▪ Blindness
▪ Mental retardation
Infants with congenital rubella syndrome
o Contagious
o Maintain contact precautions until they
are at least 1 year old, unless repeated
nasopharyngeal and urine cultures after
3 months old are (-) for rubella

RUBELLA SYNDROME MEASLES, MUMPS, RUBELLA (MMR) VACCINE

o Microcephaly o 1st dose: 12 months
o PDA o 2nd dose: 4-6 years old
▪ Blood was oxygenated blood and o Those who have not received the 2 nd dose
goes through the four pulmonic should complete the schedule during the
veins to enter the left atrium and 11-12-year-old visit
passes the bicuspid valve, then o The WHO recommends the first dose be
left ventricle, then aortic valve given at 12 to 18 months of age with a
and enters the ascending aorta and second dose at 36 months
there is a connection: the o Pregnant women are usually tested for
pulmonary artery and descending immunity to rubella early on. Women found
aorta. Unoxygenated blood in the to be susceptible are not vaccinated
descending aorta and higher until after the baby is born because the
pressure in artery. There’s mixing vaccine contains live virus
of unoxygenated blood and o It is recommended that all susceptible
oxygenated blood. Blood with less non-pregnant women of childbearing age
oxygen sent to descending aorta, should be offered rubella vaccination
affecting growth of child due to o Due to concerns about possible
less oxygen teratogenicity, use of MMR vaccine is not
o Cataracts recommended during pregnancy
o Instead, susceptible pregnant women
CONGENTIAL RUBELLA should be vaccinated as soon as possible
in the postpartum period
HEARING LOSS o All non-immune women should be vaccinated
o WHO definition (Smith, 1999): permanent during the immediate postpartum period
unaided hearing threshold level for the and before discharge
netter ear of 26 dB or greater ▪ Breastfeeding is not a C/I to
o Most common manifestation of congenital postpartum immunization
rubella
o Occurs in 70-90% of CRS cases CENTER FOR DISEASE CONTROL AND PREVENTION
o In 50% of these children it is the only PREVENTION OF INFECTIOUS DISEASES 2005-2006
sign of CRS o Immunization contraindicated during
o Most important cause of non-genetic pregnancy
congenital hearing loss o Do not conceive 28 days after vaccination
o Average age of identification: 2 years o Can cross placenta, infect fetus but do
not produced defects
GENERALIZED GROWTH RETARDATION o Inadvertent administration of vaccine
o Most common manifestation of congenital during 1st trimester is not an indication
rubella readily apparent at birth for termination of pregnancy
▪ 3% rate of viral isolation
EYE FINDINGS o Each patient should be counseled to avoid
o Cataracts pregnancy for 28 days after vaccination
o Congenital glaucoma because of the theoretical risk for
vaccine virus affecting the fetus
NEUROLOGIC o If vaccination of an unknowingly pregnant
o Meningoencephalitis – 10 to 20% of woman occurs or if she becomes pregnant
infants within 4 weeks after MMR, she should be
counseled about the theoretical basis of
CARDIOVASCULAR concern for the fetus
o PDA, Pulmonary Artery Stenosis o MMR vaccination during pregnancy should
o Myocarditis – most common cause of death not be regarded as a reason to terminate
pregnancy
ISOLATION o Gamma-globulin to pregnant women
▪ Reduce frequency of symptomatic
Infants with congenital rubella disease in the mother
o Infected actively at the time of birth ▪ Little effect on
o Contagious frequency/severity of fetal and
o Placed in isolation neonatal disease

Room isolation and urine precautions

o Should be continued for the duration
unless repeated viral culture are
negative
 RABIES ACUTE KIDNEY INJURY
o an abrupt decrease (within 48 hours) in
DOG BITES kidney function that includes:
o Stay still when an unfamiliar dog comes ▪ increase in serum creatinine,
up to you greater than 0.3 mg/dL (reliable)
o If knocked over by a dog, roll into a ▪ decrease in urine output (less
ball and lie still; do not look a dog in than 0.5 mL/kg/hour) for more than
the eye 6 hours
o Vital areas on your torso, head, and neck
are also now vulnerable to attack. These RISK FACTORS
are the most important spots on your body o Age 75 or older
to protect because bites in these places ▪ less blood supply to the brain,
will inflict the most damage and will heart, kidneys
have the greatest chance of killing you. o Diabetes
Protect your vitals by rolling onto your ▪ glucose will stay in blood and
stomach, tucking your knees in, and makes blood viscous increasing
bringing your hands (balled in fists) up blood pressure
to your ears o Hypertension
▪ viscous and slow movement of blood
FIRST AID TREATMENT decreasing blood supply to kidneys
o Wash the wound with ANTIBACTERIAL soap o CKD
for 5 full minutes o Heart or liver failure
▪ This is a vital step to combat ▪ heart is unable to eject a good
wound infection supply of blood due to damage:
▪ Flush the wound for additional 5 less cardiac output
full minutes allowing water to run o Sepsis
into the dog bite wound ▪ decreased blood supply
▪ there is severe infection causing
injury to the tissues. Injured
tissues will release cytokines,
histamine, bradykinin, increasing
capillary permeability. Plasma
including albumin goes out from
intravascular going to
interstitial compartment,
decreasing circulating blood.
Kidneys being a secondary organ,
will receive less blood supply and
lead to AKI
o Use of intravascular radiocontrast agent
▪ Should increase fluid intake
o Cardiac surgery after use of
radiocontrast agent

AKI
o Approximately 70% of patients who develop
AKI are age 70 or older
o Renal function may decline by 50% or more
by age 70

3 MAJOR MECHANISMS

PRE-RENAL - HYPOPERFUSION
o Decreased blood supply → decreased blood
supply to kidneys → kidneys will be
damaged
o Bleeding d/t vehicular accident, stab or
gunshot wound
o Hypertension
o Diabetes mellitus

HYPOTENSION
o Hypotension decreasing blood supply to
the brain and kidneys.
o For each hour of hypotension, the risk of
kidney injury more than doubled with each
10 mmHg drop in MAP below 80
o Report if BP goes down (drop in mean
arterial pressure)
 o Formula: systolic + diastolic x2 /3
INTRARENAL - DIRECT TISSUE INJURY
Directly destroying the kidneys by:
o Microorganisms: Streptococci (acute
glomerulonephritis, nephrotic syndrome)
o Drugs: aminoglycosides because they are
nephrotoxic; NSAIDs like Alaxan,
Ibuprofen, Voltaren
o Chemicals (take years before kidneys will
be damaged)
o Nephrotoxic drugs
▪ Amphotericin B
▪ Aminoglycosides
➢ Neomycin, Gentamycin,
Amikacin
▪ Vancomycin
o Rhabdomyolysis is a life-threatening
condition in which skeletal muscle tissue
breaks down and releases the oxygen-
carrying muscle protein myoglobin into
the blood
o Rhabdomyolysis may result from
▪ Traumatic muscle injury
▪ Heat-related hyperthermia
▪ High-voltage electrical or
extensive third-degree burns
▪ Pressure injuries related to
immobility
▪ Toxins (snake venom, black widow
spider venom, carbon monoxide)
o Hypersensitivity
▪ It causes renal inflammation;
kidney dysfunction occurs within
7-14 days of drug administration
▪ This type of AKI is usually
reversible, but recovery may take
several months and in rare cases
dialysis may be necessary
▪ Hypersensitivity reactions: rash,
hives, eosinophilia, fever
POSTRENAL AKI
o obstruction (calculi in the ureter-tube
where urine will pass going to urinary
bladder)
o urine formed by the kidneys cannot pass
and goes up to the kidneys, destroying it
o Results from obstruction of urine outflow
by:
▪ Tumors
▪ Calculi
▪ Prostate gland enlargement
➢ BPH
➢ Prostate gland nourishes
the sperm for motility
➢ Due to diet, obesity,
hormone (testosterone)
➢ Prone to UTI
PHASES OF ACUTE KIDNEY INJURY
I. ONSET PHASE
o Time when an insult occurs until cell
injury
o Last from hours to days
o The GFR is decreased because of impaired
blood flow to the kidney
o Urine output at 30mL or less per hour
(only 50% of patients are oliguric)
o The remainder excreting 600ml/8hours
o Urinary sodium excretion greater than 40
mEq/L
II. OLIGURIC-ANURIC PHASE
o Lasts 5 to 8 days in NONOLIGURIC patient
o 10 to 16 days in OLIGURIC patient
o Below 400 mL/day
▪ Oliguric: less urine formed in 24
hours (less than 300 per hour or
600 cc or below for 24 hours)
▪ Anuric (50 cc in 24 hours)
o GFR is greatly reduced → AZOTEMIA
▪ Toxins: Should not accumulate in
the body and must be removed by
urinating creatinine, uric acid,
urea
▪ Uremia – toxins accumulating in
the body (urinary output is less,
not all toxins will be excreted)
▪ Azotemia – big amount of toxins in
the body and can destroy the heart
and the brain, patient will become
confused and disoriented
o ↑ serum CREATININE
o Electrolyte abnormalities
▪ Hyperkalemia
▪ Hyponatremia
▪ Hyperphosphatemia
▪ Hypocalcemia
o Metabolic acidosis
HYPERKALEMIA
o Due to tissue trauma, bleeding, or blood
transfusion because K is released from
damaged cells
o In metabolic acidosis, the K levels
increase as hydrogen ions enter the cells
and force K out of the cells
o lead to cardiac dysrhythmia and then lead
to cardiac arrest
o 98% of potassium are removed by kidneys
o Due to toxins, it shortens the life span
of RBC, releasing potassium leading to
hyperkalemia.
o Potassium goes out because of the acids.
Hydrogen ions will go inside the cell,
potassium will go out in exchange of
hydrogen ions.
HYPONATREMIA
o Sodium normal value: 135-145
o body is compensating
o ADH and aldosterone will be released
because there is decreased circulating
blood volume. Will reabsorb plenty of
water
o dilutional hyponatremia (plenty of water
in the body)
HYPERPHOSPHATEMIA
o foods rich in protein are also rich in
phosphates
HYPOCALCEMIA
o low calcium because kidneys are
responsible in activating vitamin D.
 o calcium will not be absorbed by vitamin
D if kidneys are damaged in the small
intestine. Have a high phosphate
Phosphate and Calcium should be balanced
o controlled by parathyroid gland,
posteriorly of the thyroid gland.
o Since kidneys are destroyed, phosphates
will not be eliminated, thereby
increasing it. Calcium will not be
absorbed from the food that we eat in the
small intestine.
o Doctors will give medicines that lower
phosphate so that calcium will be
absorbed
o Vitamin D from early exposure to sunlight
(6-7 am), egg yolk, butter, milk.
Inactive once taken in and kidneys
activate it. If kidneys are damaged,
calcium won’t be absorbed in the small
intestine
METABOLIC ACIDOSIS
o so much hydrogen ions in the body
(acids).
o Because kidneys are damaged/destroyed and
it cannot produce adequate amount of
bicarbonates, cannot remove toxins (urea,
creatinine, uric acid)
o Pyelonephritis
o Edema from brain injury/surgery
Causes of increased USG
o DM
o Syndrome of Inappropriate
o Secretion of Antidiuretic Hormone
o over secretion of ADH
o CHF
TWENTY-FOUR-HOUR URINE COLLECTION
o All urine voided during a 24-hour period
is collected
o Urine is kept chilled (on ice)
o May need preservative added
o Void to begin test – discard this urine
o Collect for next 24 hours
o The patient is instructed to void and
discard the first specimen (8AM day 1)
o The patient collects all urine voided up
to and including that at 8
AM the following morning (day 2)
o If any urine is removed or discarded
during a timed collection, the entire
time collection is invalid
o A 24-hour creatine clearance test is
necessary to detect changes in renal
reserve

III. DIURETIC PHASE

o May last 7 to 14 days
o The tubular obstruction has passed but
EDEMA and SCARRING remain
o The urine is able to flow through the
tubular space, but the cells cannot
concentrate the urine
o When the client moves from the oliguric
to the diuretic phase, hypovolemia and
electrolyte losses are the primary
problems
o In the oliguric phase, fluid and
electrolytes are retained
o Because of fluid loss the patient
experiences:
▪ Hypovolemia
▪ Hypotension
▪ Hyponatremia
▪ Hypokalemia

