CARE OF CLIENTS WITH I.

Health Care Facilities

PROBLEMS IN OXYGENATION,

FLUID AND ELECTROLYTES, Health Infrastructures:

INFECTIOUS, INFLAMMATORY General: a hospital that provides services

for all kinds of illnesses, diseases, injuries or
AND IMMUNOLOGIC deformities. A general hospital shall provide
RESPONSE, CELLULAR medical and surgical care to the sick and
uninjured, maternity, newborn and child
ABERRATIONS ACUTE, AND care. It shall be equipped with the service
capabilities needed to support board
CHRONIC certified/eligible medical specialists and
other licensed physicians rendering services
in, but not limited to, the following:
Concepts in the care of at risk and Sick
a. Clinical Services (Family Medicine,
Adult Clients Pediatrics, Internal Medicine, Obstetrics

A. Health Care Situations and Gynecology, Surgery)

B. Chronic Illness b. Emergency Services

C. Cultural and Health Ethnic disparities c. Outpatient Services

and culturally competent care

d. Ancillary and Support Services such as,

clinical laboratory, imaging facility and
pharmacy
HEALTH CARE SITUATIONS

HEALTH SYSTEM: All the activities whose

primary purpose is to promote, restore or  Specialty: a hospital that specializes
maintain health. in a

particular disease or condition or in one

type of
From how they are financed to the
workforce, facilities and supplies available, patient. A specialized hospital may be
a strong health system will ensure that devoted
everyone is able to access high-quality
healthcare without financial difficulty. to treatment of any of the following:
Everyone has the right to access healthcare.

a. Treatment of a particular type of illness

Health Services: or for a particular condition requiring a
range of treatment.
 Mental health care
b. Treatment of patients suffering from
 Dental care
diseases of a particular organ or group of
 Laboratory and diagnostic care
organs
 Substance abuse treatment
 Preventative care  District/first-level referral hospital-
 Physical and occupational therapy A hospital at the first referral level
 Nutritional support that is responsible
 Pharmaceutical care
 Transportation for a district or a defined geographical area.
 Prenatal care
 II. Health Workforce
Physicians, Nurses, Midwives, Pharmacists,
Dentist and Other Health Care Providers.
Level of Hospital: Defined as the service
capabilities of hospitals reflected in the
2020 license to operate.
These service capabilities can be classified
into the
following categories:
Health Care Problems/ Issues
 Physical Activity and Nutrition
 Overweight and Obesity
 Tobacco
 Substance Abuse
 HIV/AIDS
 Mental Health
 Injury and Violence
 Environmental Quality
 Immunization
 Access to Health Care
Health care situations
 Global
 National
 Local
Global: Ten most common Health Issues:
 Physical activity and nutrition
 Overweight and Obesity
 Tobacco
 Substance abuse
 Hiv/Aids
 Mental Health
 Injury and Violence
 Environmental Quality
 Immunization
 Access to Health Care
SIX Prominent Global Health Issues
 Pandemics
 Environmental Factors
 Economic
 Political
 Noncommunicable diseases
 Animal health, food sourcing
National: Health Issues affecting the
Philippines in 2020
 Ischemic heart disease
 Neoplasms
 Cerebrovascular disease
 Diabetes Mellitus
 Covid-19
Local: Top Leading Cause of Mortality in
Zamboanga City
1. Heart Disease
2. Diseases of the vascular system
3. Pneumonias
4. Malignant neoplasms/cancers
5. Tuberculosis (all Forms)
6. Accidents
7. COPD and allied conditions
8. Diabetes mellitus
9. Nephritis/nephritic syndrome
10. Other diseases of respiratory system
6 are non-communicable 4. Excessive alcohol use.

4 major NCDs

Chronic illness affects individuals and

CVD, cancers, COPD and diabetes mellitus.
Top Leading Cause of Morbidity in
Zamboanga city
family, changes family members role,
responsibilities and boundaries. It disrupts
their self-image and self-esteem. It results
in uncertain and unpredictable futures.

1. AURI/URTI C. Cultural and Health Ethnic Disparities

and Cultural competent care
2. Pneumonia

3. Acute Respiratory Infections

Culture – Set of patterns of human activity
4. Hypertension within a community or social group and the
symbolic structures that give significance to
5. Influenza such activity. Customs, laws, dress,
architectural style, social standards,
6. Wounds
religious beliefs, and tradition.
7. UTI

8. Bronchitis
Health Disparities – Refers to a higher
9. Diarrhea burden of illness, injury, disability, or
mortality experienced by one group relative
10. Skin Disease to another.

Health Care Disparity - Refers to differences

between groups in health insurance
Chronic Illness
coverage, access to and use of care, and
quality of care.

Conditions that last 1 year or more and
require ongoing medical attention or limit
activities of daily living or both.
Seven (7) most common chronic disease:
 Heart disease
 CA
 Chronic lung disease
 Stroke
 Alzheimer’s disease
 Diabetes disease
 Kidney disease
Many chronic diseases are caused by a
short list of risk behaviors:
In spite of significant advances in the
diagnosis and treatment of most chronic
diseases, there is evidence that racial and
ethnic minorities tend to receive lower
quality of care than non-minorities and that,
patients of minority ethnicity experience
greater morbidity and mortality from
various chronic diseases than non-
minorities. Unequal treatment concluded
“racial and ethnic disparities in healthcare
exist and, because they are associated with
worse outcomes in many cases, are
unacceptable.

1. Tobacco use and exposure to secondhand

smoke. Things to consider for cultural competence

2. Poor nutrition, including diets low in

fruits and vegetables and high in sodium
and saturated fats. Respect for patients who feel their health
care provider:
3. Lack of physical activity.
- Respect their beliefs

- Customs, values, language and traditions PERIOPERATIVE CONCEPTS

Jehovah's Witnesses believe that a human  Is a Nursing Specialty that works

must not sustain his life with another with patients who are having
creature's blood, and they recognize no operative or other invasive
distinction "between taking blood into the procedure.
mouth and taking it into the blood vessels."  surgical or an operating room nurse,
It is their deep-seated religious conviction this specialized nurse cares for
that Jehovah will turn his back on anyone patients before, during, and after
who receives blood transfusions. Thus, surgery.
Jehovah's Witnesses regularly refuse
transfusions for themselves and their
children because they believe the
 Who are the people involved?
procedure creates a risk of losing eternal
salvation. Perioperative nurses
 Legally, such refusals are based on Surgeons
the constitutional grounds that the
transfusion is an invasion of the right Anesthesiologists,
of privacy and a violation of the
Nurse anesthetists
individual's freedom of religious
practice. Surgical Technologists

Five principles of cultural competence:

 Open attitude
 Self-awareness
 Awareness of others
 Cultural knowledge
 Cultural skills

