Integrated Concepts - Np3 and Np4

PHILIPPINE NURSES ASSOCIATION – UNITED ARAB EMIRATES CHAPTER
SPECIAL PROFESSIONAL LICENSURE EXAMINATION 2023 - NURSING
INTEGRATED CONCEPTS
 Metrorrhagia (bleeding between menstrual periods) - first sign of cervical cancer.

 Reducible hernia protruding mass spontaneously retracts into the abdomen.
 Atropine Answer: increases heart rate.
 A mechanical ventilator indicated to a patient can't maintain a safe PaO2 or PaCO2 level.
 goal of treatment for a patient with angina pectoris is to reduce the heart's workload, thereby reducing the
myocardial demand for O2 & preventing MI.
 Drainage of more than 3L of fluid daily from a NGT may suggest intestinal obstruction.
 Ecstasy is also known as (MDMA /Molly)- methylenedioxy-methamphetamine (MDMA)
 MDMA's effects last about 3 to 6 hours
 (Viagra®) Answer: sildenafil
 MDMA acts by increasing the activity of three brain chemicals: dopamine, norepinephrine, and serotonin.
 Effects include euphoria, increased energy, distorted perception, involuntary teeth clenching, dangerously
high body temperature, and depression.
 After a corneal transplant Answer: avoid lying on the affected site , soapsuds and sex
 Persistent bleeding after open heart surgery may require the administration of protamine sulfate to reverse
the effects of heparin sodium used during surgery.
 The risk of cancer is nearly doubled in frequent users of Answer: ACETAMINOPHEN.
 A triage nurse gathers information upon a patent's arrival to a hospital emergency room, including name,
age, symptoms and the current medical condition of the patient.
 Dopamine— Answer: causes a surge in euphoria and increased energy/activity
 Norepinephrine—increases heart rate and blood pressure, which are particularly risky for people with heart
and blood vessel problems
 Answer: deer ticks = LYME'S DISEASE.

 REVERSE TRIAGE is system of categorization of patients in a mass casualty situation based on decisions as to
which can most safely be DISCHARGED rather than on priority for treatment.
 Answer: About 50% of people who experience a systemic allergic reaction will have a recurrent reaction
when re-stung.
Priming IV Tubing
 If you see a small bubble of air get them out of the line by flicking the tubing with your finger.
 Answer: a sterile syringe to aspirate air through a port.
 Meningitis, and pertussis- Answer: DROPLET PRECAUTIONS for

 MERS and EBOLA- Answer: Contact precaution for
 Answer: Droplet – 3 feet distance or less
 Answer: PROGNATHISM - INITIAL MANIFESTATION of ACROMEGALY.
 Triad of ADHD: Answer: Inattention, Hyperactivity, Impulsivity
 Answer: Latanoprost eye solution control the progression of glaucoma or IOP
Administering Oral Inhalation Therapy

 Answer: Squeeze the inhaler as client breathes in deeply through the mouth.
 Tell client to hold breath up to a count of five seconds.
 Answer: Anaphylaxis may cause respiratory (bronchoconstriction) and shock (vasodilation). It's considered a
crisis.
 Mastoidectomy is required in Answer: 50% of cases of MASTOIDITIS.
 Answer: Pure-tone audiometry- is a behavioral test used to measure hearing sensitivity.
 The most common cause of corneal ulceration is Answer: prolonged or improper use of contact lenses.
 A person with Antisocial Personality Disorder lacks Answer: superego and needs immediate gratification.
 After a patient undergoes a femoral-popliteal bypass graft, Answer: the nurse must closely monitor the
peripheral pulses distal to the operative site and circulation.
 Osteoarthritis is also known as Degenerative Joint Disease. It commonly affects the Answer: weight-bearing
joints (spine, hips and knees).
 Answer: Colonoscopy - is the "screening" for colorectal cancer.
 Biopsy is the confirmatory.
 Answer: Veracity: habitual observance of truth in speech or statement; TRUTHFULNESS.
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 The closest predisposition to Type 2 DM (NIDDM) is Answer: obesity.
 Dyspnea and sharp, stabbing pain that increases with respiration are symptoms of pleurisy, which can be a
complication of pneumonia or tuberculosis.
 GERD is also known as Answer: chalasia.
 Z-Track Injection
 adult, the most commonly used needles are 1’(inch)or 1/2, Answer: 22 to 25 gauge thick
 Preparation
 Verify doctor’s order on the patient’s chart.
 Hand washing.
 Use a proper needle. Rule of thumb in needle selection for IM injection are as follows:
 Answer: Aspirate the prescribed medication into the syringe. Draw 0.2-0.5 cc of air (depending on the
hospital policy) to create an air lock. (Air-lock technique is used with this procedure.)
 Answer: Pancolitis refers to inflammation of the entire colon.
 hallmark of Ulcerative colitis is bloody Answer: diarrhoea / rectal bleeding.
 Recurrent Ulcerative collitis treat with Answer: sulfasalazine
 Gastroesophageal reflux disease: GERD or chalasia: relaxation of cardiac sphincter
 Caused by:
• Answer: Smoking, alcohol, caffeine, chocolate, hiatal hernia.
 Findings:
• Chest pain, cough, asthma, heartburn, acid injury to enamel, Barrett's esophagus.
 Congenital pyloric stenosis:
• Answer: Projectile vomiting.
• Hypertrophy of muscles in pyloric sphincter.
 Inflammatory bowel disease:
 Ulcerative colitis:
• Most common.
 Answer: *Rectum and sigmoid – most common site
• Ulcerations.
 Crohn's disease:
• Granulomatous, ulceroconstrictive disease.
• Discontinuous spread throughout entire GI tract.
 Irritable bowel syndrome:
• Alternating bouts of diarrhea and constipation.
 Answer: **Diverticulitis – LLQ pain
 Answer: Diet : avoid fruits and vegetables high in fiber and no seeds
 Barrett's esophagus:
• Answer: Complication of GERD.
 Colon cancer:
• Increasing age.
• Answer: Low-fiber diet.
• Smoking.
• Familial polyposis, ulcerative colitis.
• Answer: Common location:rectosigmoid.
• Test: fecal occult blood test, colonoscopy, barium enema.
• Answer: Constipation and diarrhea with or without bleeding.
• Spreads to: liver (common), lungs, bone, brain.
 Colorectal cancer – primary diagnostic test is Answer: colonoscopy
 Acute appendicitis:
• Children: lymphoid hyperplasia.
• Answer: Adults: fecalith obstruction of proximal lumen.
• Initial colicky periumbilical pain.
• Nausea, vomiting, fever.
• Answer: Tenderness at McBurney's point (Blumberg's sign).
• Laboratory: neutrophilic leukocytosis.
• Diagnosis: CT scan.
• Complications: periappendiceal abscess; pylephlebitis.
• Treatment: appendectomy.
 Pheochromocytoma is the formation of a benign tumor in adrenal medulla causing hypertensive crisis.
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 Answer: DOC: Phentolamine Mesylate (Regitine)
 In otitis media, the tympanic membrane is bright red and lacks its characteristic light reflex (cone of light).
 Answer: Dopamine is the drug of choice for shock.
 Aneurysms:
• Weak vessel walls followed by dilation.
• Tendency of vessel wall to rupture.
 Abdominal aortic aneurysm:
• AORTA is located at the
• Answer: EPIGASTRIC REGION
• hiatus hernia most common hiatus hernia, in which the stomach passes, partly or completely, into
the chest cavity through the hole for the oesophagus
Complications of hernias
 Answer: impossible to return to their normal state (irreducible).
 swollen and fixed within their sac (incarcerated).
 cut-off from their blood supply, becoming painful and eventually gangrenous (strangulated).
 the best position for inguinal hernia the client must be in a Answer: standing position
 Surgical repair of an inguinal hernia is recommended
 Answer: to prevent strangulation of the bowel, which could result in intestinal obstruction and necrosis
 Osteomyelitis:
• Bone infection due to: S aureus (most common).
• Findings: fever, bone pain.
 Osteoporosis:
• Loss of bone matrix and minerals.
• Primary: idiopathic, senile, postmenopausal (lack of estrogen).
• Secondary: disease, drugs, space travel.
• Prevention: vitamin D, calcium, weight-bearing exercise.
• Treatment: bisphosphonates, calcitonin.
 Osteoarthritis:
• Non-inflammatory joint disease.
• Universal after 65 years of age.
• Degeneration of articular cartilage in weight-bearing joints.
• Osteophyte formation.
 Bone rubs on bone.
 Rheumatoid arthritis:
• Rheumatoid factors activate complement, attracting neutrophils.
• Synovial tissue proliferates forming a pannus.
• Findings: MCP/PIP involved; knees, ankles, hips involved; lungs, hematologic disease, carpal tunnel
syndrome, rheumatoid nodules, vasculitis, popliteal cyst
 Lyme disease:
• Ixodes tick transmission; white-tailed deer is reservoir.
• Early: bull's eye lesion.
 Late: arthritis, Bell's palsy, myocarditis and pericarditis; babesiosis (secondary infection).
 Myasthenia gravis:
• Thymus-synthesized auto-antibodies against ACh receptors.
• Findings:Ptosis, dysphagia, risk for thymoma.
• Confirmation:Tensilon (edrophonium) test.
 Hypokalemia: muscle weakness, U waves on ECG, polyuria, rhabdomyolysis.
 Hyperkalemia: ventricular arrhythmias, peaked T waves on ECG, muscle weakness.

 K loss caused by:
o Decreased intake, GI loss, renal loss, alkalosis.
 Respiratory acidosis:
• Hypoventilation
• Findings: somnolence, cerebral edema.
 Respiratory alkalosis:
• Hyperventilation
• Findings: light-headedness, tetany (Ca binds to albumin, so decreased Ca).
 Pulmonary Embolism:
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• Originates in femoral vein, pelvic vein, or vena cava; occludes pulmonary artery branches; sudden
death.
 Position to Left side lying
 Transfusion Reactions: Acute Hemolytic Transfusion Reaction:
• Fever, back pain, hypotension, DIC, oliguria.
Hemolytic disease of newborn: ABO
• Mom = type O; baby = type A or B.
• Jaundice develops 24 hours after birth.
• Anemia.
• + Coombs' test on baby blood.
Hemolytic disease of newborn: Rh
• Mom is RH negative; baby is Rh positive.
• Mom exposed to fetal blood, develops anti-D-IgG antibodies.
• First pregnancy plays no role.
• During second pregnancy, anti-D-IgG enters placenta coats baby RBCs.
 Treatment:
• At 28th week of pregnancy, give mom anti-D globulin
• which lasts ~3 months.
 Findings:
• Jaundice, kernicterus, positive direct/indirect Coombs' test.
• Use blue fluorescent light on newborn skin
• Produced by liver, End product of amino acid and pyrimidine metabolism., Increased in CHF.
 Blood urea nitrogen (BUN):
 Prerenal:
• Causes: decreased CO.
 Renal:
• Causes: parenchymal damage to kidneys; tubular necrosis, renal failure.
 Postrenal:
• Causes: urinary tract obstruction below kidneys.
 Angina pectoris:
 Stable angina:
• Caused by atherosclerotic coronary artery disease.
• Exercise-induced chest pain.
• ST depression.
• Relieved by resting or nitroglycerine.
 Prinzmetal angina:
• Coronary artery vasospasm at rest.
• Vasoconstriction.
• ST-elevation.
• Nitroglycerine and Ca-channel blocker.
 Unstable angina:
• Severe atherosclerotic disease.
• Chest pain even at rest.
• May progress to MI.
• Balloon angioplasty.
• Stents.
 Congestive Heart Failure:
 Left-sided HF:
• Pulmonary edema.
• Difficulty breathing.
• Left-sided S3 sound.
• Paroxysmal nocturnal dyspnea.
 Right-sided HF:
Prominent jugular veins
• Right-sided S3 sound.
• Painful hepatomegaly.
• Pitting edema and ascites.
 acid–base disturbances generally observed in Heart failure is?
- Metabolic and Respiratory Alkalosis
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 Varicella-zoster virus:
Varicella (chickenpox): rash; + Tzanck tes
• Herpes zoster (shingles).
• Drug: ACYCLOVIR (ZOVIRAX)
 Eczema:
• Acute: weeping, erythematous rash.
• Chronic: dry, thickened skin due to scratching.
• Atopic dermatitis: type I IgE-mediated hypersensitivity reaction in children.
• Contact dermatitis: allergic; type IV hypersensitivity reaction.
• Photodermatitis: UV light reaction.
• Drug: prednisone
 Cerebrovascular accidents:
• Most common: Atherosclerotic (thrombotic) stroke:
 Labs:
• Viral: increased CSF protein; normal CSF glucose.
• Bacterial/fungal: increased CSF protein; decreased CSF glucose.
 Multiple sclerosis:
• More common in females.
• Sensory and motor dysfunction, visual and speech disturbances, ataxia, tremor, nystagmus, bilateral
internuclear ophthalmoplegia
 Labs:
• Increased CSF leukocyte, protein, myelin basic protein; normal CSF glucose; oligoclonal bands on CSF
electrophoresis; central pontine myelinolysis
 Parkinsonism:
• Idiopathic degeneration of neurons in substantia nigra causing deficiency of dopamine.
 Findings:
• Muscle rigidity, resting/rolling pill tremor, expressionless face, shuffling gait.
 Treatment:
• Dopamine
 Acromegaly excess GH .... Initial signs and symptoms ENLARGEMENT OF HANDS ND FEET other is
enlargement of forehead, jaw and nose.....
 Benign prostatic hyperplasia:
• Digital rectal exam 50% sensitive.
- DHT( Dihydrotestosterone) is mediator.
• Estrogen is co-mediator
 Prostate cancer:
• 2nd Most common cancer in adult males next to lung Cancer.
• Risk: age, familial, black, smoking, high saturated fats in diet.
• DHT is mediator.
 Erectile dysfunction:
• Psychogenic, decreased testosterone, vascular insufficiency
 Treatment:
• Sildenafil (Viagra); Yohimbe.
 Endometriosis:
• Growth of endometrial implants or tissues outside uterus
 Locations:
• Most common is ovaries.
 Findings:
• Dysmenorrhea, painful menses
 Treatment:
• Hormonal estrogen and progesterone therapy
Breast cancer
• Mean age: 64 years old.
• Due to: prolonged estrogen exposure; smoking, radiation, endometrial cancer.
• Painless mass.
• Skin, nipple retraction.
 •BSE – SUPINE 7 days after
• Spreads to: lungs, bone, liver, brain, ovaries.
• Treatment: radical mastectomy
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 Pneumonia:
 Community acquired pneumonia:
• Often due to S. pneumoniae
• Acute bronchitis; lung has areas of consolidation.
 Chronic bronchitis:
• Productive cough for 2 months - 3 years
• from bronchi.
• Acute inflammation.
• Dyspnea.
• Cyanosis of skin.
• Blue bloaters; stocky patients.
• Cor pulmonale (hypertrophy of right ventricle due to lung disease).
• Respiratory acidosis
Asthma
Type I hypersensitivity
• InterLeukin4 = isotype switching to IgE production.
• InterLeukin5 = production and activation of neutrophils.
• Histamine released.
• Expiratory wheezing, nocturnal cough, increased anteriorposterior diameter.
 Theophylline
Asthma (wheezing)
Side-effects of theophylline  Nausea, diarrhea  Increase in heart rate, tachyarrhythmias
Theophyllin
 Hypothyroidism:
 Causes:
• Hashimoto's thyroiditis, cretinism.
 Findings:
• Weight gain, fatigue, cold intolerance, constipation, hypertension, muscular myopathy.
 Lab findings:
• Decreased T4, increased TSH
 Treatment:
• Levothyroxine.
Graves' disease:
Hyperthyroidism and thyrotoxicosis
 Findings:
• Exophthalmos, pretibial myxedema
 Plummer's disease:
• Goiter.
 Endemic:
• Iodide deficiency.
 Sporadic:
• Goitrogens (eg., cabbage, cassava, broccoli and cauli flower)
 Hypoparathyroidism:
• Hypocalcemia.
• Causes: surgery, autoimmune, DiGeorge
• syndrome, hypomagnesemia.
• Findings: tetany, basal ganglia calcification, cataracts.
• Lab: hypocalcemia, hyperphosphatemia, decreased PTH.
Primary hyperparathyroidism
• Answer: Common cause of hypercalcemia.
 Causes:
• Adenoma.
 Findings:
• Calcium stones
acute pancreatitis, constipation
 Acute pancreatitis:
• Alcohol, gallstones
Trypsin plays a role in activating enzymes
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Fever, nausea, vomiting, midepigastric pain radiating to back, shock, hypoxemia, Grey-Turner's sign (flank
hemorrhage), Cullen's sign (periumbilical hemorrhage), tetany
 Obesity:
• Answer : BMI over 30
• Answer : Excess fat on waist is more harmful.
• Genetic predisposition: 50-80%.
 Obesity causes:
• Depression, cancer, diabetes mellitus 2, hypertension, obstructive sleep apnea, and more.
 Tobacco use causes:
• CV disease, lung cancer, stroke.
• Nicotine is the most addictive substance in tobacco.
• This also includes chewing tobacco and second-hand (passive) smoke.
 Alcohol use:
• Answer : Stomach absorption.
• Metabolism in liver and stomach.
 Cocaine:
• Stimulant; mydriasis, tachycardia, hypertension, AMI, CNS infarction.
 Heroin:
• Opiate; miotic pupils, frothing at mouth,
 Marijuana: Answer : “cannabis Sativa”
• Stimulant; Answer : red conjunctiva, euphoria, delayed reaction time.
 Acetaminophen:
• Damage to liver and kidneys; production of free radicals.
• Give ACETYLCYSTEINE
 Aspirin (also known as acetylsalicylic acid or salicylate) overdose:
• Tinnitus, vertigo, altered mental status, tachypnea, respiratory alkalosis, metabolic acidosis
 Burns
 R - RESCUE /REMOVE anyone in immediate danger
A - Activate the Manual Fire ALARM
C - CONFINE the fire (close the door)
E - EXTINGUISH small controllable fires/or
E- EXIT
E-EVACUATE
 Answer : *log roll yourself when you are in fire
 The principles of STOP, DROP, and ROLL are simple
 Answer : Stop, do not run, if your clothes catch on fire.
Drop to the floor in a prone position.
Cover your face with your hands to protect it from the flames.
Answer : Roll over and over to smother the fire.
 If you are near someone whose clothing catches on fire, be sure to stop them from running and make them
STOP, DROP, and ROLL.
 BURNS CHARACTERISTIC:
1st degree - Superficial Thickness
2nd degree - Partial Thickness
3rd degree - Full Thickness
4th degree - Deep Penetration

