Cancer Pain

PAIN CONCEPTS
Pain Quality of Life Activities Affected by Chronic Pain

• An unpleasant sensory and emotional experience 1. Concentrating
associated with actual or potential tissue damage or 2. Having Sex
described in terms of such damage (American Pain 3. Exercising
4. Sleeping
Society, 2003)
5. Socializing
• It is a universal experience and is unique to the 6. Walking
individual 7. Working around the house
 It is whatever bodily hurt the patient says he has 8. Working a full day at employment
• It exists whenever the patient say it does 9. Enjoying hobbies and leisure time
 “All pain is real” regardless of its cause even when 10. Maintaining relationships with family & friends
the cause remains unknown (Cardinal Rule) 11. Caring for children
• It is the 5th vital sign
 It is subjective in nature and only the person Cancer Pain
experiencing it may describe it • Pain associated with cancer and its treatment which
• It is protective because it provides warning signal for may be acute or chronic
tissue injury
Examples
Types of Pain 1. Directly associated with cancer – Bony infiltration
In Terms of Duration with tumor cells or nerve compression
Acute Pain 2. A result of cancer treatment – surgery or radiation
• Pain that lasts from seconds to 6 months
• It warns that some degree of damage or injury has In Terms of Location
occurred in the body that requires treatment Visceral Pain
• Subsides when healing occurs and gradually • Arises from internal organs such as the heart,
disappears kidneys, and intestine that are diseased or injured
• It tends to appear diffuse and is frequently caused by:
Chronic Pain (Non-Malignant)
 Ischemia (reduced arterial blood flow to an
• Pain that lasts from 6 months or longer
organ)
• Persists long after injury has healed
 Compression of an organ (tumor)
 Intestinal distension with gas (obstructed bowel)
Comparison of Acute and Chronic Pain  Contraction (spasm) like in gallbladder or kidney
Acute Pain Chronic Pain stones, or muscle spasms
Short duration – from split second Prolonged duration – lasts 6
to 6 months months or longer
Referred Pain (pain radiates)
Has an identifiable cause Has an unidentifiable cause • Pain felt in a general area of the body, but not in the
(although the cause may be difficult
to determine) exact site where an organ is anatomically located
Examples: Examples: Involved Organ Area of referred Pain
1. A prick in the finger 1. Exacerbation of rheumatoid
2. Appendicitis arthritis  immobility 
Heart Neck, left jaw, left arm, upper back
3. Incisional pain after surgery withdrawn  isolated
2. HIV/AIDS  AIDS related pain
4. Pain of childbirth Lungs Left shoulder
5. Sore throat
3. Burns (extensive)
Diaphragm Left shoulder
Related to tissue injury; subsides Persists long after injury has healed Liver Right shoulder, right side
as healing occurs
Spleen Right sided back pain
Client reports pain Client often does not mention pain
unless asked Stomach Epigastric region, middle back
Client exhibits behavior indicative of Pain behavior often absent

Kidney Right or left flank pain, thigh
pain: crying, rubbing area, holding Pancreas Left hypochondriac region, LUQ
area, focusing on the pain,
guarding the painful part Gallbladder Umbilical region
Responsive to analgesics Rarely responsive to analgesics Ovaries Right & left inguinal region
Appendix Right inguinal region, RLQ
Sympathetic nervous system Parasympathetic nervous system
responses: HR, RR, BP, responses: Vital signs normal, dry Ureters Right & left inguinal region
diaphoresis, dilated pupils, warm skin, pupils normal or dilated
Bladder Suprapubic, posterior gluteus / thigh
Client’s appearance: anxious, Client’s appearance: depressed,
appears restless, appetite is fatigue, irritable his weight changes,
decreased, mobility is decreased social withdrawn
GERICKA IRISH HUAN CO 2

PAIN CONCEPTS
Phantom limb pain is actual pain felt in a body

part that is no longer present (amputated leg)
Gate Control Theory

• Conceptualizes that there is a gate in the spinal cord
called substantia gelatinosa
• When the gate is open, pain stimulus is transmitted,
thus pain is perceived
• When the gate is closed, pain stimulus is blocked
thus, no pain is perceived
In Terms of Etiology
Physiological Pain
• Experienced when an intact, properly functioning
nervous system sends signals that tissue is damage,
requiring attention and proper care
Somatic Pain
− Originates in the skin, muscles, joints, bones or
connective tissues and is caused by mechanical,
chemical, thermal, or electrical injuries or
disorders
a. Superficial Somatic Pain (cutaneous pain) −
arises from nociceptive receptors in the skin
and mucous membranes is perceived as sharp
or burning discomfort
Example: insect bite or a paper cut in the finger
causing a sharp pain, minor (first degree) burns
b. Deeper Somatic Pain originates from
Conditions that open Conditions that close
structures such as joints, bones, tendons, and the gate the gate
muscles and produces localize sensations that Extent of the injury Medication
are sharp, throbbing and intense such that is Physical
conditions Inappropriate activity Counter stimulation,
caused by trauma level e.g. massage
Example: an ankle sprain, a fracture. Dull aching, Anxiety or worry Positive emotions
diffuse discomfort is more common with long term Emotional
Tension Relaxation
Conditions
disorders like arthritis
Depression Rest
Visceral Pain Intense concentration

Focusing on the pain
Mental or distraction
− Results from activation of pain receptors in the conditions Involvement and
organs and/or hollow viscera Boredom
interest in life activities
− It tends to be poorly located, and may have
cramping, throbbing, aching quality and often it is
Physiology of Pain: 4 Phases of Pain Transmission
associated with feeling sick
Example: Labor pain (sweating, nausea and
vomiting), Angina Pectoris
Neuropathic Pain
• Experienced by people with damage or
malfunctioning nerves
• The nerves may be abnormal due to:
 Illness − diabetic peripheral neuropathy, post
herpetic neuralgia
 Injury − spinal cord injury, phantom limb pain,
Carpal Tunnel Syndrome

PAIN CONCEPTS
Transduction • Are located in the skin and responds to strong

• Represents the initiation of the stimulus at the time of pressure, a cut, or high temperature, eliciting the
injury and conversion of that stimulus into an electrical withdrawal reflex
impulse that travel from the periphery to the spinal • Fast pain elicited by the mechanical and thermal type
cord at the dorsal horn receptors (A delta fibers)
• Initiated by cellular disruption during which affected  Pain that occurs in about 0.1 sec when painful
cells release various inflammatory chemicals stimuli are applied
/biochemical mediators such as:  Referred to as sharp, pricking, acute, or electric
Histamine – produces the redness, swelling and pain pain
 Pain felt when the skin is cut, burned, or electric
Prostaglandins – sends additional pain to the CNS
shock is felt
Bradykinin – produces the redness, swelling and pain
 Caused by a more superficial stimulus, so it is rare
Substance P – sensitizes receptors on nerves to feel in deep tissues
pain  The pain stops when the initiating stimulus is
• Inflammatory chemicals released by the damage cells stopped
stimulate specialized pain receptors located in the
free nerve endings of peripheral sensory nerves
C Fibers (larger unmyelinated)
called nociceptors
• Produces deep somatic and visceral pain
• Nociceptors (pain receptors) are found in free nerve
• Transmits nociception slowly and produces the
endings in the skin that transmit pain sensation and
“second pain” which can be described as dull, aching
can be excited by mechanical, thermal, or chemical
and burning
stimuli
• more pain is perceived if there is repeated C fiber
Types of Pain Stimuli
input and it is important to treat patients with analgesic
agents when they first feel pain
Stimulus Type Physiologic Basis
• Slow Pain
Mechanical
 Begins 1 second or more after stimulation and
Trauma to body tissues Tissue damage; direct irritation of
e.g. Surgery the pain receptors; inflammation increases slowly over seconds or minutes
Alterations in body tissues  Referred to as burning, aching, throbbing or
Pressure on pain receptors
e.g. edema chronic pain
Blockage of a body duct Distention of the lumen of a duct  Often associated with tissue destruction and is felt
Tumor
Pressure on pain receptors; in both superficial and deep tissues
irritation on nerve endings
Muscle Spasm Stimulation of pain receptors
Thermal
Tissue destruction; stimulation of

Extreme heat or cold
thermo sensitive pain receptors
Chemical
Stimulation of pain receptors
because of accumulated lactic
Tissue ischemia Ex. Blocked
acid (and other chemicals, such
coronary artery
as bradykinin and enzymes) in
tissues
Tissue ischemia secondary to
Muscle spasm
mechanical stimulation
Pain Receptors (Nociceptors) – carry pain impulses by

fast and slow nerve fibers
2 Main types of fibers (Nociceptors)

A Type Fibers (small myelinated)
• Myelin sheath speeds up information transmission
a. A Beta fiber − carries sensory information of touch
b. A Delta fiber − conduct impulses at a very rapid
rate and are responsible for transmitting acute
sharp pain signals from the peripheral nerves to Pain medications can work during this phase by
the spinal cord 1. Blocking the production of prostaglandin (e.g. using
Ibuprofen)

PAIN CONCEPTS
2. Decreasing the movement of ions across the cell endogenous opioids to inhibit the ascending painful
membrane (e.g. giving local anaesthetic) impulses in the dorsal horn
3. Depleting the accumulation of substance P and • Neuromodulators are morphine like compounds with
blocks transduction (e.g. using topical analgesic like analgesic activity and alter the perception of pain
capsaicin (Zostrix)
Descending Control System
Transmission • A system of fibers that originate in the lower and
midportion of the brain and terminate on the inhibitory
• The phase during which peripheral nerve fibers form
interneural fibers in the dorsal horn of the spinal cord
synapses with neurons in the spinal cord and the pain
• Prevents continuous transmission of stimuli as
impulses move from the spinal cord to sequentially
painful, partly through the action of neuromodulators
higher levels in the brain
• Pain control can be made with the use of opioids
(narcotic analgesics) to block the release of Neuromodulators
neurotransmitters, particularly Substance P, which Endorphins (endogenous opiods)
stops the pain at the spinal level • Located primarily in the brain stem structures are
opium like compounds manufactured by the body
• Powerful pain blocking chemicals that have prolonged
analgesic effect and produce euphoria
Substance P
• May be released when certain measures are used to
− A neuropeptide which is a relieve pain
pain-specific neurotransmitter  Relaxation techniques
that is present in the spinal  Placebo
cord’s horn  Massage
− It is present in the synaptic  Distraction
vesicles of the unmyelinated
fibers, activates the pain Enkephalins (endogenous opioids)
response when it is released • Neurotransmitters that are prevalent in the midbrain,
after injury hypothalamus, and dorsal horn of the spinal cord and
inhibit the release of Substance P from the terminals
of afferent neurons, thereby modulating pain
Other endogenous opioids: serotonin & epinephrine

Perception
• The process in which the client becomes conscious of
the pain
a. Fast pain fibers – ascend to cerebral cortex (center
for interpretation of pain)
b. Slow pain fibers – ascend to thalamus (center for
awareness of pain)
• Interpretation of pain
a. Pain Perception – the actual feeling of pain
b. Pain Threshold – is the smallest stimulus for which
a person reports pain. It is generally uniform
among people
c. Pain Tolerance – the most pain an individual is
willing / or able to tolerate before taking evasive
actions
• Non-pharmacologic interventions such as distraction, A. Pain impulse causes presynaptic neuron to release burst
guided imagery and music can help direct the client’s of neurotransmitters across synapse. These bind to
postsynaptic neuron and propagate impulse.
attention away from the pain B. Inhibitory neuron releases endorphins, which bind to
presynaptic opiate receptors. Neurotransmitter release
is inhibited, and pain impulse interrupted.
Modulation
• The phase during which the brain interacts with the
Concepts Associated with Pain
spinal nerves in a downward fashion by releasing
substances – neuromodulators which are Hyperalgesia – excessive sensitivity to pain

PAIN CONCEPTS
Intractable Pain – is pain that is highly resistant to relief • Behavior related to pain is part of the socialization
or cure process
Examples: pain from advanced malignancy (cancer of • Regardless of culture, the nurse should avoid
the cervix, prostate and lower bowel cancer) stereotyping the patient but provide individualized
Psychogenic Pain – is primarily due to emotional care
factors, with no physiologic basis
Neuropathic pain – pain that is related to damage or Gender
malfunctioning nervous tissue in the peripheral and/or • Women have consistently reported higher pain
CNS intensity, pain unpleasantness, frustration and fear
compared to men
Factors Influencing Pain Response
Placebo Effect
Past Pain Experience
• It occurs when a person responds to the medication
• A person with repeated pain experiences may have
or other treatment because of an expectation that the
learned to fear the escalation of pain and its
treatment will work rather than because it actually
inadequate treatment
does so
• Example of placebo are saline solution or a starch
Anxiety and Depression tablet
• Anxiety is associated with pain because of concerns
and fears about the underlying disease and Environment and Support People
depression is associated with chronic pain and
• An environment such as hospital, with its noises,
unrelieved cancer pain
lights and activity, can compound pain
• The most effective way to relieve pain is by directing
• Lonely persons who are without a support network
the treatment at the pain rather than at the anxiety
may perceive pain as severe, whereas the person
Anxiety that is relevant or related to the pain may who has supportive people around may perceive less
increase the patient’s perception of pain pain
Example: Hip pain experienced by a person who was • Family caregivers can be a significant support for a
treated 2 years ago for breast cancer may fear that person in pain
the pain indicates metastasis. In this case, the anxiety
may result in increased pain Age
• The way older people respond to pain may differ from
Anxiety that is not related to the pain may distract the the way younger people respond
patient and may actually decrease the perception of • Elderly people have a slower metabolism and a
pain greater ratio of body fat to muscle mass than younger
Example: A mother who was hospitalized with people do, small doses of analgesic agents may be
complications from abdominal surgery and is anxious sufficient to relieve pain
about her children may perceive less pain as her • Elderly patients deal with pain according to their
anxiety about her children increases lifestyle and personality as do younger adults and
many of them are fearful of addiction and as a result
Meaning of Pain do not report that they are in pain or ask for
• Some clients may accept pain more readily than medication to relieve pain use it actually does so
others, depending on the circumstances and the
client’s interpretation of its significance Assessing Pain
• If the pain is associated with a positive outcome, a
Accurate pain assessment is essential for effective pain
client may withstand the pain amazingly well
management
Example: Giving birth to a child or an athlete undergoing
Two Major Components of Pain Assessment
knee surgery to prolong his career may tolerate pain
better because of the benefit associated with it 1. Pain history – to obtain facts from the client
2. Direct observation of behaviors, physical signs of
Ethnic and Cultural Values tissue damage and secondary physiologic
responses of the client
• Beliefs about pain and how to respond to it differ from
one culture to the next Goal: To gain an objective understanding of a
• Early in childhood, people learn from those around subjective experience
them what responses to pain are acceptable or
unacceptable

PAIN CONCEPTS
Characteristics of Pain Behavioural Pain (FLACC) Scale

Intensity − Used for patients who are cognitively impaired or
• Magnitude of pain from none to mild to excruciating cannot speak
pain − The nurses assess the patient’s behavior in
• The reported intensity is influenced by the person’s categories such as facial expression, limb
pain threshold and pain tolerance movement, and activity level
− A score of 0 – 2 is obtained for each category,
Pain Intensity Rating Scales and the category scores are added together to
Simple Descriptive Pain Intensity scale arrive at a pain score total of 0 – 10
− Uses such words as “mild”, “moderate”, and − It is useful when assessing the pain of confused
“severe” to describe the patient’s pain intensity or nonverbal adults, infants, and young children
− It is use with adults in intensive-care units (ICU)
who are unable to speak due to intubation
The FLACC Pain Scale
Scoring
Categories 0 1 2
No particular Occasional grimace Frequent to constant

Numbered Scale Face expression or
smile
or frown, withdrawn,
disinterested
frown, clenched jaw,
quivering chin
− Ask the patient to rate the degree of pain as a
Normal position or Uneasy, restless, Kicking, or legs
number from 0 – 5 or 0 – 10, with 0 indicating no Legs
relaxed tense drawn up
pain and the highest number indicating the Lying quietly, Squirming, shifting
Arched, rigid, or
Activity normal position, back and forth,
greatest amount of pain imaginable moves easily tense
jerking
− It can be used very effectively with people who Moans or whimpers, Crying steadily,
No cry (awake or
have a good understanding of the numerical Cry
asleep)
occasional screams or sobs
complaint frequent complaints
concept
− It is not appropriate for young children, anyone Reassured by
occasional touching, Difficulty to console
who has difficulty with numbers, or anyone who is Consolability Content, relaxed
hugging or talking to, or comfort
distractable
confused or disoriented
Timing
• The nurse inquires the onset, duration, relationship
between time and intensity (e.g. At what time is the
pain worst) and changes in rhythmic patterns
• The patient is asked if the pain began suddenly or
Visual Analog Scale
increased gradually
– Requires patients to mark a point on a 10 cm
horizontal or vertical line to mark their pain Sudden pain (reaches maximum intensity) – indicates
intensity, with 0 indicating “no pain” and 10 tissue rupture and immediate intervention is important
indicating “the worst possible pain” Gradual pain (increases and becomes intense) –
indicates ischemia
Location
• The patient is asked to point in what area of the body
the pain is felt
Faces Pain Scale
− Has 6 faces depicting the expressions that range Quality
from contented to obvious distress • The patient is asked to describe the pain in his own
− The patient is asked to point to the face the most words without offering clues
closely resembles the intensity of his or her pain • The nurse must give enough time for the patient to
The Wong-Baker “FACES” Rating Scale describe his pain
• If the patient cannot describe the quality of pain, the
nurse can suggest words like burning, stabbing
• Document the exact words used by the patient

PAIN CONCEPTS
Personal Meaning of Pain Cutaneous Stimulation and Massage

• Some clients may accept pain more readily than • Stimulation of fibers that transmit non painful
others, depending on the circumstances and the sensations can block or decrease the transmission of
client’s interpretation of its significance pain impulses
• If the pain is associated with a positive outcome, a • The use of long, firm strokes; short, soft circular
client may withstand the pain amazingly well strokes and occasionally gentle pounding with the
sides of the hand stimulates circulation, relaxes
Aggravating and Alleviating Factors muscles, and increase the general sense of well-
being
• The patient is asked what makes the pain worse and
• When the painful area has inflammation or consists of
what makes it better and asks specifically about the
a wound or an incision, massaging another area of
relationship between activity and pain
the body with gentle but firm pressure helps the
• This helps detect factors associated with pain
patient direct attention away from the pain
• Simple massage can be done by a family member
Examples of aggravating factors
with just a little instruction, giving them an opportunity
1. Pain with coughing may signal spinal cord
to assist in the care in a positive and loving way
compression in a patient with advance metastatic
• Massage should not be used on any area that has
cancer
been reddened with pressure
2. Migraine headache when there is emotional tension
 This tissue is already compromised and massage
3. Angina pain during intense fear or intense physical
can cause further damage through shearing, the
exertion
traumatic pulling of tissue layers away from one
another
Examples of alleviating factors
1. Making the room warmer/cooler may help the patient
relax and may decrease his pain Thermal Therapies
2. Medications of the patient for pain • Stimulate the non-pain receptors in the same receptor
3. Herbal teas field as the injury
4. Application of heat or cold
Ice Therapy (Cryotherapy)
5. Prayer
6. Distractions like watching TV or playing video games − Local vasoconstriction and numbness, alters the
pain sensation
− Ice should be placed in the injury site immediately
Pain Behaviors
after injury or surgery to reduce localized swelling
• When experiencing pain, people express pain in and decreases vasodilation
many different behaviors − When used after a joint surgery, it significantly
 For clients who are very young, aphasic, reduces the amount of analgesic medication
confused, or disoriented nonverbal expressions required
may be the only means of communicating pain − Assess the skin before ice application. Avoid
• Facial expression is often the first indication of pain using it in patients with compromised circulation
 Clenched teeth, tightly close eyes, biting the − Ice application should be no longer than 15 to 20
lower lip, groaning, crying and screaming are min at a time. Nerve injury and frost bite may
sometimes associated with pain result when used longer
• Immobilization of a body part may also indicate pain
• The client with chest pain often holds the left arm Heat Therapy
across his chest − Provides some analgesia
− Sources – warm compresses, water filled heating
Pain Management Strategies devices, tub baths, hydrocollator pads
Non-Pharmacologic Interventions − Assess the skin before applying and monitor
Sleep closely to avoid injury
− Gentle heat promotes vasodilation and increases
• Rest increases pain tolerance and improve response
the blood flow to an area and helps reduce pain
to analgesia
by speeding healing
• Allow adequate time between treatments for naps
− Always check the temperature before applying
and plan care to keep sleep interruptions to a
heat
minimum
− Compresses and packs are usually left in place
 For instance, take vital signs when the patient is
for 15 – 20 min. Water filled heating devices may
awake to use the bathroom or request pain
be used longer
medication

PAIN CONCEPTS
− Contraindicated in cases of acute injury because Distraction

it can increase the initial response to edema • Focuses the client’s attention away from the pain and
− Do not use in areas with impaired circulation or onto something that the client’s find more pleasant
on patients with impaired sensation • Used in labor, mild to moderate pain
− Heat should not be applied to a painful area that Visual Distraction – reading books or watching TV,
is the site of acute untreated infection (e.g. watching a game (basketball game) and guided
mastitis, tooth abscesses), because it may cause imagery, watching comedy films
increased pain with increased blood flow to the
Tactile Distraction – slow, rhythmic breathing,
site
massage, holding or stroking a pet or a toy
− Heat treatments should be limited to 20-30-
Auditory Distraction – humor, active listening to
minute intervals because maximum dilation
recorded music. (Have client tap fingers in rhythm to
occurs in that time
the beat)
Intellectual Distraction – crossword puzzle, card
Transcutaneous Electrical Nerve Stimulation (TENS)
games, hobbies (story writing), reciting a poem or
• Non-invasive alternative to traditional methods of pain rhyme (children do this well)
relief
Other examples − visits from family and friends,
• Used in treating acute pain (e.g. post-op pain) and
involve the toddler/preschooler in blowing bubbles as
chronic pain (e.g. chronic low back pain)
a way of “blowing away the pain”
• Uses a battery-operated unit with electrodes applied
to the skin to produce a tingling, vibrating, or buzzing
sensation in the area of pain Relaxation Techniques
• Mechanism based on gate control theory: electrical • reduces pain by relaxing tense muscles that
impulse stimulates large diameter nerve fibers to contribute to the pain
“close the gate” • Regular relaxation periods may help combat the
fatigue and muscle tension that occur with and
Nursing Responsibilities increase chronic pain
1. Do not place electrodes • A simple relaxation technique consists of abdominal
 Over incision site, broken skin – may cause breathing at a slow, rhythmic rate
hemorrhage  The patient may close both eyes and breathe
 Carotid sinus – could cause cardiac problems slowly and comfortably
(usually hypotension)  With each inhalation he counts (“in, two, three”)
 Eyes – may cause an increase in intraocular and exhalation (“out, two, three”)
pressure
 Laryngeal or pharyngeal muscles – may cause Guided Imagery
laryngeal spasm • It is a combination of slow, rhythmic breathing with a
 Skin with diminished sensation because nerve mental image of relaxation and comfort
damage is likely to diminish TENS effectiveness • The nurse instructs the patient to close his eyes and
and the patient may be unaware that high- breathe slowly in and out
intensity currents are causing skin irritation  During exhalation, the patient imagines muscle
2. Do not use in client with cardiac pacemaker tension and discomfort being breathed out,
 The electrical field generated by TENS could carrying away pain and tension and leaving
interfere with implanted electrical devices behind a relaxed and comfortable body
3. No electrodes can be placed over the uterus of a  With each inhaled breath, the patient imagines
pregnant woman healing energy flowing to the area of discomfort
 May cause uterine contractions and induce • Usually, it is performed for about 5 minutes, 3x/day.
premature labor
4. Provide skin care
Hypnosis
 Remove electrodes once a day; wash area with
soap and water and air dry • The mechanism is thought to be related to positive
 Wipe area with skin prep pad before reapplying suggestions that alter the client’s perception of pain
electrode • This has been used in labor and delivery and pain
 Assess area for signs of redness; reposition control in cancer
electrodes if redness persists for more than 30
minutes Music Therapy
• Listening to music lifts mood and reduces pain and
anxiety

PAIN CONCEPTS
Alternative Therapies Example: Xylocaine 1-2%

Aromatherapy means "treatment using scents"
− It is a holistic treatment of caring for the body with c. Intraspinal Narcotic Infusion
pleasant smelling botanical oils such as rose, − Involves intraspinal infusion of narcotics or
lemon, lavender and peppermint local anesthetic agents for relief of acute or
− The essential oils are added to the bath or chronic pain
massaged into the skin, inhaled directly or − Medication is infused through a catheter
diffused to scent an entire room placed in the subarachnoid (intrathecal) or
− Aromatherapy is used for the relief of pain, care epidural space in the thoracic or lumbar area
for the skin, alleviate tension and fatigue and − Repeated injections of narcotics produce
invigorate the entire body analgesia without many of the side effects
Acupressure associated with systemic narcotics (e.g.
− Uses the power and sensitivity of human touch to sedation)
eliminate stress, relieve pain and alleviate acute Indications:
and chronic conditions
1. Temporary intraspinal narcotic therapy is used
− It is a science that deals with the human body and
most frequently for postoperative pain
the flow of natural energy within the body
2. For chronic pain, cancer pain – catheter may
Acupuncture be tunneled under the skin and implanted
− A Chinese technique of pain control by insertion subcutaneously in the abdomen; an
of fine needles at specific points on the body that implantable infusion device may be used to
is believed to block energy flow and restore the provide continuous narcotic infusion
body’s harmony
− Needle insertion activates production of Nursing interventions:
endorphins 1. Monitor client closely for respiratory depression
especially during initiation of treatment
 Maybe reversed with Naloxone (Narcan)
Pharmacologic Interventions
2. Assess for other side effects:
Anesthetic Agents
 Urinary retention: Foley catheter may be
• Anesthetic is a pharmacologic substance that, in used in post-op client until infusion is
addition to abolishing pain, generally causes loss of discontinued
feeling and sensation  Pruritus: may be treated with antihistamine
Regional anesthesia  Nausea and Vomiting
− Depresses superficial nerves and interferes with  Check insertion site frequently for signs of
the conduction of pain impulses from certain area infection
or region
− The sensory nerves are the first affected. The Implantable infusion device or pump – for more
patient remains conscious frequent doses or continuous infusion
DepoDur (morphine sulfate) – is a one-time
a. Topical application – the anesthetic agent is injection (during or shortly after surgery) that
applied directly to the mucosal membrane or into maintains a therapeutically effective level of
an open wound. It blocks the peripheral nerves morphine in the patient's bloodstream for 48
around the incision site hours
Uses:
1. For anesthesia of the respiratory passages, to Analgesics
eliminate laryngeal reflexes and cough • Medication is the most common approach to pain
2. For therapeutic and diagnostic procedures management
• Uses a preventive approach to pain management
Technique: spray. Instillation-cream, jelly, eye
Predictable Pain – post op pain and cancer pain
drop
medications are given around the clock (ATC)
Examples: Xylocaine, Pontocaine, EMLA- rather than prn. An ATC schedule maintains
emulsion of local anesthetics therapeutic blood levels of analgesics. With a PRN
schedule, the patient may have frequent periods of
unrelieved pain and may have more significant and
b. Simple Local Infiltration – the agent is injected into
frequent side effects such as sedation
the tissue around the incision area

PAIN CONCEPTS
Unpredictable Pain – administer medications on a Side Effects:

PRN basis. Instruct the patient to request 1. Anorexia, nausea and vomiting
medication as soon as the pain begins rather than 2. Rash
waiting for the pain to become more severe 3. Hepatoxicity
Examples: Tylenol, Tempra

Nonopioid Analgesics
− Initial treatment for mild pain Nursing Interventions:
− Maybe combined with opioids to control moderate 1. Monitor liver and renal function and CBC
to severe pain periodically for clients in long therapy
− Tend to block pain transmission peripherally 2. Teach client to avoid alcohol
− Have a ceiling effect on analgesia. This property 3. Instruct the client that self-medication should
means beyond a certain dose, improved not be used longer than 10 days and 5 days for
analgesia will not occur and toxicity may occur a child
− Some nonopioids should be used cautiously in  Do not exceed the recommended dose – 4
patients with congestive heart failure or grams daily (maximum)
hypertension because they cause fluid retention,  The antidote is acetylcysteine (Mucomyst)
which may aggravate these conditions
c. Nonsteroidal anti-inflammatory drugs (NSAIDs)
a. Salicylates – peripherally acting analgesics
Mechanism of Action:
Aspirin – also known as acetylsalicylic acid (ASA) 1. Act on peripheral nerve endings and decrease
Mechanism of Action: inflammatory mediators by inhibiting
prostaglandin synthesis
1. Analgesia – inhibits formation of prostaglandins
2. Have analgesic, anti-inflammatory and
involved with pain
antipyretic effects
2. Antipyretic – reduces fever, causes peripheral
vasodilation Use:
3. Anti-inflammatory – reduces inflammation 1. Rheumatoid arthritis
4. Antiplatelet – interferes with platelet 2. Osteoarthritis
aggregation 3. Mild to moderate pain
4. Primary dysmenorrhea, fever
Use:
1. Mild to moderate pain Side Effects:
2. Control of fever 1. Gastrointestinal ulceration and bleeding
3. Inflammatory conditions 2. Nausea and vomiting
4. Reduce risk of MI in persons with unstable 3. Constipation or diarrhea
angina 4. Allergic reaction: varies from rash to
anaphylaxis
Side Effects: 5. Anemia, decreased platelet aggregation
1. GI bleeding 6. Visual disturbances
2. Nausea and vomiting 7. Tinnitus
3. Tinnitus 8. Confusion
4. Confusion and dizziness 9. Seizures
Nursing Interventions: Examples:
1. Observe for bleeding gums, bloody or black 1. Oral NSAIDs – Ibuprofen (Motrin, Advil),
stool, bruises, ecchymoses, petechiae Naproxen (Naprosyn), Mefenamic acid
2. Give with milk, water or food to minimize gastric (Ponstan), Naproxen sodium (Flanax)
distress 2. Parenteral NSAIDs – Ketorolac (Toradol)
3. Pregnant women should not use 3. COX-2 inhibitors – Celecoxib (Celebrex), a
popular drug for arthritis
4. Discontinue use if tinnitus, dizziness, or GI
distress occurs Nursing Interventions:
5. Do not ingest large amounts of alcohol as this 1. Give with food, milk, full glass of water or
increases risk of GI bleeding antacid to decrease GI irritation
 Contraindicated in clients with ulcer
b. Acetaminophen disease
Mechanism of Action: analgesic, antipyretic 2. Check auditory and visual status periodically

PAIN CONCEPTS
3. Instruct client to observe for any signs of Common Opioid Side Effects, Preventive and
bleeding Treatment Measures
4. Monitor liver function Respiratory Depression − most serious S.E.
5. Avoid use of alcohol or aspirin when taking Nursing Actions
other NSAID’s
1. Use with caution especially in elderly, very ill
patients, asthma and those with respiratory
Opioid Analgesics depression
− Generally used for moderate to severe acute 2. Administer an opioid antagonist (e.g. Naloxone
pain, chronic cancer pain hydrochloride [Narcan], Naltrexone [Revia]) until
− Produces analgesia by binding to opioid respirations return to an acceptable rate
receptors in the central nervous system  Administer the medication slowly by IV route
− It can suppress respiration and coughing by with 10 ml of saline
acting on the respiratory and cough center in the  Monitor the client and repeat the procedure as
medulla of the brainstem required
− It can produce euphoria and sedation and can 3. If the client is receiving IV PCA, stop or slow the
cause physical dependence infusion
a. Opioid Agonist – produce analgesia but also Nausea and Vomiting

produce unwanted side effects like decrease Nursing Actions
respiration, drowsiness and nausea
1. Inform client that tolerance to this emetic effect
Examples: generally develops after several days of opiate
1. Codeine therapy
2. Fentanyl 2. Provide an antiemetic as required
3. Hydrocodone 3. Changed the analgesic as indicated
4. Hydromorpone (Diludid) 4. Adequately hydrate patient and change his position
5. Meperidine (Demerol) slowly
6. Morphine sulphate
7. Propoxyphene (Darvocet) Constipation
Nursing Actions
Meperidine (Demerol)
1. Increase fluid intake (e.g. 6-8 glasses daily)
o It is primarily used for preoperative and 2. Increase fiber and bulk-forming agents to the diet
postoperative medication and for anesthesia (e.g. fresh fruits and vegetables)
because it does not decrease uterine 3. Increase exercise regimen
contractions and has less depressive effect on 4. Administer stool softeners and if necessary, provide
neonatal respiration than morphine a laxative
o Duration of action: 2-3 hours
o It may cause CNS toxicity Dizziness, Drowsiness & Impaired Thinking
o Its metabolite, Normeperidine (CNS stimulant)
Nursing Actions
may cause anxiety, twitching, tremors muscle
1. Inform patient to use caution when driving or making
jerking and generalized seizures
decisions
o Demerol is contraindicated for long term
administration, specifically for 48 hours and for
Pruritus
patients with diminished renal function
Nursing Actions
1. Apply cool packs, lotion, and diversional activity
b. Opioid Agonist – Antagonist – relieves pain when
2. Administer an antihistamine (Benadryl)
given to a client who has not taken any pure
3. Inform the client that tolerance also develops to
opioids. However, they can block or inactivate
pruritus
other opioid analgesics when given to a client who
has been taking pure opioids
Urinary Retention
Examples: Nursing Actions
1. Buprenorphine (Buprenex) 1. May need to catheterize the patient
2. Nalbuphine (Nubain) 2. Administer narcotic antagonist − Naloxone
3. Butorphanol (Stadol) Hydrochloride (Narcan)

PAIN CONCEPTS
Sedation • It is programmed so that the patient can decide when

Nursing Actions a dose is given, but cannot exceed the maximum
1. Inform client that tolerance usually develops over 3- dose or minimum time interval ordered by the
5 days physician
2. Administer a stimulant, such as Dexedrine or Ritalin • Goal is to achieve more constant level of analgesia
each morning to client who receive opiate therapy for as compared to prn IM injections; also, in general,
chronic pain and do not develop tolerance causes less sedation & lower risk of respiratory
depression
• Used most often for postoperative pain management;
Definitions Related to the Use of Opioids in Pain
also used for intractable pain in terminal illness
Treatment
Addiction – a behavioral pattern of substance use Nursing Interventions
characterized by a compulsion to take the substance 1. Instruct client in use of PCA pump
primarily to experience its psychic effects  Demonstrate how to push control button. Keep
Physical Dependence – is a physiologic state in which control button within client reach
abrupt cessation of the opioid, or administration of an  Explain concept of client-controlled analgesia
opioid antagonist, results in a withdrawal syndrome  Press the PCA button, when pain begins to
Withdrawal Symptoms: irritability, chills, sweating, return; then put it down and wait for 10-15
nausea minutes to evaluate pain relief. If pain returns,
Tolerance – is a form of neuroadaptation to the effects push the PCA button again and repeat the
of chronically administered opioids, which is indicated process until the pain is relieved. If pain not
by the need for increasing or more frequent doses of relieved: Notify the registered nurse so referral
the medication to achieve the initial effects of the drug. to the physician can be made
2. Assess client’s level of consciousness, respiratory
rate, & degree of pain relief frequently
Routes of Administration
Oral – preferred route when tolerated and can control Epidural – for post op pain and cancer pain; an
severe pain when given in adequate dose levels anesthesiologist inserts the infusion catheter
Intramuscular Route – may be used to administer

Adjuvant Analgesics
opioids for breakthrough pain
− Drugs with other specific uses that can provide
Breakthrough Pain – pain that occurs between
analgesia in clients with chronic pain and cancer
regularly scheduled doses of pain medication. It
pain
requires immediate acting or short acting analgesic
medication, such as morphine
a. Anticonvulsants – used in situations with nerve
injury (trigeminal neuralgia)
Rectally – used when the patient is nauseated or has
Examples: Carbamazepine (Tegretol),
difficulty in swallowing, e.g. when the patient is dying
Phenytoin (Dilantin)
Example: Morphine, hydromorphone, oxymorpho- b. Antidepressants – promote normal sleeping
neopically for joint and other pain patterns in clients with chronic pain
Examples: Amitriptyline (Elavil), Doxepin
Transdermal Patches – provide relief from systemic
(Sinequan)
pain
c. Local anesthetics – used for a nerve block or given
Example: Fentanyl patches – can cause death from
via a spinal route
overdose
Example: lidocaine, EMLA, Bupivacaine
Signs of Overdose: difficulty breathing, shallow
d. Corticosteroids – for a variety of painful conditions,
breathing, extreme sleepiness and inability to think,
for metastatic bone cancer
talk, or walk normally, faintness, dizziness and
confusion Examples: Dexamethasone (Decadron),
Prednisone (Deltasone)
e. Muscle Relaxants – for muscle spasms associated
Intravenously – analgesics injected or infused over a
with pain and anxiety. Can cause sedation, which
prescribed time directly into the vascular system
limits the amount of opioid that can be safely given
at the same time
Patient-Controlled Analgesia (PCA)
Examples: Methocarbamol (Robaxin),
• An infusion device controlled by the patient that
Cyclobenzaprine (Flexeril)
injects the prescribed dose of analgesia

PAIN CONCEPTS
f. Benzodiazepines – for muscle spasm and anxiety Spinal Cord Stimulation

Examples: Alprazolam (Xanax), Lorazepam − A surgically implanted device allows the patient
(Ativan) to apply pulsed electrical stimulation on to the
g. Antihistamines – for nausea and anxiety dorsal aspect of the spinal cord to block pain
Examples: Hydroxyzine (Vistaril, Atarax) impulses
− The unit consist of
h. Psychostimulants – analgesic effect, cancer pain
a. Radiofrequency stimulation transmitter – worn
Examples: Dextroamphetamine (Ritalin),
externally
Methylphenidate (Ritalin)
b. Transmitter antenna – worn externally
i. Clonidine – pain from spinal cord injury, phantom c. Radiofrequency receiver – implanted
limb pain, peripheral nerve injury d. Stimulation electrode – implanted Used for the
relief of chronic intractable pain, ischemic
Approaches For Using Analgesic Agents pain, pain from angina
Balance Analgesia
• The use of more than one form of analgesia
concurrently to obtain more pain relief with fewer side
effects
• Using 2 or 3 types of agents (opioids, NSAID’s, local
anesthetics) simultaneously can maximize pain relief
while minimizing the potentially toxic effects of any
one agent
• When one agent is used alone, it usually must be
used in a higher dose to be more effective
Example: Instead of 15 mg of morphine to relieve a

certain pain, it may take only 8 mg morphine + 30 mg
Ketorolac (NSAID) to relieve same pain
Pro re nata (PRN)

• The nurse waits for the client to complain of pain and
then administer analgesia
• This method leaves the client sedated or in severe
pain much of the time Interruption of Pain Pathways
• To receive pain relief from an opioid analgesic, the • Involves surgical destruction of nerve pathways to
serum level of the opioid must be maintained at a block transmission of pain
therapeutic level • It is permanent
• By the time the patient complains of pain, the serum
opioid concentration is below the therapeutic level Rhizotomy − interruption of posterior nerve root close
to the spinal cord
Preventive Approach ✓ Laminectomy is necessary
✓ Results in permanent loss of sensation
• Agents are administered at set intervals so that the
✓ Performed to alleviate pain of the head and neck
medication acts before the pain becomes severe and
from cancer or neuralgia
before the serum opioid level decreases to a
subtherapeutic level
Neurologic and Neurosurgical Procedures for Pain

Control
Performed for persistent intractable pain of high
intensity
Stimulation Procedures
• Intermittent electrical stimulation of a tract or center to
inhibit the transmission of pain impulse
• It is reversible, when discontinued the nervous
system continuous to function

PAIN CONCEPTS
Cordotomy − interruption of pain-conducting 6. Relieved anxiety and fears.

pathways with the spinal cord  Spend time with the client
✓ Laminectomy usually required  Offer reassurance, explanations
✓ May be done by percutaneous needle insertion 7. Provide distraction and diversion, e.g. music,
✓ Interrupts conduction of pain and temperature puzzles
sense in affected parts 8. Administer pain medication as needed
✓ Done for pain felt in the legs and trunk  Administer pain medication in early stages
before the pain becomes severe
 Administer pain medication prior to procedure
that produces discomfort
 If pain is present most of the day, a preventative
approach may be used, e.g. an around the clock
schedule may be ordered in place of a prn
schedule
 Document effectiveness of intervention
9. Teach client about pain and pain control measures,
e.g. relaxation techniques, cutaneous stimulation
Expected Patient Outcomes for the Patient with Pain

Nursing Responsibilities 1. Relief of pain, evidenced when the patient
1. Provide pre and post-op care for a laminectomy  Rates pain at a lower intensity (on a scale of 0
2. Assess extremities for sensation (ex. Touch, pain, to 10) after intervention
temperature,) and movement  Rates pain at a lower intensity for longer period
3. provide safety measures to protect client from injury 2. Correct administration of prescribed analgesic
& carefully monitor skin for signs of damage or medications, evidenced when the patient or family
pressure  States correct dose of the medication
4. Teach client ways to compensate for loss of  Administers correct dose using correct
sensation in affected parts procedure
 Visually inspect skin for signs of injury or  Identifies side effects of medication
pressure  Describes actions taken to prevent or correct
 Check temperature of bath water side effects
 Avoid use of hot water bottles, heating pads 3. Use of non-pharmacologic pain strategies as
 Avoid extremes of temperature recommended, evidenced when the patient
 Reports practice of non-pharmacologic
strategies
General Nursing Interventions  Describes expected outcomes of non-
1. Establish nurse-client relationship pharmacologic strategies
 Let the client know that you believe that his pain 4. Minimal effects of pain and minimal S.E. of
is real interventions, evidenced when the patient
 Respect the client’s attitudes and behavioral  Participates in activities important to recovery
responses to pain using a standardized pain (drinking fluids, coughing, ambulating)
scale appropriate to age and condition  Participates in activities important to self and to
 Document effectiveness of interventions in a family (family activities, interpersonal
timely manner relationships, parenting, social interaction,
2. Assess characteristics of pain and evaluate client’s recreation, work)
response to interventions  Reports adequate sleep and absence of fatigue
3. Promote rest and relaxation and constipation
 Prevent fatigue
 Teach relaxation techniques, e.g. slow, rhythmic
Care of the patient with pain is a rapidly expanding
breathing, guided imagery
science that utilizes pharmacology, technology, and
4. Institute comfort measures
complementary therapies to provide safe,
 Positioning: support body parts
comprehensive treatment. Optimal pain management
 Decrease noxious stimuli such as noise or bright
promotes healing, comfort, and a feeling of well-being.
lights
Effective pain management permits performance of
5. Provide cutaneous stimulation: massage, pressure,
critical activities, improves quality of life, and reduces
baths, vibration, heat, cold packs
the length of hospital stay.

PERIOPERATIVE NURSING
Perioperative Nursing 3. To cure a disease by removing the diseased tissue

• Used to describe the nursing functions in the total or organs
surgical experience of the patient Example: Appendectomy
4. To remove traumatized tissue and structures
Three Phases of Perioperative Nursing Example: Debridement of burn wounds
Preoperative Phase – period of time that begins when 5. To repair certain congenital malformations
the decision is made to undergo surgery and ends when Example: cleft lip or cleft palate
the patient is transferred to the operating room table 6. To relieve symptoms by means of palliative
procedures
Intraoperative Phase – period of time that begins when Example: Intestinal bypass to relieve symptoms
the patient is in the operating room table and ends when of intestinal obstruction due to a late colon cancer
the patient is admitted in the recovery room/post 7. To improve appearance by cosmetic procedures – to
anesthesia care unit (PACU) enhance appearance such as in cosmetic and
aesthetic surgeries (facelift); or to restore function or
Postoperative Phase – period of time that begins when
normal appearance of damage tissues like scar
the patient is received in the PACU, to the time he is
removal
transported back to the surgical unit, discharge from the
8. To perform prophylactic procedures – as a
hospital, and ends after a follow-up evaluation in the
preventive measure against possible physical
clinical setting or home
ailments
Example: Excision of precancerous lesion such
The Art and Science of Surgery
as a hairy mole
Surgical Nursing
9. To preserve life – this enables the surgeon to
• Field of nursing which encompasses with those perform a stat surgical procedure to control bleeding
nursing activities that assist the surgical patient in cases of traumatic injuries (e.g. stabbing incident,
through pre-operative assessment and planning, fall, vehicular accident)
intra-operative intervention and post-operative Example: Exploratory Laparotomy –
evaluation. Hepatorraphy and Ligation of bleeders
• Restore and maintain the health and welfare of the
client before, during and after surgical intervention
Classification of Surgeries
Surgery According to Purpose
• Branch of medicine that encompasses preoperative, Diagnostic − removal and study of tissue to make a
intra-operative, and postoperative care of patients diagnosis
• The work of a surgeon is both science and art Example: Biopsy tissue sample as in prostatic biopsy,
excision of breast mass
Surgical Conscience
Exploratory − to estimate the extent of the disease and
• Awareness that develops from a knowledge base of
usually involves exploration of a body cavity or use of
the importance of strict adherence to principles of
scopes inserted through small incision
aseptic and sterile techniques
Example: Exploratory Laparotomy, Exploratory
Surgical Procedure Laparoscopy
• Invasive incision into body tissues or a minimally
Ablative − to remove a diseased organ
invasive entrance into a body cavity for either
Example: Cholecystectomy, Total Hip Replacement
therapeutic or diagnostic purposes during which
protective reflexes or self-care abilities are potentially Palliative − to relieve symptoms of a disease without
compromised treating or correcting the disease itself
Example: Colostomy, debridement of necrotic tissue,
Reasons For Surgery resection of nerve roots
1. To obtain tissue for examination – this enables the
surgeon to confirm a diagnosis; usually done to rule Reconstructive/Restorative – to repair tissue/organs
out malignancy whose function and appearance has been damage
Example: Excision of breast mass Example: Skin grafting of burn injury, creation of a
2. To visualize internal structures during diagnosis – new breast
performed to determine the extent of a pathologic
process and sometimes to confirm a diagnosis Constructive − to repair a congenitally malformed
Example: Diagnostic Laparoscopy tissue/organ

Example: Cheiloplasty to repair cleft lip, Uranoplasty Elective − done in cases wherein surgical intervention is
to repair cleft palate, closure of atrial septal defect of needed to improve well-being though not absolutely
the heart necessary for life
Example: Repair of scars, vaginal repair, simple
Cosmetic/Aesthetic – to improve personal appearance hernia
Example: Blepharoplasty to correct eyelid deformities,
rhinoplasty to reshape the nose, facelift Optional − decision rests with patient, personal
preferences
Curative – elimination or repair of pathology Example: cosmetic surgery – Rhinoplasty,
Example: removal of a ruptured appendix or ovarian Mammoplasty
cysts
Surgical Setting
Procurement for Transplant – removal of organs and/or Elective Surgery – carefully planned event
tissues from a person pronounced brain dead for Emergency Surgery – may arise with unexpected
transplantation urgency
Example: kidney, heart, or liver transplant Same-day admission – patient most often admitted on
the day of surgery for in patient surgery
Removal – to remove a foreign body
Ambulatory Surgery – is done on an out-patient basis
Example: removal of a slug in gunshot wound
Advantages
patients, removal of foreign body in the esophagus
1. Less stress to the patient
(e.g. dentures, coin swallowed by a toddler)
2. Less risk of nosocomial infection
3. Less decrease in patient’s productivity
According to Risk Involved
4. Less costly to the patient
Major – entails removal or surgical manipulation of a
major organ. Involves a high degree of risk, for a variety
Disadvantages
of reasons; it may be complicated or prolonged, large
1. Less time to monitor and assess patient
losses of blood may occur, vital organs may be involved
2. Less time to establish holistic care
Example: Modified Radical Mastectomy (MRM),
3. Patient will be responsible for assessing
Cholecystectomy, Caesarean Section, Craniotomy
complications
Minor – involves less risk. It entails removal or surgery
on less important body structure, produce few Surgical Terminologies and Abbreviations
complications it includes surgical procedures done It is important for the nurse to know surgical terminology
under local anesthesia and often performed in a “day before trying to assist the surgeon and anesthesiologist.
surgery” Only by knowing the surgical terms can the nurse
Example: Circumcision, Excision of breast mass, prepare the proper instruments and supplies for a
Debridement, Dilatation & Curettage particular procedure.
According to URGENCY Prefixes Meaning

Emergent − patient requires immediate surgical a or an without, not, absence
intervention. No unnecessary delays are allowed ante before, forward
Example: gunshot wounds, stab wounds, fractured anti against, opposite
skull, severe bleeding bladder or intestinal circum around, about
obstruction, extensive burns dys bad, difficult
ecto external, outside
Urgent/Imperative − patient requires prompt attention hemi half
and is performed within 12-24 hrs. hyper above, over, excessive
Example: Kidney stones, ureteral stones, fractured
infra below
hip, acute gallbladder infection
inter between
intra within
Required/Planned − done for conditions necessitating
surgery but which maybe scheduled or planned within a pan all
few weeks or months peri around, near
Example: Thyroid disorders, cataracts, prostatic poly many
hyperplasia without bladder obstruction pseudo false
retro behind, posterior to
supra above

Roots Meaning How Operations Are Named

adeno gland To form names of the operations, place the name of the
arthro joint anatomical site first, and the name of the foreign root
auto self describing the work done last.
blepharo eyelid
Suffixes Meaning Examples
cardio heart
centesis aspirate, puncture Paracentesis, Thoracentesis
cephalo head
Appendectomy,
cerebro brain Cholecystectomy, Embolectomy,
ectomy removal, surgical excision of
cheilo lip Fistulectomy, Mastectomy,
Hemorrhoidectomy
chole bile gall
lysis freeing of Adhesiolysis
cholecyst gallbladder
choledocho common bile duct oscopy
examination of an organ by Bronchoscopy Cystoscopy,
viewing Laparoscopy, Laryngoscopy
colon colon
the creation of new or
colpo vagina
artificial opening through the Colostomy, Cystostomy,
ostomy
costo rib wall of an organ for Gastrostomy, Thoracostomy
cranio skull drainage
cysto urinary bladder otomy cutting into an organ/tissue Laparotomy, Thoracotomy
dent teeth pexy fixation or suturing in place Orchidopexy
dermat skin restoration of a lost part/ piece

plasty Arthroplasty, Blepharoplasty
entero intestines of tissue; reconstruction
gastro stomach rraphy repair, suturing of

Herniorrhaphy, Gastrorraphy
Tenorraphy,Perineorraphy
hepato liver
hystero uterus
jejuno 2nd part of the intestines Common Abbreviations You Should Know
lamin posterior vertebral arch AAA Abdominal aortic aneurysm, “triple A”
lapar rib AKA Above knee amputation
mast breast APR Abdominal perineal resection
myo muscle APR Anterior posterior repair
nephro kidney AXR Abdominal x-ray
neuro nerve B1 Billroth 1 gastroduodenostomy
oophoro ovary B2 Billroth 2 gastrojejunostomy
opthalm eye BE Barium enema
orchi testis BIH Bilateral inguinal hernia
osteo bone BKA Below knee amputation
oto ear BTL Bilateral Tubal Ligation
phlebo vein CA Cancer
procto anus CABG Coronary Artery Bypass Graft
pyelo pelvis of the kidney CBD Common bile duct
rhino nose CBI Continuous Bladder Irrigation
salpingo fallopian tube C/O Complains of
spermato semen CS Cesarean Section
teno tendon C&S Culture and Sensitivity
thoraco chest CXR Chest x-ray
vas vessel, duct D&C Dilatation and Curettage
Dx Diagnosis
Suffixes Meaning EBL Estimated blood loss
algia pain ECCE Extra Capsular Cataract Extraction
ectomy removal Esophagogastroduodenoscopy (also
EGD
itis inflammation EKG)
lith stone, calculi ELAP Exploratory Laparotomy
logy science or study of FNA Fine needle aspiration
oma tumor GET(A) General endotracheal (anesthesia)
I&C Incision and curettage
I&D Incision and drainage

IVF Intravenous fluids in preparing for surgery. This usually requires hospital
IVPB Intravenous piggyback stay with the exception of emergency surgery.
LAP APPY Laparoscopic Appendectomy
LAP CHOLE Laparoscopic Cholecystectomy Risk Assessment
LIH Left inguinal hernia Risk assessment is about the patient. In the OR, the
NGT Nasogastric tube patient is the reason for your existence
NPO Nothing per os
NS Normal saline Medical Conditions that Increase the Risks of Surgery
Type of Condition Reason for Risk
ORIF Open reduction internal fixation
Bleeding Disorders
Increase risks of hemorrhaging during and
PFC Peritoneal fluid cytology (thrombocytopenia,
after surgery
haemophilia)
Percutaneous endoscopic gastrostomy
PEG Increases susceptibility to infection and may
(via EGD and skin incision) impair wound healing from altered glucose
Diabetes Mellitus metabolism and associated circulatory
POD Postoperative day impairment. Stress of surgery may cause
Physical therapy, patient, posterior increase in blood glucose levels
PT Heart Disease (Recent MI, Stress of surgery increases demands on
tibial dysrhytmias, CHF) and myocardium to maintain cardiac output.
PTX Pneumothorax peripheral vascular General anesthetic agents depress cardiac
disease functions
RIH Right inguinal hernia Administration of opioids increases the risk
Rx Treatment Obstructive sleep apnea
of airway obstruction postoperatively. Clients
will desaturate as revealed by drop in O2
SBO Small bowel obstruction saturation by pulse oximetry
STSG Split thickness skin graft Increases risk of respiratory complications
Upper respiratory infection during anesthesia (e.g. pneumonia and
Sx Symptoms
spasms of laryngeal muscles)
TAH Total Abdominal Hysterectomy Alters metabolism and elimination of drugs
given during surgery and impairs wound
Total Abdominal Hysterectomy with Liver disease
TAHBSO healing and clotting time because of
Bilateral Salpingooophorectomy alterations in protein metabolism
Predisposes client to fluid and electrolyte
TBA To be admitted
Fever imbalances and may indicate underlying
T&A Tonsillectomy and Adenoidectomy infection
TURP Transurethral resection of the prostate Reduces client’s means to compensate for
Chronic respiratory
acid base alterations. Anesthetic agents
Transurethral resection of bladder disease (emphysema,
reduce respiratory function, increasing risk
TURBT bronchitis, asthma)
tumor for severe hypoventilation
Immunological disorders
(leukemia, AIDS, bone
Increased risk of infection and delayed
Preoperative Patient Care marrow depression and use
wound healing after surgery
of chemotherapeutic drugs or
Goals: Preoperative Phase immunosuppressive agents)
Person abusing drugs may have underlying
1. Assessing and correcting physiologic and Drug abuse
diseases (HIV/Hepatitis) which affect healing
psychological problems that might increase surgical Regular use of pain medications may result
risk in higher tolerance. Increased doses of
Chronic pain
analgesics may be acquired to achieve
2. Giving the person and significant others complete postoperative pain control
learning/teaching guidelines regarding surgery
3. Instructing and demonstrating exercises that will Assessment Considerations for Clients undergoing
benefit the person during the postoperative period Surgery
4. Planning for discharge and any projected changes in
Age
lifestyle due to surgery
a. Infant – normal body temperature must be
maintained
Assessment b. Very young – immature physiological status
Assessment, the first part of the nursing process, c. Elderly patients are at risk during surgery – declining
is an integral part of the surgical experience. The data physiological status
obtained from a thoroughly conducted assessment is
crucial in determining the approach to the patient. • Physiologic reserve − ability to return to a normal state
Certain conditions can determine the patient’s response after a disturbance on organ equilibrium
to surgery and ultimately its outcome. • Liver function − decreased drug metabolism causing
increased drug level in blood
Before a surgical procedure is done, extensive
• Polypharmacy − practice of taking multiple
tests are conducted. This is to establish a baseline
medications. Elderly people usually have
reference for future comparison and to assess the
degenerative diseases which is why they take multiple
patient’s response to surgery. Surgical risk factors may
drugs
be covert. This is the reason why ample time is required

• Mouth condition − presence of dentures, dental Immunocompetence

carries and decayed teeth may pose the risk of airway • Cancer patients: Surgeon waits for 4-6 weeks (ideally)
obstruction during anesthesia induction. Dentures after completion of radiation treatments before
should be removed prior to surgery performing surgery
• Fragile skin − precaution should be practiced in • Chemotherapeutic agents, immunosuppressive
positioning. Decreased subcutaneous fat places medications, etc, increase the risk of infection
patient at risk for hypothermia
• Bone loss − places patient at risk for fracture. Careful Fluid and Electrolyte Imbalance
positioning is imperative. Chronic illness compounds • The body responds to surgery as a form of trauma
surgical risks • Adrenocortical stress response: Na and water
retention, and potassium is lost within the first 3-5
Nutritional Status days post-operatively
• Post-operative clients require at least 1500 kcal/day  Electrolyte imbalance may predispose the patient
to maintain energy reserves to dangerous cardiac arrhythmias
• Increase in CHON, Vitamin A& C and Zinc to facilitate • Adequate fluids are necessary to maintain blood
healing volume and urine output
• Malnutrition
 Weight loss of 10% within 6 weeks before surgery Pregnancy
must be investigated • Surgery is performed on pregnant clients only on
 Diet recommended includes high protein, calorie emergent or urgent basis
and vitamins • General anesthesia is administered with caution
 Optimum nutrition is required for wound healing  General anesthesia increases the risk for fetal
and preventing and preventing infection death and preterm labor
 Malnourished clients have:
o Poor tolerance to anesthesia Previous Surgery
o Poor wound healing
• Client’s past experience with surgery can influence
o Higher risk of infection
physical and psychological responses to a procedure
o General increased risk in mortality and
morbidity – potential for multiple organ failure
Perception and Understanding of Surgery
• Ethical Dilemma: The client is misinformed or
Obesity/Bariatric
unaware of the reason for surgery
• In increased surgical risks – reduces ventilator and
• Nurse should confer with the physician if the client has
cardiac function
inaccurate perception or knowledge of the surgical
 CAD, DM, CHF are common to bariatric
procedure before the client is sent to surgery
• Postoperative complications: embolus, atelectasis,
• Determine whether the physician explained routine
pneumonia
preoperative and postoperative procedures
• Susceptible to poor wound healing – because of the
• Reinforce the client’s knowledge and maintain
structure of fatty tissues which contain a poor blood
accuracy and consistency
supply, slowly delivery of essential nutrients,
antibodies and enzymes needed for wound healing
Medication History
• Often difficult to close surgical wound – because of
Drug Class Effects During Surgery
the thick adipose layer
Antibiotics potentiate action of anesthetic
• At risk for dehiscence (opening of the suture line)
agents. If taken within 2 weeks prior to
surgery, aminoglycosides (Gentamycin,
Antibiotics
Neomycin) may cause mild respiratory
depression from depressed neuromuscular
transmission.
Antidysrhytmics can reduce cardiac
Antidysrhythmias contractility and impair cardiac conduction
during anesthesia.
Anticoagulants alter normal clotting factors
and thus increase risk of hemorrhaging. They
should be discontinued at least 48 hours prior
Anticoagulants
to surgery. Aspirin is a commonly used
medication that can alter clotting
mechanisms.
Long term use of certain anticonvulsants (e.g.
Anticonvulsants Phenytoin [Dilantin] and Phenobarbital) can
alter metabolism of anesthetic agents

Antihypertensive agents interact with Alcoholism

anesthetic agents to cause bradycardia,
hypotension and impaired circulation. They
• Patients who use alcohol excessively may need a
Antihypertensives higher than normal dose of anesthetic agent because
inhibit synthesis and storage of
norepinephrine in sympathetic nerve of increase drug tolerance
endings.
With prolonged use, corticosteroids cause
Use of Recreational Drugs
adrenal hypertrophy, which reduces the
Corticosteroids body’s ability to withstand stress. Before and • Use of cocaine, methamphetamine, and marijuana,
during surgery, dosages may be temporarily can increase the heart rate, alter cardiac function and
increased.
increase the need for higher than usual doses of
Diabetic client’s need for insulin after surgery
is altered. Stress response and IV anesthesia
Insulin
administration of glucose solutions can
increase dosage requirements. Family Support
Diuretics potentiate electrolyte imbalances
Diuretics
(particularly potassium) after surgery.
• It is best to have the client identify his/her source of
NSAIDS inhibit platelet aggregation and may support
NSAID’s prolong bleeding time, increasing • Family presence should be encouraged
susceptibility to postoperative bleeding. • Family member/s can become the client’s coach,
The herbal therapies have the ability to affect
Herbal therapies; offering valuable support during the postoperative
platelet activity and increase susceptibility to
ginger, ginko,
postoperative bleeding. Ginseng may period when the client’s participation is vital
ginseng
increase hypoglycemia with insulin therapy
Review of Emotional Health
Allergies • Surgery is psychologically stressful
• Allergies need to be delineated from unpleasant side • Nurse should assess the client’s feelings about the
effects surgery, self-concept, body image and coping
 An allergy to shellfish is also allergic to iodine skin resources, to understand the impact of surgery on a
preparations (Iodophor and Betadine) or any client’s and family’s emotional health
other products containing iodine such as dyes • Explain that it is normal to have fears and concerns
 Note: Allergic to shellfish does not necessarily
Fears of Surgery at Different Developmental Stages
have an allergy to seafood
Toddler
• Latex allergy – Goal: Provide a latex free environment
 Latex allergy are allergic reactions to natural Specific Fears: Fear of separation
rubber latex and synthetic rubber latex Nursing Actions:
 Latex fruit syndrome, at risk for latex allergy, if 1. Teach parents to expect regression, e.g. in toilet
allergic to: training and difficult separations
✓ Bananas ✓ Potatoes
✓ Avocados ✓ Tomatoes Preschooler
✓ Kiwi ✓ Grapes Specific Fears: Fear of Mutilation
✓ Apricots ✓ Guava Nursing Actions:
✓ Peaches ✓ Hazelnuts 1. Allow child to play with models of equipment
 Latex allergy immediate reaction (life threatening) 2. Encourage expression of feelings (e.g. anger)
✓ Pruritus and flushing ✓ Cramping School-age
✓ Diaphoresis ✓ Dyspnea
Specific Fears: Loss of control
✓ N&V
Nursing Actions:
 Delayed response – 18-24 hrs. after contact
1. Explain procedures in simple terms
dermatitis
2. Allow choices when possible
Smoking Habits Adolescence
• Smokers have increase amount and thickness of Specific Fears: Loss of independence being different
mucous secretions from peers e.g. alterations in body image
• General anesthesia increases airway irritation and Nursing Actions:
stimulates pulmonary secretions which are then
1. Involve adolescence in procedures and therapies
retained as a result of reduction in ciliary activity
2. Expect resistance
during anesthesia  Ineffective Airway Clearance
3. Express understandings of concerns
• Nurse should emphasize on the importance of post-
4. Point out strengths
operative deep breathing and coughing

Manifestations of Fear Preadmission Procedures

1. Anxiousness The preoperative preparations include the following:
2. Bewilderment
3. Anger Medical History and Physical Examination
4. Tendency to exaggerate • Obtain history of past medical conditions, surgical
5. Sad, evasive, tearful, clinging procedures, allergies, dietary restrictions, &
6. Inability to concentrate medications
7. Short attention span • Perform baseline head-to-toe assessment, including
8. Failure to carry out simple directions vital signs, height, & weight
9. Dazed
Laboratory Tests
• Client’s ability to share feelings partially depends on
CBC to check for abnormalities (increase WBC-
the nurse’s willingness to listen. The nurse should be
infection). Hemoglobin, hematocrit, blood urea
supportive and clarify misconceptions
nitrogen and blood glucose may be routinely tested
• Client feels powerless or loss of control – attempts to
for patients ages 60 years old.
determine the reason; assure client of his/her right to
ask questions and seek information Electrolytes to assess for any imbalances.
• Assess manifestations of anger and anxiety PT/PTT (Prothrombin time; partial thromboplastin
time) to avoid bleeding problems
Self-Concept Urinalysis may be indicated by medical history and/or
• Assess and identify personal strengths and P.E.
weaknesses
• Poor self-concept hinders ability to adapt to the stress Blood Type and Cross Match
of surgery and aggravate feelings of guilt or • If a transfusion is anticipated the patient’s blood is
inadequacy typed and cross matched
• If the patient refuses to accept blood transfusions, the
Body Image appropriate documentation of refusal should be
• Response is determined by culture, self-concept, completed according to the policies and procedures
degree of self esteem of the policy
• Nurse should encourage expressions of concerns
about sexuality Chest Radiographic Study (not routinely required)
• Chest x-ray may be required to help in the clinical
Coping Resources evaluation of patient with (who is)
• Nurse must be aware of the responses; assist in  Cardiac or pulmonary disease
stress management; determine behaviors that help  Cancer
resolve any tension and/or nervousness; and identify  A smoker
sources of support  60 years old or older
Culture Electrocardiogram (ECG)

• Culture refers to a system of beliefs that have been • Patient has known or suspected heart disease.
developed over time and subsequently have been • It may be routine for patients 40 years of age or older
passed on through many generations by policy
• The nurse should acquire knowledge of the client’s
cultural and ethnic heritage Diagnostic Procedures
• Special procedures like Doppler studies are
Client Expectations performed when specifically indicated (e.g. Doppler
• Assess expectations studies for vascular surgery)
• Nurse should provide accurate information and clarify
misconceptions Nurse Interview
A perioperative nurse/perianesthesia nurse
should meet with the patient to make a preoperative
assessment. The nurse also provides emotional support
and teaches the patient in preparation for postoperative
recovery. Before or after the interview, the patient may
view a videotape to reinforce information.

Structured Pre-Operative Visits Elevated temperature – a cause of concern, if the client

• Review the patient’s chart and records has underlying infection the surgeon may choose to
 Biographic information postpone the surgery until infection has been treated
 Physical findings Elevated temperature – also increases the risk of fluid
 Special therapy and electrolyte imbalance
 Emotional status Dehydrated client – at risk for developing serious fluid
• Choose an optimal time and place without and electrolyte imbalance intraoperatively
interruptions Local and systemic body infection − inspect for
• Greet the patient by introducing yourself and possibility
explaining the purpose of the visit
Jugular vein distention – at risk for cardiovascular
• Obtain information by asking about the patient’s
complications during surgery
understanding of the surgical procedure
Loose or cap teeth – must be identified for they can
• Orient the patient to the environment of the OR suite
become dislodge during endotracheal intubation
and interpret policies and routines
• Review the preoperative preparations that the patient Dentures – must be remove
will experience Inspect bony prominences of the skin – prolonged
• Tell the patient that the anesthesia provider will visit surgery may increase the risk of pressure ulcers
to discuss specific questions relative to anesthesia, if Older adult – at high risk for alteration of skin integrity
this is routine from positioning and sliding on the OR table, causing
• Encourage the patient and family to discuss their shear and pressure during surgery and intubation →
feelings or anxieties regarding the surgical procedure inform the physician
and anticipated results Peripheral pulses are not palpable – use of a Doppler
• Answer the patient’s questions about the surgical instrument for assessment of their presence. Normal
procedure in general terms. Refer specific questions capillary refill time: < 2 seconds
to the surgeon
• Identify any special needs of the patient that will alter
The Patient with Individualized Needs
the plan for intraoperative care
 IV infusion should be started in the right arm of a Language Barrier
left-handed person to minimize the limitation of • The inability to understand or to express oneself
manual dexterity verbally is frustrating
 Observe the patient for physical limitations such • Nonverbal body language through eye contact,
as pain on moving, an amputated extremity, pleasant facial expressions, and a gentle touch can
paralysis or sensory loss. A pad of paper and comfort the patient who speaks a different language
pencil may be needed to communicate with a • Get an interpreter to assist the patient and the health
patient who is unable to speak or hear care team. Some patients are reluctant to share
 Ask the patient whether he or she wears any type confidential medical information with a relative or
of prosthetic device. Explain that the device will friend. The interpreter should be
be removed either at the bedside or in the OR  Trusted and accepted by the patient
 Determine how a pre-existing medical condition  Sensitive to the needs of the surgeon and
should be managed in the OR. For example, it is caregivers
important that the circulating nurse know about
the presence of an implanted pacemaker. Hearing Impairment/Deafness
Monopolar electrosurgery could cause certain • Determine whether the patient
models of pacemakers to malfunction and  Communicates Through Sign Language
monopolar surgery would therefore be  Has A Hearing-Assistive Cochlear Implant
contraindicated  Has a hearing aid
 Know the patient’s special request. Placing a note
on the front of a chart is one method of relaying Steps to be observed when communicating with a
temporary information about the patient’s special patient who has a hearing impairment
request. These notes are not part of the
1. Make sure the room is quiet and well lit, with minimal
permanent record
distractions
2. Look directly at the patient. Speak clearly and slowly
Physical Assessment Key Points in a moderate tone of voice
Preoperative vital signs – to establish baseline with 3. Greet the patient without wearing a facemask and
which to compare alteration that occur during and after attract the patient’s attention before speaking. Make
surgery eye contact

4. Be sure the patient understands and responds cardiac reserve and observes signs of dyspnea. 4. Asks
appropriately to questions. An interpreter can assist about teeth. If indicated explains the dental work may
with patients who use sign language be damage inadvertently during airway insertion. 5.
5. To help explain your actions, show the patient any Evaluates physique of the patient for technicalities in
equipment (e.g. safety strap) before placing it on administration of anesthesia: ▪ A short stout neck may
him/her cause respiratory problems or difficult intubation. ▪
6. Allow the patient to wear a hearing aid in the Active athletic and obese persons require more
perioperative environment, if possible anesthetic than inactive persons. ▪ Accurate body
weight must be known because dosage of many
Visual Impairment/Blindness medications is calculated from body weight. 6. Explains
preference of anesthetic. 7. Tells patient that oral intake
• Eyeglasses should be permitted to be worn as much
is restricted before anesthesia and gives reason for this
as possible in the perioperative environment
I.V. therapy is explained. 8. Discusses preoperative
 If a general anesthetic is used, the glasses should
sedation in relation to the time the surgical procedure is
be sent to the post-anesthesia care unit (PACU)
scheduled to begin. 9. Reassures patient that constant
so they are available when the patient’s wakes up
observation will be given during the entire procedure
 Contact lenses must be removed before the
and also postoperative. The methods of monitoring vital
administration of a general anesthetic, because
functions are explained. 10. Explains risks of anesthesia
they may dry on the cornea or become dislodged
but without causing the patient undue stress. 11.
Answers the questions of the patient and allay fears
Steps to be observed when communicating
related to anesthesia
Patients who are blind feel insecure in a strange
environment
Nursing Diagnoses
1. Address the patient by name in moderate tones and
introduce yourself. Make some noise as you 1. Ineffective airway clearance
approach so as not to startle the patient 2. Anxiety
2. Always speak to the patient before touching him or 3. Risk for imbalanced body temperature
her. A gentle word followed by a gentle touch can be 4. Ineffective coping
comforting 5. Risk for deficient fluid volume
3. To prevent a distressful reaction to unexpected 6. Risk for injury
noises or sensations, the patient should be told of 7. Impaired physical mobility
what is going to happen before any physical contact 8. Powerlessness
4. Guiding the patient’s hand will help him or her feel 9. Disturbed sleep pattern
secure, such as being moved from the operating 10. Risk for latex allergy response
room bed 11. Disturbed body image
12. Ineffective breathing pattern
13. Fear
Physical Challenge
14. Risk for infection
• Patients with contractures or pressure sores – difficult 15. Deficient knowledge
to position the patient in the OR bed 16. Acute pain
• Patients with spastic muscle motion as in cerebral 17. Impaired skin integrity
palsy will require additional personnel around the OR
bed for safety during transfer or the random body
Planning
movement could cause the patient to fall
• Paralyzed patients, such as those with spinal cord • Involve the client and family in preoperative instruction
injury, are unable to move • Provide therapies aimed at minimizing the client’s fear
or anxiety regarding surgery
• Plan therapies to reduce surgical risks
. Anesthesia assessment • An anesthesia history and
• Consult with other healthcare provider
physical assessment are performed before a general or
regional anesthetic is administered. Preoperative visit
by anesthesia provider 1. Takes a history pertinent to Implementation
administration of anesthetic agents by questioning the Informed Consent (operative permit)
patient about past anesthetic experiences, allergies, • It is an agreement by a client to accept a course of
adverse reactions to drugs and habitual drug usage. 2. treatment or procedure after being provided complete
Evaluates the patient’s physical, mental and emotional information, including the benefits and risks of
status to determine the most appropriate type and treatment, alternatives to the treatment, possible
amount of anesthetic agent/s. 3. Investigates patient’s

complications, and prognosis if not treated by a health 4. Illiterate, he/she may sign it with an X, after which the
care provided witness writes “Patient’s mark”
• This is a legal requirement  Because illiteracy implies the inability to read
• The surgeon has the ultimate responsibility for and write, the patient should indicate an
obtaining informed consent for the procedure. The understanding of a verbal explanation
physician should obtain informed consent from the 5. Unconscious, a responsible relative or guardian
patient or legal designee should sign
• The patient or appropriate guardian may be required 6. Mentally incompetent, the legal guardian should sign
to sign this record in the presence of a witness 7. An adult/emancipated minor who is mentally
• A witness verifies that the consent was signed without incapacitated by alcohol or other chemical
coercion after the surgeon explained the details of the substance, the spouse or responsible relative of legal
procedure age may sign when the urgency of the procedure
• Witnesses may be physicians, nurses, other facility does not allow time for the patient to regain mental
employees, or family members competence
• The witness signing a consent document attest only
to the following: Consent in Emergency Situations
 Identification of the patient or legal substitute 1. Permission for a lifesaving procedure, especially for
 Voluntary signature, without coercion a minor, may be accepted from a legal guardian or
 Mental state of signatory (i.e. not coerced, responsible relative by telephone, fax, or other
sedated, or confused) at the time of signing. written communication
2. If it is obtained by telephone, two nurses should
Purposes of Informed Consent monitor the call and sign the form, which is signed
1. To ensure that the client understands the nature of later by the parent or legal guardian on arrival at the
the treatment including the potential complications facility. Permission via telepax is also acceptable
and disfigurement
2. To indicate that the client’s decision was made Written Instructions
without pressure • The patient should receive written preoperative
3. To protect the client against unauthorized procedure instructions to follow before admission for the surgical
4. To protect the surgeon and hospital against legal procedure
action by a client who claims that an unauthorized  These instructions should be reviewed with the
procedure was performed patient in the surgeon’s office or in the
preoperative testing center
Circumstances Requiring a Permit
1. Any surgical procedure where scalpel, scissors, Preoperative Written Instructions
suture, hemostats of electrocoagulation may be used 1. NPO before the surgical procedure (“NPO after
2. Entrance into a body cavity- paracentesis, midnight”)
bronchoscopy  To prevent regurgitation or emesis and
3. Use of general anesthesia, local infiltration, regional aspiration of gastric contents
block 2. The skin should be cleansed to prepare the
surgical site
Validation of Consent  Shower with antibacterial soap to cleanse the
Patient should personally sign the consent unless skin as ordered especially for clients who will
he/she is undergo a surgical procedure on the face, ear
1. A minor (below 18 years old) and neck
2. Unconscious 3. The physician may want the patient to take any
3. Mentally incompetent essential oral medications that she/he normally takes
4. In a life-threatening emergency situation  These can be taken as prescribed with a minimal
fluid intake
If the patient is: 4. Nail polish and acrylic nails should be removed
1. A minor, a parent or legal guardian should sign  To permit observation of and access to the nail
2. An emancipated minor (not subject to parental bed during the surgical procedure
control), married, or independently earning a living  Uncover at least one finger nail
he/she may sign  The nail bed is a vascular area, and the color of
3. A minor who is the parent of the infant or child who the nail bed is one indicator of peripheral
is having a procedure. He/she may sign for his/her oxygenation and circulation
own child

 The oxisensor (optode) of a pulse oximeter may afterward that patient will go to the recovery
be attached to the nail bed to monitor oxygen room. Emphasize that delays may be attributed
saturation and pulse rate to many factors other than a problem developing
 Nail polish or acrylic nails inhibit contact between with this patient (e.g. previous case in the OR
these devices and the vascular bed may have taken longer than expected or an
5. Jewelry and valuables should be left at home to emergency case has been given priority)
ensure safekeeping  Let the patient know that the family will be kept
 If electrosurgery will be used, patients should be informed and that they will be told where to wait
informed that all metal jewelry, including and when they can see patient; note visiting
wedding bands and religious artifacts, should be hours
removed to prevent possible burns  Explain how a procedure or test may feel during
 Loss prevention is a consideration as well or after. Describe the recovery room; what
6. Patients should be given other instructions personnel and equipment the patient may expect
about what is expected, such as when to arrive at to see and hear (specially trained personnel,
the surgical facility monitoring equipment, tubing for various
 A responsible adult should be available to take functions, and a moderate amount of activity by
the patient home if the procedure, medication or nurses and health care providers)
anesthesia renders the patient incapable of  Stress the importance of active participation in
driving postoperative recovery
 Family members or significant others should 4. Use of Audiovisual aids if available
know where to wait and where the patient will be  Videotapes, booklets, brochures, and models, if
taken after the surgical procedure available, are helpful
 Demonstrate any equipment that will be specific
Pre-Operative Teaching for the particular client. Examples: Drains and
drainage bags, monitoring equipment, ostomy
• Teaching is a function of nursing practice and
bag
embraces perception, thought, feeling and
performance
• During the preoperative visit, the nurse supplements Preoperatively, the patient will be instructed in the
the instructions of the other perioperative team following postoperative activities. Teach coughing &
members and gives information unique to the patient’s breathing exercises, splinting of incisions, turning side
specific surgical procedure to side in bed, & leg exercises; explain their importance
• The perioperative nurse teaches patients how to in preventing complications. This will allow a chance for
participate in their own postoperative recovery. practice and familiarity
Patients must have a readiness to learn
Diaphragmatic (Abdominal) Breathing
Pre-operative teaching should take place at three levels • This is a mode of breathing in which the dome of the
1. Information diaphragm is flattened during inspiration, resulting in
2. Psychosocial support enlargement of the upper abdomen as air rushes into
3. Skill training the chest
*Frequently done on an out-client basis • During expiration, abdominal muscles and the
diaphragm relax
Implementing the Teaching Program  It is an effective relaxation technique
1. Begin at the patient’s level of understanding and
proceed from there Purpose
2. Include family members and significant others in 1. To promote lung expansion and ventilation and
teaching process enhance blood oxygenation
3. Provide general information and assess the patient’s  This is taught to client who is at risk for
level of interest in or reaction to it developing pulmonary complications, such as
 Explain details of the preoperative preparation atelectasis or pneumonia
and provide tour of area and view of equipment
when possible Instruct the patient to:
 Offer general information on the surgery. Explain 1. Assume bed position similar to that most likely to be
that the health care provider is the primary used postoperatively (semi-Fowlers)
source person
 Tell when surgery is scheduled (if known) and
approximately how long will it take; explain that

2. Place both hands on the lower rib cage; make a *Note: Certain position changes may be contraindicated
loose fist and rest the flat surface of the fingernails after some surgeries (e.g. craniotomy, eye or ear
against the chest (to feel chest movement) surgery)
3. Exhale slowly and fully; ribs will sink downward and
inward toward midline Turning
4. Inhale slowly and deeply through mouth and nose;
• Changing positions from back to side-lying (and vice
permit abdomen to rise as lungs fill with air
versa) stimulates circulation, encourages deep
5. Hold this breath through a count of 5
breathing, and relieves pressure areas
6. Exhale and let all air out through the mouth and nose
• The client who is at risk for circulatory, respiratory, or
7. Do these15 times, with a brief rest after 5 sets
gastrointestinal function following surgery is taught to
8. Practice this twice each day preoperatively
turn in bed
Nursing Intervention
1. Assist the patient to move onto side if assistance is
needed
2. Place the uppermost leg in a more flexed position
than that of the lower leg and place a pillow
comfortably between the legs
3. Ensure that the patient is turned from one side to
back and onto the other side every 2 hours
Incentive Spirometry
• Preoperatively, the patient uses a spirometer to
measure deep breaths (inspired air) while exerting
maximum effort
• The preoperative measurement becomes the goal to
be achieved as soon as possible after the operation
Mechanism
1. Postoperatively, the patient is encouraged to use the
incentive spirometer about 10 -12 times an hour Muscle Pumping Exercises
2. Deep inhalations expand alveoli, which in turn, Instruct the patient to:
prevents atelectasis and other pulmonary 1. Contract and relax calf and thigh muscles at least 10
complications times consecutively
3. There is less pain with inspiratory concentration than
with expiratory concentration, such as with coughing
Coughing
• Coughing promotes the removal of chest secretions
Leg Exercises
Instruct the patient to:
• Moving the legs improve circulation and muscle tone
1. Interlace the fingers and place the hands over the
• This is taught to the client who is at risk for developing
proposed incision site; this will act as a splint during
thrombophlebitis (inflammation of the vein), which is
coughing and not harm the incision
associated with the formation of blood clots
2. Lean forward slightly while sitting in bed
3. Breathe, using the diaphragm as describe under
diaphragmatic breathing
4. Inhale fully with the mouth slightly open 1. Have the patient lie on back; instruct patient to bend
5. Let out 3 or 4 sharp “hacks” the knee and raise the foot-hold it a few seconds,
6. Then, with mouth open, take in a deep breath and extend the leg, and lower it to the bed
quickly give 1 or 2 strong coughs 2. Repeat above about 5 times with one leg and then
7. Secretions should be readily cleared from the chest with the other. Repeat the set five times every 3-5
to prevent complications (pneumonia, obstruction) hours

3. Then have the patient lie on side; exercise the legs Minimum
by pretending to pedal a bicycle Liquid and Food Intake Fasting
Period (HR)
Clear liquids, (e.g. water, clear tea, black coffee,
2
carbonated beverages, and fruit juice without pulp)
Breast milk 4
Nonhuman milk, including infant formula 6
Light meal (e.g. toast and clear liquids) 6
Regular or heavy meals (may include fried or fatty
8
food, meat)
Ankle and Foot Exercises Maintenance of Normal Fluid and Electrolytes

Instruct the patient to: • IV route for fluid replacement is started
1. Rotate both ankles by making complete circles, first
to the right then to the left Reduction of Risks for Surgical Wound Infection
2. Repeat five times and then relax • Determinants of developing a surgical wound
3. With feet together, point toes toward the head and infection
then to the foot of the bed • Amount and type of microorganism contaminating a
4. Repeat this pumping action 10 times, and then relax wound
• Susceptibility of the host
• The surgical wound itself
• Antibiotics may be ordered preoperatively
• Improper skin preparation  increased risk of
postoperative wound infection
• If required, hair removal, preferably with a clipper or
shaver, is performed as close to the time of surgery
Getting Out of Bed as possible
Instruct the patient to: • Have full bath to reduce microorganisms in the skin
1. Turn on your side
2. Push yourself up with one hand as you swing your Preparation of the GIT and GUT
legs out of bed • Preparation of the bowel is imperative for intestinal
surgery because escaping bacteria can invade
Examples of Other Pre-op Teachings adjacent tissues and cause sepsis
1. Mobility and active body movement
2. Pain management Preparation of the GIT
3. Coping strategies 1. Enemas and cathartics remove gross collections of
4. Psychosocial Interventions stools
 Reduce anxiety & fear  Cleanse the GIT to prevent postoperative
 Respect cultural, spiritual & religious beliefs constipation
2. Oral antimicrobial agents (e.g. neomycin,
Physical Preparation erythromycin) suppress the colon’s potent microflora
3. Empty bowel reduces risk of injury to the intestines
• NPO to keep the stomach empty  reduce the risk of
and minimizes contamination of the operative wound
vomiting and aspiration
if a portion of the bowel is incised or opened
• Preoperative diet: High CHON, sufficient CHO, fats
accidentally
and vitamins
4. “Give enemas until clear”
• Fasting from intake of light meal or non-human milk
 Administer enemas until enema return contain
for 6 hours or more, clear liquids: 2-3 hours; before
no solid fecal material
elective procedures requiring GA, RA, or sedation
 No more than 3 enemas should be given
(American Society of Anesthesiologist)
because of negative effects on fluid and
• Nurse can allow the client to rinse mouth with water
electrolyte balance (it is also exhausting to the
or mouthwash and brush the teeth immediately prior
patient)
to surgery as long as the client does not swallow
5. Recheck potassium levels after bowel preparation
water. Notify the surgeon and anesthesiologist if the
 Too many enemas given in a short period of time
client eats or drinks during the fasting period.
can cause fluid and electrolyte imbalance
• Avoid alcohol and cigarette smoking for at least 24
6. A clean bowel allows for accurate visualization of the
hours before surgery
surgical site and prevents trauma to the intestine

Preparation of the GUT  Dentures are permitted during local anesthesia,

1. Instruct the patient to void just before leaving for the especially if the patient can breathe more easily
OR and before preoperative medications are given with them in place
2. Empty bladder prevents a client from being  Dentures are necessary to retain facial contours
incontinent during the surgery; makes the organs for some plastic surgery procedures
more accessible. • Remove colored nail polish to permit
3. Insertion of a Foley catheter to maintain empty observation/access to the nail bed during the
bladder procedure
4. A medication douche may be prescribed  Color of the nail bed is one indicator of
preoperatively if the patient is to have a gynecologic oxygenation and circulation
(e.g. hysterectomy) or urologic preparation  The oxisensor of a pulse oxymeter may be
5. A distended bladder increases the risks of bladder attached to the nail bed to monitor oxygen
trauma and difficulty in performing the procedure saturation and pulse rate
 Nail polish inhibits contact between these devices
and the vascular bed
Promotion of Rest and Comfort
 The patient should be advised that at least one
• Rest is essential for normal healing
fingernail should be uncovered
• Nurse should attempt to make the environment quiet
• Make-ups, powder, blush, lipstick should also be
and comfortable
removed to expose normal skin color and aid in the
• Sedative – Hypnotics (e.g. temazepam [Restoril],
assessment of skin and mucous membrane, to
diazepam [Valium]) affect and promote sleep
determine the client’s level of oxygenation
• Anxiolytic agents (e.g. alprazolam [Xanax]) act on the
• Remove jewelry for safekeeping
cerebral cortex and limbic system to relieve anxiety
 If a wedding ring cannot be removed, it is taped
loosely or tied securely to prevent loss
Eliminating Wrong Site and Wrong Procedure  The patient may be permitted to keep a religious
Surgery symbol, but the patient should understand this
• Whenever an invasive surgical procedure is to be may be removed during the surgical procedure
performed, the nurse and the surgeon must be sure • Removed all removal prostheses (e.g. eye, extremity,
that the site has been marked by the surgeon contact lenses, hearing aids, eye glasses, false
• Indelible ink is used to mark left and right distinction lashes). In some instances, the patient may be
multiple structures (e.g. fingers), and levels of the permitted to wear eye glasses or hearing aid to the
spine OR
• If the patient refuses a mark document and note on • Antiembolic stockings or elastic bandages may be
the procedure checklist ordered for the lower extremities to prevent embolic
• Verify the client and procedure to be performed phenomena
 The stockings are applied before abdominal or
Preparing the Patient on the Day of Surgery pelvic procedures; for patients who have
varicosities, are prone to thrombus formation, or
Early Morning Care
have a history of emboli; and for some geriatric
• Awaken the patient one hour before preop patients
medications will be given to him  They also are applied for long procedures
• Morning bath, offer the client mouth wash and • Take baseline VS before preop medication
toothpaste and caution the client not to swallow water • Check ID band, skin prep
• Provide a clean hospital gown • Check for special orders- enema, GI tube insertion, IV
 The surgeon permits some patients who are very line
embarrassed and uncomfortable to wear pajama • Check NPO
pants if the lower body segment is not part of the • Have client void before PREOP medication to prevent
surgical site over distention of the bladder or incontinence during
 Menstruating patients should use a sanitary unconsciousness
napkin if they will be under general anesthesia for • Continue to support emotionally
more than 2 hours • If ordered, an antibiotic is given 1 hour preoperatively
• Remove hairpins to prevent from scalp injury, braid to establish and reach a therapeutic blood level of
long hair, and cover hair with cap. Hairpieces or wigs antibiotic prophylaxis intraoperatively
should be removed, or in special cases, covered with  If cultures or specimens are obtained during the
surgical cap surgical procedure, a notation should be made on
• Remove dentures and foreign materials (chewing the pathology specimen sheet to indicate
gum) to prevent aspiration antibiotic use

• Prepare client’s chart for OR, including operative Drugs Used

permit & complete pre-op checklist. Allergies should Sedatives and Tranquilizers
be prominently noted on the chart and patient’s • Sedation reduces the effect of anxiety
wristband • Amnesia helps to provide comfort
• Patient should be given other special instructions • Sedatives and tranquilizers produce a calm, hypnotic
about what is expected state
• Administer pre-op medication as ordered
Benzodiazepines – produce excellent amnesia and
mild sedation sufficient to reduce anxiety and fear.
Pre-operative Medications They cause inhibitory effect on interneuron
• Pre-operative meds are given to reduce the client’s transmission to sites in the central nervous system
anxiety, the amount of GA required, the risk of nausea associated with anxiety and fear
& vomiting and resultant aspiration and respiratory a. Diazepam (Valium) – given orally
secretions b. Lorazepam (Ativan) − given orally than IM, has
• Consent form needs to be signed before the good antiemetic effect
administration of pre-operative medications c. Midazolam (Dormicum) − given IM for pre-op
• The client should not be allowed to leave the bed or med and slow IV for conscious sedation
stretcher until surgical personnel arrives to transport Barbiturates – usually given the evening and or the
the client to the OR. Elevate side rails & provide quiet morning before the surgery to promote restful sleep.
environment
a. Pentobarbital (Nembutal)
• Warn the client to expect drowsiness and dry mouth
Anti-emetics/Antinauseants – to minimize nausea and
• Preoperative medications may be given orally (PO),
vomiting, usually used in combination with other drugs
IV, subcutaneously (SC), or intramuscularly (IM)
a. Oral medications – should be given 60-90 minutes a. Promethazine Hydrochloride (Phenergan)
before the patient goes to the OR. Because
patients are fluid before surgery, the patient should Narcotics
swallow these medications with a minimal amount • Produce analgesia by acting an opiate receptor in
of water CNS
b. IM and SC injections should be given 30-60 • Effectively raise the pain threshold and lower the
minutes before arrival at the OR (minimally 20 min) metabolic rate, moderately
c. IV medications are usually administered to the • Decreasing the amount of anesthetic to be used
patient after arrival in the preoperative holding area • Should not be given to asthmatic clients and those
or OR with cardiopulmonary disease
 Side effect: respiratory depressant
Purposes of Pre-operative Medications • Cause circulatory depression and hypotension
1. Provide analgesia a. Meperidine Hydrochloride (Demerol)
2. Prevent nausea and vomiting b. Morphine (Roxanol)
3. Promote sedation and amnesia c. Fentanyl (Sublimaze)
4. Decrease anesthesia requirements d. Nalbuphine (Nubain)
5. Facilitate the induction of anesthesia
6. Relieve apprehension and anxiety Anticholinergics
7. Prevent autonomic reflex response
• Are given primarily to reduce respiratory tract
8. Decrease respiratory and gastrointestinal secretions
secretions and to prevent severe reflex slowing of the
heart during anesthesia
Frequently Used Preoperative Medications
• Typically given in conjunction with an opiate less than
1. Narcotic analgesics (Demerol & Morphine Sulfate) an hour before the patient’s trip to the OR
2. Sedatives a. Atropine Sulfate
3. Anticholinergic (Atropine Sulfate) b. Scopolamine
4. Fentanyl c. glycopyrrolate (Robinul)
5. Histamine H2-receptor antagonist
6. Antacids
7. Antiemetics Note: Preanesthetic medication, if ordered, should
be given precisely at the time it is prescribe. If given
too early, the maximum potency will have passed
before it is needed. If given too late, the action will
not have begun before anesthesia is started.