IV. RECOVERY PHASE

o Kidney function may return to normal or
near normal or near normal
o Edema diminishes and the tubular cells
begin to slowly resume normal functioning
o GFR that is 70% to 80% normal within 1 to Nurse fills up the data
2 years
CREATININE
URINE SPECIFIC GRAVITY
o Measures the concentration of particles
in urine Proteins (bubbles
o To gauge the patient’s hydration status in the urine)
as well as the functional ability to the
kidneys Proteins should
o Normal Value: 1.010 – 1.020 not be present in
the urine
Causes of decreased USG
o Excessive fluid intake
o Diabetes insipidus
o Glomerulonephritis
URINALYSIS ▪ Example: 75kg should have a fluid
o Protein or cells in the urine may intake of 2,250 mL/day
indicate intrarenal damage, such as
glomerulonephritis or kidney infection Xerostomia (dry mouth)
o Hematuria, pyuria, or urinary crystals o A metallic taste
may indicate a postrenal cause o An unusual breath odor from bacterial
interaction with urea in the saliva
✓ Provide foods soft to masticate and
nutritious
✓ Prepare solutions
✓ Frequent oral hygiene
✓ Moisturize the lips every 2 to 4 hours to
prevent breakdown

✓ Caution patients using NSAIDs to be

mindful of potential adverse effects such
as hypersensitivity
▪ Drink plenty of water when taking
these medications
Pyuria (milky)
✓ Instruct patients to discontinue any
medication to which they have a
DIAGNOSTIC STUDIES
hypersensitivity reaction
o Renal ultrasound may show renal tissue
✓ A repeat serum creatinine level should be
damage or urinary tract obstruction
obtained 7 to 10 days after any
o Renal biopsy to investigate possible
hypersensitivity reaction
intrarenal disorders: (7-10k)
✓ Clean all equipment used between
▪ Glomerulonephritis
patients, practice SCRUPULOUS HAND
▪ Nephritis
HYGIENE
▪ Ensure that everyone on the unit
MEDICAL MANAGEMENT
does so as well
For volume overload ▪ Instruct patient on infection
Volume overload (cannot form urine, fluid is prevention
accumulating in the body → edematous d/t protein ✓ Manage peripheral and central venous
na lumabas. Has albumin that maintain osmotic access devices as well as dialysis access
pressure (holds water in the blood vessel) catheters with STRICT STERILE TECHNIQUE
o Furosemide ✓ Administer prescribed antibiotics
o Dialysis – machine, cleaning blood (5k) strictly on time to prevent any drop in
therapeutic drug levels
For hyperkalemia ✓ If patient needs a urinary catheter,
o Kayexalate maintain a
o Furosemide ▪ Closed drainage system
o Glucose-insulin ▪ Unobstructed urine flow
▪ Insulin will be given to carry ▪ Perform meatal care with soap and
glucose bringing it inside the water
cell, including the potassium. ▪ Discontinuing it as soon as
Diminishing potassium in the blood possible
to not develop dysrhythmia ▪ Patient is not lying over it
▪ Use clean gloves when measuring
Avoid magnesium-containing antacids, salt I&O
substitutes, NSAIDs and other nephrotoxins ✓ Teach patients-before surgery, after
o Pantoprazole—----------Pantoloc surgery and at discharge to report any
o Aluminum Hydroxide-----Alu-tab reduction in urine output or voiding
frequency
NURSING INTERVENTIONS ▪ Surgery
✓ Accurately document intake and output and ▪ Injury
daily weight ▪ Medications
▪ Low blood volume or cardiac output ✓ In postoperative patients report any:
➢ 0.9% sodium chloride ▪ Urine output less than 0.5 mL/kg
➢ Urine: 30-50 cc/hour. If per hour, assess vital signs and
less, report urine output every 15 to 30
▪ For hypervolemia minutes until VS are stable
➢ Restrict sodium intake ▪ Report any hypotension or
✓ Early identification and prevention of tachycardia
dehydration, especially in older patients
▪ Older adults should have 30mL of
daily fluid intake per kg of body
weight
 TYPHOID FEVER

o Small intestine is affected INFECTIOUS AGENT: Salmonella typhosa

o Once the bacteria enter the bloodstream, INCUBATION PERIOD: 5 to 45 days
it can affect the pancreas, heart, brain MODE OF TRASNMISSION
etc. o The disease can be passed from one person
o Bacteria can grow inside the macrophages to another through fecal-oral
transmission
DEFINITION o Through the ingestion of contaminated
Typhoid fever is an acute bacterial infection food, water and milk
characterized by constitutional symptoms like o Contamination is usually by hands of
prolonged pyrexia, prostration and involvement carrier
of spleen and lymph nodes. It does not cause
lifelong or sufficiently prolonged immunity, SOURCES OF INFECTION:
second attack often occurs o A person who has just recovered from the
disease or has recently taken care of a
TYPHOID FEVER-OTHER NAMES patient with typhoid
o Enteric fever o Ingestion of shellfish (oyster) taken
o Bilious fever from waters contaminated with sewage
o Yellow Jack disposal
o The stools and vomitus of an infected
TYPHOID FEVER individual
o Typhoid spreads when people consume food
or water, which is contaminated by the PERIOD OF COMMUNICABILITY
feces of another infected person o As long as the patient is excreting the
o People with a poor immune system are more microorganisms, he is capable of
prone to the disease and are more likely infecting others
to be severely affected
CAUSES
BACTERIOLOGY-TYPHOID FEVER o Poor sanitation
o The Genus Salmonella belong to o Contaminated or infected water
Enterobacteriaceae o Food: contaminated with germs by flies
o Facultative anaerobe (attracted to yellow color)
o Gram negative bacilli o People who have the disease if they
o Distinguished from other bacteria by prepare or serve the food
biochemical and antigen structure o Unhealthy diet faulty style of livings

TYPHOID MARY PATHOPHYSIOLOGY

o The most notorious carrier of typhoid Salmonella typhi
fever – but by no means the most ↓
destructive – was Mary Mallon, also known Survives the acidity of the stomach
as Typhoid Mary. In 1907, she became the ↓
first American carrier to be identified Invades the Peyer’s patches of the intestinal
and traced. She was a cook in New York; wall (tonsils of small intestine)
some believe she was the source of ↓
infection for several hundred people Macrophages (Peyer’s patches)
o Mary Mallon was a cook in Oyster Bay, New ↓
York in early 1900s The bacteria are within the macrophages and
o Gave rise to more than 1300 cases in her survives
lifetime ↓
o She died of pneumonia after 26 years in Bacteria spreads via the lymphatics while
quarantine inside the macrophages

o Natural infection is by ingestion

followed by either direct invasion of the
 mucosa of small intestine or
multiplication for several days before
invasion
o The Peyer’s patches are potential sites
where S. typhi is internalized and
transported to the underlying lymphoid
tissues
o From the submucosa, the organism travel
to the mesenteric lymph nodes, multiply
and then enter the bloodstream
▪ Mesenteric (hold organs in place)
o During the bacteremia phase, the organism
may invade any organ but most commonly
are found in the liver, spleen, bone
marrow, gallbladder, and Peyer’s patches
in the terminal ileum
o The Peyer’s patches become hyperplasic
with infiltration of inflamed cells
o Hemorrhage and perforation may occur due
to the growth of the lesion and the
continuous erosion of the epithelial
lining of the small intestines
o Since the toxins are absorbed into the
bloodstream, almost all organs of the
body are affected
o The mesenteric lymph glands are red and
swollen
SOURCES
o Food handlers
o Flies
o Street foods/vendors
o Taho vendors
o Jollijeep in Makati
SIGNS AND SYMPTOMS
o High fever
o Headache
o Diarrhea
o Constipation
o Weakness
o Dry cough
o Rashes
o Rose Spots
▪ Occurs in up to 20-30% of people
infected with Salmonella typhi
▪ Characteristically, rose spots are
seen in untreated typhoid fever
▪ Usually occur between the second
and fourth week of illness
▪ They are usually distributed
between the level of the nipples
and umbilicus, but can also be
found on proximal extremities and
back
▪ Each lasts 3 to 5 days
▪ are thought to be bacterial emboli
to the skin, i.e. clumps of
bacteria have spread through the
bloodstream
DIAGNOSIS
Physician still plays the key role
o Because there is no definitive rest for
typhoid or parathyroid fever, the
diagnosis often has to be made
clinically. The combination of a history
of being at risk for infection and a
gradual onset of fever that increases in
severity over several days should raise
suspicion of typhoid or parathyroid fever
o An elevated WBC
o Blood culture during first week of the
fever can show S. typhi bacteria
o A stool culture
o A platelet count (decreased platelets)
PREVENTION
o Clean water
o Sanitation
o Hygienic handling of foodstuffs
o Typhoid fever vaccine-give protection
o Good hygiene
o Avoid raw vegetable that cannot be peeled
o Avoid foods and beverages from street
vendors
o Wash hand with soap and water
o Sanitary and proper disposal of excreta
o Proper supervision of food handlers
o Provision of adequate amounts of safe
drinking water supply
o Education of the general public on the
mode of transmission
o Food inspection
NURSING CARE
o Increase fluid intake and stay on a
liquid diet until the diarrhea stops
o Isolate the patient or have him use a
separate bathroom
o Rest in bed until symptoms subside (to
slow metabolism; lessen workload)
o Wash hands thoroughly and frequently
o High caloric diet after the diarrhea
stops

TREATMENT
o In most cases typhoid fever is not fatal
o Antibiotics such as ampicillin,
chloramphenicol, trimethethoprim-
sulfamethoxazole, and ciprofloxacin
o These antibiotics have been used in most
developed countries
Fluids in the form of:
o Tender coconut water
o Electrolyte fortified water (gatorade)
o Fresh fruit juice
o Vegetable soup (chicken macaroni soup
with finely chopped carrots; pumpkin
soup)
o Water
Should be consumed until body temperature comes
back to normal
Consume liquid diet for a few days and then
gradually take fruits like:
o Bananas
o Cantaloupe (high in potassium)
o Watermelon
o Grapes
o Peaches
o Apricot
As the person’s appetite gets better, semi-solid
foods can be given
o Boiled rice (lugaw)
o Baked potato
o Soft boiled or poached eggs
o Yoghurt
o Vegetable soup
o Avoid high fiber foods: intake of whole
grain cereals and their products like
oatmeal, whole wheat bread, and raw
vegetables in the form of salads, are
rich in fiber
▪ It can add on the stress on your
digestive system
o Avoid vegetables like cabbage, capsicum
and sweet potato, as these can cause
bloating and gas
o Stay away from oily foods, spices and
seasonings like pepper, cayenne and chili
powder to make sure that the digestive
tract dies not inflame all the more
▪ Spicy foods: Decrease absorption
of small intestine
LEPTOSPIROSIS
o Also known as canicola fever, hemorrhagic
jaundice, infectious jaundice, mud fever,
spirochetal jaundice, swamp fever,
swineherd’s disease, caver’s flu or
sewerman’s flu, is a bacterial infection
resulting from exposure to the Leptospira
interrogans bacterium
o Infectious disease caused by spirochete
bacteria (Leptospira interrogans)
o Acquired when coming in contact with
flood water contaminated by urine of
animals such as rats, dogs, goats, and
swine
o Common in tropical countries with heavy
rainfall
INFECTIOUS AGENT: Leptospira interrogans
INCUBATION PERIOD: 6 to 15 days
o Found in river and lake waters, sewage,
and in the sea
o Spread mainly by the urine of infected
animals
o Not transmitted from person to person
MODE OF TRANSMISSION
o Ingestion or contact with the skin or
mucous membranes
o Mucous membranes of the yes, nose, and
mouth and through breaks in the skin
o Common among watersport enthusiast,
prolonged immersion in water is known to
promote the entry of bacteria
 TREATMENTS
o Penicillin G- drug of choice
o Ampicillin, Amoxicillin, Doxycycline
o In more severe cases, Cefotaxime or
Ceftriaxone
o Glucose and salt solution infusions
o Dialysis in serious cases
o AMPICILLIN – broad-spectrum penicillin,
weaken the bacterial cell wall, causing
lysis and death
o CEFTRIAXONE – bactericidal
o DOXYCYCLINE – suppress bacteria growth by
inhibiting protein synthesis