DEPTH OF INVOLVEMENT:
1st degree - Epidermis;
2nd degree – Epidermis AND dermis. corium. tegument. derma. stratum. Cutis
3rd degree - Subcutaneous Layer; FATTY layer

 4th degree - Muscles, and Tendons and Bone
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Full Thickness Burn (3rd deg)
 Destroys both the epidermis & dermis
- burn appears white or charred
- dead skin becomes tough & leathery
- painless
 PAIN:
1st degree - MILD PAIN;
2nd degree –MOST PAINFUL;
3rd degree - NO PAIN;
4th degree - NO PAIN
 HEALING PERIOD:
1st degree - 3-5 DAYS;
2nd degree - 14-21 DAYS;
3rd degree - GRAFTING NEEDED;
 COLOR:
1st degree - Pink or Red known as ERYTHEMA;
2nd degree - Cherry Red or White and Mottled;
3rd degree - Tan, Brown, Black or Marble White;
4th degree - Black
 SKIN SURFACE:
1st degree - Dry, Flaking or Peeling within 2-3 days;
2nd degree - Moist, Blisters
3rd degree - Charred, Dry, Leathery Tissue Formation;
4 degree - Charred, Dry Scar Tissue Formation
 Third-degree burn, the surface of the skin is swollen and looks dry, waxy white, leathery, brown, or
charred.
 NO pain because of nerve damage.
 Some burn victims go into shock.
 Third degree burns are among the most severe categories of burn injuries.
 Third-degree burns typically destroy the top layers of skin down to the SUBCUTANEOUS TISSUES
 The IM or SQ routes should not be used because Circulatory blood volume is reduced, delaying absorption
form the subcutaneous tissues and muscle tissue
 The most preferred route to administer drugs in 3rd degree burn is through I.V intravenous route
 2nd most appropriate is to administer the drug through oral route via NGT.
 Cheapest and most ideal IVF – is PLRS
How should you treat a Heat (Thermal) burn while waiting for help to arrive?
 Check the scene for safety, remove the person from the source of the burn (if safe),
 check for life-threatening conditions, cool the burn with cold running water, cover the burn with sterile
dressing, make sure the person isn't chilled or overheated, comfort the person,
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 DO NOT apply ice,

 DO NOT cover with unsterile dressing,
 DO NOT remove embedded pieces of clothing,
 DO NOT try to clean the burn,
 DO NOT break any blisters,
 DO NOT use any kind of ointment on the burn.
How should you treat a Chemical Burn while waiting for help to arrive?
 flushing it with tap water.
 Continue flushing the burn as long as it takes EMS personnel to arrive.
 If the eye is affected, flush it FOR 2O MINUTES , with the affected eye lower than the other.
 Remove any contaminated clothes.
How should you treat an Electrical Burn while waiting for help to arrive?
 DO NOT go near the person until you are sure that they are no longer in contact with the power source.
 Turn off the source and care for any life-threatening conditions. Be on the watch for any need for CPR/AED.
 Look for exit and entry wounds.
 Burns: Emergent Phase
*Fluid shifts: IV to IS
*Electrolyte imbalances: Hyponatremia & Hyperkalemia
*Acid-Base imbalance: Metabolic acidosis
 Stage 1 (Emergence)- This stage is from the onset of the injury until the patient stabilizes. HYPOVOLEMIC
SHOCK becomes the major concern for up to 48 hours after a major burn
 Stage 2 (Acute)- Also known as DIURETIC PHASE. Begins 48-72 hours after the burn injury. The GREATEST
CONCERN IS CIRCULATORY OVERLOAD from the fluid shift back from the interstitial spaces into the
capillaries
Stage 3 (Rehab)
 Patient care outcome involves returning the patient to as normal as status as possible. A second outcome
would include freedom from wound infection
 In a burn injury the greatest fluid loss occurs during the first- 12 hours
 Fluid shift and the loss of intravascular fluids may cause the person to develop this and most deaths from
burns result directly from - Burn Shock
 What is the most common complication and cause of death after the FIRST 72 HOURS - Infection
 Fluids begin to shift back to the vascular compartment in approximately- 48 TO 72 HOURS
 The fumes produce damage to the cilia and mucosa of the repiratory tract. - Alveolar surfactant decreases
and this condition can occur- Atelectasis
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 Symptoms for this include headache, nausea, vomiting, and unsteady gait - Carbon Monoxide poisoning
 During the emergent phase, the nurse performs a thorough assessment every- 30 minutes to 1 hour
 This is recommeded hourly urine output in patients with moderate to severe burns- 30 to 50 mL
 Primary goals of Emergent phase - Maintain respiratory integrity and to prevent hypovolemic shock which
may result in death
 During the acute phase this increases - Metabolism

 a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body; the first sign is
usually vomiting of bright red blood- Curling's ulcer
 Surgical transplantation of any tissue from one part of the body to another location in the SAME
INDIVIDUAL- Autograft
 The transfer of tissue between two genetically DISSIMILAR INDIVIDUALS of the same species tissue from
another species- Heterograft (xenograft)- Homograft (allograft)
 The tissue is left partially attached to the donor site and the other portion of the tissue is atached to the
burn site - Pedicle method
 The tissue is completely removed from the donor site and is attached to the burn site
- Free standing method
 Requirements of this nutrient are greater than normal for recovery from burns - Protein
 Approximately how many calories are needed for recovery from a burn injury - 6000 calories
 When does rehabilitation of the burn patient begin? - Admission
 Iron-overload disorders:
• Hemochromatosis and hemosiderosis.
 Answer: Give desferal or deferoxamine.
 Z TRACK IRON – Answer : 10 mins hold
 diagnosed with Diabetes - Answer : above 5.5 mmol/mol

 Normal: Below 42 mmol/mo
 Obese- Endomorph body
 For ID injection: needle size is ¼ -1/2 inch26-27 gauge
 Generic Name of Dilantin? Answer: Phenytoin
 Condom catheter How to apply it: spirally around the shaft of penis
 A teenage girl was raped. But she wants to keep it from her parents. – disclosed the information or divulge
and tell to the parents
 Affordable Rich in calcium – Anchovies
 Rheumatic Fever infected mother – delivery in semifowlers or sitting position
 Pink eye disease - Viral conjunctivitis
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 BON powers- to issue and, after due investigation, suspend or revoke certificates of registration
 What is the best position when suctioning the client with tracheostomy?
- Semi-Fowler’s Position
 What is incorrect when suctioning the patient?

- Apply suction when inserting suction catheter.
 Apply suction intermittently for how long?

- 5 – 10 seconds
 Before suctioning the client with tracheostomy administer how many % of oxygen?
- 100%
 What is the main goal after the patient has under gone tracheostomy?
- Maintain patent airway
 When cleaning the non-disposable inner cannula you use?

- Sterile Gloves
 What is the recommended mm Hg of the cuff pressure?

- 18 mm Hg
 What is the incorrect use of a Cuffed Tracheostomy Tube?

- Don’t use positive pressure ventilation
 Patients who need emergency treatments should not hesitate and immediately call an ambulance. This
corresponds to these cases except:
- A CLIENT IS NOT SPEAKING CLEARLY.
 Why is it so that we need to do Cardiopulmonary Resuscitation as soon as possible?

- BECAUSE IT ONLY TAKES 3 TO 4 MINUTES FOR THE PATIENT TO BECOME BRAIN DEAD BECAUSE OF A
LACK OF OXYGEN.
 When you are emotionally angry to the patient because he is a gay; you are exhibiting:
- COUNTER TRANSFERENCE
 Which of the following is not a cause of Hemorrhoids?

- INFECTION.
 The patient was then transferred to Room of Choice After Hemorrhoidectomy. As a nurse, you positioned the
patient prone. The rationale for this nursing action would probably be:
- TO PREVENT BLEEDING.
 To mitigate patient’s pain, which of the following nursing actions will you really not do?
- APPLY VASELINE TO THE ANAL-RECTAL AREA.
 To promote good bowel movement, which of the following contingent nursing intervention will the patient
or health care expected for you to carry out?
GIVE CASTOR OIL AS ORDERED.
 The Gastro Esophageal Reflux is a precipitous of what disorder?

- HIATAL HERNIA
 Which of the following foods can be a cause of GERD?

- ENERGY DRINKS.
 The patient prescribes Maalox for the patient with GERD. Which of the following diagnosis will you inform to
the Doctor of choice by the patient?
BATHE PATIENT HAD UROLITHIASIS.
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 Lemon who was hooked to Chest tube after 4 hours, it is removed accidentally. Which of the following
reminders about caring of Mr. is untrue? .
THE NURSE SHOULD COVER THE REMOVED AREA WITH WET STERILE DRESSING.
 Which of the following information provided is absolute true about angioplasty?

- THIS PROCEDURE CAN BE DONE IN CARDIAC CATHETERIZATION LAB WITH MEDICATIONS.
 What is the positioned of the patient for the first 8 hours post PTCA?
- FLAT ON BED.
 Streptokinase was given as anticoagulant. What should you remember about important action prior giving
the medication?
DO NOT SHAKE VIAL WHEN RECONSTITUTING.
 Which of the following is the cause of Lung cancer?

Smoking
 To breathe properly, which of the following position will the nurse expect?
ORTHOPNEA/ORTHOPNEIC
 he patient undergoes Cholecystectomy. Which of the following is TRUE statement among list of choices?
B. REPORT CLAY-COLORED STOOLS TO PHYSICIAN.
 A client taking levodopa should be taught about the signs of Levodopa toxicity.
- TWITCHING.
 Selegilline (Eldepryl) is prescribed for a client with Parkinson’s disease Levodopa therapy.
- IF A SEVERE HEADACHE OCCURS, IT SHOULD BE REPORTED TO THE PHYSICIAN IMMEDIATELY.
 among males aging 50 years old and above.

 The normal drainage after Transurethral Resection of Prostate within 24 hours is:- REDDISH PINK WITH
SMALL TO MEDIUM SIZED BLOOD CLOTS.
 The nurse is aware that the signs and symptoms of hypothyroidism include:
d. Weight gain
 Among which is the Priority for public health care? C.community
 client was placed in skeletal traction after sustaining a pelvic fracture 12 hours ago. The charge nurse should
immediately intervene after making which of the following observations?
C. The assigned assistive personnel adjusts the weights to relieve pressure
 RA 9173. Ung sa
 niyug niyogan
 What is the medication for moderate pain? Answer: codeine..
 Thrombolytic answer: dissolve clot
 Rheumatoid arthritis intervention : bath with cold water in the morning
 Light for dying patient? BRIGHT
 Position for ICP? 30-40 degree
 A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications
should the nurse anticipate administering immediately?B. Lorazepam
“Adrenal gland problems”

 What is a common location of an adenoma within the adrenal gland
- Adrenal cortex
 Describe a PHEOCHROMOCYTOMA crisis
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- Relatively rare condition in which the patient presents with rapid acceleration in the frequency and
severity of potentially life-threatening catecholamine-induced hemodynamic disturbances
(tachycardia, hypertension) – HYPERTENSIVE SYNDROME
 The LIVER is a common source of Bleeding during a lap right adrenalectomy
 The largest arterial branch to the right adrenal gland is usually from the - Renal artery
 Prior to resecting the right adrenal gland, this maneuver allows easier access to the posterior IVC-
Laparoscopically releasing the retroperitoneal attachments to the liver
 A small cautery injury to the IVC with lap right adrenalectomy is a - Lethal problem
 A small cautery injury might be a lethal problem to which organ anterior to the IVC during lap right
adrenalectomy - Duodenum
 Hernias are most commonly seen with trocar incisions for 10 mm ports
 The best option is to enlarge the trocar site incision if it is difficult to = Close the fascia primarily
 The barrier between the colon and left kidney = Gerota's Fascia
 During a straightforward left lap adrenalectomy, what might a surgeon slip into near the splenic apex and
stomach? - Lesser sac
 Left adrenalectomy typically uses __3___ ports -
 Right adrenalectomy typically uses __4___ ports-
 The ____ is the 4th "retractor" for left adrenalectomy - Spleen
 A straightforward lap adrenalectomy in a thin person will take: - 45 minutes
 Pre Op: High dose of IV ______? Cortisone
 Pre Op: High dose of IV Cortisone ensures adequate response to stress of the Procedure
 Post Op: Risk for _______ due to high levels of Cortisol? Infection
 Post Op: Delayed Wound healing
 Post Op: Monitor Calcium and Potassium Levels
 What is synthesized by the adrenal cortex? - cortisol, aldosterone, and small amounts of the sex hormones,
androgen and estrogen
 What does the ADRENAL MEDULLA PRODUCE?
- Epinephrine and Norepinephrine (catecholamines)
 What is pheochromocytoma?
- Hypersecretion by the adrenal medulla due to a catecholamine-producing tumor which is normally
benign.
 Is pheochromocytoma bilateral? Only 10% of the time
 What are the manifestations?
- Intermittent episodes of sympathetic nervous system attacks of HTN, headaches, palpitations, flushing,
apprehension, profuse diaphoresis, sense of impending doom.
 How long SNS attacks last for? = minutes to hours
 What provokes the SNS attacks?= abdominal pressure, urination, vigorous abdominal palpitation
 What agent in foods can cause a SNS attack? = Tyramine found in aged cheese, and red wine, avocado,
tuna
 What are the 5 H's of pheochromocytoma?
- Hypertension, Headache, Hyperhydrosis, Hypermetabolism, Hyperglycemia
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 What urine test is performed to diagnose pheochromocytoma?

- 24 hour collection of urine to detect metanephrine, catecholamines, and vanillylmandelic acid (VMA).
These are byproducts of catecholamine metabolism and are diagnostic if elevated.
 What does a Clonidine Suppression test do?
- It is diagnostic for pheochromocytoma. If there is no suppression with Clonidine then it indicates
pheochromocytoma.
 To prevent attacks, what medications may be used with pheochromocytoma?
- alpha/beta blockers (Trandate), Dibenzyline or smooth muscle relaxants, Nipride, and calcium channel
blockers (Procardia)
 What surgery is tx for pheochromocytoma?
- unilateral or bilateral adrenalectomy
 For what complication should be monitored post-adrenalectomy?
- Bleeding so monitor for hypovolemic shock; and Addisonian Crisis (sudden decrease in glucoccorticoids)
 Patient with pheochromocytoma must do what at home?
- take BP
Addison's Disease?
 What is Addison's Disease?
- Hyposecretion of adrenal cortex hormones (cortisol and aldosterone).
 What is the prognosis for Addison's?
- fatal if untreated and a medical emergency if it occurs rapidly
 What are the causes of Addison's?
- atrophy of the adrenal gland r/t use of steroids or autoimmune process. Also related to TB
 What lab values are altered by Addison's?
- Hypoglycemic, Hyperkalemic, Hyponatremic, Hypovolemic, Acidotic, BUN is increased
 What are the s/s of Addison's?
- anorexia, weight loss, postural hypotension, lethargy, dehydration, nausea/vomiting, salt cravings,
hyperpigmentation, mood swings, and dysrhythmias
 What are nursing interventions for Addison's?
- promote fluid balance, weigh daily, strict I/O, orthostatic BP, monitor for dysrhthmia, monitor labs for
hemoconcentration (HCT and BUN)
 What med is given if the someone with Addison's Disease is not a candidate for surgery?
- metyrosine (Demser) suppresses catecholamine synthesis
 What is an appropriate diet for Addison's?
- High salt, low potassium, encourage fluids
 What is given for cortisol deficiency?
- Prednisone (Deltasone)
 What is an aldosterone deficiency?
- Fludrocortisone (Florinef)
 How are corticosteroids given?
- In the smallest effective dose, in divided doses (more physiologic), and tapered slowly
 Side effects of corticosteroid therapy?
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- reduces inflammatory response (avoid ill people), osteoporosis, GI upset (take with food), blood sugar
elevation, weight gain, edema, hypertension
 What are the s/s of corticosteroid toxicity?
- fluid retention, ROUND FACE, BUFFALO HUMP
 What is an Addisonian Crisis?
- life threatening acute adrenal insufficiency
 What PRECIPITATES AN ADDISONIAN CRISIS?
- stress, infection, trauma, surgery, decreased salt intake (HYPONATREMIA), cold exposure, or over
exertion
 Manifestations of an Addisonian Crisis?
- Severe headache, severe adominal/leg/lower back pain, generalized and profound weakness,
CONFUSION, severe hypotension, hypovolemic shock
 What interventions should be implemented for an Addisonian Crisis?
- IV Solu-Cortef initially, later oral corticosteroids, monitor vitals especially BP, maintain patent airway,
monitor neuro status, note irritability and confusion, monitor I/O
 What will be GIVEN TO CORRECT ELECTROLYTE IMBALANCES DURING AN ADDISONIAN CRISIS?
- KAYEXALATE, INSULIN AND 5% DEXTROSE, and calcium
 What dysrhthmias may be present during an Addisonian Crisis?
- peaked T waves, VT, and VF
Cushing's Disease
 What is Cushing's Disease?
- hypercortisolism; endogenous hypersecretion by ADRENAL CORTEX OF CORTISOL (excess stimulation by
ACTH)
 What is Cushing's Syndrome?
- HYPERCORTISOLISM; chronic use of exogenous corticosteroids
 What are the manifestations of Cushing's?
- MOON FACE, BUFFALO HUMP, MUSCLE WASTING, poor wound healing, striae, acne, HIRSUTISM,
emotioanl lability, ELEVATED BLOOD SUGAR, HTN, pathologic fractures, decreased immune function,
altered sleep patterns
 What is diagnostic of Cushing's?
- Plasma cortisol is high, Primary Cushing's and Cushing's from steroid use has low ACTH
 What lab values are altered by Cushing's?
 Blood glucose inc, dec lymphocyte, inc sodium, dec calcium, and dec potassium
 HYPOKALEMIA AND HYPOCALCEMIA WITH HYPERNATREMIA
 What are the goals of treatment for Cushing's?
- reduce cortisol plasma levels, remove tumors, prevent complications, restore normal or acceptable body
image
 What nursing implications should be implemented for Cushing's?
- Weigh daily, I/O, prevent skin breakdown and pathologic fractures and GI bleeding
 What diet is appropriate for Cushing's?
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- High calorie, with calcium and vitamin D
 Use what meds for GI upset?
- H2 blockers and antacids
 Avoid what meds with Cushing's?
- aspirin, NSAIDS, alcohol, and caffeine
 What is given for inoperable adrenal tumors?
- mitotane (Lysodren)
 What is used TO REDUCE CORTISOL PRODUCTION with Cushing's?
- AMINOGLUTETHIMIDE (ELIPTEN) or metyrapone (METOPIRONE)
 How is a pituitary adenoma treated?
- radiation and surgery (more effective)
 Before an adrenalectomy, what is done?
- electrolyte imbalances are corrected, cardiac rhythm monitoring, and hyperglycemia is controlled
 What is given before and after an adrenalectomy?
- glucocorticoids
 Is an adrenalectomy an incisional surgery or laproscopic?
- A flank incision is prefered but can be done laparoscopically
 What is the post-op care for an adrenalectomy?
- ICU, frequent vitals, assess for adrenal crisis
 What is necessary for an unilateral adrenalectomy?
- requires glucocorticoid replacement until remaining gland can compensate; this may take 2 years
 What is necessary for a bilateral adrenalectomy?
- requires immediate and lifelong glucocorticoid replacement therapy
 What is hyperaldosteronism?
- excess aldosterone usually r/t adrenal adenoma or increased renin levels
 What are the manifestations of HYPERALDOSTERONISM?
- HYPOKALEMIA, HTN, C/O headache, fatigue, muscle weakness, nocturia, polyuria, PARESTHESIA
(HYPOKALEMIA), visual changes
 What are the lab values of HYPERALDOSTERONISM?
- DEC POTASSIUM, INC SODIUM, DEC RENIN, INC SERUM ALDOSTERONE, metabolic alkalemia, low urine
specific gravity and high urine aldosterone
 After an adrenalectomy for hyperaldosteronism, what is resolved?
- hyperkalemia but HTN may remain
 In order to correct hypokalemia, what med may be given?
- Aldactone (spironolactone) potassium sparing diurectic and aldosterone antagonist
 What are the side effects of aldactone?
- diarrhea, gynecomastica, headache, urticaria, HYPERKALEMIA
Triage:
S.T.A.R.T, one of the 5 S's, is an acronym for