Administering “On Call” Medications

1. Have medications ready and administer as soon as
call is received from the operating room
2. Proceed with remaining preparation activities
3. Indicate on the chart or preoperative checklist the
time when medication was administered and by
whom
Transporting the Patient to the OR

• Adhere to the principle of maintaining the comfort and
safety of the patient
• Accompany OR attendants to the patient’s bedside for
introduction and proper identification
• Assist in transferring the patient from bed to stretcher
unless bed goes to the OR floor
• Complete chart and preoperative checklist; include
laboratory reports and x-rays as required by hospital
Functions of Members
policy
• Recognize importance of coordinating team effort to The Scrubbed / Sterile Team
ensure arrival of the patient in the OR at the proper • Perioperative caregivers, who provide direct care
time within the sterile field
• The members of this team scrub their hands and
arms, don a sterile gown and gloves and enter the
The Patient’s Family
sterile field
• Direct the patient’s family to the proper waiting room
• The sterile field is the area of the O.R. that
where magazines, televisions and coffee may be
immediately surrounds and is specially prepared for
available
the patient
• Tell the family that the surgeon will probably contact
• To establish and maintain a sterile field, all items
them there immediately after surgery to inform them needed for the surgical procedure are sterile and
about the operation
handled in a sterile manner
• Acquaint the family with the fact that a long interval of
waiting does not mean the patient is in the OR all the
The team is composed of the following:
while; anesthesia preparation and induction take time,
1. Surgeon
and after surgery the patient is taken to the recovery
2. First assistant (second or third assistant if needed)
room (PACU)
3. Scrub person (RN, ST)
• Tell the family what to expect postoperatively when
they see the patient- tubes; monitoring equipment;
and blood transfusion, suctioning, and oxygen The Unscrubbed / Unsterile Team
equipment • Perioperative caregivers who provide direct care from
the periphery of the sterile field and environment
Intraoperative Patient Care  They do not enter the sterile field; they function
outside and around it
Team Members
• Responsible in maintaining sterile and aseptic
1. Surgeon
techniques during the surgical procedure
2. First assistant (second or third assistant if needed)
 Handle supplies and equipment not considered
3. Scrub person (nurse, surgical technologist (ST))
sterile
4. Anesthesia provider (anesthesiologist, certified
• Keeps the sterile team supplied, give direct patient
registered nurse anesthetist (CRNA))
care and handle situations that may arise during the
5. Perianesthesia nurse
operation
6. Circulator
7. Pathologist
The team is composed of the following:
8. Others (e.g. biomedical technicians, nursing
1. Anesthesia provider:
orderlies, students, x-ray personnel, laboratory
a. Anesthesiologist
personnel, sales representatives)
b. Nurse anesthetist
2. Perianesthesia nurse
3. Circulator

4. Pathologist 2. Provides hemostasis (control of bleeding)

5. Others (e.g. biomedical technicians, nursing 3. Handles tissue safely
orderlies, students, x-ray personnel, laboratory 4. Uses surgical instruments and sutures
personnel, sales representatives) 5. Close wounds and apply dressings
6. Applies human anatomical and physiological
Duties and Responsibilities of Each Team Member considerations in practice; recognizes structure,
function and location of tissues and organs;
The Scrubbed / Sterile team
manipulates tissues accordingly to avoid injury
Surgeon – a physician who specializes in the treatment
of injury, disease, and deformity through operations
Second and Third Assistant − may be a resident, intern
Duties and Responsibilities or a registered nurse
1. Serves as the leader of the team
Duties and Responsibilities
2. Responsible for the preoperative diagnosis and care
3. Performs the surgical procedure 1. Usually holds retractors
4. He must be certain that all team members are aware
of what is needed during the procedure and that all Scrub Nurse
necessary supplies, instruments, drapes and Duties and Responsibilities
equipment are available Prepares
5. Responsible for the postoperative management of
1. Sterile instruments and supplies
care
2. Works in concert with the circulating nurse to set up
6. Obtains informed consent
the OR
3. Surgeon’s specific procedural needs
First Assistant (a surgeon, a resident, an intern, a 4. Procedure specific needs
registered nurse first assistant (RNFA) − is a person 5. Hemostatic techniques
other than the surgeon who directly assists the surgeon 6. Suture and closure materials
with the operation at hand
Sterile Technique
Duties and Responsibilities 1. Scrubs, gowns and gloves using the closed gloving
1. Provides surgical exposure (assists in retraction of method
tissues and suctioning of surgical field) 2. Establishes the sterile field

3. Facilitates the surgical procedure and training to administer anesthesia. The title, Certified
4. Anticipates the needs of the sterile team Registered Nurse Anesthetist (CRNA), reflects the
5. Gowns other team members using the open-assisted nurse's qualifications and abilities.
gowning and gloving technique
Perianesthesia Nurse
Adaptability
Duties and Responsibilities
1. Remedies any breach of sterile technique
2. Requests and prepares material needed by the 1. Preoperatively assesses the patient and documents
surgeon the findings
3. Keeps the sterile field neat and functional  Any information that contributes to the care of
the patient in the intraoperative area is
Accountability communicated to the intraoperative team
1. Establishes baseline counts circulating nurse members
2. Informs the circulating nurse of items placed inside 2. Postoperatively, cares for the patient until his/her
the patient physiologic status is stable
3. Double-checks items dispensed on the sterile field
4. Labels all medication containers and delivery Circulating Nurse − directs and coordinates the
devices activities of the intraoperative environment during the
5. Reports volume of drug administered to the patient surgical procedure; should be an RN. Involves patient
for documentation of the circulating nurse assessment, planning and critical thinking skills.
Safety Duties and Responsibilities

1. Manages sharps Indirect Patient Care
2. Prevents retained foreign objects in the patient 1. Assists with OR preparation
3. Reconciles counts and is accountable for items used 2. Opens sterile supplies
in the surgical procedure 3. Prepares medication for use in the OR
4. Maintains patient confidentiality
Surgical Technologists 5. Communication with surgical services personnel
Duties and Responsibilities 6. Pretest equipment
1. Assist surgical operations, as well as pass 7. Plans postoperative care
instruments to the surgeon 8. Initiates discharge planning
 All surgical technologists work primarily under
Direct Patient Care
the supervision of the attending surgeon of each
procedure 1. Patient identification
2. Patient assessment
3. Ensures time out takes place and is documented
The Unscrubbed / Unsterile Team
4. Identification of correct surgical site.
Anesthesiologist – a medical doctor trained to 5. Transfers patient between cart and bed
administer anesthesia and manage the medical care of 6. Assists the anesthesia provider
patients before, during, and after surgery 7. Provides skin antisepsis
8. Provides thermoregulation
Duties and Responsibilities 9. Prevents electrosurgical injury
1. Must see to it that all supplies and equipment 10. Collaborates with patient fluid intake and output
necessary for the induction of anesthesia are 11. Monitors vital signs as needed
available 12. Provides dressings and drains
2. Gives and controls the anesthetic agent to the patient
3. Determine when the surgeon or circulating nurse Coordinates
may proceed with positioning and preparing the 1. Plans for each member of the sterile team to enter
operative site the sterile field
4. Keeps the surgeon aware of the patient’s condition 2. Positioning, prepping and draping
5. Oversee the post-anesthesia care unit (PACU) until 3. Connection of surgical machinery
each patient has regained control of his/her vital 4. Laboratory tests
functions 5. Multidisciplinary teams
6. Diagnostic Activities
Nurse Anesthetist – a registered nurse and advanced 7. Emergency response to patient crisis
practice nurse who has acquired additional education 8. Communication with patient’s significant others

Anticipates moistened with sterile saline or to pour sterile saline

1. Sequence of the procedure directly over the gloved hands
2. Needs of the sterile team
3. Breaches of sterile technique Any counted sponge should be unfolded and dropped
4. Hemostatic needs into the sponge bucket for counting
5. Radiation protection for sterile team
Arrange on the Mayo stand the instruments and
6. Potential for patient’s physiologic changes
accessory items needed to create the primary incision
7. Wound class at conclusion of the procedure
and control of bleeders
8. Patient responses to care
9. Significant others response to patient’s condition
Accountability
1. Validates implants
2. Documents patient care
3. Hands off report to postoperative care giver
Example of basic instrument table setup. Contents will vary according to the
4. Specimen care and reporting type of surgical procedure.
5. Promotes a culture of safety

6. Accountability for sponges, instruments and sharps
7. Patient’s advocate
8. Evaluates patient’s outcomes
Pathologist – a specialist in the scientific study of the

Example of setup for Mayo stand.
alterations in tissue produced by disease. He/she is
consulted by the surgeon during surgery (e.g sends Prepare sutures in the sequence in which the surgeon
specimen for frozen section tissue examination, like a will use them
breast mass to find out if a MRM is needed or not) and
 The surgeon may ligate (tie off) large blood vessels
after surgery of any tissue removed for histopathology
with a suture ligature shortly after the incision is
made unless electrosurgery is preferred to seal
Reminders for the Scrub Nurse vessels
When draping an unsterile table with a separate sterile
drape, unfold it toward yourself to cover the front edge Dispensing reels, strands of ligating materials can be
of the table first placed in a suture book (an old pet name for a fan-folded
 This minimizes the possibility of self-contamination towel), with the ends far enough for rapid extraction
from the edge of the table  To prevent contamination, strands are pulled out
 Unfold the remainder of the sterile table drape over toward the surgical field, never away from it
the surface of the table and away from yourself
Syringes with needles are used for injection and
When draping the Mayo stand, drape both the frame aspiration and syringes without needles (e.g. Asepto)
and tray are used for irrigation
 The Mayo stand cover is like a long plastic pillow  Do not recap any needle by hand
case with a single sheet of nonwoven fabric that will  Place near the working end of the table with the
lie on the flat surface that will hold instruments needle pointing away from yourself
 It is fan folded with a wide cuff to protect gloved
hands Once a perforating towel clip has been fastened through
 With hands in the cuff, support the folds of drape on a drape, do not remove it, because the points are
the arms, in the bend of the contaminated and the drape now has holes
elbows, to prevent it from
Because skin cannot be sterilized, the initial skin scalpel
falling waist level
is contaminated, whether or not the surgeon has cut
 While sliding the cover on the
through an adhering plastic adhering skin drape
Mayo stand, place a foot on
the base of the stand to The tip of the ESU pencil becomes hot and could burn
stabilize it the patient or a team member
 Accidental activation can occur if pressure is
The preferred method for removing powder or blood
exerted on the hand piece; this can cause ignition
from gloves are either to use a sterile towel or sponge
of the draping material or dry sponges

 Therefore, attach a container (holder/holster) to the When handling a specimen from the field to the
drape with a non-perforating clip for containment of circulating nurse, hand it in a basin or appropriate
the ESU container; never place it on a surgical sponge
 When not in use, the tip of the ESU pencil is cleaned  Tell the circulating nurse exactly what the specimen
on a tip polisher/scraper and placed on the holder is, if there are any identifying notations for the
 The ESU tip should not be cleaned with a scalpel pathologist or if the specimen is to have special
blade testing (e.g. frozen section)
 The char should not be permitted to fall into the  If there are any doubts of about the specimen’s
patient identification, markers, or processing, ask the
surgeon for clarification
If the instrument towel on the sterile field becomes
bloody, do not remove it but cover it with a fresh, sterile
towel During Closure
Alert the circulating nurse that closure is about to begin
When bleeding is obvious, the surgeon needs  Count sponges, instruments and sharps with the
hemostatic forceps and /or ESU pencil circulating nurse
 If the bleeding is in a deep wound, the extended
ESU pencil tip may need to be attached quickly Clear unnecessary instrumentation from the mayo
Keep instruments as clean as possible stand, leaving a pair of tissue forceps, suture scissors
and 4 hemostats
 Wipe blood and organic debris from them with a
moist sponge  Place unneeded instruments and supplies on the
instrument table in the original set position
To keep the suction tip and tubing patent, periodically  This makes the instrument count easier than trying
flush the suction tip with a few milliliters of saline or to dig through a pile of jumbled instruments
sterile water
The instrumentation setup and the Mayo stand should
 Keep track of the amount of solution used to clear
remain sterile until the patient has left the room
the line, and inform the circulating nurse
 The volume of fluid in the suction canister may be  Cardiac arrest, laryngospasm, hemorrhage,
confused with the blood loss premature drain extraction or other emergencies
can occur in the immediate postoperative post-
Place a ligature in the surgeon’s hand anesthesia period
 Draw a strand out of the suture book and toward the  Even though sterile instrument sets are nearby
sterile field, grasp both ends, and place the strand valuable time can be lost in reopening sterile
securely with an upward sweep in the surgeon’s supplies, and every second counts in emergency
outstretched hand situation
The end of a ligature may be placed in long-curved Have a clean, warm, saline – moistened sponge ready
forceps, in a maneuver referred to as “tie on a passer” to wash blood from the area surrounding the incision as
soon as skin closure is completed
 This method is used when the structure will be
circumferentially tied off  Have the sterile dressings ready
 When handling tie on a passer, lace the forceps in  Radiopaque sponges are never to be used for
the surgeon’s hand in the same manner used to dressing
pass hemostatic forceps  After the dressing is in place, the team will undrape
the patient
Never put a large clamp on a small specimen; this may
crush cells and make tissue identification difficult Reminders for the Circulating Nurse
 Some specimens have borders and margins that After the Scrub Person Scrubs
the surgeon will mark with specific sutures as tags Use an appropriate method of sterile transfer to the
for the pathologist’s identification of and to attention sterile field
to certain areas
 Place the item on the edge of sterile instrument
Specimens designated as right or left be kept separately table with the inside of the wrapper everted over
in clearly marked containers your hand. Never reach over the sterile field and
shake an item from its package.
 Keeping bilateral specimens separated helps
 Expose the contents so the scrub person can
prevent confusion if part of the tissue sample is
remove the item from the wrapper or package by
found to be positive for cancer
using forceps or by grasping the item. The scrub

person avoids touching the unsterile outside. Cover the patient’s hair with a cap to prevent
Remember that the sterile boundary of a peel open dissemination of microorganisms and protects the hair
package is the inner edge. from being soiled
 Flip only small, rigid items (e.g. suture) and do so
with caution. Flipping an item from a package may After the patient has transferred to the OR bed, apply
result in the item missing the intended sterile the safety belt over the thighs 2-3 inches above the
surface and landing on the floor. Larger items such patient’s knees and place his/her arms on arm boards.
as staplers or implants can become contaminated The safety belt should be placed over the blanket so it
or damage and therefore are never flipped. is visible, and it should not impair circulation to the
extremities. Other considerations include the following:
Check the list of suture materials and sizes on the  The patient’s legs should not be crossed. A small
surgeon’s preference card, but verify with the surgeon pillow may be placed under the patient’s knees to
before opening packets decrease strain on the lower back.
 Avoid opening suture packets in advance that may  The angle of abduction of the arm on the arm board
not be used should not exceed 90 degrees-a right angle with the
 The surgical procedure might be cancelled at the body. The brachial nerve flexus can be damaged by
last minute or the patient’s condition may warrant lengthy, severe abduction of the arm
something different, and then the sutures may be
wasted Help the anesthesia provider as needed. Apply and
connect monitoring devices, and assist with IV infusion,
To establish a baseline of table contents for the record, induction, and intubation as necessary
count sponges, instruments and sharps with the scrub
person in the manner as described in facility policy and After the Patient is Anesthetized
procedure
Attached the anesthesia screen and other table
 Record this number immediately on the tally sheet attachments as needed
or wipe off board to begin the ongoing tally
 Reposition the patient only after the anesthesia
 Leave a sufficient space for the listing of items that
provider says the patient is anesthetized
maybe added during the procedure
If an ESU is to be used, place the dispersive electrode
After the Patient Arrives pad in contact with the skin
Greet and identify the patient, introduce yourself, and  Avoid scar tissue and hairy and bony areas
identify your title and role  If an excessively hairy area is used for the
 Offer the patient a blanket from the warming cabinet electrode, a small area is dry shaved
 Check the wristband for identification by name and
number
 Ask the patient to verbally identify himself/herself
and (in his own words) describe an understanding
of the surgical procedure
If the surgical site is designated left of right, validate the

Path of electric current from electrosurgical unit (ESU) Placement of electrosurgical unit (ESU) dispersive
area by having the patient point to the spot electrode
 Double check this spot against the permanent

Expose the appropriate area for skin preparation and/or
record and the scheduled procedure
foley catheter insertion
 The correct surgical site should be marked by the
surgeon’s initials with an ink marker Prepares the patient skin with antiseptic solution
Verify any allergies or environmental and /or chemical  All prep solutions should be completely dry before
sensitivities may have the patient is draped
 These may be identified with an additional

wristband and by special notation on the patient’s After the Surgeon and Assistants(s) Scrub
chart Assist with gowning the team
 Ask the patient to describe his/her reaction to the
drug or substance Observe for any breaks in sterile technique during
draping
 Stand near the head end of the operating bed to
assist the anesthesia provider in fastening the

drape over the anesthesia screen or around an IV  The routine care for each type of tissue specimen
pole next to the arm board may vary as follows
o Pathology tissue specimen should not be
The drainage bag of the foley catheter should be placed allowed to dry out. Saline or a solution of
in view of the anesthesia provider and the circulating aqueous of formaldehyde (10% formalin) is
nurse commonly used as a fixative. Fresh tissue and
frozen sections are not place in preservative
The scrub nurse will move the sterile mayo stand into
solution.
position over the table. The circulating nurse will move
o Cultures should be refrigerated or sent to the
the instrument table in to position, being careful not to
laboratory immediately. Cultures are obtained
touch the sterile surface of the drapes
under sterile condition. The tips of swabs must
not be contaminated by any other source. The
Place steps or platforms for team members who need
circulating nurse may hold the tube with gloved
them or place sitting stools in position for the team that
hands, but swabs are handled only by sterile
needs to operate while seated
team members. OR and laboratory personnel
Position kick buckets (sponge buckets) on each side of must be protected from contamination. If the
the operating bed tube is handed off the sterile field, the
circulating nurse (wearing gloves) can hold
Connect suction, the ESU cord, the dispersive electrode open a small plastic bag into which the scrub
cable, or any other powered equipment to be used person drops the tube.
o Cultures for suspected anaerobic pathogens
Place put pedals within easy reach of the surgeon’s right require immediate attention. Exposure to air
foot and confirm and document the desired settings on may kill anaerobes in a few minutes. Most
all machines laboratories provide special transport devices
or media for their survival. If such devices are
During the Surgical Procedure not available, purulent material can be
Be alert to anticipate the needs of the sterile team, such aspirated into a sterile disposable syringe
as adjusting the operating light, removing perspiration through a disposable needle. This needle is
from brows and keeping the scrub person supplied with removed and placed with counted sharps on the
sponges, sutures, warm saline, and other necessary instrument table. Air is expelled away from the
items field, and the syringe is capped with the syringe
tip supplied with the syringe; the syringe is then
Assist the surgeon and the anesthesia provider to sent immediately to the laboratory. The needle
monitor blood loss should not be sent with the needle attached and
 Estimate the blood volume in the suction container the needle should not be recapped by hand
by subtracting irrigation and body fluids from the because of the potential of needle stick injury.
total volume in the container o Smears and fluids should be taken to the
 Obtain blood products for transfusion from the laboratory as soon as possible. These may be
refrigerator or send a patient care assistant to the placed on glass slides or drawn into evacuation
blood bank tubes.
o Stones are placed in dry container so they will
Prepare and label specimens for transport to the not dissolve.
laboratory o Foreign bodies should be sent for accession
 An error in labelling a tissue specimen or culture according to policy, and a record is kept for legal
could cause an inaccurate diagnosis or improper purposes. The description and disposition of the
therapy or necessitate another operation object are recorded. A foreign body may be
 Each container is labelled with the patient’s name, given to the police, surgeon or patient
identification no. and type and size of specimen depending on its legal implications, policy or
 Accompanying the specimen is a requisition that surgeon’s wishes.
specifies the laboratory test requested by the o Amputated extremities are wrapped in plastic
surgeon. The requisition includes the date, name of before sending them to a refrigerator in the
surgeon, preoperative and postoperative diagnoses laboratory or morgue. Avoid placing the
 Specimens taken from bilateral aspects of the body, amputated limb on the patient’s field of vision to
such as tonsils should be separated and labelled as prevent emotional distress. The patient may
left or right. This is important if there is potential for request that an amputated extremity be sent to
the diagnosis of cancer a mortuary for preservation for burial with
his/her body after death.

After the Surgical Procedure is Complete c. Floor Count – the circulating nurse counts
Assist with securing the dressing(s) over the surgical sponges and any other items that have been
wound and managing the surgical drainage system recovered from the floor or passed from the
sterile field to the kick buckets. These counts
See that the patient is clean should be verified by the scrub person
 Wash off body substances or plasters 4. Final count (Second closing count)
 Put on a clean, warm gown and blanket  The final count is performed to verify any counts
 A final count may be taken during subcuticular or
Remove radiographs from the view box, place them in skin closure
an envelope and take them to the designated area to be  The circulating nurse totals the field, table and
returned to the radiology department floor count
 If the final counts match the totals on the tally
Transfer the patient to the PACU sheet, the circulating nurse tells the surgeon the
 The anesthesia provider guards the head and neck counts are correct
from injury and calls the count for the move
Incorrect Count
Sponge, Instrument and Sharps Counts 1. The surgeon is informed immediately
• A counting procedure is a method of accounting for 2. The entire count is repeated
items put on a sterile table for use during the surgical 3. The circulating nurse searches the trash receptacles,
procedure under the furniture, on the floor, in the laundry
hamper, and throughout the room
Importance of counting items used during the surgical 4. The scrub person searches the drapes and under
procedure items on the table and Mayo stand
1. Item can be lost in patient’s body, causing the need 5. The surgeon searches the surgical field and wound
for additional surgery 6. The circulating nurse should call the immediate
2. Item can be lost in trash or linen, causing harm to supervisor to check the count and assist with the
other personnel search
3. Item can be lost from inventory, resulting in high 7. After all search options have been exhausted, policy
replacement cost should stipulate that a radiograph film be taken
before the patient leaves the OR
Counting Procedures 8. The circulating nurse should write an incident report
and document on the OR record all efforts and
1. Initial count when the tray is assembled
actions to locate the missing item, even if the missing
 The person who assembles and wraps items for
item is located in the radiograph
sterilization will count them in standardized
multiple units
2. Baseline count during setup for the surgical Sponges
procedure Types of Sponges
 The scrub person and the circulating nurse Gauze sponges
together count all items before the surgical • Supplied sterile, pre-counted, and folded
procedure begins and during the surgical • Also called Raytec or Raytex sponges
procedure as each additional package is opened
and added to the sterile field Laparotomy Tapes (lap pads, tapes, pads)
3. Closing counts (First Closing count) • Used for retaining the viscera and keeping them moist
 Counts are taken in 3 areas before the surgeon and warm
starts the surgeon starts the closure of a body • Normal saline or Ringer’s Lactate is commonly used
cavity or a deep or large incision to moisten tapes
a. Field Count – either the surgeon or the
assistant assists the scrub nurse in counting. Dissecting Sponges: Peanut Sponges
This area should be counted first. Counting • Very small, ovoid gauze sponges used for blunt
this area last could delay closure of the dissection or absorption of fluid in delicate procedures
patient’s wound and prolong anesthesia • They are clamped into the tip of an Adson or right-
b. Table Count – the scrub person and the angle clamp during use
circulating nurse together count all items on
the Mayo stand and instrument table. The Compressed Absorbent Cottonoids (Patties)
surgeon and assistant may be suturing the • Small squares or rectangles made of compressed
wound while this count is in process rayon or cotton

• They are moistened with Ringer’s Lactate or a topical 2. Give needles to the surgeon on an exchange basis;
hemostatic agent like thrombin, for use on delicate that is, one is returned before another is passed
structures such as nerves, brain, and spinal cord 3. Use needles and needle holders as a unit
• The surgeon will pick up the moistened, flat cottonoids  A Good Rule is: No needle on the Mayo stand
with forceps (commonly bayonet forceps) and apply it without a needle holder and no needle holder
to the area intended for use without a needle
Towels By the Circulating Nurse

• Occasionally but not universally used for protecting 1. Open only the necessary number of packets of
the viscera sutures with swaged needles
2. Counted sharps should not be taken from the OR
Counting Sponges during the surgical procedure
By the Scrub Nurse 3. A sharp is passed off the sterile field if it punctures,
1. Keep sponges, tapes, peanuts, and other such cuts, or tears the glove of a sterile member
materials separated on the instrument table and far
away from each other and from any draping material, Instruments
especially towels Counting Instruments
2. Keep sponges far away from small items (e.g.
1. Instruments are counted as they are assembled in
needles, hemostatic clips) that might be dragged into
standardized sets
the wound by a sponge or tape
Cluster Counting – a method of counting all scissors,
3. Do not give the pathologist a specimen on a sponge
pick-ups, needle holders, retractors, and other like
to take from the room instead put the specimen on a
groups together without having to name each item
basin or on a towel
with its formal name
4. Do not be wasteful of sponges
Example: in a tray are 2 pairs of each different
types of scissors, the cluster can be counted as “6
By the Circulating Nurse
scissors” instead of 2 Mayo, 2 Metzembaum and 2
1. To prevent the possibility of confusion in the count, suture scissors
nonradiopaque gauze sponges used on different 2. Account for all detachable and disassembled parts
trays (e.g. spinal, shave, or prep trays) should be 3. Recover and retain all pieces of an instrument that
bagged and moved away from the sterile field before breaks during use
the incision is made 4. After the initial count is taken, count any instruments
2. Count and bag sponges in the same increment in added to the table
which they are supplied, such as group of 5 or 10 of
like sponges
3. Give additional sponges or tapes to the scrub person Documentation by the Circulating Nurse of Direct
when it is convenient for him/her to count them Intraoperative Care
4. Give dressings to the scrub person after the final • Initial assessment of the patient on arrival to the OR
sponge count  The identity of the patient and verification of the
5. Do not discard or remove counted sponges from the procedure should be validated
room for any reason until the patient is out of the  Correct surgical site should be marked by
room surgeon’s initials
• The significant times, such as arrival, start,
completion, and room exit times
Sharps
• Disposition of sensory aids or prosthetic devices
• Sharps include surgical needles, hypodermic accompanying the patient on arrival in the OR
needles, knife blades, electrosurgical needles and • Position, surgical safety devices, and/or restraints
blades, and safety pins used during the surgical procedure
• If a needle or blade has broken, both the scrub person • Placement of monitoring and electrosurgical unit
and the circulating nurse must make sure all pieces (ESU) electrodes, tourniquets and other special
are recovered or accounted for equipment and identification of units or machines
used, as applicable
Counting Needles and Other Sharps  The settings and duration of use should be
By the Scrub Nurse recorded
1. Leave needles swaged to suture material in their • The names and times of all personnel in the room for
inner folder until the surgeon is ready to use them the procedure
• The type of anesthetic administered, and by whom

• The surgical site preparation, the antiseptic agent blood. They should then be returned to proper
administered, and by whom position
• Medications, solutions, and doses administered, and 9. Instrument tables should never be in a disorderly
by whom state during an operation so that the scrub nurse can
• Timeout validation of site, patient and procedure work smoothly and with speed
• A description of the actual surgical procedure 10. Impaired instruments should never be passed to the
performed surgeon
• Contact with the patient’s family or significant others 11. Any instruments or supplies that have come in
• Type, size and manufacturer’s identifying information contact with contaminated areas must be discarded
(lot numbers) of prosthetic implants, or the type,  They should be lifted from the field with transfer
source and location of tissue transplants or inserted forceps or received by the kidney basin and
radioactive materials should never be touched with the gloved hands
• Use of radiograph or imaging
• Disposition of tissue specimens and cultures Passing and Handling of Suture Materials
• Correctness or incorrectness of surgical counts (if
1. The scrub nurse should study the suture preferences
incorrect, the remedial measures to locate the lost
of each surgeon with whom she works
item)
2. The sutures are prepared and kept between the fold
• Placements of drains, catheters, dressing and
or compartments of the towel on the mayo table with
packing
the ends far extended for easy extraction
 Output is recorded if receptacle is emptied in the
3. The scrub nurse should prepare sutures suitable to
OR
the nature of the operation and to the surgeon’s suture
• Wound classification is designated at the end of the
4. If the scrub nurse is not sure of the surgeon’s suture
procedure
preferences, she may ask him what will he require and
• Charges to patient for supplies, according to hospital
will arrange her work accordingly
routine
5. The scrub nurse should always prepare 3 working
• Piece of equipment sent from OR with patient to unit
needles in advance
(e.g. tracheostomy set that accompanies the patient
6. Needle and holder are received from the surgeon
after thyroidectomy, wire scissors if patient has had
before another suture is passed
teeth wired together
7. Needles should be kept in a suture towel if not
 These items are to be returned
threaded on needle holder
• Disposition of the patient after leaving the OR
8. All needles must be counted by the scrub nurse
• Any unusual event or complication
9. The suture ligature is passed in a functional position
10. The suture material does not get entangled or coiled
Precautions and Techniques for the Scrub Nurse 11. The scrub nurse should not allow sutures to hand
Passing and Care of Instruments over the edge of the table which are not considered
1. The scrub nurse should know the various steps of the sterile
different operations so that he/she may keep one
stop in advance of the surgeon at all times Three Areas of the O.R.
2. He/she must be thoroughly familiar with the Unrestricted Area
characteristics of each surgeon’s technique
• Street clothes are permitted and traffic is not limited
3. The scrub nurse may pass the instruments to the
• It includes a central control point that is established to
surgeon with the right hand, or the one nearest the
monitor the entrance of patients, personnel and
operative field
materials
4. When passing an instrument, it should be held at the
shank between the cushions of the thumb and first Semi Restricted Area
two fingers, with the tip visible and the handle is free
• Traffic is limited to properly attired, authorized
for the surgeon’s palm
personnel
5. The curve of the instrument goes with the curves of
• Scrub suits and head coverings are required attire
the surgeon’s hands
• This area includes peripheral support areas and
6. By a slight turn of the wrist, the rings of the
access corridors to the ORs, storage areas for clean
instruments handle are gently rung over the
and sterile supplies and work areas for storage and
surgeon’s finger
processing of instruments
7. Tissue, thumb, debakey forceps are held with the tip
• The patient hair is also covered
down
8. Slightly soiled instrument should be wiped off with a
wet sponge to remove all free fatty substances and

Restricted Area 7. If a sterile package wrapped in a pervious woven

• Includes operating and procedure rooms and scrub material drops to the floor or other area of
sink areas questionable cleanliness
• People in this area are required to wear full surgical  A dropped package is considered contaminated
attire and cover all head and facial hair  If the wrapper is impervious and the area of
• Masks are required where open sterile supplies or contact is dry, the item may be transferred to a
scrubbed persons are located sterile field
Modes of Contamination Sterile persons are gowned and gloved

Direct Contact Between a Non-Sterile and Sterile • Gowns are considered sterile only from the chest to
Surface the level of the sterile field in front, and from 2 inches
• The surgeon’s back touching sterile wash basin above the elbows to the cuffs on the sleeves
• Bacterial seepage through moist linen • When wearing a gown, only the area that can be seen
• A puncture in a sterile glove in front down to the level of the sterile field should be
• Possible contact by the circulating nurse with any considered sterile
sterile item passed to the scrub nurse
• Anesthesiologist touching the top of the anesthesia The following practices are observed
screen 1. Self-gowning and gloving should be done from a
• Infected fluids from the patient wetting sterile gloves separate sterile surface to avoid dripping water onto
or instruments sterile supplies or a sterile table
• Surgeon touching the exposed skin of the patient 2. The stockinet cuffs of the gown are enclosed
beneath sterile gloves
Non-Sterile Moisture Droplets Falling on a Sterile  Once the cuff has been contained within the
Surface closed glove, it should not be pulled back over
• Droplets passing through the mask of the surgeon and the hand for any re-gloving procedure
scrub nurse  Re-gloving should be performed using the open
• Perspiration- drop falling in the surgical site gloving technique. Another sterile team member
• Respiration from the patient’s unmasked mouth can assist with this process as necessary
• Perspiration permeating through a sterile gown 3. Sterile persons keep their hands in sight at all times
and at or above waist level or the level of the sterile
field
Principles of Sterile Technique
4. Hands are kept away from the face, and the elbows
Only sterile items are used within the sterile field
are kept closed to the sides
• If there is any doubt about the sterility of any item, it  The hands are never folded under the arms
should be considered not sterile and therefore should because of perspiration in the axillary region
not be used  The neckline, shoulders, and the back also may
become contaminated with perspiration
Examples of questionably sterile items include, but are 5. Sterile persons are aware of the height of team
not limited to, the following: members in relation to each other and the sterile field
1. If a sterilized package is found in a contaminated  Changing levels of sterile field is avoided
area (e.g. the general unsterile workroom, the locker  The gown is considered sterile only down to the
room) highest level of the sterile working field
2. If uncertain about the actual timing or operation of the  If a person must stand on a platform to reach the
sterilizer surgical site, the standing platform should be
 Items processed in a suspect load are positioned before this person steps up to the
considered unsterile draped area
3. If an unsterile person or object comes into close  Sterile persons should sit only when the entire
contact with a sterile table and vice versa procedure will be performed at this level
4. If a sterile table or unwrapped sterile items are not  If one person on the team sits, the entire team
under constant observation should be seated
5. If the integrity of the packaging material is not intact
6. If a sterile package wrapped in a material other than
plastic or another moisture-resistant barrier becomes
damp or wet

Unsterile persons avoid reaching over the sterile field,

while sterile persons avoid leaning an unsterile area
The following practices are observed
1. The unsterile circulator never reaches over a sterile
field to transfer sterile items
2. The circulator holds only the lip of the bottle over the
basin when pouring solution into a sterile basin to
avoid reaching over a sterile area
 He/she should avoid making contact with the
bottle and the basin and avoid splashing
solutions
 The entire contents of the bottle should be
dispensed in one pouring motion
Tables are sterile only at table level  If some of the solution is not poured it is
Because tables are sterile at table level, OR personnel considered contaminated and may not be
must adhere to the following: recapped for later use or dispensed to another
sterile basin
1. Only the top of a sterile, draped table is considered
 Once the cap is off, it is considered
sterile
contaminated
 The edges and sides of the draped extending
3. The scrub person sets basins or glasses to be filled
below table level are considered contaminated
at the edge of the sterile table; the circulator stands
2. Anything falling or extending over the table edge,
a safe distance away from the edge of the table to fill
such as a piece of a suture or suction tip, is
them
contaminated
4. The team uses sterile light handles for manipulation
 The scrub person does not touch the part
and adjustment of the surgical lights
hanging below table level
5. The surgeon or team member steps away from the
3. When unfolding a sterile drape, the part that drops
sterile field to have perspiration removed from the
below the table surface is not brought back up to the
brow
table level
6. The scrub person drapes an unsterile area by:
 Once placed, the draped is not moved or shifted
4. Cords, tubing, and other materials are secured on Unfolded Drape − Placing the drape over the
the sterile field with a non-perforating clip to prevent unsterile surface nearest self-first and carefully
them from sliding over the table edge completing the coverage of the far side. This protects
the front of the gown from coming into contact with
the unsterile surface being covered. Gloved hands
are protected by cuffing a drape over them.
Folded Drape − Unfolding toward self-first to protect
the gown when working with a folded drape. When
completing the coverage, the rest of the drape is
unfolded away from self
7. The scrub person stands back from the unsterile
table when draping it to avoid leaning over an
unsterile area
The edges of anything that encloses sterile contents are

Sterile persons touch only sterile items or areas, while considered unsterile
unsterile persons touch only unsterile items or areas
The following precautions should be taken
The following practices are observed
1. When opening sterile packages, a margin of safety
1. Sterile team members maintain contact with the is always maintained
sterile field by means of sterile gowns and gloves  The inside of the wrapper is considered sterile to
2. The unsterile circulator does not directly contact the within 1 inch of the edges
sterile field  The circulator opens the top flap away from self,
3. Supplies are brought to sterile team members by the then turns the sides under. The ends of the flaps
circulator, who opens the wrappers using aseptic are secured in the hand so they do not dangle
technique loosely. The last flap is pulled toward the person

opening the package, thereby exposing the Destruction of the integrity of microbial barriers results
package contents away from the sterile hand in contamination
2. Sterile persons lift contents from packages by 1. Sterile packages are laid only on dry surfaces
reaching down and lifting them straight, holding their 2. If a sterile package wrapped in an absorbent material
elbows high becomes damp or wet, it is discarded
3. The flaps on peel-open packages should be pulled
back, not torn, to expose the sterile contents
Microorganisms must be kept to an irreducible minimum
4. If a sterile wrapper is used as a table cover, it should
1. Skin cannot be re-sterilized
amply cover the entire table surface
 Skin is a potential source of contamination in
5. After a bottle of sterile solution is opened, the
every invasive procedure
contents are either used or discarded
 If a glove is torn or punctured by a needle or
 The cap cannot be replaced without
instrument, it is changed immediately
contaminating the pouring edges
 The puncturing needle or instrument is removed
from the sterile area
The sterile field is created as close as possible to the 2. Some areas cannot be scrubbed (mouth, nose,
time of use throat and anus)
Precautions must be taken as follows 3. Drapes placed over the anesthesia screen or
1. Sterile tables are set up just before the surgical attached to IV poles at the head of the bed separate
procedure the anesthesia area from the sterile field
2. Covering sterile tables for later use is not
recommended Personal Protective Equipment (PPE)
• PPE is a special set of equipment that can be added
Sterile areas are continuously kept in view to the surgical attire
1. Sterile persons face sterile areas • It protects us from specific threats that otherwise plain
2. Someone must remain in the room to maintain surgical attire would not be able to handle
vigilance when sterile packs are opened in the room • However, PPE is effective only if it prevents contact
with possibly infected bodily fluids
Sterile persons keep well within the sterile area
1. Sterile persons stand back at a safe distance from Apron − it is worn on top of the surgical attire to protect
the operating bed when draping the client the body
2. Sterile persons pass each other back to back at a Decontamination apron is worn during
360-degree turn decontamination of instruments since most of the
3. Sterile persons turn their backs to an unsterile substances used this process are toxic;
person or area when passing decontamination starts with the wearing of PPE
4. Sterile persons face a sterile area to pass it Fluid proof apron is worn during surgeries when
5. Sterile persons ask an unsterile individual to step excessive bleeding is expected; a special kind of PPE
aside rather than risk contamination that prevents blood or fluid from saturating the
6. Sterile persons stay within the sterile field surgical attire
 They do not walk around or go outside the room Lead apron is worn during surgeries or procedures
requiring radioactive materials like radiation implants
Sterile persons keep contact with sterile areas to a
minimum
1. Sterile persons do not lean on sterile tables or on the
draped patient
 Leaning on the patient can cause injury to
tissues and structures
Unsterile persons avoid sterile areas

1. Unsterile persons maintain a distance of at least 1
foot from any area of the sterile field Decontamination apron Fluid proof apron Lead apron
2. Unsterile persons never walk between 2 sterile area
(e.g. between sterile instrument tables)

Eyewear / face shield – prevents blood and body fluids disposable nail cleaning products are available
from splashing on the face and are usually supplied with disposable scrub
Laser eyewear − protects the eyes from intense light brushes.
created by laser surgery  Six drops (about 2-3 ml) solution is sufficient to
generate lather for the scrub procedure. Waste
of antiseptic solution should be avoided.
Surgical Scrubbing
• The process of removing as many microorganisms as
Eyewear Face shield Laser eyewear
possible from the skin of the hands and arms by
mechanical washing and chemical antisepsis before
participating in a surgical procedure
Gloves
Nonsterile gloves – donned for clean procedures Scrub Sink
Sterile gloves – donned for sterile procedures − Scrub sinks with automatic sensor controls or
foot-or knee-operated faucets are preferred to
Lead gloves – worn when radiation is involved; usually
eliminate the hazard of contaminating the hands
by the surgeon
after hand and arm washing
Thick gloves – skin protection for handling sterilization
− Scrub sinks should be used only for scrubbing
using ethylene oxide
and handwashing
Double gloving – reduces risk of needle prick injuries o They should not be used to clean or rinse
and injury from bone shards in orthopedic cases; inner contaminated instruments and equipment
glove is larger than outer glove (this creates air
pockets that prevent tightness inside the glove) Preparation for Surgical Hand Cleansing (also called the
Utility gloves – worn for cleaning and housekeeping. surgical scrub)
General Preparations
Surgical Hand Washing and Scrubbing 1. The skin and nails should be kept clean and in good
• The surgical scrub is the process of removing as condition; the cuticles should be uncut
many as microorganisms as possible from the hands  If hand lotion is used to protect the skin, a non-
and arms by mechanical washing and chemical oil-based product is recommended. Oil can
antisepsis before participating in a surgical procedure weaken the integrity of the gloves
• Despite the antimicrobial component of the hand and 2. Fingernails should not extend beyond the fingertips
arm cleansing process, skin is never rendered sterile to avoid glove puncture
 The process of scrubbing is not a sterile 3. Fingernail polish should not be chipped or cracked
procedure 4. Artificial devices should not cover natural fingernails
 In scrubbing, the skin is cleansed of as many 5. All jewelry should be removed from the fingers, wrist,
microorganisms as possible and neck
• Two processes are commonly used:  Jewelry harbors microorganisms
Mechanical – the process removes soil and transient
organisms with friction Preparations Immediately Before Surgical Hand
Chemical – the process reduces resident florae and Cleansing
inactivates microorganisms with an antimicrobial or 1. Be sure all hair is covered by headwear
antiseptic agent  Pierced ear studs should be contained by the
head cover
Purpose  They are a potential foreign body in the surgical
1. To decrease the number of resident microorganisms site
on skin to an irreducible minimum 2. Adjust the disposable mask snugly and comfortably
2. To keep the population of microorganisms minimal over the nose and mouth
during the surgical procedure by suppression of 3. Clean spectacles if worn
growth  Adjust and secure protective eyewear or the face
3. To reduce the hazard of microbial contamination of shield comfortably in relation to the mask and
the surgical wound by skin florae spectacles
4. Equipment 4. Adjust water to a comfortable temperature
 Debris should be removed from the subungual
area of each finger. Plastic, single use,

Steps in Hand Washing Brushless/Waterless Surgical Hand Cleansing

1. Check nails • Wash hands before applying the antiseptic solution
 It should be kept short  The antiseptic does not remove debris from under
2. Remove jewelry and watch. Roll up sleeves 2 inches the nails and hands (as recommended by AORN)
above elbow • Most brushless cleansing agents have an alcohol
3. Stand in front of the sink. Maintain arm’s length base with an antimicrobial ingredient
distance, turn on the water and regulate its flow
4. Wet hands and forearms with water. Apply an Gowning and Gloving
antibacterial liquid soap and form lather
• The sterile gown is put on after drying the hands and
5. Using a clasp, scrubbing and sweeping motion,
arms with a sterile towel, immediately after the
make sure enough lather is formed
surgical hand and arm cleansing
6. Make sure hands, wrist, and lower forearms are
washed for one full minute to remove superficial dirt
Purpose
7. Rinse fingertips and forearms while keeping hands
1. A sterile gown and gloves are worn to exclude skin
above the elbow
as a possible contaminant and to create a barrier
8. Dry hands either with paper towel or dryer, if
between the sterile and nonsterile areas
available
Drying the Hands and Arms

Surgical Hand and Arm Scrub with a Brush
The hands and arms are dried as follows
• A vigorous 2-5-minute scrub with a reliable agent is
effective 1. Reach down to the opened sterile gown package and
pick up the towel with one hand by one corner. Be
Steps in Surgical Hand and Arm Scrub with a Brush careful not to drip water onto the pack.
2. Grasp the opposing corner of the towel with the other
1. Repeat steps 1-8 in hand washing
hand and open the towel full-length. Use one end of
2. Apply antiseptic agent from dispenser and /or pre-
the towel to dry one hand and arm. Use a
packed brush. No need to apply soap
circumferential motion to rub in one direction from
3. Start timing. Scrub the four surfaces of each finger,
hand to upper arm. Don’t rub back and forth.
beginning with the thumb and moving from one finger
3. To dry the second arm, hold the dry end of the towel
to the next, down the outer edge of the 5th finger,
in the opposite hand and use a circumferential
over the dorsal (back) surface of the hand, then the
motion to dry the hand and all areas of the arm to the
palmar(palm) surface of the hand, or vice versa, from
elbow.
the small finger to the thumb
4. Discard the towel with the hand that is currently
4. Proceed to the wrist and up the arm, in thirds ending
holding it without letting it touch the scrub suit. Do not
2 inches above the elbow
wad it and toss it across the room to the laundry
5. Repeat the process on the other hand and arms
hamper or trash.
while keeping the hands higher than the elbows to
allow water and suds to flow from the cleanest area,
the hands to the marginal area of the upper arms Gowning and Gloving Technique
 Take care not to slip in water that may have • The person will don the gown before the gloves
dripped to the floor during the process
 If the hands touched anything, the scrub must be A. Gowning
lengthened by one minute for the area that has Steps in Gowning
been contaminated 1. Reach down to the sterile pack and lift the folded
6. Rinse the hands and arms by passing them through gown directly upward
the water in one direction only, from fingertips to 2. Step back away from the table into an unobstructed
elbows area to provide a wide margin of safety when
7. Proceed to the OR suite maintaining arm’s length gowning
3. Holding the folded gown like a book by its binding,
Note: All steps of the scrub procedure begin with carefully locate the neckline and the armholes
cleaning the fingernails and hands and end with 4. Holding the inside front of the gown just at the
the elbows armholes with both hands; let the gown unfold
keeping the inside of the gown toward the body and
the hands in the armholes
 Do not touch the outside of the gown with bare
hands

 If the top of the gown drops downward 3. Hold securely the cuff of the glove, and with the other
inadvertently, discard the gown as contaminated protected hand, stretch the glove cuff over the end of
 Never reverse a sterile gown if the wrong end is the right sleeve and hand
dropped toward the floor  The cuff of the glove is now over the stockinette
5. Extend both arms into the armholes simultaneously cuff of the gown, with the hand still inside the
as the gown and its sleeves unfold sleeve
6. The circulating nurse standing behind the scrub 4. Pull the glove on over extended fingers until it
brings the gown over the shoulders by reaching completely covers the stockinette cuff
inside to the shoulder and arm seams 5. Using the gloved hand, pick up the other glove from
 The gown is pulled on, leaving the cuffs of the the package, and repeat steps 2 through 4
sleeves extended over the hands
 Do not push the hands through the cuffs Open Glove Method
 The back of the gown is securely tied at the waist
• Uses skin to skin, glove to glove technique
first, followed by the neckline
• The first glove is put on with the skin-to-skin
technique, bare hand to inside cuff
 The sterile fingers of that gloved hand then may
touch the sterile exterior of the second glove
(glove to glove technique)
• It is used when changing a glove during a surgical
procedure
• It is used when donning gloves for procedures not
requiring gowns
• Assisted open gloving technique is used by the scrub
person to help other sterile team members don gowns
and gloves before entering the sterile field
Procedural Steps
1. Open glove package by grasping the two center folds
of the wrapper and spreading them apart
2. Lift the left glove up from the wrapper by the edge of
the cuff, using thumb and index finger of the right
hand
3. Slide the glove over the left hand, holding the cuff,
and adjust each finger into its own slot
B. Gloving
4. Invert the gloved hand so the gloved fingers are
Gloving Methods touching the sterile glove and lift it off the wrapper
Close glove method – surgical scrub and sterile gown 5. Slide ungloved hand into glove and adjust fingers
• The scrub person keeps the hands inside the cuffs of 6. Adjust both gloves for comfort and covering of wrists
the sterile gown
• Preferred for establishing the initial sterile field by the Gowning Another Team Member
scrub person
1. Open the sterile towel and lay it across the palm of
• Affords assurance against contamination when
the team member being gowned
donning gloves, because no bare skin is exposed in
2. Unfold the gown carefully, holding at the neckband
the process because the bare hands do not extend
so that the inside of the gown faces the wearer
through the cuffs of the gown
3. Keeping gloved hands covered by the outside gown
shoulders, place the gown on the arms of the wearer,
Procedural Steps
as he/she slips into the sleeves of the gown, and
1. Using the stockinette cuff of the gown as a “mitten”, push up toward the shoulders
open the inside wrappers of the glove package, and 4. Release the gown at shoulder height, and adjust the
with the left hand, lift the right glove off the wrapper sleeves in preparation for assisted open gloving
by the cuff
2. Extend the right forearm with the palm upward. Place
the palm of the glove against the palm of the
protected hand thumb to thumb with fingers pointing
towards the elbow

3. The gloves are removed using a glove to glove and

Note:
then skin to skin technique to protect the clean hands
o Do not hand a towel from a bloody back table
from contaminated outside of the gloves, which bear
or hand a towel with contaminated gloves or
blood and body fluid of the patient. The gloves are
any instrument from the active sterile field. The
removed as follows:
biologic contamination is a hazard. The
a. Grasp the cuff of the left glove with the gloved
circulating nurse can open a separate gown
fingers of the right hand, and pull it off inside out
and towel package for additional persons who
b. Slip the ungloved fingers of the left hand under
want to enter the sterile field.
the cuff of the right glove, and slip it off inside out
o Do not hand a gown from a back table when the
c. Discard the gloves in a trash receptacle
case is in progress. The drapes and gowns on
d. Wash hands
the field in progress are considered biologically
contaminated and could contaminate the
wearer. Anesthesia
General Anesthesia
• Pain is controlled by general insensibility
Gloving a Team Member (Open Glove Method)  Basic elements include loss of consciousness,
1. Offer the right glove first. analgesia, interference with undesirable reflexes
Pick up the right glove, and muscle relaxation
and grasp it firmly with • Association pathways are broken in the cerebral
the fingers of both hands cortex to produce more or less complete lack of
under the everted cuff on sensory perception and motor discharge
the sterile side. Hold the • Unconsciousness is produced when blood circulation
palm of the glove toward the person being gloved. to the brain contains an adequate amount of the
2. Stretch the cuff sufficiently open to aloe for passage anesthetic agent
of the right hand  It results in an unconscious, immobile, quiet
 Avoid touching the hand by holding your thumbs patient who does not recall the surgical procedure
out (abducted) • Induction involves putting the patient safely into a
3. Exert upward pressure as the person slides the hand state of unconsciousness
into the glove Preoxygenation
 Don’t allow the hand to drop below the level of − Anesthesia provider may have the patient breath
the sterile field pure (100%) oxygen by facemask for a few
4. Pull the glove cuff up and over the cuff of the right minutes
sleeve. Enclose the entire cuff. − This provides a margin of safety in the event of
5. Repeat for the left hand. The person being gloved airway obstruction or apnea during induction, with
can facilitate the process by supinating the gloved resultant hypoxia
right hand and flexing the fingers like a hook to hold
Loss of Consciousness
open the cuff of the glove being donned.
− Induced by IV administration of a drug or by
inhalation of an agent mixed with oxygen
Removing or Changing Contaminated Gown and
− Because the technique is rapid and simple, an IV
Gloves drug usually is preferred by anesthesia providers
• Occasionally a contaminated gown must be changed and often is requested by patients
during a surgical procedure. This means that both Intubation
gowns and gloves must be removed and changed
− Is insertion of an endotracheal tube between
• The circulating nurse obtains sterile gowns and gloves
vocal cords, usually with an oral tube by direct
for personnel needing to change
laryngoscopy
− A nasotracheal tube may be inserted by blind
Procedural Steps
intubation or with a direct approach using Magill
1. NOTE: The gown is always removed first, followed forceps to guide the tube through the pharynx.
by the gloves. The contaminated team member steps Epistaxis can be a complication of nasal airway
away from the field, and the circulating nurse use.
unfastens the neck and waist ties of the soiled gown − A patient airway must be established to provide
2. The contaminated person grasps the front of the adequate oxygenation and to control breathing of
gown at the shoulders below the neckline the unconscious patient
 The gown is pulled off inside out by the wearer − The patient’s tongue and secretion can obstruct
and rolled off away from the body respiration in the absence of protective reflexes

− An oropharyngeal airway, nasopharyngeal

airway, laryngeal mask, endotracheal tube or
endobronchial tube (for lung procedures) may be
inserted
Cricoid Pressure (Sellick’s Maneuver) – pressure is

applied using one or two fingers to the cricoid cartilage
to occlude the esophagus and immobilize the trachea. It
prevents regurgitation of stomach contents.
Methods of Administration
1. Inhalation
Methods of Administration
2. IV injection
Inhalation – gases and vapors can be delivered via
Preparation of the Patient face mask, laryngeal mask, or endotracheal tube
1. Care is taken not to compromise circulation by
securing the restraint too tightly Mask Inhalation – anesthetic gas or vapour of a volatile
2. Head support, a donut, pillow, or headframe is liquid is inhaled through a face mask/laryngeal mask
adjusted or removed at the discretion of the attached to an anesthesia machine by breathing tubes.
anesthesia provider
3. For procedures performed in the supine or lithotomy a. The Face Mask – must fit the face tightly to minimize
position that are of short duration, those in which escape of gases into the environment
profound muscle relaxation is not usually required,
patency of the airway is managed with a mask and
b. The Laryngeal Mask Airway (LMA)
oral (or nasal) airway or by means of a laryngeal
− An alternative airway device used for anesthesia
mask airway (LMA)
and airway support
4. Endotracheal intubation
− It consists of an inflatable silicone mask and
 If patient’s position is to be other than supine or
rubber connecting tube
lithotomy
− It is inserted blindly into the pharynx, forming a
 For a prolonged procedure in the supine position
low-pressure seal around the laryngeal inlet and
 For surgeries that affect respiration
permitting gentle positive pressure ventilation
 When profound muscle relaxation is needed
− The Laryngeal Mask Airway is an appropriate
5. Patient’s eyes are protected by the instillation of
airway choice when mask ventilation can be
ophthalmic ointment and/or by taping the lids closed

used but endotracheal intubation is not  Positive pressure can be given immediately
necessary by pressing the reservoir bag on the machine
− When inserted appropriately, the LMA lies with without danger of dilating the stomach
its tip resting over the upper esophageal 2. It protects the lungs from aspiration of blood,
sphincter, cuff sides lying over the pyriform vomitus of gastric contents or foreign material
fossae, and the cuff upper border resting against 3. It preserves the airway regardless of the patient’s
the base of the tongue position during the surgical procedure
− Such positioning allows for effective ventilation 4. It interferes minimally with the surgical field during
with minimal inflation of the stomach head and neck procedures
5. It helps minimize the escape of vapors or gases
Advantages into the room atmosphere
1. Allows rapid access
2. Does not require laryngoscope General Inhalation Anesthetic Agents
3. Relaxants not needed Agent Form Characteristics/Comments
4. Provides airway for spontaneous or controlled • When used in combination with
other forms of inhalants and IV
ventilation Compressed drugs, excessive depth of
Nitrous oxide
5. Tolerated at lighter anesthetic planes (laughing gas)
air in blue anesthesia is avoided
colored tank • Rapidly cleared from the circulation
6. Alternate to endotracheal intubation it reduces the • Incidence of nausea and vomiting
incidence of sore throat is minimal
• Slow, smooth induction
• Wide spectrum of maintenance
Disadvantages • For pediatric and burn patients as
Halothane well as for adults
1. Does not fully protect against aspiration in the Volatile liquid
(Fluothane) • Bradycardia
non-fasted patient • Hepatotoxic in some recipients
2. Standard LMA does not allow high positive (check prior history)
• Non-malodorous
pressure ventilation • Wide spectrum of maintenance
3. Requires re-sterilization Isoflurane • Good relaxation
Volatile liquid
(Forane) • Cardiovascular stability
• Useful for cardiac patients
Contraindications • Wide spectrum of maintenance
• Good relaxation
1. Non-fasted patients Desflurane
Volatile liquid • Rapid recovery
(Suprane)
2. Morbidly obese patients • Malodorous
• Increased postoperative nausea
3. Obstructive or abnormal lesions of the oropharynx
• Rapid induction
• Rapid recovery
• Good relaxation
Enflurane • Wide spectrum of maintenance
Volatile liquid
(Ethrane) • May cause hypotension
• Associated with seizures in
children
• Less often used
• Rapid induction (useful for mask
induction in children)
Sevoflurane
• Rapid recovery
(Sevorane, Volatile liquid
• Good relaxation
Ultane)
• May cause emergence delirium in
children
c. Endotracheal Administration Intravenous – a drug that produce hypnosis, sedation,

− Anesthetic vapor or gas is inhaled directly into amnesia and analgesia that is injected directly into the
trachea through a nasal or oral tube inserted circulation, usually via the peripheral vein in the arm
between vocal cords by direct or blind
laryngoscopy General Intravenous Anesthetic Agents
− The tube must be securely fixed in place to Agent Form Characteristics/Comments
minimize tissue trauma • Rapid induction
•
− The patient is given oxygen before and after Thiopental
Stable liquid
Short duration
(Pentothal) • Respiratory depressant
suctioning • Can cause laryngospasm and BP
• Rapid induction
Advantages of Endotracheal Administration • Ultra-short acting
Methohexital • Rapid recovery
1. It ensures a patent airway and control of (Brevital)
Stable liquid
• May cause hiccoughs
respiration • Can be administered rectally via
 Secretions are easily removed from the Fr14 catheter in pediatrics
trachea by suctioning

• Rapid induction Uses

Propofol • Short duration
(Diprovan) • Respiratory depressant 1. To increase muscular relaxation during surgery and
Note: a.k.a - • Transient BP to shorten duration of operation
Stable liquid
Milk of amnesia, • Can be used for continuous
Michael Jackson infusion with clear-headed rapid 2. To facilitate controlled breathing and tracheal
drug recovery intubation by relaxing jaw and larynx or to
• Some antiemetic effect
• Can be given IV or IM
supplement receding anesthesia
• Short acting anesthetic, long-acting
analgesic
Ketamine Examples
• Used for pediatric and burn wound
(Ketalar, Stable liquid
Ketaject)
procedures, and trauma cases Nondepolarizing Neuromuscular Blockers – act on
• May cause emergence
hallucinations if given in larger
enzymes to prevent muscle contraction. They produce
dosages (especially in adults) tetanic electrical impulses that gradually fade, but they
• Induction used for unstable cardiac do not cause muscular fasciculation on IV injection
patients
• Some nausea 1. Short acting with rapid onset and recovery – often
Ethomidate
• Local pain on injection need not to be reversed
(Amidate, Stable liquid
• May be used for sedation in
Hypnomidate)
critically ill patients and with Mivacurium (Mivacron)
fentanyl for percutaneous
angioplasty 2. Intermediate acting muscle relaxants
Vecuronium (Norcuron)
Adjunctive Drugs Used in Anesthesia Atracurium (Tracrium)
To supplement the anesthetic agents, numerous Cisatracurium(Nimbex)
additional drugs may be administered intravenously to Rocuronium (Zemuron, Esmeron)
“balance” the anesthesia 3. Longer acting muscle relaxants – to effect reversal
Neostigmin (Prostigmin) is used
Narcotics − produce analgesia and sedation.
Pancuronium (Pavulon)
Clinical Signs of Narcotic Toxicity Tubocurarine (Curare)
1. PRC – pinpointed pupils, respiration depressed,
Depolarizing Neuromuscular Blockers – cause
consciousness reduced
muscular fasciculation (involuntary muscle
contractions) after IV injection.
Examples
1. Succinylcholine (Anectine, Quelicin)
1. Morphine Sulfate
 Onset of action in seconds, produces paralysis
 Produces analgesia for pain relief without loss of
for up to 20 minutes and is used primarily for
motor, sensory or sympathetic functions
endotracheal intubation
 Maybe given IM, IV, or epidural
2. Decamethonium (Syncurine)
2. Meperidine Hydrochloride (Demerol)
 Used for deep relaxation of a short duration,
 Produces analgesia, for post-op pain, may cause
such as endoscopy, treatment of laryngeal
BP and HR spasm, abdominal closure and endotracheal
3. Fentanyl (Sublimaze) intubation
Narcotic Reversal (Narcotic Antagonist) – reverses the Muscle Relaxant Reversal Agents (Cholinergics)
effects of narcotics. Have a Narcotic antagonist always
1. Neostigmine (Prostigmin)
ready
 Reverses the nondepolarizing neuromuscular
Examples blockers
1. Naloxone (Narcan) 2. Endrophonium (Tensilon)
 Reverses respiratory depression caused by  Reverses the nondepolarizing neuromuscular
narcotics blockers
2. Flumazenil (Romazicon)
 A benzodiazepine antagonist used for complete
Balanced Anesthesia
or partial reversal of general anesthesia
• Has become a widely used technique to achieve
physiologic homeostasis, analgesia, amnesia and
Muscle Relaxants – referred to as neuromuscular muscle relaxation
blocker, facilitate muscle relaxation for smoother • A combination of agents is used with many possible
endotracheal intubation and working condition during variations, depending on the condition of the patient
surgical procedure. The chief danger is that they and requirements of the procedure
decrease pulmonary ventilation causing depression.