PREVENTION
o The risk of acquiring leptospirosis can
be greatly reduced by not swimming or
wading in water that might be
contaminated with animal urine, or
eliminating contact with potentially
infected animals
SIGNS AND SYMPTOMS o Wear boots
o Diarrhea o Boil water for cooking
o Vomiting o Immerse vegetables in water with
o Eye redness vinegar/salt/baking powder and rinse
o Headache thoroughly before cooking
o High fever o Cover trash bins
o Conjunctival suffusion (dilated o Vaccinate dogs
conjunctival blood vessels in the absence o Cover foods
of discharge) o Rat killers
o Pharyngeal erythema without exudate
o Muscle tenderness
o Rales on lung auscultation or dullness on
chest percussion over areas of pleural
hemorrhage
o Rash (macular, maculopapular,
erythematous, petechial, or ecchymotic)
o Jaundice
o Meningismus
o Hypo- or areflexia, particularly in the
legs

SYMPTOMS-MILD FORM
o Leptospirosis is a BIPHASIC DISEASE
begins with flu like syndrome (fever,
chills, intense headache, myalgia)
o First phase resolves, and the patient is
briefly asymptomatic until the second
phase begins
o Red eyes, diarrhea, rash
o Jaundice
o Pulmonary symptoms
 MEDICAL SURGICAL NURSING ▪ Red blood cells
FINALS o When this DNA is gone, the cell
responds to signals for
CANCER programmed cell death, apoptosis
o The purpose of apoptosis is to
ensure each organ has adequate
number of cells at their
functional peak

Chemotherapy AE: alopecia because these

drugs are very effective in cells that
are growing rapidly and hair follicles
are one

Some cells will not leave G0 (resting

phase) and most of the cells come from
CNS and it would not regenerate
(permanently damaged)

CHARACTERISTICS BENIGN MALIGNANT

o Persistent Proliferation Dangerous, can
Localized
o Cancer cells undergo UNRESTRAINED spread
GORWTH and DIVISION Slow growing Fast growing
o Cancer cells are able to continue Capsulated Non capsulated
multiplying under conditions that Invasive and
Non-invasive
would suppress further growth and infiltrate
division of normal cells Do not
Metastasize
o INVASIVE GROWTH metastasize
o Malignant cells can penetrate Well Poorly
adjacent tissues, thereby differentiated differentiated
allowing the cancer to spread Suffix “oma” Suffix “carcinoma”
o The various type of cells that e.g. Fibroma or “sarcoma”
compose a tissue remain
segregated from one another WELL-DIFFERENTIATED CANCER
o Cells of one type do not invade Well-differentiated cancer cells
territory that belong to cells of o Looks more like normal cells
a different type o Tend to grow and spread more
o Malignant cells are free of the slowly than poorly differentiated
constraints that inhibit invasive or undifferentiated cancer cells
growth
▪ It goes everywhere else to POORLY DIFFERENTIATED CANCER
metastasize because they go o The cells of poorly
with blood. Through also the differentiated or
lymphatic system undifferentiated cancers
o FORMATION OF METASTASIS (carcinomas) looks very different
o Ability of malignant cells to from normal cells under the
break away from their site of microscope
origin
o Migrate to other parts of the body Metastasis can occur by the following
and then re-implant to form a new mechanisms
tumor o Direct spread of tumor cells by
o IMMORTALITY diffusion to other body cavities
o Unlike normal cells, which o Circulation by way of blood and
eventually die, cancer cells lymphatic channels
undergo endless divisions o Transplantation or direct
o Normal cells have a finite life transport of tumor cells from one
span site to another
 ▪ Abdominal surgery, the
surgical instrument
touching the tissue can
spread to cells
Lymph Nodes
o 600-700
o most abundant in the head and neck
STAGING IN CANCER
Reasons
1. To know the treatment
▪ Stage 1 & 2: surgery
▪ Stage 3 & 4: radiation and
chemotherapy; will only
prolong life
2. To know the prognosis
▪ Stage 1: 90% chances of
living
▪ Stage 4: 10-15% chances of
living
3. To know the extent of tumor
1. A way in which the characteristics
of CANCER can be described
2. Classifying the EXTEND and SPREAD
of Cancer.
3. Allows decisions to be made about
the management of the CANCER
patient; identifying appropriate
treatments
4. A way of estimating the PROGNOSIS
of a case.
STAGE I: Malignant cells are confined
to the tissue of origin, no signs of
metastasis
STAGE II: Spread of cancer is limited
to the local area, usually to area
lymph nodes
STAGE III: Tumor is larger, probably
has invaded surrounding tissues or both
STAGE IV: Cancer has invaded or
metastasized to other parts of the body
7 WARNING SIGNS
1. A change in bowel habits or
bladder function
2. Sores that do not heal
3. Unusual bleeding or discharge
4. Thickening or lump in breast or
other body parts
5. Indigestion or difficulty
swallowing
6. A recent change in a wart or mole
7. A nagging cough or hoarseness
Pain is a late manifestation of cancer
(stage 3 or 4)
RISK FACTORS ON CANCER
o Of all cancer cases, 77% occur in
people older than 55 years of age
(American Cancer Society, 2005).
This higher incidence reflects a
lifelong accumulation of DNA
mutations that result in cell
changes and cancer.
o Older adults may not be able to
repair these mutations as they
once did. Immune function,
especially cell-mediated immunity
(WBC, macrophages), is also
reduced in the older adult.
BREAST CANCER
o Pectoral muscle: tumor can adhere
inside minor outside major
o Modified: minor pectoral removed
o Total: minor and major pectoral
removed
2 MAIN KINDS OF BREAST CANCER
o Ductal: Meaning it starts in the
tubes, or milk ducts
o Lobular: Meaning it starts in the
milk-producing glands
DUCTAL CARCINOMA IN SITU (Inside)
o Most common non-invasive cancer
(localized)
o Cancerous cells are confined to
the duct
o It has an excellent prognosis with
treatment
o Unchecked it could turn into
invasive cancer
INFILTRATING DUCTAL CARCINOMA (Going
out)
o Most common type of breast cancer,
making 75% of all invasive cancers
o Cancerous cells break through the
duct wall and invade the breast
tissue
o Most common sites for metastasis
are the bones, lungs, liver and
brain
LOBULAR CARCINOMA IN SITU
o Collection of abnormal cells is
present, but doesn’t extend
beyond the affected lobule
 o Women with lobular carcinoma in o Obesity
situ have an increased risk of ▪ Decreasing immune system-
developing invasive breast cancer responsible in killing
in either breast later in life carcinogen
o Exogenous hormones
INFLAMMATORY BREAST CANCER o Benign breast disease
o An aggressive cancer in which the o Oral contraceptives
affected beast looks inflamed, o Alcohol
red and feels warm ▪ Suppresses the ability of
o The skin has the appearance of an WBC to multiply and inhibit
orange peel, with an engorged look the action of killer WBC on
▪ Edema: late manifestation cancer cells
o Sometimes, there’s also lump in ▪ Lessen the ability of
the breast macrophages to produce TUMOR
o Symptoms begin to appear when NECROSIS FACTORS
lymph vessels become blocked
o Death occurs within 18 to 24 CLINICAL MANIFESTATIONS
months of diagnosis o Single lump, painless, non-tender
o The classic sign of this cancer and fixed
is the peau d’orange of the breast o Lump
skin accompanied by erythema. ▪ Firm to hard in consistency
▪ Irregularly shaped
PAGET’S DISEASE ▪ Fixed, not mobile
o This cancer is associated with ▪ Often attached to the chest
nipple changes wall (minor or major
▪ Eczema pectoralis) upper outer
▪ Itching quadrant of the breast
▪ Thickening of the areola o Upper outer quadrant
o Can be invasive or non-invasive o Dimpling and retraction of the
skin and nipple
RISK FACTORS FOR BREAST CANCER o Peau D’orange: Late manifestation
o Age >50 years old o Nipple discharge that is
▪ About 78% of breast cancers unilateral
occur among women over 50 ▪ Serosanguineous
years of age ▪ Bloody
o Family History ▪ Watery
o Female Gender o Breast distortion
▪ Estrogen is the food of o Pain: Late manifestation of any
cancer cells cancer
o History of previous breast CA o Axillary adenopathy
o Menstrual History
▪ Menarche prior to age 12 STAGES OF BREAST CANCER
▪ Menopause after age 55 Stage I
▪ menopause at 58 exposure to o Tumor smaller than 2cm
estrogen high risk of cancer o No node involvement
o Estrogen Exposure Stage II
▪ Nulliparity o Tumor more than 2 cm but less than
▪ First born child after 30 5 cm.
y/o o Possible axillary node
▪ Breast feeding of at least involvement
one-year duration Stage III
o Researchers have found out that o tumor greater than 5 cm.
the more years a body is exposed o axillary lymph (+) for cancer
to estrogen, the greater risk of cells
developing breast cancer Stage IV
o Ionizing radiation o Tumor any size.
o High fat diet o Distant metastases evident
SCREENING TESTS BREAST ULTRASONOGRAPHY
PREPARATION:
MAMMOGRAM o No fasting or sedation is required
o The BEST IMAGING TOOL for o Instruct the patient not to apply
detecting breast CA any lotions or powders to the
o Yearly screening between the ages breast.
40-50 o Supine position, a conductive
o BEST TIME: 1 week after menstrual paste is applied.
period or 1-2 weeks after the o Duration: 15 minutes
onset of menses.
▪ Before menstruation, breast SENTINEL LYMPH NODE BIOPSY
is dense and hard because of o To map the lymphatic drainage of
the presence of progesterone a primary cancer so that surgery
o MAMMOGRAPHY + MRI can be directed:
o Done for women with a high risk 1. For diagnostic
for breast CA 2. Possibly therapeutic
o 2 techniques when combined, resection of lymph nodes
detects 94% of tumors
o Detection of breast cancers, THREE REASONS
benign tumors, and cyst before 1. To stage the patient
they are even palpable. appropriately
o Inform the patient that some 2. To determine treatment based on
discomfort may be experienced stage
during breast compression. 3. Remove cancer cells and decrease
o Compression allows better amount of tumor
visualization of the breast
tissue. Functions of the Lymphatic System
o Talcum powder can give the o Filtration of foreign objects
impression of calcifications o Fluid transport
within the breast o Initiation of immune responses
o Tell the patient that NO FASTING
is required Side Effects of SLNB
o Explain to the patient that a o Tenderness around the area of
minimal radiation dose will be surgery
used during the test. o Numbness
o Jewelry worn around the neck can o Limited range of motion
preclude total visualization of o Infection
the breast o Lymphedema
o Breast augmentation implants
prevent total visualization of Techniques