PERIOPERATIVE NURSING

PERFORMS 3 PHASES OF OPERATIVE

PROCESS

1. Preoperative Phase

2. Intra-Operative Phase

3. Post-Operative Phase

SURGERY
A procedure performed for the purpose of
structurally altering human body by incision
or destruction of tissues and is part of the
practice of medicine.
TYPES OF CONDITIONS REQUIRING
SURGERY
 Obstruction Impairment to the flow
of vital fluids. e.g. Blood, Urine, Bile,
CSF
 Perforation Rupture of an organ e.g.
Ruptured appendicitis, Ruptured
uterus
 Erosion Wearing off of a surface or
membrane e.g. Peptic ulcer,
 Tumors Abnormal new growths e.g.
Breast tumor, Bone tumor, Lung
tumor, Brain tumor
Classification of Surgical Procedures
According to PURPOSE:
1. Diagnostic – To confirm the presence of a
disease condition. e.g. Biopsy
2. Exploratory – To determine the extent of
the disease condition, e.g. explore lap
3. Curative – To treat the disease condition
3 Types of Curative Surgeries
a. Ablative – Involves removal of an organ
suffix use “ ectomy “ e.g. appendectomy
b. Constructive – Involves removal of a
congenital defective organ suffix use
“plasty, orrhaphy, pexy” e.g. cheiloplasty,
orchidopexy, herniorrhaphy,
c. Reconstructive – Involves repair of
damage organ e.g. plastic surgery for severe
burns
4. Palliative - To relieve distressing S/S , not
necessarily to cure the disease e.g.
Colostomy
According to degree of RISK /
MAGNITUDE / EXTEND
1. Major surgery – criteria involve high risk
of morbidity and mortality, extensive, large
amount of blood loss, vital organs are
removed and great risk of occurrence of
complications e.g. TAH-BSO.
2. Minor surgery – criteria involve lesser
risk procedure is not prolonged and does
not usually involve serious complications.
According to URGENCIES
1. Emergency – The surgery is done
immediately to save the patient’s life or
limb.
2. Imperative – The surgery must be done
within 24-48 hrs.
3. Planned Required – The procedure is
necessary for the well-being of the patient
4. Elective – The procedure is not absolutely
necessary for survival, delay will not cause
adverse effect.
5. Optional – The procedure is required by
the client for aesthetic purposes.
GENERAL RISK FACTORS FOR SURGERY
f. (-opexy) surgical suspension or
 Aging
fixation (e.g. hysteropexy)
 Obesity
 Fluid electrolyte imbalance
g. (-oplasty) surgical repair or remodel
 Presence of disease/s
(e.g. angioplasty, rhinoplasty)
 Concurrent or prior
pharmacotherapy
 h. (-otripsy) crushing or destroying (e.g.
lithotripsy)
Glossary of Terms
i. (-scopy) examination often related
Prefixes can be seen at the beginning of a to visual observation with an
medical word. They refer to the site or the endoscope (e.g. endoscopy)
body part being discussed.

 (angio-) signifies a type of

PREOPERATIVE PHASE
receptacles such as vessel (e.g.
angioplasty) -Begins when the patient decision has made
 (arthro-) refers to a joint or a for surgical procedure and Ends when
junction that separates different patient is transported to the Operating
parts (e.g. arthroplasty, arthroscopy) room and Care is transferred to the
 (endo-) means inner or internal (e.g. operating room nurse
endoscopy)
 (epi-) indicates a position that is - Physical History and Assessment
above, on, or near a surface (e.g.
-Patient Education
episiorrhaphy)
 (hystero-) denoting the uterus (e.g. -Pre-op Checklists
hysterectomy, hysterotomy)
 (nephro-) referring to the kidney - Ethical and Legal Issues
(e.g. nephrectomy)
- Patient's Surgical Consent
 (thoraco-) indicating the chest (e.g.
thoracotomy, thoracentesis)

2.
Suffixes, when applied to medical terms
would connote a procedure, condition, or
disease of the body part. These letters are
situated at the end of words which changes
the original meaning.
a. (-centesis) to puncture a cavity to
remove fluid (e.g. amniocentesis,
arthrocentesis)
b. (-ectomy) to remove or excise (e.g.
appendectomy, cholecystectomy)
PREOPERATIVE ASESSMENT
1. Identification of the patient - Using 2
identifiers
2. Physical,psychological and social state.
3. Functional Status (Ability to perform ADL)
4. Cardiovascular and Respiratory status
5. Skin Condition
6. Nutritional Status

7. Range of Motion

c. (-ostomy) the surgical creation of an 8. Any prothetics or corrective devices use

opening in an organ for the removal
9. Pain, Anxiety
of waste (e.g. colostomy,
tracheostomy) 10. Sensory Impairments

d. (-otomy) the cut or make an incision 11. Language barrier, cultural and spiritual
but without removal (e.g. needs
craniotomy,
12. Previous surgeries and anesthesia
experience
e. (-oorhaphy) to repair or suture (e.g.
cystorrhaphy, herniorrhaphy) 13. Allergies
14. Medications, herbs, nutritional
supplements and drug abuse
15. Support System
 Fluid and electrolyte balance
 Infection
 Renal function
 GIT function
 Liver function
 Endocrine function
 Hematologic function
 Presence of trauma
INTRA-OPERATIVE PHASE
-Begins when the patient is inside the
operating room for surgical procedure to
the time anesthesia is administered,
performance of the surgical procedure until
transported to the recovery room or post
anesthesia care unit (PACU)
SURGICAL TEAM
STERILE FIELD -Primary Surgeon, Assistant
Surgeon, Scrub Nurse
OUTSIDE STERILE - Circulating Nurse,
Anesthesiologist Other personnel
-Safe administration of anesthesia
-Asepsis and infection control
- Homeostasis
- Hemostasis
Intra-operative Nursing Responsibilities:
1. Continue assessment of patient's
physiologic and psychologic status
2. Promotes safety and privacy
3. Prevent wound infection
4. Promote heal
CIRCULATING NURSE
1.Coordinate patient care before, during
and after the surgical procedure
2. Provide emotional support to the patient
3. Assists the anesthesiologist during the
initiation of anesthesia.
4. Ensuring patient safety, positioning,
monitoring and enforcing policies and
procedures throughout the surgery
including “TIME OUT”
5. Maintaining sterile technique while
providing supplies and equipment for the
sterile team.
6. Documenting all nursing care during the
procedure, including the monitoring of
specimens.
7. Recognize and resolve environmental
hazards
8. Ensuring with scrub nurse that all
sponges, instrument and sharp counts are
completed and documented.
9. Communicate relevant information to
family and other healthcare workers
outside OR.
SAFE AND THERAPEUTIC ENVIRONMENT
FOR THE PATIENT
1. Traffic in and out of the OR must be
controlled.
2. Use antimicrobial agents to surroundings
of the OR
3. Temperature kept between 68-75
degrees to reduce risk of infection.
4. Relative humidity kept between 40-60%
which diminishes bacterial growth and
restricts static electricity.
HOW TO MAINTAIN STERILITY IN OR FOR
ASEPSIS
1. Scrub persons should function within a
sterile field.
2. Sterile drapes should be used to establish
a sterile field.
3. Items used within the sterile field should
be sterile.
4. All items introduced into the sterile field
should be opened, dispensed and
transferred by methods that maintain
sterility and integrity.
5. Sterile persons remain close to the sterile 4. Mechanical scrubbing at the incision site
field and never turn their backs to it. moving out in a circular fashion.