• The technique is especially useful for preventing CNS 4. Highly nervous, apprehension, excitability or inability
depression in older and poor risk patients to cooperate because of mental state or age
Induction – accomplished with a thiobarbiturate
derivative (Thiopental [Penthotal], Diazepam Types of Conduction Anesthesia
[Valium], Midazolam [Verzed]) Topical Anesthesia
Maintenance – combinations of narcotics and • Direct application of an anesthetic agent such as a
neuroleptic drugs (tranquilizers) given IV liquid solution, eye drops, jelly, ointment, and/or spray
to the site of the surgery
Local or Regional Block (Conduction Anesthesia) • Local or general anesthesia may be required to
• Depresses superficial nerves and interfere with the supplement these anesthetics
conduction of pain from certain area or region
• The sensory nerves are the first affected Uses
• The patient remains conscious 1. For anesthesia of the respiratory passages to
eliminate laryngeal reflexes and cough
Advantages 2. For therapeutic and diagnostic procedures
1. Minimizes the recovery period
 The patient can ambulate, eat, void and resume Technique
normal activity 1. Spray − direct laryngoscopy
2. Requires minimal equipment and is economical 2. Instillation − cystoscopy, phacoemulsification
3. No loss of consciousness unless anesthesia is
supplemented with additional drugs Examples of Drugs
4. Avoids the undesirable effects of general anesthesia 1. Xylocaine
5. Suitable for patients who recently ingested foods or 2. Pontocaine
fluids (e.g. before an emergency procedure)
6. Useful for ambulatory patients having minor
Simple Local Infiltration
procedures
• Injection of the anesthetic agent into, or immediately
7. Ideal for procedures in which it is desirable to have
adjacent, to the site of surgery, anesthetizing smaller
the patient awake and cooperative
nerves directly
• May be administered by the surgeon without the
Disadvantages
presence of the anesthesia provider
1. Not practical for all types of surgery
• When the patient receives “conscious sedation” the
 For example, too much drug would be needed
patient must be closely monitored
for some major surgical procedures; the duration
• Epinephrine (Adrenalin) is added to the anesthetic
of anesthesia is insufficient for others
solution to prolong the effect of the anesthetic solution
2. Individual variations-pain threshold
• Skin preparation for the injection and the surgery are
3. Rapid absorption of drug into the blood can cause
usually the same
severe, potentially fatal reactions
4. Apprehension may be increased by the patient’s
Example: Xylocaine 1-2% (excision of breast mass,
ability to see and hear
circumcision)
 Some patients prefer to be unconscious and
unaware
Regional Nerve Block
Contraindications • Achieved by depositing an anesthetic agent
1. Local infection or malignancy at the site of injection, immediately adjacent to a larger peripheral nerve(s)
which may be carried to and spread in adjacent • It is used primarily for surgery of the extremities
tissues by injection • Skin preparation is performed before the block is
 A bacteriologically safe injection site should be established, most often by the person performing the
selected block (anesthesia provider or surgeon)
2. Septicemia  The circulator may be requested to prep the skin;
 In a proximal nerve block, a needle may open the prep begins at the site of injection, extending
new lymph channels that drain through a region, for an appropriately wide margin circumferentially
thereby causing new foci and local abscess
formation from the perforation of small vessels Purpose
and escape of bacteria 1. To decrease pain and phantom symptoms following
3. Allergic sensitivity to the local anesthetic drug amputation

2. To increase circulation in vascular disease by After the Administration

sympathetic ganglion block 1. Patient is placed in the selected operative position or
3. To decrease severe neurologic pain such as tic the patient remains in the same position (prone
douloreaux position after caudal or hypobaric spinal is
4. To establish a diagnosis of essential hypertension administered for anorectal surgery)
and peripheral arterial disease, to block the
sympathetic nerve ganglia
Spinal Anesthesia
5. To stop prolonged hiccoughing (the phrenic nerve is
• The anesthetic agent is injected into the CSF in the
injected)
subarachnoid space of the meninges which causes
desensitization of spinal and motor roots
Examples
• It is used in almost types of surgery below the
Surgical Blocks
diaphragm such as laparotomy, rectal, or lower
1. Paravertebral block of the cervical plexus for extremity operation
procedures in the area between the jaw and the • Immediately after the anesthetic is injected the
clavicle. anesthesia provider carefully test the level of
2. Intercostal block for relatively superficial anesthesia by pinprick, touch, or nerve stimulation,
intraabdominal procedures, such as drain tilting the bed as necessary to achieved the desired
placement. Segmental thoracic pain fractured rib level of the surgical procedure
3. Brachial plexus or axillary block for arm procedures • After anesthetic fixation and with the anesthesia
4. Median, radial, or ulnar nerve block for the elbow or provider’s permission, the patient is placed in surgical
wrist position
5. Hand and digital block for fingers ( an additive
vasoconstrictor such as epinephrine, is not added to Note: A vasoconstrictor (e.g. ephedrine) can be
the local agent because necrosis can result from added to the anesthetic mix to provide a longer
inadequate circulation to the digit) effect
6. Blocks in other specific areas, such as penile block
for circumcision in adults.
7. Field block-blocking off of the operative site with wall Components of Spinal Anesthesia
of anesthetic solution by series of injection into 1. Pontocaine − main anesthetic agent
proximal and surrounding tissues. Used for limited 2. Dextrose 10% in water − diluent
abdominal surgeries: gastrostomy, inguinal 3. Ephedrine – prolongs the effect of spinal anesthesia
herniorrhaphy. by causing constriction of blood vessels.
8. Pudendal block-gynecologic surgery
9. Perianal block-anorectal surgery Physiologic effects of spinal anesthesia due to
neurologic blockage
Spinal and Epidural Anesthesia 1. Vasodilation accompanying hypotension due to
Central Nerve Blocks autonomic nerve block
2. Anesthesia due to sensory nerve block
• Achieved by injecting anesthetic solutions
3. Muscle paralysis due to motor nerve block
intrathecally into the subarachnoid space, into the
epidural space, or into the caudal canal (an extension
Advantages
of the epidural space)
1. Patient is conscious, throat reflexes maintained,
Examples cooperation is possible
2. Easy administration
1. Spinal
3. Non-irritating to respiratory passages
2. Epidural
4. No effect on childbirth
3. Caudal
5. Minimal toxicity
6. For patient who has eaten and needs emergency
Position of Patient During Administration
surgery
1. Sitting − with the back arched and feet supported on
7. For alcoholics
a stool (spinal or epidural)
2. Lateral − with the knees, hips, back and neck flexed
Disadvantages
(spinal or epidural)
1. Psychic strain
3. Prone − with the body flexed at the waist (caudal or
2. Conscious
hypobaric spinal)
3. No control over the drug once injected

4. Danger of trauma and infection due to poor

technique
5. Respiratory and circulatory depressant effect
 Paralysis of the intercostals muscle and
interference from venous return due to paralysis
of the lower extremities
6. BP
7. Nausea and vomiting Trendelenburg’s Position
8. Headache – loss of spinal fluid • Used for procedures in the lower abdomen or pelvis
(e.g. urinary bladder or colon surgery, gynecologic
Complications of Spinal Anesthesia operations) when it is desirable to tilt the abdominal
During Surgery viscera away from the pelvic area for better exposure
1. Hypotension
 Paralysis of the vasomotor nerve
2. Respiratory failure
 Whenever the anesthesia reaches the T3 level
due to affectation of diaphragm muscle
3. Nausea and vomiting
 Due to vagal nerve stimulation, traction placed
on various organs
4. Cardiac arrest Reverse Trendelenburg’s Position
 Due to cerebrovascular collapse (hypertension)
• Used for thyroidectomy to facilitate breathing and to
and interference in venous return due to motor
decrease blood supply to the surgical site
paralysis of the lower extremities
• Also, for laparoscopic gallbladder, biliary tract or
stomach procedures to allow the abdominal viscera to
Continuous Epidural Anesthesia/Continuous caudal fall away from the epigastrium, giving access to the
anesthesia upper abdomen
• used if a longer procedure is contemplated or • In supine position, the entire OR bed is tilted 30-40
postoperative central analgesia is to be utilized degrees so the head is higher than the feet; a padded
• Anesthesia provider places a catheter secured in tape footboard is used to prevent from sliding toward the
to deliver increments of an anesthetic agent tilt
• Postoperatively morphine specially prepared for this
purpose may be injected for pain relief
Commonly used Local and Regional Anesthetic Agents
Agent Route of Administration Comments
Epidural, spinal, peripheral Rapid onset, shorter

Lidocaine
intravenous anesthesia acting Useful topically
(Xylocaine)
and local infiltration for cystoscopy
Fowler’s Position
• For shoulder, nasopharyngeal, facial and breast
Bupivacaine Epidural, spinal, peripheral Longer acting, longer
(Marcaine, intravenous anesthesia analgesia after return of reconstruction
Sensorcaine) and local infiltration sensation • Patient lies on his back with the buttock at the flex of
Tetracaine Topical, infiltration and Long acting, produces
the OR bed and the knees over the lower break
(Pontocaine) nerve block good relaxation • The foot of the OR bed is lowered slightly, flexing the
Procaine
Local infiltration
Commonly used in oral knees
(Novocaine) or dental surgery
Surgical Positions
Supine (Dorsal) Position
• Used for procedures on the anterior surface of the
body, such as abdominal, abdominothoracic, and
some lower extremity procedures

Lithotomy Position Knee Chest Position

• Used for cystoscopy, TURP, perineal repair, vaginal − Used for sigmoidoscopy or culdoscopy
hysterectomy, D&C and rectal surgery − The OR bed is flexed at the center break, and the
• The patient’s buttocks rest along the break between lower section is broken until it is at a right angle to
the body and leg sections of the OR bed. The legs are the OR bed. The patient kneels on the lower
supported with stirrups. section; the knees are thus flexed at a right angle to
the body
Lateral Position
• Patient is anesthetized and intubated in the supine
position and then turned to the unaffected side
 Right lateral position – patient lies on the right
side with the left side up (for a left sided
procedure); the left lateral position exposes the
right side
• Patient is turned by no fewer than 4 people to maintain
Prone Position body alignment and achieve stability.
• For laminectomy, back surgery, excision of baker’s • Patient’s back is drawn to the edge of the bed. The
cyst knee of the lower leg is flexed slightly to provide
stabilization and the upper leg is flexed to provide
counterbalance.
• A large, soft pillow is placed lengthwise between the
legs to take pressure off the upper hip and lower leg
and therefore prevent circulatory complications and
pressure on the peroneal nerve.
Sims Recumbent Position

− For endoscopic examination performed via the anus
in obese or geriatric patients
− Patient lies on his/her left side with the upper leg
flexed at the hip and the knee; the lower leg is
straight
Modified Prone Position

Kraske (Jackknife) Position
− For rectal surgeries (e.g. hemorrhoidectomy), the Kidney Position
buttocks are retracted with wide tape strips
− For procedures on the kidney and the ureter
− The patient remains supine until anesthetized and
− Flank region is positioned over the kidney elevator
is then turned onto the abdomen (prone position) by
on the OR bed when the patient is turned on the
rotation
unaffected side
− The pelvis is at the lower break of the table and the
− A body strap or wide adhesive tape is placed over
leg section of the OR bed is lowered the desired
the hip to stabilize the patient after the OR bed is
amount (usually about 90 degrees), and the entire
flexed and the elevator is raised
OR bed is tilted head downward to elevate the hips
above the rest of the body Lateral Chest (Thoracotomy) Position
− Used for thoracotomy, pneumonectomy,
esophagectomy

Anterior Chest Positions

Commonly Used Incisions, Their Characteristics
− Used for pneumonectomy, esophagectomy, heart and Uses
surgery
Paramedian Incision
This is a vertical incision made approximately 2 inches
The Nurses Role in Positioning or in Assisting in lateral to the midline on either side in the upper or lower
Positioning the Patient abdomen
1. The nurse must see to it that all of the necessary
positioning attachments and equipment are in the Used in
room before the surgery begins 1. Right upper paramedian
2. The circulating nurse must apply principles of a. Gallbladder and biliary tract surgery
anatomy and physiology while assisting the patient b. Liver surgery
into the position 2. Right lower paramedian
3. An anaesthetized patient must never be moved a. Appendectomy
before the anesthesiologist indicate that the patient b. Small bowel resection
is ready to be moved or positioned 3. Left Upper Paramedian
4. The patient must be moved slowly and with no a. Spleen surgery
sudden movements b. Gastric surgery
4. Left lower paramedian
Surgical Incisions a. Sigmoid colon resection
Importance of Knowing the Operative Incision
For the Circulating Nurse Longitudinal Midline Incision
1. To know the extent and the area to be prepared It can be upper abdominal, lower abdominal or a
2. To prepare the gadgets necessary for positioning the combination of both going around the umbilicus
patient
Upper Abdominal Midline Incision – incision is started
For the Scrub Nurse in the epigastrium at the level of the xiphoid process
1. To serve as a guide for draping the operative site and is carried vertically downward to the level of the
2. To have the correct instruments and supplies umbilicus
available
3. To be able to assist the surgeon effectively and Used in
efficiently 1. Rapid entry into the abdomen to control a bleeding
ulcer
Choice of Incision 2. Gastric surgery
3. Exploratory Laparotomy
The choice of incision is made by the surgeon with the
4. Pancreatic Surgery
following considerations:
5. Transverse Colostomy
1. Type of surgery (location)
2. Maximum exposure
3. Case and speed of entering (for emergency surgery) Lower Abdominal Midline Incision – this is a lower
4. Possibility of extending the incisions abdominal, vertical incision. The incision is started
5. Maximal postoperative wound strength opposite the umbilicus and is extended vertically
6. Minimal postoperative discomfort downward in the midline to the suprapubic region
Used in
1. TAHBSO
2. CS

3. Exploratory Laparotomy Infraumbilical Incision

4. Suprapubic prostatectomy The incision is curvilinear below the umbilicus
5. Cystectomy Used in: umbilical hernia repair, laparoscopy
6. Sigmoid colon operation
Inguinal Incision (Lower Oblique)

Midabdominal Transverse Incision
This is an oblique incision in the inguinal region
The incision starts on either right or left side and slightly
Used in: inguinal herniorrhaphy
above or below the umbilicus. It may be carried laterally
to the lumbar region between the ribs and crest of the
ileum Lumbotomy Incision (Simple Flank Incision)
Used in: transverse colostomy, choledochojejunostomy This incision begins at the costovertebral angle and
parallel to the 12th rib. It extends forward and downward
between the iliac crest and the thorax.
Subcostal Upper Quadrant Oblique Incision
Used in: ureterolithotomy, nephrolithotomy
A right or left oblique incision begins in the epigastrium
and extends laterally and obliquely just below the lower
costal margin Thoracotomy Incision
Right Subcostal Incision – liver transplantation and An incision is made from the anterior midline on the
resection, gallbladder & biliary tract surgery external border to the lateral midaxillary line. The 4th rib
may be resected.
Left Subcostal Incision – gastric surgery, spleen
surgery Used in: lung operation and heart operation
McBurney’s Incision Miscellaneos Incisions

McBurney’s point is located in the right lower quadrant, Collar incision – thyroid surgery
just below the umbilicus Butterfly incision – craniotomy
Used in: Appendectomy Limbal incision – cataract surgery
Elliptical halsted incision – MRM
Pfannenstiel Incision (Bikini Incision) Post aural, end aural incision – mastoidectomy
It is a curve transverse incision across the lower Canine fossa incision – Caldwel luc
abdomen and within or superior to the hairline of the Sterna split – cardiac surgery
pubis
Used in
1. CS
2. TAHBSO
3. Pelvic Laparotomy
4. Prostrate surgery
5. Urinary bladder surgery
Thoracoabdominal Incision
The patient is placed in a lateral position, either a right
or left incision begins at appoint midway between the
xiphoid process and umbilicus and extends across the
abdomen to the 7th or 8th costal interspace and along
the interspace into the thorax
Advantage: Allows excellent exposure for the upper end Hemostasis, Implants and Wound Closure
of the stomach and lower end of the esophagus Hemostasis – control of arterial and /or venous bleeding
in the surgical site
Uses Suture – a strand of material used for sewing tissue
1. Hiatal hernia repair together or ligating a structure
2. Esophagectomy Ligature – a strand of suture of material used to tie or
3. Esophagogastrectomy bind. Suture ligature is a free tie. Tie on a passer is tie
held in the tip of a clamp.

Methods of Hemostasis Silver Nitrate

Chemical Methods • Commonly used in the treatment of burns or other
Absorbable Gelatin (Gelfoam) moist wounds
• It is an absorbable sponge when placed on an area of • It can be used to seal areas of previous surgical
capillary bleeding, fibrin is deposited in the interstices incisions that are left open to heal by secondary
and the sponge swells, forming a substantial clot intention
• It should not be used in the face because it may cause
Absorbable Collagen discoloration of the skin
• Applied dry directly to oozing sites or bleeding sites
Ferric Subsulfate 20% (Monsel’s solution)
• The collagen activates the clotting mechanism to
activate clot formation • creates hemostasis over denuded areas caused by
shaved biopsies of the skin or anorectal or uterine
Examples of hemostatic sponges: Collastat, Superstat,
cervix punch biopsies
Helistat
• It is applied by a cotton swab and causes the vessels
to occlude by denaturing protein
Microfibrillar Collagen
• An absorbable topical hemostatic agent. It is applied
Tannic Acid
dry
• A powder made from astringent plant is used
• When it is placed in contact with a bleeding surface;
occasionally on mucous membranes of the nose and
hemostasis is achieved by adhesion of platelets and
throat to help stop capillary bleeding
prompt fibrin deposition with interstices of the collagen
Examples: Avitene, Instat
Sclerotherapy
• A caustic sclerosing agent is injected into the veins,
Oxidized Cellulose
as in the mucosal lining of the esophagus or anus to
• It is applied dry, may be sutured to, wrapped around
stop/prevent venous bleeding
or held firmly against the bleeding site or laid dry on
an oozing surface until hemostasis is achieved
• When it comes in contact with whole blood, a clot form Mechanical Methods
rapidly External Mechanical Methods
• As it reacts with blood, it increases in size to form a Anti-embolic Stockings
gel and stops bleeding in areas in which bleeding is • Applied to the lower extremities to prevent
difficult to control by other means of hemostasis thromboembolic phenomena
Example: Surgicel • Static compression prevents venous stasis
• Stockings are available in knee or groin length sizes
Zeolite Beads (Quick Clot)
• Used for emergency hemostasis by emergency Tourniquet
squads in the field • Provides hemostasis by constricting the flow of blood
• It is used for emergency bleeding and eviscerating in an extremity
wounds • It should not be used when circulation to an extremity
is impaired or when an arteriovenous access fistula
Oxytocin for dialysis is present
• It is used to treat uterine bleeding after childbirth or • A tourniquet can cause tissue, nerve and vascular
abortion after the delivery of the placenta injury. Paralysis may result from extreme pressure on
the nerves. Prolonged ischemia can cause gangrene
Styptics and loss of extremity
• It checks hemorrhage by causing vasoconstriction • Tourniquet time should be kept to a minimum
• Pneumatic Tourniquet – similar to a BP cuff although
Epinephrine heavier and more secure
• A vasoconstrictor that is used in some local anesthetic Average adult arm – cuff pressure is 250- 300 mm Hg
agents to constrict the vessels locally, it keeps the Average adult thigh – cuff pressure is 350 mm Hg
anesthetic concentrated within the area injected and Tourniquet time – should not exceed 1 hour on an arm
reduces the amount of bleeding when the incision is should not exceed 1 ½ hour on a leg
made • If needed for more than the time recommended, the
tourniquet may be deflated at intervals periodically at
the discretion of the surgeon

Pressure dressing
• Pressure on the wound in the immediate Compressed Absorbent Patties
postoperative period can minimize the accumulation • Compressed absorbent radiopaque patties
of intercellular fluid and decrease bleeding by (cottonoids) are used for hemostasis when placed on
eliminating dead space the surface of brain tissue and to absorb blood and
fluids around the spinal cord or nerves
Packing
• Used with or without pressure to achieve hemostasis Bone Wax
and to eliminate dead space in an area where • Composed of a sterile nonabsorbable mixture of bee’s
mucosal tissues need support, such as the vagina, wax, isopropyl palmitate, and softening agent, bone
rectum, or nose wax provides a mechanical tamponade barrier to stop
oozing from cut bone surfaces
• Small pieces can be rolled into 1 cm balls and placed
Internal Mechanical Methods
around the rim of a medicine cup. When needed the
Hemostatic Clamps
cup can be presented to the surgeon
• Clamps for occluding vessels are used to compress • Used in orthopedic and neurosurgical procedures and
blood vessels and to grasp or hold a small amount of when the sternum is split (sternotomy) for
tissue cardiothoracic procedures
• The hemostat is the most frequently used surgical
instrument and the most commonly used methods of Digital Compression
hemostasis
• When Digital pressure is applied to an artery proximal
Examples: mosquito, Kelly to the area of bleeding, such as in traumatic injury,
hemorrhage is controlled
Ligating Clips
• When placed on a blood vessel and pinched shut, Suction
clips occlude the lumen and stop the bleeding from • The application of pressure less than atmospheric,
the vessel either continuously or intermittently
• A special forceps is needed for their application • In surgical procedures, it helps remove blood and
Examples: Cushing clip for brain surgery, Titanium clip tissue fluids from the surgical field, primarily to
for brain surgery enhance visibility
Drains
• Postoperatively, drains aid in removal of blood, fluid,
and air from the surgical site to obliterate dead spaces
and to enhance approximation of tissues, thus
Ligatures preventing hematoma and seroma formation
• Tied around a blood vessel to manually occlude the • Drains are usually placed through a stab wound in the
lumen and prevent bleeding skin adjacent to the primary incision
Examples: cotton, silk, plain
Thermal Methods
Pledgets Cold methods
• Used most frequently in cardiovascular surgery Cryosurgery
• Small pieces of Teflon felt are used as a buttress • Local freezing of diseased tissue without harm to
under sutures when bleeding might occur through the normal adjacent tissues
needle hole in a major blood vessel or when friable  Extreme cold causes intracapillary thrombosis
tissue might tear, such as cardiac muscle during and tissue necrosis in the frozen area
cardiomyotomy • Frozen tissue may be removed without significant
• Placed over an arteriotomy site, they exert pressure bleeding during or after the surgical procedure
to seal off bleeding
Hypothermia
Packs • Lowers BP to slow the circulation and increases the
• Used to sustain pressure on raw wound surfaces and viscosity of the blood
keep viscera from becoming injured during a • This process results in hemoconcentration, which
procedure contributes to capillary occlusion and microcirculatory
Examples: sponges, laparotomy tapes

stasis to provide an essentially dry field for the Sutures

surgeon Definition of Terms
• Hypothermia is used as an adjunct to anesthesia, Suture – any strand of material used for ligating or
particularly during heart, brain, or liver procedures approximating tissue; it is also synonymous to stitch
Ligature or tie – a suture that is tied around a blood
Hot Methods vessel to occlude the lumen
Electrocautery Suture ligature or stick tie – a suture attached to a
• A small, battery-operated pencil with a tiny, thin wire needle for a single stitch for hemostasis
loop heated by a steady direct electric current to red Free tie – a single strand of material handed to the
heat will coagulate or destroy tissue on contact surgeon or assistant to ligate a vessel
 Heat is transferred to tissue from the preheated Tie on a passer – is a tie handed
wire
Tensile strength – the amount of tension of pull that
• Commonly used for plastic surgery, eye procedures,
strand will withstand before it breaks when knotted
and vasectomies
Primary suture line – refer to the main layers of the
tissue which must be stitched in closing an incision
Electrosurgery
Stay or tension sutures – sutures placed in an incision
• High frequency electrical current provided from an
as a secondary measure of reinforcement where
electrosurgical unit (ESU) frequently is used to cut
coughing or undue pressure or strain may cause the
tissue and to coagulate bleeding points
incision to separate
• Because the high frequency electric current goes
through tissues, a dispersive return electrode is
applied to the patient and plugged into the grounded Uses of Suture
generator 1. To tie off a clamped vessel to prevent bleeding
2. To approximate tissue until healing is complete
Ultrasonic Scalpel (Harmonic Scalpel)
• The titanium blade of the scalpel moves by a rapid Classification of Sutures
ultrasonic motion that cuts and coagulates tissue Absorbable Sutures
simultaneously
• Sterile strands prepared from collaged derived from
• Vibrations from the blade denature protein molecules
healthy mammals or from synthetic polymer
as it cuts through tissue, producing a coagulum that
• They are capable of being absorbed by living
seals bleeding vessels
mammalian tissue but may be treated to modify
• Used primarily for laparoscopic and thoracoscopic
resistance to absorption
procedures
Non-absorbable Sutures
• Strands of natural or synthetic material that effectively
resist enzymatic digestion or absorption in living
tissue
• During the healing process, suture mass becomes
encapsulated and may remain for years in tissues
without producing ill effects
Wound Closure
• Closure of a surgical site or other wound is performed
after necessary hemostasis has been achieved
• Methods of wound closure include sutures, staples,
clips, tapes and glues

Instrumentation c. Snares – a loop of wire may be put around a

Classification of Instruments pedicle to dissect tissue such as tonsil. The wire
Cutting and Dissecting cuts the pedicle as it retracts into the instrument.
The wire is replaced after used
• Cutting instruments have sharp edges
 They are used to dissect, incise, separate or
excise tissues Grasping and Holding
• These instruments should be kept separate from other • Tissues should be grasped and held in position so the
instruments, and the sharp edges should be protected surgeon can perform the desired maneuver, such as
during cleaning, sterilizing, and storing dissecting or suturing without injuring the desired
tissues
Scalpels (also known as knife handle)
− Scalpel no. 3 or 7 is fitted for blades no. 10, 11, Adson Forceps – used to pick up or hold soft tissue
12, and 15 (10 series) during closure
− Scalpel no. 4 is fitted for blades no. 20, 21, 22, 23,
24 and 25 (20 series) Smooth Forceps (thumb forceps, toothless forceps,
pickups) – are serrated at the tip and used to hold
delicate tissues
Toothed Forceps (Tissue Forceps) – have a single

tooth on one side that fits between two teeth on the
opposing side or they have a row of multiple teeth at
the tip. These instruments provide a firm hold on
tough tissues, including skin
Allis Forceps – each jaw curved slightly inward, and

there is a row of teeth at the end. The teeth hold tissue
gently but securely
Knives Babcock Forceps – the end of each jaw is rounded to

− Have a blade at one end that may have one or fit around a structure or to grasp tissue without injury
two cutting edges
− Examples: Cataract knife for cataract surgery, Clamping and Occluding
Dermatome used in skin grafting • These instruments are used to apply pressure
Scissors Hemostats – most commonly used surgical
a. Tissue/dissecting scissors instruments and are used primarily to clamp blood
Metzenbaum vessels. Hemostas have either a straight or curved
Curved mayo – tissue scissors, to cut tough slender jaws that taper to a fine point
tissues
Crushing Clamps – are used to crush tissues or clamp
b. Suture scissors – have blunt points to prevent
blood vessels (e.g. Kocher or Ochsner clamp)
structures close to the suture from being cut (e.g.
straight mayo scissor) Non-crushing Vascular Clamps – are used to occlude
c. Wire scissors – have short heavy blades to cut peripheral or major blood vessels temporarily, which
stainless steel suture minimizes tissue trauma
Bone Cutters and Debulking Tools
− Instruments with cutting edges suitable for cutting Exposing and Retracting
bones and cartilages • Soft tissue, muscles, and other structures should be
pulled aside for exposure of the surgical site
Other Sharp Dissectors
− To cut tissue apart or to separate tissue layers Handheld Retractors – have a blade on a handle and
a. Biopsy forceps and punches – used to remove a are usually in pairs, and they are held by the first or
small piece of tissue for pathologic examinations second assistant (e.g. Double ended Army-Navy
b. Curettes – tissue or bone is removed by scrapping retractor, Harrington Sweetheart liver retractor)
with the sharp edge of the loop, ring, or scoop on
the end of the curette\

Malleable Retractors – flat length of low-carbon Suction – involves the application of pressure to
stainless steel that may be bent to the desired angle withdraw blood or fluids, usually for visibility at the
and depth for retraction surgical site
Hooks – single, double, or multiple very fine hooks Poole Abdominal Tip – is a straight hollow tube with a
with sharp points are used to retract skin edges during perforated outer filter shield. It is used during
a wide-flap dissection such as facelift or mastectomy abdominal laparotomy
(e.g. Skin hooks)
Frazier Tip – is a right-angle tube with a small
Self-Retaining Retractors – holding devices with two diameter used in brain, spinal, plastic, or orthopedic
or more blades can be inserted to spread the edges procedures
of an incision and hold them apart (e.g. Balfour, Rib
spreader – holds the chest open during cardiac Dilating and Probing
surgery)
Dilator – is used to enlarge orifices and ducts, such as
dilatation of the uterine cervix
Suturing or Stapling
Needle Holders – used to grasp and hold curved Probe – is used to explore a structure or to locate an
surgical needles obstruction. Also, probes are used to explore the
depth of a wound or to trace the path of a fistula
Staplers – made of titanium, stainless steel, or
absorbable material Measuring
Clip Appliers – are used to mark tissue or to occlude • Rulers, depth gauges and trial sizers are used to
vessels or small lumens of tubes measure parts of a patient’s body
Terminal End Staplers Postoperative Patient Care

− Designed for closing the end of a hollow organ Post-Anesthesia Care Unit (PACU)
(e.g. bowel, stomach) with a double staggered • Also called the recovery room or post-anesthesia
line of staples recovery room, is located adjacent to the operating
− The stapler is L-shaped and is positioned across rooms suite
the end of the hollow organ to be closed or the • Patients still under anesthesia or recovering from
tissue to be amputated anesthesia are placed in this unit for easy access to
experienced, highly skilled nurses, anesthesiologists
Internal Anastomosis Staplers – are designed to
or anesthetists, surgeons, advanced hemodynamic
connect hollow organ segments to fashion a larger
and pulmonary monitoring and support, special
pouch or reservoir
equipment, and medications
End to End Circular Staplers − are designed to staple
two hollow, tubular organs end to end to create a Admitting the Patient to the PACU
continuous circuit. They are commonly used for bowel • Transferring the postoperative patient from the OR to
anastomosis after resection the PACU is the responsibility of the anesthesiologist
or anesthetist
Viewing  During transport from the OR to the PACU, the
• These instruments are used by surgeons to examine anesthesia provider remains at the head of the
the interior body of cavities stretcher (to maintain the airway), and a surgical
team member remains at the opposite end
Speculum – the hinged, blunt blades of a speculum • The surgical incision is considered every time the
enlarge and hold open a canal (e.g. vagina, rectum) postoperative patient is moved to prevent further
strain on the incision
Endoscopes – the round or oval sheath of an • The patient is positioned so that he or she is not lying
endoscope is inserted into a body orifice or through a on and obstructing drains or drainage tubes
small skin incision  Orthostatic hypotension may occur when a
patient is moved too quickly from one position to
Suctioning, Irrigating and Aspirating another (e.g., from a lithotomy position to a
• Blood, body fluids, tissue and irrigating solution may horizontal position or from a lateral to a supine
be removed by mechanical suction or manual position), so the patient must be moved slowly
aspiration and carefully

• The patient is placed on a stretcher or bed and the

soiled gown is removed and replaced with a dry gown
 The patient is covered with lightweight blankets
and warmed
 Side rails may be raised to prevent falls
• The nurse who admits the patient to the PACU A. A hypopharyngeal obstruction occurs when neck flexion permits the chin
to drop toward the chest; obstruction almost always occurs when the head
reviews essential information with the is in the midposition. S/S - choking; noisy and irregular respirations;
anesthesiologist or anesthetist decreased oxygen saturation scores; and within minutes, a blue, dusky
color (cyanosis) of the skin
B. Tilting the head back to stretch the anterior neck structure lifts the base of
A concise verbal report of the anesthesia provider and the tongue off the posterior pharyngeal wall. The direction of the arrows
indicates the pressure of the hands.
/or circulating nurse to the PACU nurse includes the C. Opening the mouth is necessary to correct a valvelike obstruction of the
following: nasal passage during expiration, which occurs in about 30% of
unconscious patients. Open the patient’s mouth (separate lips and teeth)
✓ Name and age of the patient and move the lower jaw forward so that the lower teeth are in front of the
✓ Type of surgical procedure and the name of surgeon upper teeth. To regain backward tilt of the neck, lift with both hands at the
ascending rami of the mandible.
✓ Type of anesthesia and name of anesthesia provider
✓ Vital signs (baseline, preoperative, and 2. Assess rate, depth, & quality of respirations. Watch
intraoperative) including current body temperature out for the development of hypoxemia
✓ Types and locations of drains, packing and dressing Subacute hypoxemia – subacute hypoxemia is a
✓ Preoperative level of consciousness and current constant low level of oxygen saturation when
status breathing appears normal
✓ Medications given preoperatively and Episodic hypoxemia – develops suddenly, and the
intraoperatively, as well as those taken by patient may be at risk for cerebral dysfunction,
prescription or self-medication myocardial ischemia, and cardiac arrest
✓ Medical history, including previous surgical  Risk for hypoxemia is increased in patients who
procedures have undergone major surgery (particularly
✓ Allergies and responses to allergens, substance abdominal), are obese, or have preexisting
sensitivity pulmonary problems. Hypoxemia is detected by
✓ Positioning on the OR bed and devices attached to pulse oximetry that measures blood oxygen
the skin saturation
✓ Complications during the surgical procedure  Factors that may affect the accuracy of pulse
✓ Intake and output, including IV fluids and blood oximetry readings include
✓ Location of the waiting family or significant others o Cold extremities
✓ Special considerations o Atrial fibrillation
✓ Sensory and/or physical impairments; eyewear, o Tremors
hearing aids, dentures, or other personal property o Acrylic nails
brought to the OR is returned to the patient when the o Black or blue nail polish (these colors
level of consciousness is appropriate interfere with the functioning of the pulse
✓ Language barrier and level of understanding oximeter; other colors do not)
✓ Use of tobacco, alcohol and/or addictive drugs 3. Administer oxygen as ordered until they are
✓ Orders such as “no code”, do not resuscitate (DNR), conscious and are able to take deep breaths on
or do not attempt resuscitation command
4. Check vital signs every 15mins until stable, then,
Post-op Care in PACU every 30 mins to determine the rate of progression
1. Assess for & maintain patent airway 5. Note level of consciousness; reorient client to time,
a. Position unconscious & conscious client on side place, & situation
(unless contraindicated) or on back with head to 6. Assess color & temperature of skin, color of nail
side & chin extended forward beds, and lips
b. Check for presence or absence of gag reflex 7. Monitor IV infusions; condition of site, type, and
c. Maintain artificial airway in place until gag & amount of fluid being infused & flow rate
swallow reflex have returned 8. Administer postoperative analgesics
d. Prevent hypoxemia (reduced oxygen in the blood) 9. Encourage client to cough & deep breath after airway
and hypercapnea (excess carbon dioxide in the is removed
blood)  Helps mobilize secretions, prevent atelectasis,
e. Watch out for hypopharyngeal obstruction and expel residual anesthetic agents

 Coughing is contraindicated in patients who 13. If spinal anesthesia is used, maintain flat position &
have check for sensation & movement in lower
o Head injuries or who have undergone extremities
intracranial surgery – risk for increasing ICP
o Eye surgery – risk for increasing IOP
Post-Operative Discomforts
o Plastic surgery – risk for increasing tension
on delicate tissues
2. Thirst
10. Check all drainage tubes & connect to suction or
3. Constipation and gas cramps
gravity drainage as ordered
4. Pain
 Note color, amount, & odor of drainage
11. Assess dressing for intactness, drainage &
hemorrhage Transfer Responsibilities
12. Monitor & maintain client’s temperature 1. relay appropriate information to the unit nurse
 May need extra blankets regarding condition; point out significant needs
2. physically assist in the transfer of the patient

3. orient patient to room, attending nurse, call light, and Closed Drainage System – uses a compression and
therapeutic devices suction to remove drainage and collect it in a
reservoir. It reduces the risk of infection and allow
Care in Surgical Floor more accurate measurement of drainage.
1. Maintain respiratory status & promote optimal a. Jackson Pratt Silicone
functioning Drain – has a small bulb
2. Monitor cardiovascular status & avoid post-op on the end of a plastic
complications tube with a plug that
3. Promote adequate fluid & electrolyte balance allows the removal of
4. Promote optimum nutrition drainage. Compressing
 Clear liquid diet – water, juice, tea the bulb after emptying it
 Soft diet – gelatin, custard, milk, and creamed and before replacing the plug generates enough
soups pressure to facilitate drainage. Recompression is
5. Monitor & promote return of urinary function indicated when the bulb fills with drainage or is no
 Patient is expected to void within 8 hours after longer compressed.
surgery (this includes time spent in the PACU) b. Hemovac – incorporates a larger, disc shape
 All methods to encourage the patient to void reservoir for collecting drainage. It has a pouring
should be tried (e.g., letting water run, applying spout for emptying the collection reservoir
heat to the perineum)
 Use a commode if patient cannot void on a
bedpan
 Male patients are often permitted to sit up or
stand beside the bed to use the urinal, but
safeguards should be taken to prevent the
− Changing the dressing
patient from falling or fainting due to loss of
− First post-operative dressing is usually
coordination from medications or orthostatic
changed by the surgeon or surgical resident
hypotension
− Subsequent dressing changes usually is
 If the patient cannot void in the specified time
performed by the nurse
frame, the patient is catheterized and the
− Dressing is applied for the following reasons:
catheter is removed after the bladder has
✓ Provide a proper environment for wound
emptied
healing
6. Promote bowel elimination
✓ Absorb drainage
 Early ambulation
✓ Splint or immobilize the wound
 Improved dietary intake
✓ Protect the wound and new epithelial tissue
 Stool softener (if prescribed)
from mechanical injury
7. Administer post-op analgesics as ordered; provide
✓ Protect the wound from bacterial
additional comfort measure
contamination and from soiling by feces,
8. Provide wound care
vomitus, and urine
 Inspection for approximation of wound edges,
✓ Promote hemostasis, as in a pressure
integrity of sutures or staples, redness,
dressing
discoloration, warmth, swelling, unusual
✓ Provide mental and physical comfort for the
tenderness, or drainage.
patient
 Management of wound drains. Drains are tubes
− Dressing change is performed at a suitable
that exit the peri-incisional area, either into a
time (eg, not at mealtimes or when visitors are
portable wound suction device (closed) or into
present). Privacy is provided, and the patient
the dressings (open). The principle involved is to
is not unduly exposed.
allow the escape of fluids that could otherwise
− Hand hygiene is performed before and after
serve as a culture medium for bacteria.
dressing change and disposable gloves
Open Drainage System – uses a small plastic tube
(sterile or clean as needed) are worn.
that collapses easily and has a safety pin or clip
− Dressings are never touched by ungloved
attached or loose stitch to
hands because of the danger of transmitting
keep drain to keep it in place.
pathogenic organisms.
An absorbent dressing is
− The tape or adhesive portion of the dressing is
applied to the area to collect
removed by pulling it parallel with the skin
drainage and to keep it dry.
surface and in the direction of hair growth,
Example – Penrose drain
rather than at right angles. Alcohol wipes or

nonirritating solvents aid in removing adhesive Hemorrhage

painlessly and quickly. The soiled dressing is • Copious escape of blood from the blood vessels
removed and deposited in a container Capillary − slow, generalized oozing
designated for disposal of biomedical waste
Venous − dark in color and bubble out
9. Maintain a safe environment
Arterial − spurts and is bright red in color
 Have side rails up
 Assesses the patient’s level of consciousness
Clinical Manifestations
and orientation
 Determine whether the patient can resume 1. Apprehension, restlessness, thirst, cold, clammy,
wearing his or her eyeglasses or hearing aid, moist, pale skin
because impaired vision, inability to hear 2. Deep, rapid RR, low body temperature
postoperative instructions, or inability to 3. low CO (cardiac output)
communicate verbally places the patient at risk 4. decreased BP, low hemoglobin
for injury
 All objects the patient may need should be within Nursing Considerations
reach, especially the call light 1. Replace blood – blood transfusion, IV fluids
10. Provide adequate psychological support 2. Monitor vital signs
11. Provide appropriate discharge teaching 3. Use pressure dressing
4. Give vitamin K (aquamephyton), Hemostan
5. Ligation of bleeders
Postoperative Complications
Shock
Atelectasis
• Response of the body to a decrease in the circulating
blood volume, which results to poor tissue perfusion • A collapse of lung tissue affecting part or all of one
and inadequate tissue oxygenation (tissue hypoxia) lung
• Bleeding is an obvious cause of low blood volume • This condition prevents normal oxygen absorption to
• Dehydration without adequate fluid replacement or healthy tissues
fluid losses through wounds and suction can explain • Experienced 2nd day postop
low blood volume
Clinical Manifestations 1. Dyspnea, cyanosis, cough
1. Anxiety or agitation 2. Elevated temperature
2. Cool, clammy skin 3. Pain on affected side.
3. Confusion 4. Tachycardia
4. Decreased or no urine output
5. General weakness Nursing Considerations
6. Pale skin color (pallor) 1. Reinforce deep breathing, coughing, turning
7. Rapid breathing exercises)
8. Sweating, moist skin 2. Suctioning
9. Unconsciousness 3. Postural drainage
4. Antibiotics as ordered
Nursing Considerations 5. Change position at least every 2 hours
1. Assess wound dressing 6. Incentive spirometry
2. Report excessive drainage or bleeding 7. Rest
3. Monitor vital signs every 15 min until stable 8. Administer oxygen as ordered
4. Note early changes in vital signs
5. Report tachycardia, tachypnea, hypotension Paralytic Ileus
6. Monitor input and output • Obstruction of the intestine due to paralysis of the
7. Keep intravenous fluid rate on schedule intestinal muscles
8. Assess respirations before giving opioids • The paralysis does not need to be complete to cause
9. Fluid or blood replacement ileus, but the intestinal muscles must be so inactive
10. Vasopressors (drugs to raise blood pressure as that it prevents the passage of food and leads to a
ordered) functional blockage of the intestine
11. Additional surgery may be needed to control • Ileus commonly follows some types of surgery,
bleeding especially abdominal surgery

Clinical Manifestations Within 48 hours − UTI (urinary tract infection)

1. Absent bowel sounds Within 72 hours − wound infection
2. No flatus or stool
Wound Complications
Nursing Considerations
Hemorrhage / hematoma
1. Nasogastric suctioning
Wound dehiscence – separation of wound edges (.5-
2. Use of decompression tubes
6 days postop)
3. Give IV fluids
Wound evisceration – externalization of bowel
(experienced 5-6 days postop)
Pulmonary Embolism
• Experienced 2nd day postop
• It is an occlusion of the pulmonary vasculature
causing blood flow obstruction
• It is a problem with perfusion not ventilation
1. Dyspnea, cyanosis, cough
2. Restlessness
3. ABG − low oxygen, high carbon dioxide
1. Apply abdominal binder
Diagnostic Test
2. Encourage proper nutrition
1. Chest x-ray
 High CHON, vit C
 Watermark’s Sign − an abrupt tapering or
3. Stay with the client, have someone call for the doctor
narrowing of a vessel caused by pulmonary
4. Keep in bed rest
embolism
5. Supine or Low Fowlers position, bend knees to
2. ABG
relieve tension on abdominal muscles
3. ECG – to detect dysrhythmias
6. Evisceration − cover exposed intestine with sterile
4. Ventilation and perfusion scan
moist saline dressing
5. Pulmonary angiography − confirmatory test
7. Reassure, keep him quiet and relaxed
 Outlines the pulmonary vasculature to show the
8. Prepare for surgery and repair of wound
location of emboli
Nursing Considerations Urinary Retention

1. Give oxygen, • occurs most frequently after operation of the rectum,
2. Anticoagulants (heparin) to be given anus, vagina and lower abdomen caused by spasm of
3. IV fluids to be infused the bladder sphincter
• Experienced 8-12 hours postop
Wound Infection
experienced 3-5 days postop Causes- Staphylococcus
1. Unable to void after surgery
aureus, E. coli, Pseudomonas aeruginosa
2. Bladder distention
1. Elevated WBC and temperature, chills
1. Catheterized the patient
2. Pus or other discharge on the wound
 Positive cultures
3. Foul smell from the wound Deep Vein Thrombosis
4. Redness, swelling, pain, warmth • The formation of a blood clot (thrombus) in a deep
vein, predominantly in the legs
Nursing Considerations • Experienced 6-14 days up to 1 year later
1. Antibiotic therapy, aseptic technique
2. Good nutrition Clinical Manifestations
3. Wound care 1. Calf pain (+ Homan’s sign)
Rule of thumb 2. Edema, tenderness
Fever 1st 24 hours − pulmonary infection

Prevention
1. Hydrate adequately to prevent hemoconcentration
2. Encourage leg exercises and ambulate early
3. Avoid any restricting devices that can constrict and
impair circulation
4. Prevent use of bed rolls dangling over the side of the
bed with pressure on the popliteal area
Active Intervention
1. Bed rest; elevate the affected leg with pillow support
2. Wear anti-embolic support hose from the toes to the
groin
3. Avoid massage on the calf of the leg
4. Initiate anticoagulant therapy as ordered (Heparin)
Postop Psychological Disturbances

Delirium (Mental Aberration)
ACS (Acute Confusional State)
Causes
1. Dehydration
2. Insufficient oxygenation
3. Anemia
4. Trauma (especially in nervous persons)
Manifestations
1. Poor memory
2. Restlessness
3. Disoriented
4. Sleeps disturbances
1. Sedatives to keep client quiet and comfortable
2. Explain reasons for interventions
3. Listen and talk to the client and significant others
4. Provide physical comfort air, replace plug, and check
system for operation

CARDIOVASCULAR DISORDERS
Functions of the Heart • Pericardial space is the space between the visceral
• Pumps oxygenated blood into the body and parietal layer, that consists of at least 10 to 50 mL
• Moves one-way flow providing oxygen and nutrients of fluids in order to lubricate the surface of the heart
to the body allowing easy movement during contraction and
• Regulate blood supply to the body expansion of the heart
 Take note that if there is a sudden rapid filling of
Different Activities of the Heart 100 mL, it can compromise cardiac function and
cause cardiac tamponade (places extreme
Circulation
pressure on your heart)
• Right – Pulmonary circulation
 The pressure prevents the heart's ventricles from
• Left – Systemic circulation
expanding fully and keeps your heart from
Cardiac Conduction System functioning properly
• 3 Layers of cardiac muscle:
• Conduct electrical impulse through the heart
Epicardium – outermost
Cardiac Cycle Myocardium – contracting layer
• Complete one heartbeat (one contraction, one Endocardium – inner layer, lines the inner chamber
relaxation) of the heart, valve, chordae, tendineae and
papillary muscles and it is the only portion or only
Cardiac Output
layer that receives oxygen and nutrients from
• Volume of blood that is ejected by the heart, it may blood circulating the heart
indicate the pumping functions of the heart
• The heart has 4 chambers but functions as a two-
sided pump. The atria serves as the collecting
Divisions of Circulation chamber while the ventricle serves as the pumping
Systemic – supply oxygen and nutrients to the body chamber
tissues and bring blood back to the heart • Valve ensures a one-way blood flow and prevent the
Pulmonary – send blood to the lungs for removal of CO2 backflow that produce heart sounds
and oxygen uptake • Atrioventricular valve produces the S1 heart sound
that separates the atria from ventricle which includes
the mitral and tricuspid valve
• Semilunar valve is the relaxation or ventricular
diastole of relaxations. This refers to the second heart
sound, the closure of the aortic and pulmonic valve.
Structure of the Heart

• Consists of pericardium, the valve, and the arteries • Thickness of the cardium varies according to the
• Under pericardium there is two layers: pressure generated to move blood to its destination
Parietal – outer layer, a loose-fitting sac that  Left ventricle is thicker than the right ventricle
surrounds the heart
Visceral – inner layer (epicardium); adheres to the Arteries
outside of the heart
• Arteries are blood vessels that carries oxygen rich
blood away from the heart whereas they keep blood
flow towards the heart except pulmonary arteries
which carry blood to the lungs for oxygenation
• Arterial system is the higher-pressure portion of the
circulatory system
• During heart contraction, it is called systolic pressure,
and diastolic pressure when the heart expands and
refills

• Arteries also help the heart in pumping blood 2 Phases of Cardiac Cycle
• As the blood moves to the periphery, arteries Diastole – atrial contraction and ventricular relaxation
subdivide to become arterioles, which can dilate or Systole – ventricular contraction and atrial relaxation
constrict in response to ANS control
 Dilation – decrease resistance to flow
• Amount of blood pumped by the ventricles into the
 Constriction – increase resistance to flow
pulmonic and systemic circulation per one minute
• Therefore, arterioles distribute blood to the capillaries
 CO = HR x SV (4 to 8 LPM)
and function in controlling systemic vascular
• Stroke volume – volume of blood ejected with each
resistance and referred to as “arterial pressure”
heartbeat (60 to 100 bpm)
• Coronary arteries are vessels that delivers oxygen-
• The cardiac function based on the adequacy of the
rich blood to the myocardium, the vessels that remove
cardiac output, this refers to the amount of blood that
the deoxygenated blood from the heart and muscles,
is pumped by the ventricles into the pulmonary and
also known as the “cardiac vein”
systemic circulation (this is about the total volume)
• Collateral circulation is an alternate circulation around
• Cardiac output indicates how well the heart is
a blocked artery or vein via another path, such as
functioning as it pumps, so it depends also in stroke
nearby minor vessels (anastomotic channel –
volume and heart rate
adaptation)
 A network of capillaries that supplies the
myocardial cells Cause of Low CO
 There are numbers of functional and non- Inadequate left ventricular ejection – CAD,
functional anastomosis that exists between the cardiomyopathy, HTN, Aortic stenosis, mitral
coronary vessels which can enlarge when the regurgitation, drugs that are negative inotropes and
flow in one arterial branch decreases metabolic disorders
 Enlargement of anastomosis can improve blood Inadequate left ventricular filling – hypovolemia,
flow to myocardial segment to provide collateral tachycardia, stenosis, rhythm disturbance
circulation
High CO – exercise, fear, anxiety and sepsis
Major Coronary Arteries Causes of low cardiac output are inadequate left
There are 2 major coronary arteries, the right and the ventricular ejection (pump out of blood from the heart)
left coronary artery
Right coronary artery (RCA) – extends to the R & Stroke Volume
continues to R AV sulcus to the posterior surface of the
• Volume of the blood ejected with each heartbeat,
heart
appx. From 60 to 100 mL per beat
Left coronary artery (LCA) – extends to the left then • Ejected from each ventricle due to the contractions of
divides into major branches (left ant. Descending and the heart muscles which compresses these ventricles
circumflex arteries • Stroke volume is expressed in ml/beat
• Decrease in stroke volume may increase heart rate
Factors That Regulate Stroke Volume

Preload – give the volume of the ventricle has available
to pump, so it depends on the venous return
Contractility – it is the force that the muscle can create
at a given time
 The force of contraction generated by the
myocardium
Cardiac Output (CO) Afterload – arterial pressure against which the muscle
will contract
• Cardiac cycle is one contraction and one relaxation of
the heart to form one heartbeat  These factors establish the volume of blood that
• The circulating volume of blood to the heart varies pump with each heartbeat
according to the needs of the tissue cells, any
Note: these factors establish the volume of blood
increase in the work of the cells causes an increase in pumped with each heart beat
blood flow and a subsequent increase in the work of
the heart on myocardial oxygen consumption

Factors Affecting Cardiac Output Decrease in Preload

Heart Rate 1. Decreased circulating blood volume (bleeding)
• Cardiac output can be increased or decreased directly 2. Mitral or aortic stenosis
by changes in the heart rate 3. Vasodilator (NTG)
• Heart rate of less than 40 beats/min, expect that the 4. Atrial fibrillation
cardiac output is decreased, this may lead to 5. Cardiac tamponade
possibility of dysrhythmia or arrythmia because of the 6. Blood loss
automatism that contributes to the uncoordinated 7. Dehydration
myocardial contraction that may further depress
contractility Treatment
• Increase in heart rate may reduce the time that the 1. Fluids (0.9% NS, LR) – isotonic solutions
heart is in diastole that may result to decrease in left 2. Blood and Blood products
ventricular filling and coronary blood flow to the 3. Vasopressor – but not effective if full tank
myocardium 4. Volume expander
• Hear rate and contractility are intrinsic factors
• The characteristic of the cardiac tissue employs by the Afterload
humoral and neural mechanism, whereas the preload
• The resistance or pressure which the ventricle must
and afterload depend on the characteristic of the heart
overcome to eject its volume of blood during
rate and vascular resistance
contraction
• Has 2 functions, arterial pressure and left ventricular
Medication that Lowers Heart Rate size
1. Adenosine • Any increase in vascular resistance may cause
2. Beta Blockers increased ventricular contractility in order to maintain
3. Calcium Channel Blockers stroke volume and cardiac output
4. Digoxin • Therefore, if there’s an increase in afterload, there will
be an increase in heart workload
Medication that Increases Heart Rate • Afterload is directly related to arterial blood pressure,
1. Epinephrine wherein ejection of blood into systemic circulation
2. Norepinephrine • For instance, as the arterial pressure increases, more
3. Atropine energy is required to generate enough pressure to
eject blood
Preload • As more energy is required for ventricular systole,
then the myocardial oxygen demand increases
• Based on the principle of Starlings Law – the greater
• Vascular resistance is the resistant that must be
the stretch of the cardiac muscle fibers and the
overcome to push blood into the circulatory system
greater the course in which the fiber contract to
and to create flow
accomplish emptying
• Right ventricle – pulmonary vascular resistance
• Preload is affected by the venous blood pressure and
(PVR) – The right ventricle ejects blood through the
the rate of venous return
pulmonic valve against the low pressure of the
• Factors that may affect preloading are blood volume,
pulmonary circulation, or pulmonary vascular
distribution of blood supply in the body, ventricular
resistance (PVR)
functions, and ventricular compliance
• Left ventricle – Systemic Vascular Resistance (SVR)
– The left ventricle ejects blood through the aortic
Conditions Affecting Preload
valve against the high pressure of the systemic
1. Increased in preload circulation, also known as systemic vascular
2. Increased circulating blood volume resistance
3. Mitral or aortic insufficiency
4. Heart failure
Conditions Affecting Afterload
5. Hypovolemia
1. Ventricular outflow obstructions – aortic valve
6. Overtranfusion
stenosis
7. Polycythemia
2. SNS stimulation – epinephrine release causes
increase PVR
Treatment
3. Hypertension
1. Diuretics (Furosemide) 4. Hypercoagulability
2. Vasodilators – nitrates and morphine

Treatment (Afterload) • Good indicator of the heart’s ability to maintain

Decrease Afterload contractility and it is the relationship between the
1. Vasodilators – morphine, nitroprusside, hydralazine, diastolic volume and stroke volume
Clonidine, ACE inhibitors, ARBs • If the ventricle received 100 mL of blood during a
2. Intra-Aortic Balloon Pump (IABP) - Increase cardiac cycle, it should be pumped out at about 60 to
myocardial oxygen perfusion, increasing cardiac 75 mL with each beat
output (CO) and increases coronary blood flow • If there is a decrease in ejection fraction, it results to
ventricular failure, because the ventricle is unable to
pump effectively
• The systolic dysfunction occurs when the ejection
fraction falls below 50%
• Measured by echocardiogram, nuclear studies, MRI,
CT scans
Increase Afterload
1. Vasopressor – like dopamine, dobutamine,
norepinephrine, epinephrine
 Dopamine – increase contractility and oxygen
consumption
 Be sure to correct hypovolemia with volume
replacement before considering vasopressors
Contractility
• Inotropic Depolarization
• Refers to the inherent ability of the myocardium to • Contraction
contract normally and influenced by preload • Once an electrical impulse is generated then the
• Force generated by the contracting myocardium and movement of Na rapidly enters the cell and exit of K
influenced by circulating catecholamine, which means
that the ability of the myocardium to contract normally Repolarization
and influenced by preloading • Relaxation
• Sometimes referred to as inotropic state • Return of the ions to its previous resting state, which
• May be affected by corresponds to relaxation of myocardial cells
 Ventricular muscle mass
 Heart rate Action Potential
 Oxygen status • The change in electrical potential associated with the
 Chemical or pharmacological effects passage of an impulse along the membrane of a
muscle cell or nerve cell
Conditions Affecting Contractility • Any stimulus that increases the permeability of the
membrane will generate an electrical potential
Increase Contractility
• This is the nerve impulse that can cause the
1. Sympathetic stimulation (fear or anxiety)
permeability of ions across the cell membrane
2. Calcium
• Action potential are nerve impulse fire
3. Inotropes – digitalis, epinephrine and dobutamine
Decrease Contractility Electrophysiologic Properties of Cardiac Muscle

1. Negative inotropes (Beta-blockers, Calcium Automaticity/rhythmicity
Blockers, barbiturates and most antidysrhythmic • Spontaneous initiation of an impulse without control
2. Infarction • Automaticity is spontaneous generating and
3. Cardiomyopathy discharging of an electrical impulse in the SA node
4. Vagal stimulation wherein the Na move into the cell
5. Hypoxemia • Rhythmicity is regular discharging of the action
6. Acidosis potential
Terms Excitability
Ejection Fraction • Ability of the cell to respond to an electrical
• Normally 55 to 70% impulse/stimulus

Conductivity Pulse Pressure

• Propagate electrical impulses • Difference between systolic and diastolic pressure (30
• The ability of the cells to response to an electrical – 40 mm Hg)
impulse from one cell to another • This reflects the stroke volume, ejection velocity, and
systemic vascular resistance
Refractoriness • May indicate how well a patient could maintain a
• Inability to respond to a new stimulus while still in a cardiac output
state of contraction from an earlier stimulus. • If there is an elevation in pulse pressure, it results to
• Myocardial cells repolarize before they can depolarize increased stroke volume, decrease in peripheral
again volume or decrease in systemic vascular resistance
• Absolute and relative refractory periods or reduce distensibility of the arteries. This is due to
Absolute phase – the cell is completely high pressures in the aorta (e.g. light exercise, fever,
unresponsive to any electrical stimulus and not anxiety, atherosclerosis, hypertension)
capable to initiate early depolarization • If there is a decrease in pulse pressure, it reflects a
reduced stroke volume, which indicates that there is a
Relative Phase – if the electrical stimulus is stronger
drop in the left ventricular stroke volume and
than normal then premature contraction may occur
insufficient preload. Therefore, there’s also a
placing patient at risk for dysrhythmia
decrease in cardiac output (e.g. hypovolemia, blood
loss, heart failure or shock)
Cardiac Conduction System
Sinoatrial node (SA) or Pacemaker Mean Arterial Pressure
• (60 – 100 bpm) • Average pressure maintained in the aorta (70 – 110
• Located at the junction or near the inlet of the superior mm Hg)
vena cava and in the upper wall of the right atrium • The pressure of which the blood move through the
• Impulse is initiated that follows a specific path through vasculature for cells to receive adequate oxygen and
the heart and usually does not flow backward nutrients needed to metabolize energy in an amount
sufficient to sustain life
Atrioventricular Node or Junction • If there is a decrease in mean arterial pressure, it
• Secondary pacemaker (40 – 60 bpm) usually indicates a decrease in blood flow, and
• Located in the lower portion of the right atrium at the decrease in perfusion in the vital organs
juncture of the atrial septum • If there’s an increase in mean arterial pressure, it
• Allows for atrial emptying and filling of the ventricle increases the cardiac workload
Bundle of His (AV bundle) Peripheral Resistance

• Fuse with the AV node to form another pacemaker (40 • A resistance of all peripheral vasculature in the
– 60 bpm) systemic circulation
• Divided into right bundle and left bundle branch • If there is a clogged vessel, it may cause elevation of
peripheral resistance (vasoconstriction)
Purkinje Fibers • If there is a decrease in peripheral resistance it may
• Inherent the rate of 30 – 40 bpm or more slowly. result to vasodilation
• NOT activated as a pacemaker unless conduction
through the bundle of His becomes blocked Venous Pressure
• Blood flows back to the heart via venous system with
assistance from vessel wall tone, pumping action of
the skeletal muscle
Central venous pressure – approximation of right
atrial pressure; N = 5 – 10 cm H2O
(Brunner 4 – 12 mm Hg)
Capillary Pressure
• Pressure exerted by the blood against the capillary
• Capillary pressure and plasma oncotic pressure
contribute to balance of interstitial fluid
 25 to 30 mm Hg at the arterial
 10 – 15 mm Hg at venous end

Regulation of Cardiac function and Blood Pressure Stretch Receptors

Neural / ANS  Sends impulses to the CNS to stimulate HR and
PNS – inhibitory effects blood vessel constriction to regulate circulatory
 There is parasympathetic nervous system that volume status that affect BP
release neurotransmitter acetylcholine that may  Responds to pressure changes that affect the
decrease the rate of SA node firing or decrease in circulating blood volume
heart rate or even decrease in atrial or ventricular  If there’s an increase in the volume of blood, it
contractility and conductivity sends impulse to the CNS in order to regulate the
SNS – acceleratory effects volume status which also may affect the BP
 Release neurotransmitter norepinephrine
Chemoreceptor
producing acceleratory effect on the heart
 Sensitive to hypoxemia and 2° to ↑ CO2 and ↓
increasing heart rate, conduction speed, atrial or
arterial pH
ventricular contractility, and peripheral
 It senses the chemical changes in the blood
vasodilation
primarily hypoxia or hypoxemia, secondary to
increase in CO2 and decrease arterial pH
 Usually, blood chemical changes, especially the
pH, CO2, O2 level can alter the cardiac and
respiratory activity
Local control / Peripheral receptors

• pH, O2 & CO2 concentration
• It is based on the metabolic needs of the surrounding
Endocrine Control cells that cause the cardiac output may be the same
• Hormones contribute to regulation of the circulation of but blood flow depending on the cell need
the heart
• Changes in response to PNS and SNS
Baroreceptor
 Sends impulses to the medulla oblongata to
stimulate either vagal response
 Also called as the pressure receptor
 Located at the wall of the aortic arch and aortic
sinus
 Sensory nerve endings in the blood vessels that
detect BP level and report any abnormal BP to the
CNS which response by regulating the resistance
of blood vessels, the rate and strength of the heart
contraction
 Detecting the amount of stretch
 If there are changes in the arterial pressure, it may
• Other categories of mechanism in the circulation
signal the medulla
aside from the neural, there is the endocrine control
 If elevated, it may signal to PNS in order to
• There are several hormones contributing to the
respond by decreasing the pressure
regulation of the circulation of the heart
 If there is a low pressure, it may initiate
• In response to physical activity and stress,
sympathetic stimulation in order to increase the
catecholamine is released which my influence heart
heart rate, pulse rate, contractility, and even
rate, myocardial contractility, and peripheral vascular
vasoconstriction
resistance
 If there is high pressure, it stimulates the stretch
• Other hormones that play a major role in the
receptor that causes a reflex vagal response
regulation of the circulation includes the angiotensin,
therefore it may decrease the heart rate, BP, and
adrenocorticotropic hormones, vasopressin,
cause vasodilation in the systemic arterioles
ranitidine, and prostaglandin
 Baroreceptor plays a role in blood pressure
regulation

Health Assessment B. Patient History

Subjective Data 1. Past medical history – since childhood
A. Chief Complain  Consider the treatment and where the
1. Chest pain/discomfort – SOCRATES or PQRST patient had last taken his/her ECG test or
Pain Assessment Model blood test
• Note: Try to determine the location of pain, 2. Medication history – vitamins, herbal and other
whether its substernal or precordial OTC medications
• Determine the characteristic or the quality of 3. Family history
pain (pressure pain, burning pain, crashing 4. Diet and nutrition – height and weight, food
pain) preferences and preparation
• Determine the intensity of pain (mild, moderate, 5. Elimination – bowel and bladder habits
severe)  Nocturia
• Determine the onset and duration of pain  Valsalva maneuver
(sudden, gradual, intermittent, continuous) 6. Socio-cultural – education level, occupation,
❖ Angina pectoris = 5 – 15 min, sleep pattern, exercise, tobacco use, economic
uncomfortable pressure, squeezing or resources
fullness in substernal chest area 7. Psychological – self-perception and self-concept,
❖ Acute coronary syndrome (ACS) - > 15 min coping and stress strategies (depression),
❖ Pulmonary disorders – sharp, severe prevention strategies (behavioral changes)
epigastric pain or substernal arising from
inferior portion of pleura Objective Data
Head to toe physical exam – IPPA techniques
Pain Assessment Model
A. General Appearance
S Site Where exactly is the pain? 1. LOC, mental status and the size (normal,
over/underweight or cachectic), height and
What were they doing when
O Onset
the pain started?
weight, and BMI
2. Skin – color (pallor, peripheral and central
What does the pain feel
C Character
like? cyanosis, ecchymosis), turgor, temperature,
moisture
Does the pain go anywhere
R Radiates
else? 3. Nail – color, shape, thickness, symmetry,
clubbing of the fingers and toes
A Associated Symptoms e.g. nausea/vomiting 4. Extremities – edema, ulcerations, capillary refill
time
How long have they had the
T Time/Duration 5. Pulse – PR, rhythm, quality, configuration or
pain?
Exacerbating/Relieving Does anything make the

contour, bruits, and palpation of arterial pulse
E
Factors pain better or worse? 6. Precordium
✓ Inspection – apical pulse, retraction in MCL 5th
S Severity Obtain an initial pain score
ICS
✓ Palpation – thrills (aortic or pulmonic stenosis)
2. Palpitations – rapid or irregular heartbeat, or skip ✓ Auscultation – murmurs, abnormal heart
beat sounds
3. Dyspnea – EOD, PND, orthopnea (e.g. ACS, ✓ Jugular veins – 1 to 3 cm above the level of
cardiogenic shock, HF and valvular heart manubrium
disease) ✓ Blood pressure – SBP, DBP, Pulse pressure
4. Cough
5. Unusual fatigue • There are times patients may have postural
6. Peripheral edema – grading scale of pitting hypotension in which there is a decrease of 20mm Hg
edema systolic within 3 minutes of moving from lying, sitting,
7. Syncope – transient loss of consciousness and standing up accompanied by dizziness,
because of decreased blood flow to the brain, lightheadedness, this is due to reduce in preloading
usually from low BP which compromise the cardiac output
8. Weight gain • Also consider the neck circumference which may add
9. Hepatosplenomegaly (HF) information regarding the shape, risk of predicting
10. Dizziness cardiometabolic syndrome
11. Postural hypotension

• Even abdominal fats in female that is greater than 35 3. Aspartate Transaminase (AST) or SGOT (serum
inches for male greater than 40 inches, may indicate glutamic oxaloacetic transaminase)
the possible risk of patient for coronary artery disease  Elevated AST can cause liver damage or insult
to the heart
 Heart failure may lead to generalized swelling
of the body that causes elevated AST
 10 – 40 U/L
4. Myoglobin
 Oxygen-binding protein found in striated
muscle
 Hemoglobin transport O2 while myoglobin
stores O2 which is the carrying pigment of the
muscle tissue
 Increase in 2 hours after acute myocardial
infarction
 Any injury in the skeletal muscle will cause the
release of myoglobin into the blood
Diagnostic Studies  Return to normal about 12 hours
A. Serum Enzymes  30 – 90 mcg/L
 It is not specific to diagnose MI, but helps in
1. Creatine Kinase (CK) – CK-MB
diagnosing the oxygen-carrying capacity to the
 Formerly known as creatine phosphokinase muscle tissue or stored oxygen in the muscle
 The 3 types of CK are called isoenzymes. tissue
They are:
 CK-MM, found in your skeletal muscle and
5. Troponin
heart
 Normally, the cardiac troponin level is very low
 CK-MB, found in the heart and rises when
but increases rapidly with an MI
heart muscle is damaged
 Released ONLY when myocardial necrosis
 CK-BB, found mostly in your brain. It's also
occurs.
found in smooth muscles such as the intestine
 Preferred marker for myocardial injury
or uterus.
 If there’s an elevation in troponin, the physician
 If there’s an elevation in CK-MB, it may
may suspect for myocardial injury or ischemia
indicate myocardial infarction, it is a cardiac
 Increase within 3 – 12 hours from the onset of
marker that have greater specificity found only
chest pain
in the heart
 T may indicate myocardial ischemia, I may
 As much as possible avoid IM injection, it
indicate unstable angina
should be prior to extraction or else it may
 Peak at 24 – 48 hours
increase within 6 hours of injury
 Return to baseline over 5 – 14 days
 Found in the heart
 Troponin level increase earlier than CK-MB
 Rise within 6 hours of injury
level
 Peak at 18 hours post injury and return to
 N: T = < 0.2 mcg/L; I = < 0.35 mcg/L
normal in 2 – 3 days
 N: CK = 36 – 188 u/L; CK-MB = < 25 u/L
6. C-reactive Protein (CRP)
 A marker for systemic inflammation
2. Lactate Dehydrogenase (LDH) – L1 & L2
 Identify myocardial injury
 Isoenzyme L1 & L2 are used to assess
 CRP is produced by the liver and increases in
myocardial damage
response to tissue inflammation or injury
 Useful in diagnosis of MI
 A better predictor for an MI than cholesterol
 Detected within 24 – 72 hours
 If there’s an inflammation in the arterial wall,
 Peaks within 3 - 4 days
the body respond to the inflammation that may
 Elevated 14 – 24 hours after onset of MI
trigger a cardiac event
 LDH: 90 – 176 units/L
 < 1 mg/dL
 Return to normal after 2 weeks
7. Lipid Profile
 Cholesterol – < 200 mg/dL

 Triglycerides – 100 to 200 mg/dL  If there’s a decrease in BNP, it may cause a

 Lipoproteins decrease in Na retention, increase in diuresis
a) LDL – < 160 mg/dL by improving glomeruli filtration, and inhibits
b) HDL – 35 to 70 mg/dL (M); 35 to 85 mg/dL aldosterone secretion
(F)
 Transport of cholesterol to the peripheral may 10. Homocysteine
increase due to coronary artery disease  Indicate high risk for CAD, stroke, and
 HDLs are cholesterol that may be excreted in peripheral vascular disease. Normal value: 5 –
the body 15 umol/L
 Triglycerides may be stored as unused  It is an amino acid that is linked to the
catalyst that provide the body with energy. development of atherosclerosis, so patients
Diet, weight loss, and physical activity is are at high risk of coronary artery disease and
encouraged to lower down the triglycerides stroke peripheral vascular disease
 Used to determine cardiovascular diseases
8. Coagulation Studies  If there’s an increase in homocysteine, patient
 It is routinely performed before any invasive is at risk of development of coronary artery
procedure such as cardiac catherization, disease. It can be due to a genetic factor
electrophysiology testing, and cardiac surgery  If there’s a decrease in homocysteine, it is
 Consist of prothrombin time that measures the usually caused by increased intake of folate
extrinsic coagulation system and also helps from food or folic acid, Vitamin B6 and B12
screen for coagulation deficiency factors like I,
II, V, VII, X 11. Atrial Natriuretic Peptide (ANP)
 Start to monitor patients who are taking oral  Control body water, Na, K release by the atria
anticoagulants and screening for early in response to blood volume
deficiency in vitamin K  Regulate the extracellular volume; acts to
 Measure the amount of time it forms a clot, if reduce water, Na, K, therefore reducing BP
less than 30 seconds, the patient is at risk for  May counteract the secretions of aldosterone
thrombus formation, if it is greater than 30  It may show elevations in ANP in patients who
seconds, the patient is in critical condition and have heart failure because of hypervolemic
at risk for bleeding state
 Prothrombin time – 10 to 14 seconds
 Activated Partial thromboplastin time (aPTT) – 12. Electrolytes
20 to 39 seconds Electrolytes play a major role in heart muscle
 This integrate intrinsic coagulation system; it function: Ca, K and Mg
may identify any bleeding or clotting disorder Sodium – diuretic therapy; 135 – 145 mEq/L
as well as monitoring the effects of heparin  Whether low or high levels of Na does not
 It is a screening test that helps evaluate a affect cardiac function, but decrease in Na
person's ability to appropriately form blood may indicate fluid excess and can cause
clots. heart failure, administration of diuretics will
 It measures the number of seconds it takes for be needed
a clot to form  Increase in Na levels, it may indicate fluid
 If there’s a prolonged PPT, it takes longer to deficit from low water intake or loss of water
clot and thrombus may not occur or develop due to excess sweating or diarrhea
 Long term use of diuretics may predispose
9. Brain Natriuretic Peptide (BNP) patients to hyponatremia
 < 100 ng/L
 It is a neurohormone used to regulate BP of Potassium – 3.5 – 5.5 mEq/L
fluid volume, it is secreted from the ventricle in
Affects heart muscle
response to increased preload which may
 Plays a major role in cardio
result to elevation in ventricular pressure
electrophysiologic function
 If there’s an elevation of BNP, it increases
Ventricular dysrhythmias
pressure in the ventricular wall which is very
significant in paatients’ with heart failure, acute  Hypokalemia is due to administration of
MI, hypervolemic state like renal failure potassium excreting diuretic that can cause
 It is used to diagnose mainly heart failure, MI, many forms of dysrhythmia
pulmonary embolism

 It may include the life-threatening ventricular myocardium resulting to heart block; in some
tachycardia or ventricular fibrillation which severe cases it causes asystole
may predispose patients who are taking  Severe deficiency causes life-threatening
digitalis preparation to digitalis toxicity ventricular arrhythmias
In hypokalemia, there is a presence of U wave in  Elevated caused hypotension and
the ECG tracing bradycardia
 Hyperkalemia is due to increased intake of
K, decrease renal excretion of K, and use of 13. Basal Metabolic Panel
potassium-sparing diuretics like Aldactone  Blood test that measures your sugar (glucose)
 Consequences of hyperkalemia includes level, electrolyte and fluid balance, and kidney
heart block, asystole, and life-threatening function (creatinine and BUN), bicarbonate
ventricular dysrhythmia and chloride
 Digitalis toxicity increase electrical instability  Patient needs to fast 10-12 hours prior to
taking the test
 N: Creatinine – 0.7 -1.0mg/dL, BUN – 10-
20mg/dL
14. Complete Blood Count (CBC)

 RBC – hemoglobin and hematocrit
Calcium – 8.5 – 10.5 mg/dL  WBC
 Calcium is needed in blood coagulation,  Platelets
neuromuscular activity, and automaticity of
nodal cells Hemodynamics
 Decrease in calcium level may slow the • Circulation; close examination of cardiac function in
normal function, and also affect myocardial acutely ill patients
contractility which increase the risk of heart • Rapid identification of complications after MI
failure • To differentiate pulmonary disease from left
 Increase in calcium level may occur due to ventricular failure
the administration of thiazide diuretics • Guide in the management of low cardiac output
(reduce renal excretion of calcium) • Measures the pressure of the heart or direct pressure
 Hypocalcemia – dysrhythmia or arrythmia monitoring system
and prolong QT interval • Key factor is the cardiac output
 Hypercalcemia – shortens the QT interval • Study the movement and forces of blood in the
(patients with AV block) cardiovascular system, monitored through the use of
*Both could result to cardiac arrest invasive line
• May help to evaluate the effectiveness of cardiac
Magnesium – 1.8 – 3 mg/dL function
 It is necessary for the absorption of calcium,
maintenance of potassium, and metabolism Methods of Obtaining Hemodynamic Measurement
of adenosine triphosphate 1. Heart Rate
 Plays a major role in protein and  Point of maximum impulse
carbohydrate synthesis, and muscular  Radial pulse
contraction 2. Non-Invasive Blood Pressure Monitoring
 Associated with decreased potassium and
 Dinamap
calcium, because it is involved in
 Manual Method
neuromuscular activity
 Doppler
 Any deficiency in Mg can cause irregular
3. Invasive Methods
heart rhythm
 Arterial line
 It is needed in the conservation of K in the
 Pulmonary artery catheter (PA catheter)
kidney
 Low magnesium levels may predispose
patients to atrial or ventricular tachycardia Hemodynamic Parameters
 High magnesium levels may depress the Central Venous Pressure (CVP)
contractility and excitability of the • Measures the blood volume and venous return, right
atrial pressure (5 – 10 cm H2O or 4 – 12 mm Hg)

• It indicates the right heart filling pressure Cardiac Catheterization

• An invasive procedure used to obtain details
Systemic Intra-Arterial Pressure information about structure and performance of the
• Allows continuous monitoring of systolic, diastolic BP heart, valves and circulatory system
and mean arterial pressure (MAP) • Used to visualize the structure, performance of the
• Indwelling catheter or indwelling arterial line in heart chamber, the valve, great vessels, coronary
inserted in the artery to allow the right and continuous artery including the coronary circulation
monitoring of the systemic diastolic and mean arterial • It is a standard procedure for coronary artery disease
blood pressure in order to asses coronary artery patency, extent of
• Formula for MAP: atherosclerosis, and to determine the benefits of
SBP + (2 DBP) revascularization like percutaneous coronary
3 interventions
• Normal is 70 – 110 mm Hg • Can be used as diagnostic and therapeutic procedure
which may include electrophysiologic studies,
Pulmonary Artery Pressure (PAP) and Pulmonary hemodynamic monitoring, percutaneous transluminal
Capillary Wedge Pressure (PCWP) angioplasty, and palliative procedure for congenital
heart defects
• Swan-Ganz catheter – a catheter is passed through
• It may also diagnose pulmonary arterial hypertension
the right side of the heart into the pulmonary artery
Right
• PAP is a more accurate assessment to determine the
left heart pressure (referring to the left ventricle for  Myocardial biopsy and measure PAP
heart surgery or MI)  Includes the valves, and assess pulmonary
• PCPW is an indirect measurement of the left atrium hypertension
• Swan-Ganz monitor  Right side is safer for potential complications
Heart function such as dysrhythmia, arrythmia, venous spasm,
infection, sometimes it may cause perforation
• Right and left pumping action of the heart
 It is inserted through basilic vein or femoral vein
Blood flow
Left
• Quantitative measurement of cardiac output
 Visualize coronary arteries and ventricular
Calculation of O2 level
function
• Between arterial and venous
 Used to evaluate aortic arch and major branches
 Provide information regarding left ventricular
function and mitral or aortic valve function or
shunting
 It is inserted through vagal artery or femoral
artery
• This may improve conditions such as cardiac

tamponade, pulmonary hypertension, restrictive
cardiomyopathy, MI, cardiogenic shock
• This is to prevent overhydration and pulmonary
edema during open heart surgery
Radiographic Techniques
Indications of Cardiac Catheterization
Chest X-Ray (CXR)
1. Evaluate CAD (coronary artery disease) with
• Determine the size, contour, and position of the heart unstable, progressive, or new onset of angina, or not
• Reveal any cardiac or pericardial calcification and responsive to any medical therapy
demonstrate physiologic alteration in pulmonary 2. Diagnose atypical chest pain
circulation 3. Diagnose complications for MI
4. Diagnose aortic dissection
5. Assess for valvular function

6. Evaluate the end for coronary artery surgery or infusing bolus of intravenous fluid, and
angioplasty administration of atropine to treat bradycardia
7. Determine the efficacy of a heart transplant. 7. Hydration
 Encourage fluid intake for excretion of dye if it is
Preparation for Cardiac Catheterization not contraindicated to the condition of the patient
1. Written consent
2. History taking – allergies to iodine or shellfish Coronary Angiography
 Rationale: cardiac catheterization involves the • Technique of injecting a contrast agent into the
use of contrast dye vascular system to outline the heart and blood vessels
3. Laboratory results • It especially visualizes the coronary arteries
4. Baseline vital signs (include height and weight of
patient) Radionuclide Testing
5. NPO AMN (6-8 hrs.) • Using a radioisotope to evaluate coronary artery
6. Explain to patient the flushing feeling sensation perfusion to detect for any myocardial ischemia and
during procedure (when the catheter passed through MI
the heart and when the dye is injected) • Assess left ventricular function
 Palpitations may occur due to heart irritability Thallium 201 (TI201) – exercise
7. Voiding, no jewelries and dentures  Sometimes used with stress testing to determine
8. Pre-op medications – antihistamine, corticosteroids, changes in myocardium perfusion immediately
antioxidants, after an exercise when at rest
9. Withheld Metformin 48 hours prior to procedure (risk  Areas that do not show thallium uptake may
for lactic acidosis) indicate myocardial ischemia or MI
10. Shaving the operative site  Cardiac catheterization is recommended after a
positive result to determine whether percutaneous
 Prior to cardiac catheterization, shaving must be
coronary intervention is needed
done on the insertion site a day before
11. Health teaching Technetium 99m (Tc99m) – sestamibi
 Combined with various chemical compound giving
Post Procedure Care Cardiac Catheterization affinity to different types of cells
1. Complete bed rest (first 24 hours)  These radioisotopes can be take during resting
 Theoretical – 6-8 hrs. period before and after exercise including the
 Hospital setting – 24 hrs. resting period
2. Monitor Vital signs
Single Photon Emission Computed Tomography
 Refer also for any hypotension, hypertension, (SPECT)
and presence of bleeding that may cause
 Provides 3D images
elevation in pulse rate
 Patient is positioned supine with arms raised
3. Immobilized the affected extremities (especially on
above the head while the camera moves around
the insertion site)
the patient chest in 180 to 360 degrees to be more
4. Elevated the HOB at 30° angle precisely identify the areas of decreased
5. Check for the pressure dressing myocardial perfusion
 Use of sandbag of about 6lbs in order to prevent
bleeding Positron Emission Tomography (PET)
6. Refer if with chest pain, bleeding, dysrhythmias,  Determine the blood flow in the myocardium and
hematoma formation, any untoward signs and metabolic (cardiac and tissue perfusion) function
symptoms  Better than SPECT due to faster and lower doses
 Observe for any arrythmia or dysrhythmia due to of radiation
vasovagal reaction including bradycardia,  Evaluates organ and tissue function by identifying
hypotension, nausea. This can be precipitated body changes at the cellular level which may
by a distended bladder or discomfort from detect an early onset of disease before it is
manual pressure that is applied during removal evidenced on other imaging test
of catheter  Example: Ischemia tissue may decrease the blood
 To reverse vasovagal reaction, elevate the lower flow and increase metabolism
extremities about the level of the heart and

Nursing Responsibilities the heart is able to meet the increased oxygen

1. Refrain from using alcohol or caffeine for 24 hours demand
before undergoing PET • Evaluate cardiovascular status of patients with or at
2. Assess for any fear of closed spaces or risk for cardiovascular disease
claustrophobia • It increases the demand placed on the heart by
3. Explain the radiation exposure is safe and increasing the physical activity and determine
acceptable levels (ALARA Principle) whether the heart is able to meet the increased
4. IV access – patency oxygen demand
5. The scan takes 1 – 3 hours to complete
Dipyridamole (Persantine) scan
6. Monitor glucose level (PET) before the test
 If the patient is unable to perform exercise, they
may take Dipyridamole (Persantine) through
Graphic Studies
mouth or intravenously in order for coronary artery
Echocardiography to dilate (similar to coronary artery response during
• Evaluate internal structure and motions of the heart exercise)
and great vessels  Adenosine may also be used which is similar to
• Shows overall cardiac performance with regards to Dipyridamole stress testing, it has vasodilating
chambers, the size, motions of the intraventricular effects that has a much shorter life than
septum and posterior left ventricular wall, valve Dipyridamole; may also be used with thallium scan
motion, and directions and velocity of blood flow to  By giving Adenosine or Persantine, it allows the
determine for any leaking valve at the presence of heart rate to increase to the point of 85% of the
increase pericardial fluid maximum heart rate
• Doppler techniques are also used to determine the  Example: If the heart rate is 80, multiply it to 85%.
direction of blood flow and velocity 65+80 = 148bpm. It should not exceed 148 bpm
• May be performed with an exercise and  Contraindicated if the patient has hypertension,
pharmacologic stress test aortic stenosis, CAD, heart failure, unstable angina
M-mode / Motion Mode
Duplex Scan (arterial and venous)
 Produce an ice peak image
 Shows a 1-dimensional view unlike in 2 • Visualize the flow or movement of a structure, typically
dimensional (2D echo) produce a cross sectional used to image blood within an artery
view of the structure and lateral movements toward • Determine the flow velocities through a region of
special relationship between the heart structure narrowing or resistance of a vein or artery
• Duplex scan combined with doppler flow information
Doppler ultrasonography is used to visualize the structure within the blood
 Record the direction of blood flow through the heart vessels
 Detects presence, direction, speed and character • Useful to estimate the diameter of a blood vessel as
of arterial or venous blood flow within the vascular well as the amount of obstruction
lumen. (can also be done at the carotid area)
Color-flow Doppler
 Recorded flow frequencies into different colors
Electrophysiologic Studies (EPS)

• Evaluate the electrical conduction system of the heart
in order to diagnose and manage arrythmia for
patients experiencing syncope and palpitation
• Distinguish atrial from ventricular tachycardia
• Assess the effectiveness of anti-arrhythmic
Stress Test medications and devices
• The test increases the demand placed on the heart by • There is also a need for other therapy interventions
increasing physical activity and determined whether like pacemaker, radiofrequency ablation, implantable
cardioverter defibrillation

• Treat certain dysrhythmias through the destruction of Post-op

the causative cells 1. Monitor vital signs
• Identify the location and mechanism 2. Positioning at 45 °
• Assess function of SA and AV node 3. Monitor for dyspnea, LOC
• Measurement of baseline conduction intervals 4. Check for gag reflex
• Atrial pacing 5. Inform of sore throat and dysphagia for the next 24
 Assessment of SA nodal automaticity and hours
conductivity 6. Cool liquids
 Assessment of AV nodal conductivity and 7. Avoid talking
refractoriness
 Assessment of His-Purkinje system conductivity CT Scan
and refractoriness
• Determine cardiac masses, diseases of the aorta and
 Assessment of atrial refractoriness
pericardium
Transesophageal Echocardiography (TEE)

Magnetic Resonance Angiography
• Gives higher quality picture of the heart and useful in
• Evaluate physiologic and anatomic properties of the
clients who have thickened lung tissue or thick chest
heart
walls or who are obese.
• Higher technology than the CT scan
• Soundwave do not have to pass through the skin,
muscles, or bone tissue
Electrocardiogram (ECG, EKG)
• For patients who are obese, have pulmonary disease
like emphysema, may interfere with the ability to • Record the heart’s electrical activity, by detecting
obtain adequate image of the heart when the magnitude and direction of electrical currents
transducer is placed on the chest wall produced in the heart
• There are certain conditions of the heart such as
mitral valve disorder, blood clots, masses, dissections
on the lining of the aorta, implanted prosthetics heart
valve, are better visualized and assessed with the use
of TEE
Holter Monitoring
• 24-hour monitoring of the heart activity
Indications
1. Assess the heart function and structure
2. Evaluate heart during open heart surgery after
procedure such as CA bypass, valve replacement
3. Evaluate cardiac status of patient with no heart
disease during non-cardiac surgery
Nursing Responsibilities (TEE)

1. Obtain consent ECG Tracing
2. Restrict foods and fluids
 NPO for 6 to 8 hrs prior to procedure
1. IV access
2. Vital signs
3. Lab result
4. Emotional support