Simple Triage And Rapid Treatment.
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"Triage" in French means
"To Sort"
Virginia Triage Tag Concept

Red: highest priority - immediate
Yellow: second priority - delayed
Green: third priority - minor
Black: lowest priority – dead
Red: Poor respirations, perfusion, mental status, and severe burns (life-threatening injuries)
-May survive with immediate life-saving measures
-Imminent risk asphyxiation or shock but can be stabilized
Yellow: Burns, major or multiple bone/back injuries (potentially life-threatening)

-Should survive if given care w/in a few hours
-Severely debilitating injury
Green: Minor painful, swollen deformities, minor soft tissue injuries

-Walking wounded: minor injuries that do not require rapid care
Black: Deceased or non-salvageable

-Deceased or severely injured patients unlikely to survive
-Unresponsive with no circulation
Reverse Triage
Used for mass-casualty lightning injuries
Treat dead first - high potential for resuscitative success from respiratory arrest
Examples of the IMMEDIATE CATEGORY (RED) are:

 Airway obstruction
 Open pneumothorax (sucking chest wound) with respiratory distress:
 Tension pneumothorax
 Unstable abdominal wounds with shock
 Massive external bleeding (e.g. amputation)
 Hypovolemic (hemorrhagic) shock
 Any burns to the face, neck, hands, feet, or perenium or genitals
Delayed: YELLOW
Casualties who have less risk of losing life or limb by treatment delayed
Examples of the delayed category are:
Open chest wound (without respiratory distress)
Abdominal wounds (without shock)
Eye and central nervous system (CNS) injuries
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Soft tissue wounds requiring debridement (removal of foreign material and dead or damaged tissue); all forms of
combat wounds will require debridement
Other fractures open or closed
Second and third degree burns (not involving the face, hands, feet, genitalia, and perineum) covering 20% or more of
TBSA
Maxillofacial wounds without airway compromise
Genitourinary tract disruption
Minimal: GREEN
Walking wounded
Can be managed by self-aid or buddy-aid
This category is compromised of casualties with wounds that are so superficial, they require no more than cleansing,
minimal debridement under local anesthesia, administration of tetanus toxoid, and first-aid dressings
Minor lacerations, abrasions
Contusions
Sprains and strains:
Minor combat stress problems
Burns, first or second degree under 20% of TBSA and not involving critical areas such as hands, feet, face, genitalia,
or perineum
Upper extremity fractures without neurovascular compromise
Behavioral disorders or other obvious psychiatric disturbances
Suspicion of blast injury (ruptured TMs)
Symptomatic but unqualified radiation exposure
Expectant:BLACK
Unresponsive casualties with penetrating head wounds and signs of impending death
Burns, mostly third degree, covering more than 85% TBSA
Cervical (high) spinal cord injuries
Mutilating explosive wounds involving multiple anatomical sites and organs
Profound shock with multiple injuries
Agonal respirations
Convulsions and vommitting within 24 hours post-radiation exposure
Without vital signs or life
Transcranial gunshot wound (GSW)
Open pelvic injury with uncontrolled bleeding (shock with decreased mental status)
Triage categories
1. Resucitation: Immediate Resuscitation
Cardiopulmonary arrest
Respiratory failure
Status epilecticus
Unresponsiveness
2. Emergent: if not Tx'd NOW life, limb and

sight threatening (ACETAMINOPHEN OR DRUG TOXICITY OR OVERDOSAGE)
Emergent
Many interventions safe life or limb
Any altered LOC Mod-Sev dehydration
RDS Febrile infant < 3 mos
EX: Toxic ingestion, asthma distress, DKA, r/o sepsis, suspected abuse
3. Urgent: if not Tx'd in 1-2 hr potential

significant morbidity, pain
Requires intervention i.e., ABX, pain meds, sutures, wound repairs, casts
Febrile child > 3mos, minor burns, simple fractures, pneumonia, post seizures, mild-mod RDS, simple trauma
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4. Non-urgent: stable requires care in 4-6 hrs,

no risk of mortality or permanent fxn loss
URI, diaper rash, thrush, impetigo, conjunctivitis, sore throat, OM
Rheumatoid Arthritis
 RA is a chronic systemic autoimmune disorder.
 RA causes inflammation to - CONNECTIVE TISSUE, primarily in joints
 Cause of RA- UNKNOWN

 RA normal antibodies become- autoantibodies and attack host tissue
 Transformed antibodies, usually present in people with RA are called- Rheumatoid Factors
 Activation of B lymphocytes and T lymphocytes results in- increased production of rheumatoid factor and
increase and continue the inflammatory process
 RA affects more - women
 onset of RA occurs most frequently between the ages- 40-60
 Onset- insidious
 Course- generally progressive, characterized by periods of remissions and exacerbation
 PAIN AND STIFFNESS- predominant on arising, LASTING > 1HOUR occurs after prolonged inactivity
 Affected Joints- appear red hot swollen, boggy, tender to palpation
multiple joints affected in symmetric pattern
proximal interphalangeal , metacarpophalangeal, wrists, knees, ankles, toes
 the pattern of joint involvement is typically

-POLYARTICULAR (involving multiple joints) and symmetric
 deformities include:
subluxation
hallux valgus
lateral deviation of the toes
cock-up toes
 Juvenile Rheumatoid Arthritis

 chronic inflammatory autoimmune disorder diagnosed in children that is characterized by joint inflammation
resulting in decreased mobility, swelling, and pain
 types of JRA
 PAUCIARTICULAR: affects knees, ankles, elbows
 systemic: affects males and females equally, high fever, polyarthritis, rheumatoid rash
 polyarticular: 5+ joints
 Goals of RA
 RELIEVE PAIN
- reduce inflammation
- slow or stop joint damage
 Does a cure exisit?

 no cure, goal is to relieve manifestations
 Diagnostic Test
 Lab Studies
Rheumatoid Factor - 80% of patients
ESR: elevated
CBC: detect anemia
C-Reactive Protein elevated
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Serum complement
WBC up to 25,000/ul
 Pharmacologic Therapies
 NSAIDS First drug prescribed in the treatment of RA therapeutic blood level 15-30mg/dL
 Immune and inflammatory agents

Methotrexate treatment of choice
o Maybe used with Nsaids
o Gastric irritation and stomatitis are most frequent side effects but can be controlled if taken with folic acid
*Humira to reduce the inflammatory events of polyarthritis and to slow the progression of joint damage.
Given by SQ
 synovectomy: excision of synovial membrane

arthrodesis: joint fusion
arthroplasty: total joint replacement
 MANAGEMENT:
 Rest and excercise
 regular rest periods during the day are beneficial to reduce manifestations of the disease
 MOIST HEAT COMPRESS most effective
 orthotic and assistive devices
 orthotic devise
splints provide joint rest and prevent contractures
 Diagnosis
 chronic pain r/t joint inflammation
disturbed body image r/t joint deformities
activity intolerance r/t chronic pain
 Diagnostic Criteria at least 4 of seven must be present to establish diagnosis:

1. morning stiffness lasting for at least an hour and persisting at least 6 weeks
2. arthritis with swelling or effusion of three or more joints
3. arthritis of wrist, MCP, PIP joints
4. symmetric arthritis with simultaneous involvement of corresponding joints on both sides
5. rheumatoid nodules
6. positive serum rheumatoid factor
7 characteristic radiologic changes of RA noted in hands and wrist.
 Steroid therapy is usually done as part of a taper-dose treatment plan.
 Swan-neck deformity occurs at the proximal interphalangeal joint.

Gold salts can cause anaphylaxis, so monitoring is required.
 About 80% of children with JRA experience a remission with no recurrence
 The CAUSE OF RA IS UNKNOWN, but it most likely is due to a variety of unknown environmental factors,
including infectious agents and chemical exposures, all triggering an autoimmune response.
 Pannus is vascular granulation tissue composed of inflammatory cells that erodes articular cartilage and
eventually destroys bones
 Supportive, nonpharmacologic measures for the client with rheumatoid arthritis include applying splints to
treat inflamed joints, using Velcro fasteners on clothes to aid in dressing, and applying moist heat to joints to
relax muscles and relieve pain.
 NEVER MASSAGE INFLAMED JOINTS because massage can aggravate inflammation.

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 Patients are advised to AVOID REPETITIOUS MOVEMENTS.

 SITTING DURING HOUSEHOLD CHORES IS RECOMMENDED to decrease stress on joints.
 When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient
that it is most helpful to start the day with
- a warm bath followed by a short rest.
TAKING A WARM SHOWER OR BATH IS RECOMMENDED TO RELIEVE JOINT STIFFNESS, which is worse in the
morning.
OSTEOARTHRITIS
CHARACTERISTICS OF OSTEOARTHRITIS?
 -Most common arthritis

-DEGENERATIVE, chronic,NOT systemic
-stiffness in morning, after exercise
-achieness weather
-crepitus, motion
-narrowed joint space
-pain/stiffness inc w/activity dec w/rest
-mild tenderness joint area
-decrease ROM
-joint enlargement
WHICH POPULATIONS ARE AFFECTED BY OSTEOARTHRITIS?
 =<65yrs
=obesity (knees) disability in lower extremities due to effects on weight bearing joints
WHAT ARE THE TWO TYPES OF OSTEOARTHRITIS AND WHICH POPULATIONS ARE AFFECTED BY THEM?
 Primary: (idiopathic) norm aging, MOSTLY WOMEN, genetic

 -Secondary: MOSTLY MEN, pre-disposing event ex. trauma, Paget’s leads to degenerative changes
WHAT IS THE PATHOPHYSIOLOGY OF OA?
 =new tissue prod in response to joint insult and cartilage (chrondocyte) deterioration—irritates synovial
lining
-new bone formation on joint
 -cartilage becomes Fibrotic
Symptoms / Clinical Features of OA
- Pain- Worse with use (b/c these are weight bearing joints) as day progresses
- Minimal morning stiffness (<30 minutes) (morning stiffness b/c joint fluid composition changes at
night when not using joint -- should last LESS THAN 30 MIN vs. RA am stiffness)
 Signs of OA from P/E

- Pain with movement
 HOW IS OA DIAGNOSED?
-x ray showing OSTEOPHYTES and dec joint space
 WHAT IS A COMMON REGIMEN USED TO TREAT OA?

-Exercise-regular, stimulates cartilage growth, protects joints, weight bearing creates support
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WHAT IS USED TO MANAGE OA AND RHEUMATOID ARTHRITIS?
 -Pain and Inflamation relief

-Dec joint stress
-low impact exercise
-independent ADL
 Weight loss is a major factor in relieving pain from osteoarthritis.
 Exercise is a big part of the lifestyle change that’s necessary to deal with OA
 Exercises like aquatics swiming, cycling, and walking can build strength
 **HEAT OR WARM COMPRESS CAN RELAX MUSCLES AND HELP LUBRICATE JOINTS. HEAT THERAPY MAY BE
USED TO RELIEVE MUSCLE AND JOINT STIFFNESs, help warm up joints before activity, or ease a muscle spasm.
 Apply Alternating heat and cold. Some people alternate between heat and cold therapy. For example:
 FIRST : A patient may be encouraged to use heat therapy to warm up a joint(s) before physical therapy
exercise and to use cold therapy after exercise.
 A person can use heat therapy in the morning to loosen up an osteoarthritic knee and use cold therapy to reduce
swelling a few hours later. This process can be repeated throughout the day.
WHAT MEDICATIONS ARE USED TO HELP MANAGE OA AND RHEUMATOID ARTHRITIS?
 -TYLENOL for OA
-NSAIDS for rheumatoid
• Acetaminophen: first line (toxicity – give acetylcystein)
- • NSAIDs: if acetaminophen ineffective/signs of inflammation
- More effective than acetaminophen but more toxicity (GI, renal, cardiovascular)
- COX-2 inhibitors
- Tramadol- Gastric bleeding and gastric ulcers -- big problem w/ elderly pts
• Opioids for severe pain- OPIOIDS toxicity give Narcan or Naloxone Drug
WHAT ARE THE 3 MAJOR NURSING RESPONSIBILITIES WHEN CONSIDERING OA?
 -Promote Healthy Life: exercise, rest, reg meds, emotional supp

-Education: proper fit and correct use of appliance, not systemic, avoid over exertion
-Assist w/self ADL: ROM,
 WHAT ARE SURGICAL INTERVENTIONS USED TO HELP MANAGE OA?
 -Osteotomy: bone excision
-Arthrodesis: bone fusion, LAMINECTOMY
-Arthroplasty: prosthetic, knee hip
Buerger's Disease
 What is another name for Buerger's Disease? - What are other names for BUERGER'S DISEASE?
 THROMBOANGITIS OBLITERANS
INTERMITTENT CLAUDICATION
CHILLBLAINS
 ETIOLOGY of Buerger's disease is unknown.

The disease occurs exclusively in smokers
 Buerger's disease affects males only.

 Age of start of Buerger disease - 20-40 years
 Which extremities are affected by it? Lower extremities only
 Inflammation is thought to occur in the 2 layers coating arteries + arterioles.
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 The group with the highest incidence of Buerger's disease is _____. - Smokers
 Upon walking the patient with Buerger's experiences ______ ______.- Intermittent Claudication
 What is intermittent claudication? - Pain in calf upon walking
 Obstructive arterial disorder caused by segmented recurring INFLAMMATION IN THE - - ARTERIES AND VEINS
 Major cause of Buerger's Disease- MODERATE TO HEAVY SMOKING
 Patho of Buerger's Disease- Inflammation develops in small and medium arteries and veins of feet and
hands, also wrists and lower legs
 Most common symptom of Buerger's disease-
PAIN: CLAUDICATION OF ARCH OF FOOT OR LOWER CALF
 What are the SYMPTOM'S of BUERGER'S DISEASE?
 REST PAIN is an early feature & trophic changes are common
changes in skin color (definite redness or cyanosis when dependent) or temperature
Peripheral pulses are often Absent
Sensitivity to cold
Thickened Nails
Ulcers or gangrene of digits may be present
 COLD FEET (white, blue, red, tingling/prickly)

2) INTERMITTENT CLAUDICATION (cramping pain in calf/foot)
3) Progression= Pain comes sooner & subsides more slowly
4) LA REICH SYNDROME- intermittent claudication felt as cramping/aching in buttocks, implies arterial
occlusion is progressing proximally
5) COLDNESS/NUMBNESS/TINGLINGING/ BURNING even before objective evidence is seen
6) Skin of foot is COOL, THIN, INELASTIC with no hair growth on dorsum of toes
7) PITTED EDEMA (end of day)
8) NO DORSALIS PEDIS PULSE after arterial atrophy
9) GANGRENE
10) RED/TENDER spots appear over superficial veins
 #1 medical management of disease : MUST QUIT SMOKING!