6. Policies and procedures for maintaining 5. Sponge contaminated must be discarded,

sterility should be developed, reviewed and use new one each time the area is
readily available. scrubbed.

SURGICAL ATTIRE “TIME OUT” - Verbal Agreement Initiated by

the Circulating Nurse
 Reduces patient's risk for surgical
site infections (SSI)  Correct patient
 Reduces personnel exposure to  Correct Site
hazardous substances and infectious  Correct procedure
microorganism.  Verify any implant devices
 Document time out time

Everyone in the OR Wears;

ANESTHESIA Types
- Surgical Cap
1. General Anesthesia - produces patient
-Face mask unconsciousness
-Shoe/boot covers 3 phases

 Induction - Administration (ET tube,

Dressing in OR attire progresses from head Cricoid pressure)
to toe  Maintenance - Anesthesiologist
maintains appropriate level
- Surgical cap  Emergence- Anesthesiologist begins
to awaken the patient and
-Surgical scrub suit
extubated.
-Face mask

-Safety eyewear
2. Regional Anesthesia- Creates temporary
-Shoe/boot covers loss of sensation in a particular area

ex. Spinal- surgery on the lower abdomen,

STERILE FIELD
1. Wear surgical scrub
2. Sterile gown
3. Sterile gloves/double gloving - prevents
SSI and protect healthcare providers
SKIN PREPARATION
1. Antiseptic Wash prior to surgery
2. Hair removal from the surgical site
3. Clean incision site with skin antiseptic
(take into consideration manufacturer's
instruction as to contact and drying time.
groin area, perineum or lower extremities.
- Anesthetic agent injected in CSF in
subarachnoid space
- Risk Hypotension, Respiratory arrest,
complete paralysis, neurologic
complications and infection.
Epidural - abdominal surgery, genitourinary,
lower. extremities,
- anesthetic agent injected into epidural
space outside CSF, requires higher doses of
anesthetic,
slower onset, the provider can titrate dose
throughout the procedure. Higher potential
for resp failure than spinal.
Nerve Block - local anesthesia injected into
the peripherical nerve.
Bier Block - Intravenous regional
anesthesia. Injected into veins in arms, legs
to prevent entering the systemic circulation.
(limited for less than 2hrs) Tissue damage
3. Local Anesthetic Agent - may be used
alone or with other
LEVEL OF SEDATION
1. Minimal Sedation- Patient remain
responsive
2. Moderate Sedation-Patient remain
responsive but won't remember after the
procedure
3. Deep Sedation - depression of
consciousness but respond purposefully
after painful stimulation independent
breathing may be impaired.
 Stage 1- ONSET OR INDUCTION
STAGE
 Stage 2 – EXCITEMENT OR DELIRIUM
 Stage 3 – SURGICAL STAGE
 Stage 4- MEDULLARY OR DANGER
STAGE
NOTE: Differentiate each stage
REGULATORY RESPONSE OF THE PATIENT
DURING SURGERY
1. Intra-operative hypothermia
Decrease in temperature
- Due to cool environment
- General anesthetics, muscle relaxants
- Infusion of IV fluids- Cool skin preps
solutions
- Cold dry anesthetic gases
- decrease core body heat due to escape
from incision site.
2. Intra-operative hyperthermia
Increase in body temperature
- Cause by sepsis
- Infection
- Malignant hyperthermia - results from
fatal complication of general anesthesis
when a genetic defect in muscle membrane.
Treatment = 100% Oxygen, cooling with ice
packs, restore acid base balance, treating
hyperkalemia
POSTOPERATIVE PHASE
-Begins when the patient is inside/admitted
in post anesthesia care unit (PACU) and
ends once the anesthesia has worn off and
patient is ready to be transported to
Ward/Unit
(POSTOPERATIVE NURSE MUST MONITOR
FOR POST SURGICAL COMPLICATIONS)
POSTOPERATIVE NURSING
RESPONSIBILITIES
1. Monitor Vital Signs
2. Monitor Airway patency
3. Monitor Neurologic Status
4. Manage pain
5. Assess surgical site
6. Assess and maintain fluid and electrolyte
balance
7. Provide thorough report of patient's
status to the receiving unit nurse and family
8. Maintain adequate body system
functions
9. Restore homeostasis
10. Ensure adequate discharge planning and
teaching
11. Prevent postop complications
Postoperative Complications
 Shock
 Hemorrhage
 DVT
 Pulmonary complication
 Pulmonary embolism
 Urinary retention
  Intestinal obstruction
 Hiccups (Singultus)
 Wound infection
 Wound dehiscence / Evisceration

FOUR MOST COMMON POSTOPERTIVE

COMPLICATIONS WERE HIGH SUSTAINED
FEVER OCCURS:

The Role of the Circulating and Scrub Nurse

1. Atelectasis --------- Within the first 48 hrs.

2. Wound Infection –-- In 5-7 day

3. Urinary Infections – 5-8 days

4. Thrombophlebitis – 7-14 days

PERIOPERATIVE CONCEPTS

I. Surgical team

The sterile team

 Surgeon
 Surgical first assistant
 Scrub nurse

Scrub hands and arms

Don sterile gowns and gloves

Enters the sterile area

Handles all sterile items needed for the

patient

Non-sterile team

 Anesthesia provider
(anesthesiologist)
 Circulating nurse
 Others (students, technicians)

Provide direct care outside of the sterile

field and environment

Handle supplies and equipment that not

considered sterile

The Sterile and Nonsterile Team in their PPE

(personal protective equipment) in the
COVID-19 Pandemic Principles of Asepsis and Sterility
Circulating Nurse – holding patient’s chart, ASEPTIC & STERILE Techniques: Facts to
with blue-colored, clean surgical gloves Consider
Scrub Nurse – positioned right beside the
instruments

Stages of General Anesthesia

 1. These practices are based on sound
scientific principles and are carried
out primarily to prevent the
transmission of microorganisms that
can cause infection
2. An object can be aseptic without
being sterile
3. It is impossible to remove all
microorganisms from the
environment, nevertheless, every
effort is made to maximize and
control the organisms.

Asepsis- absence of pathogenic (viruses,

bacteria, fungi, protozoa, and worms)
microorganisms that cause infection.

Ventilation is a term that refers to the

molecular exchange of oxygen and carbon
dioxide in the body. Carbon dioxide is
transported through the veins to the lungs
where it can be exhaled. This natural
phenomenon keeps the acidity down and
the pH within the normal range.

Oxygenation is a term that refers to the

molecular absorbance of oxygen. Air enters
the lungs and oxygen is picked up in the
hemoglobin of red blood cells so that it can
be transported and distributed to the
tissues of the body.

What is the Difference Between

Ventilation and Oxygenation?