ECG Waveform Components  MI

 Hypertrophic cardiomyopathy
ST Segment
• The period between completion of depolarization and
the beginning of repolarization of the ventricles
• Beginning of the ventricular repolarization
• Elevated or depressed indicates cardiac ischemia
• ST elevation indicates myocardial injury
• ST depression changes in the ventricular wall (usually
ischemia)
P wave
• Electrical activity associated with SA node impulse
and depolarization of the aorta
• Atrial depolarization and contraction
• Impulse is from the SA node
• Up in all leads except aVR
T wave
Abnormalities
• Recovery or repolarization, phase of the ventricles
1. Inverted P-wave • Ventricular repolarization
2. Wide P-wave (P- mitrale) • Abnormal T wave indicate myocardial ischemia or
3. Peaked P-wave (P-pulmonale) injury or electrolyte imbalances
4. Saw-tooth appearance – Atrial flutter
5. Absent normal P wave – Atrial fibrillation
Summary of ECG Timing
P 0.06 – 0.12 sec
P-R Interval QRS 0.04 – 0.12 sec
• The time the impulse from the atria to the AV node, ST segment 0.12 sec
the His-Purkinje system and through the ventricles T 0.16 sec
PR interval 0.12 – 0.20 sec
• PR interval time 0.12 seconds to 0.20 seconds QT interval 0.32 – 0.40 sec
• 0.20 sec – delay in conduction from SA node to the
ventricle
Adjunctive Modalities (Counter Shock)
• That is three small squares to five small squares
Cardioversion
PR abnormalities • Used to treat tachydysrhythmias by delivering an
1. Short PR interval electrical current that depolarizes a critical mass of
 WPW syndrome myocardial cells
2. Long PR interval • Procedure used for an abnormality such as
 First degree heart block tachycardia and arrythmia which then is converted to
a normal rhythm using electricity
Synchronized
QRS Complex
− Low energy
• Electrical depolarization and contraction of the
− Therapeutic dose of electric current to the heart
ventricles
at a specific moment in a cardiac cycle
• QRS duration (0.04 - 0.12 seconds)
− Delivers electricity that is synchronized with the
• That is less than almost three small squares
peak of QRS
• Morphology: progression from Short R and deep S
(rS) Pharmacologic Cardioversion
Abnormalities − Also referred to as “chemical cardioversion”
1. Wide QRS complex − Uses anti-arrhythmic medications instead of
 Bundle branch block electrical shock
 Ventricular rhythm
2. Tall R in V1 Non-Emergency Basis
 Posterior MI
3. Abnormal Q wave [ > 25% of R wave]

Patient is sedated with diazepam Key Points to remember in Assisting External

− Digoxin is withheld for 48 hours before Defibrillation
cardioversion to ensure resumption sinus rhythm 1. Conducting medium (gel) is used – DO NOT use gel
and contraction or paste with poor electrical conductivity like UTZ gel
2. Paddles are placed on the chest wall – one in the left
Defibrillation (unsynchronized) of the pericardium and the other on the right of the
• Emergency procedure that consists of discharging of sternum just below the clavicle
unsynchronized electrical impulse 3. Apply 20 – 25 pounds of pressure to the paddles
• Most effective method in terminating or treatment of 4. The operator calls “ALL CLEAR”
ventricular fibrillation, dysrhythmia, and pulseless
ventricular tachycardia (Adjunctive therapy and RFA will be discussed in
• Defibrillator is the device for both cardioversion and cardiac dysrhythmias)
the defibrillation
• High energy shock Implanted Cardioverter-Defibrillator (ICD)
• Fall randomly anywhere within the cardiac cycle • Similar with a pacemaker but slightly larger, implanted
(QRS complex) inside the body
• Delivers an electric shock of 200 – 360 joules • Delivers low level and high level of electrical impulses
✓ Initial shock – 200 joules • Used for prophylactic therapy in patients who are at
✓ Second – 200 – 300 joules high risk for sudden cardiac death or ventricular
✓ Third shock – 360 joules fibrillation (V-Tach)
• External units like automated external defibrillator, it is
a lightweight, portable device that delivers an electric Function of ICD
shock through the chest to the heart 1. To reset abnormal heart beat
 The shock can potentially stop an irregular heart 2. Send high energy shock if an arrhythmia become
beat (arrhythmia) and allow a normal rhythm to severe
resume following sudden cardiac arrest 3. Treatment of certain fast rhythm (anti-tachycardia
pacing)
4. Detect sudden cardiac arrest or shock
1. Withheld digoxin 48 hours before cardioversion
2. NPO at least 4 hours before the procedure
Link or Chain of Survival
3. Defibrillation: epinephrine is given after initial
• Depending on the early access to
unsuccessful defibrillation
• CPR / Defibrillation
4. Anti-arrhythmia: amiodarone and lidocaine or
• Advanced cardiac life support
magnesium if ventricular dysrhythmia persists
• Integrated post-cardiac care
5. Continuous CPR
Safety measure when defibrillating

1. Maintain good contact between the pads and the
patient’s skin
2. No one should be in contact with patient when the
defibrillator is being discharge

Cardiac Dysrhythmias Conduction disturbances

• A disturbances or irregularity in the electrical system − Indicates bradyarrhythmia
of the heart such as heart rate and rhythm that can be
evidenced by hemodynamic changes Classification of Arrhythmias by Site
• Also known as arrhythmia SA node (60 – 100 bpm) – normal looking PQRST
• Primary disorder or secondary response to a systemic complex
problem or complication (blood toxicity, electrolyte
✓ Sinus bradycardia
imbalance)
✓ Sinus tachycardia
• Heart rate influenced by the ANS which consists of
✓ Sinus arrhythmia
SNS and PNS
• Cardiac rhythm is identified according to the site of Atria – abnormal looking P wave, normal QRS complex
origin like SA node and AV node ✓ Premature atrial contraction
• Identified as mechanism of conduction like normal ✓ Atrial flutter
rhythm, bradycardia, tachycardia, dysrhythmia, flutter, ✓ Atrial fibrillation
fibrillation, premature complexes, and conduction
block AV junction (40 – 60 bpm) – prolong PR interval > 0.20
seconds
Major Classification of Dysrhythmias ✓ AV blocks
Rate
Ventricles (30 – 40 bpm) – abnormal wide QRS complex
• Very slow or very rapid > 0.20 seconds; serious life threatening
• Patients with hypoxia, metabolic alkalosis, electrolyte
✓ Premature ventricular contractions (PVC)
imbalance
✓ Ventricular tachycardia
• Causes prolonged QT that can lead to electrical
✓ Ventricular fibrillation
instability
Causes of Cardiac Dysrhythmias

Mechanisms
1. Myocardial Infarction (MI) – conduction problem on
• Based on the electrophysiologic mechanism
the damaged tissue
Re-entrant 2. Rheumatic Heart Disease (RHD)
3. Heart failure
− Electrical impulse travels in a tight circle within the
4. Electrolyte Imbalances
heart instead of moving from one end to another
5. Drug toxicity – digitalis, quinidine
− Caused by:
6. Hypothermia
1. A point at which there are 2 conduction
7. Trauma
pathways for an impulse to follow
8. Coronary Artery Disease (CAD)
2. Due to slow conduction through one portion of
the pathway
3. There’s a unidirectional block at some point Signs and Symptoms of Dysrhythmias
along the conduction pathway 1. Palpitations – most common
 Feeling of skip heartbeat
Abnormal enhanced automaticity  Some palpitations are harmless, but many of
− Normally the SA node has a higher automaticity them predispose to adverse outcome like higher
than the rest of the heart risk of blood clotting or insufficient blood being
− If any part of the heart that initiate an impulse transported to the heart
without waiting for the SA node is called “ectopic  Others are embolism, stroke, and sudden
focus” cardiac death
− If ectopic focus happens far more than the SA 2. Light headedness or dizziness
node, it can produce abnormal rhythm 3. Syncope – fainting
− Every heartbeat that is not originated from the SA 4. Chest discomfort
node is considered as “ectopic beat” 5. Pounding chest
− When the ectopic beat is early, it is called “extra 6. Weakness or fatigue
systole”, and “skipped” if it is late
− There are factors that contribute to reduced Diagnostic Studies
resting membrane potential which includes
1. 12 lead ECG
ischemia, hyperkalemia, hypoxia, and effects of
2. 24-hour ambulatory ECG or Holter monitoring
drugs
3. Electrophysiologic studies (EPS)

 To assess the electrical activity and conduction Amiodarone prevents reentrant arrhythmias,
pathway of the heart increases PR interval of the QT interval, prolongs the
 Investigate the cause, location of origin, and best QRS duration
treatment for various abnormal heart rhythm  Amiodarone is a powerful inhibitor of ectopic
4. Stress Test pacemaker automaticity
5. Laboratory test  Side effects are hypotension and bradycardia
 Electrolytes – K, calcium, Mg and FBS (fasting  It may affect heart rhythm and usually treat
blood sugar) ventricular tachycardia or ventricular fibrillations
 Hypoglycemia can lead to prolonged slow  Should not be used for AV block or any allergy
heartbeat that may disturbed blood flow to the to iodine
heart which result to lethal cardiac event  Contraindicated to bradycardia
 Test for digitalis and quinidine level (assess for  Interacts with food like grapefruit. Grapefruit
drug toxicity level) can raise the levels of amiodarone in your body
and lead to dangerous side effects
General Management for Cardiac Dysrhythmias  Causes photosensitivity to ultralight, instruct
1. Diet – SVT (Supraventricular tachycardia) avoid patient to avoid sun exposure and the use of
overuse of stimulants sunscreen
2. Cessation of smoking – nicotine effects on Class IV – calcium channel blockers
ventricular threshold – Decrease the conduction through the AV node
3. Oxygen therapy – low-flow oxygen is beneficial for and shorten the phase 2 of cardiac action
patients who are dyspneic or who have chest pain potential
4. Cardiac monitoring – Prevents calcium from entering the cell of the
5. Anti-arrhythmic drugs – lidocaine, β-adrenergic heart and blood vessel wall
blockers, calcium channel blockers, digitalis – Relax and widen the blood vessels of the arterial
preparation wall
Class I – Class IV is not recommended for patients who
̶ Depress upstroke of action potential have heart failure since it reduces the
̶ Interferes with the Na channel that depress the contractility of the heart
fast inward of sodium – Side effect is to reduce the BP, may cause
̶ Lidocaine, quinidine, pronestyl headache, nausea, and constipation
Quinidine is to treat fever and malaria that has anti- – Verapamil, Nifedipine, Diltiazem
arrhythmic properties and at the same time it Other antiarrhythmic (unknown mechanism)
suppresses the SVT and ventricular arrhythmia Digoxin – increase conduction of electrical impulse
Lidocaine is not widely use due to its effect on the to the AV node and increase vagal activity; increase
ischemic tissue than on non-ischemic tissue. in acetyl production which may decrease the speed
Suppresses the contraction more in ischemia tissue of conduction
than a normal Adenosine – used intravenously for terminating SVT
Class II MgSO4 – decrease the calcium influx, prevent any
– Beta-adrenergic receptor blockers depolarization
̶ Affects the SA node by decreasing BP, heart 6. Electrical countershock – terminate ventricular
rate, and myocardial contractility fibrillation
̶ Inhibits sympathetic activation of cardiac 7. Adjunctive therapy
automaticity, slow conduction velocity, and Cardiac pacemaker
prolong refractoriness. – Battery-operated generators that initiate and
̶ Beta-blockers decreases MI mortality, prevents control the heart rate by delivering an electrical
recurrence tachyarrhythmia impulse via an electrode to the myocardium.
̶ Atenolol, metoprolol, propranolol, carvedilol – Burrowed within subcutaneous tissue below right
Propranolol has sodium channel blocking effect clavicle
Class III – Bed rest for 24 hours and gradual increase of
– Prolong duration of action potential (S/E: activity to prevent dislodging of the leads
hypotension and bradycardia) – Life span of battery from 6 to 12 years
– Prolong repolarization and prevent the reentrant
arrhythmias
– Does not allow the permeability of ions because
it may cause assimilation of the contraction

6. Use of plastic sheet to reduce the risk of

pneumothorax
Health Teachings
1. Wound care
2. Discuss activity allowances and limitations
 NO strenuous exercise or lifting heavy objects,
avoid contact sports; avoid arm and shoulder
Indications of Pacemaker Therapy activity
1. Symptomatic bradyarrhythmia and long QT 3. Avoid near high voltage wires, power plants, radio
syndrome transmitters, microwave ovens, theft detectors
2. Maintenance of adequate HR and rhythm during 4. Avoid contact from objects that contain magnet such
surgery and postoperative recovery as large stereo speaker, jewelries – should not be
3. Irreversible bradycardia (not responsive to near the generator for longer than a few seconds
medications)  Move away from the area if dizziness or
4. Sinus node dysfunction palpitations occur
5. Tachyarrhythmias 5. Describe signs and symptoms of pacemaker failure
6. Symptomatic AV Heart Block 6. Avoid traveling and driving for 1st 4 weeks following
 Especially 2nd and 3rd degree AV block insertion
7. Fibrosis or sclerotic changes of the cardiac 7. Explain need for continuous medical follow-up and
conduction system for periodic battery check-up.
8. Avoid constricting clothing
Forms of Pacemaker Implantation

Adjunctive therapy continuation:
Temporary Cardiac Pacing
Cardiac Conduction Surgery
• Used for hemodynamic or life-support purposes.
• Indications: complete heart block, symptomatic Electrode Catheter Ablation
bradyarrhythmia, acute MI, emergency measure for − Radiofrequency energy that “burn” the areas
malfunction of an implanted permanent pacemaker or pathway of the abnormal rhythm and
• Not only controlling heart rate but also used in EPS to promote normal conduction of impulses or
evaluate cardiac dysrhythmia and interrupt electrical pathway between the atria and the
tachycardia ventricle
− Common in patients who have
Permanent Cardiac Pacing tachyarrhythmia that is not responsive to
• Indicated in the continuous presence of symptomatic medication
bradyarrhythmia which is common like chronic atrial RFA – radiofrequency ablation
fibrillation with a slow ventricular response − For atrial flutter, atrial fibrillation who are not
responsive to medications
Complications of Pacemaker Use Cryoablation
1. Dislodgment of the pacing electrode – common − Applied cold temperature to destroy the
2. Local infection selected cardiac cells
3. Pneumothorax Maze Procedure
4. Bleeding and hematoma − Making an incision on the upper chamber of
5. Hiccups – sign of phrenic nerve, diaphragmatic the heart (atria) to form a scar tissue (the
stimulation maze) to prevent re-entry conduction of the
6. Hemothorax – puncture of the subclavian vein or electrical impulse
internal mammary artery
Sinus Rhythms
Measures to Prevent Complications
1. Prophylaxis antibiotics (to prevent infection)
2. CXR – to check for placement and r/o pneumothorax
3. Continuous ECG monitoring
4. Bed rest for 12 hours
 Minimal arm and shoulder activity to prevent the Heart
Rhythm P Wave
PR Interval QRS
Rate (sec.) (sec.)
dislodgement of the implanted pacemaker lead
Before each
5. Discontinue use of anti-platelet or anti-thrombotic 60 – 100 Regular 0.12 – 0.20 <.12
QRS, Identical
medications

Disorders of Atria muscles. Also decreases aqueous humor production, increases

aqueous outflow, and dilates pupils by contracting dilator muscle.
Sinus Bradycardia Atropine
Inhibits acetylcholine at parasympathetic neuroeffector junction of
• Conduction pathway is similar with a normal sinus A smooth muscle and cardiac muscle, blocking SA and AV nodes. There
actions increase impulse conduction and raise heart rate.
rhythm which has a normal PQRST but the SA node
Beta blockers reduce circulating catecholamine levels, decreasing
discharging at a rate of less the 60bpm both the heart rate and blood pressure Typically, atropine is the drug
• Rate: < 60 bpm of choice for symptomatic bradycardia. Antiarrhythmics and digoxin
may also be used. So, if you have symptomatic bradycardia and
• Causes of sinus bradycardia are: hypotension, remember to have an IDEA!
a. Low Metabolic Needs (athletes, sleeping,
hypothyroidism)  Drugs increases hear rate and peripheral
b. Vagal Stimulation – vomiting, suctioning, severe vasoconstriction
pain, hypothermia, and Valsalva maneuver 2. Pacemaker
(straining which can reduce cardiac output
because of increased intrathoracic pressure Sinus Tachycardia
therefore, decreasing venous return and cardiac • Heart rate of greater than 100bpm is the result of the
output) decrease in venous return and cardiac inhibition of vagal reflex or the stimulation of SNS
output may elevate systolic BP and pulse rate • As the heart rate increase, the diastolic filling time
c. Medications – calcium channel blockers, decreases, resulting to reduced cardiac output and
amiodarone, beta-blockers (these drugs reduce subsequent symptoms of syncope and low BP
the heart rate) • If the rapid rate persists, the heart cannot compensate
d. Carotid Sinus Massage for the decreased ventricular filling, acute pulmonary
edema may develop
Causes of Sinus Tachycardia

• 0.5 mg of AtSO4 every 3 – 5 minutes for a maximum
Physiologic and Psychological Stress – acute blood
total dose of 3 mg
loss, hypoglycemia, hyperthyroidism, fever, anxiety,
 It increases the heart rate and SA discharging
hypoxia, heart failure, myocardial ischemia
thus, blocking the vagus nerve
Effects of Medications – epinephrine, norepinephrine,
 If not responsive, the doctor may do
atropine, theophylline, nifedipine, hydralazine (increase
transcutaneous pacing or the use of
the heart rate)
catecholamine such as dopamine and
epinephrine Autonomic Dysfunction – postural orthostatic
• Theophylline 100 – 200 mg SIVP who had a cardiac tachycardia syndrome (POTS)
transplantation and acute inferior MI or spinal cord  POTS results to sinus tachycardia without
injury hypotension within 5-10 minutes of standing or
 Increases heart rate and contractility therefore sitting upright
relaxing bronchial smooth muscle  Treatment includes increase of fluid intake, use of
graded compression stockings to prevent the
Bradycardia and Hypotension Management pooling of blood in the lower extremities
“IDEA”
Isoproterenol
Management of Sinus Tachycardia
Acts on beta2-adrenergic receptors, causing relaxation of bronchial
smooth muscle; acts on beta1-adrenergic receptors in heart, causing
1. Synchronized cardioversion – hemodynamic
I positive inotropic and chronotropic effects and increasing cardiac instability
output. Also lowers peripheral vascular resistance in skeletal muscle
and inhibits antigen-induced histamine release. 2. Adenosine administration – decrease conduction
Dopamine through AV node, a vasodilator
Causes norepinephrine release (mainly on dopaminergic receptors),
D leading to vasodilation or renal and mesenteric arteries. Also exerts  Contraindicated to asthma patients, may cause
inotropic effects on heart, which increases the heart rate, blood flow,
myocardial contractility, and stroke volume
bronchoconstriction due to histamine release
Epinephrine and causes granulation of the muscle
E Stimulates alpha- and beta-adrenergic receptors, causing relaxation
of cardiac and bronchial smooth muscle and dilation of skeletal

3. Vagal maneuvers – may increase the • Treatment is withdrawal from stimulants, use of
parasympathetic nervous stimulation causing a slow Sympathomimetic drugs and betablockers to
conduction through the AV node and blocking the re- decrease premature atrial contraction
entry of the rerouted impulse • PAC is not significant to healthy people, but for
 Example: coughing, gagging, cold broth, carotid patients with heart diseases who have frequent PAC,
sinus massage, it indicates enhanced automaticity of atria or entry
4. Beta-blockers and calcium channel blockers – rarely mechanism
used considering narrow QRS tachycardia
 Used to reduce heart rate and decrease
myocardial oxygen consumption, lower BP and
cardiac output, decrease automaticity of the
heart
5. Procainamide, amiodarone – options for wide QRS
tachycardia
6. Catheter ablation
Sinus Arrhythmia
• One upright uniform p-wave for every QRS
• Rhythm is irregular Supraventricular Tachycardia (SVT) or
 Rate increases as the patient breathes in Paroxysmal Atrial Tachycardia (PAT)
 Rate decreases as the patient breathes out • Atria is originating anywhere above the bifurcations of
• Rate is usually 60-100 (may be slower) the bundle of his or anywhere above the ventricle
• Variation of normal, not life threatening • P wave cannot be identified
• Common in children and young adult • Rapid but regular heart rhythm that comes from the
atria; prevents the gating mechanism
• When an impulse is conducted to an area in the AV
node causing the impulse to be rerouted back into the
same area of over and over again at a fast rate
• Each time the impulse is conducted through these
Heart PR Interval QRS areas, it then also become conducted into the
Rhythm P Wave
Rate (sec.) (sec.)
Before each
ventricle causing fast ventricular rate of 150-250 bpm
Var. Irregular 0.12 – 0.20 <.12
QRS, Identical • Normally, the ventricle is protected against excessive
heart rate arising from the supraventricular areas by a
Premature Atrial Complex (PAC) gating mechanism at the AV node which prevents
high rates and slow only a proportion of the fast
• Also known as premature atrial contraction / atrial
impulse to pass
extrasystole / atrial ectopic
• Commonly seen in patients with Wolff-Parkinson-
• Due to abnormal electrical foci (any stimulus or
White (WPW) syndrome, wherein it bypasses the
impulse without waiting the SA node)
gating mechanism avoiding the node and its
• Common in normal hearts
protection, and the fast rate may be directed
• Early, extra heartbeats that originate in the atria
transmitted to the ventricles
• 60 – 100 bpm and irregular
• Tachycardia is usually a short duration resulting to
• P wave is abnormal
palpitation
 It may be a notch or negative deflection or hidden
• Increased heart rate may cause reduced cardiac
in the preceding of the P wave
output resulting to significant sign and symptoms
• PR interval delayed or normal
• HR regular rhythm, rate 150 – 250 bpm
• Result from emotional stress, use of caffeine, nicotine
• Abnormal P wave present but may be hidden on ST
or alcohol, low potassium level, hypermetabolic states
segment or T wave
(pregnancy), lung diseases, Infection,
• Associated with overexertion, emotional stress, RHD,
hyperthyroidism, COPD, heart disease (CAD) and
digitalis toxicity, CAD, or cor pulmonale
valvular disease
• Cor pulmonale – pulmonary heart disease, an
• Seen among patients with enlarged heart and
enlargement and failure of the right ventricle of the
premature atrial contraction
heart as a response to increased vascular resistance
• No treatment is necessary but if they are frequent of
or high pressure in the lungs
more than 6 per minute this may be signs of atrial
fibrillation

4. DC cardioversion – if patient becomes

hemodynamically unstable
Atrial Flutter
• Conduction defect in the atrium, the atrial rate is faster
than the AV node meaning not all atrial impulses are
✓ HR – 150 – 250 bpm conducted into the ventricle
✓ Abnormal P wave present but may be hidden • The premature electrical impulse arises from the atria,
before T wave or ST segment and has abnormal so the electrical activity moves in a localized cell or in
contour a circular fashion
✓ PR interval – shortened • If all atrial impulses were conducted to the ventricles,
✓ QRS complex normal or abnormal contour then the ventricular rate would be ranging from 250-
✓ Prolonged episode of the heart rate is 180 or 250 350 bpm, then ventricular fibrillations may occur
which may precipitate a decrease in cardiac • Life-threatening
output with hypotension and myocardial • More than one P-wave for every QRS complex
ischemia • Demonstrate a “sawtooth” appearance
• More organized and regular than fibrillation
Signs and Symptoms of SVT • The impulse slow down at the Av node, not all atrial
1. Shortness of breath beats are transmitted to the ventricle
2. Restlessness • Atrial rhythm is regular. Ventricular rhythm will be
3. Chest pain regular if the AV node conducts consistently. If the
4. Rapid breathing pattern varies, the ventricular rate will be irregular
5. Loss of consciousness • CAD, hypertension, mitral valve disorders, pulmonary
6. Dizziness embolus, cor pulmonale, hyperthyroidism
7. Hypotension
Treatment for PSVT or PAT

1. Vagal stimulation
Carotid massage – decrease the heart rate
Valsalva maneuver – increase intrathoracic pressure
which may affect the baroreceptor within the aorta
2. Drug therapy
Adenosine (Adenocard) – common
 To convert the supraventricular tachycardia
to a normal sinus, so this allows the slow ✓ PR interval is variable
conduction of the AV node to visualize the P ✓ QRS complex is normal unless bundle branch
wave block or pre-excitation is present
 Try to prevent the calcium reflux and activate
the PNS and inhibit SNS Signs and Symptoms
 Avoid caffeine since it may antagonize the 1. Fatigue
effects of adenosine 2. Palpitations
 Given intravenously by rapid administration, 3. Chest pain
then immediately followed by a 20 mL of 4. Light-headedness
saline flush and elevations of the IV line to 5. Syncope
promote rapid circulation of the medication 6. SOB
 Effect is too short, so if the patient is 7. Low BP
unresponsive, then electro cardioversion is *Patients with atrial flutter is at risk to develop stroke
the treatment of choice because of the risk of thrombus formation in the atria
Diltiazem
Digitalis Treatment
Amiodarone 1. Warfarin – used to prevent stroke of patients with
 Digitalis and amiodarone increase contractility atrial flutter of greater than 48 hrs. duration
and enhance cardiac output, and may also help 2. Anti-arrhythmic agents – convert atrial flutter to sinus
in the perfusion of the kidney rhythm (amiodarone, procainamide)
3. Radiofrequency Ablation therapy 3. Diltiazem, digoxin

4. β-adrenergic blockers – to control ventricular rate by Clinical Manifestations of AF

decreasing SNS (atenolol, metoprolol) 1. Palpitations
5. Adenosine – block the SNS and slow the conduction 2. Shortness of breath
in the AV node and allow better visualization of the 3. Hypotension
flutter 4. Dyspnea on exertion
6. RFA – curative therapy 5. Fatigue
 Delivers energy in the tiny areas of the heart 6. Pulse deficit
muscles, the energy can either disconnect the 7. Anginal symptoms due to myocardial ischemia
pathway of abnormal rhythm, block the abnormal
path, and promote conduction of impulse or Diagnostic Findings
disconnect the electrical pathway between 1. 12-lead ECG
the atria and ventricle 2. Transthoracic echocardiogram (TEE)
7. Electrical cardioversion – successful 3. Thyroid screening
 Can convert the atrial flutter to sinus rhythm in 4. Renal clearance test
an emergency situation 5. Hepatic function test
6. Chest X-rays – evaluate pulmonary vasculature
Atrial Fibrillation (AF) suspected for pulmonary hypertension
7. Exercise stress test – to exclude myocardial
• Characterized by a total disorganization of atrial
ischemia
electrical activity without effective atrial contraction
8. Holter monitoring
• Fibrillation can affect the atria or the ventricle,
9. EP study – prior to catheter ablation
ventricular fibrillation is life threatening, if atrial
fibrillation, it affects the upper chambers of the heart AF Management
• Atrial fibrillation is due to an underlying medical
“ABCDE”
condition and not typically a medical emergency
Anticoagulants
• Since it is too fast it may cause a decrease in cardiac A To prevent embolization.
output because of the effective atrial contraction and Beta-Blockers
B To block the effects of certain hormones on the heart to slow the heart
rapid ventricular response rate.
Calcium Channel Blockers
• Exact cause is unknown but may involve different Help slow down the heart rate by blocking the number of electrical
theories like autonomic foci or reentry phenomenon, C impulses that pass through the AV node into the lower heart chambers
(ventricles).
when an interchamber of the heart is involve in a Digoxin
multiple micro re-entry circuit, it causes shaking Help slow down the heart rate by blocking the number of electrical
D impulses that pass through the AV node into the lower heart chambers
chaotic impulse (ventricles).
Electrocardioversion
• Risk to: HF, myocardial ischemia, embolic events
E A procedure in which electric currents are used to reset the heart’s
such as stroke, cardiomyopathy, pericarditis, alcohol rhythm back to regular pattern.
intoxication, electrolyte imbalances, stress Atrial fibrillation is the most common sustained atrial arrhythmia. A
variety of medicines are available to restore normal heart rhythm. A
• Blood pooling that leads to clot formation and may beta-blocker, such as bisoprolol or atenolol, or a calcium channel
Mocker, such as verapamil or diltiazem, will be prescribed. Digoxin
result to thromboembolism may be added to help control the heart rate further. In some cases,
• Without P wave amiodarone may be tried, or simply remember the mnemonic ABCDE.
1. Calcium channel – increases myocardial oxygen

supply and decrease the afterload
2. EC – indicated for hemodynamically unstable
patients like acute alteration in the mental status,
chest discomfort, hypotension
 Catheter ablation that destroy the specific cells
that cause tachydysrhythmia
300 – 600 No P waves; irregular;
3. Maze – incision on the transmural to prevent re-entry
bpm amplitude and shape are
120 -200 seen and referred as conduction of the electrical impulse
bpm fibrillatory or f waves
4. EPS study – to reduce periprocedural
✓ Atrial rate: 360 bpm thromboembolism event
✓ Ventricular rate: 120-200 bpm  Sedation and heparin are administered
✓ PR is not measurable
✓ QRS: normal or irregular

Premature Junctional Contraction PJC:
Causes: Causes: Causes:

• Heart failure • Older adults/ • SNS stimulation r/t anxiety
• Hypertension advanced age with • ETOH – ethanol, ethyl
• Hyperthyroidism CAD alcohol
• RHD • Caffeine
Manifestations: • Mitral valve disease
Heart PR Interval QRS
• Palpitation Manifestations: Rhythm P Wave
• Irregular peripheral pulses • Palpitations,  CO, Manifestations: Rate (sec.) (sec.)
• Pulse deficit d/t loss of atrial BP • Fluttering sensation in chest Premature,
kick lead to CO, BP, or throat
• RVR may CO, BP, LOC,
Usually abnormal, may
SOB, fatigue, angina Treatment: Irregular Short <.12 <.12
• Significant r/f and cause cool clammy, normal be inverted or
• IV, O2, call MD if
thromboemboli
new onset
skin hidden
• Diltiazem or
EKG: metroprolol initially EKG:
• Rate: atrial 300-600 bpm • Ibutilide, • Rate: atrial 300-600 bpm
(too rapid to count), synchronized (too rapid to count), Heart Block
ventricular 100-180 bpm cardioversion – ventricular 100-180 bpm
• Rhythm: no P-waves, AV convert to NSR • Rhythm: no P-waves, AV • Delayed or complete block of the electrical impulse as
node bombarded with rapid • Warfarin to node bombarded with rapid
atrial impulses  irregularly prevent atrial impulses  irregularly it travels from SA node to ventricle
irregular ventricular thromboemboli – irregular ventricular
response therapeutic INR response AV Block
2.0-3.0
Treatment: Treatment: • Every impulse is conducted to the ventricles but the
• Can add digoxin to control • IV, O2, call MD if new onset
chronic AF – need Rx that  • Needs Rx that  conduction
duration of the AV conduction is prolonged
rapid ventricular response of impulses through AV
• Amiodarone – convert to node
NSR First-Degree AV Heart Block
• Radiofrequency catheter
ablation if AF unresponsive
to Rx or cardioversion
• The duration of AV conduction is prolonged
• HR – normal and regular rhythm
• P wave is normal
Junctional Arrhythmias • PR interval is prolonged > 0.20 second
• Originate from the AV node • QRS complex has a normal contour
• When the SA node becomes slow or impulse cannot • No treatment
be conducted through AV node, therefore the AV • PR Interval > 0.2 seconds (5 small sq)
node becomes the pacemaker. So, the impulse may • Note – the PR Interval is constant
move in a traditional fashion that produce an
abnormal P wave occurring just before or after the
QRS complex
• Abnormal P wave – inverted
• HR 40 – 60 bpm
• PR interval is < 0.12 sec • PR Interval > 0.2 seconds (5 small sq)
• Similar to PAC, the heart rate is different but the P
wave has abnormal contour (inverted)
• Associated with AMI especially inferior MI, digitalis
toxicity, open heart surgery • Note – the PR Interval is constant
• Treatment: do not give atropine for digitalis toxicity, β-
adrenergic blockers, calcium channel blockers and Second-Degree AV Block
amiodarone Type I (Wenckebach Phenomenon)
• Treatment of digitalis toxicity is through IV hydration,
• PR interval lengthen progressively due to AV
provide oxygen, support ventilatory function, and
conduction time that is prolonged until an atrial
discontinue medication, correct electrolytes.
impulse is not conducted and QRS complex is drop
• The antidote for digitalis toxicity is Digibind (Digoxin
• PR interval becomes longer with each succeeding
Immune Fab), an immunoglobulin fragments that bind
ECG complex until there is a P wave that is not
with digoxin
followed by a QRS complex
• DC cardioversion is NOT be used
• Warning signal of an impending AV conduction
• The ECG criteria for premature junctional complex are
disturbances
the same as for PAC, except for the P wave and the
• Almost always transient and well generated
PR interval. The P wave may be absent and PR
• Treatment: atropine and temporary pacemaker
interval of less than 0.12 seconds
(increase heart rate)

• PR interval is variable; no relationship between P

wave and QRS complex
• Result from severe bradycardia
• Treatment: temporary pacemaker - for emergency
basis in patients who have acute MI; drugs (atropine
– not responsive to complete AV block
Epinephrine, dopamine – increase heart rate and
support BP before a pacemaker insertion can be done
Isoproterenol – produce vasodilation and cardiac
stimulation and lowers diastolic and MAP but
increases systolic pressure by increasing heart rate
and contractility
Type II second-degree AV block

• Less common but severe
• PR constantly unchanged prior to the P wave
suddenly feels to conduct
• PR interval may be prolonged but remain fixed at a
conducted beat with intermittent drop beat
• Ventricular rhythm is irregular
• PR interval is prolonged (P = 2:1 or 3:1 to 1 QRS)
• P wave has a normal contour
• QRS complex is widened <0.12 seconds
• Serious type of block, occurs in the His-Purkinje
system ✓ Note irregular PR intervals
• Acute anterior MI, CAD, RHD
• May progress to 3rd-Degree AV block Summary – AV blocks
• Presence of constant PR interval and presence of 1º ̶ prolongation of PR Interval
more P waves than QRS.
2º ̶ Mobitz I – Increasing PR Interval until dropped beat
• QRS is usually abnormal, but may be normal is seen
Mobitz II – Constant PR Interval with more P waves
to QRS
3º ̶ Complete dissociation between P waves & QRS
Treatment
1. Permanent pacemaker
2. Atropine, epinephrine, and dopamine, as a
temporary measure to increase the heart rate until a
pacemaker therapy is available
Third-Degree AV Block
• Having two impulses stimulate the heart results in a
condition referred to as AV dissociation which may
also occur during VT
• Complete heart block wherein there is no atrial
impulse is conducted through the AV node into the
ventricle
 That’s why P wave can be seen but electrical Disorders of the Ventricle
activity is not conducted down into the ventricles Premature Ventricular Contractions / Complex
 Result to reduced cardiac output with subsequent (PVCs)
ischemia and heart failure • Also known as “ventricular ectopic beats”
• Sinus rate is 60 – 100 bpm, ventricular rate depends • Premature occurrence of the QRS complex which is
on the site of the block wide and distorted in shape
• Related to stress, nicotine, exercise, caffeine

• PVC without symptoms does not require treatment 2. Multifocal or polymorphic (having different shapes
• Low potassium level (hypokalemia) indicates the and rhythms)
presence of U wave, and needs to correct the 3. Occur two in a row (pair)
electrolyte imbalance 4. Occur on the T wave
• Mitral valve prolapses (MVP), CHF, CAD, MI,
hypokalemia, emotional stress Ventricular Tachycardia (V- tach or VT)
• Those with aortic stenosis is followed by ventricular • When 3 or more PVCs occur
tachycardia or ventricular fibrillation that may result to • Irregular rhythm, rate = 100 – 250 bpm
sudden death • P wave is absent
• PVC may appear different in contour from each other • PR interval is absent
referred to as “multifocal PVC” • QRS complex distorted and > 0.12 seconds
• PVC with the same contour is called “unifocal PVC” • Pulmonary edema, shock, decreased blood flow to
wherein changes in the wide QRS have the same the brain
contour in every beat • Cause a severe decrease in cardiac output as a result
• In ventricular bigeminy, after every routine beat, you of decreased ventricular diastolic filling time and loss
have a beat that comes too early, or what's known as of atrial contraction, ventricular fibrillation may
a premature ventricular contraction (PVC) (every develop
other beat is PVC) • Can lead to cardiac arrest
• In ventricular trigeminy, PVC happens in a pattern of • Symptoms: palpitations, chest pain, anxiety,
three beats lightheadedness, syncope, hypotension, tachypnea
• Ventricular couplets are defined as two PVCs in a row • Signs of diminished perfusion: altered level of
• Ventricular triplets three consecutive PVCs in a row consciousness, pallor, diaphoresis
• PVC reduces cardiac output which may precipitate • Treatment: amiodarone; cardioversion/ defibrillation
angina and heart failure • If the patient is conscious, instruct the patient to inhale
• If PVC is evidenced in an ECG tracing in patients with deeply and cough forcefully every 1 to 3 seconds to
ischemic heart disease or acute MI, it may indicate help reverse 2 sinus rhythm
ventricular irritability
• Assess presence of hypoxia or hypoxemia, treat by
giving oxygen supply and correcting electrolyte
imbalances
• P wave is rarely visible and lost in the QRS complex
of PVC
• QRS complex is wide and distorted, > 0.12 seconds
• T wave is generally large and opposite direction to Heart
Rhythm P Wave
PR Interval QRS
Rate (sec.) (sec.)
deflections of the QRS
No P waves
• Treatment: hemodynamic assessment – to determine 100 –
Regular
corresponding to
NA
Wide
250 QRS, a few may be >.12
if the treatment with drug therapy is indicated seen
 Beta-adrenergic blockers, amiodarone,

procainamide, lidocaine 2 Classification
 Lidocaine, as of 2014, is no longer Non-sustained v-tach if the rhythm self-terminates
recommended because of its toxic effects within 30 seconds
Sustained v-tach if the rhythm terminate beyond 30
seconds and pulseless v-tach needs defibrillation
Types (depending on the QRS configuration)

Monomorphic V-tach – QRS complex have the same
Heart PR Interval QRS shape size, and direction
Rhythm P Wave
Rate (sec.) (sec.)
No P waves
 Patients who have myocardial scarring from
Var. Irregular
associated
NA
Wide previous MI cannot conduct electrical activity so the
with premature >.12 potential circuit around the scar result to ventricular
beat
tachycardia
Polymorphic V- tach – QRS complex gradually changes
PVC Associated to VT back and forth from one form to another over a series of
PCV is not precursors of VT (recent studies). However, beats
PVC follow VT if  Sometimes called as torsades de pointes
1. PVCs are more frequent than 6 per minute

Torsades de Pointes • If left untreated within 3-5 minutes because of low

• Polymorphic v-tach cardiac output it may lead to death
• QRS complex gradually changes back and forth from • Rapid disorganized ventricular rhythm
one form to another over a series of beats • Effective pumping of blood stops
• Prolonged QT interval • Lower chamber of the heart quiver
• PR not measurable • Considered as a form of cardiac arrest
• Wide QRS complex • Rhythm is irregular and chaotic
• > 0.12 seconds • P wave is NOT visible
• HR not measurable ( > 300 bpm)
• PR interval and QRS complex are NOT measurable
• Unconscious, absence of pulse, apnea, seizures
• If not treated, patient will die
Heart PR Interval QRS

Rhythm P Wave
Rate (sec.) (sec.)
0 Chaotic None NA None
Management for V Fib

1. Early defibrillation
2. CPR and ACLS (as preparing defibrillator and 5
additional cycles of CPR, about 2 minutes of
continuous chest compression
 Maintaining cardio cerebral resuscitation
Common Causes of Torsades de Pointes (CCR), continuous doing chest compression,
1. Diarrhea give emphasis on the use of positive pressure
2. Hypokalemia ventilation
3. Hypomagnesemia – depress the CNS and block 3. Epinephrine – if defib is unsuccessful
neuromuscular transmission 4. One dose of vasopressin instead of epinephrine if
4. Malnourished the cardiac arrest persists.
5. Chronic Alcoholism 5. Other antiarrhythmic medications – amiodarone,
6. Heart failure lidocaine, magnesium as soon as possible after the
7. Chronic alcoholism 3rd defibrillation.
8. Certain drugs – cimetidine, Haldol, amiodarone,  Amiodarone and epinephrine may facilitate the
erythromycin return of spontaneous pulse action defibrillation
9. Certain foods – grapefruit
*May experience palpitation that may lead to syncope Asystole
and sudden death • Total absence of ventricular electrical activity
• Characterized by a straight line and sometimes there
Treatment: avoid offending odors, magnesium sulfate, is an atrial activity or P wave
anti-arrhythmic drugs, electrical therapy • End-stage CHF, advanced cardiac disease, severe
(unsynchronized defibrillation) cardiac conduction disturbances
MgSO4 – to prevent recurrence of trades 2g/1-2mins per • Treatment: CPR, ACLS measures which include
IV push or for 4-6hrs if IV infusion intubation, transcutaneous pacing, IV therapy,
epinephrine and atropine
Slows the rate of SA node and prolong conduction time
• Commonly called flatline
and block calcium flow
 Contraindicated in the presence of hypertension
or ischemia
Ventricular Fibrillation
• Life threatening and medical emergency

Coronary Vascular Disorders − Because of increase dependency towards

connective tissue degeneration that may
account for the development of atheroma
− Diabetic patient also has alteration in lipid
metabolism and tend to have higher cholesterol
and triglyceride level
3. Hyperlipidemia
− If the cholesterol is greater than 200mg/dl, this
cause the elevations of triglycerides are
corelated to obesity, physical activity, high
alcohol intake and intake of trans fatty acid that
is found in snack food like cookies, crackers, and
fries that need to be avoided to lower the risk of
developing CHD
Coronary Artery Disease − With regards to lipoprotein, the low density of
• Narrowing or obstruction of the coronary arteries, lipoprotein has an active affinity for arterial wall,
resulting in a reduction of blood supply to the whereas the very low-density lipoproteins
myocardium, then there will be ischemia, injury and contain most of the triglycerides that has direct
infarction correlations with heart disease
• Atherosclerosis – a disorder of the lipid metabolism − That is why, we have to maintain high density
characterized by: lipoprotein and need to lower the LDL or VLDL
a. Development of fat-containing substances − Eat fish at least twice a week which contains
along the intima of the blood vessels alpha-linolenic acid like flaxseed, canola,
b. Smooth muscle cell proliferation soybeans – these may help lower LDL and
increase the HDL
4. Elevated Homocysteine
− Damages the inner lining of the blood vessels,
promote blood build up, and alter clotting
mechanism
• The intima lining of blood vessels has accumulated − Supplementing with vitamin B complex such as
fatty substances that may be partial or completely B6, B12, and folic acid may lower the blood level
blocked of homocysteine
5. Psychosocial Factors
− Can be combined with factors including high
Risk Factors
lipid, age, and smoking
Modifiable
− Usually type A personality which is aggressive,
Pathologic – hypertension, DM, hyperlipidemia, competitive, and has urgent sense of time
elevated homocysteine, psychosocial factors, metabolic − Predisposed to develop COD; even sleep apnea
syndrome and premature menopause is one factor
1. Hypertension 6. Metabolic Syndrome
− If there’s an elevation or constant elevation of − Major risk factor for cardiovascular diseases,
BP, it may increase the rate of atherosclerotic especially CAD because it may increase the BP
development − High in triglycerides may cause increased insulin
− Related to the sheering stress causing denuding levels, excess body fats that may result to CAD
that cause injury of the endothelial lining − Diagnosis for this syndrome includes:
− Causes narrowed or thickened arterial wall that Insulin resistance which may damage the
may decrease the distensibility and elasticity of endothelium that causes thickening of the vessel
the vessel wall and potential inflammation
− More force is required to pump blood through Central obesity – waist circumference of greater
disease arterial vasculature and is reflected in a than 35 inches in female and 40 inches in male
higher BP is at risk of developing cardiovascular diseases
− Increase cardiac workload that causes left
Dyslipidemia – BP persisting of greater
ventricular hypertrophy and decrease stroke
than130/85 mm Hg and pro-inflammatory state
volume with each contraction
wherein there is a high level of c-reactive protein
2. Diabetes Mellitus

Lifestyle – Smoking, obesity, elevated LDL, physical • However, if the endothelial lining is being altered, it
inactivity, Diet, Use of oral contraceptives, Hormone may result to chemical injury from hypertension,
replacement in women hyperlipidemia that may suggest certain bacterial and
1. Smoking viral infections that play a major role in the damage of
− Nicotine cause the release of catecholamine endothelium
(epinephrine and norepinephrine) • With endothelial alteration, the platelets are activated
− Increase the heart rate, stroke volume, cardiac and releases growth factors that may stimulate the
output, and BP smooth muscle proliferation
− Carbon monoxide directly damage the inner • May entrap the lipid which may calcify over time and
lining of the blood vessels form an irritant to the endothelium on which platelet
− Peripheral vasoconstriction may increase adhere and aggravate
ischemic changes that occur and decrease blood
Lipid Infiltration – altered endothelial permeability
flow
− Nicotine deceases the threshold for ventricular • Lipid from circulation enter the endothelium and
fibrillation by interfering the oxygen from binding accumulate in the smooth muscles in response to
with hemoglobin therefore impairing oxygen mechanical or inflammatory trauma
diffusion into the mitochondria • Lipoprotein become trapped and damage occur then
− Nicotine also enhances platelet adhesion endothelial permeability is altered
2. Obesity Aging
− Increased food intake is associated with
• Atherosclerotic changes occur in everyone and
elevations of LDL
become more evident as one ages
− Risk for hypertension, glucose intolerance
− Should not be greater than 20% above of the Thrombogenic
ideal body weight • RBC, platelets and lipids accumulate along the intima
3. Physical Inactivity of the arteries in microthrombi form
− Lack of exercise • It may release substances that may alter the
− Decrease in activity is directly associated with endothelial permeability
the decrease in HDL • Thrombus extends and reactivate the cycle
4. Diet
− High intake of fat and carbohydrate leads to high Vascular Dynamics
serum plasma cholesterol • Increase intraluminal pressure leads to altered
5. Use of Oral Contraceptive/Hormone replacement membrane permeability
− May affect cholesterol, particularly lowering the • Mechanical factors like hypertension because of
good cholesterol and increasing the risk of blood constant elevation in the BP which may increase the
clot rate of atheroma formation
• Increase intraluminal pressure which lead to altered
Non-modifiable membrane permeability that may result to increased
lipid infiltration
Age – middle-aged men
 60 yrs. old Inflammation
Gender – attribute to sex hormones • Major role in the pathogenesis of atherosclerosis
 Men have greater risk than women • Inflammatory reaction may be a consequence of
 Attributed to female sex hormones since infectious stimuli
advantage of it declines rapidly after menopause
 Increase social and economic pressure on women Developmental Stages in Atherosclerosis
and changes in lifestyle, including the incidence of Fatty streaks
smoking and the use of oral contraceptive or
• Earliest lesions
hormone replacement
• Characterized by lipid-filled smooth muscle cells, a
Family history
yellow pink appeared in the intima of the blood
Race – common in African-American vessels
Raised fibrous plaque

Theories of Atherogenesis
• Beginning of progressive changes in the arterial wall
Endothelial Injury – hyperlipidemia, hypertension and
• Usually occurs at the age of 30 or increase with age
chemical irritants
• Arterial wall changes are initiated by chronic
• A normal intact endothelium is usually non-reactive to
endothelial injury that result from many factors like
platelet, leukocytes, coagulation, and fibrinolytic

elevated BP, increase in cholesterol, hereditary,

carbon monoxide produced by smoking, and even
immune reaction toxin substance within the blood
vessel
• Normally, the endothelium repairs itself immediately,
but not in patients with CAD because it allows the LDL
and growth factor from platelet to stimulate smooth
muscles proliferation and thickening of the arterial wall
Collateral Circulation
• Lipoproteins transport cholesterol and other lipids into
• Arterial branching exists within the coronary
the arterial intima
circulation. Attributed to inherited predisposition and
• Fatty streak is covered by collagen forming a fibrous
presence of chronic ischemia
plaque that appears grayish or whitish
• Result = narrowing of vessel lumen
• The lipid may directly damage the smooth muscles
and contribute to plaque thickening and instability
• As the lipid pass through the vessel, they may adhere
causing the lesion buildup and structure abnormality
• Platelet also play a part in the hypertrophy of smooth
muscles cells
• The large number of platelets accumulate in the • When an atherosclerotic plaque occludes the normal
internal wall of the artery and may lead to thrombus flow of blood through coronary artery, the ischemia is
causing the narrowing of the artery chronic then increased collateral circulation develop
• When occlusion of the coronary arteries occurs lowly
Complicated Lesion Phase over a long period, there’s a chance of adequate
• Incorporation of lipid, thrombus, damaged tissue, and collateral circulation developing
accumulation of calcium • Myocardium may still receive adequate amount of
• The growing lesion becomes complex oxygen
• As it grows, the necrotic tissue that is hardened within • Rapid onset of CAD or coronary spasm, the time is
the arteries causing rigidity and hardening that may inadequate for collateral development and a
partially occlude the arteries diminished arterial flow result in a more severe
• Thrombus formation may develop ischemia or infarction
• Continued inflammation can result in plaque • Younger person will have more severe MI, because of
instability, ulceration, and rupture inadequate collateral formation
• Platelets accumulate and thrombus form
• Increased narrowing or total occlusion of lumen Pathophysiology of CAD
Three Major Clinical Manifestations of CAD

1. Angina pectoris
2. Acute coronary syndrome (ACS)
3. Sudden cardiac death
4. Rapid pulse
5. Shortness of breath
6. Palpitations
7. Weakness

Diagnostic Studies for CAD  Used to treat abrupt closure or re-stenosis

1. 12 Lead ECG following percutaneous coronary intervention
2. Exercise stress test  Stent is thrombogenic – antiplatelet agents is
3. 2D Echo prescribed: aspirin, clopidogrel (Plavix),
4. Coronary angiography ticlopidine (Ticlid)
5. MRA  Complications: hemorrhage, vascular injury and
arrhythmias
Management of CAD
Reduce Risk Factors
1. Stop smoking, regular exercise, diet (low potassium
and avoid trans fatty foods), reduce weight, control
HPN, DM, and cholesterol
Restore Blood Supply (PCI)

Revascularization is the restoration of perfusion to a
body part or organ that has suffered ischemia through
percutaneous coronary intervention (PCI) formerly 3. Atherectomy
known as angioplasty and stenting which may improve  The plaque is shaved off using a type of
blood flow and restore blood supply rotational blade – high speed rotating shaver that
1. Percutaneous Transluminal Coronary Angioplasty grinds the plaque into tiny pieces or a small
(PTCA) rotating cutter that shaves off pieces of the
 Restores luminal patency by compressing blockage
atheromatous plaques within the coronary  It decreases the incidence of abrupt closure as
arteries compared with percutaneous coronary
 Increases luminal size by 20% intervention (PCI)
 A catheter is equipped with an inflatable balloon  Recanalizing of block vasculature via a needle
tip which is inserted into coronary arteries puncture in the skin to try removing the plaque
passing through the lesion and the  Improves blood flow to the ischemic limb or
atherosclerotic plaque is compressed resulting in peripheral arterial blood vessels
vessel dilation  Limited to proximal and middle portion of a
vessel greater than 3 mm in diameter, less than
Advantages of PTCA
15 mm long, and not heavily calcified
1. Provides an alternative to surgical procedure
2. Ambulatory 24 hours after the procedure
3. Shortened the length of hospitalization (compared
to open heart surgery or coronary bypass graft
CABG)
4. Rapid resumption of work in one week after the
procedure
Pharmacologic Therapy
1. Vasodilator – Nitroglycerin (NTG)
 Vasoactive agent
 Reduce myocardial oxygen consumption
 Decrease ischemia and relieves pain
 Dilates vessels and improve perfusion
 Helps increase coronary blood flow, prevent
2. Intracoronary Stent Placement
vasospasm
 A stent used to maintain vessel patency by
2. β-adrenergic blocker – atenolol, metoprolol
compressing the arterial walls and resisting
vasoconstriction.  Decrease myocardial oxygen consumption by
 Usually in conjunction with angioplasty blocking the β-adrenergic sympathetic
 Expandable mesh like structure designed to stimulation of the heart
maintain long term vessel patency  Decrease HR, BP and myocardial contractility

 Reduce cardiac workload, excitability, and renin Preoperative Tests

release 1. Full blood count (CBC)
 Check the heart rate and BP before giving these 2. Screening for clotting
medication 3. Creatine and electrolytes
4 B’s 4. Check for abnormalities
✓ Bradycardia 5. Liver function test
✓ BP (reduced) 6. CXR
✓ Bronchial constriction 7. 12 Lead ECG
✓ Blood glucose (decrease) 8. 2D echo
3. Calcium Channel Blocker – nifedipine, diltiazem, 9. Coronary angiography – used to determine the
verapamil (very nice drug), amlodipine, felodipine, extent and location of coronary artery
nicardipine
 Block calcium into the cell Nursing care for patients who have undergone
 Decrease contractility CABG:
 Arterial construction 1. Care for the 2 surgical sites (chest, arm, leg,
 Decrease in BP and peripheral vascular abdomen)
resistance 2. If radial artery is used, observe for distal thumb
 ↓ SA node automaticity and AV node and finger for perfusion and oximetry of distal
 ↓ strength of the heart muscle contraction finger
 Relax blood vessel 3. Monitor for hypotension since it may cause
4. Antiplatelet – aspirin and heparin collapse of vein graft
 Aspirin prevent platelet aggregation that 4. Increase in BP indicates an increased pressure
impedes the blood flow that promote leakage from the suture line and
 Heparin prevent formation of new blood clot may cause bleeding
5. Calcium channel blocker for 3 months to
Surgical Management decrease the incidence of arterial spasms at the
1. Myocardial revascularization or CABG arm or at the anastomosis sites, especially the
 Performed in patients with CAD that has not radial artery
been under PCI or failed PCI 6. Prevent pulmonary complications
 Consist of the construction of new conduit within 7. Restrict fluids because patient usually have
the aorta and arteries in order to improve quality edema
of life, good survival rate, and cardiac related
mortality
 It’s a palliative therapy but not a cure for CAD
 Graft is obtained from saphenous vein, internal
mammary arteries, radial artery, gastroepiploic
artery, or inferior epigastric artery
Indications
1. Left main coronary artery stenosis is greater than
50%
2. Stenosis of proximal left anterior descending and
proximal circumflex greater than 70%
2. Transmyocardial Laser Revascularization (TMR)
3. Three-vessel disease (3VD) which is
 Use of laser to create a channel between the left
asymptomatic with mild or stable angina
ventricular cavity and the coronary micro
4. 3VD with proximal left anterior descending
circulation
stenosis with poor left ventricular functions
 The channel allows blood to flow into the
5. Ongoing ischemia of non-ST segment elevation
ischemic area
MI that is unresponsive to medical therapy
 Can be performed during cardiac catheterization
and using a left anterior thoracotomy incision
Contraindications
 Involves the use of vessels that are too small or
1. Asymptomatic patients who are at low risk of MI
numerous replacement and balloon
or death
catheterization
2. Less commonly performed in elderlies because
they have a shorter life expectancy, CABG may Complications
not prolong survival and may experience
1. Ventricular arrhythmia
perioperative complications after CABG

2. Post-op bleeding 4. Severity – using 0 – 10 pain scale

3. Cardiac tamponade 5. Timing – 5 seconds to 30 minutes
4. Accidental perforation of the blood vessels –
cause a low cardiac output ❖ Usually located at left shoulder, jaw, intrascapular or
suprascapular area, and medial aspect of left arm
❖ Manifestation is usually in the early morning after
Nursing Management of CAD
awakening
1. Treat pain
 Stop all activities
Location of Chest Pain (Angina)
 Bed rest – semi-fowlers position to reduce
oxygen requirements
 Observe signs of respiratory depression
 NTG (nitroglycerine)
 Monitor vital signs
2. Reducing activity
3. Health education on reducing risk factors
4. Teach stress reduction techniques
Relationship Between CAD, Chronic Stable Angina,

and ACS
4 E’s of Precipitating Factors of Angina

Acute coronary syndrome – prolonged lack of oxygen 1. Exertion
supply to the myocardium 2. Eating
3. Emotional distress
4. Extreme temperature
Angina Pectoris
• A clinical syndrome characterized by episodes of pain
Precipitating Factors of Angina
or pressure in the anterior chest due to insufficient
coronary blood flow Increase myocardial needs that damage the
• In layman’s term, chest pain myocardium
• Due to imbalance between the myocardial oxygen 1. Physical Exertion
supply and demand  Increase heart rate that decrease the time of the
• Usually occurs in patients with coronary heart spent in diastole
atherosclerosis  Time of the greatest coronary blood flow
• The pain usually last for only a few minutes (3-5 mins.)  Walking outdoor is the most form of exertion
and subsides when the precipitating factors are  Isometric exertion of the arm like lifting heavy
relieved objects may cause exertional angina
• Due to vessel factors like atherosclerosis, arterial 2. Extreme Temperature
spasm, smoking, stress, and emotions  Exposure to cold could increase the workload of
• Circulatory factors: Hypotension because of the heart
decreased blood returning to the heart / aortic  Blood vessel constrict in response to a cold
stenosis – decrease in feelings stimulus
• Blood factors: anemia, hypoxemia, polycythemia – all  Blood vessels dilate and blood pools in the skin
contribute to decreased oxygen supply in response to a hot stimulus
3. Strong Emotion
PQRST Assessment of Angina  Stimulates SNS that may increase the workload
1. Precipitating factors (activity, exercise, resting) of the heart
2. Quality (dull, aching, sharp, tight, burning, pressure, 4. Consumption of Heavy Meal
chocking, suffocating)  Increase the workload of the heart during the
3. Radiation of pain (back, arms, jaw, shoulder) digestive process

 When blood is delivered to the gi system, it • It is predictable hence, medication may be timed to
causes a decrease in flow rate in the coronary provide relief
artery • Strenuous activities, cold weather heightened
5. Cigarette Smoking emotional stress may trigger angina (relieved by
 Nicotine stimulates the release of catecholamine nitroglycerin or rest)
release causing vasoconstriction and increased • Described as a crushing, tightness or squeezing
heart rate, and diminish the available oxygen by sensation in the chest
increasing the level of carbon monoxide • In ECG tracing, there is down sloping of ST segment
6. Sexual Activity that indicates CAD
 Increase cardiac workload and sympathetic • If ECG remains normal and the patient complains for
stimulation signs and symptoms, there is no proof unless exercise
 Nitrates or nitroglycerin is prescribed before stress test is done (stress test or treadmill exercise
engaging to any sexual activity test)
7. Stimulants – cocaine, amphetamine
 Cause increased heart rate and subsequently it Important Treatment /Elements of Stable Angina
may increase myocardial oxygen demand A aspirin, anti-anginal therapy
8. Circadian Rhythm Patterns B β-adrenergic blocker, blood pressure
 Related to the occurrence of stable angina or C cigarette smoking, cholesterol
prinzmetal angina D diet, diabetes
 Cause Mi or sudden death E education, exercise
Pathophysiology Nursing Management for Stable Angina

1. Administration of supplemental oxygen
2. 12-lead ECG
3. Prompt pain relief first with a nitrate followed by an
opioid analgesic if needed
4. Auscultation of heart sounds
5. Proper positioning to decrease cardiac workload
Unstable Angina
• Also known as pre-infarction angina or acute coronary
insufficiency
• Usually associated with deterioration of once stable
atherosclerotic plaque
Types of Anginas  Once the plaque ruptured, exposing the intima to
blood and stimulating the platelet aggregation on
1. Stable angina
local vasoconstriction with thrombus formation
2. Unstable angina
• Pain last longer and more frequent and not relieved
3. Intractable – severe incapacitating chest pain
by rest
4. Variant angina – due to coronary vasospasm
• Unpredictable
5. Silent ischemia – objective evidence of ischemia but
• May be precipitated by factors other than effort or
patient reports no
activities
6. Nocturnal – associated with rapid eye movement
• More severe than stable angina
sleep during dreaming
• Frequency preceding to MI because of the imbalance
7. Angina decubitus – characterized by the onset of
between myocardial oxygen demand and supply
chest pain when the patient is resting or lying down
coronary artery spasm
• Stress related catecholamine release and platelet
Stable Angina
aggregation
• Characterized by effort induced chest discomfort with • Unstable angina is the first clinical manifestation of
or without radiation that last for a few seconds to 15 CAD
minutes  These unstable lesions increase the risk of
• Usually at rise when lumen stenosis is greater than complete thrombosis of the lumen with
70% which may impair blood supply to the heart only progression to MI
during exertion or increase metabolic demand • Requires immediate hospitalization, ECG monitoring,
• Generally, stable angina is relieved by rest, removal and bed rest
of provoking factors, or taking sublingual vasodilator • Treatment: aspirin, heparin, and antiplatelet agents

Variant or Prinzmetal’s Angina Diagnostic Studies

• Characterized by chest pain that occurs at rest in the 1. 12 Lead ECG or Holter monitoring – for outpatient
early hours of morning 2. Treadmill exercise test
• Often associated with ST elevations on the ECG  Important for stable angina because of ST
• Underlying cause is thought to be coronary artery segment and P wave changes during exercise or
spasm indirect assessment of coronary artery perfusion
• Due to the sudden reduction in coronary blood flow 3. Blood test – lipid profile and cardiac enzyme
brought on by spasm and not by increase myocardial 4. Nuclear imaging – myocardial perfusion
oxygen demand 5. Positron Emission Tomography
• It has been suggested that the spasm caused by 6. 2-D echocardiography
strong contraction of the smooth muscles in coronary 7. Coronary angiography
arteries caused by an increase in the intracellular 8. Electron beam CT – assess CAD in all stages
calcium.
• The decrease in the myocardial consumption occur Goals for Management of Angina
during sleep or rest may lead to coronary artery 1. Alleviate manifestations
vasoconstriction and responsible for the spasm 2. Prevent the progression of coronary heart disease
• Not directly related to atherosclerosis but caused by and myocardial infarction
coronary vasospasm 3. Relieve acute attacks
• Not precipitated by exertion or stress
• Occurs at the same time everyday
Nursing Management for Angina
• Frequent between midnight to 8am and may
disappear spontaneously or some form of exercise 1. Oxygen as ordered
• May have dysrhythmia and conduction abnormalities  If oxygen saturation is decreased
• Treatment: Nitrates, Calcium channel blocker 2. Pain relief – nitrates, narcotics
 Administer NTG sublingually and assess the
Prinzmetal’s patient’s response
Stable Unstable
Angina
Rupture of
3. Monitor vital sign and cardio function
Myocardial ischemia thickened plaque  Observe for any respiratory distress and assess
Etiology usually secondary exposing Coronary spasm
to atherosclerosis thrombogenic cardiac function
surface
Increased Occurs primarily 4. ECG monitoring
Episodic pain
frequency, duration at rest
lasting 5 – 15 min
or severity Triggered by
5. Semi-High fowler
Provoked by
Characteristics
exertion
Occurs at rest or smoking  To decrease the myocardial demand
minimal exertion Occurs in
Relieved by rest or
NTG
Pain refractory by presence or
absence of CAD
NTG
 To reduce anxiety
 Explore implications that the diagnosis has for
Clinical Manifestation of Angina
the patient
1. Chest discomfort and may experience epigastrium  Explore various stress reduction method with the
(upper central abdomen), back, neck area, jaw, or patient such as music therapy
shoulder 7. Minimize precipitating events
o When caring for elderly, make sure to take the 8. Gradual increase in exercise
history properly 9. Allow for rest periods
o Because in an elderly with angina, they10. may Notify MD if chest pain persists not relieved by rest
not exhibit the typical pain profile because of / NTG
the diminish responses of neurotransmitter
that occur with aging
o Most of the time, the presenting symptoms in Acute Coronary Syndrome
elderly is dyspnea • A group of symptoms arise when vessel or coronary
o Sometimes there are no symptoms making arteries becomes occluded or obstructed by thrombus
recognition and diagnosis a clinical challenge • When oxygen supply is decreased for a long period of
2. Shortness of breath time which cannot be immediately reversed, then it
3. Cold sweat – due to diaphoresis and increased SNS may cause ACS
stimulation • Usually precipitated by plaque rupture and clot
4. Weakness – decrease cardiac output formation
5. Diaphoresis – increase sympathetic stimulation • ACS is also associated with coronary thrombosis
6. Dizziness • Primary symptom is chest pain, radiating from left arm
7. Nausea and vomiting or angle of the jaw which is very common
8. Anxiety

• Acute ischemic usually related to ACS ranging from • The transmural infarction produces myocardium
unstable angina to myocardial infarction (MI) with or necrosis which release cardiac enzyme
without ST elevation secondary to acute plaque • Positive cardiac enzyme, positive in ST changes in
rupture and plaque erosion the ECG, T wave inversion, and pathologic Q wave
• Cardiac chest pain may be precipitated by anemia, • It is an emergency situation that needs
bradycardia, or tachycardia revascularization of the occluded artery
• Etiology: Atherosclerosis • Treatment is through thrombolytic or angioplasty
Unstable Angina NSTEMI STEMI

Subtypes of ACS
Non-occlusive thrombus
Unstable Angina Non occlusive sufficient to cause Complete thrombus
• When atherosclerotic plaque shoot of embolus thrombus tissue damage & mild occlusion
myocardial necrosis
downstream to cause microinfarct
• When there is a reduced blood flow in the coronary Non-specific ST depression +/- ST elevations on
ECG T wave inversion on ECG ECG or new LBBB
artery due to a ruptured atherosclerotic plaque, a clog
begins to form on top of the coronary lesion, but the Normal cardiac Elevated cardiac Elevated cardiac
enzymes enzymes enzymes
artery is not completely occluded
• This acute situation may result to chest pain that is More severe
symptoms
referred to as pre-infarction angina because the
patient is likely to develop MI and clog interventions
Signs and Symptoms of ACS
do not occur
1. Palpitations – first symptoms in patients with
o NSTEMI and STEMI are named according to the dysrhythmia
appearance in the ECG as to which form of MI 2. Chest pain – pressure, squeezing, or a burning
are classified under ACS sensation across the precordium and may radiate to
the neck, shoulder, jaw, back, upper abdomen, or
either arm
NSTEMI (Non-ST Segment Elevation Myocardial
 Cardinal sign of decreased blood flow into
Infarction)
the heart
• If ECG does not show typical changes, this is called
 Pain radiates to the left arm
Non-ST segment elevation ACS but the patient may
3. May experience indigestion
still have suffered a NSTEMI
4. Exertional dyspnea that resolves with pain or rest
• The occlusions of about 25% or partial block in the
5. Diaphoresis from sympathetic discharge
coronary artery but still there is little blood perfusion
6. Nausea from vagal stimulation
into the blocked artery
7. Decreased exercise tolerance
• The presence of collateral circulations is very
8. Jugular venous distention
important
9. Cool, clammy skin
• No ST or Q wave alteration on the ECG when
10. Feeling of being acutely ill
necrosis is confined to endocardial layer (most
susceptible to ischemia) o When doing the physical assessment, it’s not
• It could be negative or positive cardiac enzyme only jugular venous distention that may be seen
depending on the site that is affected o The presence of S3 and S4 heart sounds can be
heard
Treatment o The presence of rales in pulmonary examination
1. Conventional lifestyle modification  It is suggestive of left ventricular dysfunction
or mitral regurgitation and even hypotension
2. Medications such as aspirin, clopidogrel, or heparin
due to MI or myocardial ischemia
3. Revascularization like PTCA o If there’s a hypertension, it may precipitate
angina or reflect in elevated catecholamine level
STEMI (ST Segment Elevation Myocardial Infarction) due to anxiety or exogenous sympathomimetic
• When full thickness necrosis of the ventricular wall stimulation
occurs
• There’s a sudden occlusion in the coronary artery that Diagnostic Studies
cause ischemia 1. 12 Lead ECG
• Usually there is a presence of clot  Indicate acute heart damage
• If ECG confirms changes, it suggests myocardial  if there’s an elevation in ST segment or new
infarction left bundle branch block
• 30% of the transmural infarction of the myocardium 2. Chest X-ray
undergoes necrosis that may result to ST elevations

3. Troponin I and T – cardiac markers Three Zones of Tissue Damage

4. D-dimer – if pulmonary embolism is suspected Ischemia – T wave inversion
5. Telemetry monitoring – monitor heart rhythm • The greater chance of viability of myocardial cells,
6. Brain natriuretic peptide (BNP) – provide predictive unless ischemic persist or worsen – it will take about
information to develop MI 20 minutes
7. C-reactive protein (CRP) – estimate the extent of • In ECG, there is inversion in T wave
systemic inflammation
8. Interleukin-6 – major determinant of acute-phase risk Injury – ST elevation
of unstable angina • Surrounding necrotic tissue that causes injury on the
myocardial cells that is potentially viable if adequate
Management of ACS circulation is quickly restored
1. Monitor and treat arrhythmia • In ECG, there is ST elevation which shows injury in
2. Correct electrolyte imbalances – potassium and the leads especially in the bipolar leads
magnesium
3. Provide oxygen therapy – to correct hypoxia or Infarction – deep Q waves
hypoxemia • Sometimes called “central area” that consist of
4. Pharmacologic therapy – aspirin, clopidogrel, necrotic myocardial cells, capillaries, and connective
nitroglycerin tissue
 Morphine and analgesics if the chest pain or • The infarction causes the presence of Q wave due to
discomfort persist inability of this necrotic muscles to conduct an impulse
• The clinical picture of MI with a Q wave infarction
Myocardial Infarction (MI) means deprivation of oxygen to the cells so it
becomes necrotic in 5-6 hours after occlusion
• Decrease in coronary perfusion in the myocardial
• Presence of deep Q wave in the ECG tracing means
layers
its permanent
• There is a sudden coronary occlusion caused by
atherosclerotic plaque with thrombus formation which
• Also indicates sustained coronary occlusion and
extensive of necrosis’
result to abrupt cessations of blood and oxygen to the
heart
• Complete or nearly complete occlusion of a coronary
artery usually precipitated by rupture of a vulnerable
atherosclerotic plaque and subsequent thrombus
formation
Basic Types of MI Based on Pathology

Transmural
• All layers are affected, complete occlusion
• Extends from endocardium to epicardium
Subendocardial
• Small areas of myocardium are affected
• Susceptible to ischemia
• Endocardial wall of the left ventricle, ventricular
septum, or papillary muscles
• Majority involves the left ventricle
Site of Infarction
Anterior wall of the left ventricle near the apex –
common
• Result from thrombosis of descending branch of the
left coronary artery
Posterior wall of the left ventricle near the base

• Result from occlusion of the right coronary artery or
the circumflex branch of the left coronary artery

Inferior surface of the heart Clinical Manifestations of MI

• Result from right coronary artery occlusion whereas 1. Chest pain – sudden and continuous
the lateral MI occlusion of left circumflex artery  Primary symptom
 Continuous substernal pain despite of rest and
Lateral – left circumflex artery medication
• The severity of MI depends on 3 factors:  Some patient may experience epigastric pain or
a. The level of occlusion in the coronary artery feeling of indigestion which may indicate that the
b. The length of time of occlusion patient is experiencing chest pain
c. The presence or absence of collateral  Another characteristic of typical chest pain in MI
circulation – intense, not relieve for 30-60 minutes, and
radiation of pain from substernal to the neck,
Etiology of Myocardial Infarction shoulder, jaw, and down to the left arm
1. Coronary artery spasm can cause acute occlusion  Sensation is characterized by squeezing and
2. Decrease oxygen supply from acute blood loss, sharp pain
anemia, or low blood pressure  Usually BP is initially elevated because of chest
 Can lead to infarction, ischemia or the death of pain and peripheral arterial vasoconstriction
myocardial cells resulting from adrenergic response to pain and
 It may deliberate the different intramyocardial ventricular dysfunction
cellular enzyme such as the CPK or CK-MB, 2. Unexplained anxiety
myoglobin, troponin that result to the 3. Restless
development of chest pain 4. Stomach, back and abdominal pain
3. Unstable angina 5. SOB and dyspnea
4. Plaque rupture 6. Weakness
7. Diaphoresis or sweating
8. Syncope – without cause
9. Cognitive impairment – without cause
• The affected myocardial muscles do not regenerate

after an infarction o Sinus bradycardia is common in MI
• Healing requires the formation of the scar tissue that o Some patients may experience fever for MI as
early as 4 to 8 hours after the onset of infarction
replaces the necrotic myocardial muscles
• The morphology changes will be ranging from “no
apparent cellular change” within the first 6 hours to the Diagnostic Studies in MI
“total replacement by scar tissue” Laboratory Test – very significant to identify cardiac
• When there’s a scar tissue, it may inhibit the markers
contractility and causes slow conductions of electrical CK-MB
impulse that may trigger re-entry mechanism that  Elevated 4 – 6 hours after onset of chest pain
result to ventricular fibrillation  Peak is 12-18 hours and may normalize in 3-4
• As the contractility falls, heart failure may follow, so days
the body begin to use the compensatory mechanism
in attempt to maintain cardiac output

Troponin T and I • Once the patient recovers from MI, the first to return
 T (84% sensitivity for MI 8 hours after onset) – to normal is the ST segment taking 1-6 weeks
very sensitive to detect myocardial ischemia followed by T wave becoming large and symmetric for
 I (90% sensitivity to predict high risk of unstable the first hours and invert within 1-3 days or 1-2 weeks
angina) • Q wave alteration will be permanent and changes in
Myoglobin Q wave occur within 36-48 hours if proper treatment
 Elevations indicate myocardial damage in the is not given
absence of skeletal muscle damage • Evidence of Q wave may persist due to an old
 Sensitivity may not be that reliable after 10-12 infarction and can be used to localized the effect
hours because of rapid renal clearance throughout the person’s life
 LDH Management
 Elevate 12 hours after onset of chest pain 1. Hemodynamic monitoring
 Peak in 24-48 hours and may remain elevated for 2. Oxygen therapy
10 days especially the isoenzyme L1 and L2  Measure partial arterial oxygen
which indicate myocardial damage  Hypoxemia – 2-4 L/min. as per doctor’s order
CBC
3. Bed rest
 Leukocytosis – vascular injury with subsequent  To decrease myocardial oxygen consumption
ischemia 4. Diet
 ESR – elevated because It affects tissue necrosis  Liquid diet 1st 4 to 12 hours to reduce gastric
C-reactive protein (CRP) distention subsequently reducing cardiac
 Marker for acute inflammation workload
 Saturated fat restriction and low sodium
Radionuclide Imaging 5. Pharmacologic therapy
• Provide information in the presence of coronary artery 6. Percutaneous Coronary Intervention (PCI) – intra-
disease aortic balloon pump, angioplasty, stent placement,
• If there’s an occlusion in the blood vessels because of etc.
fatty plaques, it can affect coronary perfusion thereby Intra-Aortic Balloon Pump
depriving oxygen and nutrients to the myocardial cells − Mechanical device that may increase the
• It may also identify the location of ischemia in coronary perfusion and lowers systolic blood
infarcted tissue pressure
• Helps in identifying the site and extent of MI − Reduce afterload and improve coronary blood
• Serve as a basis for the assessment of the effect of flow in patients with cardiac contractile function
reperfusion therapy impairment
− Increases cardiac output by improving the
MRI coronary blood flow
• High technology that could differentiate reversable − If there’s an increase in coronary blood flow,
and irreversible tissue injury therefore there’s more myocardial oxygen
delivery
Positron Emission Tomography (PET) Scan − Inflates during diastole or ventricular filling that
• Evaluates cardiac metabolism and assess tissue may increase pressure in the aorta thereby
perfusion increasing the blood flow to the coronary and
• Evaluate or detect presence of coronary artery peripheral arteries
disease and coronary flow reserve, even MI − Deflates during systole that may lessen the
pressure within the aorta before the left ventricle
2-D Echo contractions thereby decreasing the amount of
• Identify the different areas of abnormal regional wall resistance to the heart
motions
• Helps in detecting complications associated with
acute MI
ECG
• During acute phase, there’s an elevation; only the ST
segment and T wave changes
• ST elevations can be seen in patients having acute MI
• ST depression for ischemia

7. Cardiac rehabilitation − Avoid using in patients with severe renal

 Long term program of medical evaluation, diseases
indications to patient, and counselling in order to − Should be administered with food to prevent
limit the physical and psychological effect of bleeding (assess for melena)
cardiac illness − Sometimes combined with clopidogrel, an
 Also helps in improving patient’s quality of life adjunctive reperfusion therapy
 Rehabilitation includes 4 phases
Indirect thrombin inhibitor
 Includes exercise and medication to help patient
Heparin
return to optimal fitness and functions after MI
 Helps improve functional mobility, decrease the − Increase the ability of anti-thrombin by
risk factors through indications that is related to inhibiting the activation of the circulating
cardiac injury thrombin and limit the formation of thrombus
 Also helps the family to manage the − Monitor the aPTT levels (check the results and
psychological effect that may increase recovery notify the physician)
after MI − Antidote: Protamine sulfate
Streptokinase
Pharmacologic Intervention − Made from streptococcus organism
Morphine − Increases the amount of plasminogen
Analgesic drugs such as morphine are to reduce pain and anxiety, activator that increase the amount of both
M also has other beneficial effects as a vasodilator and decreases the
workload of the heart by reducing preload and afterload. circulating and blood bound plasminogen
Oxygen
To provide and improve oxygenation of ischemia myocardial tissue;
− Not to be given in patients who recently have
O enforced together with bedrest to help reduce myocardial oxygen been exposed to a streptococcal infection or
consumption. Given via nasal cannula at 2 to 4 L/min.
Nitroglycerin those who received streptokinase in the past 6
N First-line of treatment for angina pectoris and acute MI; causes months
vasodilation and increases blood flow to the myocardium.
Aspirin − Given for first heart attack or MI attack
A Aspirin prevents the formation of thromboxane A2 which causes
platelets to aggregate and arteries to constrict. The earlier the patient
− Do not use after 4 days from the first day of
receives ASA after symptom onset, the greater the potential benefit. administration because it may cause allergic
Thrombolytics
To dissolve the thrombus in a coronary artery, following blood to flow reaction
T through again, minimizing the size of the infarction and preserving − In the occurrence of allergic reaction, tissue
ventricular function; given in some patients with MI.
Anticoagulants plasminogen activator (tPA) may be given
A Given to prevent clots from becoming larger and block coronary
arteries. They are usually given with other anticlotting medicines to
− Monitor heart rate and rhythm and observe for
help prevent or reduce heart muscle damage. any bleeding
Stool Softeners
S Given to avoid intense straining that may trigger arrhythmias or Tissue-type plasminogen activator (tPA)
another cardiac arrest.
Sedatives − Activates plasminogen on the clot for it to break
S In order to limit the size of infarction and give rest to the patient. Valium
or an equivalent is usually given. down
MONA is a mnemonic for the four primary interventions that are − Heparin is combined with it (Alteplase)
performed when treating a patient with Myocardial Infarction (MI).
However, MONA does not represent the order and prioritization of
administering them. Aside from MONA, TASS is also given which 3. Angiotensin-Converting Enzyme Inhibitor (Captopril)
includes thrombolytic drugs are also given within 6 hours of onset to  Prevent conversion of angiotensin I to II
interrupt MI evolution. Anticoagulant therapy reduces the risk of
recurrent infarction and death in patients with ST-segment elevation.  ↓ BP, kidney excrete Na and fluid to ↓ O2
Stool softeners are used to avoid straining of stool, and sedatives and
tranquilizers to increase rest.
demand by the heart
4. Beta blocker
 Reduce pain, limit infarct size
1. Analgesics – morphine
 ↓ HR, reduce cardiac work and myocardial O2
 Vasodilator which may reduce the pain and
demand
anxiety of the patients
5. Nitrates
 Reduce the workload of the heart, thereby
 Reduce cardiac workload
reducing the preload and afterload
 Dilate coronary arteries and collateral channels
 Also helps in the relaxation of the bronchioles
in the heart
that enhance oxygenation
 Adverse effect: tachycardia and hypotension
2. Thrombolytic – aspirin, heparin, streptokinase, tPA
6. Dopamine
Antiplatelet aggregating agent – aspirin
 Improves blood flow, prevent renal ischemia
− Blocks the prostaglandin synthesis
− Prevents additional platelet activation that may
Nursing Management
interfere in platelet adhesion
1. Assess the characteristic of pain
− Limits the formation of thrombus
2. Maintain an IV access