the breast. Injecting a dye (radioactive or blue
dye)
DIGITAL MAMMOGRAPHY
o On the day of your mammogram, SLNB
please DO NOT USE deodorant, o With the use of SLNB, the first
powder, perfume or lotion under lymph node in the chain of lymph
your arms or near or your breast nodes can be identified and
area. These products may show up biopsied
on your mammogram images.
o Caffeine should be eliminated one CLINICAL BREAST EXAM (Physician)
week prior to your exam. This is o YEARLY if 40 y/o or older
for your comfort, as caffeine can o EVERY 3 YEARS if 20-39 y/o
sometimes cause breast tenderness
o Wear a two-piece outfit so you BREAST SELF- EXAM (Patient)
only need to remove your top. o MONTHLY for all, beginning at age
20
 o Done 5-7 days after the onset of
menstruation
*The latter half of menstrual cycle
is influenced by the secretion of
progesterone, which causes the
breast vasculature and ductal
structures to dilate with resultant
tissue engorgement.
o Put a small pillow underneath to
distribute equal fat
o Elevate arm if you are palpating
that side of the breast being
GENETIC SCREENING
o Done if a family member dies of
cancer
o Normally, the BRC1 and BRCA2 genes
protect you from getting certain
cancers. (chromosome 17 and 13,
respectively)
o But some mutations in BRCA1 and
BRCA2 genes prevent them from
working properly
o If you inherit one of these
mutations, you are more likely to
get breast, ovarian and other
cancers
o Their function is to produce
proteins that prevent abnormal
cell growth and, therefore,
CANCER
o However, if a person inherits a
BRCA gene mutation from either
parent, the risk of developing
cancer is greater
o BRCA1 is a gene that when healthy,
prevents breast tumors from
forming
o If BRCA1 is mutated, the protein
that is makes is unable to
regulate cell division, leaving
your breast cells susceptible to
the growth of cancer.
o BRCA2 is a gene that, when
healthy, prevents breast tumors
from forming
o BRCA2 makes a protein that is
involved in DNA repair and genetic
stability.
o If BRCA2 is broken (mutated), the
protein that it makes is unable
to repair broken DNA, leaving your
breast cells susceptible to the
growth of cancer.
o The BRCA gene test is offered only
to people who are likely to have
an inherited mutation, based on
personal or family history, or who
have specific types of breast
cancer. The BRCA gene test isn't
routinely performed on women at
average risk of breast and ovarian
cancers.
COST OF BRCA
o The BRCA test in St. Luke’s Quezon
City and Global, costs
PHP170,000.00. They start with
testing your blood for infection.
If you don’t have the infection,
then it’s a go for the BRCA gene
test.
o BRCA Testing is expensive. In the
US, it may cost from hundreds to
thousands.
o According to the Texas Medical
Association, the cost of BRCA gene
testing can range from US$385 for
a single site analysis to US$3,120
for full sequencing of both genes.
o According to the National Cancer
Institute, women with an abnormal
BRCA1 or BRCA2 gene have about a
60% risk of being diagnosed with
breast cancer during their
lifetimes.
o Does inheriting the BRCA gene
mutation mean that cancer
inevitably will develop?
▪ The answer is NO
o Those who don't have genetic
mutations also may develop cancer
from other known and unknown
causes.
GENETIC SCREENING
o In a retrospective study of 639
women with a family history of
 breast cancer who had bilateral
mastectomy between 1960 and 1993
at the Mayo clinic
o Researchers concluded that
PROPHYLACTIC SURGERY reduced the
risk of developing breast cancer
by at least 90%.
o A mutation in the BRCA1 gene-
indicating a lifetime risk of
ovarian cancer as high as 60% and
a lifetime risk of breast cancer
as high as 85%.
o In hormone-related cancers, these
prophylactic operations stop the
flow of estrogen and the growth
of tumors
BREAST ULTRASONOGRAPHY
o a supplemental tool to further
investigate an abnormality found
on mammography.
o It reveals whether a lump is a
fluid-filled cyst that is likely
to be harmless or a solid tumor
which could be cancerous.
o Researchers concluded that
bilateral prophylactic
oophorectomy reduces the risk of
developing either coelomic
epithelial cancer or breast
cancer in women carrying either a
BRCA1 or BRCA2 mutation.
PREOPERATIVE
o Shower with an antibacterial soap
o Teaching topics include:
▪ Expected length of stay
▪ Routine postoperative
monitoring
▪ Caring for a drainage tube
▪ ROM
▪ Pain management
SURGICAL MANAGEMENT
STAGES I and II
o Surgery is the initial treatment
of early-stage breast cancer
o For PRIMARY LOCALIZED BREAST (<2-
4 CM and no metastasize)
2 Surgical Options may be offered
1. Modified Radical Mastectomy
▪ Breast tissue, nipple and
lymph nodes are removed
▪ Pectoralis muscles are left
intact
2. Lumpectomy or Tylectomy
▪ Only the tumor is removed
▪ Some AXILLARY LYMPH NODES
may be excised at the dame
time for microscopic
examination
Other Types of Breast-Conserving
Surgery
The Breast-Conserving results in 5- and
10-year survival.
1. Partial or Segmental Mastectomy
▪ The tumor and some breast
tissue and some lymph nodes
are removed
2. Simple of Total Mastectomy
▪ All breast tissue is removed
▪ No lymph node dissection is
performed
Typically, radiation therapy follows to
eradicate residual tumor cells
STAGES III and IV
o Mastectomy in combination with
SYSTEMIC CHEMOTHERAPY or HORMONAL
THERAPY
o Patients who were initially
treated by breast-conserving
therapy and develop recurrence
undergo TOTAL MASTECTOMY
POST OP INTERVENTIONS: MASTECTOMY
Prepare the client what to expect
immediately following surgery
o One or two drains inserted round
the incision site COVERED BY A
BANDAGE
JACKSON-PRATT DRAINS
▪ Usually in place for 2-4
days
▪ Drainage should not exceed
200ml in 8 hours
DRAIN
o Excessive BRIGHT RED DRAINAGE may
indicate HEMORRHAGE
o Little or no return may indicate
OBSTRUCTION of the drainage
apparatus
o Drains are generally removed when
drainage is about 30 mL/24 Hours
(3rd or 4th postop day)
POST OP INTERVENTIONS: MASTECTOMY
✓ Her arm ELEVATED
o Shoulder positioned at
appropriate angles:
▪ No greater than 65 degrees
of FLEXION
▪ 45 degrees to 65 degrees of
ABDUCTION
▪ 45 degrees to 65 degrees of
INTERNAL ROTATION
o Forearm resting on a pillow to
facilitate DRAINAGE & ADEQUATE
CIRCULATION
✓ Continue to elevate her affected
arm at home for 4 to 6 weeks after
surgery to help reduce initial
swelling and discomfort
✓ Give the patient a small foam ball
and tell her to squeeze it with
the hand on her surgical side to
help circulate lymph fluid. (20
times)
✓ PAIN MANAGEMENT – Prime concern
(Demerol)
o Patient-controlled analgesia
o Medicating the patient before
activities such as:
▪ Turning
▪ Getting out of bed for the
first time is ADVISABLE
✓ The affected arm is kept IMMOBILE
FOR 24 HOURS to decrease any
strain on the incision line
✓ HAND EXERCISES to facilitate
lymphatic flow may be started good
lymphatic flow (24 hours after
surgery)
▪ Squeezing a ball (rubbery)
▪ Opening closing fist
▪ Flexing and extending the
wrist and elbow
*May be done several times at
each hour*
✓ Instruct the patient to get out
of bed form the UNAFFECTED SIDE:
▪ This lessens the pain and
tension on the operative
site.
✓ The patient should sit with the
head of the bed at least 30
degrees
✓ Do not use the affected arm for:
▪ Venipuncture
▪ BP reading
▪ Blood sampling
▪ Injections
✓ Encourage your patient to look at
her incision
▪ So, she can see what’s
normal
▪ To monitor for signs and
symptoms of infection
✓ The nurse should be beside in her
first look for reassurance and
comfort
✓ Infection and wound problems are
rare. They’re most likely to occur
in first 2 weeks after surgery
✓ Mastectomy patients SHOULD NOT
WEAR ANYTHING THAT MIGHT IRRITATE
THE INCISION UNTIL AFTER THE WOUND
HAS HEALED, GENERALLY in 6-10
weeks.
✓ A patient who has undergone
axillary node dissection should
not shave the affected underarm
or apply depilatory creams or
strong deodorants to it for at
least 2 weeks postop
LYMPHEDEMA
o Results from inadequate lymph
flow with tissue swelling due to
interstitial accumulations of
plasma proteins and fluid
o RADIATION THERAPY can damage
healthy lymph nodes and vessels →
scar → tissue → obstruction →
lymphedema
o When lymphatic system suffers
from trauma, the ability to remove
excess fluid is compromised
o Lymphedema can develop weeks,
months or years after breast
cancer surgery
o Weeks, months, or years
LYMPHEDEMA S/S
o Swelling of the fingers or arm
o Limb heaviness and skin tightness
o “Heat” or burning or “pins and
needles” to numbness
o Less flexibility in the hands,
wrist or ankle
o Jewelry feels tight even though
they haven’t gained weight
o Feelings of tiredness, aching,
weakness
PREVENTING/MINIMIZING LYMPHEDEMA o Teach them to use the affected
Once lymphedema is established it limb for normal everyday
cannot be cured activities such as hair brushing,
o Wear no constricting or jewelry bathing
including wristwatch on affected o Avoid prolonged exposure to heat
arm (wear jewelry at the non- such as hot tubs and sauna (cause
affected arm) vasodilation)
o Place the arm in sling when the o Avoid immersing the affected arm
client ambulates initially; in hot water
Eventually, the arm can be o Sleep on her back or her
positioned at the client’s side. nonsurgical side
o Use protective hand and finger o Carry luggage or her handbag on
covering when washing dishes, her nonsurgical side
cooking, sewing o AFTER 6 WEEKS OR WHEN ARM FUNCTION
o Avoid lifting or moving heavy IS RESTORED post-operative arm
objects (6-8 weeks) and shoulder exercise are
o Avoid using bags with shoulder instituted gradually (pic mo to)
straps on the affected side ▪ No discomfort (do arm
o The client is vulnerable to exercises). Allow edema to
secondary edema in the arm on the subside first
operated side for life.
o Heavy lifting could lead to edema RADIOTHERAPY
in the arm and trauma in the arm o Lumpectomy or modified radical
may lead to edema and infection mastectomy will be followed by
o AFTER 6 WEEKS OR WHEN ARM FUNCTION radiation
IS RESTORED post-operative arm o It’s usually started 2-3 weeks
and shoulder exercise are after surgery, when the wound is
institute gradually completely healed and the patient
▪ Head wall climbing can comfortably raise her arms
▪ Rope turning over her head.
▪ Broomstick lifting o The treatments are usually done 5
▪ Towel stretch days a week for a total of 5-6
weeks.
o ADVERSE EFFECTS:
▪ Fatigue
▪ Skin Reactions: Redness,
burning, itching, and
dryness
▪ Pain