 Nursing Care for Buerger's disease
prevent injury (wounds heal slowly)
Promote activity (Increase oxygenation to tissues)
Promote tissue perfusion and comfort (avoid exposure to cold)
Teach client to know signs of, thrombophlebitis: redness and heat; arterial obstruction: pallor and cold
 What is the TREATMENT for Buerger's Disease? NO specific drug
 Can ELEVATE LEGS
 What is the HOMECARE for BUERGER'S DISEASE?
COLD FOOT BATH + BUERGER'S EXERCISES
ACTINOTHERAPY (infrared or ultraviolet) can be used to keep skin healthy
What HYDROTHERAPY may you use?
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HEAT LUMBOSACRAL/GLUTES
WARM/COOL contrast to Legs and feet
DAILY COLD FOOT BATHS as with Raynaud's but stop if condition worsens
What is the REMEDIAL EXERCISE for BUERGER'S?

 SUPINE, Legs elevated to 45 degrees (2 minutes)
 SITTING, Legs over edges (3 minutes)
 SUPINE, Legs flat (2 minutes)
Repeat 4-5x/3xday
Raynaud's Disease
 Raynaud's Disease causes vasospasm which restricts blood flow to certain areas of the body.
 Most often the fingers, toes, tip of the nose and ears
 Idiopathic- the origin is unknown
 Symptoms
 cold fingers and toes in response to cold temperatures or stress with a numb, prickly or stinging feeling.
 May take more than 20 minutes for the fingers/toes to return to normal temperature.
 Sequence of color changes White to Blue to Red.
 Risk Factors
 - Primary Raynaud's disease- most common form and is NOT associated with an underlying disease or
condition.
Gender- Mostly occurs in women
Age- 15 to 30 years
Climate- More common in cold climates.
 -Secondary Reynauds-
- An Associated Disease- Most commonly scleroderma and lupus
Certain Occupations- people in occupations that cause repetitive trauma, such as workers who operate tools
that vibrate.
Exposure to certain substances- Smoking, medications that affect the blood vessels and chemicals such as
vinyl chloride.
 Oral Manifestations- experience dry mouth, mouth sores, difficulty swallowing and chewing.
 Treatment
 Exercise regularly.
 Avoid stress.
Treatment
 There is no cure for Raynaud's phenomenon
Non-Drug Treatment- Keep the hands and feet warm by wearing thick gloves and socks.
 Avoid touching cold objects.
 Run cold feet/hands under warm water to warm them.
 Avoid smoking and second-hand smoke.
 Avoid sudden changes in temperature, such as going from warm air to air conditioning
 Wear a coat, mittens and hat in cold weather (gloves allow cold air to surround fingers)
 Nursing Education
-Wear loose, warm clothing
-Wear gloves when using the refrigerator or freezer
24 |
-At all time, pt should avoid extreme temp.
-Immersing hands in warm water to decrease the vasospasm
-STOP using all TOBACCO products and avoid caffeine and vasoconstrictive drugs.
 First line drug:
> Calcium channel blockers (diltiazem (Cardizem). it relax smooth muscles of the arterioles
Surgery: SYMPATHECOMY cut the nerves in the area only in advance cases.
Diabetes Mellitus
 What are the 3 main risk factors or predispositions for DM Type 2?
 genetics
OBESITY
lack of activty
 Neuropathy is more common in DM T1
 What important GI complication can arise due to Autonomic Neuropathy? Gastroparesis
-slow stomach emptying
 What are the characteristics of Gastroparesis?
 Nausea, vomiting, bloating, loss of appetite
 How is gastroparesis managed?

 Diet: small frequent meals, low in fat and fibre
Promotility drugs: metocopramide,
Anti-nausea: Ondansetron
 BP goal in diabetic- 140/90

 What is the process behind Type 1 Diabetes?
 Destruction of the beta cells in the pancreas
 Where is insulin produced?
 Beta cells of the islets of langerhans in the pancreas
 What is the treatment for type 1 diabetes?
 Insulin - subcutaneous or an insulin pump
Short acting given after meals or in acute hyperglycaemia
Intermediate/Long acting - basal insulin/overnight control
e.g. Actrapid, Novorapid (short acting), Insulin Glargane
 Describe how type 2 diabetes is treated

 Lifestyle Management first - suggested to lose weight, cut down sugar and increase exercise
Biguanides e.g. Metformin - first line
 What are some complications of Diabetes?

Macrovascular disease --> stroke, coronary artery disease, IHD
Microvascular disease --> Retinopathy
Peripheral Neuropathy --> sock and glove distribution
Diabetic foot
Infection - serious infections such as necrotising otitis media and rhinocerebral mucormycosis
Diabetic Ketoacidosis – Kussmaul respiration
 What are the main types of anti-obesity drugs?
 Orlistat - gastric and pancreatic lipase inhibitor
causes soft fatty stools, flatulence, faecal discharge – it targets ADYPOCYTES CELlS
 What is the normal blood glucose level?
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 normally maintained at 5mmol/l
Range 3.5mmol/l - 8mmol/l
 In type 1 diabetes, fat breakdown occurs and results in - diabetic ketoacidosis (DKA)
 What are s & s of diabetic ketoacidosis DKA?
 abdominal pain, nausea, vomiting, hyperventilation, a fruity breath odor, and if left untreated, altered
LOC, coma and death
 What is DKA? - A diabetic coma
 What is the treatment for DKA?
 insulin, fluid & electrolytes as needed.
 Type 2 diabetes occurs among people who are greater than = 30 years old
 What does typically not occur in type 2 diabetes?
= DKA, because there is enough insulin to prevent the breakdown of fat
 Uncontrolled type 2 diabetes may lead to

 hyperglycemic hyperosmlar nonketonic syndrome (HHNS) sometimes seen as HHNK
 What are s & s of type 2 diabetes?
 fatigue, irritability, polyuria, polydypsia, skin wounds that heal poorly, vaginal infections, or blurred
vision.
 What is the primary treatment for type 2 diabetes?
 weight loss ( if obese)
 What enhances the effectiveness of insulin? - Exercise
 What may be added for a type 2 diabetic if exercise and diet are not successful?
 Oral antidiabetic agents or insulin thearpy
 Type two diabetics may need insulin during periods of
 stress (illness and surgery)
 When is screening for diabetes in preg. women done?
 Between the 24th and 28th weeks of gestation.
 If a preg woman has gestational diabetes it increase the risk for - hypertensive disorders
 Oral antidiabetic agents SHOULD NOT BE USED during pregnacy by the woman with gestational diabetes
Cardiac Catheterization
 Cardiac Catheterization- invasive procedure in which a long, thin, flexible tube
(catheter) is inserted into blood vessels and/ or into the heart for cardiovascular diagnosis, treatment and
monitoring
 What must a patient always do when having a cardiac cath done?
= sign a consent form
 catheter insertion site is in the = groin area
 Patient will be NPO --- after midnight
 Swan-Ganz catheter is - a catheter that monitors capillary wedge, pulmonary artery, right atrial and central
venous pressures after introduction through the jugular vein or subclavian vein
 also used to monitor cardiac output, administer drugs and monitor oxygen saturations
 Coronary angiography is one of the main uses for Cardiac Cath
 Coronary angiography - liquid contrast agent is introduced through the coronary arteries
- to evaluate stenotic lesions or malformations of the coronary arteries
 Cardiac Catheterization - to evaluate cardiac output and congenital defects such as shunts or AV
malformations
 Fick method uses oxygen concentrations in different heart chambers and analysis of gases in expired air to
determine cardiac output
 Balloon valvuloplasty to widened narrowed mitral valve
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 The major advantage to Cardiac Cath
- (gold standard for CAD)
 The left heart cath is approached via - percutaneous femoral artery or Brachial Artery with a PIGTAIL
CATHETER
 Right heart cath is approached via- percutaneous femoral vein with a SWAN GANZ CATHETER
 What is the gold standard for detecting blood clots in the lungs or PE?
- Pulmonary Angiography
 Atherectomy is used to open a partially blocked coronary artery
 What is the gold standard for determining CO with cardiac cath? - FICK
 What are the pressures in the LV and RV?

LV = 120
RV = 25
 What technique is used as a percutaneous approach in cardiac cath?
- Seldinger Technique
HEART BLOCK
 What is heart block? - SA node has trouble conducting to the ventricles
 Heart block may be delayed or blocked in the ___ - •AV node
 Causes of temporary heart block
•Myocardial ISCHEMIA
 Causes of permanent heart block

•Myocardial INFARCTION
 1st degree heart block

•All beats conducted, but delayed
•Not a true block
•PRI will be constant, but is greater than 0.20 seconds
Every QRS has a p wave
•Causes: Athletes and Digitalis

 2nd degree Heart Block
•Some beats conducted
•Intermittent block, some impulses will pass to the ventricles but not all
•Normal P waves, but some QRS's dropped
 2 types of 2nd degree Heart Block

•Type I (Wenckebach, Mobitz I)
•Type II (Mobitz II)
 3rd degree Heart Block
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 •Complete heart block

•Normal SA node function but no impulses get to ventricles
•NO BEATS CONDUCTED
 A Complete Heart Block will have no PRI because ___

- the P waves and the QRS complexes are created independent from each other
 Treatment for Heart Block
•ATROPINE
•Consider Epinephrine or Dopamine
GBS and MG
 Guillian Barre’- An immune disease that demylenates nerves.
 what kind of paralysis does Guillian Barre’ have?- Ascending paralysis
 4 Common infections for Guillian Barre’
 Campylobacter, parainfluenzae, mycoplasma, and mono
 The most prominent signs of Guillian Barre’ - Paresthesia and dysthesia
 two signs that come from apnea in GB - cyanosis and hypoxemia
 4 symptoms from both GB and MG

 anxiety, drooling, decreased speaking, decreased swallowing
 Myasthenia Gravis
 An immune system disease caused by IgG antibodies disrupting chemical transmission of ACH
neuromuscular junction
 Causes of Myasthenia Gravis - family history of autoimmune diseases
 6 signs of myasthenia gravis
 Cyanosis (severe), weakness, Respiratory failure, ptosis, diplopia, and hypoxemia
 breath sounds for both diseases - diminished, crackles, coarse/ ronchi
 Test that checks for paralysis of the diaphragm
 X-Ray outcome
 Fluoroscopy
 Another name for Fluoroscopy- SNIFF test
 PaCO2 level that indicates respiratory failure - >45
 CSF test in Guillian Barre- INCREASED PROTEIN
 Guillian Barre’ is rapid onset

 IgM level increased
 Myathenia Gravis – is slow progression and progressive fatigue
28 |
 IgG level is increased
 Ice pack test - a test used in the presence of ptosis for Myathenia Gravis patients, in order to prove the
disease
 TensiLon test- A test that uses acetylcholine esterace inhibitors(mestinon)
 Edrophonium- An acetylcholine esterace inhibitor used for the tension test. Improves muscle function for
about 10 min.
 Vital capacity that is abnormal<20mL/kg
 Normal Vital capacity65mL/kg
 If apnea continues on the BiPAP what would you move the patient to?- Mechanical ventilator
 when a patient has excessive secretions on a mechanical ventilator that are not being managed what would
you do? - tracheostomy
 therapies for Myasthenia Gravis neostigmine or immunosuppressive therapy
 Other therapy for both Guillian Barre’ and Myasthenia Gravis
 Neostigmine - an acetylcholine esterace inhibitor, long acting
Aerobic training for GBS

 Home exercise and walking
 bike training 3 times a week
exercise modalities for Myasthenia gravis

 walking overground,
 stationary bike,
 weight training,
 swimming shallow water.
Breast Cancer
 Most common cancer and second most common cause of death in adult women
 BRCA1 and BRCA2 mutations are associated with multiple / early onset breast and ovarian cancer.
Incidence:
o most common in the elderly
o 50% of all breast cancer occur in woman over the age of 65
o Risk factors include:

o increasing age
o breast cancer in first degree relatives or mother with breast cancer
o A low fiber, high fat diet
o obesity
o increases # menstrual cycles or exposure to ESTROGEN
 nulliparity
 Prevention
o smoking cessation
o alcohol cessation
o exercise
o breastfeeding
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Presentation
o asymptomatic
o breast lump
o nipple discharge
 especially bloody, unilateral
 Most often presents in upper/outer quadrant
 BSE must be in supine lying
 Physical Exam shows:

o firm immobile, painless lump
o some skin changes (redness, ulcerations, edema, nodularity)
 skin retraction indicates involvement of Cooper's ligament
o axillary lymohadenopathy in more advanced cases
o breast skin edema with dimpling (peau d' orange) is a finding with a poor prognosis
 represents obstruction of the lymphatics cancer
 Combination of the physical exam, mammography, and fine-needle aspiration biopsy is highly accurate
How can breast cancer be prevented
 Tamoxifen - ER+, increases endometrial cancers and VTE

 Raloxifene - only in post menopausal women
TMN Staging
> 5cm Stage IIB Stage IIIA Stage IIIA Stage IV
2-5 cm Stage IIA Stage IIB Stage IIIA Stage IV
< 2cm Stage I Stage IIA Stage IIIA Stage IV

Mobile axilalry Fixed axillary Distant mets (including ipsilateral supraclavicular
No nodes
nodes nodes nodes)
Types of Breast Cancer
The TNM system: Tumor, lymph nodes, metastasis
T for tumor size. The size of a tumor is rated on a scale from 0 to 4.
A T4 tumor would have grown into other neighboring tissue and is often quite large for its type.
TX: The tumor size can't be measured

T0: No primary tumor, or it can't be found
Tis: Tumor is "in situ," meaning it is small and completely contained in the tissue where it started
T1-4: The tumor is increasing in size and invading surrounding tissues and organs
N for lymph nodes.
The nearby lymph nodes are rated on a scale of 0 to 3.
A score of N0 means the lymph nodes are free of cancer.

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N1 means that a few cancer cells have reached one or more lymph nodes.
N3 means that cancer in the lymph nodes is extensive and widespread.
NX: Nearby lymph nodes can't be tested or evaluated

N0: No cancer in nearby lymph nodes, or it can't be found
N1-3: Cancer is present in an increasing number of nearby lymph nodes
M for metastasis. An M0 cancer has not spread to other parts of the body, but an M1 cancer has.
MX: It's unknown if the cancer has spread

M0: Cancer has not spread to other parts of the body, or it can't be found anywhere else
M1: Cancer has spread to one or more distant parts of the body
Treatment
 Radiation
o induction therapy can reduce the initial tumor burden prior to surgery
 Excision
 Chemotherapy
Mammogram Screening
 Highly effective screening tool except in young women
o most effective in postmenopausal patients
 All women aged 40-74 should have mammograms every 1-2 years
 Women with with first degree relatives with cancer should begin screening ten years before family
member developed cancer
 WHO PAIN LADDER ANALGESICS
MILD PAIN- nonopioids (aspirin and paracetamol);

MODERATE PAIN - mild opioids (CODEINE); dihydrocodeine or tramadol
SEVERE PAIN- strong opioids such as morphine, , diamorphine, fentanyl, buprenorphine, oxymorphone,
oxycodone, or hydromorphone
MORPHINE – analgesic of choice for pancreatitis and chole..
- Allegedly causes spasm of sphincter of oddi
 To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours
RADIOTHERAPY
 Treatment of disease by ionising radiation
 External radiotherapy- Given over 7 days
Effects of radiotherapy
 Damage to healthy cells
Tiredness = anaemia
N+V= prescribe anti emetic
Sore skin
Hair loss
Muscle and joint pain
Fertility
 External RT
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- radiation comes from outside body
- most frequent form of radiotherapy
 Brachytherapy
- radioactive sources placed precisely in area of treatment (i.e. within tumor or nearby)
Specific precautions
 time/distance/shielding); time limit, rotate, and minimize contact.
no pregnant women or children under age 18 years;
 limit visitors to 30-60 minutes/day;
 visitors should stay at least 6 feet from source
 use lead apron with dosimeter badge
 inspect linen before discarding to make sure implant/seeds have not been released; only change when soiled
 radioactive discard into an ORANGE COLOR CODED BIN
 staff must wear individual dosimeter (film) badge (no sharing) when in room; post signage on patient's door
 lead shield if close contact
 maintain bedrest, with minimal movement (e.g. cervical implant, some prostate implants); HOB no higher
than 20-30 degrees
1. avoid complete baths/complete linen change (unless soiled; may change underpad)
2. check position of source every 4 hours
3. if implant falls out:
a. do not touch with bare hands
b. call hazardous waste team, if available; if not available, USE LONG-HANDLED FORCEPS (LEAD GLOVES) &
PLACE IN LEAD CONTAINER
 do not massage radiation area; fragile skin is subject to blistering & sloughing
 advise patient to avoid wearing tight-fitting clothing or harsh fabrics (e.g. avoid wool/corduroy) over
treatment area; wear loose, light-weight clothing (e.g. cotton is best); don't scratch
 instruct patient to avoid direct sun exposure for at least one year to radiated areas; if have to, use
precautions
 avoid swimming in salt water or chlorinated water during treatment

 when does hair grow back after chemo?- 1-3 months begins;
fully grown back within 6-10 months
EMERGENT DISEASES
Anthrax
 (Splenic fever, Siberian ulcer, Charbon, Milzbrand)
 Bacillus anthracis.
 most common in wild and domestic herbivores (eg, cattle, sheep, goats, camels, antelopes)
 B anthracis spores can remain viable in soil for many years.
 Raw or poorly cooked contaminated meat is a source of infection for zoo carnivores and omnivores; anthrax
resulting from contaminated meat consumption has been reported in pigs, dogs, cats, mink, wild carnivores,
and people
 Specific diagnostic tests include bacterial culture, PCR tests, and fluorescent antibody stains to demonstrate
the agent in blood films or tissues
 Treatment
 Oxytetracycline given daily in divided doses also is effective.
 Ciprofloxacin,Amoxicillin, Gentamicin, Erythromycin Doxycycline, Streptomycin,
Modes of Transmission
1. Direct transmission – through contact with infected animals or contaminated animal products.
2. Indirect transmission – through animal bites and ingestion of contaminated meat.
32 |
3. Airborne transmission – through inhalation of contaminated or polluted air.
Diagnostic Evaluation
1. Nasal swab testing
Pharmacologic Interventions
- Antibiotic prophylaxis after exposure 60 days therapy is advised.
 Ciprofloxacin 500 mg bid for adults
 Doxycycline 100 mg bid
 Amoxicillin 500 mg bid for adults;
Complications
1. Antrax meningitis
2. Anthrax sepsis
Nursing Interventions
Priority : airway
1. Auscultate chest for crackles, indicating need for better secretion mobilization.
2. Monitor oxygen saturation and abg
3. Monitor level of consciousness and for meningeal signs such as nuchial rigidity.
4. Provide supplemental oxygen or mechanical ventilation, as needed.
5. Position for maximum chest expansion and reposition frequently to mobilize secretions.
6. Suction frequently and provide chest physiotherapy to clear airways, prevent atelectasis, and maximize
oxygen therapy.
Middle East respiratory syndrome coronavirus (MERS-CoV)

- CAMEL FLU or SARS of MIDDLE EAST
 a viral respiratory disease caused by a novel coronavirus (MERS‐CoV) that was first identified in Saudi Arabia
in 2012.
 1st case - april 2012
2nd case - sept. 2012
 1st Outbreak
- SAUDI ARABIAN PENINSULA
 MERS COV IS A CLADES "B" VIRUS
 Republic of South Korea is the largest outbreak outside of the Middle East year 2015
 Source of the virus
originated in bats and was transmitted to camels sometime in the distant past.
 camels - major reservoir host for MERS-CoV and an animal source of MERS infection in humans
 Where is the virus thought to have come from?