 Ventilation refers to the patient’s

ability to take in oxygen and remove
carbon dioxide.
 Oxygenation refers to the patient’s
ability to take in oxygen from the
lungs and distribute it to the tissues
and organs of the body.
 Capnography can be used to
monitor the patient’s ventilation
status, whereas, pulse oximetry can
be used to monitor their
oxygenation status.

A capnography monitor is used in

OXYGENATION PROBLEMS healthcare facilities to measure end tidal
CO2 (EtCO2), or the amount of carbon
dioxide a patient exhale.
End-tidal CO2 (EtCO2) monitoring is a
noninvasive technique which measures the
partial pressure or maximal concentration
of carbon dioxide (CO2) at the end of an
exhaled breath, which is expressed as a
percentage of CO2 or mmHg. The normal
values are 5% to 6% CO2, which is
equivalent to 35-45 mmHg
Pulse oximetry is a noninvasive and
painless test that measures your oxygen
saturation level, or the oxygen levels in your
blood. It can rapidly detect even small
changes in how efficiently oxygen is being
carried to the extremities furthest from the
heart, including the legs and the arms.
Normal: A normal ABG oxygen level for
healthy lungs falls between 80 and 100
millimeters of mercury (mm Hg). If a pulse
ox measured your blood oxygen level
(SpO2), a normal reading is typically
between 95 and 100 percent.
According to the World Health Organization
(WHO):
 “80% of Covid-19 cases reported are
mild.
 Only 15% Covid patients may have
moderate disease where one’s
oxygen saturation level may go less
than 94%.
 And the remaining 5% Covid
infected people may end up having
severe disease which shows
respiratory rate higher than
30/minute and oxygen saturation
level less than 90%,"
 Hypoxemia (low oxygen levels in
blood) may eventually result in loss
of life.
 When oxygen levels become low
because of a sickness such as Covid-
19, the cells in the body don’t get
enough oxygen to perform their
normal functions.
 If the level remains low for long,
maybe due to lack of treatment,
organs start to malfunction; in
severe cases, it may cause death.
Oxygen – A Vital Need for the Fight Against
COVID-19
Oxygen can be administered in a variety of
ways. For low to moderate oxygen
deficiencies, patients can be put on either a
nasal cannula – a medical tube that goes
through both nostrils – or on a simple or
reservoir face mask. In these cases, one to
15 liters (3.3 gallons) of oxygen per minute
is delivered to supplement a patient’s
regular breathing.
Phase 1: Cell invasion and viral replication
in the nose
 Both SARS-CoV-2 and SARS-CoV gain
entry via a receptor called ACE2.
angiotensin-converti ng enzyme
 More commonly known for their
role in controlling blood pressure
and electrolytes, these receptors are
also present in the lungs, back of the
throat, gut, heart muscle, and
kidneys.
 A molecular model of the spike
proteins (red) of SARS-CoV-2 binding
to the angiotensin-converting
enzyme 2 (ACE2) protein, the
receptor (blue) which is it’s the entry
route to the target cell\
Phase 2: Replication in the lung and
immune system alerted
 The viral load study in Germany
showed that active viral replication
occurs in the upper respiratory tract.
 Seven out of nine participants listed
a cough among their initial
symptoms.
 In two individuals with some signs of
lung infection, the virus in sputum
peaked at day 10–11.
 It was present in the sputum up to
day 28 in one person.
Phase 3: Pneumonia
 Approximately 13.8% of people with
COVID-19 will have severe disease
and will require hospitalization as
they become short of breath. Of
these individuals, 75% will have
evidence of bilateral pneumonia.
  Pneumonia in COVID-19 occurs
when parts of the lung consolidate
and collapse. Reduced surfactant in
the alveoli from the viral destruction
of pneumocytes makes it difficult for
the lungs to keep the alveoli open.
Phase 4: Acute respiratory distress
syndrome, the cytokine storm, and
multiple organ failure
 The most common time for the
onset of critical disease is 10 days
and it can come on suddenly in a
small proportion of people with mild
or moderate disease.
 In severe acute respiratory distress
syndrome (ARDS), the inflammation
stage gives way to the fibrosis stage.
Fibrin clots form in the alveoli, and
fibrin-platelet microthrombi (small
blood clots) pepper the small blood
vessels in the lung that are
responsible for gas exchange with
the alveoli.
UPPER AIRWAY INFECTIONS
Nursing Care of Clients with Upper Airway
Disorders:
Rhinitis is also known as Coryza/ Hay
Fever…
 Inflammation of the mucous lining
of the nasal cavity.
 Mucous membranes become
infected or irritated.
ALLERGIC RHINITIS
Caused when an allergen such as
pollen, dust, animal dander, is
inhaled by an individual with a
sensitized immune system, triggering
antibody production.
PATHOPHYSIOLOGY:
 These antibodies, IgE, mostly bind to
mast cells, which contain histamine.
When the mast cells are stimulated
by an allergen binding to the IgE,
histamine is released, along with
prostaglandins leukotrienes,
bradykinins, and heparin.
 This causes rhinorrhea (sneezing,
congestion, itching, redness, tearing,
swelling, ear pressure, postnasal
drip.). Mucous glands are
stimulated, leading to increased
secretions. Vascular permeability is
increased, leading to plasma
exudation. Vasodilation occurs,
leading to congestion and pressure.
 Sensory nerves are stimulated,
leading to sneezing and itching. All
these events constitute the early
phase or immediate phase of the
reaction.
SIGNS/SYMPTOMS:
Sneezing:
 itching: nose, eyes, ears,
 Rhinorrhea (runny nose)
 Postnasal drip
 Congestion
 Anosmia (absence of sense of smell)
Headache
Earache
Tearing
Redeyes
Eye swelling
Fatigue
Drowsiness
Malaise
COMPLICATIONS:
include Acute or Chronic sinusitis
Otitis media
Sleep disturbances
Dental problems (overbite): caused by
excessive breathing through the mouth
Palatal abnormalities and Eustachian tube
dysfunction
NURSING MANAGEMENT:
 Instruct patient with allergic rhinitis
to avoid or reduce exposure to
allergens, irritants such as dusts,
molds, animals, fumes, powders,
perfumes, tobacco smoke.
 Saline nasal spray may be helpful in
soothing mucous membranes,
softening crusted secretions,
removing irritants.
 Antihistamines may be administered
for sneezing, itching and rhinorrhea.
Example of Antihistamines:
 Diphenhydramine (Benadryl)
 desloratadine (Clarinex)
 loratadine (Claritin)
 levocetirizine (Xyzal)
 cetirizine (Zyrtec)
VIRAL RHINITIS (COMMON COLD)
Caused by a virus, highly contagious
because virus is shed for about 2
days before the symptoms will
appear.
6 common viruses: rhinovirus,
parainfluenza, coronavirus, respiratory
syncytial virus, influenza, and adenovirus.
Clinical Manifestations:
 Nasal congestion
 Runny nose/discharge
 Nasal itchiness, tearing watery eyes
 Scratchy or sore throat
 General malaise
 Low grade fever
 Chills, headache, muscle pain
 Each virus has multiple strains.
 The incidence of viral rhinitis follows
a specific pattern during the year
depending on the causative agent.
 Three waves: US
 (September, Late January, Towards
end of April)
NURSING MANAGEMENT:
 NO SPECIFIC TREATMENT,
SYMPTOMATIC THERAPHY
 PROVIDE ADEQUATE FLUID INTAKE
 ENCOURAGE REST
 INCREASE INTAKE OF VITAMIN C
 WARM SALT GARGLES (SORE
THROAT)
 NSAIDS- MUSCLE ACHE/ PAIN
 ANTIHISTAMINES- SNEEZING
 PARACETAMOL- FEVER
PHARYNGITIS
Acute pharyngitis (sore throat) is a
sudden painful inflammation of the
pharynx, the back portion of the
throat that includes the posterior
third of the tongue, soft palate, and
the tonsils.
CAUSES:
MOST COMMON- VIRAL INFECTION
Factors that can increase a person’s risk of
pharyngitis include:
 having a history of allergies
 having a history of frequent sinus
infections
 smoking or exposure to secondhand
smoke
Diagnostic exams:
Rapid Screening tests for Streptococcal
Antigens: LATEX AGGLUTINATION ANTIGEN
TEST
 The latex agglutination test is a
laboratory method to check for
certain antibodies or antigens in a
 variety of body fluids including
saliva, urine, cerebrospinal fluid, or  PERSISTENT INFLAMMATION OF THE
blood. PHARYNX.
 The test depends on what type of  COMMON IN ADULTS WHO WORK
sample is needed. OR LIVE IN DUSTY SURROUNDINGS,
Saliva USE THEIR VOICE TO EXCESS, SUFFER
Urine FROM CHRONIC COUGH, HABITUAL
Blood USER OF ALCOHOL AND TOBACCO.
Cerebrospinal fluid (lumbar
puncture) 3 TYPES:

The sample is sent to a lab, where it is

mixed with latex beads coated with a HYPERTROPIC- GENERAL THICKENING AND
specific antibody or antigen. If the CONGESTION OF PHARYNGEAL MUCOUS
suspected substance is present, the latex MEMBRANE
beads will clump together (agglutinate).
ATROPIC- LATE STAGE, WHITISH, WRINKLED
Latex agglutination results take about 15
minutes to an hour. CHRONIC GRANDULAR- “CLERGYMAN’S
SORE THROAT “-NUMEROUS SWOLLEN
 A throat culture or strep test is LYMPH FOLLICLES ON THE PHARYNGEAL
performed by using a throat swab to WALL
detect the presence of group A
streptococcus bacteria, the most
common cause of strep throat.
 These bacteria also can cause other CLINICAL MANIFESTATIONS:
infections, including scarlet fever,
 COMPLAIN OF A CONSTANT SENSE
abscesses, and pneumonia. OF IRRITATION/ FULLNESS IN THE
(Antiseptic mouthwash should be avoided THROAT
prior the test)  MUCUS IN THE THROAT (EXPELLED
BY COUGHING)
Your doctor will ask you to open your  DIFFICULTY SWALLOWING
mouth and tilt your head back. If necessary,
your doctor may use a tongue depressor.
This can help your doctor have a better view
Nursing management:
of the back of your throat. They will then
rub a sterile cotton swab across the back of  Nurse instructs the patient to avoid
your throat, your tonsils, and any other sore contact with others until fever
areas for a few seconds. The swab will subsides.
collect a sample of the secretions being  Alcohol, tobacco, second hand
produced in the back of your throat. smoke exposure to cold should be
avoided.
 Wear a mask.
Nursing management:  Increase in fluid intake
 Lozenges
 A liquid / soft diet during the acute  Nasal sprays- congestion
stage.  Antihistamine decongestant
 Encourage to increase in fluid intake (Dimetapp)- PO q4 to 6 hrs.
 Instruct patient to stay in bed during
the febrile stage.
 Used tissues should be properly
disposed to prevent spread of
infection.
 Warm saline gargles
 Full course of antibiotic therapy
(penicillin, erythromycin,
azithromycin)- 7- to 10 days
complete the course
CHRONIC PHARYNGITIS
TONSILLITIS
TYPES OF TONSILLECTOMY

Coblation Tonsillectomy
 Instruct patient to avoid vigorous tooth
brushing or gargling-cause bleeding

How long is the healing process after a

tonsillectomy?

 Pain is common and may get worse

Nursing management: POST-OPERATIVE
CARE
Continuous nursing observation is required
in the immediate post-operative and
recovery period.
3 to 4 days after the surgery.
 This pain is often worse in the
morning and may last up to 2 weeks.
 There may be discoloration where
the tonsils were removed. When the
area is healed completely in about 3
to 4 weeks, the discoloration will be
gone.
 There is a risk of bleeding after a
tonsillectomy. The risk decreases
after 10 days.
 Limit Activity for 2 weeks.

Significant risk of HEMORRHAGE (may occur

12- 24 hrs. after surgery)

Prone position with head turned to side-

immediate post-operative

Allows drainage from the mouth and

pharynx.

Signs of primary hemorrhage right after a

tonsillectomy include:

 bleeding from the mouth or nose

 frequent swallowing
 vomiting bright red or dark brown
blood

Alkaline mouthwash and warm saline

solutions- thick mucus and halitosis.

Explain to the patient that a sore throat,

stiff neck, vomiting may occur in the first 24
hours.

Semi liquid or liquid diet is given for several

days.

instruct patient to avoid spicy, hot, acidic,

foods.

Milk and milk products (ice cream, yogurt)

may be restricted makes removal of mucus
difficult.

Explain to the patient that halitosis and

some minor ear pain may occur for the first
few days.
 OXYGENATION PERFUSION Hypercalcemia- tachycardia/
bradycardia, cardiac arrest.
Introduction: 3. Magnesium- Hypomagnesemia-
 Our human body can’t survive ventricular tachycardia
without oxygen. When our body Hypermanesemia- muscle weakness,
tissues are not receiving enough bradycardia.
oxygen from capillaries, obviously
there will be a problem of ineffective
tissue perfusion.
 Sometimes, there is disruption in the
exchange of gases between the
blood and the cells. The cells and
tissues will ultimately not receive
adequate amount of oxygen supply.
 A lot of conditions can disrupt the
exchange of oxygen and carbon
dioxide however, conditions like
coronary artery disease and 2. Difficulty of breathing may mean
hypertension as well as acute pulmonary complications hence,
coronary artery syndrome, vascular respirations should be checked.
disorders and even Diabetes Ischemic pain can lead to respiratory
Mellitus, obesity and anemia are distress.
some of the common risk factors
leading to ineffective tissue 3. In cerebral assessment, check for
perfusion. mental status. B/P should be
monitored especially in orthostatic
Assessing for Ineffective Tissue perfusion: changes. Changes in cognitive and
patient’s speech indicates alteration
 This procedure is vital and needed to
in cerebral perfusion.
identify risk factors that leads to
possible problems on tissue
4. Check for gastrointestinal
perfusion:
assessment. The following
1. Laboratory data should be reviewed
symptoms should be checked, bowel
such as:
sounds, anorexia, abdominal
 BUN, electrolytes, prothrombine
distension, vomiting, constipation,
time, creatinine.
as well as nausea. Check for loss of
Make sure that clotting factors are within peristalsis.
therapeutic levels especially when
anticoagulants are used as treatment.