ANTI ESTROGENS

TAMOXIFEN (Novaldex, Fenahex, Gyraxen)

20 mg PO DAILY FOR 5/10 YEARS
o Tamoxifen will not allow the
estrogen to enter the cancer cell.
The cell will feel hungry and die
o GOLD STANDARD OF BREAST CANCER
TREATMENT
o Tumor cell proliferation
declines. Tumor regress in size
and cell death
o To suppress the growth of residual
cancer cells following TOTAL
MASECTOMY, LUMPECTOMY &
IRRITATION
Adverse Effects o Nicotine can persist on INDOOR
o Hot flushes SURFACES such as:
o Fluid retention ▪ Walls
o Vaginal discharge ▪ Floors
o Nausea and vomiting ▪ Carpeting, drapes
ENDOMETRIAL CANCER THE BIGGEST CONCERN: ▪ Furniture
tamoxifen acts as estrogen agonist at for days, weeks and even months.
receptors in the uterus – endometrial o Studies have revealed that
hyperplasia tobacco residue that lingers on
surfaces can react with other
LUNG CANCER chemicals in the air to form
POTENT CARCINOGENS
RISK FACTORS
1. Cigarette smoking – 85-90% WARNING SIGNS OF LUNG CANCER
2. Genetic o Any pattern in respiratory
3. Inhaled toxins patterns
➢ Tragically, SMOKING kills 10 o Persistent cough
Filipinos every hour and hundreds o Sputum streaked with blood
of teenagers take up smoking every o Frank hemoptysis
day o Purulent sputum
o Chest, shoulder or arm pain
o Lung cancer remains the deadliest o Recurring episodes of:
type of cancer globally ▪ Pleural effusion
accounting for 1.18 million ▪ Pneumonia
people dying each year or two ▪ Bronchitis
deaths per minute o Dyspnea, unexplained
o The top cause of cancer-related ▪ Because of tumor, WBC are
deaths for MALES not growing normally, and
o Lung cancer is detected inly
can cause infection like
during ADVANCED STAGES
o More and more women are dying of pneumonia
cancer, 2043 patients have died, Protective Mechanism of Respiratory
(Philippine Cancer Society, 2010) System
o Research has shown that WOMEN are o Cilia is found in the trachea and
approximately 1.5 times more it will contract in an upward
likely to develop LUNG CANCER than motion a thousand times per minute
men because of the unsterile
environment and cause the person
o Tobacco contains hundreds of to cough or sneeze
carcinogens and other toxic o The vibrissae and mucus produced
chemicals such as: by sinuses which is something
▪ Nicotine sticky can trap foreign body
▪ Benzene thereby stopping it from entering
▪ Formaldehyde the lower part of the respiratory
▪ Arsenic system (lungs)
▪ Toluene o If smoking, it can paralyze the
cilia and it will not contract and
o FIRST-HAND smoke is inhaled when you inhale the air from the
directly by the smoker environment, it can easily enter
o SECOND-HAND is the smoke exhaled the lungs and there will be plenty
(and inhaled by others) of WBC to phagocytize it, but when
o THIRD-HAND smoke is the residue you have lung cancer, it cannot
from second-hand smoke (can give space for other cells to do
adhere to curtains, walls, its action.
carpet, furniture for days,
weeks, or months. Carcinogenic
when suspended in the air)
2 CATEGORIES OF LUNG CANCER
1. SMALL-CELL LUNG CANCER (SCLC)
o Prognosis is poor (not good; give
complications)
▪ Prognosis: outcome or result
of the disorder
o Accounts for 18-20% of all primary
lung tumors
o Very aggressive and always
considered systemic
o Tends to spread bilaterally
o Always considered MESTATIC
▪ Bones
▪ Liver
▪ Brain
o Patients have POOR PROGNOSIS
2. NON-SMALL-CELL LUNG CANCER
(NSCLC)
o Represents 80% of lung cancers
NSCLC 3 MAIN HISTOLOGIC GROUPINGS
1. ADENOCARCINOMA
o Accounts for 40% of all cases of
lung cancer
o A significant number of NON-
SMOKERS develop this malignancy
o Grows in the LUNG PERIPHERY and
metastasizes widely to other
parts of the body
▪ Brain
▪ Liver
▪ Other lung
o The predominant type on
NONSMOKERS and the most frequent
type of lung cancer found in WOMEN
2. SQUAMOUS CELL CARCINOMA
o Accounts for 30% of all cases of
all lung cancers
o Occurs most frequently in the
CENTRAL ZONE OF THE LUNG
o Closely linked to SMOKING
o Tends to grow locally and cause
ATELECTASIS
o Grows more SLOWLY and easier to
resect, may have BETTER PROGNOSIS
Atelectasis-collapse of the lung
Consequence: the tumor is growing in
one part of the lung and growing in size
and it compresses the bronchi, as well
as the alveoli. The air cannot pass by
that airway making oxygen exchange in
the alveoli impaired. Not all blood
will be oxygenated because part of the
lung has collapsed. The blood that will
enter the heart has less oxygen and
there will be hypoxemia and lessening
the amount of oxygen in different cells
of the body and result to dyspnea and
easy fatiguability.
3. LARGE-CELL CARCINOMA
o Least common of all NSCLC
o Accounts for about 15% of all lung
cancers
o Peripheral lung tumor that is:
▪ Poorly differentiated
▪ Aggressive
▪ Quick to metastasize
o Survival rate: POOR
DIAGNOSTIC ASSESSMENT
Currently, no effective screening test
exist to detect LUNG CANCER early
enough to cure it
CHEST X-RAY
o To identify a lung mass or
infiltrate
SPUTUM CYTOLOGY
o Useful when the tumor is located
in the CENTRAL PART of the lung
o 3 early-morning sputum specimen
for microscopic examination
PERCUTANEOUS FINE-NEEDLE ASPIRATION
o When lesion sits on the LUNG
PERIPHERY
o If the mass is well visualized on
CT Scan and is accessible
COMPUTED TOMOGRAPHY (CT SCAN)
▪ Can detect small-size tumors in
early stages of development
THORACENTESIS
o Patient is with pleural effusion
(fluid in the pleural space
between the parietal and visceral
pleura)
▪ Pleural space has a minimal
amount of fluid about 20 cc
and the purpose is for the
parietal pleura not to come
in contact with visceral
pleura
▪ Prevent lungs to expand
because space was taken by
water and when the lungs
 cannot expand well, less
blood will go the affected
lung and not all blood will
be oxygenated – less oxygen
in the blood and that blood
will be distributed to the
body (hypoxemia). The
patient cannot breathe and
there is shortness of breath
o Performed by a physician at the:
▪ Patient’s bedside
▪ Procedure room
▪ Physician’s office
o DURATION: less than 30 minutes
o Extract pleural fluid and check
for cancer cells
BEFORE THORACENTESIS
o Explain the procedure and obtain
informed consent
o NO FASTING OR SEDATION necessary
o Inform the patient that movement
or coughing should be minimized
to avoid INADVERTENT NEEDLE
DAMAGE to the lung or pleura
DURING THORACENTESIS
POSITION:
o UPRIGHT POSITION with the arms and
shoulders raised and supported in
an overhead table
o SIDE-LYING POSITION on the
unaffected side with the side to
be trapped UPPERMOST
▪ If a patient cannot assume
sitting position, place the
patient on a side-lying
position. If right lung,
left lateral position so
that the left lung is at the
bottom and the right lung
which will be tested, is
uppermost
o The thoracentesis is performed
under STRICT STERILE TECHNIQUE
o The needle is positioned in the
PLEURAL SPACE and fluid is
withdrawn with a syringe and a
THREE-WAY STOPCOCK
o Once the needle is inserted, tell
patient not to move or cough
because it can puncture the pleura
and air can enter and have
pneumothorax
AFTER THORACENTESIS
o Small bandage over the needle site
(to prevent bleeding)
o POSITION: turn the patient on the
UNAFFECTED SIFE FOR 1 HOUR to
allow the pleural puncture to heal
o CHEST X-RAY examinations are done
after the procedure to check for
PNEUMOTHORAX
▪ To see if they have
punctured the pleura
o Monitor the patient’s vital signs
(bleeding or dyspnea)
GEFITINIB
IRESSA (250mg tablet)
o Most commonly used for locally or
advanced metastatic non-small-
cell lung cancer
o Suppression of cell proliferation
and promotion of apoptosis
(programmed cell death)
o A cancer medication that
interferes with the growth and
spread of cancer cells in the body
o Used to treat non-small cell lung
cancer
ADVERSE EFFECTS
o Diarrhea Most frequent
o Acne-like rash reactions
o Dry skin
o Nausea
o Vomiting
o INTERSTITIAL LUNG DISEASE is the
most serious adverse effect
▪ Acute-onset dyspnea
▪ Cough
▪ Fever
➢ the drug should be discontinued
o Avoid taking an antacid or stomach
acid reducer (Nexium, Pepcid,
Prevacid, Prilosec, Zantac, and
others) within 6 hours before or
6 hours after you take Iressa
LUNG SURGERY o Remove if output is less than 50
cc

POSITIONING
o After LOBECTOMY, the patient
should be turned onto the
NONOPERATIVE SIDE to promote V/Q
matching
o When ventilation is compromised
in one lung, the patient should
be positioned with that lung in
o Wedge resection: small section of DEPENDENT POSITION (bottom) to
lung facilitate ventilation in the
o Lobectomy: one lobe other lung (has complication)
o Pneumonectomy: entire lung ▪ Right pulmonary lobectomy
place patient in ride side-
LOBECTOMY lying position, turn patient
o Lesion confirmed to a single lobe at his back then side-lying
o PTB o Avoid positioning patient on
o Lung abscesses or cysts operative side if a WEDGE
o Bronchiectasis RESECTION or SEGMENTECTOMY has
been performed
WEDGE RESECTION ▪ It impedes expansion of
o Small, peripheral lesions without remaining lung tissue and
lymph node involvement may impede normal gas
o Peripheral granulomas exchange
o Pulmonary bled (air at the upper
part) POST OPERATIVE CARE: PNEUMONECTOMY
o The patient may lie on the BACK
PNEUMONECTOMY OR OPERATED SIDE ONLY
o Malignant lesion o Avoid COMPLETE LATERAL
o Unilateral TB POSITIONING after pneumonectomy
o Multiple lung abscesses o Help the patient cough as soon as
o Massive hemoptysis he/she is CONSCIOUS and EXTUBATED
▪ If BP IS STABLE, help
THORACIC SURGERIES patient to a sitting
o Chest tubes are placed after most position
thoracic surgery procedures to ▪ Use surgical pillows TO
remove air or fluid SUPPORT THE INCISION
o The drainage will initially
appear BLOODY becoming BREATHING EXERCISES
SEROSANGUINEOUS and then SEROUS The recommended procedure is
over the first 2 or 3 days o Contracting (pulling in) the
postoperatively abdominal muscles
▪ Serosanguineous drainage: o Take a slow, deep breath through
thin watery that is blood the nose; this breath is held 3-5
tinged seconds
▪ Purulent drainage: thick o Exhaling slowly as if trying to
green, yellow, or brown blow out a candle
drainage
o Approximately 100 to 300 ml of POST OPERATIVE CARE: PNEUMONECTOMY
drainage will occur during first o Closely monitor the amount of
2 hours postoperatively, which fluids and blood given to prevent
will decrease to less then 50 fluid overload
ml/hour over the next several ▪ The remaining lung needs 2-
hours 4 days to adjust to the
increase in blood flow
 o Passive ROM arm exercises begins o Advice about smoking cessation
the evening of surgery to prevent
restriction of motion, 4 hours CHEMOTHERAPY
after recovery from anesthesia o Chemotherapy, alone or combined
o POSITION: UPRIGHT OR LYING ON THE with radiation, may be used
ABDOMEN before, after or instead of
▪ Elevating the scapula and surgery in treating lung cancer
clavicle (prevent frozen
shoulder and contractures) COLORECTAL CANCER
▪ Bringing the scapula as
close together as possible Large Intestine (Colon) Function
▪ Hyperextending the arm o Formation of feces
o Proper pain control (Demerol: o Reabsorption of water (body gets
50mg/1cc) water from the large intestine)
o Passive ROM 2x every 4 to 6 hours
o 10 to 20 times every 2 hours PERCENTAGE DISTRIBUTION OF CANCER SITES
o Use the arm of the affected side IN THE COLON AND RECTUM
in daily activities
o Keep bedside table on the
operative side to encourage
reaching

SHOULDER ANKYLOSIS
o A stiffness of a joint due to
abnormal adhesion and rigidity of
the bones of the joint, which may
be the result of injury or disease
o Teach the patient to raise the arm
on the affected side over the head
o This exercise will:
▪ Restore normal shoulder
movement
▪ Prevent stiffening of the RISK FACTORS
shoulder joint o High-fat diet, low fiber
▪ From animal fat (red meat)
PNEUMONECTOMY CARE increases bile acid
o ROM exercises prevent adhesions secretion and anaerobic
of the incised muscles bacteria → carcinogenic
o Prevent “frozen shoulder” within the bowel
o Regular use of the affected arm ▪ Processed meat – bacon, ham,
and shoulder reduces the hotdogs, sausage, and so on
possibility of contractures o Inflammatory bowel disease
o Medication for pain every 1-4 o Obesity
hours during the 1st 48-72 hours ▪ A high body mass index (BMI)
o BLEEDING into the space occurs increases the risk of
within the first 36 hours developing colorectal
following surgery cancer
▪ The volume of fluid ▪ Normal BMI is 18.5 to 24.9
accumulating within the in men
space may be regulated for o Sedentary lifestyle
the 1st 24 hours with a CHEST o Alcohol use
DRAIN ▪ Consuming more than four
▪ The chest drain is kept alcoholic drinks per week
clamped but released for 1 increases the risk
minute every hour o Genetic factors
o Return to work, 6-8 weeks post o Environmental exposure to
operatively carcinogens
 o COLON CANCER ranks fourth in 2. If you have hemorrhoids, wait
incidence and mortality among all until they stop bleeding before
cancers in the country (Phil. doing the test
Cancer Society) 3. Women shouldn’t collect stool
o It is the third most malignant samples near the time of
neoplasm in the world menstruation
o The risk of colorectal increases 4. Foods to avoid include red meat
at age 40, rising sharply between (the blood it contains can turn
ages 50 to 55 you positive)

o Those with symptoms related to the COLONOSCOPY

colon including:
▪ Rectal bleeding
▪ Anemia
▪ Constipation
▪ Abdominal pain
o Should seek medical consult
without delay

SIGNS AND SYMPTOMS

ASCENDING PORTION
o Crampy or achy abdominal pain
o Dark reddish-brown stools/black
tarry tools
o Weakness and weight loss RECOMMENDATIONS FOR EARLY DETECTION OF
o No change in bowel habits COLORECTAL CANCER
People should begin colorectal
TRANSVERSE PORTION screening earlier if they have any of
o Diarrhea or constipation the following risk factors:
o Bloody stools o Personal history of colorectal CA
o Feeling of fullness in the abdomen o Strong family history of
o Abdominal pain with cramping COLORECTAL CA or POLYPS
o Personal history of CHRONIC
DESCENDING COLON INFLAMMATORY BOWEL DISEASE
o Sense of fullness
o Constipation/diarrhea COLOSTOMY
o Ribbonlike stool
o Bright red stools
o Fever
o Weight loss