 Thought to have originated from bats, due to the high degree of adaptive evolution within their DPP4 gene.
 Host- humans, camels, maybe bats
 Distribution- Middle East, esp. Saudi Arabia.
Transmission- human-to-human contact

 Highest Risk : IMMUNOSUPRESSION (CANCER)
 Symptoms- Mild-severe respiratory illness
Gastrointestinal symptoms
Complications-pneumonia, kidney failure
33 |
 Is person to person transmission possible?

- Only if in close personal contact.
 What is a 'Silent Mers CoV' case? How frequent are these cases?
 An asymptomatic sufferer who carries Mers CoV antibodies within their bloodstream. It is estimated to occur
in 20% of cases.
 Timeline of current outbreak?

 2012 outbreak in Saudi Arabia. Bat -> Camel -> Human. Man consumed milk/meat of infected camel.
 Signs and symptoms

A- airway problems
B- breathing difficulty
C- cough and colds
D- diarrhea
E- elevated temperature
 Treatment: No specific treatment
 No vaccine or specific treatment is currently available.
 avoid contact with camels, drinking raw camel milk or camel urine, or eating meat that has not been
properly cooked.
 Avoid contact to camel droplets
 Cover your nose and mouth with a tissue when you cough or sneeze, then throw the tissue in the trash.
 Avoid touching your eyes, nose and mouth with unwashed hands.
 Avoid personal contact, such as kissing, or sharing cups or eating utensils, with sick people.
 Severe Acute Respiratory Syndrome (SARS) is an acute respiratory illness caused by infection with the SARS
virus.
 Fever followed by a rapidly progressive respiratory compromise is the key complex of signs and symptoms,
which also include chills, muscular aches, headache and loss of appetite.
 greater than 50% in persons aged 65 years and older (WHO Update ). – mostly affected
 The etiologic agent of SARS is a coronavirus which was identified in March 2003. The initial clusters of
cases in hotel and apartment buildings in Hong Kong
 Attack rates in excess of 50% have been reported.
 virus is predominantly spread by droplets or by direct and indirect contact. Shedding in feces and urine also
occurs.
 Medical personnel, physicians, nurses, and hospital workers are among those commonly infected.
 NO drugs or a vaccine for SARS,
 control of this disease relies on the rapid identification of cases and their appropriate management, including
the isolation of suspect and probable cases and the management of their close contacts.
 Supportive care is of primary importance. Immunomodulation by steroid treatment may be important
 The SARS outbreak of 2003
 Symptoms of SARS
 SARS begins with a high fever (temperature greater than 100.4°F [>38.0°C]).
 headache, an overall feeling of discomfort, and body aches.
 Some people also have mild respiratory symptoms at the outset. About 10 percent to 20 percent of patients
have diarrhea.
 After 2 to 7 days, SARS patients may develop a dry cough. Most patients develop pneumonia.
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Avian flu – bird flu
 H5N1 – MOST DEADLIEST strain
 Avian influenza is flu infection in birds.
 The virus that causes the bird infection can change (mutate) to infect humans.
 A (H5N1) virus - Highly pathogenic influenza virus , primarily from bird to human transmission
- The first avian influenza virus to infect humans occurred in Hong Kong in 1997.
- The epidemic was linked to chickens and classified as avian influenza A (H5N1).
- Human cases of avian influenza A (H5N1) have since been reported in Asia, Africa, Europe,
Indonesia, Vietnam, the Pacific, and the near East.
 - Hundreds of people have become sick with this virus. Slightly more than 60% of those who became ill have
died.
H5N1 - Risk Factors

 higher risk for developing the bird flu:
• Farmers and others who work with poultry
• Travelers visiting affected countries
• Those who touch an infected bird
• Those who eat raw or undercooked poultry meat, eggs, or blood from infected birds
- Health care workers and household contacts of patients with avian influenza may also be at an increased
risk of the bird flu.
 - The avian flu virus (H5N1) has been shown to survive in the environment for long periods of time.
- Infection may be spread simply by touching contaminated surfaces.
- Birds who were infected with this flu can continue to release the virus in their feces and saliva for as long
as 10 days.
H5N1 virus in humans causes typical flu-like symptoms, which might include:
• Cough (dry or productive)
• Diarrhea
• Difficulty breathing
• Fever greater than 100.4°F (38°C)
• Headache
• Malaise
• Muscle aches
• Runny nose
• Sore throat
 H5N1 - Tests
- A test for diagnosing strains of bird flu in people suspected of having the virus gives preliminary results
within 4 hours.
 Your doctor might also perform the following tests:
• Auscultation (to detect abnormal breath sounds)
• Chest x-ray
• Nasopharyngeal culture
• White blood cell differential
 - antiviral medication oseltamivir (Tamiflu) or zanamivir (Relenza) may make the disease less severe if you
start taking the medicine WITHIN 48 HOURS AFTER your symptoms start.
 - Oseltamivir may also be prescribed for persons who live in the same house as those diagnosed with avian
flu.
- human avian flu appears to be resistant to the antiviral medicines amantadine andrimantadine. Therefore
these medications should not be used if an H5N1 outbreak occurs
H5N1 - Prognosis
 depends on the severity of infection and the type of avian influenza virus that caused it. Death is possible.
 Complications
• Acute respiratory distress
• Organ failure
35 |
• Pneumonia
• Sepsis
 Vaccine (only available from U.S. government's supply)
 Nursing Considerations-Nursing Interventions

 Give oseltamivir as ordered and give other medications as directed.
 If administering zanamivir or peramivir, administer I.V. and ensure patent I.V. access.
 Follow standard and droplet precautions; N-95 masks are recommended.
 Administer oxygen therapy based on oxygen saturation levels via pulse oximetry or arterial blood gases, if
warranted.
 Auscultate lung sounds for changes.
 Anticipate the need for endotracheal intubation and use of mechanical ventilation if pulmonary status
deteriorates.
 Elevate the head of the bed to facilitate chest expansion and ease the work of breathing.
 Encourage meticulous respiratory hygiene measures.
 Encourage adequate fluid intake.
 Encourage deep breathing, coughing, and pulmonary hygiene.
2017 outbreak in the Philipines: Region 3- Central Luzon
San Luis Pampanga And San Isidro And Jaen Nueva Ecija
AH5N6 – identified strain in Philippines
AH7N9- Identified strain in china 18 cases with 6 deaths
First Aid?
– The immediate care given to an injured or suddenly ill person. ------(CBQ)
– Legal Considerations
• Implied Consent
• Scene Survey- only take a few seconds. (10 seconds)
PRIORITY:
A = Airway Open? – Head-tilt/Chin-lift.
B = Breathing? – Look, listen, and feel.
C = Circulation? – Check for signs of circulation.
Unconscious Victim
Poisoning: First aid

Take the following actions until help arrives:
 Swallowed poison. Remove anything remaining in the person's mouth.
 If the suspected poison is a household cleaner or other chemical, read the container's label and follow
instructions for accidental poisoning.
 Poison on the skin. Remove any contaminated clothing using gloves. Rinse the skin for 15 to 20 minutes in a
shower or with a hose.
 Poison in the eye. Gently flush the eye with cool or lukewarm water for 20 minutes or until help arrives.
 Inhaled poison. Get the person into fresh air as soon as possible.
 Have somebody gather pill bottles, packages or containers with labels, and any other information about the
poison to send along with the ambulance team.
Caution
 Syrup of ipecac. Don't give syrup of ipecac or do anything to induce vomiting.

 Button batteries. The small, flat batteries used in watches and other electronics — particularly the larger,
nickel-sized ones — are especially dangerous to small children. A battery stuck in the esophagus can cause
severe burns in as little as 2 hours.
For corrosive poisoning substance – NEVER INDUCE VOMITING!!
ANAPHYLAXIS to stings or allergen injections is usually rapid: 70% begin in < 20 minutes and 90% in < 40 minutes.
Food/ingestant anaphylaxis may have slower onset or slow progression. Rapid onset
36 |
initial priority intervention is to inject IM epinephrine to reverse cardiovascular and respiratory effect of
anaphylaxis
Epinephrine is the first line treatment because it can relieve bronchospasm of the airway..
What are the main types of food allergies?

Shellfish
Fish
Peanuts
Tree Nuts
Explain insect stings and anaphylaxis?

Many times those individuals who have not had a previous reaction will have a reaction upon a second sting.
What are the distinct families of stinging insects?
Bees (honeybees, bumblebees)
Vespids (yellow jackets, hornets, wasps)
Stinging ants
- 50% recurrence of sting
Perioperative Nursing
.
SURGEON - A physician who treats disease, injury, or deformity by operative or manual methods.
*
STERILIZATION
-the destruction of all living microorganisms, as pathogenic bacteria, vegetative forms, and spores.
BACTERIOSTATIC -Capable of inhibiting the growth or reproduction of bacteria.
Perioperative Nursing
Phases
 Preoperative phase – begins when the decision to have surgery is made and ends when the client is
transferred to the OR table.
 Intraoperative phase – begins when the client is transferred to the OR table and ends when the client is
admitted to the PACU.
 Postoperative phase – begins with the admission of the client to the PACU and ends when the healing is
complete.
CLASSIFICATIONS OF SURGERY
According to Urgency :
EMERGENT – patient requires immediate attention ; disorder maybe life- threatening.
URGENT – patient requires prompt attention.
> indications for surgery : within 24-30 hours.
REQUIRED – patient needs to have surgery.
> indications for surgery: plan within few weeks or months.
PROBLEMS THAT MAY ARISE IN SURGERY:

 Surgical risk pts – probability of mortality
 Pain
 Hemorrhage
 Infection
37 |
 UTI
INFORMED CONSENT is necessary in the ff. Circumstances:

- Invasive procedures
- Procedures requiring sedation or anesthesia
- A non-surgical procedure
- Procedures involving radiation
- Adult client (over 18 y/o) signs own permit unless unconcious or mentally incompetent.
- Consents are not needed for emergency care if all 4 of the ff. criteria are met:
- There is an immediate threat to life.
- Experts agree that it is an emergency.
- Client is unable to consent.
- A legally authorized person cannot be reached.
*Minors (under 18 y/o) must have consent signed by an adult (i.e. Parent or legal guardian)
*Able to read and understand cannot write- sign with” X” by patient
NURSING ACTIVITIES:
 Activities providing for pt’s safety.
 Maintenance of aseptic environment.
 Ensuring proper function of equipments.
 Providing surgeons with specific instruments & supplies for surgical field.
 Completing documentation.
 Positioning pts.
 Acting as scrub/circulating nurse.
Members of the Surgical Team

 Patient
 Anesthesiologist or anesthetist
 Surgeon
 Nurses (Scrub & Circulating)
 Surgical technologists
PATIENT
- the most important member of the surgical team.
-
OPERATING SURGEON
- Captain of the ship
- performance of operation.
- post-op mgt & care
- endorsement to PACU with Anesthesiologist
SURGEON & ASSISTANTS

- scrub & perform the surgery.
ANESTHESIOLOGIST / NURSE ANESTHETIST

- administers the anesthetic agent & monitors the pt’s physical status throughout the surgery.
- Little angel of the team
SCRUB NURSE
- provides sterile instruments & supplies to the surgeon during the procedure.
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- performs surgical hand scrub.
CIRCULATING NURSE
- coordinates the care of the pt. in the O.R.
- care provided includes assisting with pt. positioning , skin prep, managing surgical specimens & documenting
intraoperative events.
THE OPERATING ROOM

Basic Guidelines for Surgical Asepsis
- All materials in contact with the wound and within the sterile field must be sterile.
- Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above
the elbow to the cuff.
- Only the top of a draped table is considered sterile. During draping, the drape is held well above the area
and is placed from front to back.
- Items are dispensed by methods to preserve sterility.
- Movements of the surgical team are from sterile to sterile and from unsterile to sterile only.
- Movement around the sterile field must not cause contamination of the field. At least a 1-foot distance from
the sterile field must be maintained.
- Whenever a sterile barrier is breached, the area is considered contaminated.
- Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered
unsterile.
- Sterile fields are prepared as close as possible to time of use.
Dehiscence
 Partial or complete separation of the outer layer of the wound.
Possible causes:
 Poor suturing technique
 Distention
 Excessive vomiting
 Excessive coughing
 Dehydration
 Infection
Evisceration
 Total separation of the layers & protrusion of internal organs or viscera through the open wound.
Causes: same as dehiscence
 Treatment:
 Call for help
 Cover with sterile NS soaked gauze/towels
 Keep moist
 DO NOT ATTEMPT TO REINSERT ORGANS.
 Keep in supine position with knees/hips bent
 Assessment/VS q 5 min. until MD arrive
 Prepare for surgery.
Gerontologic considerations
 Mental status- attributed to medications, pain, anxiety, depression.
 Delirium- infection, malignancy, trauma, MI, CHF, opioid use.
 Dementia-sundowning-sleep disturbances, lack of structure in the afternoon or early morning, sleep apnea.
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NP3-4 part 3
I. BLOOD TRANSFUSION
Which blood group type is the universal donor?

= Type O negative
Which blood group type is the universal receiver?

= Type AB positive
Patient can donate 1 to 5 units of their own blood up to = 5 weeks before surgery.
For how long should whole blood transfuse?

over = 3-4 hours
For how long should packed blood transfuse?

over = 2 hours
What is the volume of 1 unit of whole blood?

= 500 mL
What is the volume of 1 unit of packed blood?

= 300 mL
What must be OBTAINED PRIOR to administering blood products?

= Informed consent
Observe AUTONOMY PRINCIPLE especially if client refuse treatment procedure
Who will administer blood products?

- RN
What needle gauges may be used for blood transfusion?

= 18 or 19 gauge needle is preferred.
= 22 or 23 gauge may be used FOR CHILDREN or an adult w/ inaccessible veins.
For blood transfusions, what should the tubing have?

= an in-line filter
What should be done at the beginning and end of the blood transfusion?
- Start and end the blood transfusion with
*Normal Saline to prevent RBC hemolysis
What is important about priming the tubing for a blood transfusion?

= Prime with Normal Saline (PNSS)
What is important to remember about adding medications during a blood transfusion?

= never add medications to the line UNLESS flushed with Normal Saline first
Prior to administration, blood products must be checked by:

= 2 RN's (or an RN and a doctor, etc.)
How soon should a blood transfusion begin?

= Begin within 15-30 minutes after receiving blood from the lab
What should the nurse do when he sees gas bubbles in the blood product bag?
= return the bag to the blood bank
How soon must blood be transfused after spiking?

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= within 4 hours of spiking
During the first 15 minutes, the blood product must be administered at what type of rate?
= At slow rate, 10-24 mL should infuse in adult. = Can also go by 10-15 drops/minute for 1st 10 minutes
During the first 15 minutes, how much should have infused in children?
= no more than a fifth (1/5) of total volume
How often do you monitor vitals during a blood transfusion?

= Get vitals before starting
= then close monitor for 5-15 minutes, then every 15 minutes for 2 hours, and then every 30 minutes for the
remainder of the infusion
What can you dispose the bag and tubing in?

= biohazard waste container
shaRp needles disposal- RED color coded bin
Your patient develops a transfusion reaction reaction during the infusion. What do you do?
- First, stop the transfusion & maintain IV access to FLUSH PNSS;
- monitor vitals;
- perform clerical check of labels, forms & patient identification;
- report reaction to the physician & blood bank personnel;
- draw a post-transfusion sample & urine sample and send it along w/ the unused product to the blood bank;
- treat symptoms per order;
complete transfusion reaction report per agency policy;
and document on the client's chart.
Documentation of a blood transfusion should include:

physician order,
indication for transfusion,
informed patient consent,
patient identification checks,
patient monitoring during transfusion,
assessment of client outcome,
applicable lab or clinical results before & after transfusion
What are the different blood transfusion reactions?

Allergic reaction,
anaphylactic shock,
acute hemolytic transfusion reaction,
febrile non-hemolytic transfusion reaction,
septic transfusion reaction,
and circulatory overload.
What should a nurse know about allergic reaction to a blood transfusion?