3. Monitor ongoing assessment Ventricular Aneurysm

4. Minimize anxiety • Late complication of the MI that involve thinning,
5. Minimize metabolic demands ballooning, and hypokinesis of the left ventricular wall
6. Assess vital signs after transmural infarction
7. Provide calm environment • Aneurysm often creates a paroxysmal motion of the
8. Limit visitors left ventricular wall and ballooning out of the
9. Elevate legs and avoid pressure under the knees aneurysmal segment of the ventricular contraction
10. Administer drug therapy as ordered (MONA)
11. Prepare for treatment (PTCA, CABG) Congestive Heart Failure (CHF)
 Pre-op and post-op health teaching
• Heart Failure is not a heart attack unlike MI
12. Support system
• Not a disease but associated with various type of
13. Patient teaching
heart diseases particularly with long standing
14. Physical exercise – isometric or isotonic
hypertension and coronary artery disease
15. Resumption of sexual activity – use of nitrates
• Heart failure means the heart is:
before sexual activity
 Weakened
16. AVOID activities
 Pumping action is impaired
 Small frequent meal is on way to decrease
 Cannot pump enough blood to supply the cellular
cardiac workload
needs of the body
 Avoid Valsalva maneuver since it may cause
• Type of circulatory failure which may include
bradycardia
hypoperfusion resulting from extracardiac conditions
17. Patient discharge
like hypovolemia, peripheral vasodilation, and
 Proper exercise
inadequate oxygenation of hemoglobin
 Resumption of sexual activity • The occurrence of circulatory congestion is from
 Submit to cardiac rehabilitation decrease myocardial contractility that resulted from
inadequate cardiac output to maintain blood flow to
Complications the body organ that developed from cardiac causes of
Dysrhythmias CHF
• Because of the damaged muscles which may • If it is non-cardiac cause, these are conditions such as
generate abnormal current causing abnormal cardiac increase blood volume from sodium or salt retention
contractility and the infarct damage of the conductive and primarily from a decreased peripheral resistance
tissue • In short, the heart is unable to provide sufficient
• Result of predisposing factors include tissue injury, pumping action to maintain blood flow to meet the
hypoxemia, lactic acidosis, hemodynamic needs of the body
abnormalities, and electrolyte imbalance
• hemodynamic abnormality, and electrolyte imbalance Compensatory Mechanisms for Maintaining Cardiac
• Because of decline in cardiac output, it increases the Output
cardiac irritability which may further compromise Ventricular Dilation
myocardial perfusion • Based on the Frank–Starling law of the heart
• As heart enlarge, it may cause extra pressure in the
Congestive Heart Failure (CHF) left ventricle
• Compromise myocardial function by reducing • The muscle fiber of the heart stretches, increasing the
contractility producing abnormal wall motions contractile force
• Patients may also experience cardiogenic shock due • ↑ contraction leads to ↑ CO and maintaining arterial
to the failure the heart to pump adequately thereby blood pressure and perfusion
reducing cardiac output and compromise the tissue • The dilatation is an adaptive mechanism in order to
perfusion cope with the increasing blood volume but eventually,
• Necrosis usually occurs on the left ventricle this mechanism becomes inadequate because of the
elastic elements of the muscle fibers being
Pericarditis overstretched
• If it is overstretched, it is no longer functional and no
• Sometimes called the “Dressler’s Syndrome”
longer able to contract effectively decreasing cardiac
• Usually occur after a transmural infarction
output
• It is a pericardial friction rub that may occur about
10%-20% of the affected individual
• Usually appears after the 1st week after infarction

Myocardial Hypertrophy  Has an effect in the development of heart failure

• There is an increase in muscle mass and cardiac wall 3. Anemia
thickness in response to overwork and strain  Decrease oxygen carrying capacity of the blood
• Occur slowly because it takes time for the increase stimulating increase in cardiac output to meet the
muscle tissue to develop tissue demands
• Hypertrophy usually follows persistent or chronic 4. Thyroid Disorders
dilation and may also cause the increase in contractile  Changes in the tissue metabolic rate which may
fibers of the muscle fibers leading to increase cardiac increase heart rate and workload of the heart,
output and maintain tissue perfusion indirectly it may predispose to atherosclerosis in
• However, hypertrophic heart muscle has a poor patients with hypothyroidism reducing
contractility myocardial contractility
5. Pulmonary Embolism
Sympathetic Nervous System Activation  Blood clot increases pulmonary pressure on the
right ventricle leading to hypertrophy and failure
• Release of epinephrine and norepinephrine ↑ HR,
6. Nutritional Deficiency
myocardial contractility, and peripheral vascular
 Decrease cardiac function because of decrease
constriction
myocardial muscle mass and contractility
• Vasoconstriction may cause an immediate increase in
7. Hypervolemia
the preload which initially increase the cardiac output
 Increase preload and cause blood volume load
• An increase venous return to the heart is considered
in the right ventricle
a volume overload and may worsen ventricular
performance
Factors that may cause interference with the normal
mechanism regulating the cardiac output:
Neurohumoral Response
1. Preload
• Vasoconstriction secondary to norepinephrine or
 Because of the amount of blood filling the
epinephrine
ventricles before contraction (venous return and
• Decrease the cardiac output by stimulating the
elasticity of ventricles)
sympathetic nervous system which may increase the
 Decrease elasticity causes hypertrophy of the
heart rate, BP, contractility, and catecholamine
myocardium
release
2. Afterload
• It decreases the renal perfusion or the stimulation of
 Amount of resistance to the ejection of the blood
RAA (renin angiotensin aldosterone) which increases
vessels from the ventricle
vasoconstriction, BP, muscular volume and
 Related to stroke volume
decreases water excretion (Na and water retention)
 Factors affecting preload including the diameter
• If the cardiac output fails, blood flow to the kidney
and distensibility of the great vessels, aorta,
decrease causing decreased glomeruli blood flow, so
pulmonary artery, and even the opening of aortic
the kidney may release renin which coverts to
and pulmonic valve
angiotensin I and II
• The adrenal cortex will release the aldosterone and o Consider the heart rate, myocardial contractility,
cause hypertension and metabolic state
• Increase in peripheral vasoconstriction increase the o Any alteration of these factors mentioned can
arterial bleeding lead to decrease ventricular function and results
to manifestation of heart failure
Risk Factors of CHF
1. High blood pressure Etiology of CHF
2. Myocardial Infarction Abnormal Loading Condition
3. High cholesterol
•  preload – regurgitation of mitral or tricuspid valve,
4. Damage to heart valves
hypovolemia, congenital defect (ventricular or atrial
5. Diabetes
septal defect and patent ductus arteriosus)
6. Obesity
•  afterload – hypertension, aortic or pulmonic
7. Advancing age
stenosis, high peripheral vascular resistance
Note: Precipitating Factors
1. Infection Abnormal Muscle Function
 Increase oxygen demand of tissues increasing • MI due to infarcted or necrotic tissue in the
cardiac output myocardium that may affect the functions of the heart
2. Stress

• Cardiomyopathy which may affect the contractility of • Result from the inability of the left ventricle to function
the ventricles normally causing the blood to back up through the left
• Ventricular aneurysm because of abnormal muscle atrium
function • If there’s a pressure in the left atrium, it may affect the
pulmonary vein causing the elevations of pulmonary
Limited Ventricular Filling pressure due to fluid extravasation from the
• Mitral and tricuspid stenosis pulmonary capillary bed to the inerstitium
• Cardiac tamponade or pericardial tamponade, a type • It may also affect arterial which may manifest as
of pericardial effusion in which the fluids accumulate pulmonary congestion or edema and dyspnea from
in the pericardium exertion
 Occur when the pericardial space is filled up with • There is also an increase pressure in the blood
fluid faster than the pericardial sac can stretch vessels of the lungs or called as “pulmonary
 If the amount of fluid increase slowly, then the hypertension”
pericardial sac can expand to contain up to 1L or • May cause impaired gas exchange
more
 If the fluid occurs rapidly as little as 100ml can Right
cause tamponade therefore increase in • The congestion in the peripheral tissue and viscera
pericardial pressure and decrease venous return determinates
to the heart and cardiac output • The right ventricle has reduced capacity to pump
3 Determinants of Beck’s Triad of Acute Cardiac blood into pulmonary circulation causing backup of
Tamponade fluid into the right atrium and venous circulation
3 D’s of Beck’s Triad: • May produce primarily sign and symptoms ascites,
1. Distant heart sound (muffled) hepatomegaly, peripheral edema due to vascular
2. Distended jugular veins (JVD) congestion
3. Decreased pulse pressure • Venous congestion can cause jugular neck vein
• Constrictive pericarditis in which the muscles become distention
thickened resulting to non-compliance around the
heart and prevents the heart to expand Major Alteration in CHF
Diminished Cardiac Output – inadequate perfusion of
Types of Ventricular Failure the vital organ results to deprivation; oxygen and
Ventricular failure of any type has low systemic arterial nutrients requirement are not met
blood pressure, cardiac output, and poor renal perfusion Pulmonary vascular bed no longer emptied effectively
Systolic Failure by left atrium and ventricle – engorged pulmonary
vessel that may result to pulmonary hypertension and
• Common cause of CHF
may be followed by pulmonary edema
• ↓ the left ventricular ejection fraction caused impaired
contractile function Increase venous pressure – engorged capillaries
• Inability of the heart to pump blood because of a leading to ascites and peripheral edema
defect in the ventricular contraction
• The left ventricle loses its ability to generate enough Signs and Symptoms
pressure to eject blood toward the high-pressure aorta
Diastolic Failure
• Impaired ability of the ventricles to fill during diastole
• Ventricle becomes less compliant or stiff which impair
ventricular filling since the wall is thick and rigid and
cannot relax thereby decreasing stroke volume
•  filling of the ventricles will result to  stroke volume
Forms of CHF
Left
• The left ventricle has reduced capacity to pump blood
into systemic circulation – decreased CO and backup
of fluid into the pulmonary circulation

Integumentary – pallor or cyanosis, cool and clammy

skin, diaphoresis
• Decreased supply of oxygen to organs
• Diaphoresis is very common in patients who have
heart failure because of the stimulation of the SNS
Respiratory – DOE, SOB, tachypnea, orthopnea, dry

cough, crackles in lung base
• Semi-fowlers or high fowlers to facilitate breathing
• Due to the pressure in the pulmonary vasculature, it
will result to impaired gas exchange
• Patients sometimes cough up pink, frothy blood in
sputum because of the presence alveolar edema
wherein the alveoli lining cells are disrupted and fluid-
contained RBC moves into the alveoli
Gastrointestinal – anorexia, nausea, abdominal

distention, liver enlargement, RUQ pain
• Because of the pressure going back to the venous
system
Musculoskeletal – fatigue and weakness

• Lack of oxygen that supplies the muscle
Clinical Manifestations per System
Cardiovascular – activity intolerance, tachycardia, Metabolic Processes – peripheral edema and weight
palpitations, S3 and S4 heart sounds, elevated CVP, gain
neck vein distention, hepatojugular reflux, • Weight changes due to fluid retention
splenomegaly
• Activity intolerance because of reduced cardiac Diagnostic Studies
output, impaired circulation, and decreased oxygen 1. ECG
delivery to the tissue  Determine the cause of left ventricular failure
• Tachycardia, the first compensatory mechanism due 2. CXR
to diminished cardiac output and increased  Shows enlarge cardiac silhouette, pulmonary
stimulation of SNS congestion
• S3 and S4 heart sounds during auscultation 3. 2-D Echo
• Elevated CVP and neck vein distention is because of  Provide cardiac chamber size and ventricular
pressure returning back from the pulmonary function (EF − >55%) and is used to differentiate
vasculature to the right ventricle and atrium if it is systolic or diastolic heart failure
4. ABG – respiratory alkalosis or acidosis
Neurologic – confusion, impaired memory, anxiety,  Occur in patients with pulmonary edema due to
restlessness, insomnia hyperventilation resulting to respiratory alkalosis
• There will be a problem in the cerebral circulation  Hypoventilation results to acidosis
secondary to decreased cardiac output 5. Laboratories – electrolytes, blood chemistry urine
• Lack of oxygen and nutrients that is being supplied to studies
the brain Electrolytes – assess for presence of sodium,
• Impaired memory may be a result of poor gas potassium, and chloride
exchange and worsening of renal failure − Usually, patients may have hyponatremia due to
water retention or urinary sodium loss in
Genitourinary – decreased urine output, nocturia response to diuretic
• Due to impaired renal perfusion − Hypokalemia may result in excessive use of
• When the person lies down at night, fluid moves from diuretics or secondary to manifestation of
interstitial space back into the circulatory system aldosteronism
increasing renal blood flow and diuresis Blood chemistry – creatinine, BUN
− May increase because of decreased glomeruli
filtration

− Also include the liver function value; if the liver is  Reduce preload and afterload, and increase the
affected, it somehow increases the liver myocardial oxygen supply
enzymes 2. Nitroprusside (Nitrate)
Urine studies  Potent vasodilator that may reduce preload and
− Expect a decrease in urine output afterload
− Diuretics are given to increase the urine output  Improves myocardial contractility and increase
and decrease the pulmonary congestion cardiac output reducing pulmonary congestion
4. Nuclear imaging studies  IV nitride complication includes hypotension and
 Determine the motion and areas of myocardial thiocyanate toxicity
perfusion  In hypotension, it regards the use of dopamine to
maintain a mean arterial or blood pressure of
Management greater than 60 mm Hg
3. Morphine
1. Oxygen therapy
 Dilates pulmonary and systemic blood vessels to
2. Intubation
improve gas exchange
 In patients with severe heart failure, especially
 Also reduce preload and afterload Patients may
severe pulmonary edema to assist ventilation
experience restlessness
3. Positioning
 High Fowler’s in order to decrease venous return
 Helps in the reduction of anxiety
as well as increase thoracic capacity allowing for Recommended by Expert:
an improved ventilation
4. Diuretics
4. Monitor I and O, weigh daily
 Help control symptoms
 There may be changes in weight due to water
 Removes excess extracellular fluid by increasing
retention
the rate of urine production in patient with fluid
5. Fluid restrictions
overload; it mobilizes the edematous fluid
 Less than a liter per day to decrease the
 Reduce pulmonary venous pressure and reduce
accumulation of fluid
preloading
 Prevent more fluid that may hamper the
 Most commonly given is the loop diuretics such
functions of the heart
as furosemide, acting on the ascending loop of
6. Decrease Na in diet
Henle to promote sodium chloride and water
 To prevent water retention
excretion
7. Rest
Furosemide
 Patient easily get fatigued because of decreased
− More predictable in its response
cardiac output
− Side effects of furosemide are reduced serum
8. Auscultate heart and lung sounds
potassium level
9. Hemodynamic monitoring (PCWP)
Thiazide
10. Surgery – heart Transplant; cardiomyoplasty
 For cardiomyopathy or severe heart failure − Usually used and is the first choice for patients
11. Drug therapy with chronic heart failure
− To treat edema secondary to heart failure
o Intra-aortic balloon pump, it may somehow assist the − Controls hypertension
failing heart by decreasing afterload and increasing − Inhibits sodium reabsorption in the distal
coronary artery perfusion tubules at the same time promoting excretion of
sodium and water
− One example is hydrodiuril, an oral medication
Spironolactone (Aldactone)
– Potassium-sparing diuretic
5. Digoxin
 Helps control symptoms
 Increase the force and strength of cardiac
contraction
 It has an inotropic action, so it decreases the
conduction speed within the myocardium and
slows the heart rate
Pharmacologic Intervention
 Check HR before administering, do not give if
1. Nitroglycerin (NTG)
heart rate is lower than 60 bpm
 Vasodilator that may improve coronary artery
circulation

 Allows complete emptying of the ventricle during

diastole Theories:
 May increase cardiac output and stroke volume Neural − Contributing factor to hypertension because of
from the improved contractility excessive neurohumoral stimulation that increases
6. ACE Inhibitors muscle tone
 Can slow disease progression SNS activation − Increased central nervous activity
 Treatment for all stages of heart failure could raise BP by release of catecholamine that cause
 Useful for both systolic and diastolic heart failure arterial constriction
 First line therapy in the treatment of heart failure Renin-angiotensin-aldosterone system − Increase
because it promotes vasodilation and increases plasma renin that leads to conversion of angiotensin 1
urine output by decreasing preload and afterload to 2 & vasoconstriction will stimulate aldosterone that
 Captopril, enalapril leads to retention of salt and water
7. Beta-adrenergic Agonist
Vasodepressor −  vasoconstriction (prostaglandin and
 Can slow disease progression
kinins)
 Increase myocardial contractility and increase
the blood flow to the renal, mesentery, coronary,
and cerebrovascular bed Secondary
 Highly effective in patients with heart failure • Elevated BP is related to underlying condition such as
because it increases the cardiac output and kidney disease
promotes diuresis • Has a known cause like chronic renal disease that
 Dopamine, epinephrine may result to hypertension
Secondary Hypertension Causes

Hypertension
1. Chronic kidney disease
• Abnormal elevation of the systolic arterial BP with age
2. Disorders of the adrenal gland (pheochromocytoma
related differences
or Cushing syndrome)
• It could be intermittent or sustained elevations of
3. Pregnancy (preeclampsia or toxemia)
systolic or diastolic BP
4. Medications such as birth control pills, diet pills,
• Major cause of cerebrovascular accident (CVA), in
some cold medications, and migraine medications
layman’s term stroke or cardiac diseases and renal
5. Narrowed artery that supplies blood to the kidney
failure
(renal artery stenosis)
Labile hypertension – a phenomenon when BP can be
markedly elevated at one time and normal at another
6. Hyperparathyroidism
Isolated systolic hypertension –  in systolic pressure
Pathophysiology
without diastolic elevation
• Increase peripheral resistance that mainly attribute to
 Occurs in elderly person, in the presence of
structural narrowing of small arteries
hyperdynamic circulation, or aortic insufficiency
• Associated with a decreased peripheral venous
compliance which may increase the venous return,
Causes of Hypertension
cardiac preload, and cause diastolic dysfunction
Nonmodifiable Factors
1. Genetics, family history JNC (Joint National Committee) 7 Parameters
2. Age
• Prevention, detection, evaluation, and treatment of
3. Race
high BP is one of the foremost regional regulatory
Modifiable Factors bodies on the management of hypertension
1. Inactivity
Classification of Blood Pressure (BP)
2. Stress
Category SBP mmHg DBP mmHg
3. Obesity
4. Alcohol and tobacco use Normal <120 and <80
5. High sodium diet Prehypertension 120-139 or 80-89

6. Menopausal medications Hypertension, Stage 1 140-159 or 90-99
7. Low K, Ca, Mg Hypertension, Stage 2 ≥160 or ≥100
Key: SBP = Systolic Blood Pressure
Types of Hypertension DBP = Diastolic Blood Pressure
Primary (essential or idiopathic)

• Common form
• No specific cause, usually asymptomatic

AHA (American Heart Association) 2018  Nicotine stimulates the release of catecholamine
• Guideline for normal BP values in adults release (epinephrine and norepinephrine)
Systolic BP Diastolic BP causing vasoconstriction and increased heart
BP Classification
(mm Hg) (mm Hg) rate, and diminish the available oxygen by
Normal 120 – 129 80 – 84 increasing the level of carbon monoxide
Elevated 130 – 139 85 – 89  Increase the heart rate, stroke volume, cardiac
Stage 1 HTN 140 – 159 90 – 99 output, and BP
Stage 2 HTN 160 – 179 100 – 109  Carbon monoxide directly damage the inner
lining of the blood vessels
Stage 3 ≥180 > 110
 Peripheral vasoconstriction may increase
Isolated ≥ 140 < 90
ischemic changes that occur and decrease blood
flow
Clinical Manifestations 3. Reduce stress factor
1. Headache in occipital area  Use strategies like meditation, relaxation
2. Light-headedness
3. Tinnitus – buzzling in the ears Lifestyle Modification Recommendations
4. Early morning vertigo
Avg. SBP
5. Flushed face Modification Recommendation
Reduction Range
6. Epistaxis
Maintain normal body
 Not everyone who have hypertension result to Weight reduction weight (body mass 5-20 mmHg /10kg
epistaxis index 18.5-24.9 kg/m^2)
 If there is too much pressure in patients with
Adopt a diet rich in
stage 2 and 3 HTN fruits, vegetables, and
 Response of the body because of too much DASH eating plan low-fat dairy products 8-14 mmHg
with reduced content of
pressure in the capillaries in the nasal area saturated and total fat
7. Altered vision or fainting
Reduce dietary sodium
8. Nausea and vomiting Dietary sodium intake to ≤100 mmol per
9. Oliguria 2-8 mmHg
reduction day (2.4g sodium or 6g
sodium chloride)
Diagnostic Studies Regular aerobic

physical activity (e.g.
Aerobic physical
1. Blood Test activity
brisk walking) at least 4-9 mmHg
30 minutes per day,
 BUN, creatinine most days of the week
 In regards to endocrine, assess for the thyroid
stimulating hormone because hyperthyroidism Men: limit to ≤2 drinks
Moderation of per day
may result to HTN alcohol Women and lighter 2-4 mmHg
 Check for electrolyte levels (K, Na, Calcium) consumption weight per sons: limit to
≤1 drink per day
 Cholesterol and FBS is associated with the
development of HTN
2. Urinalysis – proteinuria Drug Therapy
 To check for any complications or damage in the Do not abruptly stop anti-hypertensive agent because it
kidney can cause rebound HTN. If there’s a rebound HTN, it is
3. Chest X-ray difficult to control. Goal is to decrease peripheral
4. ECG resistance, blood volume, and strength and rate of
contraction
Management 1. Thiazides
Lifestyle Modifications  Promotes excretion of Na, Cl, and water
1. Diet and exercise  Side effect: may cause photosensitivity so ask
 Engage in regular exercise (10 minutes/3x a the patient to apply sunscreen and avoid too
day) much sun exposure
 Sodium restricted diet  Another SE is hypokalemia, replacement of
 DASH diet (dietary approach to stop HTN), it potassium by eating banana to help prevent this
should be low sodium, high potassium, and high side effect
calcium 2. Aldosterone blocking diuretics (Aldactone)
 Ketchup has a high sodium content  Inhibits reabsorption of Na, Cl, while retaining K
2. Limit alcohol and tobacco use in the distal loop of Henle
 Potassium-sparing diuretics

3. Furosemide (Lasix) Eyes

 Inhibits reabsorption of Na, Cl in ascending loop • Due to decrease blood flow, it may increase the
of Henle. pressure in the arterioles in the eyes causing retinal
 More predictable response vascular sclerosis and visceral disturbances such as
4. Calcium Channel Blockers blurred visions and presence of spot
 Anti-diuretic effect wherein it may decrease BP, • If not corrected may result to blindness
relax vascular smooth muscle, and cause
vasodilation Peripheral System
 Decrease peripheral vascular resistance • Because the blood flow pressure in the arterioles is
5. Adrenergic Blocking Agents
affected, it may cause claudication of the blood
 Blocks sympathetic activity at beta or alpha
vessels resulting to gangrene
receptor sites
• Patients may experience pain upon walking
6. Angiotensin-Converting Enzyme (ACE)
 Suppress the renin-angiotensin mechanism
Kidney
 Reduce arterial and venous pressure
 Lowers BP by reducing the vascular resistance • If there’s a decrease in the perfusion of blood flow to
 Common side effect is dry cough because of the kidney, it may cause the stimulation of renin that’s
elevations of the bradykinin level leads to conversion of angiotensin 1 to 2 which may
7. Anti-Hypertensive Drugs increase BP
 Nifedipine, metoprolol, atenolol • Patient may experience polyuria and proteinuria
• There will be a Na & water absorption increasing the
blood volume
Effects of Hypertension to Organ Systems
• It affects blood flow and reduce oxygen supply
Blood Pressure >140/90 mm Hg Damages Target
causing the damage of parenchymal and filtrating
Organs
capability of the kidney resulting to azotemia
• Azotemia means that there is an elevation in the
amount of urea and nitrogen in blood
• It also affects the renal arterioles resulting to
nephrosclerosis and eventually lead to renal failure if
not treated or corrected
Complications of HTN
Hypertension Crisis – severely and abrupt elevated BP
of >180 mm Hg
Hypertensive urgency – BP is elevated but there is no
evidence of impending or progressive target organ
damage
Heart Hypertensive emergency – direct damage to one or
more organs are as result of ↑ BP
• Heart failure, left ventricular hypertrophy
• Increase workload that may result to myocardial  Non-compliance to medications
hypertrophy  Can be asymptomatic
• If there is a myocardial hypertrophy, the patient may Aortic Aneurysm – peripheral vascular diseases
experience angina, HF, ventricular hypertrophy that 5 C’s – CAD, Cerebrovascular Disease, Chronic Renal
eventually will result to ischemia Disease, CHF, and Cardiac Arrest
Coronary Artery Disease

Brain C Can lead to narrowing of blood vessels making them more likely to
block from blood clots.
• Because of peripheral vasoconstriction, it may Chronic Renal Failure
decrease blood flow to the brain, oxygen supply, and C Constant high blood pressure can damage small blood vessels in the
kidneys making it not to function properly.
weaken the blood vessel wall Congestive Heart Failure
• Patients may have transient ischemic attack (TIA), C Pumping blood against the higher pressure in the vessels causes the
heart muscles to thicken.
thrombosis, aneurysm, and hemorrhage which may Cardiac Arrest
High blood pressure can cause CAD, damaged arteries cannot deliver
alter the mobility, memory, and speech of the patient C enough oxygen to other parts of the body eventually leading to heart
and may also result to paralysis attack.
Cerebrovascular Accident
Hypertension leads to atherosclerosis and hardening of the large
C arteries. This, in turn, can lead to blockage of small blood vessels in
the brain.

The excessive pressure on the artery walls caused by hypertension or

high blood pressure can damage the blood vessels, as well as organs
in the body. The higher the blood pressure and the longer it goes
uncontrolled, the greater the damage. With time, hypertension
increases the risk of heart disease, kidney disease, and stroke.
Valvular Disorder (Inflammatory and Valvular Heart

Diseases)
Aortic Aneurysm
• Outpouching or dilations of the arterial wall and
involving the aorta
Basic Classification
• There is an outpouching or a sac form by the dilations
of an artery as a result of localized weakness and True Aneurysm
stretching of the arterial wall • Involves 3 layers of the wall of the artery (intima,
• Common cause is unknown but the accepted theory media, adventitia)
is because of atherosclerosis • Includes the atherosclerotic, syphilitic, as well as the
• Because of atherosclerotic plaque deposit beneath congenital and ventricular aneurysm which follow
the intima, the inner layer of the arterial wall, it is transmural myocardial infarction
thought to cause degenerative changes in the medial • Wall of artery forms the aneurysm and subdivided into
leading to the loss of elasticity, weakening, and fusiform and saccular
dilations of the aorta
False Aneurysm or Pseudoaneurysm
Types of Aneurysms • Complete tear of all three arterial coats resulting to
Thoracic Aneurysm bleeding that fills the surrounding tissues producing a
• Abnormal bulging of the portion of the aorta that pulsatile hematoma
passes through the chest • Collection of blood that leaks completely out of an
• The most common cause is atherosclerosis or artery or vein that confine next to the vessel by the
hardening of the arteries surrounding tissue
• Common in male ages 40-70 y/o • False aneurysm is caused by an infection and trauma
that punctured the artery such as knife or bullet wound
Abdominal Aneurysm as a result of percutaneous surgical procedure
• Also called as AAA (abdominal aortic aneurysm)
• Very common
• Prevalent in elderlies wherein there is an enlarged
area in the lower part of the aorta
Categories of True Aneurysm
Peripheral Aneurysm
• Located in the popliteal, femoral, or carotid Saccular
• Occur in the legs behind the knee and along the groin • Outpouching on one side of an artery
• Looks like a berry
Aortic Aneurysm • Occur in the arteries of the blood vessels
• Occurs in the major artery from the heart because of • Frequently arise from the ascending and descending
the constant stress on the vessel wall and absence of thoracic aorta
penetrating vasa vasorum in the medial layer

Fusiform Etiology of Aortic Aneurysm

• Produce a circumferential arterial dilation 1. Unknown
• Balloon on all side 2. Atherosclerosis
• Fills with necrotic debris and thrombus  Plaque formation that causes degenerative
• The calcium may infiltrate the area, the sac may dilate changes in the middle layer of the arterial wall
because of the weakened medial layer 3. Genetic predisposition
4. Congenital
Dissecting 5. Mechanical, traumatic, infection – least common
• The tearing and degeneration of the medial layer
allows the blood to separate the arterial intimal layer Clinical Manifestations
from the adventitial layer 1. Chest pain – common
• Cause is unknown, but exposure to certain disorder  Thoracic aneurysm since it is located in the
like HTN is susceptible for aortic dissection causing ascending aorta & aortic arch that sometimes
degeneration and necrosis produce hoarseness in patients due to the
• Pregnancy because of the hormonal changes pressure on the laryngeal nerve
together with an increase blood volume and HTN that  Patient may also experience substernal chest
may discrete the integrity of the media which can lead pain that may radiate to neck, lower back,
to generation shoulder, and abdomen
• Traumatic dissection due to direct injury during  It is important to take patient history
special procedure or even arteriography 2. Dysphagia – compression of the esophagus
 Common in thoracic aneurysm
Classification of Aneurysm 3. Pulsatile mass in the periumbilical area slightly to the
True Aneurysm, Saccular type − the wall focally bulges left of the midline during PE
outward and may be attenuated but is otherwise intact  Common in AAA
 Perform assessment in the periumbilical area,
True Aneurysm, Fusiform type − there is circumferential slightly to the left of the midline and do not do
dilation of the vessel, without rupture deep palpation if pulsatile mass is suspected
4. Bruits audible with a stethoscope
False Aneurysm − the wall is ruptured, and there is a 5. Abdominal or back pain
collection of blood (hematoma) that is bounded  Results from compression of nearby anatomic
externally by adherent extravascular tissues structures
 Common in AAA and it sometimes mimic the
Dissection − blood has entered (dissected) the wall of pain of the patient
the vessel and separated the layers. Although this is  Patient may experience a blue toe syndrome
shown as occurring through a tear in the lumen, wherein there is a mottling of the feet and toes in
dissections can also occur by rupture of the vessels of the presence of palpable pedal pulses and is
the vaso vasorum within the media common in patients with AAA
Diagnostic Studies
1. CXR
 Determine mediastinal silhouette and abnormal
widening of the aorta
2. ECG – to r/o evidence of MI
3. Echocardiography
 Assist diagnosis of aortic insufficiency related to
ascending aortic dilation
4. Ultrasound
Risk Factors  Screen for any aneurysm and monitor the size of
1. Age (65 y/o above) non-surgical candidate
2. High BP 5. CT scan
3. Smoking – AAA  Most accurate test to determine the anterior to
4. Atherosclerosis – aortic aneurysm posterior length and cross-sectional diameter of
5. Hypercholesterolemia the aneurysm
6. Peripheral vascular disease  Also identify the presence of thrombus in the
aneurysm

6. Angiography flow that help prevent infection from settling on the

Mapping of the aortic system by contrast image endocardial structure. But there are times that a
 If it is using a contrast agent, check for the virulent microorganism can cause endocarditis on the
creatinine and BUN level of the patient normal cardiac valve
• Generally, infective endocarditis occurs when the
Management bacteria from another body part (mouth) spreads
through the bloodstream and attaches itself to the
1. Risk factor modification
damaged area of the heart
 Diet – sodium restriction
• It primarily affects the mitral (Left) and tricuspid valves
 Use of anti-hypertensive drugs
(Right)
 Monitor the size of aneurysm every 6 months
2. Hemodynamic monitoring Left sided endocarditis is more common in patients
3. Pain management – morphine sulfate who have bacterial infection and underlying heart
4. Surgery disease
Open-Suturing Right sided endocarditis is more common in patients
− Repairs the artery by closure or application of a who takes IV drugs, and those people who abuse IV
synthetic patch graft over the arterial defect drugs, especially cocaine abuse
Endovascular Aortic Repair (EVAR)
− By gaining access to the lumen of the abdominal
aorta through a small incision over the femoral
vessels wherein a stent is placed within the
lumen of the AAA
Common Complications
1. Rupture
2. Shock
3. Blood clot
Elements of Infective Endocarditis
1. Endocardial damage such as trauma, prosthetic
valve (which are the common risk) therefore
turbulence blood flow caused by these abnormalities
affects the atrial surface of the AV valve or the
semilunar valve
 The endocardial damage attracts platelets and
stimulate thrombus formation
2. Adherence of blood-born microorganisms which may
damage the endocardial surface
3. Formations of infective endocardial vegetation
Predisposing Factors
1. Aging
 Older people have more degenerative heart
disease and undergo invasive testing
o Aortic dissection usually occurs in thoracic aorta 2. Intravenous drug abuse or Illegal drug abuse
as a result of tear in the intimal lining of the 3. Structural heart or valves defect
arterial wall that allows blood to enter between  Increase number of platelet and fibrins in the
the intima and medial which may create a false
endothelium, especially those who have
lumen
congenital defect
4. Catheter or needle use
Infective Endocarditis  Tattooing, body piercing, contaminated needles
• Previously termed as “Bacterial Endocarditis” and syringe
• An infection of the inner layer (endocardium) of the
heart which may affect the cardiac valves – mitral and Etiology
tricuspid valves
• Presence of microorganism in the body;
• Normally, a normal heart is resistant to infection
Streptococcus and Staphylococcus. Most common
because the bacteria do not adhere easily in the
endocardial surface because of the constant blood

organism is Streptococcus viridians or pyogenes, or  It’s a manifestation of infective endocarditis

aureus 4. Petechiae
• Congenital heart defect  Common as a result of fragmentation and
• Predisposing abnormalities of the endocardium, microembolization of vegetative lesions
valvular defect, and prosthetic heart valve are  Common in conjunctiva, lips, buccal area/
particular risks mucosa, palate, and over the ankle, feet and
• Microorganism in the bloodstream that may originate antecubital area
from a distant infected site such as patients who have 5. Osler’s nodes
infected gums or UTI  Painful, tender, red, pea-size lesion found in the
• Even a portal of entry such as a central venous fingertips or toes
catheter, or a drug injection site 6. Janeway’s lesion
• Therefore, it is important to maintain aseptic  Flat, painless, small red spots found on the
technique when administering intravenous push or palms and soles
any administration of medication intravenously to
reduce or minimize the chance of the virulence
microorganism to travel to the heart valves
• Even brushing of the teeth and chewing can cause
bacteremia (presence of bacteria in the bloodstream)
in patients with gingivitis
• Most common organism is the Streptococcus viridians
or pyogenes, or aureus
7. Roth’s spot
Pathophysiology  Hemorrhagic retinal lesion through funduscopic
• Vegetation is the primary lesions that consist of fibrin, examination
leukocyte, platelet, and microbes that may stick to the 8. Murmur
valve surface or the endocardium  Noted in 80% of cases with aortic and mitral
• after colonizing this vegetation, the microorganism is valve that is affected
covered by a layer of fibrin and platelets which  Since the cardiac valve is affected, expect the
prevents the access of neutrophils, immunoglobulin presence of murmurs
and complements thus block the host’s defense 9. Splenomegaly
• Right side vegetation: it embolizes the lungs  Because of the embolization of the spleen that
• Left side vegetation: it embolizes the liver, kidney may result to sharp left upper quadrant pain
brain, lymph, and spleen 10. Embolization to the brain
• Because of the valvular incompetence, eventually  40% of patients may have this neurologic
invasions of the myocardium tissues will occur that disease which causes neurologic problems such
causes a local damage of the heart valves that leads as hemiplegia, ataxia, aphasia, even a change in
to CHF, sepsis, and myocardial dysfunction the level of consciousness (intracranial
hemorrhage, multiple micro abscess)
Diagnostic Studies
1. Blood culture – primary tool
2. Leukocytosis – around 11,000 u/L
3. Erythrocyte sedimentation rate (ESR) − > 30
mm/hour
 Elevated due to the presence of an infection
4. Echocardiography
 Evaluate diagnosis because it affects the cardiac
valve
5. CXR
 Determine the presence of an enlarge heart
Clinical Manifestations 6. ECG
1. Fever and chills – 90%  Shows 1st or 2nd-Degree block
2. Fatigue and weakness, body malaise, anorexia 7. C-Reactive Protein (CRP)
3. Splinter hemorrhage  May detect the presence of infection and
 Black longitudinal streaks that occur in the nail inflammation
bed of the vascular

Management • As the heart enlarges, the valve annulus is being

1. Antibiotic includes prophylaxis stretched and the valve no longer need to allow full
 Prophylaxis is recommended for patients with closure
specific cardiac conditions prior to dental or • Excess blood volume behind can cause dilations of
surgical procedures the chamber
Ceftriaxone (Rocephin) – streptococcus
Vancomycin (Vanocin) – staphylococcus Pathophysiology of Cardiac Valve Disorders
2. Antipyretic Mitral Stenosis
 90% of patients with infective endocarditis may • Narrowing of the cardiac valve
experience fever and chills • Reduce in the flow of blood into ventricle, resulting in
3. Provide rest a decrease in cardiac output.
4. Anti-embolic stocking • Because of this pressure in the left ventricle, it may
 Prevents thrombus formation affect the left atrium because of the pressure and
 Make sure to give appropriate size and is applied dilations of the increase of blood volume in the left
early in the morning before the patient gets out atrium that may cause atrial hypertrophy.
of bed • The increased pressure may be a domino effect that
5. Restrict normal activity 4-6 weeks could also cause the blood to back up into the
6. Surgery pulmonary vein that may result to pulmonary
 Repair or replacement for severe valvular hypertension.
damage • It may sometimes cause strain in the right ventricle
Major Types of Valvular Heart Disease Mitral Regurgitation

Stenosis • The valve is incompetent, it is unable to fully close
• Heart valve leaflets fused together, opening narrow, during ventricular contraction,
stiff, unable to open or close properly • The tendency is that it may cause the blood to back
• There is a constriction or narrowing of the valves up to the left atrium that may cause increase in the
wherein it cannot fully open or close pressure, dilatation and hypertrophy
• Opening is too narrow like a funnel and it becomes • This will affect the pulmonary system; the blood may
rigid because of: flow back into the pulmonary vein that may cause
 Scarring of the valves from endocarditis or pulmonary congestion
infarction • If there’s an increase in pulmonary vasculature, it may
 Calcium deposits also affect the right ventricle because the right
• May impede the forward flow of blood to the next ventricle has to work harder increasing its workload
chamber decreasing the cardiac output due to the lack that may eventually lead to failure
of ejection and impairment in ventricular filling
• Increase the work of the chamber behind the affected
valve as the heart attempts to move blood trough the
narrowing opening
Regurgitation
• Improper or incomplete closure of heart valves,
resulting in back flow of blood
• Sometimes referred to as “insufficient or incompetent
valve”
• Valve is too loose therefore, it cannot close
completely
• If there is a contraction, there is a back flow of blood
through the valve back into the area where it just left
• Causes:
Mitral Stenosis
 Deformity or erosion of valve cusps caused by
• Thickening and shortening between the commissures
vegetative lesions of the bacterial or infective
(junctional areas) of the leaflets that obstruct the flow
endocarditis
of blood from the left atrium into the left ventricle.
 Scarring or tearing from the myocardial infarction
• Problem in the inflow of left ventricles due to structural
even those patients with cardiac dilation
abnormalities of the mitral valve and most common in

patients with Rheumatic endocarditis that cause the  This is the primary symptoms of mitral stenosis
valve and chordae tendineae to thicken, so the because of the reduce lung compliance due to
leaflets will fuse together and eventually the mitral the increase in pressure that may cause the
valve orifice becomes narrow, that obstructs the blood transudation of fluid in lung interstitium
flow into the ventricle 2. Palpitations – from atrial fibrillation
 Common finding
Cause  Prone to accumulation of blood clots
3. Chest pain − ↓ CO
1. Rheumatic endocarditis
4. Seizures
 Main microorganism involved is Group A Beta-
 From embolus because of the stagnation of
hemolytic Streptococcus that may cause
blood in the left atrium
scarring of the valve leaflet and the chordae
5. Hepatomegaly
tendineae.
6. Peripheral edema
 So, the contracture develops with the adhesion
between the commissures of the two leaflets, it
 Back up of pressure not only to the left atrium but
also affects the right ventricle
may look like a funnel-shape, thickening and
 The pressure is a domino effect that affects the
shortening of the structure
pulmonary vasculature in the right ventricle to
the right atrium to the venous system
7. Crackles
8. Cyanosis
 Impaired gas exchange because of the
pulmonary congestion and hypertension
Management
1. Sodium restriction
2. Oral diuretics
 To relieve pulmonary congestion
3. Avoid strenuous exercise / activities
 This could increase the heart rate of the patient
4. Digitalis and anti-arrhythmic drugs – AF
 Digitalis is to prevent atrial fibrillation by slowing
the ventricular heart rate by administering
intravenously
5. Antibiotic
 The American Heart Association Guidelines do
not recommend infective endocarditis
Pathophysiology
prophylaxis to most patients with rheumatic heart
disease, but some physicians still prescribe
prophylactic antibiotic before dental or any
surgical procedure.
 However, the maintenance of optimal health
remains as an important component for an
overall healthcare program
6. Anticoagulant
 Prevent or treat emboli since the patient is
susceptible to atrial fibrillation
7. Beta blockers or Calcium Channel Blockers
 To control the long-term use of oral beta blockers
and may decrease the heart rate and increase
the tolerance of the patient to exercise
8. Percutaneous Transluminal Balloon Valvuloplasty
 To split open the fused, narrowed mitral valve
 Contraindicated to patients with left atrial or
Clinical Manifestations ventricular thrombus
1. Dyspnea sometimes accompanied by hemoptysis

 Beneficial to patients with mitral stenosis with no 2. Cool, clammy extremities

other problems or conditions like thrombus  Because of the stimulations or increase in the
formation or regurgitation SNS
9. Surgery: Mitral Commissurotomy 3. Dyspnea
 Sometimes referred to as valvulotomy. 4. Palpitations
 It is making a 1 or 2 incisions at the edge of the  Typically, the first symptom
commissure from between the 2 or 3 valves in 5. Fatigue
order to relieve constriction especially in mitral 6. Cough from pulmonary congestion
valve stenosis 7. Shortness of breath on exertion
 Because of the pulmonary congestion,
Mitral Regurgitation hypertension, edema in the pulmonary
vasculature
• Because of the shortened deformity of the chordae
tendineae or even the papillary muscles cause the Diagnostic Studies
backflow of blood from the left ventricle into the left
1. ECG
atrium during contraction or systole
2. 2D Echo
Etiology
Management
Inflammatory and infective − Rheumatic heart disease
1. Restrict physical activities
and endocarditis
 Bed rest
Degenerative changes or calcification of the mitral  Avoid strenuous exercise
annulus − occur in patients who have mitral valve 2. Reducing sodium intake
prolapse (MVP)
Drug therapy is to benefit the reduce afterload:
Process or structural cause that dilates the papillary 3. Diuretics
muscles or the chordae tendineae − left ventricular 4. Nitrates
hypertrophy and myocardial infarction 5. Digitalis
6. ACE inhibitors – captopril, enalapril
Congenital defects − a structural cause that may affect 7. Angiotensin receptor blockers (ARBs) – losartan,
the incompetence of the mitral valve valsartan
8. Surgery may also be done (mitral valve surgery)
Collagen vascular disease – systemic lupus Valvuloplasty Procedures
erythematosus (SLE) or patients with cardiomyopathy
− Annuloplasty is the repair of the valve annulus
that is the junction between the valve leaflet and
Pathophysiology the muscular heart wall
− This procedure is done to tighten or reinforce the
ring (annulus) around a valve in the heart
Chordoplasty
− Repair of the chordae tendineae
− The mitral valve is involved with chordoplasty
Mitral Valve Prolapse (MVP)

Clinical Manifestations • Structural abnormalities of the mitral valve leaflets,
• It is usually asymptomatic, but if the cardiac output papillary muscles, and chordae tendineae
diminishes or decreases, symptoms with develop • One or both mitral valve cusps buckle back into the
1. Systolic murmur left atrium during ventricular systole
 First heart sound, usually soft with lateral
displaced apex beat

• This is the displacement of the thickened mitral valve 2. Aspirin

leaflet that may cause the buckle up of the leaflets into  Prevent blood clots
the left atrium during ventricular systole 3. Change in lifestyle
 Avoid consumption of caffeine, alcohol and
smoking
4. Surgery
 Valve replacement depending of the degree and
severity of the condition
Health Teaching
1. Educate the patient of the diagnosis and the
possibility that the condition is hereditary on the first-
degree relatives so they may be advised to have an
Etiology
echocardiogram
1. Unknown 2. Practice of good oral hygiene
2. Familial incidence
3. Avoid body piercing, toothpick or sharp objects in the
3. Excess collagen tissue in the valve leaflets
oral cavity
4. Elongated chordae tendineae
4. Read labels on OTC medication like cough medicine
5. Infective endocarditis that may contain alcohol and caffeine which may
produce arrythmia
Pathophysiology of MVP
Aortic Stenosis
• Narrowing of the orifice (aortic valve opening) that
obstructs the flow of blood from the left ventricle and
the aorta during systole
• There is a left ventricular hypertrophy and increase
myocardial oxygen consumption because of the
increase myocardial mass
• It is often degenerative calcification caused by
proliferative or inflammatory changes that occur in
1. Murmur response to normal mechanical stress
 Very common wherein a mid-systolic beat is • This is similar to the changes that occur in the
heard followed by late systolic murmurs that is atherosclerotic arterial disease
best heard at the apex • Diabetes, hypercholesterolemia, hypertension and
 Usually accentuated by standing or by valsalval smoking are some of the risk factors of the
maneuver that may decrease the venous return degenerative calcification changes in the valve
to the heart that may lead to a decrease in left
ventricular diastolic filling or may decrease the
preloading Etiology
2. Palpitations 1. Congenital leaflet malformation
3. Light-headedness 2. Inflammatory changes rheumatic endocarditis
4. Dizziness  This may cause a stiffening of the valve from an
5. Chest pain inflammatory reaction
 May or not be present 3. Cusp calcification
 If present, it will not respond to nitrates but will
respond to calcium channel blockers or beta Pathophysiology
blockers
6. Activity intolerance
7. Syncope
8. Dyspnea
Management
1. Beta blockers
 Relieve any palpitations, chest pain, and
syncope

4. Rheumatic conditions (Rheumatic Endocarditis)
Pathophysiology
1. Angina pectoris
2. Syncope
3. Heart failure
4. Pulmonary edema
5. Narrow pulse pressure
6. Dyspnea on exertion
 May be experienced because of the increased
pulmonary venous pressure due to the left
ventricular failure
o Same with mitral stenosis, the only difference

is the location of the valve affected, still has Clinical Manifestations
the domino effect
1. Weakness
2. Severe dyspnea
Management 3. Hypotension
1. Bed rest 4. Palpitations
2. Antibiotic  Common
 If the cause is infection that causes the scarring  May have the possibility to have dysrhythmia
of the aortic valve 5. Corrigan’s pulse
3. Digitalis and diuretic  Very common
 If with ventricular failure but will not help aortic  Forceful and sudden collapse of pulse
stenosis because it does not reduce mechanical  This is due to the leaking aortic valve
obstruction to outflow  In assessing the carotid pulse
 Beta blocker is not used because it can depress
myocardial function and induce left ventricular o Normally, the aortic valve shuts tight and
completely to avoid backflow of blood into the
failure
ventricle, however if the aortic valve cannot
4. Percutaneous valvuloplasty close completely, the blood in the aorta will
 A procedure to open up the fused aortic valve flow back into the ventricle and the pressure
and pulse collapse (Water Hammer Pulse)
Aortic Regurgitation 6. Austin-flint murmur
• Flow of blood back into the left ventricle from the aorta  A low frequent diastolic ruble similar to mitral
during diastole stenosis
• Leaking of the aortic valve of the heart that causes  A low-pitched rumbling heart murmur which is
backflow of blood into the left ventricle from the aorta best heard at the cardiac apex
during diastole
• There is a reserve direction during ventricular diastole
Management
from the aorta to the left ventricle
1. Diet
• The ejection of blood is being regurgitated back into
 Low sodium intake in order to avoid volume
the heart
overload for asymptomatic patients
• 25% of these regurgitant blood flow may cause a
2. Activity
decrease in diastolic blood pressure in the aorta
 Avoid physical exertions and competitive sport
therefore increasing the pulse pressure
because of the reduced cardiac output
• During physical examination, it may reveal a bounding
3. Calcium channel blockers and ACE inhibitor
pulse especially in the radial pulse
4. Prosthetic or mechanical valve replacement
 Preferably performed before left ventricular
Etiology failure occurs
1. Inflammatory lesions that deform the leaflets of the
aortic valve or dilations of the aorta − endocarditis
2. Trauma
3. Congenital abnormality

Tissue Valve Replacement − If more than 3 sec. that it means that there is
Porcine Heterograft Valve (Carpenter Edwards) a diminish blood flow and return to normal
− Less likely to develop thromboemboli, a long-term color is delayed
therapy and anticoagulant is not required Edema
− Bioprosthetic wherein biological valves are made − Press the skin for about 5 seconds then
from animal tissue: porcine valves are made from release, if there is a presence of edematous
pigs, bovine valves from cows, and equine valves skin, a presence of an indention (pit), it is
from horses called a pitting edema
− The viability of these are ranging for about 7-15
years
− This is used for child-bearing women age to avoid
on the potential complications of long-term used of
anticoagulant
Autograft
− Obtaining the patient’s own pulmonic valve and a
portion of pulmonary artery for use as an aortic
valve
− Anticoagulant is not necessary because it is the Elevation pallor
patient’s own tissue, and is also not thrombogenic
− Reddish-blue discoloration of the extremities
that can be observed within 20 seconds to 2
Donor Valve Implantation minutes after the extremities is placed in
Homograft or allografts dependent position
− The use of a human valve that obtained from a − If it is rubor or redness, there is a damage in
cadaver tissue donation (used for aortic or pulmonic the peripheral arteries wherein the vessels
valve replacement) cannot constrict and remain dilated. Even
− Lasts for about 10-15 years with rubor, the extremities begin to turn pale
with elevation
− Cyanosis is when the amount of oxygenated
Mechanical Valve Replacement
hemoglobin contain in the blood is reduced
Bileaflet (St. Jude)
Clubbing
− Tilting disk or a ball and caged design to be more
− Because of the long-standing lack of oxygen
durable than tissue prosthetic valve
to the peripheral tissues
− Used for younger patients, patients who have
kidney injury, endocarditis Trendelenburg’s Test
− The significant complication of this is that it may
b. Palpation
cause thromboemboli and a long-term use of
anticoagulant is required Temperature
Caged ball valve (Starr-Edwards) − Check for both extremities, it should be
bilateral
− The upper extremities are compared with the
Peripheral Vascular Diseases
lower extremities, as well the right and left
Assessment sides
1. Health History Pulses
 Ask the patient if they experience intermittent
− Note the rhythm, amplitude, and symmetry of
claudication, it means that the patient may
pulses
experience decreased blood flow in the
− Palpate bilaterally except in carotid pulse, you
peripheries during exercise or activity and is
should not palpate the carotid pulse
being relieve by rest
simultaneously because it may stimulate
 Arterial system is unable to provide adequate
carotid sinus that may result to bradycardia
blood flow to the tissues which increase
Allen’s test
demands for nutrients and oxygen during
exercise − Assess the patency of the radial and ulnar
2. Physical examination arteries on the distal area of the wrists
a. Inspection − Usually done before taking ABG
Capillary refill - <3 seconds

Homan’s sign Collateralization

− Compress the gastrocnemius muscle of the • Wherein a peripheral gangrene develops slowly
calf for tenderness overtime if left untreated
c. Auscultation
Peripheral Arterial Occlusive Disorders
 Listen over each pulse to assess for the
presence of bruit sounds • Affect the arteries
• arterial insufficiency that mostly affects men and
caused by a disability that involves the lower
Diagnostic Evaluation extremities
1. Doppler, ultrasound, flow studies • The distal occlusion is frequently seen in patients with
 To detect the flow of blood in the peripheral history of diabetes and in elderly
vessels
2. Compute and combine the computations of the ankle
brachial index
 To assess for valve competency
3. Exercise Test
 To determine how long and far the patient can
walk then measure the ankle systolic BP in
response to walking
 This is an objective measurement of the severity
of intermittent claudication
4. Duplex ultrasonography
 To determine the extent and level of venous
disease and the chronicity of the disease
 It may localize the site of vascular disease and Signs and Symptoms
estimate the hemodynamic significance
1. Intermittent claudication − hallmark symptom
especially in patients who have deep vein
2. Cold or numb extremities
thrombosis
 Due to the reduce of arterial flow
5. Phlebography or venography
 Extremities ere cold and pale when elevated
 A radiopaque or a contrast agent is introduced in
3. Changes in the skin and nails
the venous system
 If left untreated, that sometimes may cause
 This is indicated or performed in patients who
gangrene and/or ulcerations
undergo thrombolytic therapy
4. Presence of muscle atrophy
 However, the duplex ultrasonography is the
5. Upon auscultation, bruit sounds may be heard
standard for diagnosing lower extremities for
6. During palpation, there is a diminish or absence of
endogenous thrombosis
peripheral pulse
 There should be an equal pulse between the
Peripheral Vascular Disease extremities
• Affect the arteries or veins  It is important to palpate bilaterally
• Commonly affects the elderly and diabetic patients
• There is a disturbance of blood flow through the Management
peripheral vessels as a result of damaged tissue of
1. Exercise therapy
the extremities and organ that may lead to ischemia
2. Never apply heat in patient who have arterial
and excessive accumulation of waste and fluid that
insufficiency
cause venous or lymphatic statis
3. Drug Therapy
Trental (Pentoxifylline)
Compensatory Mechanisms − Increases the erythrocytes flexibility, lowers the
Vasodilation blood fibrinogen concentration and has an
• Has a limited effect because there is a quick oxygen antiplatelet effect
deprivation which dilate the blood vessels in a full Cilostazol
state − Vasodilator that inhibits platelet aggregation
− Contraindicated to patients with history of
Cellular Anaerobic Metabolism congestive heart failure
• Waste product of lactic and pyruvic acid builds up *These drugs (esp. Pentoxifylline) are approved for
quickly and are extremely toxic and excreted slowly the treatment of symptomatic radiation

4. Surgery Pathophysiology
Endarterectomy
− An incision will be made in the artery to remove
the atheromatous obstruction
− They may do the bypass graft as performed to
reroute the blood flow around the stenosis or
occlusion
Thromboangitis Obliterans (Buerger’s Disease)

• This disease is a nonatherosclerotic segmental Clinical Manifestations
inflammatory disorder that affects small and medium- 1. Redness along the lines of the veins and arteries
sized arteries in the feet and hands 2. Spasm of the digital arteries that result to pallor
• A condition in which the small arteries and arterioles 3. Diminished sensation
constrict in response to various stimuli  Due to the lack of blood supply
• Affects only the small and medium-sized arteries, 4. Paresthesia – sensation of tickling, tingling, burning
veins and nerves of the upper and lower extremities or numbness (no apparent long-term physical effect)
• These blood vessels become inflamed, swell, and 5. Skin is shiny and thin
blocked with blood clots which will eventually damage 6. Nails are thickened and malformed
the skin tissue that may lead to infection and
gangrene
• Lipid accumulation is not the cause of this disease Clinical Diagnosis
unlike in the coronary arteries where the presence of 1. Intermittent Claudication – calf pain during activities
lipid accumulation is found in large and medium-sized 6 P’s
arteries ✓ Pallor
• It is believed that it is highly cellular inflammatory ✓ Pulses decreased
thrombus form inside the blood vessels that cause ✓ Perishing cold
tissue ischemia ✓ Pain
 It begins with the ischemia of the small arteries ✓ Paresthesia
that progress to the proximal arteries ✓ Paralysis
 Large arteries are not involved (if it is, it is very • There is no laboratory or diagnostic test specific for
rare) Buerger’s Disease
• It will only be based on the onset, history of the patient
Etiology (use of tobacco), clinical symptoms with the
1. Unknown cause but based on theories, it is strongly involvement of the distal vessels and the presence of
related to smoking ischemic ulceration
 It was observed that when a patient stops using
tobacco, the disease improves Management
2. Prevalent in younger men (25-40 y/o) 1. Smoking cessation
3. Familial history 2. Keep extremities warm
4. Autoimmune 3. Managing stress
4. Keeping affected extremities in a dependent position
5. Regular exercise
6. Wound care
7. Buerger’s Allen exercise
 To promote circulation and establish collateral
circulation
8. Pharmacologic therapy: calcium channel blockers
 To  the blood viscosity and  RBC flexibility to
improve peripheral blood flow to relief symptoms
• It affects the distal part of the extremities that may 9. Surgery
travel to the proximal part and become gangrenous Amputation
due to the obstructed blood vessel
− If there is a presence of gangrene
• Tobacco smoke stains on male patient's fingers
Sympathectomy
suggest diagnosis of thromboangiitis obliterans
(Buerger disease). Patient presented with small, − There is an interruption of the SNS input to the
painful ulcers on tips of thumb and ring finger affected vessels

− During postoperative period, it may cause a drop Theories of Raynaud’s Phenomenon

in BP with no evidence of bleeding, this is due to 1. Vasospasm because of the limit circulation that
the reallocation of blood supply occurs secondary to SNS stimulation
Arterial bypass graft 2. Abnormalities in the endothelium and endothelium-
derived vasoactive substance
Steps of Buerger Allen Exercise 3. Other contributing factors: occupation related trauma
and pressure on the fingertips (typist, pianist, those
1. Elevate feet on padded chair or board for ½ to 3
who handle vibrating equipment)
minutes
4. Exposing to heavy metals
2. Sit in relaxed position while each food is flexed and
extended then pronated and supinated for 3 minutes.
The feet should become entirely pink. If the feet are Precipitating Factors
blue or painful, elevate them and relax as necessary 1. Exposure to cold
3. Lie quietly for 5 minutes, keeping legs warm with 2. Emotional upset
blanket 3. Caffeine intake
4. Tobacco use
*Exposure to cold and emotional upset have the
strongest relations to this disease
1. Sensory changes – numbness, stiffness, decreased
sensation and aching pain
2. Thickened fingertips and nails become brittle
3. Pallor due to sudden vasoconstriction
4. Skin becomes bluish
 Due to pulling of deoxygenated blood during
vasospasm
5. Hyperemia
 Due to vasodilation (red color is produced)
6. Ulcerations and Gangrene – serious complication
Raynaud’s Phenomenon
Management
• A spasm of arteries causing blanching of fingers and
1. Loose, warm clothing
toes and mostly affects women 15-40 years of age
2. Avoid extreme temperature
• Also known as white-red disease because of the
3. Smoking cessation
decreased perfusion due to the arterial vasospasm
4. Avoid caffeine and drugs with vasoconstrictive
that result in pallor (white); then, when the digits
effects
appear to be cyanotic (bluish-purple) it will be followed
5. Stress reduction management
by a change in color into rubor caused by hyperemic
 In order to develop coping strategies for patients
response that occur when the perfusion is restored.
who suffers from anxiety (biofeedback,
Hence, it is called the white-red disease
relaxation training)
• Unknown cause
6. Immerse the hands in warm water
• Characteristic: Due to the vasospasm-induced, color
 To decrease vasospasm
changes in the fingers, toes, sometimes in ears and
7. Measures to avoid injury to the hands (avoid tape
nose
measures)
8. Vasodilators
Calcium Channel Blockers (nifedipine and diltiazem)
− To relax smooth muscles of the arterials by
blocking the influx of calcium into the cell and it
also reduce the number of vasospastic attacks
Alpha-blockers (Minipress)
− May counter after the norepinephrine
9. Surgery: Sympathectomy for advanced cases

INTEGUMENTARY DISORDERS

RESPIRATORY DISORDERS
Parts of the Respiratory System Factors that may impair the action of cilia
• Respiratory System is a process of gas exchange 1. Hypoxia
wherein a person takes in oxygen from the air to the 2. Breathing on a humidified air during winter
blood and eliminates carbon dioxide from the body 3. Dehydration
4. Anesthesia
5. Smoking (nicotine)
6. Hyperoxia – too much oxygen being
administered to the patient which can affect
the motility of the cilia that paralyzes its
function
Macrophages − type 3 alveolar cells which ingest
foreign body because mucociliary blanket does not
extend into alveolar unit
Reflex Bronchoconstriction − responsible for the
constriction of the bronchus that protects distal lung
structure
Different Phases of Respiratory System
Lymphatic Vessel
Ventilation − movement of air between body and
environment Immunologic Responses − cell mediated immunity in
the alveoli, these are the humoral which produce
Alveolar diffusion and perfusion − the gas exchange
antibodies and cell mediated killer T-cell
across the alveolar capillary membrane into the
pulmonary blood supply Pulmonary Protection − respiratory epithelium
wherein the lungs responses to injury by information
Transportation of respiratory gases − the movement of
and increased vascular permeability
oxygen and carbon dioxide through the circulatory
system to peripheral tissue and back across the alveolar
capillary membrane Structure of the Upper and Lower Respiratory
Control of ventilation − depending on the neuromuscular System
and chemical regulation of air movement to maintain • Cricoid lies below the thyroid cartilage (artificial
adequate gas exchange in response to changing opening)
metabolic demand
Upper Respiratory Tract – nasal passage, mouth,

pharynx, larynx, trachea
Lower Respiratory Tract – bronchi, bronchioles, alveolar
ducts, and alveoli
Function of Airways
Upper Airway
• Transport of gases to lower airway
• Protect the lower airway from foreign bodies
• Serves as a warming, filtration and humidification of
inspired air Subdivision of the Respiratory Tract
Lower Airway
Clearance Mechanism
Cough – occur when the capabilities of the mucous
blanket and cilia are excreted
Mucous Ciliary System – consist of the mucous
blanket that is being secreted by the goblet cell that
protects the respiratory system that entraps
gas and other foreign particles that enters the
airways and clear the lower airway and alveoli
(Cilia − hair like projection that protect airway from
foreign particles that enters the airway)

Alveoli and Pleural Membrane Processes Affecting Ventilation

• Alveolar is surrounded by pulmonary capillaries Respiratory pressure and surface tension –
allowing gas exchange between lungs and blood maintained below 760 mmHg; surfactant decreases
• Alveoli are interconnected by the Pores of Kohn which the surface tension.
are tiny holes that allow even air distribution Atmospheric Pressure − every breath in is made
 Movement of air from one another up of gasses, nitrogen, and oxygen. The
combination of these pressures is called
atmospheric pressure.
Intra Alveolar Pressure − pressure between
lungs
Intrapleural Pressure − pressure between the
pleura
• To facilitate lung expansion, the pressure inside the
pleural cavity is maintained below 760 mmHg,
normal atmospheric pressure
• Pleural Membrane is surrounded by: • In the intrapleural pressure between respiration, it
Visceral pleura – attached to the lungs that does not dropped to 755 to 751 mmHg with thoracic
have apparent pain fiber expansion
Parietal pleura – attached to the chest wall but there  This slight negative atmospheric pressure is
is a presence of pain fiber therefore, irritation with enough to draw air into the lungs
parietal pleura can cause pain with each breath • A break in the pleural layer that may occur in
pneumothorax might or will increase the respiratory
Muscle Respiration pressure leading to poor pulmonary inflation or lung
Primary Muscles – diaphragm collapse
Hemidiaphragm − innervated by phrenic nerve
• The alveoli must maintain a high surface tension to
promote gas exchange and with the help of
− Two dome shape that form the flow of thorax and
surfactant, it decreases the surface tension and
separate it from the abdomen
promote even gas distribution
− During inspiration the diaphragm contract and
descent towards the abdomen
Lung Compliance − distensibility
− During exhalation relaxes and ascend because
• Degree of distensibility or elasticity of the lungs and
of the lung recoil and return to its resting state
thorax
Accessory – assist the diaphragm • Any condition that may impede lung contraction and
 Normally, the accessory muscles are not active expansion, it may decrease lung compliance
during relaxed breathing, but begins participating therefore the lungs may become stiff that usually
in breathing with heavy activity or if there is an occur from poor lung contraction such as patient’s
increased work of breathing with fibrosis, edematous, or obstruction that may
 Exercises, CPD, or any problem that increase the destroy lung tissues such as atelectasis, pulmonary
work of breathing often causes the accessory edema or even ARDS (acute respiratory distress
muscles to become active and augment syndrome)
ventilation • Those increase in lung compliance or its loss in
 sternocleidomastoid, intercostals, pectoralis elasticity, may occur in patient with COPD (Chronic
major, abdominal muscle, scalene, external Obstructive Pulmonary Disease)
oblique
Transport of Gases
• The blood transport of oxygen and carbon dioxide
between the lungs and tissues
• Erythrocytes play a major role in transporting both
gasses and diffusion
Resistance – changes in size of airway

• Changes in size of airway through which the air is
flowing
Phases of Respiration
• The causes that may affect airway resistance
Ventilation – airflow into and out of the lungs through includes bronchospasm (asthma), thickening of
conducting passages bronchial mucosa (chronic bronchitis), obstruction

of airway (excessive mucus), and loss of lung • Occur in patients with emphysema and removal of
elasticity elope
Gas Exchange / Perfusion Membrane Thickness – semi-permeable

Perfusion – blood flow • Alveolar capillary interface is normally a one cell thick
• Flow of blood in which dispersing respiratory semi-permeable membrane
gasses to different areas • In fibrotic patients, this membrane may become
• This can be accomplished by pulmonary and thickened and less permeable so gas exchange is
systemic circulation inhibited and diffusing capacity is decreased
• Integrity of the pulmonary capillary bed changes in
pressure and resistance within the pulmonary Alveolar-Capillary Gradient – partial pressure
vessels and gravity • The difference in the partial pressure of the gases on
either side of the membrane or the partial pressure
Pulmonary Vascular Pressure − very low pressure • Partial pressure is the pressure exerted by each type
• Operates as a high volume but in low pressure of gas in the mixture of gasses
system
• Example: If there is increase cardiac output the
tendency of the pulmonary artery pressure should
remain constant because of the two mechanism:
Recruitment − decrease in pulmonary vascular
resistance in order to accommodate the
increased blood flow
Capillary Dilation − directly increase the capillary
size through stimulation of ANS
• Therefore, either of these mechanisms fails, will
result to pulmonary hypertension
Ventilation – Perfusion Ratio

• V – volume of gas per minute
• Q – blood flow volume (liters) per minute
• V/Q - low, high
• Impaired ventilation may be caused by airway
obstruction, a local change in compliance
• Whereas if there is an impaired perfusion, it may
occur in changes in pulmonary artery pressure and
even alveolar pressure
Partial Pressure Calculation

Standard barometric pressure (PB) is 760 mmHg
PN2 Nitrogen: .7904 of 760 mmHg = 600.7 mmHg
P O2 Oxygen: .2093 of 760 mmHg = 159.1 mmHg
PCO2 CO2: .0003 of 760 mmHg = 0.2 mmHg
Total: 760 mmHg
Partial arterial oxygen represents the amount of oxygen
Variables in Alveolar Diffusion dissolving in plasma
Surface Area or Total Surface – sq meter and
pulmonary capillaries Mechanism of Respiration
• The total alveolar surface for a normal adult is at about 1. Inspiration
80 square meters and the pulmonary capillaries cover 2. Expiration
at least 85-95% of this surface 3. Intrapleural pressure
• Any reduction in the square meters reduces the 4. Compliance
overall diffusing capacity of the lungs 5. Airway resistance

The different lung volume capacity with Control of Breathing

corresponding average value and description • Respiratory center affecting ventilation.
Respiratory Volume • The ventilation is conducted primarily by the ANS
Adult Adult • Pacemaker of the lungs is located in the medulla
Male Female
Measurement Description oblongata
Avg. Avg.
Value Value
Amount of air inhaled or exhaled with each
Total Volume (TV) 500 ml 500 ml Medulla oblongata
breath under resting conditions
Inspiratory Reserve Amount of air that can be forcefully inhaled
Volume (IRV)
3100 ml 1900 ml
after a normal tidal volume inhalation
− It functions as the control center for ventilation and
Expiratory Reserve Amount of air that can be forcefully exhaled the final determinants of breathing patterns
1200 ml 700 ml
Volume (ERV) after a normal tidal volume exhalation
− Establish basic rhythm and depth of respiration
Residual Volume Amount of air remaining in the lungs after a
1200 ml 1100 ml
(RV) forced exhalation There are two receptor sites:
Respiratory Capacities
a. Chemoreceptors – H+ and PCO2
Maximum amount of air contained in lungs
Total Lung Capacity
6000 ml 4200 ml after a maximum inspiratory effort:
− Central chemoreceptor located in the medulla
(TLC)
TLC = TV+IRV+ERV+RV − It responds to the chemical composition
Maximum amount of air that can be expired primarily if there's changes in the pH pertaining
Vital Capacity (VC) 4800 ml 3100 ml after a maximum inspiratory effort:
VC = TV+IRV+ERV (should be 80% TLC) to CO2 or PCO2 which may convey to the lungs
Inspiratory Capacity
3600 ml 2400 ml
Maximum amount of air that can be inspired to change the depth and rate of ventilations in
(IC) after a normal expiratory: IC = TV+IRV
order to correct imbalances like acidosis and
Functional Residual Volume of air remaining in the lungs after
2400 ml 1800 ml
Capacity (FRC) normal tidal volume: FRC = ERV+RV alkalosis
− Example, if there is an increase in the of blood
Different Layers of The Mucosal Lining gas of PCO2, then there will be a decrease in pH
Epithelial Layer – respiratory epithelium that may that increases the respiratory rate and
contain several cells such as ciliated cells that propel hydrogen
secretion out of the respiratory tract b. Peripheral Chemoreceptors – PaO2
− Located in the carotid artery and arch of aorta
Goblet Cells − found in the columnar epithelium that
− Responds in the changes in partial arterial
produce and secrete mucus
oxygen, carbon dioxide, and pH
Clara Cells − one source of fluid lining in the small
− It is very sensitive if there’s a decrease in
airway
oxygen tension level that may stimulate
Basement Membrane – mucociliary membrane that trap increase in ventilation
airborne particles that is 2-10 micro millimeters in
diameter
Pons – modify ventilation
Bottom Water Layer − has a direct contact with the
 Apneustic and the pneumotaxic center
epithelium to place the cilia
 It limits inspiration and modifies inspiration
Lamina Propria – third layer that contains lymphocytes,
plasma cells and others
Hering-Breuer Reflex – prevents lung overdistention
 Sometimes called as the “inflation reflex”
 Regulates the depth of breathing by limiting lung
inflation
 It helps the medullary center to establish smooth
combination of ventilation rate and tidal volume
 The stimulation of the bronchiolar or alveolar wall
may initiate the inflation reflex

Health Assessment Dyspnea Borg Scale or Visual Analog Scale (VAS)

Nursing care of a Client with Respiratory Disorders 0 – no dyspnea 4 – somewhat moderate
Health History – presenting problem 0.5 – very very slight 5 – 6 = severe
1. Nose, sinuses 1 – very slight 7 – 8 = very severe
 Symptoms such as colds, discharges, epistaxis, 2 – slight 9 = very very severe
swelling or pain in the sinus area 3 – moderate 10 = maximal
2. Throat
 Symptoms of sore throat, hoarseness, and Lifestyle – occupation, exposure, geographic location,
difficulty swallowing type and frequency of exercise / recreation
3. Lungs – cough, dyspnea, chest pain • Exposure pertains to work condition that could irritate
Cough respiratory system such as exposure to asbestos,
Duration chemical irritant, and dry-cleaning fumes
Frequency • Geographic location like environments that could
Type or quality of cough: irritate respiratory system such as industrial pollutants
✓ Airborne irritants • Type and frequency of exercise / recreation includes
✓ Related to cardiovascular diseases smocking, always note the type of tobacco, duration
✓ Medication reactions such as those of use, number of sticks per day used, and number of
receiving ace inhibitors or patients with years
gastroesophageal diseases • Pack year − a way to measure a person has smoked
− Productive or non-productive cough (wet or dry) over a long period of time
− Sputum may be related with cough depending on  1 Pack year is equivalent to 20 cigarettes per day
the type, positions of patients, patients who talks for a year
too much, or with anxiety, and their
corresponding treatment Nutrition
• If patients have adequate intake of fluid for 24 hrs.
Dyspnea period and intake of vitamin supplements
− Take note of the onset, severity, duration, and
effort to breath
Past Medical History – immunization, allergies,
− Refer if the patients need more pillow, position of
precipitating factors
the patient in order to relieve the dyspnea
− Refer to the Dyspnea Borg Scale or Visual • Especially for elderlies, if they have submitted their
Analog Scale selves to yearly immunization for colds, flu, tuberculin
skin testing
6 P’s of Dyspnea due to:
• Check allergies to food, drugs, or contacts to
1. Pulmonary constriction or
allergens that may be a precipitating factor in the
bronchoconstriction
development of respiratory disorder and the use of
2. Presence of possible foreign bodies
these specific treatments such as nebulization for
3. Pulmonary embolus
asthma, elimination pattern, sleep and rest pattern
4. Pneumonia
5. Pump failure of the heart
6. Pneumothorax Physical Examination
Inspection
1. Rate and pattern of breathing – determine for signs
of respiratory distress
 At least 7 or 8 signs that can be seen in patients
can be considered respiratory distress
Signs of Respiratory Distress
1. Tachypnea
2. Gasping
3. Grunting
4. Central cyanosis
5. Open mouth
Chest Pain
6. Flared nostrils
7. Dyspnea
o Include in the health history if there is any
interference with the activities of daily living 8. Use of accessory muscles
9. Color of the skin and lips

Grossly bloody – PTB, pulmonary infarction, tumors

Clear mucoid, sticky – viral infection, chronic
bronchitis, post-nasal drip
Rusty-colored – bacterial pneumonia
Foul-smelling – anaerobic infection
Blood-streaked – acute respiratory tract
8. Chest Wall Configuration – 1:2 AP<TD
 Chest deformities: barrel chest, pectus
excavatum, pectus carinatum, kyphoscoliosis
 Determine / inspect chest configurations with a
normal ratio of 1:2
 Observe the chest size, the concave and the AP
2. Lip Pursing lateral diameter ratio
 Usually seen to patients with COPD Barrel chest – patients with COPD
3. Nostril Flaring Tunnel chest or pectus excavatum – patient with
 Signs for air hunger connective congenital tissue disorder
4. Cyanosis Pigeon chest or pectus carinatum – congenital septal
Peripheral – extremities and nail beds are blue due defect or severe primary kyphosis or kyphoscoliosis
to peripheral vasoconstriction; secondary to Thoracic kyphosis – patient with osteoporosis
decreased cardiac output secondary to aging or patient with spinal tuberculosis
Central – bluish discoloration of lips, tongue, face
and mucous membrane; secondary to decreased
oxygen of blood; always pathological
Differential – upper part of the body is pink and lower
half is blue or vice versa; usually seen in cardiac
diseases
5. Counting Ribs
 8 ribs are seen anteriorly while 9th to 12th ribs are
seen posteriorly
 If the count is less than or fewer ribs, it can mean
that the patient is having a consolidation in the
base of the lung field
 While if over 9 ribs, it may indicate overinflated
lungs
6. Inspect for symmetrical expansion
 Inspect for symmetrical expansion during 9. Inspect for clubbing finger and toes – Schamroth test
breathing and the use of accessory muscles
 Bulging during expiration may suggest outflow
obstruction or thoracic space compression
 If there’s unilateral retraction, it usually occurs
from a foreign body in the bronchi or obstruction
of the trachea or larynx which is characterized by
a caved-in appearance in the sternum
7. Sputum Production – normal mucus production (100
mL/day)
 Assess for presence of sputum
 Sputum refers to the substance that is being Palpation
expelled by coughing 1. Palpate for chest wall
 Note the quantity (how much the sputum is being  Skin, subcutaneous structure, temperature,
produced by the patient per day), quality and texture and degree of development
color of the sputum  Determine the texture of the muscle,
temperature and the degree of development
Yellow or greenish – respiratory infection
 Any crepitus, tenderness, or swelling of the chest
Pink, frothy – pulmonary edema, CHF, mitral valve
wall or muscle tone is considered abnormal
stenosis

2. Tracheal position Alpha 1-antitrypsin Determination (> 250 mg/dl) –

 Atelectasis, pleural effusion, tension pulmonary emphysema
pneumothorax, thyroid and lymph node • Patient with a history of emphysema because there’s
enlargement a familial tendency to have deficiency of this anti
 Palpate for tracheal position for any deviation enzyme
especially associated in patients with
atelectasis, pleural effusion, fibrosis, lymph node Angiotensin Converting Enzyme (ACE) –
enlargement, tumor, and unilateral emphysema sarcoidosis, tuberculosis, HTN
3. Thoracic Excursion
• ACE is usually used to evaluate for special cases of
 Take note of the thoracic exertion for symmetric
hypertension
and asymmetric
• Any elevation of ACE is found to be high percentage
4. Tactile fremitus or voice transmission
in patients with sarcoidosis, and is used to evaluate
 Fremitus is the transmission of vibration of air
the severity of the disease and the response of this
movement in chest wall
disease to the therapy
Increase: pneumonia, pulmonary fibrosis, tumor • ACE inhibitor is also used to determine tuberculosis
Decrease: COPD, pneumothorax, pleural but is not the definite test but can be part of the test
effusion
 Rhonchial fremitus is an abnormal palpable D-dimer Assay
vibration • To determine the presence of clot
• Diagnosis of pulmonary embolism, DVT
Percussion • <0.5 mcg/mL
1. Diaphragmatic excursion – 3 to 5 cm
2. Tones Tuberculin Skin Test – diagnose bacterial, fungal, or
Resonant sound for normal lung field viral pulmonary diseases
Dull sound for any consolidated mass • PPD – purified protein derivatives
• Usually used to detect tuberculosis infection but does
not differentiate active from dormant infection
Auscultation
• With the use of PPD to determine for any previous
1. Breath Sounds – vesicular, bronchovesicular, sensitization to tubercle bacillus
bronchial
Methods of Administration of Tuberculin Skin Test
Tine Test – stainless steel disc with 4 lines impregnated
with PPD tuberculin
 Being pressed to the skin
2. Adventitious Sounds – rales/crackles, rhonchi,

wheezes, pleural friction
Rales – heard during inspiration (s) Mantoux Test – 0.1 mL injected in the forearm
Rhonchi – loud heard during expiration (L) containing PPD tuberculin
Wheezes – during inspiration and expiration (s)  Done by the doctor
 Whoever performed the test should be the one to
Pleural friction – during inspiration and expiration
read the result within 48 to 72 hours
Laboratory Tests
Hematogram Studies
• Gives the general information about the overall state
of the health and respiratory function
• The elements include the RBC, hemoglobin,
hematocrit, WBC as well as differential counts which
determine the proportion of each type of WBC like
neutrophils, basophils, monocytes, lymphocytes and
eosinophils

Results of PPD • Lordotic and oblique is usually a slanting position

Negative: zone diameter < 5 mm • Interpretation of chest field, usually 8 and 9 rib should
Probable: 5 to 10 mm be visible on the PA view
• Hemidiaphragm should appear round, smooth and
Positive: 10 mm and above
clearly defined
 May indicate that the patient has been exposed to
• Expect that the right side is slightly elevated because
tuberculosis
of the liver
• If there’s a flattened silhouette, it suggests
Genexpert Test overinflation of the lungs or if absence of
• A molecular test detecting the presence of TB hemidiaphragm, the patient is probably having
bacteria, as well as testing for resistance to the drug atelectasis
Rifampicin • Another need for the interpretation of chest field is the
costophrenic angle, absence of this angle may
Sputum Studies indicate pleural effusion
• Grayness of the costophrenic angle may suggest
Culture and Sensitivity
pleural effusion
− Identifying specific microorganism from a specimen
− Diagnose for bacterial infection and at the same
time, it would determine the type of antibiotic agent Tomography
that would be effective against that microorganism • Provides films of sections of lungs and different levels
either sensitive or resistant within the thorax.
Gram Stain Test – for selecting antibiotic • CT Scan and MRI which provides the different
sections of the lungs and the different level within the
Acid-Fast Stain – 3 consecutive days
thorax
− Collecting sputum for 3 consecutive days.
− Determine acid-fast bacilli then tuberculosis is
suspected Bronchoscopy
Cytology – identify tumor cells • Can be performed by passing either a rigid or flexible
fiberoptic bronchoscope into the bronchial tree to
directly inspect and observe the pharynx, larynx,
Nursing Care
trachea, and bronchi
1. Explain the necessity of effective coughing and deep • Has two purposes: diagnostic and therapeutic
breathing
2. If the patient is unable to cough, aerosol may be used Diagnostic Uses
to assist in obtaining specimen
1. To visualize the structure of the respiratory system
3. Make sure to use sterile container that can be
2. Collect secretions
capped afterwards when collecting specimen
3. Determine location or pathologic process and collect
4. The volume needed for sputum exam should not
specimen for biopsy
exceed 1-3 mL and must be delivered immediately
4. Evaluate bleeding sites
within 2 hours
5. Determine if a tumor can be resected surgically
 Beyond 2 hours, additional microorganism will
set in
Therapeutic Uses
1. Remove foreign objects
Diagnostic Procedures 2. Excise lesions
CXR – PA, lateral, oblique, lordotic position 3. Remove tenacious secretions
• Chest x-ray provides information and visualization of 4. Drain abscess
the lungs, ribs, clavicles, heart and major thoracic 5. Treat postoperative atelectasis
vessels
• Useful to identify foreign bodies and abnormal Nursing Care of Bronchoscopy
shadows Usually done in the operating room
• Different positions are lateral, posterior, anterior view,
1. Explain
usually by standing
2. Consent
• Anteroposterior view can be done if the patient is
3. Medical history – medication, laboratory, asthma
unable to stand, this is done through lying or sitting
 Medication, if the patients is taking anti platelet
position
or aspirin, notify the physician in charge
• Lateral view is to determine the size and shape of the
 Check for allergies to medication
heart
 Check laboratory findings/result