 Prothrombin Time= 10 to 14
seconds.

If your blood clots more slowly or more

quickly than that, you may have a clotting
problem.

Electrolytes:

1. Potassium- hypokalemia- causes

cardiac instability
Hyperkalemia- causes asystole
(flatline)- absence of heartbeat.
2. Calcium- Hypocalcemia- cardiac
arrest
 lack of movement, buildup and
potential blockage of food materials
Peripheral artery disease- buildup
and narrowing of the arteries occur
in all arteries in the body- heart
attack and stroke
 HOW TO ASSESS THE MENTAL
HEALTH STATUS:
 The patient’s attention span is
assessed first;
 an inattentive patient cannot
cooperate fully and hinders
testing
 Orientation to time, place, and
person
 Attention and concentration
 Memory
 Verbal and mathematical abilities
 Judgment
 Reasoning
Mental status examination evaluates
different areas of cognitive function. The
examiner must first establish that patients
are attentive—eg, by assessing their level of
attention while the history is taken or by
asking them to immediately repeat 3 words.
The parameters of cognitive function to be
tested and examples of how to test them
include the following:
Test the 3 parameters of orientation:
 Person (What is your name?)
 Time (What is today’s date?)
 Place (What is the name of this
place?)
ALTERATION IN MENTAL STATUS :
 Confusion
 amnesia (memory loss)
 loss of alertness,
 disorientation (not cognizant of self,
time, or place)
 defects in judgment or thought
 unusual or strange behavior,
 poor regulation of emotions
 disruptions in perception,
psychomotor skills, and behavior
5. Peripheral system should be
assessed utilizing tools to determine
changes in oxygenation. Hgb levels
should be assessed.
Low levels of Hgb manifests reduced
oxygen delivery to tissues.
Assess for cold clammy skin, pulse, cyanosis
as well as absence of pulse which may be a
result of low cardiac output. Dry skin, shiny
skin, brittle nails and gangrene reflects
arterial insufficiency.
6. In renal assessment, check for urine
input and output intake. (Low urine
output)- inadequate tissue perfusion
HYPERTENSION
 Elevated blood pressure is another
name for hypertension which is
diagnosed when there is increased
systolic blood pressure of 140 mmhg
and above.
 Diastolic blood pressure is over 90
mmHg or higher.
 Blood pressure is being taken in two
separate days.
HYPERTENSIVE RETINOPATHY
 damage to the blood vessels in the
retina, the area at the back of the
eye where images focus.
 Narrowing of blood vessels
 Spots on the retina known as cotton
wool spots and exudates
 Swelling of the macula (the central
area of the retina) and optic nerve
 Bleeding in the back of the eye
CAUSES OF HYPERTENSION:
 May begin experiencing issues
throughout your body. High blood
pressure may be one of those issues.
For example, it’s thought that
changes in your kidney function due
to aging may upset the body’s
natural balance of salts and
fluid. This change may cause your
body’s blood pressure to increase.
 Environment: Over time, unhealthy
lifestyle choices like lack of physical
activity and poor diet can take their
toll on your body.
 Lifestyle choices can lead to weight
problems.
  Being overweight or obese can
increase your risk for hypertension.
Primary hypertension is also called
essential hypertension. This kind of
hypertension develops over time with no
identifiable cause. Most people have this
type of high blood pressure.
These factors include:
Genes: Some people are genetically
predisposed to hypertension. This may be
from gene mutations or genetic
abnormalities inherited from your parents.
 Avoid smoking cigarettes or drinking
caffeine for 30 minutes before blood
pressure (BP) is measured.
 Empty bladder.
 Sit quietly for 5 minutes before the
measurement.
 Sit comfortably, with back
supported, with the forearm
supported at
 Heart level on a firm surface, with
both feet on the ground; avoid
talking while the measurement is
being taken.

Physical changes: If something in your body

changes, you

2. Secondary hypertension may be defined

as a type of hypertension (i.e. blood
pressure >140/90n mmHg) with an
underlying, potentially correctable cause.

Secondary hypertension should be

particularly considered in (1) young patients
without a family history of arterial
hypertension, (2) patients with resistant
hypertension, and (3) late onset of Hypertension Risk factors:
hypertension
 Stress
 Smoking
 Age
 Obesity
 Alcohol
 Race
 Unhealthy diet
 Lack of activity
 Family history
 Gender
Systolic blood pressure (the first number) – Symptoms:
indicates how much pressure your blood is
exerting against your artery walls when the  Fatigue
heart beats.  Severe headache
 Vison problem
Diastolic blood pressure (the second
 Difficulty breathing
number) – indicates how much pressure
 Chest pain
your blood is exerting against your artery
 Pounding in your chest, neck, or ear
walls while the heart is resting between
 Blood in urine
beats.
 Irregular breathing
Instructions for the Patient
Scope of the problem:

 Heart attack (MI)

 Heart failure
  Stroke
 Kidney disease
Medications for lowering hpn are:
1. Diuretics – This is a drug also called water
pill. It helps kidney get rid of excess water
and salt (sodium).
Ex: Thiazide diuretics (Diuril), Potassium-
sparing diuretics, (Aldacton, amiloride),
Loop diuretics (Furosemide).
muscles of the heart and blood vessels. This
drug would cause the heart to beat less and
relaxes the blood vessels. Hence, decreases
the blood pressure.
Example are the following:
EX. Amlodipine (besylate), Norvasc (Lotrel),
Felodipine (Plendil),
Diltiazem (Cardizem), Isradipine (Dynacirc),
Verapamil
hydrochloride (Calan SR, Isoptin, Veralan).

(Administer IV FUROSEMIDE SLOWLY over 1

to 2 minutes because HEARING LOSS can
occur if INJECTED RAPIDLY.) Recommended lifestyle Modifications

2. Beta-Blockers - It decreases the heart a. Eating a healthy diet (more fruits

beat and BP. Decrease the workload of the and vegetables)
heart and decrease oxygen demands. b. Stop smoking
Contraindicated with asthma, Diabetic. c. losing weight
d. Getting more exercise
Ex. Atenolol, Propanolol (Inderal), e. Treatment with medications
Metapronol tartrate (Lopressor), f. Decrease intake of sodium
Metoprolol Succinate (Taprol), Carvedilol

(Assess for Respiratory distress, wheezing,

dyspnea.

Instruct patient not to STOP the medication

– rebound HPN, rebound tachycardia, or
ANGINAL ATTACK can occur.)