Most common type of reaction;
occurs when body reacts to plasma protein in the blood product;
S&S include flushing, itching, hives;
Pre-medicate with antihistamine per order;
if it occurs, stop infusion & give diphenhydramine (Benadryl);
you may restart infusion per order if reaction is mild.
What should a nurse know about ANAPHYLACTIC SHOCK due to a blood transfusion?
= Occurs immediately after a few mL's of transfusion;
S&S include anxiety,URTICARIA, wheezing, respiratory distress, N/V, diarrhea, cramping, shock, cardiac arrest;
= Treatment is to stop transfusion,
= have EPINEPHRINE ready
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= initiate CPR,
= notify health care provider & blood bank, start an IV of normal saline, and monitor vitals.
What should a nurse know about acute hemolytic transfusion reaction to a blood transfusion?
= the most SERIOUS KIND of reaction;
= it is acute, within 5-15 minutes, or delayed, in days or weeks;
= occurs most frequently due to ABO incompatible error;
S&S include fever & chills, chest constriction, dyspnea, LOW BACK PAIN & HYPOTENSION;
- reveals evidence of hemolysis & urine sample will show hemoglobinuria.
= Treatment is to stop transfusion;

maintain IV access flushed with PNSS;
send blood products & tubing
BT- Nursing Interventions
Steps:
 Verify doctor’s order. Inform the client and explain the purpose of the procedure.
 Check for cross matching and bloodtyping. To ensure compatibility
 ALWAYS ensure patency of IV line prior to obtaining blood from the lab.
 Obtain blood product from the blood bank promptly.
 Visually inspect the blood for clots, sediment, or bubbles.
 Confirm the patient’s ID with two identifiers (2 RN) and ensure that the consent is signed, if required by your
facility.
 Perform hand hygiene and put on clean gloves.
 Obtain baseline vital signs. Pre-existing fever should be reported to the provider prior to proceeding with
transfusion.
 Two RNs (one of whom will administer the blood product, though this policy may vary) must confirm the
following on the blood unit, lab paperwork, and the blood ID band at the bedside: blood unit ID number or
derial number, blood ABO and Rh type, unit expiration date, unit unique identifier (a code), and patient’s
name and DOB confirmed with the ID band.
 Close ALL clamps on Y set tubing. Hang 0.9 % NS. Note: Only isotonic electrolyte solutions are approved
from blood administration. Dextrose will hemolyze RBCs and the calcium in Lactated Ringers will cause
CLOTTING.
 Prime Up: Spike the normal saline with one short end of the Y tubing and open the clamps on both of the
shorter Y ends set to prime them. The descending tubing clamp remains closed.
 Prime Down: With NS clamp still open, now close the clamp on the other short end of the Y set and open
main (descending tubing) clamp to prime the rest of tubing with NS.
 Close all clamps.
 Gently agitate blood bag (suspends the blood cells). Pull back the tabs on blood bag ports to expose them.
 Prime Blood: Main tubing and NS Y arm clamps remain closed. Spike the blood bag with the free short end of
the Y tubing and open the corresponding clamp to allow blood to flow down and prime the filter with blood.
Note: The filter is housed in a large round or cylindrical drip chamber that lies below the Y set connection. It
is necessary to allow blood into this drip chamber until the filter is completely submerged in the blood. It is
best to allow a little air to remain at the very top of the drip chamber to allow you to observe the drip rate.
 Load tubing into the infusion pump, if used.
 Prep injection port per facility policy, and connect the tubing to patient.
 Open main clamp and begin infusion via pump or gravity. Begin the transfusion slowly, rate of 2 mL/minute
for the first 15 minutes (100 mL/hour). In most cases, the rate should not exceed 2-4 mL/kg/hr.
 Stay with the patient for the first 15 minutes and assess vital signs at 15 minutes and again at 30 minutes.
Follow institutional guidelines for monitoring vital signs for the remainder of the transfusion. Most severe
reactions occur in the first 15 minutes or 50 mL of the transfusion. Watch for pain near the insertion site,
backache, fever, chills, itching, hives, dyspnea, or unusual complaints from the patient.
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 Administer blood at prescribed rate but continue to monitor for signs of hemolytic reaction or fluid overload.
A rise of 1 degree C (2 degrees F) warrants reporting to the provider.
 Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse
quickly (20 minutes) clotting factor can easily be destroyed.
 From the time a unit of blood is spiked, the infusion should take a maximum of 4 hours.
 Each unit of plasma or platelets should be administered over 30-60 minutes.
 In addition, the tubing/administration set should be changed with each unit of blood, or at the end of 4
hours. This reduces the risk for bacterial contamination.
II. Traffic signs - Road rules - Safety & rules:
HOSPITAL SIGN - color code is BLUE

Blue road signs are classified as general services signs. Hospital signs alert drivers that a hospital is near and directs
them using arrows. The Hospital Sign shown above has an arrow pointing to the right, indicating that the hospital is
up ahead on the right.
KEEP RIGHT road signs or right way sign in hospital
A Keep Right of Divider sign warns drivers that they will be approaching a traffic island or highway divider up
ahead.
- to prevent traffic congestion in the line and not to delay any emergency services going to or out of the hospitals.
III. Ebola Virus Disease

Other Names: Viral Hemorrhagic Fever (Filovirus)
- Ebola virus is a hemorrhagic fever that is a severe, viral, zoonotic disease seen in human and nonhuman primates
(monkeys, gorillas, and chimpanzees)
The name "Ebola virus" is derived from the Ebola River—a river that was at first thought to be in close proximity to
the area in Democratic Republic of Congo
Family: filovirus
Country (origin): Africa- ebola zaire virus strain & Philippines- ebola reston virus strain
Ebola Zaire - 1st recorded outbreak: 1976 (6/27/1976) - first identified case
location: kikwit, zaire
infects: humans/ deadly to humans
fatality rate: 75-90%
- responsible for the largest number of outbreaks
- most fatal and deadliest strain
- most dangerous
TRANSMISSION
-CONTACT with body fluids: sweat, tears, blood, semen, breastmilk, mucus secretions, urine, feces
-air transmission is IMPOSSIBLE
You CAN'T get Ebola from air, water, or food.

A person who has Ebola but has no symptoms can't spread the disease.
SYMPTOMS
hemmorhagic fever:
-flu like symptoms: fever, headache, muschle ache, nausea, vomitting
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1-2 days later:
-respiratory/ kidney problems, massive hemorrhaging (from every orifice of the body)
symptoms cont
-blood clots in response to hemorrhaging
-internal organs destroyed
10 days later: death
-Hemorrhagic manifestations
- severe febrile illness, headache, chest pains, epitaxis, dysentery
-Classical appearance: deep-set eyes, ghost-like, expressionless face and extreme lethargy along with a stooped walk
and extreme cachexia (WHO)
Reservoir
-is the reservoir in the african rainforest or the african savannah?
- evidence links 3 species of fruit bat to ebola virus
treatment - NO KNOWN CURE

-supportive therapy
-passive artificial immunity
-donor serum given to recipient patient
EBOLA RESTON
1st recorded case: 1989
location: reston, virginia
- infects monkeys imported from MINDANAO PHILIPPINES
- apparently harmless to humans
fatality rate: 95% of monkeys
transmission of ebola REston
-RESTON is by contact with body fluids
-RESTON is air borne
deadly to monkeys
Viral Hemorrhagic Fever is highly contagious and spread by?

- Bodily fluids
2014 West Africa Ebola outbreak was caused by what ebolavirus species?
- Zaire virus
Largest and most recent outbreak in 2014

- West Africa
Ebola virus is a ______ virus. (spread through animal reservoirs)

- Zoonotic
What is the MOST LIKELY RESERVOIR of the Ebola virus?

- Bats
An event from infected wild animals to humans, followed by human-human transmission

- called as Spillover
Virus present in high quantity in _______, _______ and _______ of symptomatic EVD-infected patients
 Blood
 Body fluids
 Excreta
(4)Opportunities for human-to-human transmission

-Blood-Direct contact
-Sharp injury
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-Direct contact with the corpse of a person who dies of EVD
-Indirect contact with an EVD-infected patient's blood or body fluids via a contaminated object
Can be transmitted via contact with

-Fluids
-Meat of an infected animal (BUSHMEATS)
close contact with the blood, secretions, organs or other bodily fluids of infected animals such as gorilla, monkeys
chimpanzees, , fruit bats, , forest antelope and porcupines found ill or dead or in the rainforest.
Ebola Virus Pathogenesis

-Direct infection of tissues
-Immune dysregulation
-Hypovolemia and vascular collapse
-Disseminated intravascular coagulation (DIC) and coagulopathy
Progression of Ebola
-Convalescence- prolonged, marked by weakness, fatigue, arthralgia and failure to regain weight
-Extensive skin sloughing, hair loss and neuro-psychiatric illness
Examples of hemorrhagic signs (3)

-Hematemesis
-Bleeding at IV site
-Gingival bleeding
How is Ebola Diagnosed?

- ELISA
How is Ebola treated?

There's no cure for Ebola
How can you prevent Ebola

There's no vaccine to prevent Ebola.
The best way to avoid catching the disease is by not traveling to areas where the virus is found.
Health care workers can prevent infection by Hanswashing and PPE wearing masks, gloves, and goggles whenever
they come into contact with people who may have Ebola.
Nursing Considerations-Nursing Interventions

Enforce strict isolation.
Maintain contact and droplet precautions for the duration of the illness.
Provide emotional support; encourage the patient to verbalize fears and concerns, especially since the prognosis is
poor and recovery is slow.
Enlist the aid of social services or pastoral care to assist with support.
Give prescribed I.V. solutions and blood products.
Institute safety precautions to prevent injury.
Perform meticulous pulmonary hygiene measures.
Obtain daily weights.
Institute energy conservation measures; cluster nursing care activities to promote rest periods.
Encourage adequate nutritional intake
- advise to avoid Burial ceremonies, sex for 3 months (use condom) and semen analysis
after 12 months
- successfully treated person may have an immunity up to 10 years.
IV. HIV- AIDS

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Which body fluids contains HIV?

 Semen
 Blood plasma
 pre-ejaculate
 Menstruation
 Vaginal secretions
 Breast milk
 Bile
What is the hierarchy of risk?

1. Anal
2. Vaginal
3. Oral
The risk of HIV acquisition higher for the receptive partner?
What are the sexual behavioral factors for HIV transmission?

 Number of partners
 Risky lifestyle (IVDrugUsers, bisexual)
 Type and frequency of sex
 Use of condoms and other barrier methods
 Drug use
 Perception of HIV transmission risk
Why is anal sex the most dangerous?

- because rectal tissues can easily tear and bruise
Why can sharing used needles transmit HIV?

- because contaminated blood is injected directly into that person's bloodstream
An infected mother has a ____% chance of transmitting HIV to the unborn child.
- % 30
What 3 ways can HIV be transmitted from mother to child?

- development, birth, breast milk (VERTICAL TRANSMISSION)
What percentage of infants actually has HIV?

- 30%
Why does only 30% of infants actually have HIV?
- because the maternal antibodies disappear at about 15-18 months
What are some ways that HIV NOT transmitted?

- air, water, food, skin contact, sharing eating utensils, door knobs, mosquitoes, donating blood, bathrooms,
sneezing, kissing, being around someone who is infected
what fluids contain the virus?

-blood- high levels
-semen- high levels
-breast milk
-vaginal secretions- moderate/high levels
-rectal secretions- moderate levels
Note: -sperm- HIV can't infect sperm (sperm donors ok?)
TRANSMISSION CATEGORIES
-male to male sexual contact (MSM)
-intravenous drug users (IDU)
46 |
-heterosexual
-male-to-male and IDU (M2M)
FOR HIV DIAGNOSIS

-largest percentage is for BLACK/AFRICAN AMERICAN
-males--to date, the largest affected groups are BLACK/african american
-females--to date, the largest affected group is BLACK/african american
3 types of global patterns of HIV transmission

1. in wealthy countries
-most involve male-to-male sexual transmission
-after a period of decline, now showing signs of resurgence- due largely to unsafe sexual practices
2. sub-saharan africa and latin america
-mostly heterosexual transmission
(worldwide, highest frequency of HIV transmission is among heterosexuals)
3 global patterns
-needle sharing among intravenous drug users (IDU)
--very efficient way of transmitting HIV
--outside of sub-saharan africa, 1/3 of all HIV infections stem from IDU
--greatest problem seen in newly independent states, eastern europe, and china
UN-AIDS number 1 country is the PHILIPPINES
ROUTES OF TRANSMISSION
-sexual contact
-needles and syringes
-blood transfusions/organ donation
-mother-to-child (MTC)
sexual contact, vaginal sex (no drug treatment)
it's easier for an HIV+ male to infect his HIV- female partner than vise versa
why?
-more surface area in vaginal tract
-minor tears in the vaginal lining
-vaginal lining contains certain cell types that HIV can easily enter
-semen remains in vaginal tract for prolonged period of time
sexual contact, anal sex (men)
highest risk- RECEPTIVE ANAL INTERCOURSE, injection drug use
risky- insertive anal sex, vaginal sex
less risky- oral sex
low risk- rimming (oral-anal sex), fisting (inserting hand into anus or vagina)
very low risk- mutual masturbation, shared sex toys, deep kissing
absolutely safe- self masturbation, abstinence
-3 MODES OF TRANSMISSION
--during pregnancy, during birth, via breastfeeding
--about 50% occur during the final months of pregnancy
--about 50% occur during the birthing process and the early months of breastfeeding
-w/o mediacation, overall rate varies from 25-50%
-debate about whether HIV or HIV infected cells are responsible via breast milk
What race in the united States has the highest rate of HIV infection?
African American
47 |
What are primary prevention efforts?
 Abstinence
 Monogomaous relationship
 Condom usage
 Sterile Needles
HAART means
- Highly active antiretroviral therapy (using multiple drugs)
Below 200 CD4/mm^3, what develops?

- Wasting of HIV
Drug treatment for HIV wasting

- magestrol acetate
- Megestrol acetate (MGA), Megace , is a progestin medication which is used mainly as an appetite stimulant to
treat wasting syndromes such as cachexia
What are some problems with the treatment of HIV/AIDS?

-STIGMA of the disease
-Side effects
-Compliance
-Resistance
-Cost
What is the prophylaxis drug called?

- combination of 2 or 3 ART - Tenofovir + emtricitabine (Tuvada or descovy)
Who might be considered for pre-exposure prophylaxis?

- MSM with high risk sexual activity
- Heterosexuals with multiple partners in areas of high HIV risk
- partners of people with HIV (who have high viral loads)
- IVDU
HIV: What happens at the cellular level?

-retrovirus infects the T helper cells that express CD4 (captains) on their cells
-HIV replicates and lies dormant until the host cell activates an immune response
- -inactive B cell antibodies are produced
HIV antibody is produced between 4-6 weeks course of the disease

(can be detected 6w-6m after initial exposure)
Acute Retroviral Syndrome

-AKA: Primary HIV Infection
-period of time between initial exposure to the virus and the appearance of HIV antibodies
-6w-6m period, HIV replication is rapid
-Immune system produces HIV antibodies
-Flu-like S/S develop days to weeks within HIV exposure, lasting a few days to several months
Seroconversion Completion
-flu like symptoms resolve
-viral load decreases to normal
Seroconversion: specific antibodies become detectable in the blood, 6w-6m after onset of
Diagnostic test:
Finger Stick Tests
48 |
OraQuick Rapid HIV-1 Antibody Test: results in 20 minutes, 99% accurate
Uni-Gold Recombigen: results in 10 minutes, 100% accuracy
Oral Mucosa Swab

OraQuick Rapid HIV-1/2 Antibody Test: results in 20 minutes, 99% accuracy
ELISA
-initial blood test
-screens for antibodies, not HIV virus
-performed after oral or finger stick tests
-99.5% accurate when pt waits 12 weeks before testing
-if + will do western blod test
Western Blot Antibody Test -CONFIRMATORY

-when combined with ELISA, 99.9% accurate
HIV viral load test

-recommended every 3-6months once HIV+
CD4 Count
-recommended every 3-6 months once HIV
Initial/Stage 1: S/S
-flu like
-weight loss
-mono s/s
-few days to few weeks
-unsuspected pt has HIV
-"in storage" virus
-virus clusters in lymph node, low in blood stream
-inner fighting
-8-10 years mean sverage
-CD4 cells decrease, seroconversion taking place
2ND STAGE - SYMPTOMATIC STAGE - CD4 < 800 (500-799)
3rd Stage: S/S - CD4 < 500 (200-499)
-"opportunistic infections"- things most people wouldnt get with normal immunity
-CD4 cells depleting
-virus raging in blood
-2-3 years avg
4th Stage/ AIDS TRANSFORMATION: S/S

-helper T cells <200
-death in approximately 1 year
AIDS: Diagnosis Criteria
1.) HIV positive and CD4 cell count <200.... -OR-
2.) HIV positive and AIDS defining illness
49 |
Pneumocystis Carinii Pneumonia AND PTB

most common opportunistic infection
-CD4 <200
Pneumocystis Carinii Pneumonia S/S

-cough
-fever
-SOB
-tachypnea
-tachycardia
Pneumocystis Carinii Pneumonia: Tx

-antibiotics
-bactrim
-septra
*toxic to liver and kidneys
Herpes Simplex
-Opportunitic infection
-CD4 <100
-present with cold sores, genital sores to extreme degree
Toxoplasmosis: Effects, Tx
-airborne parasite
-imbeds in brain, decreases cerebral perfusion, leads to encephalitis
-tx: sulfa drugs
Cytomegalovirus
CMV, effects eyes and variable parts of body
-CD4 <50
Candidiasis
-oportunistic infection
-oral thrush, vaginal thrush
-often first indicator of progression to AIDs
Secondary Cancer
-immunity declines= higher risk for cancers
-kaposis sarcoma
-non-hodgkins lymphoma
-primary lymphoma of the brain
-invasive cervical cancer
Kaposis Sarcoma
-mainly effects homosexual men with AIDs
-often presenting symptoms of AIDs
-tumor of endothelial cells lining small blood vessels
v. 5 stages of grief
Loss- experience of parting with an object, person, belief, or relationship that one values
50 |
Five Stages of Grief
Denial, Anger, Bargaining, Depression, Acceptance
Who invented the five stages of grief?