 Usually, the doctors would do prothrombin time,  Refers to as the respiratory component in acid-
partial thromboplastin time and RBC base determination because this value is primarily
4. Assess for hypoxia controlled by the lungs
5. Nothing per orem (NPO)  The lungs are used to compensate for the primary
 No food or fluid for 6-12 hrs. metabolic acid-base derangement therefore, the
6. Dentures – remove dentures and eyeglasses pCO2 level is affected by metabolic disturbances
7. Pre-medication (Demerol and Atropine) as well
 Atropine is given to decrease the excessive  In metabolic acidosis, the lungs attempt to
salivation compensate by blowing off CO2 in order to raise
 During operative, patient may position in side the pH
lying or semi fowlers  In metabolic alkalosis, the lungs attempt to
8. Food and fluid withheld until gag reflex return compensate by retaining CO2 in order to lower the
 During postoperative, keep the patient in NPO pH
until gag reflex return
 Assess for any gum bleeding or bronchospasm HCO3 – 22 to 26 mEq/L
and immediately refer to the physician  Bicarbonate ion is used to measure the metabolic
 Application of ice bag to throat for comfort component of the acid-base equilibrium
 Discourage patient from talking, coughing and
smoking for a few hours in order to reduce ABG Analysis
irritation
1. Assess for degree of hypoxemia
 Cold fluids and warm gargles, if patient
 Mild, moderate, severe
experience soreness but make sure that the fluid
2. Assess ventilatory state
is not swallowed unless there’s already a
 Alveolar hypoventilation − >50 mmHg due to
positive gag reflex
CO2 retention
 Alveolar hyperventilation − <30 mmHg due to
Arterial Blood Gas (ABGs) over breathing
• To provide direct information about ventilatory 3. Assess acid-base imbalance
function by measuring the partial pressure of O2, CO2
in arterial blood and pH of the blood o Allen test may be done to check the patency of
the arteries
pH – 7.35 to 7.45
 Below 7.35 is considered acidic/acidosis while
above 7.45 is considered alkalosis
 Determines the hydrogen ion concentration
 Measures the alkalinity and acidity
pO2 – 80 to 100 mmHg (Partial pressure of O2)

 Indicates the indirect measurement of the oxygen
content of the arterial blood
 It measures the tension of oxygen dissolved in the Respiratory Acidosis vs Respiratory Alkalosis
plasma Respiratory Acidosis − rapid shallow respiration making
 pO2 is reduced in most patients who are unable to the patient have a hard time catching his/her breath
oxygenate the arterial blood because of the which may result to disorientation and increased cardiac
oxygen diffusion difficulty, such as in patients output
having pneumonia, shock lung or due to Respiratory Alkalosis − deep rapid breathing and
premature mixing of venous blood with arterial hyperventilation increasing the respiratory rate
blood seen in patients with congenital heart
disease
 Conditions or patients who are under ventilated or
over perfused of pulmonary alveoli is seen on
obese patients who cannot ventilate properly
when in supine position
pCO2 – 35 to 45 mmHg
 Evaluate how well the lungs could eliminate CO2
 May indicate the adequacy of alveolar ventilation

Metabolic Acidosis vs Respiratory Alkalosis Pulse Oximeter

Metabolic Acidosis − has Kussmaul respiration • A non-invasive procedure to determine the arterial
Metabolic Alkalosis − decreased respiratory rate oxygen saturation
• O2 saturation – measure by percentage of the
hemoglobin saturated with O2
• Normal: 95% to 100%
• Pulse oximetry – attached to finger, earlobe, toes,
forehead
Incentive Spirometry
• A flow-oriented, to keep the ball elevated to a pre-
marked area
• Used following abdominal or thoracic surgery to help
reduce the incidence of postoperative pulmonary
atelectasis.
• This is to reduce the incidence of postoperative
Pulmonary Function Test pulmonary atelectasis, especially in patients who will
• Measure the presence and severity of respiratory undergo CABG
disease in the large and small airways
• Also determine the extent of dysfunction that may
provide information related to the lung volume, lung
mechanics, and diffusion capability of the lungs
Spirometer – to diagram the movement of air
Body Plethysmography – measure all respiratory gas
including gas traps in the air
Lung Scan
• Sometimes called Ventilation-Perfusion Scanning
(VQ Scan)
• Evaluates the ventilation and perfusion ratio
• Assess lung ventilation, to compare for any
pulmonary embolism, infarction, emphysema, or
fibrosis
Nursing Care • Check both ventilation and perfusion
• Contraindicated to patients who are allergic to
1. Explain the procedure in order to lessen the anxiety
contrast dye, pregnant or lactating mothers, and
and to ensure the cooperation of the patient
children below 7 years old
2. Pulmonary Function Test (PFT) – is to test before
• Nursing care: ask the patient to hand wash after use
meal
of toilet and flush the toilet 3 times
3. Withhold medications that may alter respiratory
function unless ordered by the physician to continue
the medication Pulmonary angiography and Magnetic resonance
4. Asses for pulse and provide rest period after the angiography (MRA)
procedure • Locate obstruction or pathologic conditions
• Visualize the pulmonary vasculature
Indications for Pulmonary Function Test
1. Differentiate restrictive and obstructive disorders Positron Emission Tomography (PET scan)
2. Baseline data • Determine benign or malignant nodule
 If the patient is receiving respiratory agent • Malignant nodules may increase the uptake of
3. Evaluate pulmonary status prior to surgery glucose
4. Assess response to therapy
5. Screening test that involves industrial exposure

Lung Biopsy • Most common is one bottle water-seal drainage

• Obtain specimen from the • Pleurodesis – installation of medication in the pleural
lungs to determine for any space in the form of vibramycin, talc and tetracycline
malignancy
Water Bottle System
Thoracentesis Single Bottle Water-Seal System
• Insertion of needle through the chest wall into pleural Used when a small portion of the lung has collapsed.
space Fluid or air is drained from the pleural space by gravity
• Can be a diagnostic evaluation by removing pleural into the bottle. The end of the tube is submerged in
fluid accumulated in the pleural space about 1-2 cm of water, creating the water seal that
• It can be therapeutic by instilling medication into the prevents re-entry of air. An open vent releases air into
pleural space the atmosphere and prevents excessive buildup of air
• The goal of thoracentesis is to determine adequate inside the bottle.
ventilation and maintain an adequate ventilation and
patent airways for the patient to have an effective
breathing pattern
• Demonstrates increased tolerance for activities
because of fluid removal from the pleural space
Two Bottle System

If a moderate to a large amount of drainage is expected,
this system is applied. The drainage and water seal
bottles are separate, and fluid drains only into the
collection bottle. This system allows the water to remain
at a fixed level so chest drainage can be more
accurately measured. As with the one bottle system,
gravity drives the drainage system. When gravity
Nursing Care drainage is not sufficient to remove air of fluid from the
1. It is an invasive procedure that requires explaining lungs, suction may be added.
the procedure to the patient
2. Obtain consent
3. Instruct the patient not to cough during the procedure
4. Check and assess the vital signs
5. Position the patient to sit at the side of the bed with
the upper torso supported by the overbed table
including the feet and legs
6. After the procedure, observe for signs and symptoms
of pneumothorax or leakage at the puncture site, and Three Bottle System
auscultate to determine breath sounds Used when suction is necessary. The 1st two bottles
are explained above. The 3rd bottle is added to control
the amount of suction applied to the pleural space. The
Thoracoscopy – VATS (Video-Assisted Thoracotomy
bottle has 3 tubes: one tube is connected to the suction
Surgery)
source, another is connected to the water seal bottle,
• To examine the pleural cavity with an endoscope to
the long tube is the suction control manometer & is open
check for the cause of pleural effusion and staging the
to the atmosphere.
tumor through video monitoring
Interventions
Chest Tube/ Water-Seal Drainage – one, two or three
bottles and commercial type
• Principle used: gravity, water sealed, suction
• Insertion of catheter into intrapleural space in order to
maintain a constant negative pressure when air or
fluid have accumulated

Commercial Water Shelf Unit reduce the risk of lung injury, lower work of breathing,
Commercial water shelf unit, lightweight and and optimize comfort
disposable, that function like a three-bottle system and • If a patient is to be hooked into a mechanical
can be used with or without suction ventilator, an endotracheal tube must be inserted first
The Pleur- Evac

Endotracheal Tube Insertion
A single unit with all three bottles identified as
chambers. This commercially available system is safer • Involves passing an endotracheal tube through the
because they are self-contained, unbreakable, and mouth, nose or trachea
disposable, and have no connections (except to the • Usually inserted with the aid of laryngoscope
chest catheter) that may become loose. Nursing care is  Laryngoscope should be functional
easier to provide, and the convenience of the system • Comes with different sizes
encourages easier and earlier ambulation for the • Check pressure of the cuff
patient. • Guided war is used to facilitate insertion of the tube
into the trachea
• The tube goes down into the trachea till to the

bronchus
• Cuff should be inflated which serves as an anchor
• There are times that the cuff should be deflated to
prevent irritations in the trachea
Heimlich Flutter Valve

Portable, small, rigid plastic with a valve that allows a
unidirectional flow of air and fluid from the pleural space
into a drainage pump. It also prevents any reflux of air
or fluid. A water-sealed drainage system is not
necessary in this one. The valve will open when the
pressure is greater than the atmospheric pressure.
Approximately 7 inches and permits greater mobility
Care for Intubation

1. Check symmetry of chest expansion
Chest Physiotherapy – postural drainage, percussion, 2. Ensure high humidity
vibration 3. Secure the tube
4. Use sterile suction technique
5. Continue repositioning
Mechanical Ventilator
6. Provide oral hygiene
• For patients who are unable to maintain normal levels
of O2 and CO2 in the blood; patients usually cannot
Types of Mechanical Ventilation
breathe spontaneously in order to maintain life
• It also serves as a prophylactic measure for imminent Positive-Pressure Ventilation
collapse or ineffective gas exchange • Delivers a positive pressure to inflate the lungs
• Can also be used in conditions such as neurologic • Increase positive intrathoracic pressure that may
depression, neuromuscular diseases impede venous return to the right side of the heart
• The goal of this mechanical ventilation is to achieve resulting to decreased cardiac output, tachycardia or
and maintain adequate pulmonary gas exchange, hypotension

• This type of ventilator is usually seen in the hospital Controlled

setting the patient does not contribute to ventilation
• The pressure is applied at the patient's airway through − They depend on the set rate and tidal volume on
the endotracheal tube or tracheostomy tube causing the ventilator
the gas to flow into the lungs until ventilator breath is − Usually used with unconscious patients who has
terminate no drive to breath or unable to breath
Pressure-Cycled Ventilation spontaneously
− Delivers a specified pressure to the client by − Such as patients with spinal cord injury, acute
achieving a tidal volume or amount of air in ml per respiratory distress syndrome, or patient who’s
breath having asthmatic attack with paralysis
− It pushes air into the lungs until a predetermined Assist-Controlled Mechanical Ventilator (AC mode)
pressure is reached within the tracheobronchial − Provides mechanical breath either at preset tidal
tree volume or at peak pressure every time the patient
− Expiration occurs by passive relaxation of the initiates a breath
diaphragm − Patient have some control over ventilation while
− Risks include the development of pneumothorax providing some assistance from the mechanical
and decrease in cardiac output as a result of the ventilator
ventilator achieving the pressure without regards − Patient can breathe spontaneously without
for lung compliant working
− Respiratory effort may trigger ventilator which
Volume-Cycled Ventilation
then deliver breath
− Delivers a specified tidal volume − Has a potential risk for hypoventilation or
− Most often used in the clinical setting wherein the hyperventilation because there is no weaning
patient may receive adequate tidal volume with component
each breath − May increase ventilator support and decrease
− Most popular type for intubated adult or older work of breathing
children − Patients with pulmonary edema, respiratory
− Delivers air into the lungs until a certain failure
predetermined tidal volume
− The volume cycle achieves tidal volume with a Continuous Mandatory Ventilation (CMV)
pre-set pressure limit and more sensitive to lung − Preset tidal volume at preset rate is delivered to
compliance the client
− The client can initiate breaths that are delivered at
Time-Cycled Ventilation the preset tidal volume. Indications: reduction of
− Provides an inspiratory phase until a preset time work of breathing, respiratory muscle fatigue,
is reached COPD and post-anesthesia
− Common in neonates and pediatric patient
− It may permit the inspiration after a preset tidal Synchronized Intermittent Mandatory Ventilation (SIMV)
volume is regulated by adjusting the length of – breathe at own rate
inspiration and flow rate of pressurized gas Weaning
• Preset tidal volume a preset rate is synchronized with
Negative-Pressure Ventilation the client’s spontaneous breathing to reduce
• Air is removed from the patient’s chest wall competition between machine-delivered and client-
• Does not need an artificial airway spontaneous breaths.
• In patients with multiple sclerosis, muscular dystrophy • Primary ventilatory mode, used to wean clients from
and early stages of COPD mechanical ventilation
Modes of Mechanical Ventilation

Assist/Control – Continuous Mandatory Ventilation
(CMV)
• Delivers under positive pressure
• Unconscious
• No drive to breath
• Sometimes called assist controlled mechanical
ventilation

Ventilatory Maneuver
o Patients with acute respiratory failure frequently Non-invasive positive pressure ventilation wherein the
require intubation and mechanical ventilation to amount of air present in the lungs after normal
sustain life. (Burns et al., 2013)
expiration
o Important to minimize time on vent, due to
complications that can occur such as:
✓ Respiratory muscle weakness Positive End Expiratory Pressure (PEEP)
✓ Ventilator-associated pneumonia (Burns • Delivers additional positive pressure at the end of
et al., 2013) expiration allowing more time for gas exchange and
opens small airways and closed alveolar units, thus
improving oxygenation
Nursing Care of Mechanical Ventilation
• The purpose of PEEP is to improve oxygenation
1. Assess cardiac output
• Increase aeration of patent airway
2. Monitor fluid and electrolytes
• Limit oxygen toxicity and improves functional residual
 There is a positive water balance wherein the
capacity (FRC)
mechanical ventilator may increase the thoracic
• Normal is about 3 to 20 cm of water
pressure which may trigger pituitary gland
• Often 5cm of water is used prophylactically to replace
resulting to the release of antidiuretic hormones
the glottis mechanism to help maintain a normal
that may cause water retention
functional residual capacity and prevent alveolar
 Output is monitored every hour
collapse
 Weigh the patient daily
• Prevent atelectasis and may open the previously
3. Take the pulmonary capillary wedge pressure
closed alveoli and improve the oxygen entering the
reading
capillaries supplying alveoli and help in the
 To determine the left ventricular pressure
improvement of compliance of the lungs
4. Check for peripheral edema
5. Auscultate chest for any altered breath sounds
6. Monitor barotraumas Continuous Positive Airway Pressure (CPAP) – with a
 Assess for the ventilatory settings and auscultate T-piece
breath sounds every 2 hours • Maintenance of a positive airway pressure above
7. Monitor arterial blood gas as ordered atmospheric pressuring during inspiration and
8. Perform complete pulmonary physical assessment expiration in the spontaneously breathing client.
every shift • It improves oxygenation in the same manner as PEEP
9. Monitor GI problems • Restore functional residual capacity
 Stress ulcers due to disturbance in the mucus • Delivers continuously during spontaneous breathing
and bicarbonate protective layer resulting to • Prevent airway pressure from falling to zero
alteration in the mucosal microcirculation which
may lead to ischemia or decreased blood flow
2 Type of Positive Airway Pressure
 Patient may receive proton pump inhibitor
CPAP – treat disease where the problem is the supply
10. Neurological assessment
of oxygenation such as pulmonary edema
11. Administration of medications
 Muscle relaxants to relax the patient and BIPAP – treats patients with problems in ventilation and
subsequently increase machine synchrony oxygenation, usually for patients with hypoventilation
syndrome, obesity, neuromuscular disease or COPD
Ventilator Parameters
o There is a clinic (sleep clinic) where they try to
Already set in the machine evaluate patients having problem with
Tidal Volume (VT) – amount of air inspired and expired respiration called obstructive sleep apnea
with each breath o They also try to book patients to make setting on
CPAP or BIPAP
Respiratory Rate
Fraction of inspired oxygen (FIO2) – amount of oxygen
the client receives
PEEP – positive pressure applied at end expiration to
improve oxygenation and also prevents the collapse of
the alveoli
Peak Airway Pressure – maximal pressure level
required to deliver the desired tidal volume

Ventilator Alarm Tracheobronchial Suctioning

When there is an alarm, try to see what happened / what • Suctioning is the removal of secretion from the
is the reason why the ventilator is alarming tracheobronchial tree using sterile catheter inserted to
the airway
High-Pressure Alarm
• Usually set at 10 to 15 cm greater than the peak
airway pressure. Indicates the ventilator has met
resistance to delivering the tidal volume and requires
more pressure to inflate the lungs
• Coughing, airway plugging, changes in client position,
pneumothorax, incorrect ETT position
Low-Pressure Alarm
• Sudden decrease in peak airway pressure
• Sounds when the ventilator has no resistance to
inflating the lung
• Kinked ventilator circuit, excessive water in ventilator Tracheostomy
circuit, decreasing lung compliance • For tracheostomy care, this is performed to avoid the
• The client may be disconnected from the ventilator or bacterial contamination and obstruction of the
a leak has developed in the ventilator circuit tracheostomy tube
The Mech Vent also has settings to regulate the

temperature of the water in the humidifier known as the
cascade. The temperature of the heater in the cascade
is set at or just below normal body temperature. This
provides warm, moistened air for delivery to the airway
but cascade is a potential source of contamination of the
ventilator circuit if the water that collects the ventilator
tubing is drained back into the circuit.
Oxygen Therapy
Low-Flow System – nasal cannula, standard face Cricothyrotomy
mask • Emergency surgical opening of the cricothyroid
Face Mask Non-Rebreather Mask membrane
• Only done by registered physicians
• Maintain patent airway when other methods fail or are
not feasible
High-Flow System – venturi mask

Respiratory Medications
− Comes in different colors with the specific
Sympathomimetic
percentage of oxygen concentration that will be
delivered to the patient • Albuterol, Ventolin
• Relaxes the smooth muscle of the bronchi
1. Blue – 24% • A bronchodilator
2. Yellow – 28% • S/E: increase in heart rate, dizziness, tremors,
3. White – 31% headache and elevations of blood sugar
4. Green – 35%
5. Pink – 40% Methylxanthine Derivatives
6. Orange – 50%
• Aminophylline, Theophylline

• Relaxes smooth muscles and decrease compression of the nose during childbirth in fetal
bronchospasm development
• S/E: nausea, vomiting, anorexia, palpitations, and • Causes the nasal septum to protrude into the air
tachycardia passage of one nostril which may cause obstruction
of air entry therefore, there will be a reduce in the flow
Glucocorticoids of air that may result to difficulty of breathing and
sometime contribute to crusting and bleeding
• Dexamethasone, Hydrocortisone, Prednisone
• Anti-inflammatory
• From trauma, irritations, congenital factors
• To reduce edema of the airway
• S/E: fluid retention, GI Irritation, and impair the Signs and Symptoms
immune response of the patients 1. Snoring
2. Sleep apnea
Mast Cell Stabilizer 3. Repetitive sneezing
4. Epistaxis
• Cromolyn Sodium
5. Facial pain
• An anti-allergic agent
• Inhibits mast cell release
• S/E: nasal sting or sneezing after inhalation or a bad Treatment
taste in the mouth Drug Therapy
1. Decongestant
Antihistamine  To reduce nasal tissue swelling in order to keep
• Diphenhydramine, Benadryl the airway open but be cautious because it could
• An H1 blocker – compete with histamine receptor site cause elevation of heart rate, blood pressure and
that may prevent histamine response sometimes can cause tremors
• S/E: drowsiness, dizziness, fatigue and even urinary 2. Antihistamine
retention may occur  To prevent allergy symptoms
3. Nasal steroids spray
 To reduce inflammation
Nasal and Systemic Decongestant
• Phenylephrine HCl, Sinutab Surgery
• Stimulates the alpha-adrenergic receptors 1. Septoplasty
• Do not abruptly stop this decongestant  Correct and repair deviated septum
• S/E: rebound inflammation of the mucus membrane 2. Rhinoplasty
 Cosmetic deformity, to reconstruct the external
Expectorants nose
3. Submucous Resection (SMR)
• Guaifenesin, Robitusin
 To correct deformity when major symptoms or
• Facilitates productive cough
discomfort occur
• S/E: GI irritations, drowsiness
 Can be used for chronic sinusitis that does not
respond to treatment
Mucolytic
• Acetylcysteine
• Thin mucus, decrease mucus production
• S/E: oral pharyngeal irritation
Antitussive
• Codeine, Dextromethorphan
• Suppresses cough reflex
• S/E: drowsiness and respiratory depression
Upper Respiratory Disorders

Deviated Septum Complication: Meningitis
• Deflection of a normally straight nasal septum that
may occur as a result of nasal trauma, thumb sucking, Nursing Care for Post-Operative
nose breathing or even congenital factors due to the
1. Intranasal packing and internal splints

 Make sure to maintain the position of the septum Types of Sinusitis

and control bleeding and prevent hematoma Acute sinusitis – if patient develops it in <4 weeks
formation (for post-operative) Subacute – from 4 weeks to 12 weeks
2. Reduce bleeding
Chronic – >12 weeks
 Refrain from taking aspirin containing drugs for
two weeks before surgery There are different side of the sinuses depending on the
 Assess for the respiratory status obstruction or infection, it could be in the frontal sinus,
 Doctor may administer analgesic to control pain, ethmoidal or sphenoidal and even maxillary (the most
edema or prevent infection common is the frontal and maxillary)
3. Cold compress or ice packs for 1st 24°
 To lessen edema and promote comfort
Causes of Rhinitis or Rhinosinusitis
 Instruct client not to blow nose or to sneeze
 If sneezing cannot be avoided, instruct client to Category Causes
open mouth when sneezing Idiopathic

Abuse of nasal decongestants
 Avoid coughing Vasomotor Psychological stimulation (anger, sexual
 Use mouth for breathing arousal)
Irritants (smoke, air pollution, fumes)
4. Increase HOB – decrease edema
5. DO NOT blow nose, sneeze, or cough Tumor
Deviated septum
6. Observe site for hemorrhage, edema and prevent Crusting
Mechanical
infection Hypertrophied turbinates
Foreign body
CSF leakage
Sinusitis or Rhinosinusitis Polyps
Chronic Inflammatory
Sarcoidosis
• Sinusitis is characterized by inflammation of the lining
Acute viral infection
of the paranasal sinuses Infectious Acute or chronic rhinosinusitis
• Because the nasal mucosa is simultaneously involved Rare cases (TB, syphilis)
and because sinusitis rarely occurs without Pregnancy
concurrent rhinitis, rhinosinusitis is now the preferred Hormonal Use of oral contraceptives
Hypothyroidism
term for this condition
• Rhinosinusitis may be further classified according to
the anatomic site (maxillary, ethmoidal, frontal, Predisposing Factors
sphenoidal), pathogenic organism (viral, bacterial, 1. Viral infection of upper respiratory tract
fungal), presence of complication (orbital,  Resulting from the obstruction of the sinus
intracranial), and associated factors (nasal polyposis, drainage and bacterial invasion
immunosuppression, anatomic variants) 2. Rhinitis
• There is a presence of infection in one or more sinus 3. Tooth abscess
cavities.  Especially maxillary dental infection
• If more than one sinus is infected, it is called 4. Swimming and diving trauma
pansinusitis  Can cause sinus irritation and impair drainage
• This is usually because of nasal swelling that may 5. Nasal surgery
obstruct the sinus opening which may impair the 6. Anatomical abnormalities
mucociliary function (the major cause of sinus  Like deviated nasal septum and nasal polyps
infection) 7. Barotraumas
• If there is an obstruction in the sinus cavity then it may  Those with increase barometric pressure like
cause a lower oxygen content in the sinus that may pilots and flight attendants that may lead to
facilitate growth of organism which may impair the impaired sinus ventilation and clearance of
local defenses and alter the function of immune cell secretions
• One is the nasal polyps
that may obstruct sinus
opening which may
facilitate sinus infection
 Constant irritation
from infection can
facilitate the growth
of the polyps

Pathophysiology  Normally the sinuses are translucent because

filled with air
 In sinus radiography or CT scan may show
opacification of the sinus, there is a thickened
mucous membrane and an air fluid level
indicating sinusitis
2. Nasal cytology
3. Transillumination
4. Endoscopy
Medical Management
The goal for managing sinusitis will be control of pain,
infection and provide sinus drainage
1. Avoid caffeine and alcohol – chronic case
Clinical Manifestations of Sinusitis  Causes dehydration
1. Pain over cheek and radiating to frontal region or  Adequate hydration and the use of nasal saline
teeth, increasing with straining or bending down sprays, analgesic (NSAIDs, acetaminophen),
2. Redness of nose, cheeks, or eyelids decongestants
3. Tenderness to pressure over the floor of the frontal  Including zinc which may stimulate the immune
sinus immediately above the inner canthus system such as pumpkin seeds, garlic, beans,
4. Referred pain to the vertex, temple, or occiput and fortified cereals
5. Postnasal discharge – purulent discharge 2. Elevate head of bed
6. A blocked nose  To facilitate breathing
7. Persistent coughing or pharyngeal irritation 3. Avoid irritating fumes
8. Facial pain 4. Antral irrigation or sinus lavage
9. Hyposmia or Anosmia  Can be performed when patient is not
10. Fever responsive to treatment or those with increase
11. Body malaise virulent exudates in the maxillary sinus
12. Pain or numbness in the upper teeth  Intranasal saline lavage is very effective in
13. Purulent or discolored nasal discharge adjunct therapy to antibiotics in order to relieve
14. Headache symptoms, reduce inflammations, and clear the
15. Sense of fullness in ears passages of stagnant mucus
16. Hyperemic and edematous mucosa  There is also a reduction in the likelihood of
17. Enlarged turbinates development of opportunistic infection or
18. Unpleasant breath microorganisms
19. Hoarseness  Humidification by normal saline to prevent
20. Loss of taste and smell crusting and in order to moisten the secretions
 Include nursing educations / health teaching to
Post Nasal Drip patient to avoid swimming, driving, air travel
There is an inflamed membrane and mucous discharge during acute infections and the use of warm
that is watery which may flow to the back of the pharynx compress to relieve pressure
down to the throat 5. Surgery: Antral Puncture
 Operative drainage is not done until after the
acute infection have subsided but exceptions
can be made if the pain remains severe and pus
fails to drain
Pharmacologic Therapy
1. Antibiotics – Amoxicillin, Clavulanic acid (Augmentin)
 Drug of choice since 2015
 To manage bacterial infection
Diagnostic Studies  If allergic to penicillin, doxycycline (coronamycin,
1. Sinus radiography quinolone, levofloxacin), Bactrim, clarithromycin,
 Assess and inspect the nasal mucosa through and azithromycin can be used as per doctor’s
transillumination. order

 Macrolides are not recommended in treating • Small sinus endoscopes are passed through the
antibiotic resistance nasal cavity and into the sinus to allow direct
2. Analgesic visualization of the sinus in order remove the diseased
3. Decongestants tissue or enlarge the sinus ostia
 Be cautious of rebound effect and hypertension • The problem with this is that there are more possible
 To reduce edema complications of the functional endoscopic sinus
 Should not be used for more than 3-4 days surgery (nasal bleeding, pain, scar formation), but
4. Steroids there are rare occasions that may cause patient to
 Steroid mucosal spray in order to reduce blindness from intraorbital hematoma formation or
mucosal inflammation direct injury to the optic nerve
 Antihistamine should be avoided because it may
increase viscosity of the mucus Caldwell-Luc Procedure
 First generation such as Benadryl is not usually • The radical antrostomy procedure, a type of surgery
used or recommended where the maxillary mucosal is irreversibly damaged
 Generation of Claritin may not have an effect on and indicate maxillary sinusitis
the viscosity of the mucus • An incision is made under the upper lip above the roof
of the teeth to enter the maxillary sinus
Chronic Sinusitis • Avoid blowing on nose and avoid forcing nasal
• Chronic sinusitis occurs when there is a recurrence of secretions back into the maxillary sinus
acute or subacute stage in which it may damage the • Upper denture should not be worn since they could
sinus mucosa causing irreversible tissue damage injure the operative area
Clinical Manifestations External Sphenoethmoidectomy

1. Headache • To remove the disease mucosal from the sphenoid or
2. Nasal obstruction ethmoid sinuses
3. Tenderness over the sinuses • Small incision under the ethmoid sinus on the lateral
4. Presence of purulent discharge nasal bridge
5. Unpleasant breath
6. Sense of fullness is ears Nursing Management
7. Hoarseness 1. Observe for signs of bleeding, respiratory distress
8. Chronic cough and edema
9. Post nasal drip  For the first 24 hrs. after surgery
2. Ice compress
Treatment for Chronic Sinusitis  May be applied to the nose and cheek to
The goal of treatment is to remove all disease tissue, minimize edema and control bleeding
restore drainage, and eradicate the infection 3. Position – semi to high-Fowler’s
1. Antral puncture and lavage  For the first 24 to 48 hrs. to minimize
2. Intranasal antrostomy postoperative edema
3. Functional Endoscopic Sinus Surgery (FESS) 4. Antral packing – remain in place for 36 to 72 hours
4. Caldwell-Luc procedure 5. Analgesic
5. External Sphenoethmoidectomy  Doctor may prescribe mild analgesic to minimize
discomfort
 Same instruction for Caldwell-Luc and FFES
Antral Puncture and Lavage
 Post-operative includes numbness of the upper
• In order to open the sinus and remove mucopurulent lip due to interruptions of the sensory nerve from
materials the mucosal incision
 The sensation may remain for several weeks
Intranasal Antrostomy
• Nasal window to open the sinus and allow pus/
Discharge Teaching
secretion to drain
1. Increase oral fluids
• A procedure to create a nasal opening
 To moisten the secretion
2. Avoid blowing of the nose for 7 – 10 days
Functional Endoscopic Sinus Surgery (FESS) 3. Sniff backwards or spit
• Necessary if non-operative measures failed to 4. Minimal physical exercise
reestablish sinus ventilation and mucociliary
clearance

5. Avoid strenuous activity, lifting and straining for 2 Signs and Symptoms of Rhinitis
weeks 1. Rhinorrhea
6. Take the prescribed nasal spray, oral medications 2. Sneezing
7. Seek consultation if with fever, severe headache, 3. Nasal congestion
nuchal rigidity, these are signs of potential 4. Sore throat
complications 5. Body malaise
8. Follow-up care 6. Fatigue
7. Generalized headache
Rhinitis
• There is inflammation in the mucus membrane of the o In chronic rhinitis, there is an abnormally large
nose amount of connective tissue so polyps that may
• The symptoms of rhinitis include: increase nasal cause atrophy of the mucus membrane and
cartilages may result in foul smelling exudates
drainage, normally the discharge is clear mucus
• If there is an infection that spread to the sinuses then
the drainage may become yellow or green Therapeutic Management
1. Bed rest
Acute Rhinitis 2. Fluids
• Also known as the common colds or coryza  Adequate fluids to prevent dehydration
• Could be bacterial or viral in origin 3. Proper diet
• It is not allergic rhinitis  Well-balanced diet includes vitamin C together
• Treated symptomatically plus 5 to 7 days with or with Zinc in order to stimulate immune system
without treatment if it is viral in origin 4. Isolation
• Self-limiting  Because it is contagious
• Virus may invade the upper respiratory tract 5. Antipyretics
6. Analgesic
Causative Agents  To relieve generalized myalgia
1. Rhinoviruses – between 5 to 40 y/o 7. Antibiotics
2. Syncytial virus – 3 years and below  Given if viral in origin to prevent secondary
3. Adenoviruses and coronavirus – winter and spring; infection by bacteria
contagious during the 1st 3 days
Nursing Management
Etiology 1. Avoid crowded areas
• Mode of transmission is by airborne droplets emitted  During cold season, client with chronic illness or
by the infected person by breathing, talking, sneezing compromised immune status should be advised
and coughing or even by direct hand contact. to avoid crowded places
• The finger is the greatest source of spread therefore,  Avoid person with obvious symptoms
handwashing is very important 2. Frequent hand washing
• Nasal mucosa and conjunctiva surface of the eye are  Most important to avoid contamination through
common portal of entry of the virus direct spread
 Avoid rubbing the eye and wash hands before 3. Reduction of physical activity
and after manipulating the nose  Encourage bed rest during acute attack
• Cold virus can survive for greater than 5 hours on the 4. Encourage increase fluid intake
skin and hand surfaces like plastic substance  Especially to liquify secretions
coughing is less important than finger  Ensure hydration to compensate for evaporative
• Antibiotic is not that effective against viral infection loss during fever
 Give tepid sponge bath but make sure to dry
Predisposing Factor – Acute Rhinitis properly and lightly cover to avoid chilling if the
temperature is greater than 38o Celsius
1. Frequently increased in winter and cold season
5. Note for any allergic reaction and precipitating
2. Overcrowding areas
factors
3. Staying indoors – dust and dander
6. Administration of antihistamine agent as ordered
4. Immune status of the client is decreased or
 Explain the medication to the client
susceptible to be afflicted with rhinitis especially if
7. Instruct patient not to blow through both nostrils
bacterial
 To equalize the pressure
5. Drug induced anti-hypertensive agents such as ACE
inhibitors or beta blockers like atorvastatin

 Do not blow too frequently or too hard because 6. Nasal polyps may be present
it may cause spread of infection to the sinuses
and sometimes ay cause perforated eardrum Diagnostic Test: Skin test to confirm any
hypersensitivity to pollens
Allergic Rhinitis – seasonal and perennial
Management: Treat the underlying cause
• Seasonal disorder associated with the exposure to
airborne particles such as dust, dander, pollens
Medications
Seasonal Rhinitis 1. OTC Antihistamine – pseudoephedrine (Dimetapp)
− Pollens from trees, flowers or grasses  Control symptoms but may have atropine like
− Last for weeks and disappear and recur the same drying effect which may dry the nasal secretions
time of the following year and also dry up bronchial secretions that may
− Usually peak during November and December worsen the cough
 May also result to dizziness, drowsiness,
Perennial Rhinitis
impaired judgement, except for patient using 2nd
− Intermittent and constant generation that may reduce drowsiness such as
− Resembles those of common colds or continuous Loratadine, Cetirizine
or repeated colds 2. Cromolyn (NasalCrom)
− May be provoked by household inhalants or food  A mast cell stabilizer that inhibits the release of
that is found in the environment or by food habits histamine and other chemicals
of an individual all year round 3. Corticosteroids
 When antihistamine is not effective to reduce the
Chemical Mediator of Allergic Reaction responsiveness of mucus membrane
• Wherein the plasma cells release the IgE antibodies 4. Leukotriene modifiers – montelukast (Singulair)
in response to specific allergen which attaches to  Given once a day
mast cells and basophils that could release the 5. Vitamin C and Zinc
chemical mediator  May help shorten the rhinitis
• Chemical mediator acts on the target cell of the body 6. Decongestant
causing tissue damage such as intravascular  Producing vasoconstriction of the capillaries
compartment wherein the patient may have reducing nasal swelling
anaphylactic shock  Take note that it may cause rebound nasal
swelling
❖ Skin – urticaria, atopic dermatitis, wheal-and-  Avoided to a person with HPN, heart disease or
flare reaction even hyperthyroidism because it has a systemic
❖ Respiratory – rhinitis, asthma attack effect that may cause elevations of this BP
❖ GI – nausea, vomiting, cramps, diarrhea 7. Desensitization Program
 Patient is instructed to avoid the antigens
Histamine Mast Cell – increase vascular permeability, and treated with antihistamine, steroid and
constricts smooth muscles, stimulates irritant receptors mast cell stabilizing spray
Leukotrienes – constrict bronchial smooth muscle,
increase vascular permeability
Health Education
Prostaglandins – stimulate vasodilation and constrict
1. Move to an area where pollen count is low
smooth muscle
 Or area with low air pollution
Kinins – smooth muscle contraction, increase vascular
2. Control indoor environment
permeability, stimulate secretion of mucus
 By removing irritating substance such as stuff
Serotonin – increases vascular permeability, stimulates toys, feather and even pets
smooth muscle contraction 3. Hyposensitization
 Educate patients with regards to
Clinical Manifestations of Allergic Rhinitis hyposensitization or also known as
1. Edematous, closed nostrils Immunotherapy wherein it increases the
2. Nasal mucous membrane – itch, burn and secretes threshold level of the patient towards offending
irritating discharge allergen
3. Sneezing – violent paroxysmal sneezing Immunotherapy
4. Eyes – red, burning and lacrimation − Gradual introduction of specific antigen
5. Congestion cause snoring

− Administration of small fibers of allergen extract  Corticosteroids − good for laryngeal edema and
to stimulate the Ig level thereby the allergen will hypotension
combine with the IgG instead of IgE
Radioallergosorbent Test (RAST) Vasomotor Rhinitis – unknown specific cause
− Laboratory determinations of IgE antibodies in • Causes the same symptoms as acute or allergic
serum rhinitis but has unknown specific cause
− Useful substitute when skin testing is • Client complaining of vaso rhinitis have negative
contraindicated culture and negative allergy evaluation
Skin Test • Treated symptomatically
− Introduction of an antigen to the skin surface or
directly beneath the skin Obstructive Sleep Apnea (OSA)
− To determine the body sensitivity and reaction to • A sleep disorder that involves cessation or significant
the antigen decrease in airflow in the presence of breathing effort
− The purpose is for diagnosis, desensitization, or • It is characterized by recurrent episodes of upper
immunization airway collapse during sleep
• These episodes are associated with recurrent
Different methods of skin test oxyhemoglobin desaturations and arousals from
Patch Test sleep
• Application of the test materials directly to the skin • Transmural pressure is the difference between
immediately covered with a small gauze dressing intraluminal pressure and the surrounding tissue
pressure
Scratch or Prick or Tine Test • Conditions characterized by partial or complete upper
• Wherein the antigen is applied to the superficial airway obstruction during sleep causing apnea and
scratch that penetrate the outer layer of the skin hypopnea
Apnea − cessation of spontaneous respiration
Intradermal Test Hypopnea − abnormally shallow and slow
• Usual skin test done to patient to test for the sensitivity respirations
to antibiotics • In OSA, the airway obstruction may occur when the
• Positive – indicates that the antibody responds to the tongue and soft palate folds backward and partially or
previous contact with antigens completely obstruct the pharynx
• Negative – there are several things to consider such • Usually last for 15 to 90 seconds
as: • During apnea period, the patient experience severe
 The antibody has been formed against the hypoxemia so there is a drop in the partial arterial
antigen oxygen
 Presence of active infection wherein there is no • During hypopnea may have increased partial arterial
enough time to build antibodies carbon dioxide
 Antigen has been injected too deeply • These changes are ventilator stimulants causing the
 Patient may be anergic, lack of reaction of the patient to partially awaken
body defense to the foreign substance
• Patient may experience some side effects such as:
Etiologies
 Itchiness
 Discomfort or pain – apply cold compress Anatomic − changes in the anatomical structure
 Allergic reaction to preservative wherein they 1. Anatomic factors
have to discontinue the substance  Enlarged tonsils; volume of the tongue, soft
 Anaphylactic shock – administer epinephrine tissue, or lateral pharyngeal walls); length of the
 Feeling of uneasiness soft palate; abnormal positioning of the maxilla
 Sneezing, nasal pruritus, generalized pruritus and mandible) may each contribute to a
 Pulse may become rapid, weak, or irregular decrease in the cross-sectional area of the upper
• If the reaction is not reversed by epinephrine, then airway and/or increase the pressure surrounding
doctors may prescribe diphenhydramine chloride to the airway, both of which predispose the airway
prevent the development of laryngeal edema to collapse
• Medications that are given: 2. Neuromuscular activity in the UA, including reflex
 Aminophylline − bronchospasm and activity, decreases with sleep
 Vasopressor − severe allergic reaction that may
cause dropping of blood pressure

Family Diseases Diagnostic Test

1. Hypothyroidism (increased soft tissue mass in the 1. Polysomnography (PSG) − monitor the chest and
pharyngeal region) abdominal movement, oral and nasal airflow, ocular
movement, and heart rate and rhythm
Genetics
Non-structure
1. Obesity
 Large neck circumference increases the amount
of parapharyngeal fat that may narrow and
compresses the upper airway
2. Male sex
 More prominent compare to women
3. Age
 After 65 years of age
 Because of the structure changes contribute to
the collapsibility of the upper airway
4. Postmenopausal state
5. Smoking and alcohol use Possible Complications
6. Sedative use 1. Cardiac problems
7. Habitual snoring with daytime somnolence 2. Increased insulin resistance
8. Supine sleep position 3. Erectile dysfunction
4. Traffic and workplace accidents
Structural Factors
5. Stroke or high blood pressure
1. Nasal obstruction 6. Memory psychological problems
 Predisposes patients with OSA to pharyngeal
collapse during sleep include polyps, septal Management
deviation, tumors, trauma, and stenosis
1. Weight loss program
Sex 2. Oral appliances
 Bring mandible and tongue forward to enlarge
1. Androgenic patterns of body fat distribution
the airway space
(deposition in the trunk, including the neck area)
3. CPAP – for severe care
predispose men to OSA
 Application of nasal mask attached to a high flow
 In general, sex hormones may affect neurologic
blower to adjust and maintain the sufficient
control of UA-dilating muscles and ventilation
positive pressure (for oxygenation problem)
4. BiPAP – for severe case
Signs and Symptoms of OSA  Capable to deliver a high-pressure during
1. Frequent awakening at night inspiration and most air is likely to be occluded
2. Insomnia in lower pressure during expiration/ exhalation
3. Excessive daytime sleepiness (for patient having problem with oxygenation and
4. Witnessed apneic episodes ventilation)
5. Snoring
6. Morning headache
7. Irritability
8. Tossing in bed, restlessness, turning in bed
5. Avoidance of alcohol intake

 3-4 hours before sleep may cause mild sleep
apnea
6. Surgery
Uvulopalatopharyngoplasty (UP3)
− Excision of nose tonsillar pillar and posterior soft
palate with the goal of removing the obstructing
tissue

 There is a white irregular patch infection in

candida albicans
Diagnostic Studies
1. Throat swab, culture and sensitivity test, or rapid
streptococcal antigen
Therapeutic Management
Genioglossal Advancement and Hyoid Myotomy 1. Antibiotic
(GAHM)  As per doctor’s order
− Made an attachment on the muscular part of the  Especially if the patient is suspected of having
tongue or the mandible streptococcal throat should be treated with
− Symptoms are in up to 60% of patients antibiotic even when the culture is negative when
infection is present
2. Bed rest
3. Warm saline gargles
 To sooth and decrease the edema of inflamed
pharynx
4. Ice collar – severe sore throat
 Sooth inflamed mucous membrane
Laser-Assisted Uvulopalatoplasty (LAUP) 5. Analgesics
− New surgical procedure that has been used to  For pain and antipyretic to reduce fever
treat OSA 6. Increase oral fluid intake
7. Bland liquids or gelatin
 To not irritate the pharynx
 Avoid citrus fruits for it may irritate the mucous
membrane
8. Hand washing techniques
Chronic Pharyngitis
Precipitating Factors
1. Habitual use of tobacco
Pharyngitis
2. Alcohol consumption
• Acute pharyngitis wherein there 3. Have chronic cough
is an inflammation or infection 4. Live in a dusty environment
of the throat or mucus 5. Excessive use of voice
membrane that may occur as a
result of chronic allergy or Nursing Management
constant post nasal discharge
1. Oral hygiene
• Caused by viral, bacterial and fungal infection
2. Health education regarding the use of antibiotics
• Both viral and bacterial pharyngitis are contagious by
 Complete antibiotic regimen
droplet spread
3. Do not share eating utensils, glasses, napkins, food,
• Common bacteria are group A beta hemolytic
or towels
streptococcus
4. Cleaning telephones after use
• Communicable period is about 3 days and subside 3-
5. Using a tissue to cough or sneeze
10 days after onset
6. Proper disposing of used tissues appropriately
7. Avoid exposure to tobacco and secondhand smoke
8. Replace toothbrush with a new one
1. Scratchy throat
2. Difficulty of swallowing
Tonsillitis
 Red congestion of blood vessels which is evident
for viral pharyngitis • Due to infection and inflammation of the palatine
3. Hypertrophy of lymphoid tissue tonsils
4. Intense red purple with patchy yellow exudates • Acute form may range from 7-10 days
 If for diarrhea, patient may have gray-white falls • Causative agent: streptococcus, the
membrane called pseudo membrane common infecting organism

Clinical Manifestations  If patient is still drowsy, observe if the patient

1. Severe pharyngitis or throat pain keeps on swallowing, it’s a possible sign of
2. Otalgia bleeding
3. Fever 2. Position – head turn to one side allow drainage
4. Difficulty of swallowing  Lateral decubitus position until patient is awake
 Dysphagia (difficulty swallowing) and alert to drain blood or other secretions
 Odynophagia (painful swallowing) through the nose and mouth
5. Tonsillar tissue – bright red and enlarged 3. Cool liquids
6. Foul breath  Give ice chips 1-2 hrs. after awakening
7. Tender cervical lymph nodes  Cold water or popsicle after 12-24 hrs. to sooth,
reduce edema and pain
Diagnostic Studies  Ice cream should be non-flavored
1. Platelet count 4. Avoid highly seasoned foods
2. Culture sensitivity test 5. Ice collar to neck
3. CBC, WBC, and bleeding time 6. Rinse mouth with cool water
7. Bed rest
Management  May resume normal activities after 2 weeks
8. Avoid clearing throat or coughing
1. Antibiotics – erythromycin
9. Avoid gargling
 Because of streptococcal microorganism
2. Bed rest
o Surgical sites will heal after 14 to 21 days
 Minimize activity
3. Increase oral fluid intake
4. Saline throat irrigation or gargle Complications of tonsillectomy
 Relieve discomfort Patients who have streptococcal tonsillitis
5. Antipyretics and analgesic 1. Pneumonia
6. Surgery: tonsillectomy and adenoidectomy (T&A) 2. Nephritis
 Streptococcus also affects the kidney
Indications for Tonsillectomy 3. Osteomyelitis
1. Recurrent and persistent tonsillitis 4. Rheumatic fever
 For at least 4x a year and does not respond to 5. Acute otitis media
antibiotic therapy, then the patient may have to 6. Acute rhinitis
undergo tonsillectomy 7. Acute sinusitis
 It is an elective procedure; not urgent 8. Peritonsillar/deep neck abscess
2. Hypertrophy of tonsils which distorts speech and
obstruct airway Laryngitis
 Difficulty swallowing due to obstruction • Inflammation in the mucous membrane lining the
3. Following resolution of a peritonsillar abscess larynx
4. Obstructed Eustachian tube occur • May or may not include edema of the vocal cord
 Patient who has obstructed eustachian tube that • Hoarseness is a common symptom due to the
may occur when there is an ear problem and inflammation of the vocal cord
sinus complication • There is an abnormal movement of the vocal cord
5. Sinus complications • Sometimes there will be a benign or malignant tumor
in the vocal cords
o Contraindicated patients to undergo • All of this may intervene with the normal motility of the
tonsillectomy are those with upper respiratory vocal cord which may produce an abnormal sound
infection, they have to wait until it is treated or
those with hematologic disorders such as
hemophilia, leukemia, hemolytic anemia before Risk Factors
proceeding to surgery 1. Exposure to irritating inhalants and pollutants
 Excessive use of tobacco and large consumption
of alcohol
Post-operative Management
2. Overuse of the voice
1. Observe any bleeding  Too much strain in the vocal cord
 By taking and monitoring the vital signs of the 3. Infections in other areas of the nose and throat
patient  Common colds, pharyngitis
 Hemorrhage is the most serious complication 4. Inhalation of volatile gases
after tonsillectomy

 Chemical agent such as glue, paint, thinner, and  Reduce the stickiness of the mucus and mobilize
other substance the mucus
5. GERD – gastroesophageal reflux disorder 5. Voice rest
 Allow edema of the vocal cord to subside
 Total voice rest, no whisper
6. Treat GERD
 Elevate head of the bed avoid eating or drinking
2-3hrs before going to sleep
 Avoid caffeine, alcohol or even tobacco because
these may increase gastric secretions
 Antacids can be prescribed or proton pump
inhibitor for a reflux laryngitis
7. Cool liquids and lozenges
Pathophysiology
Laryngeal Cancer
• There is a malignant tumor in the larynx
• The increase in incidence in men over 50 years of age
• Voice cord is spread slowly
because of lessen blood supply
whereas the extrinsic like epiglottis
may spread rapidly because of the
abundant blood supply and lymph
nodes
Diagnostic Test Common Cause of Laryngeal Cancer

1. Laryngoscopy 1. Tobacco use
 Laryngeal examination which visualizes the 2. Alcohol abuse – esp. large consumption
larynx to determine inflammation, polyps, edema 3. Voice abuse
or tumor growth  Those who use voice most of the time
2. CT Scan of the neck region 4. Chronic laryngitis
 High technology that visualizes the problem in 5. Exposure to industrial chemical
the laryngeal area 6. Unknown
7. Hereditary
8. Poor dental hygiene
Classification of Laryngeal Cancer by Anatomic Site

Glottic Tumors – true vocal cord
• ⅔ of the true vocal cord is affected
• Patient may experience hoarseness or voice changes
• Prevent the closure of the cord during speech and
may grow slowly
Clinical Manifestation • Interfere with normal closure and vibration of the vocal
cords
1. Acute hoarseness
2. Dry cough
Supraglottic – above the vocal cord
3. Dysphagia
• Affects ⅓ of the above vocal cord
Management • May cause pain in the throat especially when
swallowing and the patient may have the sensation of
1. Antibiotics
foreign body in the throat, neck mass, or pain radiating
 For bacterial infection
to the ear via glossopharyngeal and vagus nerve
2. Steroids
• Patient may have difficulty swallowing, throat pain,
 To reduce inflammation or edema
airway obstruction
3. Supplemental humidification
• Increases in size
 Liquify secretions and increase moisture in
• Carcinoma of the false cord partially hiding the true
coughing patients
cord
4. Mucolytic

Subglottic Tumor – below the vocal cord − The problem with brachytherapy is xerostomia,
• Affect 3% of the below vocal cord dry mouth or stomatitis
• No symptoms unless it obstructs the airway − Pilocarpine hydrochloride can be used to prevent
• Polyp can be single and smooth or lobulated salivation and relieve sores in the mouth
− Other mouthwash can be used such as mixture
of antacids like Benadryl and Topical Lidocaine
− The use of Hydrogen peroxide or Baking soda (1
tsp) + water (8 oz) to soothe the irritated tissue
Chemotherapy – not generally effective to advanced
laryngeal cancer
Proton Therapy – a radiation dose using a pencil
Clinical Warning Signs of Laryngeal Cancer beam technology directed at the tumor while
1. Change in voice quality or hoarseness preserving the nearby healthy tissue
2. A lump anywhere in the neck or body
3. Persistent cough, sore throat, earache Dietary Management
4. Hemoptysis 1. Includes soft, bland diet
5. Sores within the throat do not heal 2. Vitamin C, folate
6. Difficulty of swallowing or breathing 3. Herbs - green tea and garlic
7. Pain in laryngeal prominence
8. Enlarged cervical node Surgical Management
Can be through laser microsurgery, endoscopic or
• Cancer of the larynx most often is due to squamous tumor excision
cell carcinoma. It begins with a small patch then 1. Vocal stripping
becomes ulcerate then abscess may form 2. Cordectomy
• Cancer of the glottis grows slowly to limited lymphatic 3. Partial laryngectomy
supply 4. Vertical partial laryngectomy or hemilaryngectomy
• Cancer in the larynx may spread more quickly 5. Supraglottic laryngectomy
because there are abundant lymphatic vessels, 6. Total laryngectomy
• Distant metastasis may occur in the lung 7. Radical neck dissection
8. Artificial electronic larynx
Diagnostic Assessment
1. Visual exam / Laryngoscopy Vocal Stripping
2. Biopsy • Removal of the mucosa of the edge of the vocal cord
3. CT Scan followed with radiotherapy
4. MRI
5. Thyroid function study Cordectomy
 Indicate calcium level especially after surgery • Excision of middle third vocal cord
 It may cause the excessive removal of this tissue
Partial laryngectomy
that may affect the thyroid and parathyroid so, it
may need to check the calcium level • Smaller cancer; early stage
6. Hepatic function test • Removal of the small lesion on the true vocal cord
 For patients who are receiving
chemotherapeutic regimen Vertical partial laryngectomy or hemilaryngectomy
7. PET Scan • Removal of ½ or more of the larynx of one true vocal
 For staging the tumor size, locations of node cord
involvement, and the extent of metastasis
Medical Management
1. Radiation Therapy – during the early stage of tumor
even without metastasis
Brachytherapy
− Concentrated and localized method of delivering
radiation by placing a radioactive substance in
the tumor with high dose to target area while Supraglottic Laryngectomy
limiting exposure of the surrounding tissue • Indicated for supraglottic cancer

• Remove the superior portions of the larynx from the • When activated, creates a vibration that is transmitted
post vocal cord to the epiglottis. to the neck and into the mouth
• Sometimes it may extend upward to remove a portion • Words silently formed by the mouth become sounds
of the base of the tongue from the vibrations emitted by the device
• Lymph node dissection may be performed • Any type of artificial larynx requires muscle and
• Major postoperative risk is aspiration because of the tongue control and hand strength
epiglottis, which closes over the larynx has been • Electronic speech aid allow person to adjust tone,
removed therefore the airway is managed with a speech and volume
tracheostomy after surgery
• When the edema subsides in the surrounding tissue,
it can be removed
• Client needs to be taught on how to swallow to avoid
aspiration
Total Laryngectomy
• Removal of the entire larynx, permanent
tracheostomy is performed and always check for the
patency of the tube
• Loss of voice and sense of smells because no air can
enter the nose
• No risk for aspiration because the trachea and
pharynx are permanently separated by surgery so Complications After Surgery
unless a fistula formed from the trachea to the
1. Airway obstruction
esophagus
 Cause would be the edema on the surgical site
• Artificial electro larynx can be used
leading into the airway
 Loss of airway from planted tracheostomy tube
which is an emergency situation that requires
immediate intervention
2. Hemorrhage
 A blood stain in the sputum is expected in the
tracheal secretions in the first 48 hrs.
 If there is bleeding in the site of the tube, it is a
sign of hemorrhage
3. Carotid artery
 Carotid artery rupture results from a poor neck
Radical Neck Dissection
tissue integrity.
• Also referred to as radical neck dissection or “en bloc”
 This may result from a prior radiation therapy to
• Removal of lymphatic drainage channels and nodes
the area
including the sternocleidomastoid muscle, jugular
 Life threatening emergency situation and has a
vein and submandibular area to decrease the risk for
high mortality rate
lymphatic spread
4. Fistula formation
• Modified radical neck dissection that varies structure
 There is an abnormal opening between the two-
in the neck to minimize deformities
body cavity
• Removing some muscle in the sternocleidomastoid
 Especially for total laryngectomy, if there is a
fistula formation
 Patient is also at risk to develop aspiration
5. Tracheostomy stenosis
 There is a scarring and narrowing of the ostomy
site in the neck
 Usually occurs weeks or months after surgery
 Some may lead to narrowed airway and difficulty
breathing
 Stoma may be stretch often by the doctor
Artificial Electronic Larynx increasing larger tracheostomy tube
• Hand held battery powered speech and placed
against the neck

Nursing Intervention Types

1. Place patient in semi to high fowler’s position Extrinsic (Atopic) Asthma
 High risk for aspiration • Caused by external agents such as dust, molds,
 To decrease edema of the airway and facilitate spores, food (chocolate), pollens, danders
breathing may improve comfort of the patient • This is due to allergic reaction to specific allergen
2. Removal of secretions
 If patient cannot cough, suctioning is needed in Intrinsic (Idiopathic) Asthma
order to prevent secretions from being aspirated • We cannot identify specific cause that triggered
3. Coughing and lip breathing asthmatic attack, but there are many situations that
 Try to mobilize and eliminate the secretion precipitate asthmatic attack such as upper respiratory
 However, having a head and neck surgery, this tract infection, patients may have common colds or
would not be possible so suctioning of the exercise
trachea is needed
4. Cleanse the inner cannula for patients who have o Both of these extrinsic and intrinsic type of
tracheostomy asthma it can be trigger by changes in the
 By using hydrogen peroxide to loosen the environmental temperature, strong odor,
secretions then rinse with a water or saline stress, emotion, exercise.
solution o Especially for intrinsic type, stimulation of PNS
may cause the release of acetylcholine that
5. Observe aseptic technique may result to bronchoconstriction whereas if
 To avoid introducing microorganisms SNS is stimulated it may cause the release of
6. Chest physiotherapy and nebulization these muscle that may result to
 Recommended to prevent pulmonary bronchoconstriction.
complications
7. Rehabilitation for radical neck dissection Mixed Asthma
• Sometimes this is the complications of the bronchial
Obstructive Pulmonary Diseases asthma, called as “Status Asthmaticus”
Asthma • This is a severe asthmatic attack which does not
• Is one type of an obstructive airway disorder, this is respond to any pharmacological treatment in a few
due to increased resistance to air flow hours, so this is a life threatening
• Bronchial asthma is a chronic inflammatory disorder
that is marked by increase responsiveness of the Causes of Asthma Attack
airway to the various stimuli which may manifest by 1. Allergens – dust mite, pollens
airway smooth muscle contraction, hypersecretion of  Inhalation of these allergens
mucus and inflammation  Usually occur in childhood or adolescence or
• There is a bronchial hypersensitivity marked by patients who have family history
reversible airway of bronchospasm caused by: 2. Respiratory tract infections
 Increased mucosal edema  This is the most common precipitating factors of
 There’s a wrong constriction of the bronchial an acute asthmatic attack
smooth muscles  The infection may cause inflammatory changes
 Increase production of viscous mucus which in the tracheobronchial system which may alter
eventually may lead to increase mucus plugs the mucociliary mechanism
 Bronchial airway obstruction 3. Exercise-induced asthma (EIA)
 Over distention of the lungs  Patients may develop asthma after several
minutes of vigorous exercise such as climbing
stairs or walking gristly
 It may be characterized by bronchospasm,
patients may have shortness of breath, cough,
and wheezing
 During exercise, bronchospasm may be cause
by the loss of heat and water from the
tracheobronchial tree because of the need for
conditioning of the large volume of air, so it may
be exaggerated when exercising in a cold
environment

 It is recommended to those patients who have • Patients may also increase in mucosecretion because
history of asthma wearing a mask to prevent or of the edema formation and likewise it may also
to minimize attack increase amount of tenacious sputum (sticky sputum)
 Cromolyn Na, ß-adrenergic agonist is given prior • The late phase is the inflammation, usually peaks
to exercise in order to maintain a bronchodilation about 5-6 hours characterized by inflammation
during exercise. This is usually inhaled 10 to 20  The eosinophils and neutrophils may infiltrate the
minutes before exercise airway
 Stretching prior to exercise may also help the  It will be invaded by lymphocytes and monocytes
likelihood of developing symptoms into the area that may increase the airway
4. Nose and Sinus Problems resulting to air trapping in the alveoli
 Because of the altered mucociliary mechanism
5. Inhaled irritants – fumes, epoxy Pathophysiology
 These irritants may induce bronchospasm
through vagal reflex
6. Drugs – asthma triad (nasal polyps, rhinitis, asthma
and sensitivity to aspirin and NSAIDs)
 Beta adrenergic blockers that may trigger
asthmatic attack
 Adrenergic stimulation tries to inhibit the
bronchioles and prevent bronchodilation
 The doctor has to be very cautious in prescribing
these medications to patients who have history
of asthma
7. Chemicals or food additives – tartrazine
 Tartrazine may provoke asthmatic attack
8. Emotional factors and changes in hormone levels
 Because of the cholinergic response that may • Triggers are the extrinsic and intrinsic factors
cause bronchoconstriction through vagal • In muscle hypertrophy, there is a thickening of the
pathway membrane and when the goblet cells are being
 It may trigger an increase airway responsiveness stimulated, it may cause hypersecretions of the
to other factors through non-inflammatory mucus
mechanism • There’s an increase in vasodilation and permeability
9. Gastroesophageal reflux that may cause mucosal inflammation and it may also
 The reflux may act as bronchospastic factors secrete excess mucus that may cause a plugging
that may cause the vagal stimulation reflex that reducing the diameter of the airway that may increase
may result to bronchoconstriction the airway resistance and because of the chemical
mediators it may cause bronchoconstriction or
bronchospasm
Airway Response of Asthma
• If there’s an excess mucus, patient may have cough
The whole mark of the asthma is the airway
and the secretions would be a white gelatinous and
inflammation
sticky secretions
Spasm of Bronchial Smooth Muscle
S • Increase work of breathing − patients may also have
Because of these granules that is released from the muscle
Edema dyspnea because of decrease in airway diameter so
E Vasodilation and increased permeability that may cause that’s why asthma patients have expiratory wheezes,
edema formation prolonged expiration because the air is being trapped
Accumulation of Tenacious Secretions in the alveoli
A Hyperactive of the goblet cells that may cause increase
secretions of the mucus
• During the early stage, the muscles found beneath the

basement membrane of the bronchial wall. If there’s
an allergen, it may attach to the IgE receptors and the
muscles, activating the muscle to release granules,
these are the chemical mediators that may cause
bronchial smooth muscle constriction causing
bronchospasm

Clinical Manifestation 4. Radioallergosorbent test (RAST)

1. Chest constriction  Identify the cause of allergy, through this we can
2. Wheezes identify IgE antibodies
3. Thick, tenacious, white gelatinous mucus 5. CBC
4. Non-productive coughing  To check for eosinophil
5. Hypoxemia 6. C&S of sputum
6. Restlessness  To check for any bacterial infection
7. Tachycardia 7. ECG
8. Increased PR and BP  For patients with status asthmaticus, if there’s a
complication on the heart
Complications
1. Status asthmaticus
 It is a severe life-threatening complication of
asthma
 It is common that the patient may experience
respiratory arrest as status asthamaticus is not
responsive to medication resulting in severe
bronchospasm, inflammation and mucus
plugging
 There’s a force exhalation that may result to
increased intrathoracic pressure that may be
transmitted in the great vessels, the heart,
• During respiration you will observe nasal flaring and causing pulmonary hypertension, sinus
retractions of the intercostal space during physical tachycardia, ventricular arrhythmias, and all of
examination if it is severe these conditions is related to hypoxemia
• Productive cough with thick gelatinous sputum  Signs and symptoms would be:
• Shortness of breath because of inflammatory process
Extreme anxiety Tachycardia
that occur in the tracheobronchial tree
Sweating Chest tightness
• Expiratory wheezes due to air trapping in the alveoli Diaphoresis Dry cough
so there will be carbon dioxide retention
Expiratory Wheezing
• Patients may have prolonged expiration making them
prone to develop respiratory acidosis if no medication  Dry cough is due to reduction in the diameter of
or treatment is done immediately the airway because of the inflammation and air
• Hypoxia that may result to increase HR and RR trapping inside that even the tenacious secretion
or mucus is being trapped in the alveoli
 The patient may also manifest extreme
Diagnostic Studies orthopnea and obviously there is an increase
1. Pulmonary function test work of breathing that may develop
 Especially during the initial visit to their physician 2. Pulsus Paradoxus
 ↓ peak expiratory flow rate and ↓ force expiratory  Dropping of systolic pressure
volume because of the air that is being trapped  Normally during inspiration, the systolic blood
in the alveoli pressure may decrease <10mmHg and the pulse
 ↑ functional residual capacity and ↑ residual rate goes up slightly because of the intrathoracic
volume because there’s a problem in the outflow pressure become more negative
of air  But in pulsus Paradoxus, there’s a fall on arterial
2. Arterial Blood Gases (ABGs) BP of >10mmHg during inspiration
 Can be done to patients because of the retention 3. Acute Cor Pulmonale
especially seen in severe asthma or status  Hypertrophy of the right side of the heart
asthmaticus wherein there is a retention of pCO2  With or without heart failure resulting from
which may lead to respiratory acidosis pulmonary hypertension
 There is a slight elevation of pO2 in the mild  If there’s a chronic alveolar hypoxia, it may
stage cause muscle hypertrophy stimulating
 If the patient develops acidosis there is a erythropoiesis resulting to polycythemia and
significant increase in the pCO2 increased viscosity of the blood
3. CXR 4. Pneumothorax
 In order for us to reveal hyperinflation

 Because of the rapid accumulation of air in the Patient Teaching

pleural space causing an increase in intrapleural 1. Adaptive breathing techniques
pressure that may result to tension on the heart  Decrease the work of breathing and facilitate
and great vessels exhalation of carbon dioxide
2. Relaxation technique
Management  Reduce their panic and anxiety
1. Maintain patent airway to relieve bronchospasm and 3. Proper positioning
to clear the excess secretions  Facilitate breathing
4. Increase fluid intake
Bronchodilator
 Liquefy the tenacious secretion
ß-adrenergic agonist drugs produce broncho-
5. CPT
dilation and increase mucociliary clearance
 After nebulization to facilitate loosening and
(albuterol, salbutamol)
bubbling of the secretions
Magnesium sulfate may also be given to act as 6. Diet
bronchodilator  High protein − to support immune system
Methylxanthines through IV like aminophylline, it is  Low CHO − because the metabolism of
not being given through oral but this is given carbohydrate may yield more carbon dioxide
through parenteral by incorporating this in IV fluids  Avoid gas-forming foods or carbonated drinks −
Antihistamine it may limit the movement of diaphragm and
Diphenhydramine – this is the common wherein it hamper abdominal breathing
tries to compete with the histamine in the receptor  Very hot or cold foods − which may induce cough
Anti-inflammatory − works synergistically with beta spasm
adrenergic agonist to decrease mucus secretion like
Solu Cortef that is being administered parenterally Effective Ways of Using MDI or DPI
Corticosteroids – in order to relieve inflammation and 1. Tilt head back slightly and breathe out
edema; blocks the late phase response  Do not breathe into your inhaler
(betamethasone, prednisone) 2. Close your lips lightly around the mouthpiece of the
inhaler
Mast Cell Stabilizers − this is given before or it’s not
3. Breathe in deeply and quickly
use during acute attack, this is to prevent the release
4. Hold your breath for 10 seconds
of histamine (cromolyn Na)
5. Do not put the inhaler directly to the mouth
Leukotriene Montelukast (Singulair) – block the  It should be held 2 fingers width or about 11/2
action of leukotriene, one of the chemical mediators. inches then after that, gargle
This is given before exercise, do not inhibit late
phase it means it is only effective prior to the release
of muscle, prior to inflammation Metered-Dose Inhaler (MDI)
Anticholinergic – inhibits bronchoconstriction; it
blocks the acetylcholine in order to have effect on the
bronchus to cause bronchodilation (Atrovent,
Combivent)
2. Maintain supplemental gas exchange – O2
supplement
 For severe like status asthamaticus they are
hook to mechanical ventilation through
endotracheal intubation to improve gas
exchange Dry Powder Inhaler
3. Sodium Bicarbonate
 Treat respiratory acidosis
4. Nebulization
 Decrease airway resistance
5. Preventing complications
 Acute respiratory failure and status asthmaticus
(may cause respiratory arrest)
6. Alleviate anxiety
 The patients may become restless during
asthmatic attack

Chronic Obstructive Pulmonary Diseases

• Also referred to as chronic airway limitation or chronic
obstructive lung disease
• Chronic bronchitis and emphysema
• There’s a presence of airflow obstruction
Etiology of COPD
1. Cigarette smoking – benzopyrene
 It may cause hyperplasia of the goblet cells that
may result to increased production of mucus
 If there’s a production or a lot of secretion in the
bronchial area, there will be a reduction in airway
diameter so patients may have difficulty in flaring Emphysema
the secretions • Permanent over distention of the air spaces
 Benzopyrene – it may damage the ciliary; its • Also known as “pink puffers”
more dangerous than other component in the • The elasticity of the alveoli loss its function, it cannot
cigarette as it may cause abnormal dilation of the recoil anymore thereby remains dilated
distal air space
2. Infection – recurrent RTI
 It may impair normal defense mechanism so the
retained secretion may be a good medium for
further proliferation
3. Heredity – alpha-1-antitrypsin deficiency
 Premature emphysema that is seen in patient
with emphysema, it may cause the lysis of the
lung tissue from neutrophils and macrophage
that may inhibit the action of this enzyme
 More common in emphysema because it is a
genetic abnormality that may lead to COPD
4. Aging – changes in the lung structure
 As person age, there’s a gradual loss of elastic Chronic Bronchitis
recoil of the lungs so the number of functional • Normal bronchus: the diameter is wide, there’s no
alveoli is also reduced as a result of loss of problem with the inflow and outflow of air
alveolar supporting structure • With bronchitis: there’s an inflammatory process
 Thoracic cage – as the patient age it becomes occurring in the bronchial area, there’s a plugging of
thick and rigid and the ribs are less mobile. So, mucus because the cilia is also damaged affecting the
the shape of the ribs is gradually increased or small airway
changed which may increase the functional
residual capacity therefore, there’s a reduction in Acute Bronchitis – inflammation of the bronchial area
the compliance of the chest wall and increase and is self- limiting, just have adequate intake of
the work of breathing fluids, bed rest, anti-inflammatory agents, cough
suppressant or bronchodilators as per doctor’s order
Types of Obstructive Airway Disease Chronic Bronchitis − may obstruct the small airway
Chronic Bronchitis that may cause a severe hypoxia that’s why they call
it as the “blue bloaters”
• Affect the small airways
 There’s a mismatching of ventilation and
• Also known as the “blue bloater”
perfusion
• Usually secondary to severe hypoxemia because of
the excess production of mucus in the bronchi and
persistent coughing so there’s some changes or
hyperplasia of the mucosecreting gland which is the
goblet and there’s a reduction in ciliary activity

Pathologic Changes in Chronic Bronchitis 3. Chest X-ray − usually done to patient with respiratory
problem
4. Blood test
Treatment of Chronic Bronchitis

1. Stop smoking
 The only way is to stop smoking, the only
measure if the reason is due to smoking
2. Immunization
 Vaccinations become effective after 10-14 days
after administration
 Encourage patients especially the elderly to
submit their selves to vaccinations
1. Hyperplasia of mucous-secreting in the trachea and 3. Wearing a cold-weather mask or scarf
bronchi  To decrease or relieve spasm
2. Increase goblet cells 4. Antibiotics
3. Disappearance of cilia − because of the damage  To prevent infection because of the excessive
4. Chronic inflammatory changes and narrowing of mucus accumulation in the lungs
small airways  If the patients have bacterial infection already
5. Altered function of alveolar macrophage  Augmentin, azithromycin, doxycycline
 May lead to bronchial infection 5. Diet
6. Accumulation of secretion  Small frequent feeding to reduce the work of
 Not only because there is a small airway but it breathing, less effort of breathing
affects the cilia with increase production of  ↓ CHO as it may yield more carbon dioxide
mucus 6. Medications
7. Coughing − one of the defense mechanism  Anticholinergic − produce bronchodilation by
8. CO2 retention blocking the PNS
 Patient is at risk to develop acidosis  Adrenergic drugs
9. Bronchial infection  Theophylline − improve respiratory muscle
 Because of the proliferation of this bacteria in the function and increase mucociliary clearance
secretions 7. O2 therapy
 May have difficulty of breathing, hypoxia
Clinical Manifestations of Chronic Bronchitis 8. Surgery
1. Shortness of breath with progressive decrease in  If there’s a distended area of the lungs, lung
exercise tolerance volume reduction surgery (LVRS) or lung
2. Labored breathing even at rest transplantation is done
3. Hypoxemia
 Reduction in oxygen level in the blood which Complications of Chronic Bronchitis
may also stimulate the production of RBC that 1. Cor Pulmonale
may result to polycythemia (there’s an increase  Hypertrophy of right side of the lungs resulting
in blood viscosity) from pulmonary HPN because of the pressure on
4. Expiratory wheezes and crackles the pulmonary vasculature
5. Hypercapnia  Management: oxygen therapy, diet, reduce
6. Right-sided heart failure with peripheral edema intake of sodium, diuretics
 Because of cor pulmonale 2. Acute Exacerbation of Chronic Bronchitis
7. Productive cough in the morning  Colonized with streptococcus pneumonia and H.
8. Feeling of epigastric fullness Influenza which are non-pathogenic in these
9. Distended neck vein patients
10. Ankle edema  Signs and symptoms: Cough may worsen,
11. Clubbing fingers presence of hemoptysis, wheezing, SOB,
12. Pulmonary HPN viscosity of mucus become thick
 Management: Antibiotic, increase of
Diagnosis bronchodilator agents, corticosteroid,
1. Physical Examination − IPPA technique humidification, postural drainage
2. Pulmonary function test 3. Acute Respiratory Failure
4. Peptic ulcer and GERD

 Side effect from the long-term use of • Predominantly affects male smokers
bronchodilators and corticosteroid • It affects the bronchioles in the central part of the
5. Pneumonia – very common respiratory lobules with initial preservations of the
alveolar duct and sac
Emphysema
Panlobular
• Enlargement of air spaces and destruction of lung
• Lower parts of the lungs
tissue
• Not only the respiratory bronchioles are affected but
• There is an abnormal permanent enlargement of the
also the alveolar duct and sac
airspace in the thermal bronchioles and alveoli
• Common in patients with alpha 1 anti-trypsin
• Destruction of the lung tissue may cause increase in
deficiency and also found in smoker
lung compliance, decrease in the diffusing capacity,
and increase in the airway size during inspiration
which may cause collapse of the airway during
exhalation
• The destruction of normal lung lobules in emphysema
leads to a reduction of lung function
Etiology of Emphysema
1. Smoking
 Caused by lung decrease
2. Inherited deficiency of α 1-antitrypsin
 Which protect against proteases that have the
ability to breakdown the elastin and lung tissue Pathophysiology
3. Respiratory tract infections
 Decrease level of alpha 1 antitrypsin level
4. Inhaled irritants
5. Aging
6. Allergic factors
Pathogenesis of Emphysema
1. Inflammation
2. Fibrosis of bronchial wall
3. Hypertrophy of the submucosal glands
4. Hypersecretion of mucus
5. Loss of elasticity of the lung fibers and alveolar tissue
L Loss of elastic recoil (remain distended)

A Air trapping
• Irritants may lead to increase production of neutrophil
T Thoracic overdistention (barrel chest appearance)
and macrophage and this will release proteolytic
S Sputum over production (↑ introduction of mucus)
enzyme destroying the alveolar tissue causing
derangement of elastase due to decreased level of
Types of Emphysema alpha 1 anti-trypsin. The elastin and collagen will
Centrilobular destroy the lungs that causes enlargement or
• Changes in the upper parts of the lungs destruction of the alveoli.