FECAL OCCULT BLOOD TEST

o Often, this small amount of blood
is the first and sometimes the
only sign of early colon cancer,
making the fecal occult blood test
a valuable screening tool for
colorectal (colon and rectal)
cancer
1. Avoid medicines that can
interfere with the results. These PREOPERATIVE CARE
include NSAIDs and blood thinners o Oral administration of CATHARTICS
which can cause minor stomach or Fleet enema started at least
bleeding, thereby giving an 12-24 hours before surgery
abnormal test result o ANTIBIOTICS: Sulfonamides,
Neomycin or Cephalexin 12 to 48
 hours prior to surgery to decrease
bowel bacteria and postoperative
wound infection
POSTOPERATIVE CARE
o Monitoring of vital signs for
manifestations of INFECTIONS AND
SHOCK
o An NGT tube is usually in place
until peristalsis returns (to
prevent bloating); removed if
peristalsis returns
(2nd or 3rd postoperative day)
o Insertion of RECTAL TUBE for 20-
30 minutes per physician’s order
if the rectum contains gas
o EARLY AMBULATION to relieve
distention and promote
peristalsis (prevent respiratory
complications, bedsores, DVT)
▪ Ensure that you have given
opioids (Demerol) for pain
o PETROLATUM GAUZE over the stoma
to keep it moist followed by a dry
sterile dressing
o Monitor for color changes in the
stoma (reddish in color)
▪ NORMAL stoma color is PINK
to BRIGHT RED and SHINY
indicating high vascularity
▪ PALE PINK STOMA – low
hemoglobin and hematocrit
▪ PURPLE-BLACK STOMA – GASTROCOLIC REFLEX occurs
compromised circulation,
NOTIFY PHYSICIAN
COLOSTOMY STOMA
o A small amount of BLEEDING at the
stoma is normal
o The ideal stoma PROTRUDES
slightly to allow stool to drain
into the pouch
o Stomas SHRINK w/in 6-8 WEEKS
o COMPLETE HEALING of the wound may
take 6-8 months
o Measure the stoma once weekly for
the first 6 to 8 weeks to ensure
proper fit of the appliance
o Swelling of the stoma is normal
for 2 to 3 weeks after surgery
COLOSTOMY OUTPUT
o Ascending colon - liquid; stool
is looser
o Transverse colon - semi-liquid;
very soft stool; pasty
o Descending colon - semi-solid
stool; solid stool
POSTOPERATIVE CARE
o Monitor the POUCH SYSTEM for
proper fit and signs of LEAKAGE
o Expect the stool is LIQUID in the
immediate posy operative period
o Empty the pouch when it is one-
third to half full
o The colostomy begins to function
3-6 days after surgery
▪ A stoma does not have
voluntary muscular control
and may empty at irregular
intervals
COLOSTOMY IRRIGATION
o To regulate bowel movements at a
regular time
o To empty the colon of gas, mucus,
and feces
o Done according to the bowel
movements of the patient (ask the
patient about their bowel
movement)
o BEST TIME: the client’s former
schedule of bowel movement
▪ Because the bowel is ready
“trained” to evacuate at
this time
▪ After breakfast,
▪ Perform irrigation
preferably 2 hours after a
meal
o Water should flow in over 5-to-
10-minute period
o 300 ml of fluid (1-liter max) may
be all that is needed to stimulate
evacuation
o Most of the water feces, and
flatus will be expelled in 10 to
15 minutes
o Schedule of irrigations gradually
progress to every other day, every
third day or even twice a week
o Begins on the FOURTH or FIFTH
post-operative day
o AMOUNT: 500-1000ml TEPID water or
LUKEWARM water
o POSITION: sit on a toilet seat or
chair near the toilet
o Remove air by flushing it with
fluid
o Hang the container of irrigant so
that the bottom of the solution
bag is about:
✓ 12 inches above the stoma
✓ 18-20 inches
o Lubricate the distal end of
catheter and gently insert the
catheter into the stoma 2-3 inches
o Hang the irrigation bag so that
the bottom of the bag is at the
level of the patient’s shoulder
or slightly higher
o If CRAMPING occurs, STOP the flow
of solution and ask the patient
to take few deep breaths
o Allow 30-45 minutes for the
solution and feces to be expelled
o If irrigant fails to return
properly
▪ Gently massage lower abdomen
▪ Take several deep breaths
▪ Drink some warm water
o If there is STILL NO RETURN
▪ Try irrigation again the
next day
o If there is NO RETURN THE 2ND DAY,
NOTIFY THE PHYSICIAN
o The client should never:
▪ Use more than 1000ml
▪ Irrigate the colostomy more
than once a day
▪ Irrigate the colostomy if
diarrhea is present
OSTOMY CARE ▪ Banana
o The peritoneal area should be ▪ Carrots
cleaned well with mild soap and ▪ Cauliflower
water ▪ Dairy products
o Dry the skin well before the skin ▪ Eggplant
barrier and a new pouch is applied ▪ Cabbage
o The skin should be treated with a o Minimize odor - avoid odor-
SKIN BARRIER to prevent skin producing foods:
contact with stool ▪ Asparagus
o Empty the pouch when it is about
▪ Broccoli
one-third to half full
▪ Fish
▪ Garlic
▪ Eggs
▪ Highly spiced foods
▪ Carbonated beverages
▪ Beer
o Crackers, toast, and yogurt can
help prevent gas
o Cranberry juice, parsley & yogurt
help prevent odor
▪ Cranberry juice can prevent
urinary tract infections

CERVICAL CANCER

o Affects the lowest portion of the

COLOSTOMY POUCH uterus
o The best time to change the o Second most frequent malignancy f
pouching system is when the bowel the female reproductive system
is least active, usually 2 to 4 o Has its peak incidence among women
hours after meals between the ages of 35 & 50 years
o Early in the morning, before o Approximately 12 FILIPINO WOMEN
eating or drinking, when the bowel die of cervical cancer every day
and kidneys will be least active o It is the second most common
cancer among women in the
DIETARY CONSIDERATION Philippines
o Teach patient to chew thoroughly o About 6,000 women are diagnosed
o Instruct to drink at least 2 with the disease each year and
quarts of fluid per day, about 4,349 die of the disease
preferably water annually
o Control flatus/gas
▪ Intestinal gas is created RISK FACTORS
both by swallowed air and by 1. Becoming SEXUALLY ACTIVE at an
bacterial action on early age (before 17 years old)
undigested carbohydrates 2. Having MULTIPLE SEXUAL PARTNERS
o Avoid the following: or having sexual intercourse with
▪ Drinking with straws a high-risk man
▪ Chewing gum ▪ One who has multiple
▪ Smoking partners
▪ Skipping meals ▪ One who has penile condyloma
o Avoid flatus-producing foods (warts)
▪ Beans 3. Having history of CIGARETTE
▪ Onions SMOKING
▪ Broccoli ▪ Women who smoke have a 50%
▪ Peas higher risk for developing
▪ Carbohydrate beverage
 cervical cancer than non- CERVICAL CANCER
smokers o Appears to be related to repeated
injuries to the cervix
o It is not a disease exclusive to o 90% of cervical cancer arises from
PROMISCUOUS WOMEN the SQUAMOUS CELLS
o Even those in a MONOGAMOUS ▪ Squamous cell cancers spread
RELATIONSHIP have a 46% risk of by direct extension to the
developing cervical cancer VAGINAL MUCOSA, LOWER
o Any form of sexual intimacy will UTERINE SEGMENT, PELVIC WALL
make the person vulnerable to the BLADDER & BOWEL
infection: o The progression occurs SLOWLY
▪ Kissing over years rather than months
▪ Necking o It takes 10-15 years from
▪ Oral sex infection before it develops into
▪ Genital skin-to-skin full-blown cancer
contact
▪ Anal sex WHY WOMEN?
Penetration is not a prerequisite o The PENIS is outside. Skin is shed
off regularly
4. Acquiring CHRONIC CERVICITIS o The skin of the penis is the same
secondary to uterine prolapse as the skin elsewhere-it is
5. GENITAL INFECTION caused by HUMAN KERATINIZED
PAPILLOMA VIRUS (HPV) o The cervix’s skin is not
keratinized so there’s less
HUMAN PAPILLOMAVIRUS protection
o About 99.7% of cervical cancer o During sex there are MICRO
cases are caused by HPV, a ABRASIONS
sexually transmitted that is
often without symptoms
o HPV, which causes GENITAL WARTS,
invades both sexual partners
during sexual intercourse
o The virus that lives in the body
permanently, even after
treatment, and can lie dormant for
years, only to become active when
the person’s immune system is low
o HPV is passed on through genital
contact, most often during:
▪ Vaginal and anal sex
▪ Oral sex
▪ Genital-to-genital contact
o HPV can be passed on between CLINICAL MANIFESTATIONS
straight and same-sex partners o It’s a cancer that is hard to
even when the infected person has detect at the early stage
no signs or symptoms o There are almost always NO
o Health problems that can be caused SYMPTOMS during stage 1 and stage
by HPV: 2 cervical cancer
o Majority of the Filipino women are
▪ Genital warts
diagnosed at stage 3 and 4, when
▪ Cervical cancer
they experience symptoms such as
▪ Cancer of the vulva, and bleeding, foul smelling watery
vagina discharge and pelvic pain
▪ Cancer of the penis and anus o Pre-invasive cancer is often
▪ Oropharyngeal cancer asymptomatic
o Painless vaginal bleeding
 ▪ Classic symptom of INVASIVE STAGE IV B
CANCER o The cancer has spread to DISTANT
▪ Bleeding may start as ORGANS beyond the pelvic area
SPOTTING between MENSTRUAL ▪ Lungs
PERIOD OR AFTER COITUS
o watery blood-tinged vaginal PAPANICOLAOU SMEAR (PAP SMEAR/TEST)
discharge that becomes dark and
foul smelling as the disease
progresses “STRONG FISHY ODOR”
o other signs of
recurrence/metastasis
▪ flank pain
▪ dysuria
▪ hematuria
▪ rectal bleeding
▪ unexplained weight loss

STAGING: CERVICAL CA

STAGE 0
o Superficial
o Found only on the layer if cells
lining the cervix o 95% ACCURATE in detecting
o Has not invaded the deeper tissues cervical carcinoma
of the cervix o Routinely performed on women
older than 21 years or on younger
STAGE I women who are sexually active
o Has invaded the cervix but has NOT
spread anywhere else

STAGE II
o The cancer has spread beyond the
cervix to nearby areas
o II A: Still inside the pelvic area
o II B: Has spread to the upper part
of the vagina

STAGE III A
o Cancer has spread to the LOWER
THIRD OF THE VAGINA but not to
the pelvic wall

STAGE III B
o Cancer extends to the PELVIC PREPARATION FOR PAP TEST
WALL o Explain procedure to the patient
o Blocks urine flow to the bladder o Instruct the patient NOT TO DOUCHE
o Cancer has spread to the LYMPH OR RUB BATH 24 hours before the
NODES IN THE PELVIS pap smear
o Empty her bladder before the
STAGE IV examination
o The cancer has spread to nearby o POSITION: lithotomy position
organs or other parts of the body o A VAGINAL SPECULUM is inserted to
expose the cervix
STAGE IV A
o The cancer has spread to the CHEMOTHERAPY
▪ Bladder o Chemotherapy is given
concurrently with RADIATION-
▪ Rectum
 primary treatment for localized ▪ For male 13 though 21 years
disease of age who did not get any
or all of the shots when
they were younger
o For gay, bisexual and other men
who have sex with men
▪ Should receive the vaccine
through age 26 years
BRACHYTHERAPY ▪ Males 22 to 26 of age may
o Means “NEAR” also get the vaccine
o RADIOACTIVE SOURCE is embedded in
the tissue cavity or inside the ACUTE MYELOID LEUKEMIA (AML)
vagina o Adult acute myeloid leukemia
(AML) is a type of cancer in which
SURGICAL MANAGEMENT the bone marrow makes abnormal
o Surgery is the primary treatment myeloblasts (a type of white blood
o Preserve is the OVARIES if cell), red blood cells or
necessary platelets
STAGE I & II
o TOTAL ABDOMINAL HYSTERECTOMY
▪ Removal of the UTETUS &
CERVIX
o RADICAL HYSTERECTOMY
▪ The UTERUS, OVARIES,
FALLOPIAN TUBES, ADJACENT
PELVIC TISSUE, LYMPH DUCTS &
UPPER THIRD OF THE VAGINA
are removed

STAGE III & IV

o RADIATION
o PELVIC EXAMINATION
▪ Considered after
RADIOTHERAPY for RECURRENT
CERVICAL CANCER