- Kubler-Ross
Denial
- The person has thoughts that helps them reject the experience.
Anger
- Feels a generalized rage at the world for allowing something like this to happen.
Bargaining
- Feel guilty, that it's their responsibility to fix the problems.
Depression
- the dying person begins to understand the certainty of death. Because of this, the individual may become silent,
refuse visitors and spend much of the time CRYING AND GRIEVING.
Acceptance
- The loss is accepted HE IS CALM and we work on alternatives to dealing with the loss (minimize the loss)
The stages popularly known in its abbreviated form DABDA

- 1)Denial 2)Anger 3)Bargaining 4)Depression 5)Acceptance
Denial
— "I feel fine." "This can't be happening, not to me."
 initial (and most common) emotional response to the knowledge of impending death is denial. People in this
stage say, 'No, not me. It can't be!
 denial serves as a defense mechanism
 helps ease anxiety and fearful thoughts.
 Denial can be a POSITIVE COPING METHOD, allowing one to come to terms with the knowledge of dying on
their own until they are ready to cope constructively.
 Close family members and friends may also experience denial.
Anger
— "Why me? It's not fair!" "How can this happen to me?" '"Who is to blame?"
Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very
difficult to care for due to misplaced feelings of rage and envy.
 Feelings of rage or resentment may overcome this person and the anger may be directed at others as well.
 The person may ask, 'Why me?'
 doctors and loved ones should not respond to the anger of the dying person with avoidance or returned
anger, but instead through support.
Bargaining
— "Just let me live to see my children graduate." "I'll do anything for a few more years." "I will give my life savings
if..."
- involves the hope that the individual can somehow postpone or delay death.
- negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle.
- dying person may try to barter with doctors, family or even God. Saying, 'Okay, but please...'
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Depression
— "I'm so sad why bother with anything?" "I'm going to die... What's the point?" "I miss my loved one, why go on?"
- dying person begins to understand the certainty of death.
- individual may become silent, refuse visitors and spend much of the time crying and grieving.
****It is not recommended to attempt to cheer up an individual who is in this stage.
Acceptance
— "It's going to be okay." "I can't fight it I may as well prepare for it."
In this last stage, the individual begins to come to terms with her/his mortality or that of a loved one.
VI. Bioethical Principles in patient care:

 An individual's right of self-determination and freedom of decision making.
- Autonomy
 Doing good for clients and providing benefit balanced against risk.
- Beneficence
 Doing no harm to clients.

- Nonmaleficence
 Being fair to all and giving equal treatment, including distributing benefits, risks, and costs equally.
- Justice
 Being loyal and faithful to commitments and accountable for responsibilities.

- Fidelity
 Telling the truth and not intentionally deceiving or misleading clients.

- Veracity
VII. Chronic Illness Trajectory

What does trajectory refer to?
Course of action taken by a chronically ill person, their family, and Health Care Provider to manage the disease
What does trajectory address?

The impact of chronic illness and its management on everyday life and individual's sense of self
Who are considered active participants in the management process?

Patients and families
What is TRAJECTORY PROJECTION in the Nursing Process?

- Assessment phase
What is TRAJECTORY SCHEME in the Nursing Process?

- Nursing Interventions phase
What are the Trajectory Phases?

I. Pre-trajectory
II. Trajectory Onset
III. Crisis,
IV. Acute
V. Stable
VI. Unstable
VII. Downward
VIII. Dying
I. Pre-trajectory
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Genetic factors or lifestyles habits that predispose individuals for risk of chronic illness
What is the pre-trajectory phase also known as?

Preventative phase
Genetic factors or lifestyle behaviors that place a person or community at risk for a chronic condition
Nursing care :
Refer for genetic testing and counseling if indicated; provide education about prevention of modifiable risk factors
and behaviors
II. Trajectory Onset

Symptoms appearance and patient begin to cope with illness
Nursing care : Provide explanation of diagnostic tests and procedures and reinforce information and explanations
given by primary health care provider; provide emotional support to patient and family
III. Crisis
Critical event occurs which requires ER care
emergeny condition appears
Nursing care for the crisis phase

Provide direct care, collaborate with other health care team members to stabilize patient's condition
IV. Acute
- Severe, unrelieved symptoms that may be active illness or complications; hospitalization is necessary
Nursing care for acute phase
Provide direct care and emotional support to the patient and family members
V. Stable
Illness and symptoms are CONTROLLED
Nursing care
Reinforce positive behaviors and offer ongoing monitoring; provide education about health promotion, and
encourage participation in health promoting activities and health screening
VI. Unstable
Period of instability or RECURRENCE OF ILLNESS; no hospitalization
Nursing care for unstable phase
Provide guidance and support; reinforce previous patient education
VII. Downward
Rapid, gradual deterioration in physical and mental status; disability and symptoms decrease
Nursing care for downward phase

Provide home care and other community-based care to help patient and family adjust to changes and come to
terms with these changes; assist patient and family to integrate new treatment and management stratgies;
encourage identification of end-of-life preferences and planning
VIII. Dying
Final weeks or days before death
Nursing care in dying phase

Provide direct and supportive care to patients and their families through hospice programs
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 Dr.s- trained to preserve life only' LEGALLY ALLOWED TO DECLARE DEATH
 Death trajectory- course that person follows over time into death
 Long trajectories- make people worry about being a burden
 Short trajectory- Seen as the best, short trip into death
 Family- determines if organs are to be harvested
 Nurses- MOST hands on care; advocates for family
VIII. PHENYLKETONURIA (PKU) - autosomal recessive
What is phenylketonuria?
- Phenylketonuria (PKU) is a genetic disorder in which the body can't metabolize phenylalanine due to the absence
of the phenylalanine-hydroxylase enzyme.
What are the clinical features of untreated patients?

- Mental retardation
- "Musty" or "Mousy" odor, especially in Urine
- Light pigmentation
- Peculiarities in posture
- Eczema
- Epilepsy.
How can we diagnose phenylketonuria?

Blood test will show us the phenylalanine concentrations in the blood.
GUTHRIE TEST - is the first test for PKU
How can phenylketonuria be managed?

It can be managed through a low phenylalanine diet.
AVOID
- foods rich in protein (meats, eggs, fish, standard bread, most cheeses, nuts and seeds)
- Aspartame
- Flour
- Soya
- Beer
CBQ- REFER the child to DIETICIAN

CBQ- DIET FORMULA is LOFENALAC MILK
This diet is for life and the individual has to consume less than 500 mg of phenylalanine per day.
What gene is affected in phenylketonuria?

The PAH gene is affected - primarily activity in LIVER
IX. Appendicitis
Inflammation of the appendix
Order of onset of symptoms

Symptoms of appendicitis almost always occur in the same order. Name that order.
(1) Pain: usually in mid-abdomen often occurring at night waking the patient up from sleep
(2) Loss of appetite, nausea /vomiting
(3) Tenderness in McBurney's point
(4) Fever
(5) Elevated white blood count: marker of infection
(6) Local abscess (lump) at site probably means there is an appendicular perforation
Often the location of local tenderness
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Appendicitis: appendix is lying against the anterior wall near the abdominal peritoneal muscles -Other ways to check
is to flex the leg (Psoa's sign)
3 Most Important Symptoms in Appendicitis

 Local tenderness
Muscular rigidity
Fever
 Appendicitis: Fever
 -38 Celsius or 100.4 F
]
Appendix is unlikely to perforate until__-__ hours after onset of pain
- 24-36
Every patient should be operated on within -- hours of pain onset

- 24
Typical history of patient with appendicitis

Indigestion, gastritis or flatulence a few hours to a day prior to pain onset
Unusual irregularity in bowels -either constipation or diarrhea
Loss of appetite + abdominal pain = good indicator of appendicitis.

Site of pain on pressure varies according to the position of appendix -but classically at McBurney's point
Tenderness elicited by light percussion
Hyperesthesia- A condition of excessive sensitivity to stimuli
Typical hyperesthesia in appendicitis
- Usually confined to right side
*In which age group is appendicitis most common?

- children/adolescents/young adults
potential complications of appendicitis
- perforation, peritonitis, abscess
obstruction in appendix can be caused by...

fecalith, calculus, parasite, edema of lymphoid tissue, tumor, foreign body
*fecalith- hard, impacted mass of feces in colon
*age/gender group at greatest risk for appendicitis

adolescent males
*diet that is risk factor for appendicitis

- low in fiber and high in carbohydrates
dietary habits that reduce risk of appendicitis

- high fiber
CLINICAL MANIFESTATIONS of appendicitis r/t pain

- continuous
- mild
- upper abdominal pain (generalized)
- aggravated by moving, walking, coughing
- *rebound tenderness on palpation (at McBurney's Point)
older adults with appendicitis are likely to present with...

- confusion
acutely inflamed appendix can perforate within...

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- 24 hours
food & fluids + patient admitted with possible appendicitis
IV fluids, no oral foods & fluids (in case of surgery, wait until diagnosis confirmed)
*diagnostic tests for appendicitis

- abdominal ultrasound
- x-rays
- intravenous pyelogram
- urinalysis
- pelvic examination
- WBC w/ differential
treatment of choice for appendicitis

- appendectomy
types of appendectomy
laparoscopic approach, laparotomy
pharm prior to appendectomy

IV fluids & antibiotic therapy (third-generation cephalosporin)
antibiotic therapy time frame

- repeated during surgery & continued for at least 48 hours postop
*Why are strong analgesics withheld preoperatively?

sudden disappearance of pain indicates PERFORATION
POINTS TO ARTICULATE PRIOR TO APPENDECTOMY

- concerns
- understanding of procedure
- reasons for surgery
- pre-op instructions
- relief from pain w/ meds
- self-care instructions
With appendicitis the total WBC is 10,000 or 20,000
Meds.:
Cephalosporin, cefotaxime (claforan), ceftazidime (fortaz) ceftriaxone (rocephin)
Post op complications of an appendectomy?

- Improper wound care, risk of infection, abscess and possible peritonitis.
Pre op complications?
- peritonitis and perforation.
What physical characteristic may indicate a developing peritonitis?

- Increasing pain, boardlike abdomen and abdominal distention.
position post perforation:

- upright
If sepsis is present does BP?

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- it falls or hypotensive
What physical manifestations could indicate perforation?

- tachycardia, shallow breaths and fever.
Precautions to take for suspected appendicitis?

Keep patient NPO, do not administer enemas or laxatives, it could perforate the appendix.
No heat should be applied to abdomen.
Signs of peritonitis
- pain, sudden stop of pain because rupture. Increase pain diffuse. Abdomen distention, tachycard, rapid shallow
resp., pallor, chills, irritable.
*Perforation is common to Black RACE
CHOLELITHIASIS
What is cholelithiasis?
1. Gallstone in gallbladder
2. 5 F : female, fair skin, 40, fat, flatulant.
3. deep breathing make it worst
What S/S can you see for cholelithiasis?

1. Fever
2. Leukocytosis
3. Jaundice
4. Nausea & vomiting
5. abdominal pain at RUQ
6. pain may radiate to back
7. pain more with deep breath
8. can not digest fat at all
9. feeling of fullness
10. abdominal distention
what is T-Tube?
1. patient after cholecystectomy
2. shape like a T
3. it is for the liver after surgery, they liver will still make a lot of bile but giving time the bile will decrease and
patient will be able to remove.
4. usually connect to drainage
5. position - the drainage bag need to be lower.
what are other characteristics for cholelithiasis?

A. Incidence of these diseases is greater in females who are multiparous and overweight.
B. Treatment for cholecystitis consists of IV hydration, administration of antibiotics, and pain control with
meperidine or morphine.
Treatment for cholelithiasis consists of nonsurgical removal of stones

1. Dissolution therapy (administration of bile salts; used rarely)
2. Endoscopic retrograde cholangiopancreatography (ERCP)
3. Lithotripsy (not covered by many insurance carriers, thereby limiting its use)
What is ERCP?
- Endoscopic retrograde cholangiopancreatography
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what may happen to patient have ERCP?

- Following an ERCP, the client may feel sick. The scope is placed in the gallbladder, and the stones are crushed and
left to pass on their own.
These clients may be prone to pancreatitis.
what are the nursing assessment for CHOLECYSTITIS AND CHOLELITHIASIS?

A. Pain, anorexia, vomiting, or flatulence precipitated by ingestion of fried, spicy, or fatty foods
B. Fever, elevated WBCs, and other signs of infection (cholecystitis)
C. Abdominal tenderness
D. Jaundice and clay-colored stools (blockage)
E. Elevated liver enzymes, bilirubin, and WBCs
when would you performed Cholecystectomy?

C. Cholecystectomy is performed if stones are not removed nonsurgically and inflammation is absent. It may be
done through laparoscope.
what are nursing plans and interventions?

A. Administer analgesic for pain as needed.
B. Maintain NPO status.
C. Maintain NG tube to suction if indicated.
D. Administer IV antibiotics for cholecystitis, and administer antibiotics prophylactically for cholelithiasis.
what are nursing plans and interventions?

E. Monitor I& O.
F. Monitor electrolyte status regularly.
G. Teach client to avoid fried, spicy, and fatty foods and to reduce intake of calories if indicated.
preoperative
H. Provide preoperative and postoperative care if surgery is indicated.
I. Monitor T-tube drainage.
What are the types of stones?

 Cholesterol stones (75%)
 Pigment stones (25%)
What are the types of pigmented stones?

Black stones (contain calcium bilirubinate)
Brown stones (associated with biliary tract infection)
What are the causes of black-pigmented stones?

Cirrhosis, hemolysis
Is biliary colic pain really “colic”?

No, symptoms usually last for hours
What is thought to cause biliary colic?

Gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction; a stone in the cystic duct;
or a stone passing through the cystic duct
What is Boas’ sign?

Referred right subscapular pain of biliary colic
How is cholelithiasis diagnosed?
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History
Physical examination
Ultrasound
How often does ultrasound detect cholelithiasis?

- 98%
How often does ultrasound detect choledocholithiasis?

- About 33% of the time . . . not a very good study for choledocholithiasis!
How are symptomatic or complicated cases of cholelithiasis treated?
- By cholecystectomy
Define IOC, What are the indications for an IOC (6)?

IntraOperative Cholangiogram (dye in bile duct by way of the cystic duct with fluoro/x-ray)
What medication may dissolve a cholesterol gallstone?

- Chenodeoxycholic acid, ursodeoxycholic acid (Actigall®); but if medication is stopped, gallstones often recur
cholecysTITIS- inflammation of the gallbladder wall

choleLITHIASIS- presence of stones in the gallbladder related to the precipitation of either bile or cholesterol into
stones
cholelithiasis/cystitis: health promotion & dz prevention

 Consume low fat diet rich in HDL (seafood, nuts, olive oil)
 Participate in regular exercise program
 Do not smoke
The most common type of gall stones among Filipinos
- Pigment stones
cholelithaisis/cystitis: expected findings
 Sharp pain in the RUQ, often radiating to right shoulder

 Pain w/ deep inspiration during right subcostal palpation: Murphy’s Sign
 Intense pain: inc HR, pallor, diaphoresis--w/ n/v after ingestion of high fat food caused by biliary colic
 Rebound tenderness: Blumberg’s sign performed by provider
 Dyspepsia, eructation (belching), flatulence
 Fever
 Jaundice, clay colored stools, steatorrhea (fatty stools), dark urine, pruritis in clients with chronic
cholecystitis
 Older adults: if they have DM, can have atypical presentation-->absence of pain/fever
cholelithiasis/cystitis: lab tests
 Inc WBC-->inflammation
 Direct, indirect, and total serum bilirubin increased if bile duct obstructed
 Amylase and lipase inc w/ pancreatic involvement
 AST, LDG, and ALP-->inc w/ liver dysfunction and can indicate common bile duct is obstructed
CHOLELITHAISIS/CYSTITIS: DIAGNOSTIC PROCEDURES
 U/S: visualize gallstones and a dilated common bile duct

 Abdominal x-ray or CT scan: visualize calcified gallstones and an enlarged gallbladder
 Hepatobiliary scan (HIDA): assesses patency of biliary duct system after an IV injection of contrast
 Endoscopic retrograde cholangiopancreatography: allows for direct visualization using an endoscope that is
inserted thru the esophagus to common bile duct via duodenum
o A sphincterotomy w/ gallstone removal can be done during this procedure
 Magnetic resonance cholangiopancreatography: combines use of oral/IV contrast with an MRI
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o Assess in determining cause
cholelithiasis/cystitis: analgesics

Opioid analgesics (morphine sulfate or hydromorphone)
o Preferred for acute biliary pain
 NSAIDs (ketorolac)
o For mild to moderate pain
o Monitor for GI bleeding
 MORPHINE is ALLEGEDLY CAUSING SPASM OF SPHINCTER OF ODDI' (analgesic of choice still) - CBQ
cholelithiasis/cystitis: bile acids
 chenodiol, ursodiol - Gradually dissolves cholesterol based gallstones


 Nursing Considerations:
o Use caution if client has liver condition or disorders w/ varices
 Client Edu:
o Teach clients to report abdominal pain, diarrhea, or vomiting
o Limited to 2 yrs administration and requires a gallbladder U/S every 6 mos during 1st year to
determine effectiveness
cholelithiasis/cystitis: list the therapeutic procedures
 extracorporeal shock wave lithotripsy

 cholecystectomy
cholelithiasis/cystitis: extracorporeal shock wave lithotripsy
 type of therapeutic procedure