• Once there’s a destruction of the alveoli the air Diagnostic Studies for Emphysema
becomes trapped because of the inability to recoil 1. ABG – elevated pCO2; decreased pO2
resulting to impaired gas exchange  To check for any respiratory acidosis, changes
• Due to the enlargement and destruction of alveoli, in the pH, partial arterial oxygen and carbon
there will be some changes in the chest of the patient, dioxide
usually may appear barrel chest. 2. Serum electrolyte
• There will be hyperinflation and over distention due to  Potassium depletion due to diuretic
air trapping, there is too much oxygen entering the administration
lungs causing to the inability to remove the carbon 3. Pulmonary function test
dioxide because the patient may seem to be adequate  FEV, FVC, TLC, RV due to decrease in the
of oxygen that’s why they call it as the pink puffer, a elastic recoil
type of disorder 4. CXR
• Eventually because of the air that is being trapped in  Flattened diaphragm, increased A:P diameter,
the alveolar or distal area or air spaces and cannot widened intercostal space, and presence of bulla
recoil there’s a coalesce forming a bleb
Collaborative Management of Emphysema
1. Avoid causative factors
 Cigarette smoking, alcohol intake,
environmental pollutants that inhibits mucociliary
function
2. Bedrest
 Reduce the oxygen demand of the tissue
 Liquefy the secretions
4. Oral care − hygiene
 Improve the well-being of the patient and prevent
bacterial infection because of too much
secretions that is being expectorated by
coughing
5. Diet
 High calorie, high protein, low CHO
 Carbohydrates may be yield end products of
Clinical Manifestation of COPD CO2 which may result to CO2 accumulation
1. Narrow airway 6. O2 therapy
 Loss of lung elasticity 7. Intubation and Mechanical ventilation
2. Easily fatigued  If the patient has a problem to give supplemental
 Increase work of breathing oxygen or the patient cannot maintain partial
3. Frequent respiratory infection arterial oxygen above 40 mmHg
 Because of accumulation of secretions in the 8. CPT and nebulization
distal area  Aerosol inhalation is a bronchial hygiene
4. Use of accessory muscle to facilitate breathing measure
5. Orthopneic or tripod position 9. Medications (listed below)
 In order to breath easily 10. Intravenous augmentation therapy
6. Pursed lip breathing  Increase serum levels to greater than 11 mmol/L
 In order to exhale the air out of the lungs  Therapy for those who have deficiency of alpha
7. Barrel chest 1 antitrypsin protein, by administering or
8. Digital clubbing obtaining a blood plasma of alpha 1 anti-trypsin
protein of a healthy human donor to increase the
alpha 1 level circulating in blood
Lip Pursing
 Goal of this is to increase the level of alpha 1 in
the lungs to protect the lungs from destructive
effect of the neutrophil and elastase in which
these enzymes are released from our body by
WBC as a response to inflammation or infection

 Primary goal is to limit or slow down the 3. Patient teaching

progression of lung destruction by replacing the  Prevention of recurrent infections − avoid over
deficient protein crowded areas, avoid individual with known
11. Surgery (listed below) infection, receive immunization for influenza and
pneumonia, and report for worsening of
Drug Therapy symptoms
1. Expectorants (Guaifenesin)  Control environment − use of cold humidifier (30-
2. Mucolytic 50% of humidity), wear scarf over nose and
3. Antitussive (Dextromethorphan) mouth during cold weather to prevent
 Observe for drowsiness, avoid activities that bronchospasm, avoid smoke (may trigger cough
involve mental alertness (driving, operating which may affect mucociliary activity and
electrical machine) mechanism), and avoid abrupt changes in
 It may cause constipation (increase fiber intake temperature
of the patients)  Avoidance of inhaled irritants − stay indoor if the
4. Bronchodilator (aminophylline, salbutamol, pollutions are high or use air conditions with high
terbutaline − Bricanyl) efficiency to particulate air filter to remove
 To treat bronchospasm particles from the air
5. Metaproterenol − observe for tachycardia 4. Avoidance and diet
6. Anti-histamine − observe for drowsiness  High calorie diet provides source of energy
7. Steroids − anti-inflammatory affect  High protein helps maintain integrity of alveolar
8. Anti-microbial − to treat bacterial infection wall
 Low CHO limits carbon dioxide production
Surgery
1. Bullectomy
 Involves the removal of large emphysematous
bulla that compresses the adjacent lung tissue
that causes dyspnea
2. Lung volume reduction surgery (LVRS)
 Reducing the size of hyperinflated
emphysematous lungs and decrease airway
obstruction
3. Lung transplant
 To improve functional capacity
Restrictive Respiratory Disorders
Nursing Interventions for Emphysema Restrictive − decrease in the compliance of the lungs or
1. Improve ventilation chest wall
 Place the patient in semi high fowler’s position or
sometimes in a tripod position Pneumonia
 Encourage the use of diaphragmatic muscles in
• Inflammation of lung parenchyma in which
breathing and encourage productive coughing
consolidation of the affected part and a filling of the
after all treatment by splinting the abdomen to
alveolar air spaces with exudate, inflammatory cells,
help reduce more expulsive cough
and fibrin usually associated with a marked increase
 Pursed lip breathing technique, a prolonged slow
in interstitial alveolar fluid
relax expiration against pursed lip may increase
• Pneumonitis – a non-infectious bronchial and alveolar
the resistant to outflow of air
inflammation
 Oxygen therapy as ordered, do not give high
• Predisposing factors: Smoking, COPD, deficiency in
concentration of oxygen, just about 1-3L/min but
immune system, use of alcohol, and old age
the safest is placing the oxygen at least 2L/min
2. Facilitate removal of secretions
 Through increase of oral fluid intake of the Bacteria Associated with Pneumonia
patient in order to liquefy the mucus Gram Positive: streptococcal pneumonia are the most
 CPT, coughing and deep breathing, use of common type of bacterial pneumonia or staphylococcus
nebulizer, postural drainage, and suctioning aureus
 Provide oral hygiene after expectoration of Gram Negative: H. influenza, pseudomonas
sputum to prevent infection or bacterial infection aeruginosa, klebsiella pneumonia

Virus: influenza or parainfluenza • Streptococcus pneumonia − usually seen in infant,

Opportunistic Organism: amoebiasis and pneumocystis elderly or patients who have CAD, alcoholism, sickle
carinii pneumonia seen in patients with AIDS cell disease or diabetes
 May occur as a result of decrease bacterial ability
of the alveolar macrophage because of the
Routes of Bacteria Reach the Lung
extreme virulence of the bacteria or even the
Inhalation − one route for the bacteria to reach the lungs
susceptibility of the host against infection
because of the ambient air
• Viral − Produces patchy inflammatory changes that
Aspiration − which is previously colonized in the upper are confined in the alveolar septum and interstitium of
airway and usually seen in patients with altered the lungs
consciousness, depressed cough and epiglottis reflex  There are fewer striking symptoms and physical
which allow aspiration or may result to aspiration finding than bacterial
Direct spread from contagious infected sites −
hematogenous spread Cardinal Signs of Pneumonia
Critical ill patient – ET, NGT − patients with NGT or ET 1. Cough
may interfere with the normal cough reflex and 2. Sputum production
mucociliary escalator mechanism which may pass air 3. Pleuritic chest pain
pressure and humidification in the upper airway 4. Shaking chills
5. Fever − 90% may have bacterial fever
Pathophysiology
• Common features of all type of pneumonia is an

inflammatory pulmonary response to any offending
agent or organism resulting to lung stiffness, Phases Occur in the Alveoli
decrease in compliance in the vital capacity, and Engorgement / Congestion / Hyperemia (1st 4 – 12
cause hypoxia hours)
• Invasion of respiratory system − loss of cough reflex • Due to the engorgement of the alveolar space with
or damage of the ciliated endothelium that lines the fluid and hemorrhagic exudate
respiratory tract or impaired immune defenses • It is a rich medium for infiltration and rapid spread of
• Hypoxemia − due to inflammation organism through the lobe
• The alveoli are edematous, presence of serous fluid,
infection may spread to the entire lungs
Red Hepatization (next 48 hours)

• Hepatization because the lungs appear liver like
• There’s a dilation of the capillaries and the alveolar is
filled with organism including neutrophils, RBC and
fibrin
Gray Hepatization (3 − 8 days)

• 90% of the cases of pneumonia is due to bacterial
• Decrease in blood flow
pneumonia this is a result from inflammation and
• Leukocytes and fibrins consolidate in the affected part
exudations of fluid in the air field space of the alveoli
of the lungs

Resolution (7 – 11 days)  Coughing and deep breathing, and increase in

• Wherein the exudate is lysed and reabsorbed by oral fluid intake
macrophage restoring the tissue to its original 4. Oxygenation via nasal cannula
structure
Different Types of Pneumonia
o Healing occurs when there is no complication Community Acquired Pneumonia “CAP”
• Either viral or bacterial
2nd and 3rd Phase of Pneumonia • The patient may develop infection within 48 hours
after admission to the hospital
• Organisms: streptococcal, pneumococcal
Hospital Acquired Pneumonia “Nosocomial Pneumonia”

• The lower respiratory tract infection that was not
present or intubating so the infection occurs after
48hours upon admission
• The usual organisms present in hospital setting are
Diagnostic Assessment pseudomonas, Enterobacter species, Klebsiella, E.
1. CBC and WBC (Hematogram) coli
 Increase number of WBC • Those who are at risk are those who are hooked to
2. Erythrocyte sedimentation rate (ESR) mechanical ventilator or patient who have chronic
3. CXR lung disease or airway instrumentation (ET,
 Any diffuse patches in the lungs or consolidation Tracheostomy)
in the lobe
4. ABG analysis Aspiration Pneumonia
 Assess for the need of supplemental oxygen • Occur as a result of aspirated gastric content
5. Sputum studies – gram stain and culture • In patient with altered state of consciousness due to
 Identify the organism whether staphylococcal, seizure, drugs or alcohol, and anesthesia
streptococcal or klebsiella • It may occur when the anatomy is altered by
6. CT scan esophageal stricture or patient who have
7. Blood culture tracheostomy or NGT
 Assess systemic spread, leukocytosis for • It has a poor prognosis even with antibiotic therapy it
bacterial infection may cause extensive lung damage resulting in lung
abscess or emphysema
Management • May also lead to exudation and severe case of acute
respiratory distress syndrome
1. Antibiotic therapy
 Macrolide (Zithromax, azithromycin) − if they are
Legionnaires Disease
allergic to macrolides doctor may prescribe
doxycycline in the form of Vibramycin • A form of bronchopneumonia with the causative agent
 Streptomycin may be prescribed but avoid using of legionella agent which is frequently found in water
these antibiotics during minor viral infection particularly, warm standing water
because it may result to upper airway • Symptoms appear 2-10 days after infection
colonization with antibiotic resistant bacteria • Immunization may protect the patient for about 5
 Ceftriaxone, Sulbactam, Levofloxacin as years
monotherapy to those unknown drug resistance
 Multi drug resistant: Septacidin, vancomycin, Pleural Effusion
piperacillin or tazobactam • Pleurisy or pleuritis −
2. Measure to alleviate symptoms due to inflammation of
 Humidification visceral and parietal
 Prescribe antipyretics (fever) pleura
 Prescribe analgesic (myalgia) • The pleural fluid is about
 Mucolytic or expectorant (productive cough) less than 10-20ml that
 Bronchodilator (difficulty of breathing due to separates the two layers
bronchospasm) so there’s an abnormal
3. Client Education collection of fluid in the
pleural space resulting

from excess fluid production or decreased absorption the drainage of protein resulting to accumulation of
or both fluid and cells in the area of inflammation that
• Usually secondary to other diseases increases capillary permeability that is a characteristic
• Pleural effusion may be a complication of heart failure, of inflammatory condition like cancer
TB, pneumonia, pulmonary infections (particularly
viral infections), nephrotic syndrome, connective
tissue disease, pulmonary embolus, and neoplastic
tumors
• There’s an accumulation of fluid in the base of the
lungs
Mechanism of Pleural Effusion

Increase Capillary Pressure − increase in the
hydrostatic pressure that can be seen in patients with Pathophysiology
lung cancer, heart failure due to blockage of the
lymphatic drainage system and change in osmotic
pressure
Increase Permeability − occur in patients with
inflammatory conditions or neoplastic effusion
Increase Negative Intrapleural Pressure
Decrease Colloidal Osmotic Pressure − patients may
have a decrease in albumin content which occur in
• Percussion − dullness due to accumulated fluid
patients with liver diseases
• Auscultate − diminished or decrease in breath sounds
Impaired Lymphatic Drainage − result to obstruction
• Pleural pain − friction between the visceral and
process such as mediastinal carcinoma
parietal space
1. Sharp pleuritic pain
 Abrupt, unilateral and usually localize in the
lower lateral part of the chest
 May become worsen by chest movement during
deep breathing or coughing due to the changes
in pressure
2. Dyspnea − common
 When the fluid compresses the lungs, it may
Classification of Pleural Effusion
result in decreased ventilation
Transudate Exudate 3. Decrease breath sounds, dull, flat sound upon
Appearance Clear Cloudy percussion, decreased fremitus
Specific Gravity < 1.012 > 1.012 4. Tachycardia
Protein < 3.0 g/dL > 3.1 g/dL 5. Cough
LDH < 200 U > 200 U 6. Fatigue
7. Tracheal deviation from affected side
Transudate  The pressure tries to pull the trachea on the
• Due to non-inflammatory conditions from an affected side
imbalance of hydrostatic pressure and oncotic
pressure Diagnostic Evaluation &Treatment
• There’s an elevation of hydrostatic pressure and 1. CXR
reduction in oncotic pressure  Determine the side to recheck the structure of
• There’s a disturbance in the flow of protein in the the lungs
pleural space 2. CT scan
3. Physical exam − IPPA
Exudate 4. Thoracentesis
• Result from the disease of the pleural surface or any  Aspirate the fluid to categorize if it is a transudate
obstruction of the lymphatic system which prevents or exudate

5. Pleural biopsy mediastinum towards the unaffected area unlike in

 To get sample of this specimen especially to atelectasis the tracheal shifting towards the affected
patients with bronchogenic CA site
6. Pleurodesis
 Instillation of sclerosing agent (tetracycline,
bleomycin, talc) into the pleural space
 This is to remove the pleural space by forming
adhesions between the visceral and parietal
pleura
 Done in bed side, assist the doctor, and
reposition the patient every 15 mins for equal
distribution of the sclerosing agent
 This is a palliative method use for the treatment Open – gunshot
of pleural effusion caused by malignancy • Air enters the pleural space through an opening in the
7. Open surgical drainage chest wall such as gunshot wound or surgical
8. VATS – video assisted thoracotomy surgery thoracotomy
9. Tube drainage or water seal drainage
1. Consent for thoracentesis
 Check if the patient needs to undergo surgery,
thoracentesis, or even pleurodesis
2. Positioning
 Place in high fowler’s position to promote
ventilation and optimize diaphragmatic
contraction Tension − mechanical ventilation and resuscitative
3. Emotional support efforts
 Manifested by hyperventilation as a causative • Due to the rapid accumulation of air in the pleural
factor space caused by high intrapleural pressures that may
4. Coughing and deep breathing exercises result to tension in the heart and great vessels
 Facilitate lung expansion to prevent lung • Increased intrapleural pressure may lead to lung
atelectasis collapse so shifting of the mediastinum in the
5. Splint chest unaffected site
 Reduce pain during coughing
6. O2 therapy
 Given as ordered to improve gas exchange and
to reduce the work of breathing
7. Incentive spirometry
 Teach the Px how to use incentive spirometry
8. Antibiotic therapy
 If it is brought by infection
Pneumothorax
Causes of Pneumothorax
• Presence of air in the pleural space
• As the air enters the pleural space from an opening to Traumatic Pneumothorax − there’s an Injury that may
the chest wall or the lung itself be cause by penetrating or non-penetrating injuries like
fractured ribs or multiple rib fracture
Flail chest
Types of Pneumothorax
– Multiple rib fracture
Closed – no external wound, spontaneous
− Frequently a complication of a blunt chest trauma
pneumothorax
from a steering wheel injury resulting to multiple
a. perforation of the esophagus and adjacent rib fracture that may cause free
b. injury from broken ribs floating of the rib segment
c. ruptured blebs or bullae − Patient may have hypoxemia and compromised
• In the image there is shifting of the mediastinum, as gas exchange
the air enters the chest wall, it pushes the

− Respiratory acidosis as a result of carbon dioxide Flail Chest Paradoxical Breathing

retention • A patient with a blunt chest injury may develop flail
Paradoxic Chest Movement chest, in which a portion of the chest “caves in”, this
− During inspiration, the affected portion sucked in results in paradoxical breathing
and bulges during exhalation
− Increase in dead space, reduce in lung
compliance and reduce in alveolar ventilation
− Prevents adequate ventilation of the lungs in the
injured area
Spontaneous Pneumothorax − no apparent cause, no

injury
Rupture of a blebs on the visceral space
− Cause of bleb is unknown
− The blister on the lung surface ruptures and allow
atmospheric air from the airway to enter the
pleural space
Primary
− Occurs in healthy persons or young people
Interventions for Flail Chest
− Common in young men and tall boys between 10-
1. Humidified O2 therapy
30 years of age because of different pressure
2. Infusion of crystalloid IV solution
from top and bottom of the lungs that may
3. Definitive therapy: intubation and ventilation
contribute to the development of bleb or if they’re
4. Positive end-expiratory pressure (PEEP) with
smoking
mechanical ventilation to prevent atelectasis
− Changes in atmospheric pressure during
exposure to loud music that may cause
spontaneous pneumothorax Clinical Manifestations of Pneumothorax
Secondary 1. Mild tachycardia and dyspnea – mild
− Occur in people with lung diseases like asthma, 2. Respiratory distress – severe
TB, or bronchogenic cancer 3. Shallow, rapid respiration, dyspnea and air hunger
− Expect patient to have hypoxemia, stenosis, 4. Chest pain
hypercapnia or even confusion and coma 5. Cough with or without hemoptysis
6. No breath sounds over the affected area
7. Hyper resonance may be present
Latrogenic Pneumothorax – after medical treatment 8. Mediastinal shift – tension pneumothorax
• Result as a complication of central venous catheter
placement or due to barotrauma induced by
Tension Pneumothorax Pathophysiology
excessively high mechanical ventilator pressures
Inspiration
• Air enters pleural cavity through lung wound or
Flail Chest
ruptured bleb (or occasionally via penetrating chest
• Results from multiple rib fractures causing instability wound) with valve like opening
of the chest wall • Ipsilateral lung collapses and mediastinum shifts to
• Manifests with rapid, shallow respiration and opposite side, compressing contralateral lung and
tachycardia impairing its ventilating capacity
• Crepitus of the rib
• Asymmetric chest expansion means unilateral chest Expiration
expansion (one is expanding and one is not)
• Intrapleural pressure rises, closing valve like opening,
• Diagnostic assessment: serial of CXR, ABG to check
thus preventing escape of pleural air
for any respiratory acidosis especially in patients with
• Pressure is thus progressively increased with each
traumatic pneumothorax
breath
• CBC and O2 saturation can also be done
• Mediastinal and tracheal shifts are augmented,
diaphragm is depressed and venous return is
impaired by increased pressure and vena caval
distortion

Management Pathophysiology
1. Definitive therapy: chest tube insertion or Heimlich
valve
 Used to remove air out of the pleural space
2. Partial pleurectomy, stapling or pleurodesis
 For repeated spontaneous pneumothorax
3. Thoracentesis as a rule of thumb
 The chest wound is opened surgically for
thoracotomy so the doctor can perform
thoracentesis or chest tube output continuously
at greater of 200 mL
4. Mechanical ventilation for flail chest if needed
• Serotonin is a mediator that has an effect to the
Pulmonary Embolism (PE) bronchus
• Thrombus formation arise from the peripheral vein • In Pulmonary embolism
because of air, fats and blood clots blood clot from the
 Accidentally been injected during IV infusion for peripheral area may
air embolism travel or dislodge from
 If fat has been mobilized in the bone marrow after the site of origin that
a fracture may cause blockage or
 Amniotic fluid that enters the maternal circulation obstruction in the
after the rupture of membrane at the time of pulmonary arteries
delivery
• Common site: Deep vein of the legs 90% Clinical Manifestations
1. Chest pain
Predisposing Factors 2. Dyspnea
Virchow Triad described 3 factors that are critically  1st symptom accompanied by pleuritic pain
important in the development of venous thrombosis: sometimes perceived as chest pain
include intravascular vessel wall damage, stasis of flow, 3. Tachypnea and tachycardia
and the presence of a hypercoagulable state 4. Hypoxemia
1. Venous stasis − dysfunctional valves  Alters mental status of Px because of CO2
 Dysfunctional valves or inactive muscles of retention as a result of impair gas exchange
extremities usually seen in patients with prolong 5. Productive cough of blood-streaked sputum
bedrest, obesity (20% above the standard), 6. Low BP, distended neck vein
pregnancy, advanced age 7. Cyanotic and diaphoretic skin
2. Endothelial damage by trauma or external pressure Diagnostic Studies

 Fibrinolytic properties predispose to the 1. CXR
development of thrombus like surgery or injury  Helpful to exclude other possible causes but not
on the legs, pelvis abdomen or thorax a diagnostic test unless presence of infarction of
3. Increased blood coagulability (hematological about 50%
disorders)  Note for pleural effusion or any unilateral
 From severe anemia, polycythemia vera, patient diaphragm elevation, it may show if there is an
who have malignancy or taking contraceptives infiltrate or atelectasis
that are high in estrogen 2. Lung scan
4. Disease – chronic lung disease, heart (HF, MI, RD,  Assess the history of the lesions and evaluate
AF) history of thromboembolism or thrombophlebitis, the effectiveness of therapy
vascular surgery, diabetes mellitus and infection  Also assess the perfusion and ventilation ratio
3. CT scan
 Helical CT angiography may be used because it
involves the pulmonary artery
 Not only CT scan, it involves angiography
4. UTZ
 97% of the lower lung compression
5. Pulmonary angiography

 Most definite test but risk of allergies blood flow but not recommended as an initial
 There’s a need to check for creatinine result or treatment for patients with pulmonary embolism
findings of patient before any angiography  Contraindicated to patients receiving
because contrast dye is used anticoagulant
6. ECG 3. Pulmonary Embolectomy
 Done when right heart of the patient is affected  Removing embolus from the pulmonary artery
because if there is an increase in the pulmonary before the introductions of any procedure; a rare
vasculature or pressure it will increase the work procedure because of high mortality
of heart that will cause right heart strain
 Patient may have sinus tachycardia and ST
segment and T-wave abnormalities
7. Blood test – LDH
 For acute or chronic lung or tissue damage
8. ABG
 Assess for any acidosis because it can cause
retention of CO2 that may result to respiratory
acidosis
9. D-dimer assay test (N - <500 ug/L)
 Measures for any thrombotic or thromboembolic
events
 Expect to have elevation if there is pulmonary Nursing Interventions
embolism Minimize the risk of pulmonary embolism particularly in
conditions that is predisposing to a slowing venous
Treatment return
1. O2 therapy 1. Observe rate, depth of respirations, determine the
 Relieve hypoxemia, respiratory distress, and adequacy of gas exchange, dyspnea, diaphoresis
presence of cyanosis and air hunger
2. Endotracheal intubation to mech vent 2. Assess LOC – hypoxia
3. Turning, coughing and deep breathing 3. Auscultate lungs for rhonchi, crackles and wheezes
 Facilitates gas flow to and from the alveoli 4. Elevate head to semi-Fowler’s
4. Medications  Facilitate breathing and optimize diaphragmatic
 Activated thromboplastin time should be contraction
measured 5. Use relaxation technique
 Use of thrombolytic therapy to reestablish blood  If patient is conscious to relieve anxiety and
flow thorough blockage of the artery to prevent reduce work of breathing
death cells 6. Administer oxygen
Heparin is the drug of choice  If Px has hypoxia or hypoxemia
7. Assist coughing or by suctioning
Warfarin (Coumadin)
 Facilitates gas flow to and from the alveoli
− Usually given 3 days before heparin is being stop
8. Physical activity
− This is to be maintained for 3-6 months and
 Never massage the leg vigorously as it may
− Take note of drug food interaction when taking
promote thrombus formation
warfarin, it may inhibit action of digitalis,
 Do not wear constrictive clothing and do not
corticosteroid and vitamin K
cross the legs
− Food that antagonizes warfarin are spinach,
 Leg pumping exercise may increase venous flow
broccoli, and lettuce
 If ambulatory, perform ROM or isometric
− Antidote: Vitamin K
tPA
Possible Complications
1. Pulmonary infarction
Surgery
 Death of lung tissue due to alveolar necrosis and
1. Venous Ligation hemorrhage
 Prevents embolus from travelling to the lungs 2. Pulmonary HTN
2. Vena Caval Plication  May compromise the capillaries
 Insertion of a filter permitting the flow of blood by
trapping the embolus without interruption in the

Pulmonary Edema
• Restrictive type of respiratory disorder
• Accumulation of fluid in the lung tissue, the alveolar
space or both
• May be due to increased microvascular pressure from
abnormal cardiac function
• It could be cardiac in origin or non-cardiac cause
• Hypervolemia or a sudden increase in the intra
pressure in the lungs e.g. “flash” pulmonary edema –
can be seen in patient who has pneumonectomy due
to a rapid reinflation of the lung after removal of air or
fluid from the lungs
• Pulmonary edema is caused by the decreased ability
of the lungs to oxygenate blood, and the hemoglobin
leaves the pulmonary circulation w/o being fully
oxygenated that can be cardiogenic or non-
cardiogenic cause
Cardiogenic
Types of Pulmonary Edema • There is a wide distance of the capillary and the
Cardiogenic – cardiac in origin alveoli in cardiogenic that causes impairment of gas
• Underlying cardiac disease because of the left exchange and increase hydrostatic pressure
ventricle failure that causes pulling of the fluid back or • There is an Increase fluid filtration but the endothelium
increase pressure into the left atrium to the pulmonary of the alveoli is intact
vein and capillaries
• Back up of blood to pulmonary vasculature due to Non-Cardiogenic
inadequate left ventricular function
• Not only that there is an increase in permeability but
also disruption in the endothelial barrier that’s why
Non-cardiogenic there is a presence of neutrophils that invade the
Increased capillary permeability − damaged to the alveoli
capillary endothelium • There is a normal hydrostatic pressure and because
Lymphatic insufficiency − there is a blockage of the of permeability of fluid there will be accumulation of
lymphatic vessel that is seen in patient with cancer or fluid in this lymphatic system therefore there should
silicosis be increase in the lymphatic drainage
Decreased interstitial pressure − because of the rapid
removal of the pleural effusion or pneumothorax, and Stages of Pulmonary Edema
also hyperinflation Interstitial Edema
Decreased colloid osmotic pressure − because of • Involvement of lymphatic system to decrease the fluid
over transfusion or hypoproteinemia • There is increased hydrostatic pressure and
Unknown etiology − can be because of high altitude, decreased oncotic pressure
neurogenic causes, or use of heroin • Effect will be, fluid leaving the pulmonary capillaries
• Normally, there is a normal pressure in the capillary of and entering the interstitial space
the lung structure and no obstruction on the drainage • The lymph channels or vessels attempt to reduce the
lymphatic fluid fluid by widening the lumina and increasing the rate of
• In pulmonary edema, fluid and distance between the flow
capillaries and alveoli is altered • A wide distance between the alveoli and pulmonary
capillaries but has little effect on gaseous exchange in
the early stage
Alveolar Edema
• Dilution of surfactant and the fluid
• The lymphatic system usually drains away the excess
fluid but if the fluid continues to leak from the
pulmonary capillaries, it enters the alveoli

• Hydrostatic pressure is so high that it pushes the fluid Medications

into the alveoli 1. Morphine sulfate
• Since the fluid enters the alveoli, it dilutes the  Reduce venous return and reduce anxiety
surfactant with the incoming fluid causing reduction in 2. Diuretics
the surface tension in the alveoli and then may be  Such as furosemide to decrease the fluid
predisposed to collapse congestion
3. Inotropic drugs
 Improve cardiac contractility to increase cardiac
output and reduce the left ventricular diastole
pressure
 Use of digitalis, adrenergic agonist like
dopamine if there is hypotension
4. Bronchodilators
Acute Respiratory Distress Syndrome (ARDS)

Pathophysiology • It is characterized by inflammation of the lung
parenchyma leading to impaired gas exchange cause
by inflammation, hypoxemia and frequently resulting
in multiple organ failure
• Cold clammy skin is due to the stimulation of SNS
1. Rapid pulse and tachycardia
2. Lips and nailbeds are cyanotic
3. Air hunger
4. Moist and cool skin
5. Nasal flaring
6. Orthopnea • There is an increase in capillary permeability causing
7. Hypotension the lungs to become wet, heavy, congested even
8. Productive cough – frothy sputum hemorrhagic then the lungs become stiff and unable
to diffuse O2 that may result from pulmonary edema
Collaborative Care or respiratory failure secondary to increase capillary
1. Monitor vital signs permeability
2. Semi to high fowler’s • Also known as
3. O2 administration  Post traumatic pulmonary insufficiency (WW I)
 To increase O2 content in blood  Wet lung (WW II)
 Nasal O2 via nasal cannula  Da Nang Lung (Vietnam War)
4. Treat underlying condition (CHF)  Hyaline Membrane Disease
 Usually from ventricular failure • ARDS is a life-threatening lung condition that prevent
5. Cardiac monitoring and oximetry enough oxygen from getting to the blood
6. Weigh daily
7. Diet – low in sodium Causes of ARDS (ARD-direct cause)
8. Drug therapy Aspiration (gastric aspiration), bacterial or viral
A pneumonia, chest trauma, embolism (fat, air, fluid),
inhalation of toxic substance, O2 toxicity

R Radiation increase capillary permeability therefore lungs

Drug overdose, DIC, diffuse lung disease/drowning, become stiff because the alveoli are filled with
D
multiple blood transfusion, (additional acute pancreatitis)
proteinaceous exudate that has leaked up in the
S Shock/sepsis/smoke (indirect cause)
damaged pulmonary capillaries
• Stiff lungs are manifested by reduced compliance
Major problem occurs in ARDS • Cause of interstitial edema of the alveoli is due to
1. Reduction in the functional vital capacity filling of fluids and blood so there’s a problem with
2. Bronchovascular edema oxygenation
 Reduction in the interstitial negative pressure • The type 1 and 2 alveolar cells is damaged by ARDS
 There is a distal atelectasis  Type 1 is responsible for gas exchange
3. Decreased lung compliance  Type 2 is for production of surfactant
 There is a congestion and the lung become stiff • Therefore, there’s a decrease in the synthesis of the
resulting to decreased functional residual surfactant and inactivation of these surfactant may
capacity cause the alveoli to become unstable resulting to
4. Hypoxia collapse or further decrease in lung compliance
 Impaired gas exchange because of increased • Gas exchange will be compromised that may
capillary permeability contribute to hypoxemia
5. Increased O2 consumption
 Because of increased airway resistance which
Proliferative – 1 – 2 weeks (Reparative Stage)
the patient attempt to increase breathing
• Dense fibrous tissue, increased pulmonary vascular
resistance and pulmonary HTN occurs
o Patients with ARDS should be hooked to
ventilation because of impaired gas exchange • Injury has a regenerative capacity after acute lung
and possibility of congested lung injury that can be characterized by dense fibrous
tissue, increased the pulmonary vascular resistance
and pulmonary hypertension may occur in this stage
because of fibroblast and the inflammatory cells
destroyed the pulmonary vasculature
• As the lung compliance continues to decrease as a
result of interstitial fibrosis, the hypoxemia may
worsen because of the thickened alveolar membrane
causing limitations in diffusion
• This is the stage wherein the hyaline membrane may
be formed that’s why it’s sometimes called as the
“adult hyaline membrane”
Fibrotic – 2 to 3 weeks (Chronic or late phase of ARDS)

• Diffuse scarring and fibrosis, decreased surface area,
decreased compliance and pulmonary HTN
• The lungs are completely remodeled by collagenous
or fibrous tissues
Signs and Symptoms • There is a diffuse scarring and fibrosis is formed that
1. Tachypnea and dyspnea results to decreased lung compliance
2. Central cyanosis • The surface area of the gas exchange is reduced
3. Alteration in LOC because of fibrotic interstitium and hypoxemia may
4. Decreased PO2 and increased in PCO2 continue
5. Retractions • Then pulmonary HTN may result from pulmonary
6. Dry cough and fine crackles vasculature or vascular destruction and fibrosis
• If the lungs are not remodeled, the fibrous will still form
Stages of ARDS that may lead to cancer as it affects residual and vital
lung capacity
Exudation Phase – 1 – 7 days (Injury Phase)
• Interstitial and alveolar edema, atelectasis,
hypoxemia, and stiff lungs
• Usually, 24-48 hrs. after initial direct lung injury
• Neutrophils adhere to the pulmonary microcirculation
causing damage to the vascular endothelium and

infiltration throughout the lungs leaving few

recognizable air spaces
4. Lactic acid levels – due to lack of O2
 Expect elevation of lactic acid
Interventions for ARDS

1. Adequate oxygenation
 Mechanical ventilation to reverse hypoxemia
and expand distal gas exchange to prevent
alveolar lung collapse
2. Fluids and electrolytes
 Monitor fluid because excessive intravascular
fluid administration may result in cardiogenic
pulmonary edema
Pathophysiology
 Patients with capillary damaged are susceptible
to fluid leakage into the alveolar space and
hypoalbuminemic patients will be given colloidal
fluid
 All patient should have crystalloid fluid that
means all administration have IV fluid
3. ECG monitoring
4. Measure intake and output
 If there’s an increased fluid intake, balance the
diuretic due to pulmonary edema
 Urine output monitoring must be done every hour
5. Alimentation
• Damage to type I cells allows both increased entry of
 Through tube feeding or small feeding
fluid into the alveoli and decreased clearance of fluid
 Could be enteral or parenteral feeding
from the alveolar space
6. Positioning
• Damage to type II cells result in decreased production
of surfactant and subsequently decreased alveolar
compliance leading to alveolar collapse Drug Therapy
• Interference with the normal repair processes in the 1. Inotropic Agents
lung may lead to the development of fibrosis  if heart is affected
2. Antacid & H2 blockers
Diagnostic Studies  To maintain gastric pH above 4 and also a
1. Pulmonary function test prophylactic measure for stress ulcer
 Check for vital capacity 3. Morphine, corticosteroids
 Expect that there is a reduction in the vital and  Reducing pulmonary edema and stabilizing the
residual lung capacity because of decreased pulmonary membrane
lung compliance and lung volume, particularly 4. Heparin
the functional residual lung capacity  To combat microvascular emboli
2. ABG − PaO2, PaCO2, HCO3
5. Diuretics
 To determine hypoxemia and respiratory
alkalosis caused by hyperventilation  As ordered to keep patient on the dry side
 In the beginning there will be elevations in pH but
if the ARDS worsens then it may result to Interstitial Lung Disease
respiratory acidosis wherein pH may reduce • A restrictive type of respiratory disorder wherein it
3. CXR produces various degree of inflammation, fibrosis and
 To determine for any scattered interstitial disability and changes in the interstitium
infiltration • It may cause the lungs to become stiff and difficult to
 Edema may not be shown in CXR unless there inflate
is 30% increase in fluid content in the lungs
 CXR is often termed as the “white out lungs” Causes
because of the consolidated and coalescing 1. Exposure to occupational hazards
 Inorganic dust: Asbestos, silicosis, talc, coal

 Organic dust: Pigeon breeder's lung due to bird 2. Mechanical ventilation

serum excreta and feathers  Depending on the severity of interstitial lung
 AC that has bacteria that may affect the lungs disease
2. Environmental inhalants 3. ABG analysis
 Gases, fumes, aerosols  For monitoring
 Those that contain chlorine, ammonia 4. Lung transplant
 Chemotherapeutic drugs: bleomycin and
amiodarone Etiologic Determinants of Occupational Lung Disease
 TB, radiation
3. Unknown o Pneumoconiosis is the general term for a class
 Sarcoidosis (connective tissue disorder), of interstitial lung diseases where inhalation of
idiopathic pulmonary fibrosis, systematic lupus, dust has caused interstitial fibrosis
erythematosus
1. Nature of the exposure
2. Duration and intensity of the exposure
Pathological Changes of ILD 3. Particle size and water solubility
1. Thickening of alveolar wall 4. Smoking history
 Caused by edema, cellular exudate or fibrosis 5. Presence of underlying pulmonary disease
2. Reduced lung compliance
 Lung stiffness
Tuberculosis
 Causes exertional dyspnea
• Chronic respiratory disease affecting the lungs
3. Maldistribution of ventilation, perfusion and gas
characterized by formation of tubercles in the →
transfer
caseation → necrosis → calcification
 Due to hypoxemia during exertion
• Acquired from the inhalation of mycobacterium
• Similar to other bacteria, except that it has an outer
Cascade of Events in ILD
waxy capsule which makes it more resistant to
destruction
• Mycobacterium is often referred to as the acid-fast
bacilli which are aerobes that thrive in an oxygen rich
environment
• It affects the upper part of the lower lobe of the lungs
when ventilation is greatest
• Not highly infectious but the transmission requires
• Palliative care only because it’s not curable closed, frequent and prolonged exposure
Signs and Symptoms AKA: Phthisis, Consumption, Koch’s, Immigrant’s

1. Fever disease
2. Sweating Etiologic agent: Mycobacterium tuberculosis
3. Anorexia
Incubation period: 2 – 10 weeks
4. Weight loss
5. Fatigue Period of communicability: all throughout the life if not
6. Myalgia treated
7. Nonproductive cough MOT: Airborne or droplets
8. Exertional Dyspnea
Sources of infection: Sputum, blood, nasal discharge,
9. Hemoptysis
saliva
10. Sputum production
Important signs and symptoms Classification of Tuberculosis

1. Dyspnea Quantitative
2. Hypoxia Minimal – slight lesion without excavation, confined in
3. CXR – diffuse infiltration a small area of one or both lungs
Moderately advanced – not exceed 4 cm, one or both
Management lungs may be involved but not in an extent to one lobe
1. Oxygen therapy Far advanced – more extensive than # 2
 Maintain the functional status and improve the
quality of life of the patient as high as possible

Clinical • This is wherein a tiny size of a lesion may spread or

Inactive – asymptomatic, sputum is (-), no cavity on go through the blood vessels that may spread to other
chest X ray body organs such as kidney, meninges, liver
Active – (+) CXR, S/S are present, sputum (+) smear
Diagnostic
Classification Scheme 1. Tuberculin test (Mantou Test)
2. CXR
Class 0 no exposure; no infection
 Common diagnostic test
Class 1 exposure; no evidence of infection
3. Sputum studies
latent infection; no disease (e.g., positive  For acid fast bacilli
Class 2 PPD reaction but no clinical evidence of
active TB) 4. Sputum culture
 Not a standard but may be done to patient
Class 3 disease; clinically active
5. Genexpert
Class 4 disease; not clinically active
Class 5 suspected disease; diagnosis pending
Clinical Manifestations of TB
Extrapulmonary tuberculosis is tuberculosis (TB) within

a location in the body other than the lungs
Pathophysiology
Primary Complex
• TB in children: non-contagious, children swallow
phlegm, fever, cough, anorexia, weight loss, easy
fatigability
• Primary in adult: there are no manifestations and
symptoms; cannot be detected through CXR and
sputum acid-fast test
Adult TB
• Afternoon rise in temperature ranging 38-39 oC
• Night sweats • Lesions may undergo liquefactive necrosis in which
• Weight loss and body malaise – cardinal signs the liquid breaks into the connecting bronchi and may
• Sometimes amenorrhea for women produce a cavity
• Dry to productive cough • Tubercle materials may enter the tracheobronchial
• Hemoptysis − if there is ulceration or cavity px may system and allowing airborne transmission of
develop this infectious particles
• Sputum AFB (+) • Healing takes place by resolution, fibrosis, and
calcification
Miliary TB • After treatment, the granulated tissue surrounding the
• Very ill, with exogenous TB like Pott’s disease (lumbar lesion may become fibrous and form a scar around
area) the tubercle
• Considered as complication in TB patients

Pharmacologic Management
1. Isoniazid (INH)
 6 to 12 months
 Inhibit growth of dormant organisms
 Latest now up to 9 months
2. Rifampicin
 Inhibit bacterial RNA synthesis
 Orange-colored urine
 Caution on patients with liver problems, check
first for creatinine and BUN test and even liver
enzyme test
3. Vitamin B6
 Prevent peripheral neuritis especially in patients
taking INH (isoniazid)
Prevention 4. Ethambutol
 Caution with renal disease
1. BCG vaccination
 Doctor have to check the red-green color
 During neonatal period and before entering
blindness during routine check up
preschool (booster dose)
 May affect optic nerve
2. Avoid overcrowding
 Inhibit RNA synthesis and has a bacteriostatic
3. Improve nutritional status
effect on the tubercle bacillus
 To increase the immunity of the patient,
5. Streptomycin
especially elderly and children below 5 y/o
 Inhibit CHON synthesis and bactericidal
 CNS toxicity
Management
 Caution with elderlies and patients with renal
DOTS diseases
1. 6 months of RIPE 6. Pyrazinamide
2. Respiratory isolation  Bacteriostatic and bactericidal
3. Take medicines religiously – prevent resistance
4. Stop smoking o Patient is given 2 months of INH, Rifampicin,
5. Plenty of rest Ethambutol, and Pyrazinamide and 4 months of
6. Nutritious and balance meals, increase CHON, INH. Rifampicin is given 3x a day
Vitamin A, C
7. Regular follow-up
Nursing Care for TB
1. Respiratory precautions: 2-4 weeks
DOTS – Direct Observed Treatment Short-Course 2. Needs well ventilated private room
Concept of directly observed therapy (DOT), which  Make sure it’s not a closed room and open the
requires a third party to witness compliance with windows
pharmacotherapy 3. Mask to all visitors and staff, discard mask after use
4. Strict hand washing after each contact with patient
5. Small frequent meals with supplements
6. Activity as tolerated
7. Take medications as prescribed
 Effect of medication will take about 1½ mos.
8. Multi-Drug Resistance Tuberculosis (MDR-TB)
MDR-TB is defined as resistance to isoniazid and

rifampin, which are the 2 most effective first-line drugs
Primary Anti-Tubercular Agents for TB
R Rifampicin Extensively drug-resistant TB (XDR-TB), is resistant to
I Isoniazid isoniazid, rifampin, any fluoroquinolone, and at least
one of 3 injectable second-line drugs (i.e., amikacin,
P Pyrazinamide kanamycin, or capreomycin)
E Ethambutol
S Streptomycin

Types of Drug Resistant TB
Recommended
Drug Resistant TB Resistance
Diagnosis
Resistant to a single first

Mono-Resistant GeneXpert
line drug
Resistant to more than 1

GeneXpert followed
Poly-Resistant drug but not to Rifampicin
by Liquid culture’
and Isoniazid
MDR TB (Multi-Drug Resistant to at least GeneXpert followed

Resistant) Isoniazid and Rifampicin by Liquid culture’
XDR TB MDR + Resistance to

GeneXpert followed
(Extensively Drug fluroquinolones and at least
by Liquid culture’
Resistant) 1 of 3 injectable drugs
TDR (Totally Drug Resistant to all first and GeneXpert followed

Resistant) second line TB drugs by Liquid culture’
The key to complete cure in TB is Early, Complete and Accurate

diagnosis and appropriate treatment
Grouping of Anti-TB Agents
Grouping Drugs
Group 1:
Isoniazid (H), Rifampicin (R), Ethambutol (E),
First-line oral anti-TB
Pyrazinamide (Z)
agents
Group 2: Streptomycin (S), Kanamycin (Km), Amikacin

Injectable anti-TB (Am), Capreomycin (Cm), Viomycin (Vm)
Ciprofloxacin (Cfx), Ofloxacin (Ofx),

Group 3:
Levofloxacin (Lvx), Moxifloxacin (Mfx),
Fluroquinolones
Gatifloxacin (Gfx)
Group 4: Ethionamide (Eto), Prothionamide (Pto),

Oral second-line anti- Cycloserine (Cs), Terizadone (Trd), para-
TB aminosalycilic acid (PAS)
Group 5: Clofazimine (cfz), Clarithromycin (Clr),

Agents with unclear Amoxacillin/Clavulanate (amx/clv),
role in treatment of DR Thioacetazone (Thz), High dose INH,
TB Imipenem/Cilastatin,(Ipm/Cln), Linezolide (lzd)
How do we help the missed TB cases?

Ensuring Care for All with TB
Detecting people ill with TB who are either not
accessing diagnosis or receiving treatment of unknown
quality is crucial
1. Improve access to TB diagnosis (including rapid
tests) and care services
2. Intensify collaboration with community-based,
public, and private providers, including hospital and
NGOs which serve large proportion of population at
risk
3. Regulate via mandatory case notification and
strengthened surveillance


HEMATOLOGIC DISORDERS
Blood is a mixture of cells that is composed of RBC, Hemostasis

WBC, platelet, and plasma. It is circulating • Process of repairing vascular break to reduce blood
spontaneously in the heart and vascular system. loss from blood vessels
• To maintain the flow of blood through vascular system
Functions of Blood
Transportation
• Carries oxygen and nutrients to the cells, hormones
from the endocrine glands to target tissues
Regulation
• Helps regulate body temperature, fluid and
electrolytes balance and pH levels
Protection
• Promotes homeostasis to stop bleeding
• Clotting mechanisms reduce fluid loss through
hemorrhage
• Phagocytic cells to protect the body from dangerous
microorganism
• Production of antibodies in plasma
Characteristics of Blood
Color
• Arterial blood: bright red (O2 bound to hemoglobin
molecules)
• Venous blood: dark red (less O2 content)
Viscosity – 3-4 times thicker than water
Specific gravity – 1.048 to 1.066
pH – 7.35 to 7.4 (slightly alkaline)
Volume – 5-6 liters
Composition
• Plasma: 55%
• Cellular components: 45%
Steps of Hemostasis
Component of Blood
Vascular Constriction
Albumin (58%) – responsible for oncotic pressure; holds
• Leads to transient arteriolar vasoconstriction to limit
water in the vascular system
the flow of blood to the affected area
Globulin (38%) – responsible for producing anti-bodies;
• Initial reflex response of the smooth muscle in the
defense against microorganism
vessel walls
Fibrinogen (4%) – responsible for blood coagulation
2 Reflexes:
a. Nervous Reflex – initiated by the pain impulse
created by tissue or vascular trauma
b. Local Myogenic – direct damage in the vascular
wall & increase the release of serotonin from the
platelet
Hemostatic Plug
• Also called as the formation of a platelet plug
• The damage on the endothelial cell lining in the
vessels may lead to platelet adherence and activation
of coagulation cascade
• The platelet may obstruct the opening in an injured
vessels to reduce blood flow
• Collagen in the damaged vessel attracts platelet
which become sticky and adhere to each other to form
a plug called platelet adhesion or platelet aggregation

Tissue Factor Hematopoiesis

• Activation of the coagulation cascade – most effective Production or formation of blood cell
mechanism of hemostasis • Limited life span
• Activation of 1 clotting factor after another to form • Constantly forming blood cells throughout the life
fibrin clot to prevent further bleeding • Before birth, hematopoiesis occurs primarily in the
liver and spleen, but sometimes it develops in the
Clot Retraction and Dissolution thymus, lymph node and red bone marrow
• Clot Retraction: Large number of platelets that join the • After birth, most production is limited to specific region
edge of the injured vessels of red bone marrow, but lymphocytes are produced in
• Clot Dissolution: Regulates by thrombin and the lymphoid tissue from precursors cells that
plasminogen activator migrated from the bone marrow
• Hematopoiesis proliferate and differentiate from
Pluripotent Stem Cell pluripotent stem cells
• Hematopoiesis activity carry out in the skull, vertebra,
sternum, ribs and pelvis
Regulated by hematopoiec growth factor

• Example: erythropoietin
• If there is a decreased O2 level, it may stimulate the
kidney to release erythropoietin which may induce the
red bone marrow to produce more RBC
• There are 2 kinds of bone marrow in adults
a. Red bone marrow – active; found in skull, cranium,
mandible, vertebra, ribs, sternum, pelvis, humerus,
and femur
b. Yellow bone marrow − inactive; found in elderly
Hemocytoblasts (stem cell)

• Origin of all blood cells
• It explains the stem cell theory in which it comes from
the various stages of cell differentiation of the bone
marrow
Cellular Component of the Blood

BLOOD CELLS
• These are cells that continue to have unlimited
Cell Type Major Function
differentiation potentials
• Able to grow into different kinds of tissue (e.g. blood, WBC
Fights infection
(Leukocyte)
nerve, heart, bone, and so forth)
• They are capable of differentiating to produce mature Neutrophil
Essential in preventing or limiting bacterial
infection via phagocytosis
cells that can be found in the circulating blood
Enters tissue as macrophage; highly phagocytic,
Monocyte
There are 2 Properties especially against fungus; immune surveillance
Self-renewal or ability to proliferate Involved in allergic reactions (neutralizes

Eosinophil
• Involves biochemical stimulation of certain population histamine); digests foreign proteins
wherein undifferentiated cells undergo mitotic division Contains histamine; integral part of
Basophil
hypersensitivity reactions
Differentiating into specific cells
Lymphocyte Integral component of immune system
• Becomes mature
• When stem cells differentiate, it may loss capacity for Responsible for cell-mediated immunity;
T lymphocyte recognizes material as “foreign” (surveillance
self-renewal system)
• They have to become committed to a specific cell line
Responsible for humoral immunity; many mature
such as erythrocyte, leukocyte, and thrombocyte B lymphocyte
into plasma cells to form antibodies
Secretes immunoglobulin (Ig, antibody);

Plasma cell
most mature form of B lymphocyte

RBC Carries hemoglobin to provide oxygen to tissues;


(Erythrocyte) average lifespan is 120 days Stimulates the red bone marrow to produce RBC, which
combine with O2 to increase the blood oxygen
Fragment of megakaryocyte; provides basis for concentration
Platelet
coagulation to occur; maintains hemostasis;
(Thrombocyte)
average lifespan is 10 days 
Young cells (reticulocytes) enter general circulation and
matures in the bloodstream (2-4 days)
Erythrocyte (RBC)
• Life span: 100-120 days
• The normal erythrocyte is a biconcave disk
• Flexible that can past easily in the capillary allowing
• The membrane of the red cell is very thin so that
gases, such as oxygen and carbon dioxide, can easily
diffuse across it
• Primary function: tissue oxygenation & maintenance
of normal blood pH through a series of intracellular
fibers
Fig 1. Regulation of erythrocyte production

Factors of Normal RBC Production
1. Genetically normal precursor cells
2. Function of the bone marrow Destruction of Erythrocytes
3. Adequate dietary intake – Fe, Vitamin B12, folic acid,
protein, pyridoxine and traces of copper
Fe
− Absorbed from the small intestine
− 2/3 of essential Fe is use for O2 transport and 1/3 is
found in the bone marrow, spleen, liver and muscle
− Iron is stored as ferritin and when required, the iron
is released into the plasma, and binds to transferrin
Vitamin B12 and Folic Acid

− Required for the synthesis of DNA in the RBC • The life span of RBC is about 120 days. When it
− Vitamin B12 is responsible for normal RBC becomes old, it becomes fragile and worn out, and
maturation and normal nervous system function hemoglobin is released from the RBC
− Vitamin B12 and folic acid deficiencies are • Hemoglobin break into two fragments
characterized by the production of abnormally large
a. Heme Fraction
erythrocytes called megaloblasts
− Red compound that contains iron and porphyrin
− With regards to iron of heme fraction, it refers to
Pyridoxine and traces of copper
liver, spleen and bone marrow for reuse in
− Should be normal to have a normal RBC production
making hemoglobin
− The liver converts porphyrin of heme fraction
If any of these factors is missing, RBC may become into bilirubin (orange pigment) secreted into the
fragile, deformed, abnormally large or small. Even bile and excreted from the body in the form of
deficiency in hemoglobin may result to erythrocyte feces and urine
disorder
− During period of increased RBC destruction,
there’s an excessive amount of bilirubin forming
Regulation of Erythrocyte Production and accumulates in body tissues seen in
Negative feedback mechanism uses the hormone patients with hemolytic anemia
erythropoietin b. Globin Fraction
Low blood oxygen concentration − Metabolized by macrophage or absorbed in the
 blood stream
Stimulate kidneys to produce a renal erythropoietic factor
(REF)

Activates erythropoietin

Leukocytes (WBC) Agranulocytes

• Life span: 13-20 days Also known as mononuclear leukocytes. These doesn’t
• Defends the body against infected microorganism and have granules on cytoplasm
remove debris from dead or injured cells
a. Lymphocytes
Granulocytes − Immature lymphocytes are produced in the bone
Defined by the presence of granules in the cytoplasm of marrow from the lymphoid stem cells
the cell. It functions as phagocytes. − A second major source of production is the
thymus
− Most lymphocytes are transiently circulating in
a. Neutrophil or Polymorphonuclear Neutrophil (PMNs)
the blood and resides in the lymphoid tissues as
− Lifespan: 1-2 days
mature T-cells, B-cells, and plasma cells
− Capable of killing microorganism
− Catabolize debris during phagocytosis Elevation: viral infection
− Fights bacterial infection through the process of Reduction: impaired lymphatic drainage, advance
phagocytosis cancer or bone marrow failure
− Sub-classifications: metamyelocytes, bands,
segmented or hyper-segmented
b. Monocytes & Macrophages
− In the laboratory test for WBC, specifically
− Largest of the normal WBC
differential counts, you cannot see the presence
− Both monocytes and macrophage, make up the
of the count of neutrophils, but they use bands or
mononuclear phagocyte system, formerly called
stubs. The difference of this is when the
reticuloendothelial system which is responsible
immature WBC are released from the bone
for phagocytosis of erythrocytes and leukocytes
marrow into peripheral blood, it is called bands
in the blood
while stubs are horse shaped or S-shaped.
− Immature macrophage formed and released by
Elevation: indicates signs of infection and liver the bone marrow into the blood stream takes 36
damage hours to be mature in the circulating blood and
Reduction: due to severe infection in which the body continuously to differentiate into macrophage
uses all the reserved supply of neutrophil, can be − Mature monocyte becomes macrophage
caused by damage of the bone marrow wherein it migrates into a certain tissue like the
liver, spleen, and lymph nodes where they
remain active for months or years
b. Eosinophil
− Involved in allergic reaction Elevation: in response to all kinds of infection
− Plays a major role in combating allergic reaction Reduction: bone marrow failure and some form of
− Neutralize histamine and digest protein leukemia
Decrease: caused by infection that produce
purulence Leukocytosis is the abnormal elevation of WBC
Leukopenia is a decrease in the number of white
blood cells
c. Basophil
− Contains granules with histamine and anti-
coagulants
− Produce and store histamine that is involved in
hypersensitivity reaction that may provoke
allergic reaction
− Also contains heparin, keeping the blood from
clotting in inflamed tissue and microcirculation. It
is increased during the healing phase of
inflammation
Increase: may occur in radiation therapy or in

patients with leukemia (myeloid leukemia)
Decrease: during acute infection and stress Fig. 2 Development of Leukocytes

Thrombocytes (Platelets) • Spleen is not necessary for life for adequate

• Life span: 8-10 days hematologic function. However, the absence of it has
• Platelets, or thrombocytes, are not technically cells; secondary effect in the body.
rather, they are granular fragments of giant cells in the • One example is leukocytosis, a high level of
bone marrow called megakaryocytes circulating WBC. Meaning, the spleen exerts some
• Formation of platelets about 5 days sort of control over the rate of proliferation of the
• Production of platelet is regulated by thrombopoietin leukocyte stem cells in the bone marrow or the
in order to stimulate the myeloid cells in the bone release into the blood stream.
marrow to produce megakaryocytes • Another effect is the decreased amount of the iron
• Smallest blood cells that contain coagulation factors level in the circulation. It reflects the role of spleen in
to control bleeding and help regulate hemostasis the iron cycle
through the sequence of events known as the • With regards to immune response, there’s a decrease
“coagulation process” in immune function. It may diminish immunoglobulin
• They circulate freely in the blood in an inactive state, resulting to susceptibility to infection and also diminish
where they nurture the endothelium of the blood antibody production in response to soluble antigen
vessels, maintaining the integrity of the vessel
• When vascular injury occurs, platelets collect at the Assessment
site and are activated Subjective Data (General Information)
• Platelet plug are adequate to seal a tiny injury while a
Biographic Data
clot formation is to seal an injury to a large vessel
• 2/3 of the platelets enter the circulation and the Health History
remaining resides in the splenic pool (area)
• Past health history
• Old platelet are being sequestered and destroyed in
• Presenting complaint depending on the severity,
the spleen by mononuclear cell phagocytosis
location, quality, quantity
• Assess for concurrent disorders
2 Functions • PQRS model of assessment
Thromboplastic Function – provision of the chemical
component in the molecular cascade leading to Medications Taken
coagulation • Includes herbal therapy can interfere with clotting,
Hemostatic Function – work as a plug to close the antineoplastic agents, alkylating agent
opening in the capillary wall to maintain capillary
integrity Surgery or Other Treatments
• Splenectomy, tumor removal, excision of duodenum,
Lymphoid Organs gastrectomy
• Primary: thymus and bone marrow
• Secondary: spleen, lymph nodes, tonsils, and Peyer’s Lifestyle
patches of the small intestine • Cigarette and alcohol use
• All lymphoid organs are linked to hematologic and • Diet and fluid intake
immune system in the body for proliferation and • Oral hygiene, dental status, sleeping pattern,
differentiation. It functions as lymphocytes and elimination pattern, family history
mononuclear phagocyte
Activity
Spleen • Exercise pattern
Classified as:
Hematopoietic function − during the fetal development Presenting Complaint
Filter function − filter and destroy worn out circulating • Patient’s main reason for consultation
blood cells and responds to foreign substance in the
blood Review of System
Immune function − production of T-lymphocyte by the • Changes in weight, usual weight
white valve • Performance status (level of activity that they can
Storage function − 30% platelet mass and 5% tolerate), if they have easy fatigability and weakness
erythrocyte; 2/3 of platelet is stored in the spleen during exercise or increasing activity
• Skin – changes in color of the nail bed, presence of
edema or petechiae, any pruritus or flushing, enlarge
lymph nodes

• Cardio function − tachycardia, hypertension, Musculoskeletal system

palpitation, flank pain, urine (cloudy, frequency) • Joint pain
• Musculoskeletal − swelling, pain, stiffness • In regards to pain level, you may use Socrates pain
• Arthralgia – joint pain; may indicated auto-immune model or PQRS pain model
disorder secondary to increased uric production as a
result of hemolytic anemia or hematological
Common Blood Tests for Hematologic Disorders
malignancy
Diagnostic Evaluation
• Hemarthrosis – presence of blood and form in the joint
Hematologic Studies
Chemical Exposure Hemogram or CBC
• Type, amount and duration of exposure • Identifies the total number of blood cells (WBC, RBC,
• Consider the occupational background of the patient platelets, Hb, Hct and differential count)
• It provides information about the hematologic system
Elimination Pattern • Measures the general health of an individual
• Urgency (e.g., dysuria) • May also quantify the characteristic of the different
population of the cell count in the blood
Objective Data (Physical Examination – IPPA)
a. Hemoglobin
What to Assess?
− Gas carrying capacity of an erythrocyte
Skin
Pallor of skin or nail beds − low RBC Increased: hemoconcentration from polycythemia,
Presence of edema dehydration
Flushing − ruddy color in the skin, face, or conjunctiva; Decreased: hemorrhage or anemia, states of
indicate polycythemia hemoglobin such as those that occur when the fluid
Jaundice − hemolytic occurrence in the circulating volume is excessive
blood
Cyanosis − deoxygenated blood circulating in the b. Hematocrit
body − Percentage of blood volume consisting of
Pruritus − presence or elevation of basophils erythrocytes
Purpura, petechiae, ecchymosis and hematoma
Increased: hemoconcentration from loss of fluid
Eyes (dehydration) or polycythemia
• Jaundiced sclera (icteric sclera), conjunctival pallor Decreased: massive blood loss or hemodilution
Mouth c. RBC Indices

− Measures RBC size and hemoglobin content
• Gingival and mucous membrane changes, smooth
− Special indicator that reflects the RBC volume,
tongue
color, and hemoglobin concentration
• Beefy red tongue caused by vitamin deficiency
− It identifies and classifies the type of anemia
Lymph Nodes RBC Indices
• Enlarged > 1 cm and tender to touch MCV (Mean Corpuscular Volume)
• Assess different site to detect any lymph node
− Estimate the average size of the RBC.
enlargement
− Very useful to classify what type of anemia
− Increased: RBC is abnormally large (macro)
Heart and chest
− Decreased: small RBC
• Tachycardia, sternal tenderness − Both big and small RBC are very fragile that
• Auscultate for cardiac rate or HR, then palpate for any are easily destroyed by macrophage
external tenderness
MCH (Mean Corpuscular Hemoglobin)
Abdomen − Measures the content of Hgb in RBCs from
• Hepatomegaly, splenomegaly a single cell
• Abdominal examination − Determine the number of hemoglobin
present in an RBC; pertaining the weight of
Nervous system hemoglobin
• Numbness sensation, impaired muscle movement,
weakness

MCHC (Mean Corpuscular Hemoglobin Men 14 to 16 g/dL

Concentration) Women 12 to 15 g/dL
− A more accurate measurement of the Hgb Hematocrit
content of RBC as it measures the entire Men 42% - 52%
volume of RBCs
Women 35% - 47%
− This is the proportion of RB contained in
Platelets 150,000 – 450,000 / cu mm
each RBC; within 100 ml of packed RBC
d. Total Differential Count Normal Laboratory Values of RBCs Indices

− Measures the number each of the five types of Laboratory Test Normal Value
WBCs Mean corpuscular volume (MCV) 84 - 96 cu µm
− Valuable in determining the cause of illness
− It comes in percentage of different leukocytes Mean corpuscular hemoglobin
28 - 33 µµg / cell
(MCH)
− Able to identify or evaluate the body’s
capability to resist and overcome infection Mean corpuscular hemoglobin
33% - 35%
− Useful for identifying leukemia concentration (MCHC)
e. Platelet Count Normal Laboratory Values of WBCs

− Actual count of thrombocytes, which is Laboratory Test Normal Value
essential for blood clotting
WBC count 4,500 to 11,000/ cu mm
− 1/3 is in the circulation and 2/3 is stored in the
Differential
spleen
− If there is hypersplenism, there is an increased Neutrophils 60% - 70%
or exaggerated splenic activity; 90% of platelet Eosinophils 1 - 4%
in the body may be trapped in the spleen, Basophils 0 to 1%
predisposing patient to bleeding Lymphocytes 20% to 40%
Monocytes 2% to 8%
Increased: predispose to malignancy,
polycythemia
Decreased: hemolytic or aplastic anemia Coagulation Tests
• Measures the ability of blood to clot and how long it
Peripheral Blood Smear takes
• Determines the cellular morphology, pertaining to any a. Prothrombin Time (PT)
variation of abnormalities of the RBC in terms of − Is the rapidity of blood clotting
shape and appearance of cells − Normal range is 10-14 seconds
a. Normocytes – cells of normal size and shape − Evaluates the extrinsic coagulation pathway
b. Normochromic – cells of normal color
c. Poikilocytes – abnormal shape b. Partial Thromboplastin Time (PTT)
d. Microcytes – abnormally small − Normal range is 60-70 seconds
e. Macrocytes – abnormally large − Evaluates the intrinsic coagulation pathway or
f. Hypochromic – pale appearance because of low fibrin clot formation
hemoglobin count c. Prothrombin Activity
g. Spherocytes – small and round shape
− The percentage in reference to a normal
h. Sickle cells – crescent shape from presence of
plasma of 100 activity
abnormal hemoglobin (HB S)
− Normal is 70-100%
i. Target cells − thin with small amount of
hemoglobin in the center d. Activated Partial Thromboplastin Time (APTT)
− Normal range is 30-45 seconds
Normal Laboratory Values of RBCs and Platelets
e. Bleeding Time
Laboratory Test Normal Value
− Normal range is 1-9 minutes
Red blood cell count − Rarely done in hospital
Men 4.6 to 6.2 million/mm3 − Measure PT and PTT
Women 4.6 to 5.4 million/mm3
f. Coagulation Factor Concentration
Reticulocytes 0.5 % to 1.5% of total RBC
− Determine concentration of specific
Hemoglobin
coagulating factors in blood

− Factor 1,2,5,7,8,9,10,11 & 12 − Some diseases such as severe form of

− When below hemostatic level, the clotting time thalassemia causes Hb A1 to be low and Hb F
prolong to be elevated
− Identifies what exact factors are involved in the
coagulation defect, so that blood component b. Hb A2
replacement can be done − The minor component of the normal Hgb total
− This type of Hgb is found in small amount in
Fibrinogen adult
• N = 200-400 mg/dL c. Hb F
• Blood test that is related to hematologic function − Predominant during fetal development; it is
• Protein converted into fibrin to form thrombus and clot normally found in fetus but once the newborn
• Binds platelet and fibrin to form a clot is delivered, it is replaced by Hb A
• When vascular or tissue injury occurs, fibrinogen level − There are some diseases such as sickle cell
increases in the early phase of coagulation disease, aplastic anemia, and leukemia that
• Measures how much fibrinogen is in the body have this type of abnormal Hgb and has a
higher amount of Hb F
Fibrin Split Products (FSP)
• N = < 10 ug/mL d. Hb S
• Measures end products that result from breakdown of − An abnormal form of Hgb associated with
fibrin sickle cell anemia because it assumes a
• End product of dissolving clot and detected in the clot crescent shape that distort the RBC
• Provide an indication of the activity of the fibrinolytic morphology
system
e. Hb C
Increased: risk for clotting/blood clot formation − Decreases the life span and can be easily
Decreased: risk for bleeding disrupted or lysed than the normal RBC
− Example: mild hemolytic anemia or
D-Dimer thalassemia
− It does not carry the O2 wall
• N = < 0.5ug/mL
• Measures a specific product resulting from
breakdown of fibrin Reticulocyte Count
• Determine whether a clot is present • N = 0.5%-1% of total circulating red blood cells
• Helpful in diagnosis of the deep vein thrombosis and • Measures the responsiveness of the bone marrow to
disseminated intravascular coagulability a diminished number of circulating erythrocytes
• Patients who have MI or pulmonary embolism also • It is a direct measurement of RBC production by the
submit for a D-dimer test bone marrow
Elevated: there is an increased RBC production due to

Hemoglobin Electrophoresis
excessive destruction or loss
• Detect different types of hemoglobin in blood (Hb A1,
Reduced: bone marrow production of RBC is
Hb A2, Hb F, Hb S, Hb C)
inadequate due to anemia, bone marrow failure or
• Measures the different types of hemoglobin in the
pernicious anemia
blood. It also looks for abnormal types of hemoglobin
• Helpful for patient who frequently needs fresh blood
Erythrocytes Sedimentation Rate (ESR)
transfusion
• If Hb S and Hb C is elevated, there is a short life span • N = < 30 mm/hr
of blood cells; common type of abnormal cell found • Measure the distance that RBCs descend in
through electrophoresis test anticoagulated blood in 1 hour
• Use of electric current to separate the normal and • To detect for any inflammatory, neoplastic, or
abnormal type of hemoglobin in the blood infectious process
• Not a diagnostic test for a specific organ for disease
or injury
a. Hb A1
− A major component that is composed of 98% Increased: evidenced in Px with rheumatoid arthritis,
of hemoglobin in a normal RBC systemic lupus erythematosus, renal disease, infection
− This is the normal type of Hgb that should be Decreased: patients with polycythemia vera, sickle cell
found in a healthy adult anemia, or hypofibrinogenemia

Antiglobulin Test (Coomb’s Test)

• Detect serum antibodies that coat RBCs
• Determine if the blood contain antibodies that cause
the immune system to attack and destroy its own RBC
(e.g., hemolytic anemia)
• Used for cross-matching blood for blood transfusion
• Test for umbilical cord of patients with erythroblastosis
fetalis
• Also diagnose acquired hemolytic anemia
Lymphangiography
Indirect Coomb’s test • Visualization of the lymph
• Detect specific serum antibodies to RBC antigens that system radiographically
are not attached to the cell after injection of a dye
• If there’s a presence of agglutination of RBC, it (staging of Hodgkin’s and
confirms the presence of antibodies. It does not attach non-Hodgkin’s lymphoma)
antibodies that are floating in the bloodstream • Also used to evaluate
unexplained swelling of the
extremities
Serum ferritin, transferrin, and total iron-binding
• Dye is injected in each foot or hands
capacity (TIBC)
• Used to evaluate iron levels
Lymph Node Biopsy
• Serum ferritin is a good indicator for the availability of
stored iron • Performed in the operating room to obtain lymph
• Total iron binding capacity measures the blood’s tissue for histologic analysis
capability to bind iron with transferrin
Sickle Cell Test

• Screen for sickle cell disorder
• Definitive diagnosis through the use of hemoglobin
electrophoresis to screen sickle cell disease or traits
Lactate Dehydrogenase (LDH)

• May indicate hemolysis (LDH1 and LDH2) if there is
Blood Groups and Typing
an elevation
• LDH is present in the body and released during tissue Major Determinants in compatibility testing
damage or injury 1. ABO compatibility
2. Rhesus (Rh) or D antigen
Folic Acid and Cobalamin Test
ABO Blood Groups
• Detect folic acid and B12 deficiencies
1. Type A
• Folic acid test is used to determine for any deficiency
2. Type B
of folic acid that may cause folic acid anemia in which
3. Type AB (universal recipients)
RBC are abnormally large due to deficiency
4. Type O (universal donor)
Biopsy Tests
If there’s a missed matching of blood, the main symptom
Bone Marrow Aspiration and Biopsy
will be acute hemolytic reaction. That is why cross
• To determine the cellularity of bone marrow and matching is very important prior to administration of
morphology of the cell present blood to the patient. Proper and correct type of blood
• Asses the quality and quantity of each type of cells should be infused to the patient.
produced by the bone marrow
• Sites for bone marrow aspiration may include:
Types of Blood Products
sternum, iliac crest (common), tibia, posterosuperior
iliac spine Special
Description Indications for Use
Considerations
• Acute blood loss
Packed RBCs Less danger of
• Severe or symptomatic
(250 – 350 ml) fluid overload
anemia

• Bleeding caused by Cryoprecipitate

thrombocytopenia Agitate bag
Platelets
• Platelet level < 10,000 periodically (do
• AKA antihemophilic factor (Factor 8)
(30 – 60 ml)
• X-matching is NOT not shake) • Prepared from fresh frozen plasma wherein they
required
leave at least 10-20 ml per bag
Fresh Frozen • Bleeding caused by Treating • Can be stored for 1 year, but must be used once
Plasma (contain deficiency in clotting hypovolemic
NO platelet) factors shock and thawed
• X-matching
Clotting factor V
and VIII necessary
is not thrombocytopenic
purpura
• Hypofibrinogenemia is also given cryoprecipitate
 Special consideration for hypofibrinogenemia
• Replacement for clotting • Cryoprecipitate is used for VWB and factor 8 and 13
Cryoprecipitate factor VIII and fibrinogen
(antihemophilic • Von Willebrand when appropriate factor concentrate is not available
factor) 10 – 20 ml • Hemophilia A and B
• Needs ABO compatibility
Common Nursing Procedures of the Hematologic

• Blood component therapy where in manage in the use System
hematological disease that transfuse specific part of Protocol for the Administration of Blood and Blood
the blood rather than blood or whole 4 elements Products
• There are many therapeutic and surgical procedure 1. Check the agency’s policy and procedure before
depends on the blood products blood transfusion
2. Verify the physician’s order
Packed RBCs  To specify blood component, volume, and rate of
• Prepared from a whole blood product by infusion
sedimentation or centrifugation 3. Consent
• It contains a unit of whole blood (250-350ml), but still  Obtain consent form to explain to the patient the
check on the pack, bag, or unit for the amount medical indication of transfusion, its benefits,
• Packed RBC transfuse only the RBC itself excluding risk, and alternatives
the plasma, but the remaining component of blood like 4. Typing and cross match
platelet, albumin and plasma are used for patients 5. Obtain blood intravenous access line is available
with anemia  If the patient doesn’t have IV line
• Swirl from time to time  Gauge of the IV catheter should be a gauge of
19 or 18
Platelets
• Prepared from fresh whole blood within 4 hours after Additional:
collection ✓ Use normal saline solution before and after giving
• It contains 30-60 ml of platelet concentrate blood transfusion
• X-matching is not necessary but it depends on the ✓ Lactated ringer solution should not be used because
hospital policy it induces RBC hemolysis
✓ The use of microaggregate filter to filter out the
Fresh Frozen Plasma particulate. This is changed every 6 hours or 1-2
• Liquid portion of the whole blood that has been frozen units of blood
and preserved; it separates the cell and plasma ✓ Antihistamine is also given
• Contains NO any platelet so it may be stored for about o Philippine setting: 30mins before blood
a year, but must be used within 2 hours after thawing transfusion
• 1 unit of fresh frozen plasma = 200-250 ml o US setting: they minimize giving antihistamine
• Risk: disease transmission, anaphylactoid reaction, or prior to blood transfusion
patient with excessive intravascular volume ✓ Check VS 3x (15 mins before BT, 15 mins after
giving BT, and after the completion of BT)
Indication ✓ Ask another nurse to validate the data of the blood
product (ex. name of the patient, ID #, blood type, if
1. Clotting factor deficiency
Rh + or -)
 Ex. DIC, hemorrhage, massive transfusion
2. Clotting problem
 Liver disease, over dose of anti-coagulant
3. Replacement for isolated factors like deficiency in
coagulation factors 2, 5, 7, 9, 10 & 11
Blood Transfusion Set Leukoreduction Filter

✓ Microaggregate that is use in blood packed RBC Management: prophylactic measures to reduce renal
blood transfusion set failures such as hydration, use of dopamine, and
✓ Do not use blood transfusion set if giving platelet diuresis with 20% of mannitol
concentrate products because in platelet
concentrate transfusion, you need another Bacterial (Pyrogenic)
administration set that doesn’t have any filter
This is due to improper handling and of blood products;
✓ You may use leukoreduction filter in patients with
there is bacterial contamination of blood products.
leukocyte incompatibility
1. Fever and chills
2. Hypotension
Management for Transfusion Reaction
3. Flushed skin
1. Stop transfusion if there’s a BT reaction 4. Abdominal pain
2. Take a urine sample and keep the blood bag for 3-7 5. Pain in the extremities
days for investigation 6. Diarrhea
3. Avoid blood transfusion through a port-a-cath
 Risk for infection and blood clot formation Management: administer antibiotic, IV fluids, and
4. If the blood is less than 3 days old, do not transfuse steroids as directed
it because of the high risk of transmission of viral
infection from the fresh blood
Allergic Reaction
5. Maintain a patent IV line with saline solution
6. Recheck the identifying tags and numbers of the Sensitivity to plasma protein of the donor’s blood. This
patient is common in patients with a history of allergies.
7. Take VS and urine output and refer to the patient to 1. Urticaria
treat for any symptoms 2. Pruritus
8. Important to document 3. Swelling of the face or tongue
 One of the transfusion reactions is acute 4. Difficulty of breathing
hemolytic reaction. This due to mislabeling of 5. Pulmonary Edema
specimen, the nurse administered blood to the 6. Shock
wrong individual.
 Tendency is that antibodies attacks RBCs, the Management
antibodies in the recipient serum react with the 1. Antihistamine to prevent allergic reaction
antigens on donor’s RBC, resulting to 2. Epinephrine or corticosteroid for severe reaction or
agglutination of cells that can obstruct the anaphylactic reaction to increase blood flow in the
capillaries, blocking the blood flow vein and to reduce swelling in the airway
 This hemolysis of RBCs releases pre-
hemoglobin into the plasma that is filtered by the Circulatory Overload
kidney obstructing the renal tubules resulting to
Seen in patients with cardiac or renal insufficiency. They
acute renal failure
are at risk for developing circulatory overload especially
 Shock and death may occur
if a large quantity of blood is being infused in a short
9. Necessary x-matching to reduce the incident
period of time, particularly in elderly patients.
1. Chest pain
Signs and Symptoms of Blood Transfusion Reaction
2. Tightness of the chest
Hemolytic Reaction
3. Cough
1. Chills 4. Rales
2. Fever 5. Pulmonary Edema
3. Urticaria 6. Tachycardia
4. Tachycardia 7. Elevated blood pressure
5. Chest pain or complaints of chest tightness
6. Shortness of breath Management: upright position, oxygen, diuretics,
7. Nausea and vomiting morphine, phlebotomy (to decrease total blood volume
8. Hypotension from the patient)
9. Dyspnea
10. Lumbar pain
11. Rales and wheezes Anaphylactic Reaction
12. Hematuria Severe type of allergic reaction
1. Anxiety
2. Urticaria

3. Wheezing • It means potassium leaked out of RBC causes the

4. Cyanosis elevation of the potassium level of patient
5. Shock
6. Possible cardiac arrest Sign and Symptoms
1. Nausea
Management: have epinephrine ready for injection or 2. Muscle weakness
solucortef or corticosteroid (same thing with allergic 3. Diarrhea
reaction) 4. Paresthesia
Febrile Reaction Erythrocyte Disorders

• Commonly caused by leukocyte incompatibility Basic pathophysiology account for all disorder of
• 5 or more transmissions erythrocytes: anemia and polycythemia
• May develop circulating antibodies to small amounts
of WBC in the blood product
Anemia
• Can be prevented using additional filter
• Deficiency in the number of RBCs
(leukoreduction / leukofilter / leukodepletion set) in
• Is not a specific disease but it’s a manifestation of
order to minimize the human leukocyte antigen
pathologic process
Massive Blood Transfusion Reaction Causes

• Transfusing large volume of blood products of RBC 1. Insufficient production of RBC by the bone marrow
that exceeds the total blood volume within 24 hours  Due to hematopoietic tissue disorder wherein the
• In this situation, it may cause an imbalance in the bone marrow is damaged by toxin, radiations,
normal blood element resulting to clotting factors kidney therapy or there’s a hyperactive spleen
alterations, and other blood components such as 2. Defective synthesis of RBC
albumin, platelets, that are not found in IV transfusion  Due to absences of essential factors such as
• Possible massive blood transfusion reaction: folate, vitamin B12, and iron which are essential
hypothermia and cardiac arrhythmias which results to for the maturation of RBC
large quantity of cold blood being given to the patient 3. Increased destruction of RBC
 Caused by hereditary factors or any acquired
Hypothermia conditions like hemolytic anemia, infections, and
• Reduces the metabolism of citrate and lactate which bulb prosthesis
increase the likelihood of hypocalcemia, metabolic 4. Loss of erythrocytes
acidosis, and cardiac arrhythmia  Increase loss of erythrocytes caused by acute or
chronic bleeding (blood loss) or the combination
of these factors
Citrate Toxicity and Hypocalcemia
• May occur with the transfusion of large quantity of
blood, because citrate is part of the storage solution Polycythemia
wherein the calcium binds to the citrate • Sometimes called erythrocytosis, but the terms are
• Citrate toxicity it is likely to develop when the blood is not synonymous, because polycythemia describes
transfused at the rate of 1 unit in 10 mins any increase in red blood mass (whether due to an
erythrocytosis or not), whereas erythrocytosis is a
Manifestation documented increase of red cell count
1. Muscle tremors
2. Changes in ECG Causes
1. Idiopathic causes
Treatment  Increased number of circulating cells that result
1. Infusing 10% of calcium gluconate from unknown cause
 If the patients receive 3-5 units of blood, calcium 2. Compensatory mechanism
gluconate is usually ordered  In response to tissue hypoxia
 Very common in secondary polycythemia
Hypokalemia
• When potassium leaks from the RBC in the stored
blood

 Because of the low level of G6PD which is

important for RBC metabolism; it has an intrinsic
RBC defect
Bleeding
• Results from RBC loss from post-hemorrhagic
anemia due to trauma
Cause
1. Bleeding from GIT, epistaxis, menorrhagia, trauma
2. There are drug-induced that causes hemolysis
Anemia Result From

1. Impaired erythrocyte production
2. Blood loss (acute or chronic)
3. Increased erythrocyte destruction
Classification Of Anemia
Hypoproliferative or Acquired
• Results from defective RBC production meaning there
is a reduction in the production of RBC
Causes
1. Deficiencies of factors necessary for RBC production
Pathophysiology
 Iron deficiency anemia, vitamin B12 or folic acid
deficiency results to large RBC Decreased RBC
 Pernicious anemia due to lack of intrinsic factor 
2. Damage to bone marrow Decreased transport of oxygen to tissues

 Bone marrow failure that prevents erythropoiesis
Tissue hypoxia
such as medications (chloramphenicol and 
chemical benzene), cancer, inflammation Stimulate kidneys
 Example: aplastic anemia 
Increased erythropoietin

Hemolytic Anemia
Increased RBC production
• Results from RBC destruction from extrinsic sources 
such as prosthetic heart valve and thrombocytopenic  Cardiac output
purpura. It can also be a result from antibodies that 
affects the RBC  Heart rate and stroke volume
Causes
Iron Deficiency Anemia (IDA)
1. Congenital – sickle anemia
• It is chronic, microcytic (small size of RBC) and
 Due to abnormal synthesis of hemoglobin; the
hypochromic anemia (decreased color of RBC)
globin portion of Hgb molecules is defective
• Characterized by deficient hemoglobin synthesis
2. Direct injury to the erythrocytes – mechanical heart
caused by lack of iron
valve
• 1 mg of iron is loss daily through feces, sweat, and
 Trauma like burns, surgery that may cause direct
urine
injury to the erythrocytes
3. Chemical agent and medication
4. Infectious agent and systemic diseases (e.g., Etiologic Factors
Hodgkin’s lymphoma, leukemia, systemic lupus 1. Inadequate dietary intake of iron
erythematosus)  If there is a heme fraction, usually seen in
5. Autoimmune disorder that may cause abnormality patients with iron deficiency anemia
within erythrocyte − G6PD (Glucose-6-phosphate  If the globin is affected, it may result to
dehydrogenase) deficiency thalassemia

 Iron is essential in carrying O2. When this 7. Gastritis

disorder of heme synthesis become severe, the 8. Neuromuscular changes
bone marrow produces RBC that are deficient in 9. Brittle and ridged nails
hemoglobin concentration causing hypochromic
and microcytic anemia Signs and Symptoms
2. Blood loss – acute and chronic
1. Dysphagia – Plummar-Vinson’s Syndrome
 2 ml of full blood contain 1 mg of iron
 Due to mucus and inflammatory cells at the
 Loss of 50-70 ml of blood from the upper GIT,
opening of the esophagus
the stool to appears as black (melena)
2. Plummer-Vinson Syndrome
 Post-menopausal bleeding can contribute to
 Patient have dysphagia, esophageal web, and
anemia in a susceptible older woman
iron deficiency anemia
3. Medications
 Triad of symptoms affecting middle age women
 Example: aspirin, NSAIDs
 Commonly seen in post-menopausal female
4. Surgical procedures
 Decreased stomach acidity alter the absorption
of iron, and the intestinal transit time and
absorption will be delayed
5. Eating disorders
 Craving or eating non-nutritional substance
6. H. pylori infection
 Unknown; iron uptake 3. Fatigue
 Decreased O2 supplement in the body tissue
4. Cardiovascular system
Predisposing Factors
 Tachycardia, palpitation (prevents congestion
1. Indigent
and rapid venous return), shortness of breath,
2. Poor dietary intake
chest pain, and heart failure
3. Poor dentition especially in elderly
5. Neuromuscular changes
4. Lack of interest in food preparation
 Irritability, headache, numbness, prickling
5. Malabsorption − gastrointestinal surgery or
sensation
malabsorption syndrome
 Elderly iron deficiency may experience mental
 There’s an alteration in the mucosa of duodenum
confusion, memory loss, and disorientation
and proximal jejunum due to chronic diarrhea
and malabsorption (ex. celiac disease)
 Iron is mostly absorbed in the duodenum and
enhanced by gastric acid
6. Hemolysis
 Patients with liver dysfunction
 2/3 of iron is used in the bone marrow to form
iron compound, called heme which requires the
synthesis of hemoglobin
 1/3 of iron is stored in the form of ferritin in the
liver, spleen, and bone marrow
 Any imbalance of these may result to anemia
1. Pallor
 Due to reduced hemoglobin concentration
2. Atrophic glossitis Diagnostic Studies
 Tongue is inflamed and smooth
1. CBC
 Caused by soreness along with redness and
 RBC – decreased Hgb and Hct
burning sensation
 Mean Corpuscular Volume (RBC indices) –
 Reversed within 1-2 weeks of iron replacement
decreased, evidenced by of low RBC with
therapy
microcytic and hypochromic cells
3. Cheilosis
 Serum iron – low but with a high iron binding
4. Koilonychia
capacity
5. Pica
 Serum ferritin – decreased
6. Cardiovascular symptoms