PREVENTION
Cervical Cancer Vaccine is now
available
o CERVARIX (3 doses) 0, 1, 6 months
o GARDASIL (3 doses) 0, 2, 6 months

o Human Papillomavirus or HPV

VACCINATIONS are given as early
as possible, ideally, the vaccine
can be given to:
▪ Girls early as 9 years old
▪ 13 through 26 years of age
who did not get any or all
of the shots when they were BLOOD CELL DEVELOPMENT
younger o A blood stem cell goes through
▪ Women up to 45 years old several steps to become a red
o Boys and Men blood cell, platelet, or white
▪ GARDASIL is recommended for blood cell
11- and 12-year-old boys o In AML, the myeloid stem cells
usually become a type of immature
 white blood cell called 2. Remind the patient to remain very
myeloblasts (or myeloid blasts) still throughout the procedure
o The myeloblasts in AML are 3. The preferred site: posterior
abnormal and do not become healthy iliac crest
white blood cells. Sometimes in
AML, too many stem cells become
abnormal red blood cells or
platelets. These abnormal white
blood cells, red blood cells, or
platelets are also called
leukemia cells or blasts

RISK FACTORS
o Genetic
o Cigarette smoking
o Exposure to certain chemicals
such as benzene
o Farmers exposed to pesticides 4. Performed at the patient’s
o Exposure to ionizing radiation bedside using local anesthesia
5. One half to 2ml of bone marrow is
ACUTE MYELOID LEUKEMIA aspirated
o AML is the most common form of 6. Duration: 20 minutes
adult-onset leukemia 7. Apply pressure to the puncture
o The incidence rises with age, with site-adhesive tape
the peak incidence at age 67 years 8. Ice packs may be used to control
o Patients who are older than 60 bleeding
years, have a more 9. Bed rest for 30 to 60 minutes
undifferentiated form if AML after the test

COMPLICATIONS
o Bleeding
o Infection

CHEMOTHERAPY
o CYTARABINE – continuous
intravenous infusion for 7 days
(antimetabolites)
o DAUNORUBICIN – IV bolus for 3 days
(antitumor antibiotic)
o A bone marrow examination is
repeated on day 14 from the first
day of chemotherapy
o If the day 14 bone marrow shows a
persistent leukemia, a second
dose is started despite severe
CLINICAL MANIFESTATIONS PANCYTOPENIA
o Fever and infection – neutropenia
o Weakness and fatigue CHRONIC MYELOID LEUKEMIA
o Dyspnea on exertion anemia o The chromosomes in the blood cells
o Pallor swap sections with each other
o Petechiae o A section of chromosome 9 switches
o Ecchymoses thrombocytopenia places with a section of
o Bleeding tendencies chromosome 22
o Creating an extra-short
BONE MARROW BIOPSY chromosome 22 and an extra-long
1. Obtain a written informed consent chromosome 9
o BCR GENE – chromosome 22
 o ABL GENE – chromosome 9 PROSTATE CANCER
o When these 2 genes fuse BCR-ABL
gene, they produce an abnormal PROSTATE GLAND
protein TYROSINE KINASE PROTEIN o Neutralize acidic nature of
o Causes leukocytes to divide the urethra
rapidly
o Gives nutrition to the semen
PHILADELPHIA CHROMOSOME for it to be highly motile

o The most common cancer among U.S.

men and the second leading cause
of cancer death in men older than
55
o The most common cancer in men in
the UK
o ASIAN MEN have the lowest
incidence
o In the Philippines, CANCER of the
PROSTATE is the most common
overall (4.0%) and the fourth
among MALES (8.2%)
o Median survival is 52 months and
a 10-year survival is 30.74%
CML
o Tyrosine kinase promotes cancer RISK FACTORS
by allowing certain blood cells 1. Increasing age
to grow out of control 2. Ethnicity
o The tyrosine kinase caused by the 3. Family history
BCR-ABL gene causes too many white 4. High FAT diet and red meat
blood cells 5. Obesity (decreases function of
o The diseases white blood cells WBC)
build up in huge numbers, crowding 6. Vitamin deficiencies, vit. D and
out healthy blood cells and E
damaging the bone marrow 7. Exposure to ENVIRONMENTAL TOXINS
▪ Arsenic
RISK FACTORS ▪ Benzene
o Exposure to high-dose radiation
o The incidence increases with age, AGE
mean age is 65 years o Most commonly appears after age
o Patients diagnosed with CML have 50
an overall median life expectancy o 64% of all cases occur in men over
of 5 to 6 years age 65
o While 90% of prostate-related
CLINICAL MANIFESTATIONS cancer deaths occur in men over
Excessive
o Shortness of breath volume of
age 65
o Confused leukocytes
inhibits ETHNICITY
blood flow o The second most common risk factor
through the o BLACK MEN have a threefold risk
capillaries of developing prostate cancer
than white men
o Splenomegaly, left quadrant pain o A study of healthy young men that
o Abdominal fullness circulating testosterone levels
o Hepatomegaly were 15% higher in African-
o Decreased appetite, weight loss Americans than in whites
 ▪ They note that huge amounts coupled with urinary symptoms may
of androgens are required to indicate METASTASIS
induce prostate cancer

FAMILY HISTORY
o FATHER-to-SON is increased 2.5
times
o The relative risk between
BROTHERS is increased to 3.4 times
o There is also risk associated with
the increasing number of FIRST-
DEGREE relatives diagnosed with
prostate cancer

HIGH FAT DIET

o African American men were more
likely to be obese, which is
defined as having a BMI of 30 or
more DIAGNOSTIC STUDIES
o Hypercholesterolemia, o DIGITAL RECTAL EXAM (DRE)
hyperlipidemia, have been linked o PROSTATE SPECIFIC ANTIGEN (PSA)
with an increased risk of prostate
cancer PROSTATE SPECIFIC ANTIGEN (PSA)
o The overall aim of PSA testing is
LYCOPENE to recognize LOCALIZED PROSTATE
o Consuming a diet high in lycopene, CANCER when potential curative
especially tomatoes has been treatment can be provided
shown to be beneficial o The SINGLE MOST POWERFUL BLOOD
o Potent antioxidant that may TEST for identifying the presence
reduce risk of cancer of prostate cancer at a time when
the cancer is curable
CLINICAL MANIFESTATIONS o PSA is not a specific tumor marker
o Prostate cancer is often o Elevated PSA may also be the
asymptomatic result of:
o Back pain ▪ BPH
▪ Caused by metastatic spread ▪ OLDER AGE
usually to the bones ▪ INFLAMMATION
▪ First sign of prostate ▪ EJACULATION
cancer o Normal value: 0 and 4 ng/mL
o Weak urinary stream o If PSA is greater than 10ng/ml
o Frequent urination there is about a 50% chance of
o As cancer spreads to the BONES (a prostate cancer
common site of metastasis) the
first sign of prostate cancer DIGITAL RECTAL EXAM (DRE)
before the appearance of any other o KY jelly as a lubricant
local symptoms o Lateral Decubitus (sims) position
o Pain can become severe, / dogstyle???
especially in the BACK and the (sorry, idfk what
LEGS because of compression of the to call this :<)
SPINAL CORD and the destruction
of bone

o Pain or burning during urination

o Urinary retention
o Inability to urinate
o PAIN in the LUMBOSACRAL area that
radiates down to the HIPS or LEGS
DIAGNOSTIC STUDIES
o A hard, nodular, irregular
prostate is suggestive of
carcinoma

RADICAL PROSTATECTOMY
o Used when tumor is confined to the
prostate
o Surgical removal of the prostate,
seminal vesicles, tips of the vans
deferens, the surrounding fat,
nerves, and blood vessels
o ADVERSE REACTIONS
1. Sexual impotence
2. Urinary incontinence
- Pelvic floor muscle training IODINE-125 SEEDS
- Lifestyle changes o Are placed permanently and
recommended for patients with a
EXTERNAL BEAM RADIATION
life expectancy of at least 10
o Treatment sessions last
years
approximately 15 minutes
o Prostate volume of less than 50ml
o Performed 5 days a week over 4 to
o No previous prostate surgery
6 consecutive weeks
o Permanent implants are relatively
o Impotence in 10%-30% of men
low-energy sources, and therefore
have limited tissue penetration.
BRACHYTHERAPY
A well-done implant will treat the
prostate and the surrounding few
millimeters of adjacent tissue