 Shock waves are used to break up stones
o Can be used on nonsurgical candidates of normal weight who have small, cholesterol based stones
 Nursing Actions:
o Instruct and assist client to lay on fluid filled pad for delivery of shock waves
o Administer analgesia
 Client Edu:
o Inform client that several procedures can be required to break up all stones
o Client may have pain intraprocedure due to gallbladder spasm of removal of stones
cholecystectomy: what is it?
 Removal of gallbladder w/ laparoscopic, MINIMALLY INVASIVE, or open approach

 Client can be discharged in 24 hr if laparoscopic approach used
o Open approach requires hospitalization for 1-2 days
LAPAROSCOPIC APPROACH TO A CHOLECYSTECTOMY
 nurse should provide immediate post op care

 client edu:
o ambulate frequently to minimize free air pain
o Monitor incision for evidence of infection or wound dehiscence
o Pain control
o Report indications of bile leak: pain, vomiting, abdominal distention
o Resume activity gradually
o Resume pre op diet
minimially invasive approach to a cholecystectomy
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 natural orifice transluminal endoscopic approach

o Explain to the client that this surgical procedure is performed thru entry of the mouth, vagina, or
rectum
open approach to a cholecystectomy
 Jackson Pratt drain placed in gallbladder bed or a T tube in the common bile duct
o Less common but clients can have T tube placed in common bile duct to drain bile if there were
intraoperative complications involving the bile duct
 client edu:
o Resume activity gradually
 Avoid lifting for 4-6 wks
o Begin w/ clear liquids and advance to solid foods as peristalsis resumes
o Report sudden inc in drainage, foul odor, pain, fever, or jaundice
o Take showers instead of baths until drainage tube removed
o Color of stools should return to brown in about a week
o Diarrhea is common
how to care for a T tube after a cholecystectomy
 Report absence of drainage w/ manifestations of nausea and pain (indicates obstruction)

 Inspect skin for infection or bile leakage
 If prescribed, elevate T tube above level of abdomen to prevent total loss of bile
 Monitor and record color/amount of drainage
 Clamp tube 1 hour before and after meals to provide bile necessary for food digestion
 Assess stools for color
o Will be clay colored until biliary flow is re-established
 Monitor for bile peritonitis-->pain, fever, jaundice
 Monitor response to food
 Expect removal in 1-3 wks
dietary counseling after a cholecystectomy
 Encourage low fat diet: reduce dairy, avoid fried foods/chocolate/nuts/gravies

 Inc tolerance if small frequent meals
o Avoid gas forming foods: beans, cabbage, cauliflower, broccoli
 Promote weight reduction
 Take fat soluble vitamins or bile salts as prescribed to enhance absorption and aid w/ digestion
X. FDAR DOCUMENTATION:
F-DAR What is it?

• Focus on a specific patient, problem, concern, or event
• Advantages: saves Nurse's time, decreases duplicate charting, easier to read, clear & concise, & efficient for
Nurses with many patients!
F = Focus
• Subject, Purpose of Role
• Nursing Diagnosis
• Event: Admission, Transfer, Procedure, Teaching, Patient Concern: (vomiting, nausea)
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D: Data
• Written in narrative
• Contains only subjective & objective data
A: Action
• Contains action words aka "verbs"
• This is what Nurses performed... Nursing interventions
• Ex. Giving PRN medications, Calling MD, Repositioning Patient
R: Response
• Write how Patient responded to your action
XI. Acute Pancreatitis

- Pancreatic duct can become temp. obstructed
- Obstruction is accompained by HYPERSECRETION of the exocrine enzymes of the pancreas
Acute Signs & Symptoms

- severe ab. pain (midepigastrium area) also have back pain
- pain may begin 24-48 hours after a heavy meal or alcohol consumption and may be difficult to localize
- pain felt after attending to fiesta buffet or gatherings
- pain is worse after meals and unrelieved by antacid use
- nausea & vomiting (N&V)
- abdominal guarding
Acute Signs & Symptoms

- board like or rigid abdomen (ominous sign -- possible peritonitis)
- Ecchymosis in the flank area or around the umbilicus
- Fever
- Jaundice
- confusion
-Agitation
Diagnosis of Acute pancreatitis

- elevated serum amylase and lipase levels (3X normal value)
- increased urinary clearance of amylase
- elevated WBC
- hypocalcemia (severity of Diag.)
- hyperglycemia (Secondary; < insulin from pancreas, plus > hormones -- stress)
- elevated serum bilirubin
Diagnosis
- abdominal X-rays
- abdominal U/S (stone blocking duct)
- CT Scan of the abdomen (> in diameter, necrosis, fluid acculation)
Medical Management
- NPO status
- TPN
- Histamine 2 antagoints -- Zantac & Tagamet
- PPI (Protonix)
- pain management
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ASSESSMENT
- severe abdominal pain in mid-epigastric area or LUQ
- pain is sudden, radiates to back, L flank or L shoulder, intense pain and boring, and continuous, worse when lying
down
- assumes fetal position for pain relief or sits up right and bends forward
- wt loss from N/V
- general jaundice
- Cullen's sign
- Turners sign
- absent/decreased bowel sounds
- abdominal tenderness
- guarding (peritonitis)
- ascites (dull sound on percussion)
- left lung pleural effusion, atelectasis, pneumonia, diminshed breath sounds, dyspnea, orthopnea
Cullen's sign- gray-blue discoloration of ABDOMEN and periumbilical area

Turner's sign - gray-blue discoloration of FLANKS
- indicates life-threatening complication of shock
- hypotension, tachycardia may result from pancreatic hemorrhage, excessive fluid shifting, toxic effects of abd sepsis
from enzyme damage
- observe pt for changes in behavior and LOC that may be related to ETOH withdrawal, hypoxia, impending sepsis
w/shock
- DRUG THERAPY
spasmolytics: papaverine (Pavabid, Cerespan) and nitroglycerin
- drugs that relax smooth muscle
anticholinergics: dicyclomine (Bentyl)
- decrease vagal stimulation, motility, pancreatic flow
- contraindicated in pts w/paralytic ileus
comfort measures
- assume side lying position w/legs drawn up to chest can decrease abdominal pain
- sitting with knees flexed toward chest
- oral hygiene
- monitor respiratory status and provide oxygen
What is the most common cause of acute pancreatitis in men?

 Alcohol ingestion
What is the most common cause of acute pancreatic in women?

 Biliary obstruction
What are your definitive lab value in acute pancreatitis?

 ELEVATED:
- Serum lipase
- Serum amylase
What lab value is indicated of severe acute pancreatitis (necrosis)

 DECREASED calcium (hypocalcemia)--> l/t tetany
What is your early sign for acute pancreatitis?

Midabdominal/epigastric pain radiating to the back
What are 2 signs that are indicative of retroperitoneal hemorrhage?

63 |
ecchymosis:
1. Turners: discoloration of the flank
2. Cullen's: discoloration around the umbilicus
What is your primary nursing management goal?

Maintain and replenish vascular volume and electrolytes
1. Fluid resuscitate
2. Electrolyte replacement (hypocalcemia, hypokalemia, hyperglycemia,)
3. Nutritional support
4. Pain management
What is the fluid status a patient with acute pancreatitis?

1. Initial: dehydration
2. Progressed: Hypovolemic shock
What fluids should be given to patient with acute pancreatitis?

- LACTATED RINGERS
To maintain hemodynamic stability: 500mL/hr

Maintain U/O 0.5ml/kg/hr: 250-300 mL/hr for the 1st 2 days
What is an important electrolyte to assess in acute pancreatitis?

- Calcium: (serum ca <8.5 mg/dL)
What are complications hypocalcemia?

ECG: elongated QT intervales r/f torsads (VTACH)
Tetany
What are signs that are indicative of hypocalcemia?
1) positive chvostek: hyper excitability
2) positive troussea: hyperreflexion
How do you rest your pancreas?

SEVERE: NPO : TPN+ NG tube to prevent enzyme production
MILD: small amounts to prevent ileus
while on TPN: monitor for HYPERGLYCEMIA
What COMFORT MEASURES should be taken if your patient has acute pancreatitis?
- Pain management! (indicated by elevated serum lipase and amylace): opiates (MORPHINE or demerol)
or NG tube to decompress the abdomen
Knee-to-chest positioning
What are your nursing diagnosis for acute pancreatitis?

1. Fluid volume deficit d/t loss of fluid in the peritoneal cavity
2. Altered nutrition less thann body requirements
3. Impaired gas exchange r/t digestion enzyme
4. Electrolyte imbalance d/t diseases process
Peptic Ulcer Disease (PUD)
Rich man ulcer:

- Duodenal ulcers- most common, develop between age 30-55, more common in MEN
64 |
Poor man ulcer:
- Gastric Ulcers- affect older pts more between ages 55-70, more common in smokers and
who are chronic users of NSAIDS.
***Alcohol and dietary intake DOES NOT CAUSE PUD.
PUD Etiology
- Heliobactor Pylori infection major risk factor
- ADA, NSAIDS major risk factor, ASA most ulcerogenic.
-Familial tendency- genetic factor in developing pud.
- Cigarette smoking significant risk factor, doubling risk for PUD.( It inhibits the secretion of bicarbonate by pancreas
and poss causing more rapid transit of gastric acid in duodenum.)
- Chronic gastritis ( hx of ulcers)
- Stress
PUD Manifestations
Pain:
-Mid to upper epigastrium radiating to back
-Empty Stomach- occurs 2-3 hrs after meals and in middle of night, which is reduced by eating. "pain food relief"
pattern.
- Gnawing or burning
- Mid-epigastrium or back
PUD Complications
Hemorrhage: occult or obvious blood in stool ( CBQ- MELENA - upper GI bleeding), hematemesid, fatique, dizziness,
orthostatic hypotension, hypovolemic shock.
- Melena stools-most common
Obstruction: sensations of epigastric fullness, N/V, electrolyte imbalance, metabolic shock.
Perforation:
-severe upper abd pain
-radiating to shoulders
-Rapid, shallow resps
-Absent BS
-Rigid boardlike abd.
-N/V
Zollinger- Ellison syndrome

 Is a peptic ulcer disease caused by a gastrinoma, or gastrin-secreting tumor of the pancreas, stomach, or
intestines.
 More than 60% are malignant.
 Gastrin is a hormone that stimulates the secretion of pepsin and HCL acid.
 Affects portion of stomach or duodenum, as well as esophagus or jejunum.
 Characteristic of ulcer like pain is common
 High levels of HCL Acid may cause steatorrhea from impaired fat digestion and absorption.
Diagnostics
Upper GI series: use barium as contrast medium can detect 80-90% of peptic ulcers. Chosen first, less costly.
Endoscopy- allows visualization of esophageal, gastric, and duodenal mucosa and direct inspection of ulcers.Tissure
can also be obtained for biopsy.
Esophagogastroduodenoscopy ( EGD)- most definitive test
Gastric samples via endoscopy.
H. Pylori testing:
- urea breath testing- radiolabeled urea is given orally, which produces H. pylori bacteria converts the urea to
ammonia and radiolabeled co2, which can be measured when the pt exhales.
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- Stool samples- detects the H. Pylori in the feces.
Pharmacologic Management
Proton Pump Inhibitors - PPIs- Very effective, faster pain relief with more healing
H2 Receptor blocker- inhibit histamine binding to receptors on the gastric parietal cells to reduce acid secretion.
Antibiotic therapy
Sucralfate- forming a protective barrier agains acid, bile, and pepsin.
Bismuth- stimulate mucosal bicarbonate and prostaglandins production to promote healing, and coating which
prevents further damage.
Antacids stimlulate gastric mucosal defenses
Prostaglandins ( Misoprostol)- promote ulcer healing by stimulating mucus and bicarbonate secretions.
PUD Nutrition
Bland or restrictive diets are unnecessary
Mild alcohol intake is not harmful
Smoking should be discouraged
6 small feedings a day
avoid bedtime snacks
avoid caffeine
PUD Nursing Diagnoses & Planning

 Acute Pain--- Report manageable pain
 Disturbed Sleep pattern--- Have restful sleep
 Imbalanced nutrition-- Maintain adequate nutrition
 Risk for bleeding-- Rmain free from complications
What is Pyloric obstruction (PUD)?

- blockage
what are complications of pyloric obstruction (PUD)?
- metabolic alkalosis
- hypokalemia
what is the Treatment of pyloric obstruction (PUD)?

- IVF and electrolyte replacement
EGD
What is an esophagogastroduodenoscopy (EGD) for PUD?
Most accurate means of establishing a diagnosis
what is the Drug therapy for PUD?

 same as GERD
Anti-Acids
 Mucosal Barrier Fortifiers
Gaviscon
Histamine Receptor Antagonist
Proton Pump Inhibitors
Prostaglandin Analog
Prokinetic Drugs
What does Gaviscon do?

- forms a viscous foam that floats on the top of gastric contents decreasing the incidence of reflux
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What do anti-acids do?

- elevate pH level of gastric content
Tums, Maalox, Mylanta
GASTRIC SURGERIES
Why is a GastroDUODENOSTOMY (Billroth I) performed

- it is a gastrointestinal reconstruction technique. It may be performed in cases of stomach cancer, a malfunctioning
pyloric valve, gastric obstruction, and peptic ulcers.
GastroJEJUNOSTOMY(GJ) (Billroth II) - CBQ

- is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the
jejunum.
Complications of gastric surgery

Dumping Syndrome, Postprandial hypoglycemia, and Bile reflux gastritis
Dumping syndrome (rapid gastric emptying, )

- occurs when the undigested contents of your stomach are transported or "dumped" into your small intestine too
rapidly. Reservoir reduced, large hypotonic bolus draws fluid into bowel, Lumen distends (stimulates intestinal
motility
Common symptoms of Early Dumping Syndrome

- (15-30 minutes after eating. Symptoms include nausea, vomiting, bloating, cramping, diarrhea, dizziness and
fatigue.)
Common symptoms of Late Dumping Syndrome

happens 1 to 3 hours after eating. Symptoms include weakness, sweating, and dizziness.
Dumping Syndrome most common after which surgery

- Billroth II - CBQ (common board question)
67 |

Integrated Concepts - Np3 and Np4

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PHILIPPINE NURSES ASSOCIATION – UNITED ARAB EMIRATES CHAPTER

SPECIAL PROFESSIONAL LICENSURE EXAMINATION 2023 - NURSING

 Metrorrhagia (bleeding between menstrual periods) - first sign of cervical cancer.

 Answer: deer ticks = LYME'S DISEASE.

 Meningitis, and pertussis- Answer: DROPLET PRECAUTIONS for

Administering Oral Inhalation Therapy

 Hypokalemia: muscle weakness, U waves on ECG, polyuria, rhabdomyolysis.

 Hyperkalemia: ventricular arrhythmias, peaked T waves on ECG, muscle weakness.

3rd degree - Subcutaneous Layer; FATTY layer

 DO NOT apply ice,

 Burns: Emergent Phase

*Electrolyte imbalances: Hyponatremia & Hyperkalemia

*Acid-Base imbalance: Metabolic acidosis

 During the acute phase this increases - Metabolism

 When does rehabilitation of the burn patient begin? - Admission

 diagnosed with Diabetes - Answer : above 5.5 mmol/mol

 What is incorrect when suctioning the patient?

 Apply suction intermittently for how long?

 When cleaning the non-disposable inner cannula you use?

 What is the recommended mm Hg of the cuff pressure?

 What is the incorrect use of a Cuffed Tracheostomy Tube?

 Why is it so that we need to do Cardiopulmonary Resuscitation as soon as possible?

 Which of the following is not a cause of Hemorrhoids?

 The Gastro Esophageal Reflux is a precipitous of what disorder?

 Which of the following foods can be a cause of GERD?

 Which of the following information provided is absolute true about angioplasty?

 Which of the following is the cause of Lung cancer?

 among males aging 50 years old and above.

“Adrenal gland problems”

 What urine test is performed to diagnose pheochromocytoma?

S.T.A.R.T, one of the 5 S's, is an acronym for

Virginia Triage Tag Concept

Yellow: Burns, major or multiple bone/back injuries (potentially life-threatening)

Green: Minor painful, swollen deformities, minor soft tissue injuries

Black: Deceased or non-salvageable

Examples of the IMMEDIATE CATEGORY (RED) are:

2. Emergent: if not Tx'd NOW life, limb and

3. Urgent: if not Tx'd in 1-2 hr potential

4. Non-urgent: stable requires care in 4-6 hrs,

 Cause of RA- UNKNOWN

 the pattern of joint involvement is typically

 Juvenile Rheumatoid Arthritis

 Does a cure exisit?

 Immune and inflammatory agents

 synovectomy: excision of synovial membrane

 Diagnostic Criteria at least 4 of seven must be present to establish diagnosis:

 Steroid therapy is usually done as part of a taper-dose treatment plan.

 Swan-neck deformity occurs at the proximal interphalangeal joint.

 NEVER MASSAGE INFLAMED JOINTS because massage can aggravate inflammation.

 Patients are advised to AVOID REPETITIOUS MOVEMENTS.

 -Most common arthritis

 Primary: (idiopathic) norm aging, MOSTLY WOMEN, genetic

WHAT IS THE PATHOPHYSIOLOGY OF OA?

 Signs of OA from P/E

 WHAT IS A COMMON REGIMEN USED TO TREAT OA?

 -Pain and Inflamation relief

WHAT MEDICATIONS ARE USED TO HELP MANAGE OA AND RHEUMATOID ARTHRITIS?

WHAT ARE THE 3 MAJOR NURSING RESPONSIBILITIES WHEN CONSIDERING OA?

 -Promote Healthy Life: exercise, rest, reg meds, emotional supp

 ETIOLOGY of Buerger's disease is unknown.

 Buerger's disease affects males only.

 COLD FEET (white, blue, red, tingling/prickly)

 #1 medical management of disease : MUST QUIT SMOKING!