3. Alpha-beta Blockers – It has combined

effect. It lessens the constriction of the
blood vessel that has the same effect of
Alpha-1 blocks and reduce the heartbeat
and rate which has the same effect of the
beta blockers.

Examples are the following: Carvedilol

(Coreg) and Labetalol hydrochloride (

Normodyne) which are common alpha-

beta-blockers.

4. Angiotensin Converting Enzyme (ACE)

inhibitors – This drug has its effect on the
body which produces a decreased hormone
named angiotensin A, responsible for
narrowing of blood vessels. This drug
reduces the blood pressure as it expands
the blood vessels.

Examples are Benezepril hydrochloride,

Captopril, Monopril, Lisonopril.

5. Calcium channel blocker – This ROLES OF POTASSIUM:

medication causes the limit of the calcium
from emerging into the cells of the smooth
  Potassium lessens the effects of
sodium.
 The more potassium you eat, the
more sodium you lose through
urine.
 Potassium also helps to ease tension
in your blood vessel walls, which
helps further lower blood pressure.
(Apricots and apricot juice, Avocados,
Cantaloupe and honeydew melon, Fat-free
or low-fat (1 percent) milk, Fat-free yogurt,
Grapefruit and grapefruit juice)
FOOD SOURCES RICH IN POTASSIUM
 Mushrooms
 Oranges and orange juice
 Peas
 Potatoes
 Prunes and prune juice
 Raisins and dates
 Spinach
 Tomatoes, tomato juice and tomato
sauce
 Tuna
 BANANA
MAGNESIUM:
 helps reduce blood pressure by
increasing the production of nitric
oxide — a signaling molecule that
helps relax blood vessels
 Green leafy vegetables, seeds and
nuts (e.g. almonds, cashew nuts,
sunflower seeds and pumpkin seeds)
 brown rice and whole wheat
noodles
 Milk (nonfat)
 Yogurt (plain, low fat)
 Spinach
 Dark chocolate
 Legumes
 Beans
CALCIUM:
 it helps blood vessels tighten and
relax when they need to.
 It's also crucial for healthy bones
and the release of hormones and
enzymes we need for most body
functions.
 dairy products, milk, cheese and
other dairy foods, soy milk fish (such
as canned salmon and sardines)
 dark, leafy greens.
Hypertensive Crisis
 is a severe increase in blood
pressure that can lead to a stroke
 Extremely high blood pressure — a
top number (systolic pressure) of
180 millimeters of mercury (mm Hg)
or higher or a bottom number
(diastolic pressure) of 120 mm Hg or
higher — can damage blood vessels.
 S/sx: Headche,
Drowsiness,confusion, blurred
vision, dyspnea, cyanosis, seizures
 The first-line treatment for
hypertensive crisis will typically be
intravenous antihypertensive
medications to lower the person’s
blood pressure. Healthcare
providers usually aim to reduce
blood pressure for the first hour.
 Drug of Choice: intravenous
nitroglycerin, clevidipine, or
nitroprusside.

NURSING INTERVENTIONS:
 MONITOR VITAL SIGNS, ESP. BP
EVERY 5 MINUTES.
 MAINTAIN BED REST , WITH
HEAD OFBED ELEVATED AT 45
DEGREES.
 ASSESS FOR ANY HYPOTENSION
EPISODE DURING THE
ADMINISTRATION OF
ANTIHYPERTENSIVE MEDS.
PLACE PATIENT IN A SUPINE
POSITION.
 MONITOR FOR IV THERAPHY-
FLUID OVERLOAD
 INSERT FOLEY CATHETER, AS
PRESCRIBED.
 MONITOR INPUT AND OUTPUT.
NOTIFY PHYSICIAN THE
PROGRESS.
CORONARY ARTERY DISEASE
PATHOPHYSIOLOGY
 When the arteries that are used to
deliver blood to heart muscles
become narrowed and hardened,
there would be lesser blood that
would flow through the arteries.
This hardening and narrowing of
blood vessels are due to the build-
up of cholesterol and other
 materials on the inner walls called
plaque. This build up is called
Atherosclerosis.
 Hence, the muscles of the heart
can’t get adequate amount of
oxygen and blood. There would be
chest pain (Angina) or heart attack.
There could be permanent damage
especially when the heart doesn’t
receive adequate amount of blood
supply. It weakens the muscles of
the heart and contributes to heart
failure wherein the heart can’t pump
adequate blood to other parts of the
body.
Risk Factors:
Modifiable Risk factors:
 Tobacco use
 High blood cholesterol or
triglyceride levels
 Lack of exercise
 Obesity
 Stress
Non-modifiable risk factors:
 Family history of heart disease
 Older age
 Diabetes
 High blood pressure
What risk factors can be controlled?
Smoking, diabetes, blood cholesterol, high
triglyceride levels, high blood pressure,
obese or being overweight, metabolic
syndrome, lack of physical activity, Stress,
unhealthy diet, anemia and depression.
DIAGNOSTIC TEST:
 BLOOD LIPID LEVELS: ELEVATED
 CARDIAC CATHETERIZATION: SHOWS
THE PRESENCE OF
ATHEROSCLEROTIC LESIONS.
 An invasive imaging procedure that
allows your doctor to evaluate your
heart function.
 This test is also done preoperatively
for planning cardiac procedures that
involve treatment of narrow or
blocked coronary arteries, such as
coronary artery bypass surgery,
angioplasty, and stenting
Nursing responsibilities before cardiac
catheterization include:
 Instruct the patient to fast, usually
for 8 to 12 hours, before the
procedure
 Inform patient that if catheterization
is to be performed as an outpatient
procedure, a friend, family member,
or other responsible person must
transport the patient home
 Informing the patient about the
expected duration of the procedure
and advising that it will involve lying
on a hard table for less than 2 hours.
 The patient may be asked to cough
and to breathe deeply, especially
after the injection of contrast agent.
Coughing may help disrupt a
dysrhythmia and clear the contrast
agent from the arteries.
Nursing responsibilities after cardiac
catheterization:
 Observing the catheter access site
for bleeding or hematoma formation
every 15 minutes for 1 hour, every
30 minutes for 1 hour, and hourly
for 4 hours or until discharge.
 BP and heart rate are also assessed
during these same time intervals.
Maintaining bed rest for 2 to 6 hours
after the procedure.
 A hemostasis band or pressure
dressing may be applied over the
catheter access site.
 Analgesic medication is
administered as prescribed for
discomfort.
 Patients are instructed to avoid
repetitive movement of the affected
extremity for 24 to 48 hours
 Ensuring patient safety by
instructing the patient to ask for
 help when getting out of bed the catheter, to cut away or vaporize
first time after the procedure. plaque.
 The patient is monitored for
bleeding from the catheter access
site and for orthostatic hypotension,
indicated by complaints of dizziness
or lightheadedness.
 Instructing the patient to report
chest pain and bleeding or sudden
discomfort from the catheter
insertion sites promptly

SURGICAL MANAGEMENT

Before heart bypass surgery, patient

should:
ATHERECTOMY- a new invasive
 Refrain from taking any drugs
procedure for the treatment of
containing aspirin for 3 days before
atherosclerotic heart disease,
the surgery.
consists of the excision and removal
 Stop smoking immediately, as
of atherosclerotic tissue from
smoking creates mucus in the lungs
coronary artery walls.
that can interfere with recovery.
 Avoid eating or drinking after
 Removing plaque makes the artery
midnight on the night before
wider, so blood can flow more freely
surgery.
to the heart muscles.
 Follow any other instructions
provided by the doctor or care team
 In an atherectomy, the plaque is
 Complete blood tests, ecg, chest
shaved or vaporized away with tiny
xray, coronary angiogram
rotating blades or a laser on the end
of a catheter (a thin, flexible tube)
CARDIAC SURGICAL UNIT POST-OP
INTERVENTIONS:

 Mechanical Ventilation- 6 to 24 hrs.