Special considerations
o Close, prolonged contact (sitting
in the lap) with young children
should be limited to 20 minutes
per hour for the first two months
after the procedure
o It is safe to sleep in the same
bed if your partner/spouse is NOT
PREGNANT
o If your partner/spouse is
PREGNANT, separate sleeping
arrangements will be necessary
for 2 months
o The patient should avoid close
contact with pregnant women and
infants for up to 2 months
o Straining urine for seeds
o Use of condom during sexual
intercourse for 2 weeks after
implantation to catch any seeds
that pass through the urethra
GOALS OF RADIATION THERAPY ▪ Rectum
1. CURE for patients with CARCINOMA ▪ Vagina
OF THE: ▪ Brain
▪ Skin o When the implants are removed, no
▪ Vocal cords radioactivity is left in the body
2. CONTROL of the disease of cancer o During the time the implant is in
▪ Given preoperatively to place, staff entering the room are
reduce the size of the tumor exposed to gamma rays and must
▪ Given postoperatively to take precautions
destroy any remaining tumor
cells (lumpectomy) SAFETY MEASURES
3. PALLIATION o Client is places in a PRIVATE ROOM
▪ To control the distressing o STANDARDIZED SIGN is placed on
symptoms of cancer door to designate the room as a
▪ To relieve symptoms such as RADIATION ROOM
pain and destruction o PREGNANT NURSES should not care
for these clients
RADIATION o Do not allow CHILDREN YOUNGER THAN
o Considered local therapy. Only 16 years of age to visit
the tissues in the radiation path o Health care personnel LIMIT TIME
are affected SPENT in the room and LIMIT
o Therefore, this type of therapy DISTANCE from the source of
is most successful when tumors radiation
have not metastasized beyond a o Limit each visitor to ONE-HALF
local region HOUR PER DAY. Be sure visitors are
o Small doses of radiation are given at least SIX FEET from the source
on a daily basis for a set period o Leave all trash, linens and food
of time trays in the room
o This method allows multiple o Upon living the room, remove
opportunities to destroy cancer gloves and place them in the trash
cells while minimizing damage to receptacles inside the room
normal tissues o Radiation Safety surveys all
materials before they leave the
INTERNAL RADIATION THERAPY room
o Three key principle for working o After leaving the room, wash your
with radiation are distance, hands
time, and shielding o In the event a source becomes
o Exposure time generally should be dislodges, notify the Radiation
limited to 30 minutes of direct Oncology resident on call
care per 8-hour shift immediately
o Remaining 6 feet from the client o Do not permit others to enter the
would reduce exposure as compared room until the source is secured
to standing 3 feet away, but is o Do not attempt to handle a
not the recommended course of dislodged implant or applicator,
action unless you are trained to do so
o Never touch the radioactive
SEALED BRACHTHERAPY source with BARE HANDS. In the
o Needles, seeds, wires, or rare instance that it is
catheters containing the DISLODGED, use a long-handles
radioactive source are implanted FORCEPS to retrieve it
directly into the tumor o Once the treatment is completed
o Used in treatment of cancers of and the implant is removed, the
the patient is no longer radioactive
▪ Tongue and present no hazard
▪ Cervix
▪ Prostate
▪ Breast
CLIENT EDUCATION FOR EXTERNAL RADIATION CELL CYCLE
1. Wash the irradiated area GENTLY
each day with MILD SOAP AND WATER Go PHASE
2. Take care not to remove the o RESTING PHASE
MARKINGS that indicate exactly o Cells conduct their everyday
where the beam of radiation is to activities such as:
be focused ▪ Metabolism
3. Use your HAND rather than a ▪ Impulse conduction
washcloth to be more gentle ▪ Secreting
4. Dry the irradiated area with o Cells become mitotically DORMANT
PATTING MOTIONS o They do not replicate and are not
5. Use no POWDER, OINTMENTS, LOTION, active participants in the cell
or CREAMS, on the skin at the cycle
radiation site, unless prescribed o Cells remain in G0 for days,
by the radiologist weeks, or even years
6. Avoid exposure of irradiated area
to the SUN. avoid HEAT EXPOSURE G1 PHASE
7. Effects of radiation to skin: o The cell manufactures the enzyme
REDNESS, TANNING, PEELING, needed for DNA synthesis such as:
OTCHING & DECREASED PERSPIRATION ▪ RNA
▪ Proteins
CHEMOTHERAPY o 18 hours
o Considered systemic therapy and
is used as primary therapy or S-PHASE
adjuvant therapy for cancers that o DNA replication occurs in the
may not be confined to a localized preparation for cell division
body area o Lasts 10 to 20 hours
o Because chemotherapy is systemic,
it circulates through many body G2 PHASE
areas and can harm cancer cells o Specialized DNA proteins and RNA
that may be some distance from the are synthesized needed for
primary treatment mitosis
o Usually scheduled every 3 to 4 o Lasts for 3 hours
weeks
o On average, 4 to 12 times M-PHASE
o The IV route is the most preferred o Cell division
route for chemotherapy o Mitosis
o Lasts for 1 hour
NADIR
o The time after chemotherapy CHEMOTHERAPY
administration when the white o Chemotherapeutic drugs are much
blood cell or platelet count is more toxic to tissues that have a
at the lowest point high growth fraction than tissues
o For most myelosuppressive agents, that have a low growth fraction
the nadir occurs within 7 days o Most cytotoxic agents are more
after drug administration active against proliferating
o Knowledge of blood count nadirs cells than against cells in G0
help to predict when the client o Proliferating cells are
is at greatest risk for infection especially sensitive to
and bleeding chemotherapy because CYTOTOXIC
drugs usually act by disrupting
either DNA synthesis or mitosis
o These drugs are also toxic to
normal tissues that have a high
growth fraction:
▪ Bone marrow
▪ Hair follicles
 ▪ GI epithelium ANTIMETABOLITES
▪ Sperm forming cells o These drugs kill cancer cells
o The goal of cancer chemotherapy blocking synthesis of DNA and RNA
is to decrease the size of the o They’re most effective in the S-
neoplasm so that the human immune phase of the cell cycle
system can deal with it o Cell cycle phase-specific
o Antineoplastic drugs are often o METHOTREXATE (EMTHEXATE, ZEXATE)
given in COMBINATION so that they ▪ MYELOSUPPRESSION most
can affect the cells in various severe 7-14 days after dose
stages of the cell cycle ▪ GI ULCERATION
▪ KIDNEY IMPAIRMENT
CELL CYCLE-SPECIFIC o FLUOROURACIL (FLUROBLASTIN)
o Drug is selectively toxic when the ▪ Bone marrow suppression
cell in is a specific phase of ▪ Stomatitis
growth ▪ Alopecia
o Schedule-dependent drugs o If the total WBC count is <2000,
o Malignancies most amenable to place in PROTECTIVE ISOLATION to
CCSC are those that proliferate prevent systemic infection
rapidly
o Cells that are “RESTING” in G0 ANTITUMOR ANTIBIOTICS
will not be harmed o These drugs interfere with
cellular DNA, disrupting it and
CELL CYCLE-SPECIFIC ANTINEOPLASTIC causing cell death
DRUGS o Because of poor GI absorption,
o Antimetabolites they are all administered
o Mitotic Inhibitors parenterally, almost always IV
o Antineoplastic Enzymes o Classified as CCNS drugs
o Topoisomerase I Inhibitors o DOXORUBIBICIN (ADRIBLASTINA RD,
ADRIMYCIN)
CELL-CYCLE NONSPECIFIC ▪ CARDIOTOXICITY
o Drugs can act during any phase of - Assess cardiac function:
the cell cycle including G0 ECG, ECHO, palpitations,
o CCNC can increase cell kill when dyspnea
combined with CELL-CYCLE SPECIFIC ▪ EMETIGENIC
drugs - Administer antiemetic 30 to
60 minutes before
CELL-CYCLE NONSPECIFIC ANTINEOPLASTIC chemotherapy
DRUGS o EXTRAVASATION during IV injection
o Alkylating Agents ▪ Give the drug into the
o Antitumor Antibiotics tubing of a freely flowing
IV infusion
COMBINATION CHEMOTHERAPY - 0.9% sodium chloride or
1. Suppression of drug resistance - 5% glucose solution
2. Increased cancer cell kill ▪ For not less than 3 minutes
3. Reduced injury to normal cells and not more than 10 minutes
ALKYLATING DRUGS EXTRAVASATION
o These drugs kill cancer cells by o Use a DISTAL VEIN, avoid small
inhibiting DNA synthesis veins on the wrist
o They are effective in all phases o Never use an existing line unless
of the cell cycle, including the it is clearly open and running
RESTING PHASE well
o One or more ALKYLATING AGENT is o Check site frequently and ask
included in almost every patient to report any discomfort
combination chemotherapy regimen in the area
 o Leakage of infused substance into 3. Administer drugs in a SAFE,
the vasculature into the UNHURRIED environment
subcutaneous tissue
o This leakage of chemotherapy can CHEMOTHERAPY SPILLS
result in significant tissue
destruction and complication SPILL ON HARD SURFACE
o Extravasation during IV injection o Restrict the area of the spill
may produce: o Put on a:
▪ Thrombosis ▪ Protective gown
▪ Local pain ▪ Gloves
▪ Sever cellulitis and ▪ Goggles
necrosis ▪ If POWDER SPILL, a
o Drug infusion should be RESPIRATOR MASK
immediately stopped o Place ABSORBENT PADS gently on the
o Apply ice cap and notify the spill, CAREFUL NOT TO TOUCH THEM
physician o Place the saturated absorbent
pads in the waste bag (double
MITOTIC INHIBITORS bags)
o Interfere with the ability of a o Clean surface with ABSORBENT
cell to divide TOWEL + DETERGENT sol., rinse with
o They block or alter DNA synthesis CLEAN TAP WATER
o Drugs that kill cells as the o Wipe dry
process of MITOSIS
o They work in the M-phase of the SPILL ON PATIENT/PERSONNEL
cell cycle to prevent cell o Immediately remove any
division contaminated protective garments
o Cell-cycle-specific agents or linen
o VINCRISTINE (ONCOVIN, VINCASAR) o Wash the affected area of skin
▪ This drug is BONE MARROW with soap and water
SPARING o Notify the physician if the drug
▪ It is safely combined with spill on the patient
drugs that suppress bone o Place all contaminated materials
marrow in double-bagged waste disposal
bags
CHEMOTHERAPY o Discard the waste bags and
o Clinical studies have indicated contents in an approved container
that many chemotherapeutic agents o Wash hands thoroughly with soap
are: and water
▪ Carcinogenic
▪ Mutagenic EYE EXPOSURE
▪ Teratogenic o Immediately flood the affected
eye with water for at least 5
SAFE HANDLING GUIDELINES minutes
1. Personal Protective Equipment o Follow-up care with a clinical eye
includes: exam
▪ Gloves
o All personnel who handle BLOOD,
- Should be changed every 30
VOMITUS, or EXCRETA from patients
minutes during preparation
who have received chemotherapy
and administration
within the previous 48 hours
▪ Gown – closed front, long
should wear DISPOSABLE SUGICAL
sleeves, knit cuff
LATEX GLOVES and GOWNS which are
▪ Face shield discarded appropriately after use
2. Place a PLASTIC-BACKED ABSORBENT o Linen contaminated with
PAD under the tubing during chemotherapeutic drugs, blood,
administration to catch any vomitus, or excreta within the
leakage prior 48 HOURS should be places
 in a specially MARKED, IMEPRVIOUS
LAUNDRY BAG
SIDE EFFECTS OF CHEMOTHERAPY
o Nausea and vomiting
o Emaciated
o Acute nausea and vomiting occur
within 1 to 2 hours of treatment
and last approximately 24 to 48
hours
o Nausea and vomiting after the
initial 24 hours of treatment is
called DELAYED OR PERSISTENT
NAUSEA AND VOMITING
1. Administer an ANTIEMETIC at least
an hour before starting
chemotherapy
▪ To be effective, antiemetics
must be taken as prescribed
for 72 hours-even in the
absence of symptoms
2. Patient’s room is pleasant,
odorless, and comfortable
3. Distractions such as music or TV
are available
4. Keep mints, lozenges, and saltine
crackers on hand
5. Avoid CAFFEINE, and AROMATIC,
RICH, SPICY or FATTY foods
6. Six small meals instead of 3
normal meals
7. Brush teeth before and after meals
and at bedtime
8. Don’t eat or prepare food when
nauseated
Bleeding Precautions
o No flossing and use of soft
bristle toothbrush
o Apply pressure for 8-10 minutes
for accidental injuries
o Do not allow patient to fall or
have accidents. Clear the room or
house of clutters (broom, shoe,
rags, slippery floor)
o Do not take NSAIDs like aspirin
(GI irritant)
o Do not use shaver
o Avoid invasive procedures (no
IMs)
o If with IV, always monitor if
there is bleeding at the site of
insertion
NEUTROPENIA
o Normally, the mature segmented
neutrophils (“segs”) are the
major population of circulating
leukocytes, constituting 55% to
70% of the total white blood cell
count
1. Good handwashing before contact
with the patient
2. Use ASEPTIC TECHNIQUE when
performing any invasive procedure
3. Mouth care and washing of the
axillary and perianal regions at
least every 12 hours
4. Limit the number of health care
personnel entering the patient’s
room
5. Use of MASK
6. Private room
7. All visitors will have to wear
mask, gown, and gloves
8. SAFE FOOD HANDLING PRACTICES
▪ Prompt and appropriate food
storage
▪ Use of LEFTOVERS within 1 to
2 days
▪ Avoidance of public salad
bars
▪ Use of safe drinking water
supplies
▪ Fresh fruits and vegetables
are known to be frequently
contaminated with:
- E. coli
- Klebsiella Species
- Pseudomonas Aeruginosa
- Staphylococcus
LEUKOPOIETIC GROWTH FACTOR
o FILGRASTIM (NEUPOGEN)
▪ Acts on cell in bone marrow
to increase production of
NEUTROPHILS
▪ It enhances phagocytic and
cytotoxic actions of mature
neutrophils
o ADVERSE EFFECTS
▪ Bone pain-acetaminophen
▪ ↑ of plasma uric acid and
alkaline phosphate
▪ Long-term therapy →
splenomegaly
o ROUTE: IV or subcutaneous
o Prior to administration,
filgrastim can be kept at room
temperature for up to 6 hours
o Avoid VIGOROUS SHAKING
 o Filgrastim vials are for single MEDICAL MANAGEMENT
use only o Isotonic Saline (0.9 Normal
o Neupogen should be stored in a Saline)
refrigerator o Diuretic
o Hemodialysis for renal failure
TUMOR LYSIS SYNDROME o Sodium Bicarbonate
o Occurs when large number of o Allopurinol
NEOPLASTIC CELLS are rapidly o Glucose and Insulin infusions
killed, resulting in the release o Calcium Carbonate
of large amount of: o RASBURICASE (ELITEK)
▪ Potassium ▪ Converts uric acid to
▪ Phosphates ALLANTOIN which is much more
▪ Uric acid soluble urine than uric acid
o Destruction of massive numbers of ▪ Accelerates uric acid
malignant cells by CHEMOTHERAPY removal
or RADIATION THERAPY
o Unexplained weight gain NURSING CARE
o Diarrhea o I.V. hydration as prescribed and
o Muscle cramps monitor fluid balance by:
o Nausea, vomiting ▪ Weighing the patient daily
o Paresthesia ▪ Documenting intake and
o Weakness output accurately
▪ Urine output should be in
HYPERURICEMIA balance with the intake
o Occurs 48 to 72 hours after the o I.V. hydration should begin as
initiation of anticancer therapy soon as possible, ideally 2 days
o Tumor cell destruction releases before initiating chemotherapy
NUCELIC ACIDS which are o And continue during chemotherapy
metabolized into URIC ACID and for 2 to 3 days afterward
o Needed to excrete excess
HYPERKALEMIA potassium, phosphate and uric
o Occurs within 6 to 72 hours after acid
the initiation of chemotherapy o Potassium and Phosphorus
o The most deleterious of all the restrictions are necessary
manifestations of TLS ▪ Eggs, fish, meats, poultry,
o Tumor cell destruction also milk, milk products
results in the release of o Assess breath sounds, for signs
POTASSIUM of fluid overload
o Renal insufficiency related to o Encourage the patient to drink at
hyperuricemia prevents adequate least 3L of fluid a day
excretion of potassium

HYPERPHOSPHATEMIA and HYPOCALCEMIA

o Occur 24 to 24 hours after the
initiation of therapy
o Phosphorus levels also rise as a
consequence of tumor cell
destruction
o Calcium ions then bind with the
excess phosphorus → calcium
phosphate salts → HYPOCALCEMIA
o The calcium-phosphate complexes
precipitate in soft tissues and
the renal tubules → acute renal
failure