Before an atherectomy, the patient
receives sedatives to help him or her
relax. Next, a catheter is gently
Myocardial infarction
inserted in an artery, usually in the
groin or upper thigh area. It's then
guided through the blood vessel
toward the heart. When it's in
place, dye is injected through the
catheter and into the coronary
arteries. An X-ray is taken to help
the physician pinpoint the area that
is blocked or narrowed. The
physician then uses tiny blades or a
laser, attached to the end of the
 Heart rate, rhythm, urinary output,
euro status is closely monitored
 Pleural Chest tubes –observe for
drainage. >100- 150ml/hr-
report to physician ASAP.
 OCCURS WHEN MYORCARDIAL
TISSUE IS ABRUPTLY AND SEVERELY
DEPRIVED OF OXYGEN ISCHEMIA-
NECROSIS
 INFARCTION EVOLVES OVER
SEVERAL HRS
 OBVIOUS PHYSICAL CHANGES- 6
HOURS AFTER THE INFARCTION-
BLUE, SWOLLEN
  >48 HRS- INFARCT TURNS GRAY,
YELLOW STREAKS
 8- 10 DAYS- GRANULATION FORMS
(Infarct- Tissue death due to failure of
blood supply)
HISTORY
 patients with MI describe a
heaviness, squeezing, choking, or
smothering sensation.
 Patients often describe the
sensation as “someone sitting on my
chest.”
 The substernal pain can radiate to
the neck, left arm, back, or jaw.
 Unlike the pain of angina, the pain of
an MI is often more prolonged and
unrelieved by rest or sublingual
nitroglycerin.
 Associated findings on history
include nausea and vomiting,
especially for the patient with an
inferior wall MI.
 These gastrointestinal complaints
are believed to be related to the
severity of the pain and the resulting
vagal stimulation.
DIAGNOSTIC STUDIES:
1. TROPONIN LEVEL- RISES WITHIN 3
HOURS, REMAINS ELEVATED 7-10 DAYS.
2. TOTAL CK LEVEL= RISES WITHIN 6 HRS
AFTER CHEST PAIN, PEAKS WITHIN 18 HRS >
DAMAGE
3. MYOGLOBIN= RISES WITHIN 2 HRS, RAPID
DECLINE > 7 HRS.
4. WBC = RISES ON THE 2ND DAY FF MI
LASTS UP TO WEEK
5. ECG= ST SEGMENT ELEVATION, T WAVE
INVERSION, ABNORMAL Q WAVE IS
PRESENT.
HRS- DAYS AFTER THE MI, ST AND T WAVE
CHANGES TO NORMAL, Q WAVE USUALLY
REMAINS PERMANENTLY.
NURSING INTERVENTIONS:
 The most important goal of drug
therapy early in the course of acute
myocardial infarction is to improve
the oxygen supply/demand ratio for
the heart.
 Monitoring & Assessing
Cardiovascular system:
 Obtain a 12-lead EKG, have
continuous bedside cardiac
monitoring
 Monitoring blood pressure and
heart rate
 Place on oxygen via nasal cannula
per MD order 2-4 L
 Working IV access (multiple…may
start drips and administer other IV
medications)
 Monitor respiratory system: lung
sounds “crackles”..represent heart
failure
 Strict bedrest (activity puts strain on
heart)
 Collect cardiac enzymes as ordered
by the physician

Antiplatelets: decrease platelets
aggregation and thrombus formation
Aspirin: low dose (decrease the chances of
a clot forming and decrease the chance of
another heart attack). Watch for signs and
symptoms of GI bleeding, especially if
patient has a history.
Plavix: taken if can’t take aspirin (may be
prescribed short term for up to a year after
the myocardial infarction)
Morphine: for chest pain relief (may find
that morphine only relieves the chest pain
rather than nitro) hypotension, respiratory oral hygiene due to gum
depression. enlargement.

Nitrates: Nitroglycerin (ointment,

sublingual, IV, patch, or oral “Imdur”): NURSING RESPONSIBILITIES: NITRO
causes vasodilation and increases blood TRANSDERMAL
flow to the heart, hence better blood flow
to the area experiencing ischemia  Wash your hands before and after
use.
 Monitor blood pressure, assess  Put patch on at the same time of
patient’s chest pain, monitor EKG day.
and  Do not put on right after a shower or
 BP continuously if on drip. bath.
 Side effects: headache, flushing,  Put patch on clean, dry, healthy ,
dizzy HAIRLESS skin.
 Wear only one patch at a time(12 to
Beta blockers: “Coreg, Lopressor”
14 hours)
decreases work load on the heart…slows
 To reduce skin irritation, apply each
heart rate and decreases blood pressure
new patch to a different area of skin.
 monitor for bradycardia, masking  After removing the old patch, fold it
signs and symptoms of in half with the sticky sides together,
hypoglycemia in diabetics, breathing and discard out of reach of children
problems in asthmatics and COPD… and pets.
 educate patient not to take beta
Ace Inhibitors: end in “pril” Lisinopril,
blockers with grapefruit juice
Ramipril, Enalapril, Captopril
because it slows the absorption of
beta blockers  works by allowing more blood to get
to the heart muscle and this allows it
Cholesterol lowering medication such as
to work easier. It does this by
Statins: “Lipitor, Crestor, Zocor” (goal: LDL
blocking the conversion of
less than 100 mg/dL) helps lower LDL, total
Angiotensin I or Angiotensin II (this
cholesterol, lower triglycerides, and
causes vasodilation, lowers blood
increase HDL.
pressure, and allows kidneys to
 Educate not to replace diet and secrete sodium because it decreases
exercise aldosterone)
 Notify doctor if they develop muscle
pain or tenderness
 Monitor CPK (creatine kinase)
levels…. which if elevated it can
cause muscle problems.
 Monitor liver function because
statins act on the liver to block it
from producing too much
cholesterol.

Calcium Channel Blockers: Norvasc,

Cardizem

 This medications work by stopping

the transport of calcium to the
myocardium and into smooth
muscle which causes vasodilation on
the coronary arteries.

 Monitoring heart rate, orthostatic

hypotension, educate about good