2. Endoscopy
 Detects GI bleeding
3. Stool exam or guaiac test
 To evaluate for any hidden or occult blood in the
stool sample
 Red meat, turnips, radish, or horse radish may
affect the test result
Management
1. Drug therapy
 Iron supplement − FeSO4
Oral iron preparations
✓ Taken after meals to prevent GI irritation, but now Pernicious Anemia
its best taken before meals to increase absorption • Absence or inadequate intrinsic factors (IF) result to
✓ Some patient takes it with empty stomach causing decreased absorption of vitamin B12
GI irritation so its best taken after meal • IF is secreted by the parietal cells of the gastric
✓ If its in liquid form, use a straw to prevent staining mucosa
of the teeth • The combination of intrinsic factors assists in the
✓ Do not administer with milk or antacid which may absorption of cobalamin in the distal hilum
inhibit absorption • Most common cause of cobalamin deficiency
Parenteral iron preparations
✓ IM: use Z-track technique to prevent staining of Etiology
the skin upon administration (do not massage to 1. Lack of IF
prevent leakage of medication into SQ tissue) 2. Autoimmune disorder
✓ IV  H. Pylori infection cause gastric auto-immunity
2. Diet 3. Resection of the stomach or ileum
 Vitamin C to increase iron absorption  Absorption of vitamin B12 is in the distal ileum
 Black fungus (rich in iron content) 4. Chronic gastritis
3. Oxygen therapy  Especially type A gastritis wherein it decreases
 To prevent tissue hypoxia hydrochloric acid secretion by the stomach
 If the iron deficiency is severe or there’s an  Acid environment in the stomach is required for
increase in blood loss, then blood transfusion is the secretion of IF
necessary
4. Oral hygiene
Other Causes
 For patients with cheilosis and stomatitis to
promote well-being of and to reduce infections in 1. Overgrowth of intestinal bacteria
the oral cavity 2. Infestation with fish tapeworm
5. Blood transfusion  Will compete the host for the vitamin B12
6. Increase high fiber diet  Treatment: use of broad-spectrum antibiotics
 To prevent constipation 3. Malabsorption syndrome seen in vegetarians
7. Deferoxamine
 Iron chelating agent that prevents iron overload
Intrinsic factor, a transport glycoprotein, releases
 That’s why iron supplement should be
from healthy parietal cells lining on stomach,
prescribed by the doctor
parallels with hydrochloric acid, uses to break B12
from food. Before you can use B12 in blood
Megaloblastic Anemia production, brain function, nervous system
• Impaired DNA synthesis and characterized by signaling, you need IF.
presence of large RBCs
• Deficiencies in vitamin B12 and folic acid
• Two forms: cobalamin and folic acid deficiency
 Have the same signs and symptoms, the only
difference is that pernicious anemia (B12) causes
neurologic symptoms

Shows the action and secretion of IF in the stomach that will

Different oral manifestation of B12 deficiency and other conditions,
combine with vitamin B12 in the distal ileum
Notes: (A and B) Linear or band-like “beefy red” patches on the lingual dorsum
in B12 deficiency. (C) confluent erythema on the lingual dorsum and a
depapillated area in erythematous candidiasis, (D) circinate, irregular erythema
Major Characteristics of Pernicious Anemia on the dorsum of the tongue surrounded by a slightly elevated keratotic band in
1. Abnormal large RBCs geographic tongue
 Morphology RBC cells appears to be macrocytic

2. Hypochlorhydria Diagnostic Studies
 Deficiency in gastric hydrochloric acid 1. CBC
3. Neurologic and GI symptoms  Low RBC, WBC, MCH
 Sign and symptoms are similar with folic acid  High MCV and MCHC
deficiency. The only difference is that in 2. Peripheral blood smear
pernicious anemia there is neurologic symptoms  Large and abnormal shape
while in folic acid anemia, it does not show any  The cell structure may contribute to erythrocyte
neurologic involvement destruction because the cell membrane is fragile
 Symptoms include paresthesia, weakness, 3. Serum cobalamin levels
ataxia, lack of coordination, impaired thought  Low – deficiency
process 4. Bone marrow studies
4. Lifetime injection of vitamin B12  Contain high number of megaloblast
 If there’s resection of gastric or distal ileum 5. Unconjugated bilirubin
 Due to hemolysis of defective RBC
Clinical Manifestations 6. Serum LDH
1. Low RBC, hemoglobin and hematocrit  Extremely high due to hemolysis
2. Smooth “beefy” red tongue – pathognomonic 7. Schilling test
3. GI symptoms – achlorhydria, mild diarrhea  Determine if the patient have pernicious anemia
4. CNS – paresthesia, proprioception 8. Gastric secretion analysis
5. Neurologic – irritability, poor memory, headache  To check for the presence of free hydrochloric
6. Vitiligo acid
7. Proprioception 9. Endoscopy or gastroscopy and biopsy of the gastric
8. Premature graying of hair mucosa
Management
1. Parenteral vitamin B12
 Monthly injection
 Usually, it responds quickly and often takes 7
days for the reticulocytes to begin to increase (by
end of the first week)
 Without cobalamin administration, patient may
die in 1-3 years
2. Iron supplements
 If hemoglobin fails to rise in proportion to an
increased RBC count
3. Physical therapy and rehabilitation
 If there’s a neurologic involvement to prevent
permanent neurologic disability
4. Blood transfusion

5. Diet Diagnostic Studies

 Fish, egg, yogurt, chicken, and salmon 1. Serum folate − low
2. Schilling test − normal
Folic Acid Deficiency Anemia
• Inadequate folic acid supplement Management
• Folic acid is necessary for DNA synthesis of RBC 1. Emphasize on the diet (nutritious diet)
formation and maturation 2. Encourage to meet the daily folic acid requirements
3. Supplementation of folic acid via IM administration
Possible Causes 4. Vitamin C
1. Poor nutrition  Increase the goal of folic acid in promoting
 Inadequate dietary intake erythropoiesis
 Advanced age, anorexia nervosa, chronic 5. Good oral hygiene for glossitis − soft toothbrush
malnutrition 6. Monitor fluid and electrolyte
 Consuming large amount of alcohol may block  Especially in patients with severe diarrhea, they
the response of bone marrow to folic acid which need to have IV fluid replacement
may interfere erythropoiesis
2. Increased metabolic requirements Aplastic Anemia
 Pregnancy, infant, teenager, hemolytic anemia • Bone marrow is severely hypoplastic (“empty”) and
 Patients undergoing hemodialysis because folic fails to produce the three kinds of blood cells
acid is being loss (erythrocytes, leukocytes, thrombocytes)
3. Impaired absorption • Results from injury or destruction of stem cells in the
 Due to intestinal dysfunction from celiac disease bone marrow or bone marrow matrix causing
or bowel resection pancytopenia
4. Hemodialysis • Pancytopenia is when all the elements are
 Loss during dialysis suppressed; abnormally low amounts of all three
5. Impaired metabolism types of blood cells
 Receiving chemotherapeutic agent which may • Morphology of aplastic anemia is slightly macrocytic.
impede the absorption and use of folic acid It’s usually normocytic and normochromic but
sometimes there’s a slight increase in the size of RBC
Folic acid deficiency usually develops suddenly and
the symptoms may be attributed to other existing
problems such as cirrhosis and esophageal varices
Pancytopenia
Presentation varies with degree of cytopenia
❖ Anemia  fatigue
❖ Thrombocytopenia  bruising or bleeding
Clinical Manifestations ❖ Neutropenia  infection
1. Fatigue
2. Pallor Etiologic Factors of Aplastic Anemia
3. Progressive weakness 1. Congenital
4. Palpitations  Caused by chromosomal alterations such as
5. Diarrhea dwarfism and hypoplasia in the kidney or spleen
6. Slight jaundice 2. Acquired – results from exposure to
7. Glossitis and cheilosis  Ionizing radiation
 Chemical agents
Same with pernicious anemia but only difference  Infections
is there is NO neurologic involvement  Prescribed medications

Chemical agents Diagnostic Studies

− Toxin like benzene seen in dry cleaning solution 1. CBC – differential count
− Insecticide and arsenic  Neutrophils 
− Use of hair dyes (aniline content and carbon  RBC 
tetrachloride)  Reticulocytes 
Infections 2. Coagulation studies
 Bleeding time is prolonged
− Viral or bacterial
3. Bone marrow biopsy
− Hepatitis B virus, biliary TB, Epstein-Barr Virus
 Hypocellular with an increase in yellow marrow,
Prescribed medications meaning the bone marrow is empty when its
− Anti-seizure agents, anti-metabolite, anti- supposedly reproducing RBC, thrombocytes,
microbial, chemotherapy agent (alkylating agent) and leukocytes; it contains fats
− Some groups of mycotoxins cause aplastic
anemia
Management
− Cytoxan always cause mild damage, usually in
patients who are receiving it or anti-metabolites to 1. Withdraw an offending agent
treat malignancy 2. Frequent hemogram
− Chloramphenicol and sulfonamide occasionally  Taking CBC especially for radiation therapy
cause bone marrow failure 3. Blood transfusion
− Streptomycin have been linked to development of  Depending on the cause or manifestation of
aplastic anemia; a drug used in patients with TB patient
4. Bone Marrow Transplantation (BMT)
3. Idiopathic – unknown; no specific cause  Autoimmune
4. Autoimmune – DIC, leukemia  Gold standard of treatment
 Antibodies develop against the body’s owns  Performing peripheral blood stem cell
erythrocytes transplantation where it involves harvesting
specific cell line from the peripheral blood of the
donor, then filtered and preserved through
Clinical Manifestations of Aplastic Anemia
freezing and given to the recipient after the
1. Pallor
patient received intensive treatment
2. Headache
3. Tachycardia
4. Fatigue
5. Dyspnea
6. Purpura – bruising (later)
7. Granulocytopenia
8. Thrombocytopenia
 Petechiae, bleeding
 If decrease in leukocytes, prone to infection
9. Cervical lymphadenopathy
 Recurrence of throat infections
10. Retinal hemorrhage – common
11. Splenomegaly
 Expected because of the hemolysis of blood cell 5. Donor Lymphocytes Infusion

6. Drug therapy  Increased bilirubin level results to jaundice and

 Use of immunosuppressive drugs to prevent increase in fecal and urinary urobilinogen
lymphocytes from destroying stem cells 3. Failure of the bone marrow to replace destroyed
 Combination of anti-thymocyte globulin (ATG) RBC
and corticosteroid  The bone marrow compensates by erythroid
o Effective for aplastic anemia especially if the hyperplasia with accelerated production of red
causative factor is due to immune mediated cells. This reflects an increase in reticulocyte
disease count and slight macrocytosis. Meaning, there is
o Side effect: fever and chills an increased production of immature erythrocyte
o Corticosteroid alone is not useful because or young blood cells (reticulocyte) and at the
patients with aplastic anemia are susceptible same time, a bigger erythrocyte is circulating in
to the development of bone complications the peripheral blood
from corticosteroid  The expansion of bone marrow in infants and
 May give antibiotics children with severe chronic hemolysis causes
7. High fiber diet changes in bone configurations seen when
 Prone to bleeding due to decreased number of patient submits for x-ray
thrombocytes  The balance between the RBC destruction and
8. Stool softener marrow compensation determines the severity of
anemia
Hemolytic Anemia
• Accelerated destruction of erythrocytes Etiologic Factors of Hemolytic Anemia
• Shortened life span of erythrocytes Intrinsic
• Abnormal breakdown of RBC in the blood vessels, • Hereditary form of hemolytic anemia from a structural
called intravascular hemolysis defect of erythrocytes
 RBC is being lysed within the blood vessels • Caused by an abnormal hemoglobin seen in sickle
• Example: damage of the heart valve being replaced cell anemia and G6PD deficiency
with prosthetic heart valve • Inherited enzyme defect wherein there’s a defect in
• If it occurs somewhere else aside from the blood the RBC membrane production or in the hemoglobin
vessels, it’s called extravascular hemolysis production common in patients with sickle cell disease
• Can be classified as acquired or hereditary and thalassemia or a defect in red cell metabolism as
• If erythrocytes have shortened life span therefore, the seen in patients with G6PD deficiency
number in the circulation is reduced
Extrinsic
• The damage of the RBC is caused by external factors,
like:
Physical Factors – trauma

− Disruption of RBC membrane from mechanical
injury seen in patients with prosthetic cardiac
valve and those undergoing hemodialysis or
cardiopulmonary bypass
Hallmark of Hemolytic Anemia − When RBC is exposed to excessive turbulence in
1. Shortening of the RBC lifespan the circulation, they become easily fragmented
 If there’s fewer erythrocytes, it decreases the and destroyed by phagocytes resulting to anemia
availability of O2 (hypoxia) which stimulates the − In addition, the force needed to push the blood
release of increased erythropoietin from the through abnormal vessel in burn injury patients or
kidney in patients with angiopathic disease (diabetes
 Erythropoietin stimulates the bone marrow to mellitus) may damage the RBC
compensate for loss by producing new
erythrocytes to be released into the circulation Immune Reactions
2. Abnormal increase in the RBCs − Reproduce antibodies that agglutinate the
 The hemoglobin is broken down excessively, patient’s own RBC
about 80% of heme is converted to bilirubin and − Agglutinated cells clamp together which then is
excreted in the bile phagocytized within the spleen (engulf abnormal
or clamped RBC within the spleen)
− Example: blood transfusion reactions

Infectious Agents or Toxins  Due to increased excretion of bilirubin in the

− Infectious agent cause hemolysis in 4 ways: biliary tract causing excessive accumulation of
1. By evading RBC and destroying its content bilirubin within the gall bladder because of
(ex. malaria) erythrocyte destruction
2. Releasing hemolytic substance (foodborne 8. Renal failure
illness − clostridium perfringens)  Occurs if the RBC hemolyze. The hemoglobin
3. Generating antigen-antibody reactions molecule then is released and filtered by the
4. Contributing to splenomegaly as it increases kidney and when accumulated can obstruct the
removal of damaged RBC from the circulation renal tubules resulting to acute tubular necrosis
9. Hemoglobinuria
 Intravascular hemolysis wherein the O2 transport
Additional:
protein, hemoglobin, have abnormally high
• Hypersplenism may also cause hemolytic anemia
concentrations in the urine
because of increased activity of the spleen. This is
 The urine color is purple due to excessive
seen in patients who have portal hypertension
hemoglobin being filtered by the kidney
• Runners can also suffer hemolytic anemia due to “foot
10. Urobilinogenuria
strike hemolysis” due to the destruction of red cells in
 Due to increased Hgb catabolism
in the small capillaries in the soles of the feet from
11. Leg ulcers
repetitive foot striking
 Intrinsic red blood cell disorders (ex. sickle cell
disease)
Classification of Hemolysis Anemia 12. Skeletal hypertrophy
Intravascular Hemolysis  Due to severe congenital hemolytic anemias and
• Destruction of erythrocytes within the blood vessels thalassemia
• Increased LDH in patients with intravascular 13. Hematuria
hemolysis
Diagnostic Studies
Extravascular Hemolysis 1. CBC
• Destruction of erythrocytes in the macrophage of the  Erythrocyte count, Hgb, Hct – low
spleen, liver, and bone marrow 2. Peripheral smear
• Coated with antibodies or abnormally shaped  To determine RBC shape and cell fragments
membrane without being release into the circulation  Expect that there is a change in the size of RBC
• Example: autoimmune diseases 3. Elevated reticulocytes
 Due to the increased effort of the bone marrow
Associated with: to compensate for the excessive erythrocyte
✓ Increased erythropoiesis destruction
✓ Increased hemoglobin catabolism byproducts 4. Erythrocyte fragility − increased
5. Erythrocyte life span
 Shortened due to increased destruction
Clinical Manifestations 6. Elevated serum bilirubin
1. General manifestations of anemia 7. Bone marrow biopsy
 Destruction of RBC and reduced reproduction of  There is hyperplasia
erythrocytes
 Recent onset – acquired
Management
 Long standing – possible congenital
1. Eliminate causative factors
2. Pallor
2. Maintain fluid and electrolytes
3. Fatigue
4. Jaundice 3. Administer O2
 Due to accumulation of bilirubin within the blood  Decreased RBC causes hypoxia
because of excessive destruction of erythrocytes  Administer blood transfusion if there is a loss or
reduction of RBC
5. Splenomegaly
4. Maintain renal function
6. Hepatomegaly
 No. 5, 6, and 7: Accounting to the macrophage  Sodium bicarbonate to reduce pH due to
within the spleen and liver which becomes accumulation of acid
hyperactive due to the increased demand to  Sodium lactate to alkalize the urine and
decrease the likelihood of precipitation of renal
phagocytize defective erythrocytes
failure
7. Cholelithiasis
5. Drug therapy

 Corticosteroid to decrease the ability of Normal and Sickled Red Blood Cells in Blood
macrophage in order to clear the antibody Vessels
coated erythrocytes
 Osmotic diuretics – mannitol to increase urine
output and promote the excretion of toxic
substances, especially for autoimmune type
 Prophylactic folic acid because active hemolysis
consumes folic acid which can lead to deficiency
and megaloblastosis consecutively
6. Surgery: Splenectomy
 Treatment of choice if not responsive to drug
therapy
Sickle Cell Anemia

• It is an inherited, autosomal recessive disorder Figure A. Shows normal red blood cells flowing freely in a blood
passed down through families. 2 copies of abnormal vessel. The inset image shows a cross-section of a normal red blood
genes must be present in order for the disease or cell with normal hemoglobin. The shape is biconcave and flexible
traits to develop when circulating in blood vessel.
• Characterized by the presence of Hb S form in the

hemoglobin
 An abnormal form of Hb in the erythrocyte making
it stiffen and elongated
• Taking on a shape of a sickle or crescent shape in
response to low O2 level and dehydration
• It stretches the erythrocytes into an elongated sickle
shape
Figure B. Shows abnormal, sickled red blood cells clumping and

blocking the blood flow in a blood vessel. The inset image shows a
cross-section of a sickled red blood cell with abnormal strands of
hemoglobin. There is change of the shape in RBC.
Factors that Trigger Sickling Episodes

Etiology
1. Hypoxia – caused by:
1. Heredity
 Viral or bacterial infection
 The child usually inherits a normal Hg from 1
 High altitude
parent and Hg S from the other
 Emotional or physical stress
 Occur only when the child experience extreme
 Surgery
stress
 Blood loss
2. Unknown
2. Dehydration
3. Hypoxia
 Vomiting
 Due to high altitude, emotional and physical
 Diarrhea, diaphoresis
stress, blood loss, some form of surgery, viral or
 Diuretics
bacterial infection
4. Increased blood viscosity
 Dehydration, vomiting, diarrhea, excessive Sickling is not permanent; it may regain its normal
diaphoresis, use of diuretics shape after oxygenation and rehydration. If there’s an
occlusion in the microcirculation, the tendency is that
the patient may experience hypoxia causing the RBC to
become sickle or change in shape. Hypoxia may result
to hypoxemia which may result to patient experiencing
pain, infarction, and thrombosis in tissue or organ such

as brain, kidney, bone marrow or spleen. It also triggers Types of Sickle Cell Crisis
erythropoiesis in the bone marrow and liver. That is why Vaso-occlusive / Pain Crisis / Sickle Crisis
many people die from sickle cell anemia during • Occur in microcirculation
childhood from cerebral hemorrhage or shock. Organ • Causes a lag jump effect which brings the blood flow
damage affects the kidney, brain, spleen and bone through the blood vessels to stop
marrow because of elevated fibrinogen level and • Inadequate blood flow to a specific tissue or organ
plasma clotting factor which contribute to the formation results to tissue hypoxia or necrosis leading to organ
of micro thrombus resulting to micro infarction and damage
tissue necrosis of the vital organ. Because of the • The crisis is painful, lasting for 4-6 days, and is
constant demand in O2, the demand on bone marrow precipitated by localized hypoximial, low O2
and spleen is also increased to replace the damaged concentration in the body, exposure to cold,
erythrocyte dehydration, and infection
• The pain crisis is usually a sudden onset of pain in the
Clinical Manifestations of Sickle Cell Anemia long bones, joints, chest, back, abdomen, and face
1. Hand-foot syndrome and needs immediate attention
 1st symptoms experienced wherein the patient
experience painful swelling of the hands and feet Aplastic
due to ischemia of tissue • Aka megaloblastic crisis
 Pain is characterized by throbbing and heat • Results from bone marrow depression, associated
blowing pain with infections with human parvovirus B-19 that may
2. Pallor, fatigue, irritability infect the red cells progenitor in the bone marrow
3. Jaundice – prone to gallstone formation leading to the cessation of erythropoiesis, so
4. Skinny legs reticulocyte is also reduced
5. Leg ulcerations – due to occluded circulation • Characteristic: pallor, lethargy, dyspnea, possible
6. Osteoporosis coma, decrease in bone marrow activity and RBC
7. Tachycardia hemolysis
8. Murmurs and cardiomegaly
 Hallmark of sickle cell anemia
Sequestration
 Will be able to know why patient have these sign
and symptoms • Large amount of blood pool in the liver and spleen
9. Dysrhythmias • If not treated immediately, it may progress to
10. Priapism hypovolemic shock and even death
 Persistent painful erection of the penis because • There’s a fall in the hemoglobin concentration,
the penile vein is occluded increased in reticulocytes and presence of
splenomegaly
• May also experience hypotension
Diagnostic Studies
1. Peripheral blood smear
Hypohemolytic Crisis
 Presence of sickle cells, a change in the shape
of erythrocytes which becomes elongated • There is an abnormal destruction of RBC
2. Hemoglobin electrophoresis manifestation similar with severe hemolytic anemia
 Identifies the presence of HbS and HbA • Liver congestion and hepatomegaly as a result of
3. Erythrocyte life span degenerative changes may worsen chronic jaundice
 Decreased or shortened, but there is elevation of
WBC and platelet counts Multiple Organ Involvement
4. Skeletal x-rays CNS − stroke, paralysis
 Bone deformity Heart − heart failure due to ischemia from chronic
5. MRI anemia and mitral infarction
 To diagnose a stroke caused by blocked
Pulmonary − cor pulmonale, pulmonary HPN
cerebral vessels from sickled cells
6. Elevated bilirubin Hepatomegaly – related to hepatopathy (presence of
7. Elevated reticulocytes gallstone as a result of chronic hemolysis with
 Compensatory mechanism of bone marrow to hyperbilirubinemia)
produce more RBC because of the decreased Splenomegaly − occur during latter part of 1st year then
life span of erythrocyte and destruction in the eventually may cause the spleen to shrink that is why it
spleen is called auto-splenectomy. Immune deficiency may
develop and infection are common

Renal medullary ischemia − causes a decrease in the Eyes Infarction  ptosis  Vision; blindness
capacity to concentrate the urine Sickling  vascular
Penis Pain, impotence
thrombosis  priapism
Hyperactivity of bone marrow − due to repeated
infarction of the bone, joints and growth plates leading
to osteomyelitis and osteoporosis Management of Sickle Cell Anemia
Impaired circulation − hand and feet edema results in 1. Supportive care
leg and feet ulcers and may cause delayed healing and  Bedrest
opportunistic infection  Warm compress to painful area (do not apply
Ophthalmologic − may have ptosis from periorbital cold compress because it may aggravate the
infarction or even reticular vascular changes that may condition of patient)
result to vision loss  Give biofeedback technique and other stress
reduction
 Avoid restrictive clotting
2. Blood Transfusion
 Administration of packed RBC
3. Hydration
 Sickling is not permanent so it may regain the
shape of normal RBC after rehydration and
reoxygenation
4. Surgery
 If there is hypersplenism, the doctor will perform
splenectomy
5. Drug therapy
 Folic acid supplement – to correct hemolysis
 Prophylactic penicillin – prescribed if due to viral
or bacterial infection that may result to hypoxia
 Hydroxyurea (Hydrea) – increasing fetal Hgb
(HbF) level, decreasing formation of sickle cell
o Used for severe type of sickle cell anemia
o For treating cancer patient
o May help to reduce the sickling erythrocyte
o Reduce pain episode but does not cure
sickle cell
 Erythropoietin
Fig 1. Clinical manifestation and complications of sickle cell anemia  Pentoxifylline – to reduce blood viscosity and
increase the flexibility of RBC
 NSAIDs – pain management especially the
Complications in Sickle Cell Anemia
vaso-occlusive type of sickle cell anemia
Organ Involved Mechanisms Signs and Symptoms
Primary site of sickling  Nursing Interventions

infarctions  Abdominal pain; fever,
Spleen 1. Managing pain
phagocytic function of signs of infection
macrophages
 Pharmacologic and non-pharmacologic
Infection  Relaxation techniques, music therapy,
Infarction  pulmonary
Lung
pressure  pulmonary
Chest pain; dyspnea biofeedback
hypertension 2. Preventing and managing infection
CNS Infarction
Weakness (if severe);  If there is a presence of leg ulcers
learning difficulties (if mild)
3. Promoting coping skills
Sickling  damage to
Kidney
renal medulla
Dehydration 4. Minimizing knowledge deficit
Weakness, fatigue,  By explaining to them
Heart Anemia
dyspnea  Ex. Avoid extreme stress for children, use of
 Erythroid production Ache, arthralgia rehydration and reoxygenation
Bone
Infarction of bone Bone pain, especially hips
5. Monitoring and managing potential complications
Liver Hemolysis Abdominal pain
Skin and
 Viscosity/stasis 
peripheral Pain
infarction  skin ulcers
vasculature

Measures the Prevent Pain Crisis 4. If intrinsic, may cause cell death that may cause
1. Consume adequate amount of fluid to prevent ineffective production of RBC
dehydration especially during hot weather, febrile
period Classification of Thalassemia
2. Avoid mountain climbing or air flying in non- Major groups according to which hemoglobin chain is
pressurized cabin about 10,000 ft. diminished: alpha or beta
3. Avoid exposure to extreme cold
4. Exercising to exhaustion Alpha Thalassemia
5. Drugs that lead to acidosis • Affect Asian and Middle East
6. Genetic screening and vocational counselling about • Milder compared to the beta
working or taking part in extreme physical activity • AKA silent carrier
during hot weather • This may carven one or more of the 4th genes needed
7. Avoid hypoxemia during perioperative period when for making alpha-globin chain of hemoglobin is
general anesthesia is used missing
Thalassemia Beta Thalassemia

• AKA Mediterranean anemia or Cooley’s anemia • Mediterranean
 Due to high incidence of thalassemia in the • Severe form called the Cooley’s anemia
Mediterranean • Occur when one or both of the 2 genes needed form
• Congenital anemia making beta-globin chain of hemoglobin is missing
• An inherited, autosomal recessive disorders that • Required treatment: regular blood transfusion
impair the rate of synthesis of one of the two chains of
normal hemoglobin (Hb A) Characteristic of RBC
 Characterized by hypochromia – an abnormal
1. Production of RBC is extremely thin and fragile, that
decrease in the hemoglobin content of
is why it is a target cell
erythrocytes
2. Hemolysis may occur resulting to imbalance of
 Microcytosis – small erythrocytes
alpha-globin and beta-globin which is normally
 Destruction of erythrocytes element
paired, so the excess of this unpaired alpha- or beta-
• Iron deficiency anemia affects the heme synthesis,
globin may damage the RBC membrane leading to
whereas thalassemia disrupts the synthesis of the
intravascular hemolysis
globin protein of the hemoglobin
Clinical Manifestations of Thalassemia

Mild form of Thalassemia: asymptomatic except for mild
anemia
1. Jaundice, leg ulcer, cholelithiasis
 Similar with hemolytic anemia
2. Pallor
3. Hemoglobinuria
4. Fatigue
5. Protruding abdomen
6. Hepatosplenomegaly
 Occasionally occurs due to destruction of spleen
Risk Factors
causing enlargement due to destruction of large
1. Ethnic groups (Mediterranean islands: Italy, Greece, number of RBC which contains the hemoglobin
Southern Asia and Africa) 7. Retarded growth
2. Geographical location  Chipmunk deformity which develops on the face
 Associated with increased resistance to malaria as the bone expand to accommodate
hyperplastic marrow
Characteristics 8. Chronic bone marrow hyperplasia
1. Malformation of the RBC  Due to expansion of the bone marrow space
 Change in the size and color of RBC  Maxillary prominence – thickening of the
2. Genetic code for hemoglobin is missing that causes maxillary cavity leaving the appearance of down
a change in the production of the chain in the syndrome
hemoglobin
3. Changes in size and shape will cause hemolysis

 Frontal bossing – characterized by pronounced Hallmark: unrestrained or uncontrollable production of

bone hyperactivity that causes thickening of the RBC, myelocytes (leukocytes) and platelet
cranium and a monggoloid face
 Wide-set-eyes with a flattened nose Characteristics: increased volume of erythrocytes and
elevated hematocrit level caused by dehydration
Patient may have an iron overload because of the
destruction of RBC by spleen. This RBC is
Causes of Polycythemia Vera
decreased that may become anemia.Blood
transfusion for management is needed. 1. Hyperviscosity
 There is an increased number of RBC and
concentration of hemoglobin in the blood that
Diagnostic Studies results to viscosity
1. Peripheral blood smear 2. Hypervolemia
 Small defective RBC (called target cells) wherein  Increased blood volume because the liver and
the cells resemble a shooting target spleen become increasingly congested with
2. CBC RBC (congestion of tissues and organs), so
 Decreased erythrocyte count, increased Hgb, viscosity closed the blood flow
decreased in MCV due to small size of the cell  Eventually, the thick, sticky, slow moving blood
3. Elevated reticulocytes become an ideal environment for acidosis and
4. Serum bilirubin – elevated clotting
5. Fecal and urinary urobilinogen 3. Congestion of tissues and organs
 Increased due to severe hemolysis of abnormal  Tissue organs become infarcted from thrombus
cells formation which may obstruct the blood vessel,
6. Hb A2  So, if there’s severe blood congestion of tissues
 Hemoglobin electrophoresis due to increased and organs, it may increase the clot formation
level of Hb A2, the minor component as high as  Usually develop in middle age
6% instead of the normal 1.5-3%  Unknown cause
Management High risk of clot formation

1. Transfusion therapy
 Receive packed RBC given monthly or twice a Types of Polycythemia Vera
month in a regular basis Primary Polycythemia (P-vera)
 If hemoglobin falls below 3 or 4 g/dl or every 15
• Neoplastic proliferative disorder of the myeloid stem
days to maintain the hemoglobin of 12-15 g/dl
cells
2. Chelation therapy: Deferoxamine
 There is an abnormal bone marrow proliferation
 Needed because of the blood transfusion that
 Initially it involves the white and red blood
cause may iron overload
elements. Later on, it may cause thrombocytosis
3. Surgery: Splenectomy
in which it stimulates the abnormal erythropoietin
 Especially for severe splenomegaly in children
hypersensitive stem cells while suppressing
 It is not recommended if less than 6 years of age
normal stem cells
 Absence of spleen may not affect the survival
• If it is panmyelosis, this is due to hyperfunction of the
rate of the patient but there are some changes in
bone marrow resulting from excessive proliferation
the system
that affect not only the RBC but also granulocyte and
4. Stem cell transplant
platelets
 It may insert normal genes into the patient’s stem
 The proliferation of this cell may result to increase
cell
in blood count, viscosity and volume
5. Genetic counseling
 That is why the liver and spleen may become
 Hereditary; autosomal recessive disorder
congested and packed with RBC causing stasis
and thrombosis more often than the result of
Polycythemia Vera thrombocytosis
• Syn. – myeloproliferative red cell disorder
• Excessive activation of pluripotent stem cells in the Secondary Polycythemia
bone marrow
• Compensatory response to tissue hypoxia
 Overgrowth of bone marrow or bone marrow
• Common type
makes too many RBC

• If the body demands for more O2 for any reason, the resulting in the formation of tiny blood clot in the
bone may produce more RBC to prevent tissue vessels of the extremities
hypoxia  Responsds rapidly to the treatment of aspirin
• Over production of erythropoietin stimulating the bone
marrow to produce more RBC in response to Diagnostic Studies
hypoxemia
1. Elevated hemoglobin, RBC, and hematocrit
2. Elevated WBC count with basophilia
Relative Polycythemia 3. Elevated platelets – thrombocytosis
• Caused by fluid loss 4. Elevated leukocyte alkaline phosphatase
• During dehydration wherein there is an increased 5. Elevated uric acid
erythrocyte concentration found with plasma loss 6. Elevated histamine level
caused by hemoconcentration
• Some specific cause: insufficient fluid intake, Since it affects all 3 blood cell lines, all
diarrhea, vomiting, burn, excessive use of diuretics of these are elevated
7. Bone marrow examination

Clinical Manifestation  There is a hypercellularity of the RBC, WBC and
1. Circulatory manifestation platelets
 Due to increased viscosity, therefore, it may 8. Erythrocyte sedimentation rate
increase the peripheral resistance resulting to  Reduced due to an increased zeta potential
elevation of blood pressure (HPN) (electrical potential)
 Caused by hypervolemia and hyper-viscosity; 9. Erythropoietin level content
often the first symptoms related to hypoxia from  Low due to increased erythrocyte production
impairment of microcirculation
 Hypertension, headache, vertigo, dizziness, Management of Polycythemia Vera
tinnitus and visual disturbances
1. Phlebotomy
 Patients also experience angina, heart failure,  To reduce blood volume until the desired
and even thrombophlebitis which may be a
hematocrit level is achieved
complication of embolization
 More or less, about 300-500 ml of blood is
2. Generalized pruritus
removed every other day until hematocrit is
 Itchiness due to histamine release from an
reduced to normal level
increased number of basophils  Iron supplement is not given to patient with
 Especially after exposure to warm water bath
polycythemia vera
due to abnormal histamine release and
 You will notice that when there’s a reduction in
prostaglandin production
the hematocrit and blood volume, there will be an
 Common
improvement in the cognitive aspect of the
3. Hemorrhagic phenomenon patient
 Caused by either vessel rupture from over
2. Hydration therapy
distention or inadequate platelet function that
 Reduce the blood viscosity
may result to petechiae, ecchymosis, epistaxis,
3. Antihistamine
or GI bleeding
 To control itchiness
4. Hepatomegaly and splenomegaly 4. Myelosuppressive agents
 From organ engorgement
 Busulfan (Myeleran)
5. Plethora
 Hydroxyurea (Hydrea) – suppress the bone
 Ruddy complexion
marrow function but at high risk for developing
6. Hyperuricemia
leukemia
 Increased RBC destruction  Radioactive phosphorus – inhibits the bone
accompanied by excessive
marrow activity
RBC production and increase uric acid (one of
5. Allopurinol
the products of cell destruction) leading to
 Reduce the number of the acute gouty attack
hyperuricemia causing clients to complain of
6. Antiplatelet agents
certain forms of gout  Aspirin prevent thrombosis and reduce pain
7. Erythromyalgia
associated with erythomyalgia. However, there
 Severe burning pain in the hand and feet
are some controversial issues as it increases
accompanied by reddish or bluish discoloration
irritation of gastric mucosa resulting to GI
of the skin due to increased platelet count
bleeding
wherein the platelet becomes aggregated

 Dipyridamole (Persantine) is used to prevent

thrombotic complications
7. Radiation therapy
 To decrease the production of RBC in the bone
marrow
8. Treat underlying hypoxia
Nursing Management
Nurse as educator
1. Assess for signs of thrombotic complications There’s a proliferation of RBCs and crowded out of platelets
 Smoking and red cell. There is a lot of blast cell
 Obesity
 Poorly controlled hypertension due to non- Predisposing Factors of Leukemia
compliance in drug therapy Genetic Predisposition and Environment
2. Reduce likelihood of DVT
1. Inherited tendency of chromosomal fragility or
 Avoid crossing legs
abnormality (characterized by chromosomal
 Regular exercise
translocations) – e.g. down syndrome
 Avoid restrictive clothing particularly stocking
2. Hereditary immunodeficiency – chronic marrow
3. Minimize drinking alcohol
dysfunction (aplastic anemia)
 Risk of bleeding
4. Avoid iron supplements Environmental Influences
 Can further stimulate RBC production 1. Radiation exposure
5. Bathing in tepid or cool water 2. Chronic exposure to chemical – benzene
 You may use baking soda dissolved in a bath 3. Occupational exposure
water (very effective) 4. Exposure to certain drugs
 Avoid vigorous toweling after bathing  Alkylating agents
 Cytotoxic therapy for breast, lung and testicular
Leukocytic & Thrombocytic Disorders cancer
Leukemia  Excessive use of chloramphenicol has an effect
on the bone marrow that may result to leukemia
• A group of malignant disorder affecting the blood and
5. Infections – virus can be found in leukemic cell
blood-forming tissue of the bone marrow, lymph
system and spleen
 Results from accumulation of dysfunctional cells Effects Leukemia on the Body
because of loss of regulation in the cell division, 1. Attacks the immune system – immature WBC
meaning the control become abnormal 2. Infections – immature WBC
• Leukemic cells proliferate slowly but not functional as 3. Anemia
the matured WBC 4. Weakness
 Immature WBC cannot combat infection and 5. No more regular white blood cells, red blood cells,
maintain immune function and platelets (reduction)
• Normal pluripotent stem cells differentiate: myeloid, 6. Blasts clog blood stream and bone marrow
erythroid, and lymphoid pathway in the presence of
growth factor Development of Leukemia in the Bloodstream
• RBC and platelet are continuously produced causing
it to be crowded out so anemia and bleeding might
develop
• Exact cause is unknown, but theory begin with the
development of a single malignant clone of cells
• Characterized by unregulated or uncontrollable
proliferation of one cell type
• Involves any of the cell lines or a stem cell common to
several cell lines

Stage 1 – normal production of RBC, WBC and platelets (a) Infiltration of RES  Enlargement  Fibrosis
Stage 2 – there are some reductions in WBC, and (b) CNS  ICP
(c) Kidneys, testes, prostate, ovaries, GIT and lungs
presence of blast cells

Stage 3 – upon diagnosis, you will notice the blast cell Bone marrow suppression (RBC, WBC, platelet) then
becomes abundant result to
Stage 4 – worsening of the conditions; there’s a lot of 
blast cell in the blood stream and reduction of RBC and Anemia, prone to infection and bleeding tendencies

platelets. If there’s a lot of blast cells and few or no
Hypermetabolic leukemic cells eventually deprive all body
mature WBC therefore, it is prone to infection
cells of nutrient

Classification of Leukemia Metabolic starvation
Lymphoid
• Immature lymphocytes and their precursor cells in the • Leukemic cells may arise from the precursor cells in
bone marrow, infiltrates the spleen, lymph nodes, blood forming organ
CNS • These cells may accumulate and crowd out of bone
• Lymphocyte is responsible for the production of marrow, and move these elements to the peripheral
antibodies by the B-cells and T-cells that kills the blood and invade all the body organs and tissue
bacteria. However, if there’s immature lymphocyte, it • The replacement of normal hematopoietic elements
reduces the production of antibodies and cannot fight by leukemic cell results in the suppression of bone
infections marrow marked by decrease production of RBC,
WBC, and platelet
Myeloid • Bone marrow suppression ( RBC, WBC, platelet)
then results to anemia from decreased RBC
• Involve myeloid stem cells in the bone marrow,
production. There’s also a predisposition to infection
interfering with the maturation of all types of blood
due to decreased neutrophils and bleeding
cells including granulocytes, RBCs, thrombocytes
tendencies from decreased platelet production
 Patient is at risk of death from infection or
Acute
hemorrhage
• Acute onset, rapid disease progression and immature • Kidneys, testes, prostate, ovaries, GIT and lungs are
or undifferentiated blast cells possible site of long-term infiltration
• There is a massive accumulation of the non-functional
cells (blast cells) in the bone marrow
• Result from transformation of malignant stem cells
that leads to unregulated proliferation and stop the
production of matured blood cells
Chronic
• Gradual onset, prolonged course, abnormal mature-
appearing cells
• Involves matured form of WBC, so the chance of
survival rate is longer
• Patient will live around 5 or more years with or without
treatment
• Usually occur around 25-60 y/o
• Common cause of chronic leukemia is chromosomal
abnormalities
Pathophysiology of Leukemia Laboratory and Diagnostic Tests

Abnormal precursor cell 1. CBC and peripheral blood smear
  Acute lymphocytic leukemia and acute
Accumulate and crowd out of bone marrow; move to myelogenous leukemia − low RBC count,
peripheral blood hemoglobin, hematocrit and platelet
  Chronic myelogenous leukemia − high platelet
Replacement of hematopoietic elements by leukemic cell
count during early phase then later it will

decrease
 Blood smear will show immature lymphoblast

2. Bone marrow aspiration Manifestations

 To classify the subtype of leukemia and the 1. Fever at the time of diagnosis
stage of the development of leukemic cell 2. Abrupt bleeding progressing to weakness, fatigue,
population and some bleeding tendencies
3. Lumbar tap 3. CNS manifestation like meningitis due to arachnoid
 Aka lumbar puncture infiltration
 To determine the presence of blast cells in CNS
4. Radiographic test
Acute Myelogenous Leukemia (AML)
 To check for any involvement, lesions or
• Occurs at any age but prevalent in adult ages 50-60
infection
• Characterized by development of immature
 Through CT-scan and MRI, may determine the
myeloblast or uncontrolled proliferation of myeloblast
presence of these leukemic cells outside of the
• Myeloblast is the precursor of granulocytes,
blood and bone marrow
monocytes, megakaryocytes, and erythrocytes in the
5. Lymphangiogram
bone marrow
 Lymph nodes biopsy to locate malignant lesions
in the lymph nodes
6. Cytogenic evaluation Manifestations
 Client with chromosomal abnormalities 1. Low neutrophils
 For chronic myelogenous leukemia, the finding 2. Decreased monocytes, thrombocyte and RBCs
for the Philadelphia chromosome has been a 3. The patient may have manifestations similar with
diagnostic value ALL but with the addition of external tenderness due
to hyperplasia of the bone marrow and spleen
Treatment
1. Chemotherapy
2. Bone marrow transplantation − best treatment option
Chronic Myelogenous Leukemia (CML)

• AKA Chronic Granulocytic Leukemia
• Due to excessive development of mature neoplastic
granulocyte (neutrophils, basophils, eosinophils) in
the bone marrow
• May infiltrate the liver and spleen
• CML is a chronic stable phase but may be followed by
the development of more acute aggressive phase
referred as the “blastic phase”
• Common in young and middle-aged adult
• Prevalent in men than women but rare in children
• Average survival time is about 3 or 4 years after the
onset of chronic phase and about 3-6 months after the
Major Types of Leukemia
onset of acute phase
Acute Lymphocytic Leukemia (ALL)
• Common in children, not hereditary
Cause
• Arise from a single lymphoid stem cells with impaired
maturation and accumulation of malignant cells in the 1. Benzene exposure
bone marrow 2. High doses of radiation
• Lymphoid blood cell could be the key ALL or the BLL 3. Unknown but 90% of patient have a (+) Philadelphia
(more common) chromosome
• The immature lymphocyte proliferates in the bone  This is the translocation between chromosomes
marrow 22 and 9 which switch in formation
• Treatment will reduce 90% of children who have
leukemia and 65% in adult Clinical Manifestation
• It has best survival rate with an intensive therapy During Chronic Stable Phase
• First human cancer to be cured by combination of 1. Anemia
chemotherapy 2. Bleeding abnormalities

Acute or During Blastic Crisis Management for CML and CLL

1. CML transform and becomes unmanageable by 1. Biological therapy
therapy 2. Radiation
 So, during blastic phase patient may live for only 3. Chemotherapy
a few months
Treatment of Leukemia
Treatment 1. Radiation therapy
1. Chemotherapy − hydroxyurea, busulfan  Usually adjunct with chemotherapy
2. Bone marrow transplant − potential curative therapy  When a leukemic cell have infiltrate other
3. Splenectomy − increase platelet count and decrease systems like CNS, skin, rectum, testes and
the adverse effect of splenomegaly mediastinal mass
2. Bone marrow transplant
Chronic Lymphocytic Leukemia (CLL) 3. Chemotherapy
4. Stem cell transplant
• Common in elderly
 Treats different forms of leukemia and is very
• Proliferation of early B lymphocytes,
effective
lymphadenopathy; genetic predisposition
 Goal is to totally eliminate the leukemic cells in
• Characterized by an uncontrollable proliferation of a
the body using combination of chemotherapy
small abnormal matured (early) B lymphocytes in the
with or without total body eradication
lymphoid tissue, blood, bone marrow which often
5. Splenectomy
leads to decreased synthesis of immunoglobulin and
6. Blood transfusion
depresses antibody response
• Cause is unknown but some researcher suspects that
it is because of hereditary factors, chromosomal Chemotherapeutic Agents
abnormalities and certain type of immunologic defect These are the different agents given to specific types of
• This type is not associated with exposure to radiation leukemia
• If there’s an infiltration of the lymph nodes, the patient 1. ALL – vincristine and prednisone
will manifest lymphadenopathy, an enlargement of 2. AML – cytarabine, 6-thioquanine, and doxorubicin
lymph nodes, present throughout the body 3. CML – hydroxyurea and busulfan
 If there’s a pressure on the nerve from the enlarge 4. CLL – chlorambucil and glucocorticoid
lymph node, the patient will experience pain and
paralysis
Stages of Chemotherapy
 If the mediastinal lobe is enlarged, then it may
Induction Therapy
lead to pulmonary symptoms
• Incidence of infection is increased • Intensive course with drugs (vincristine and
• The B-cells in the CLL is considered to be identical to prednisone)
the matured B-cells small lymphocytic lymphoma, a • Goal is to kill most of the leukemic cells in the blood
type of non-Hodgkin’s lymphoma and bone marrow in order to restore the normal blood
cell production
• Administered every 3-4 weeks since it is intensive in
Clinical Symptoms
order to destroy the leukemic cells in the tissue
CML and CLL symptoms are almost the same, except • Patients in this stage becomes critically ill due to
for CML, patient experience abdominal fullness due to severe depression of bone marrow by the
hepatosplenomegaly while for CLL, there’s a pain in the chemotherapeutic agent
lymph nodes which resulted from lymphadenopathy • Nursing care focus: neutropenia, thrombocytopenia,
1. Usually there is no symptoms except for some anemia, and psychosocial support is very important in
pruritic vesicular lesions this stage
2. Elevation of WBC
3. Increased blood viscosity and clotting episodes
Intensification Therapy
• Higher dosages
Diagnostic Study for CML and CLL • Same drugs used in the induction stage but in higher
1. Peripheral blood smear dosages immediately after the induction therapy
 For the presence of immature leukocyte • Usually for several months
2. Genetic test
 For Philadelphia chromosome
Consolidation Therapy
• Started after a remission is achieved

• It may consist of 1-2 additional course of the same • Overall Men > Female
drugs given during the early stage • Common among teens 15-35 y/o and adults 55 years
• Purpose is to eliminate the remaining leukemic cells and older
that may be clinically or pathologically evident • Reed-Sternberg cells is the painless enlargement of
the lymph nodes that may be progress to the extra
Maintenance lymphatic sites such as liver and spleen
• Bimodal age distribution
• With lower doses of the same drugs but for a
 First peak between 2nd - 3rd decade of life
prolonged period of time to keep the body free form
 Second peak between 5th - 6th decade of life
leukemic cells
• First described in 1832 by Dr. Thomas Hodgkin
• Prevents the regrowing of leukemic cells
• But for AML, it is rarely effective therefore this is being
seldom done in AML
Nursing Management
1. Taking measures to prevent infection
 Hand washing, avoid crowds
 Avoid fresh fruits, vegetables, plants or cut
flowers in the patient’s room
2. Take measure to decrease nausea and to promote
appetite, smoking and spicy and hot foods
3. Promoting safety
4. Providing oral and perineal hygiene
• Cell of origin: germinal center B-cell
5. Preventing fatigue
 Encourage rest and limited activity
6. Promoting effective coping Etiologic Factors of Hodgkin’s Disease
7. Client and family education 1. Unknown
8. Maintain clean, warm environment 2. Infectious cause
9. Encourage increase fluid intake and food high in  Especially in patients who have advanced stage
protein HIV and with high incidence of bone involvement
10. Avoid injections and constrictive clothing, razors  Epstein Barr Virus – the possibility of this
11. Apply pressure if injection is necessary causative agent that have the ability to transform
12. Prevent constipation by using stool softener, fiber in the lymphocyte
diet 3. Genetic predisposition
13. Give small, frequent feeding 4. Caucasian group
 If the patient has lack of appetite  Predisposed or at risk to develop Hodgkin’s
14. Oxygen therapy Disease
 To reduce hypoxemia 5. Exposure to occupational toxins
15. Avoid acetylsalicylic acid (ASA) or aspirin 6. Weakened system
 Risk of bleeding 7. Long term immunosuppressive (receiving renal
16. Use soft-bristled toothbrush/soft swabs transplant)
17. Provide psychological support  Due to illness or some conditions
Lymphomas Pathophysiology
• Malignant neoplasms originating in the bone marrow • Hodgkin lymphoma starts in the lymphatic system,
and lymphatic structures resulting in the proliferation usually in a lymph node that causes the normal
of lymphocytes structure of lymph node to be destroyed by
• Lymphomas classified as Hodgkin’s and Non- hyperplasia of monocyte and macrophage
Hodgkin’s disease (NHL)  The lymph node especially the B cell become
abnormal. The abnormal cells keep dividing and
Hodgkin’s Disease making more abnormal cells that built up
• When the WBC collect around the abnormal cell, the
• Cancer (malignancy) of the lymphatic system
lymph nodes that contain abnormal cells become
characterized by the abnormal proliferation of
swollen
abnormal giant multinucleated cells called Reed-
Sternberg cells
• Predominately affects the B cells

• That’s why the presence of the Reed-Sternberg cells 11. Hepatosplenomegaly

in the lymph node is the classical type of Hodgkin 12. Pain at the site of disease after drinking alcohol
lymphoma  Pain relieved once stopped drinking
• With this single location, this may spread along the 13. B symptoms – 40% common in advanced cases
adjacent lymphatic organs. It eventually incorporates  Weight loss
other organ especially the lungs, spleen, and liver  Fever
 Night sweat
Diagnostic Studies
1. Peripheral blood analysis
 Microcytic hypochromic
 Neutrophilic leukocytosis (15,000 – 28,000)
 Platelet elevated
• Shows that there’s an enlargement of lymph nodes  Leukopenia
 The cervical lymph node is the first to be affected  Elevation of neutrophils, leukocyte associated
with decreased in lymphocytes
Assessment Data and Pathophysiologic Basis for 2. Elevated leukocyte alkaline phosphatase – liver
Hodgkin’s Disease radiographic evaluation
 If there is liver and bone involvement
Sign and symptoms, system affected, reason why
3. Lymph node biopsy − definitive diagnosis
patient experience it
 Presence of Reed-Sternberg cell
4. Bone marrow examination
 Important aspect in staging
 Reed-Sternberg cell can also be found in the
bone marrow
5. PET scan
 Expensive
 The lymphoma cell takes up sugar faster than
the normal cell; lymphoma cells look brighter on
the picture
6. Lymphangiography
 To assess the lymph node and lymph vessel
involvement and to visualize the areas that is
difficult to see like the retroperitoneal structure
7. Radiologic evaluation
 To assists or help defining all sites and the clinical
stage of the disease
Ann Arbor Staging System for Hodgkin’s Disease

Stage I – single lymph node region or single extranodal
site
Clinical Manifestations Stage II – 2 or more lymph node regions on the same
1. Lymphadenopathy – cervical (first to be affected), side of the diaphragm or localized involvement of an
axillary or inguinal lymph nodes extranodal site or 1 or more lymph node regions on the
 Extra nodal involvement is common same side of the diaphragm
 Cervical lymph node enlargement is painless Stage III – regions on both sides of the diaphragm. May
2. Generalized pruritus without skin lesions include single extranodal site, the spleen, or both;
 Common, earliest sign
Stage III1 − subdivided into lymphatic involvement of
3. Fatigue and weakness
the upper abdomen in the spleen (splenic, celiac,
4. Chills
and portal nodes)
5. Tachycardia
Stage III2 − the lower abdominal nodes in the
6. Anemia
paracortic mesenteric and iliac regions
7. Cough
8. Dyspnea Stage IV – diffuse or disseminated disease of one or
9. Stridor more extralymphatic organs or tissues with or without
10. Dysphagia – mediastinal node involvement

associated lymph node involvement; the extranodal site

is identified as:
H – hepatic
L – lung
P – pleura
M – marrow
D – dermal
O – osseous
Long Term Complications

1. Infertility
 Sperm banking should be discussed
 Premature menopause
2. Secondary malignancy
 AML, NHL, breast cancer, lung cancer, organ
dysfunction (i.e. thyroid, lung, skin)
3. Cardiac disease
Treatment for Hodgkin’s Disease

Nursing Care
1. Radiation therapy
 Submit for over 4-6 weeks 1. Observe for any common side effects like nausea
and vomiting
 It can kill about 90% of stage 1 and 2 disease
2. Give supportive care to prevent or control bleeding
2. Surgery
and infection
 Therapeutic excision of the enlarge nodes
 Enlarge nodes become fibrosis after therapy 3. Psychosocial consideration with regards to fertility
causes bulky muscles issues
4. Encourage the patient to have a regular follow-up
3. Chemotherapy
examination which is very important after the
MOPP – Mechlorethamine, Oncovin,
treatment
Procarbazine, Prednisone
ABVD – Adriamycin, Bleomycin, Vinblastine,
Non-Hodgkin’s Lymphoma (NHL)
Decarbazine (stage 3 and 4)
• A heterogeneous group of malignant neoplasms of
 Order antiemetic drugs 1-3 hours prior to the immune system
administration (especially for MOPP) • Affects the immune system; occur outside of the
lymph nodes
Guidelines for Radiation and Chemotherapy • Unpredictable and disseminated at the time of
Indications for RT diagnosis
1. Stage I disease • NHL > Hodgkin Disease (prevalent)
2. Stage II disease with 3 or lesser areas involved • If without effective treatment, they are very fatal
3. For Bulky disease • Cause is unknown
4. For pressure problems • Median age of presentation is 65-70 years of age
• Men > Female
Indications for CT • B-cell: 70% (more affected); T-cell: 30%
1. All with B symptoms
2. Stage II disease with >3 areas involved One of the complications of Hodgkin’s lymphoma is the
3. Stage III and IV disease NHL. NHL can be a genetic mutation in the lymphocytes,
either the B cells or the T cells. If something like that
Chemotherapy + Radiotherapy happened, the lymphocytes undergo apoptosis but
1. For bulky disease or palliation of symptoms − stage instead, the cells start to proliferate which become
III & IV uncontrollable and become neoplastic cells. The bone
marrow causes crowded out of the normal cells that may
result to decreased RBC, WBC and platelet.

Etiologic Factors of NHL  Resection of the extra-nodal involvement or

1. Immunodeficiency splenectomy
2. Autoimmune disorders 3. Chemotherapy
3. Family history of lymphoma CHOP – Cyclophosphamide, doxorubicin
4. Infectious agents – EBV, HIV [Adriamycin], vincristine [Oncovin]
5. Environmental exposure – ionizing radiation, prednisone
chemicals (pesticides, solvents, dye) CVP – Cyclophosphamide, vincristine, prednisone
Cytoxan, chlorambucil (Leukeran)
Clinical Manifestations Corticosteroid – to disrupt the cell membrane and
1. Painless lymph node enlargement – painless prevent the synthesis of protein, and decrease
lymphadenopathy (66%) mitosis and try to depress the immune system
2. B symptoms – weight loss, fever and night sweats (⅓
of the cases)
Thrombocytopenia
3. Mediastinum involvement – respiratory distress CXR
• Reduction of platelet count (below 150,000)
4. Abdominal masses – compression on ureters
leading to renal dysfunction
5. GI involvement – anorexia, nausea Causes of Abnormal Platelet Function
6. Hydronephrosis, ureteral obstruction 1. Suppression of platelet function
7. Unexplained anemia  Ex. Thiazide diuretics, alcohol, and some
8. CNS (headache, cranial nerve palsies, spinal cord chemotherapeutic agents
compression) 2. Abnormal platelet aggregation
 Cause the clamping of the platelet
Differences  Ex. NSAIDs, antibiotics, analgesics, spices
(ginger, cloves), vitamins (vit. C and E), heparin,
Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma herbs (garlic, ginger, ginkgo biloba, ginseng,
evening primrose)
• Both B lymphocytes
• B lymphocytes is affected
(predominant) and T
• The extent of the disease is
lymphocytes are affected
usually regional and Etiology of Thrombocytopenia
• Usually disseminated
localized
• Upon the diagnosis it is Decrease Production of Platelets
• There’s a Reed-Sternberg
already in the advance stage
cells (giant cell)
• Have B symptoms (not May develop thrombocytopenia
• Have B symptoms (common)
common)
• Extranodal involvement – 1. Leukemia
• Extranodal involvement –
rare
common 2. Anemia
• Spreading pattern − more
• Spreading pattern −
orderly downward
unpredictable progression 3. Toxins
4. Medications
5. Infection
Diagnostic Studies in NHL
1. Lymph node biopsy Increase Destruction of Platelets
 To determine cell type and pattern There are some conditions that destroy the platelet
2. CXR and CT scan more rapidly than they are being produce leading to
 For presence of pleural effusion, and shortage of platelet in blood stream
involvement of the upper retroperitoneal nodes, 1. Infection
liver, and spleen 2. Sequestration of platelets in enlarged spleen
 Helps to stage the lymphoma based on the 3. Due to antibodies
extent of the nodal and extra-nodal involvement
3. Bone marrow biopsy
Immune Thrombocytopenia Purpura (ITP)
 To determine for malignant cell
4. Bone scan • Abnormal destruction of circulating platelets
 Any involvement of bone • Caused by autoimmune
5. Peritoneoscopy with directed biopsy • Syn. – Idiopathic thrombocytopenic purpura
 To examine the peritoneal cavity and other organ (unknown cause in the past)
• Normally the platelet survives at least 8-10 days within
the circulation but in ITP, the platelet survives as brief
Treatment for NHL as 1-3 days
1. Radiation therapy • The immune system of the body attacks and destroy
 For localized stage 1 and 2 disease its own platelet
2. Surgery

 It releases auto antibodies which chemically tags • Free radical compounds build up in the body which
it owns cell as foreign resulting to shortened life need electrons to become stable
span of the platelet • Electrons from DNA can cause mutations which could
• The WBC may seek out and destroy the platelets as affect the immune system and possibly trigger the ITP
if they are fighting an infection that causes a rapid or other autoimmune disease
drop in the level of platelet, then the spleen removes
this platelet modified by the antibodies Pathophysiology
• Accompanied by short term or permanent depression
because the serotonin in the body is stored in the Autoimmune disease

platelet
Body’s immune system attacks and destroys own platelets
 If the platelets are destroyed, the mood elevating

neurotransmitter is also affected Body releases auto-antibodies which chemically tag its
own cells as foreign
Forms of ITP 
WBC then seek out and destroy platelets as if they were
Acute
fighting an infection
• Occurs predominantly in children 
• Often appears 1 to 6 weeks after a viral illness or This causes a rapid drop in the level of platelets in a
infection person’s body
• Self-limited
• Remission often occurs spontaneously within 6
months
1. Petechiae
Chronic 2. Ecchymosis
3. Epistaxis
• Affects young adults between age 20 to 40
4. Easy bruising (dry purpura)
• Onset gradual and less severe bleeding
5. Heavy menses or bleeding between periods in
• Diagnosed by exclusion of other causes of
women (menorrhagia)
thrombocytopenia
6. Pulmonary system – hemoptysis (wet purpura)
7. Depression
Theories of ITP  Due to platelet destruction, serotonin is being
Cause of ITP is unknown but there are some theories released from the stored platelet
and most of these are multi-factorial disease with a
strong genetic predisposition Diagnostic Studies
1. Platelet count – low
The Microbial Trigger Theory
2. Bleeding time – prolonged
• Links the destruction of platelets to a chemical called 3. Capillary fragility – increased (using a tourniquet test)
interleukin 12 4. Bone marrow biopsy
 Interleukin 12 regulates the lymphocyte function  To rule out production problem as the cause of
and is released when the body is fighting a thrombocytopenia, whether it is leukemia,
bacterial infection aplastic or other myeloproliferative disorder
• The interleukin 12 activates the dormant self-reactive  When the destruction of the circulating platelet is
cell or the lymphocyte which then convince the body the cause, then bone marrow analysis may show
that a cell near the bacteria is also part of the infection megakaryocytes to be normal or increased, even
though the circulating platelets are reduced
The Molecular Mimicry Theory  Absent or decreased number of megakaryocytes
• Malfunction in the production of these inhibiting on bone marrow biopsy is consistent with the
agents then the self-reactive T-helper cells are free to thrombocytopenia due to decreased bone
target platelets for destruction marrow production, especially seen in patients
• When the body T-cells recognized a viral or bacterial who have aplastic anemia
amino acid that happen to occur on the surface of a 5. Hemoglobin and hematocrit
platelet  If the patient has cardiopulmonary distress and
 Normally, the T cell that would target the somatic other manifestation of anemia
cells are inhibited by another immune agent
The Free Radical Damage Theory

• DNA is damaged by “free radicals”

Management 6. Do not use rectal thermometer, enema tube

Steroid Therapy 7. Encourage high-fiber diet
• To suppress the phagocytic response of the splenic 8. Avoid vigorous flossing of teeth
macrophage 9. Use Electric razor
 This may alter the spleen recognition of platelet
and increase the life span of platelet Hemophilia
• Depress the antibody formation to enhance platelet • A congenital deficiency of one of these clotting factor
production (factor VIII) accounting for 90-95% of the hemorrhagic
• Reduce the capillary fragility and bleeding time bleeding disorders
• Corticosteroid may also decrease the activity of the  There is a defective or deficient of coagulation
immune system. It will take 2-6 weeks, but the side factor VIII
effect is bone density loss • An X-linked recessive behavior
 Monitor bone density and give calcium • Female carriers will transmit the genetic defect to 50%
supplement and vit. K to prevent this problem of their sons and 50% of their daughters
• Other side effects: muscle weakness, GI problems • Men with hemophilia will not transmit the genetic
and weight gain defect to their sons but all of their daughters will be
carriers
Plasmapheresis  Generally, the women are the carriers and the
• Removal of the substance causing platelet men are symptomatic of the disease
thrombosis
• Short term therapy until the corticosteroid takes effect Types of Hemophilia
Hemophilia A
Intravenous Infusion of Gamma Globulin (IVIG)
• Classic hemophilia; deficiency of factor VIII
• Work by competing with the anti-platelet antibodies for
• Affects 80% of all hemophilia
macrophage receptor
• Inherited as an X-linked recessive disorder that
• Given to patient who is unresponsive to corticosteroid
affects males
or splenectomy
• A family history of this disorder confirms the diagnosis
and this is the common form
Chemotherapy
• Characterized by spontaneous or traumatic SQ and
• Vincristine IM hemorrhage, presence of hematuria, joint
hemorrhage, pain, and bleeding in mouth, gums, lips
Platelet Transfusion and tongue
• Administered during life threatening hemorrhage but
platelet should not be administered for prophylaxis Hemophilia B
purposes because of the possibility of antibody • AKA Christmas disease
formation • Factor IX deficiency
Splenectomy Von Willebrand’s Disease

• NOT recommended until the child is 6 years of age • Congenital bleeding disorder
• Deficiency of the Von Willebrand coagulation protein
Immunosuppressive Drugs and necessary for factor VIII activity
• Blocks the binding receptors in macrophage so that  A protein that serves as the carrier for Factor VIII
the platelet is not destroyed  Platelet is also affected so it cannot stick together
• The deficiency of this protein may cause the
Thrombopoietin Receptor Agonist adhesions of the platelet to the injury exposed,
• New drug that helps bone marrow to produce more collagen is impaired
platelet to prevent bruising • Causes prolonged bleeding time with mild or
moderate bleeding disorder
Nursing Management of ITP
Hemophilia C or Rosenthal Disease
1. Avoid injections
2. Apply pressures on the punctured site • Factor XI deficiency
3. Encourage to blow nose gently
4. Observe for signs and symptoms of increase Clinical Manifestations
intracranial pressures 1. Slow, persistent, prolonged bleeding
5. Avoid Valsalva maneuver

 From minor trauma or small cuts such as Management

laceration on the tongue or lips 1. Replacement or transfusion of factor VIII or IX
 These are the first signs of hemophilia in children concentrate
2. Delayed bleeding after minor injuries  This is the primary treatment to raise the level of
 Bleeding may not start from the site until hours anti-hemolytic factor in the plasma
or even days after the event of trauma 2. Whole blood cells transfusion
3. Uncontrollable hemorrhage  To replace blood volume if there is a severe loss
 After dental extraction or irritation of gingival with but fresh frozen plasma (FFP) and
the use of hard bristle toothbrush cryoprecipitate is no longer used
4. Epistaxis − after nose blowing 3. Desmopressin acetate (DDAVP)
5. GI bleeding from ulcers and gastritis  A synthetic vasopressin used to stimulate an
6. Hematuria, ecchymosis, SQ hematoma increase in factor VIII and VWF
7. Neurologic signs 4. Joint immobilization
 Decreased sensation, weakness, atrophy  During acute attack
 May develop from nerve compression caused by 5. Local chilling
hematoma formation  To relieve pain especially in patients with
8. Hemarthrosis hemarthrosis
 Bleeding into the joints that leads to joint 6. Aspirate blood from the joint
deformity causing crippling (knees, elbows, 7. Analgesic
shoulders, wrist, hip and ankles)  Acetaminophen to reduce severe pain
 Never use aspirin as it cause a decrease in the
coagulation factors
Nursing Management
1. Stop bleeding
 Monitor signs of bleeding
 Avoid intramuscular injections, rectal
temperatures that may trigger bleeding
 Direct pressure occludes bleeding vessels
 Avoid activities that increase risk of trauma
2. Prevent complications
 Review routine situations that increase the
client’s risk of bleeding and its precautions
 Prompt and effective administration of factors
Diagnostic Studies 3. Genetic counseling
1. Platelet function  If it is hereditarily form
 Usually normal and adequate except those 4. Encourage mobilization of the affected areas
patients with Von Willebrand type of hemophilia  Immobilize during acute attack
2. Prothrombin Time  Then once the bleeding stops, encourage
 No involvement of extrinsic system; it is normal mobilization of the affected areas through range
3. Activated Partial Thromboplastin Time of motion exercise and physical therapy
 Prolonged because of the deficiency in any 5. Psychosocial support and assistance
intrinsic clotting factors (VIII and IX) 6. Daily hygiene
4. Bleeding time  Must be performed without causing trauma
 Prolonged in patient with Von Willebrand’s 7. Wear a Medic alert tag
disease because of the detective platelet  To ensure that the health care provider knows
 Normal in hemophilia A and B since the platelet about the routine follow up care
is not affected 8. Educate patient
5. Factor Assay Test  To participate in non-contact sports and wear
 Reduction of factor VIII (Hemophilia A), IX gloves when doing household chores to prevent
(Hemophilia B) and Von Willebrand factors cuts or abrasion from the tool
(VWF)

FLUIDS AND ELECTROLYTES IMBALANCES
• Body fluids and electrolytes plays an important role in − Approximately 6% of the body fluid
hemostasis
b. Interstitial
• Body maintains weak control of water, electrolyte
− Fluid surrounding the cell (lymph)
distribution, and acid base balances
− Allows the movement of ions, proteins, and
• During normal metabolism, the body produces many
nutrients across the cell barrier
acids that may alter the internal environment of the
− Approximately 24% of the body fluid
body which may influence fluid and electrolyte
balance c. Transcellular
• It is also regulated in order to maintain hemostasis − Smallest division of ECF includes CSF,
• Fluid and nutrients waste product constantly shift pericardial, synovial, intraocular, and pleural
within the body compartment which is from the cell to fluids; sweat and digestive system
interstitial space and even to the blood vessels and − Does not participate in reabsorption but
back again instead it is loss (ex. Vomiting)
• Diseases and treatments may affect fluid and − Loss of this transcellular fluid can produce
electrolyte balance such as patients with metastatic serious fluid and electrolyte imbalance
breast cancer that may develop hypercalcemia
Composition of Body Fluids

• Water constitutes of the total body weight
 Infant: 70% - 80%
 Adult: 50% - 60%
 Geriatric: 45% - 50% (even up to 55%)
• Factors influence the amount of body fluids includes:
age, gender and body fat
For Age:
 Younger adult: higher percentage of body fluids
than geriatrics
 Infant and older person: high-water content in the Functions of Water in the Body
body, thereby at risk of fluid-related problem than
1. Transport substances – hormones and nutrients
young adult
2. Dilutes toxic substances and waste products to
For Gender:
kidneys and liver
 Male have more fluid than female because male 3. Oxygen transport from lungs to body cells
tends to have more limb body mass 4. CO2 transport from body cells to lungs
For Body Fats: 5. Regulates body temperature and maintain cell shape
 Fat cell contains less water than lymph tissue 6. Regulates chemical and bioelectrical distribution
 Obese patient has less fluid than thin people for within cells
about 25-30%
 Skeleton have less water content; for muscle and
skin, blood have the highest amount of water
 Any variation of 15% in both is normal
• Water requirement 2,500 cc/day, minimum of 1,500
cc/day
Fluid Compartment in the Body

• Total body water is about 60% of the body weight
Intracellular Fluid (ICF) − located within cells; 2/3 of the

body fluid
Extracellular Fluid (ECF) − found outside cell; 1/3 of the

Classification of Fluids
body fluid
Colloid
a. Intravascular
− Fluid within blood vessels (plasma) • Contains large molecules
− Contains plasma for effective circulating • Does not pass the cell membrane when infused
volume • Remains in intravascular compartment and expands
the intravascular volume

• Draw fluid from extracellular space through higher Lactated Ringer’s Solution
oncotic pressure − Contains potassium, calcium in addition to
sodium and chloride and also contains
Crystalloid bicarbonate
• Contains small molecules − This is a precursor because lactate metabolize in
• Flow easily across the cell membrane which allow the liver and it may convert to bicarbonate
transfer from bloodstream into the cell and body tissue − Administering LR sol. is for patients with
• May increase extracellular fluid but may include the metabolic acidosis but not to lactate acidosis
intravascular and interstitial space or fluid − It corrects dehydration, sodium depletion,
replacement for GI loses (fistula drainage), burns,
Types of Fluid trauma, even acute blood loss or hypovolemia
Isotonic due to 3rd space fluid shift
− Be cautious in administering to patients with
• Same concentration of particles inside and outside the
severe renal impairment or with pH of > 7.5
cell which means that it does not cause the cell to
because it contains potassium
swell or strain
• There’s no change on size and shape of cells
Hypertonic
• 1L of isotonic fluid may expand the extracellular fluid
by 1L • Exerts greater concentration of particles outside than
• However, it may expand the plasma of about 0.25 L inside the cell causing the cells to shrink
because it is a crystalloid fluid and diffuses quickly in • E.g. D5 ½ NS, D5 LR
the extracellular fluid compartment • If one solution contains a large amount of sodium and
• Patient with HPN and heart failure should be carefully the second contain a few, so the first solution is
monitored for signs of fluid overload hypertonic compared with the second solution. As a
result, the fluid from the second solution would shift
Normal Saline Solution into the hypertonic solution until the two solution has
− Expands the extracellular fluid space an equal concentration
− It is prescribed to correct the intracellular volume • If NSS or LR solution contains 5% of dextrose, the
deficit dextrose is quickly metabolized and only the isotonic
− Referred as normal as it only contains sodium and solution remains
chloride but it is not that identical to the • This solution draw water from the intracellular to the
extracellular fluid in our body extracellular fluid causing the cell to shrink
− Use for administration of blood transfusion, prior • If administered quickly or in a large quantity, it may
to blood transf. and post blood transf. cause extracellular volume excess and precipitate
− Replaces large sodium losses such as patient circulatory overload and dehydration in the cell
with burn injuries • Exerts an osmotic pressure greater than that of the
− Not used in patients with heart failure, pulmonary extracellular fluid
edema, renal impairment, and sodium retention • One example is high concentration of dextrose –
D5050 used for patients with hypoglycemia which is
D5 Water strongly hypertonic that’s why it is administered in the
− It has a serum osmolality of 250/L, from isotonic central vein so that they can be diluted by the rapid
to hypertonic blood flow
− It may cause the fluid to shift into the cell
− Once the D5 water is considered as isotonic and Hypotonic
being administered to the patient, glucose rapidly
• Exerts lesser concentration of particles outside than
metabolize so initially the isotonic solution may
inside the cells causing the cells to swell
become hypotonic fluid
• E.g. ½ NS, ¼ NS, 1/3 NS
− It is very essential to consider in giving D5 water
• It may cause the fluid to shift from the extracellular
to patient who is at risk for increased intracranial
fluid to intracellular fluid
pressure
• When a less concentrated is placed next to a more
− During fluid resuscitation, D5 water is not used as
concentrated solution, the fluid may shift from the
hyperglycemia may develop
hypotonic or less concentrated solution into a more
− It primarily supplies water and correct increased
concentrated compartment in order to equalize the
serum osmolality
concentration
− D5 water is not good for renal failure or cardiac
• It replaces cellular fluid
problems as it may cause fluid overload
• It provides free water for excretion of body waste

• Used to treat hypernatremia and hyperosmolar • Large molecules that require energy for the solute to
condition (0.45% sodium chloride) move against a concentrated gradient
• Excessive infusion of hypotonic solution can lead to  Energy pertains to adenosine, triphosphate
intravascular fluid depletion, decreased in BP, cellular • Ex. Sodium and potassium pump
edema and cell damage
• Never administer to patients with increased Diffusion and Osmosis are types of passive transport
intracranial pressure as it may cause the fluid to shift
Diffusion Osmosis
to brain tissue, and to extensive burn patient which is
already hypervolemic The movement of molecules in A special case of diffusion,
a liquid or gas only for water
Effects of Osmosis on Cells Molecules move from area of Water also spreads out, or
HIGH concentration to LOW moves from HIGH to LOW
Hypotonic Hypertonic Isotonic concentration concentration
Lower solute Higher solute If a lot of things are dissolved

Concentration is the
concentration concentration Concentration gradient is the in water, that means the
same inside and out
outside of the cell outside of the cell difference in concentration concentration of water is lower,
between two areas so fresh water will move in to
Water moves into Water moves out of Water moves in and dilute the solution
the cell the cell out
No energy is required from the
Cell swells Cell shrinks cell to make this happen
Filtration – transport of water through a membrane from

an area of higher hydrostatic pressure → L hydrostatic
pressure
• Capillary filtration caused the movement of fluid
through capillary wall to hydrostatic pressures
• It’s balanced by plasma, colloid osmotic pressure from
albumin that causes reabsorption of fluid and solute
Facilitated Diffusion – H to L conc.; need a carrier

Process of Fluid Movement
protein
Diffusion – H  L area of concentration (solute)
• It is passive which does not require energy but needs
• Solute moves from a higher concentration to a lower
a carrier molecule (almost of the cell)
concentration in order to have an equal distribution
• This is a charge molecule that is large in size that’s
• Solute is moving
why it need a carrier/channel protein for the molecules
• Passive transport which does not require energy in
to pass across the membrane
small molecules
• Ex. RBC rely on facilitated diffusion to move the
• Ex. Exchange of oxygen and carbon dioxide between
glucose across the cell membrane whereas in
the pulmonary capillary
intestinal epithelial cells, it uses active transport to
take in glucose
Osmosis – from L  H concentration (solvent)
• Passive movement of fluid from a low concentration
to a higher concentration
• Fluid is moving
Osmotic pressure – the hydrostatic pressure
needed to stop flow of water by osmosis
Oncotic pressure – osmotic pressure exerted by
protein in order to hold water (e.g. albumin)
• Osmotic diuresis may increase in the urine output
caused by the excretion of the substance like glucose,
mannitol, or contrast agent • Capillary hydrostatic pressure and interstitial pressure
causes the movement of water out of the capillary
Active transport − from L  H conc.; need energy • Plasma oncotic pressure and interstitial hydrostatic
pressure causes the movement of fluid into the
• Solute moves from a low concentration to a higher
capillary
concentration

• There is a constant fluid exchange between the Terms used for Osmotic Activity
capillary and the tissue Osmolarity
• Hydrostatic pressure is greater at the arterial end of • The value calculated from the solute concentration
the capillary than the venous end • Number of osmoles per 1L of sol. (mOsm/L)
• The pressure at the arterial end of capillary causes the • Indicates the concentration of solution by volume
movement of fluid into the tissue • Used to measure fluids outside of the body
• At the venous end of the capillary, there’s a movement • Concentration of a solute or dissolved particle
of fluid back into the capillary created by the plasma
protein
Osmolality
• Value measured by the laboratory
Forces of Water Movement
• The number of osmoles per 1 kg of water (mOsm/Kg
Hydrostatic Pressure H2O)
• Sometimes called “pushing force power” • Used to measure fluids inside the body
• The process of movement of fluid through capillary is • It measures the osmotic force of a solute per unit of
called “capillary filtration” that result from blood weight of solvent
pushing against the capillary wall • Usual test performed to evaluate the concentration of
• Force fluids and solutes through the capillary wall plasma and urine
• When the hydrostatic pressure inside the capillary is • It also measures the solution’s ability to create
greater than the pressure in the surrounding interstitial osmotic pressure and affect the movement of water
space, then the fluid and solute inside the capillary are • Serum osmolality primarily reflect the concentration of
forced out into the interstitial space sodium
• When the pressure inside the capillary is less than the • BUN and glucose also play a major role in determining
pressure outside of it, fluid and solute may move back serum osmolality
into the capillary
• Reabsorption keeps the fluids inside preventing too Organs that Regulate Water Balance
much fluid from leaving the capillaries no matter how
Hypothalamic Regulation
much the hydrostatic pressure exists within the
• Hypothalamus is the “thirst center” and primary
capillary
regulator of fluid intake
• When the fluid filter through a capillary, the protein
• Hypothalamus is an osmoreceptor that react to
albumin remains behind in the diminishing volume of
changes in the osmotic pressure and has an effect on
water
the pituitary gland
• Albumin is a large molecule that is normally cannot
• If there’s changes in the body fluid like deficit or
pass through the capillary membrane
increase in plasma osmolality, it may be sensed by
• Concentration of the albumin inside the capillaries
the osmoreceptor which then stimulates the thirst and
increases, then fluid begin to move back into capillary
anti-diuretic hormones release
through osmosis
• Anti-diuretic hormone act on the distal part of the
kidney and collecting tubules that may cause water
Osmotic Pressure
reabsorption
• It is the pooling power
• Decrease in body water may increase to osmolality
• Created by water moving across the membrane due
 Osmolality reflects the sodium concentration
to osmosis
  Na concentration = water  thirst
• The osmotic activity is when 1 solution that is usually
 If the patient experience thirst, it may act to drink
lower in conductivity or mineral content passed
water and release ADH by PPG
through a semi-permeable barrier to dilute the
 Na/osmolality = water in the body  edema
concentration of solution on the other side containing
• In short, any conditions that water, Na, circulating
conductivity or a mineral content
blood volume, blood osmolality in the body will result
to stimulation of the hypothalamus that causes the
release of ADH by PPG increasing thirst
Pituitary Gland
• Releases ADH to regulate water retention by the
kidneys by reducing diuresis and increase water
retention
• Sometimes, ADH called it as the vasopressin

• The distal tubule and collecting duct in the kidney • If there’s a failure of the kidney and cannot maintain
response to AADH by becoming more permeable to fluid and electrolyte balance, it may result to edema,
water potassium and phosphorus retention, acidosis, and
• Factors that stimulate ADH release such as stress, electrolyte imbalance
nausea, nicotine, and morphine • When ADH is low, most of the water in the collecting
• Patient with post-op status have lower serum duct is not reabsorb that result to large quantity of
osmolality because of the stress of surgery and dilute urine
narcotic use during surgery • When ADH is high, water is reabsorbed and less or
lower volume of urine
Adrenal cortical regulation • Renal tubules are the site for the actions of ADH and
• Aldosterone has effect on fluid balance aldosterone
• Adrenocorticotropic hormone (ACTH) from APG acts • Kidney regulate the extracellular volume and
of adrenal cortex to stimulate the secretion of osmolality by selective retention and excretion of the
aldosterone body fluids
• Increase in the secretion of aldosterone may cause • It also regulates the pH of extracellular fluid by
sodium retention and potassium loss retentions of hydrogen ions, and even excretion of
• Decrease in the secretion of aldosterone may sodium metabolic waste and toxic substance
and water loss and potassium retention
• Dehydration, blood loss, low BP, decrease in renal Cardiovascular
perfusion can cause the secretion of aldosterone • The atrial natriuretic factor (ANF) affect fluid volume
• Secretion of aldosterone may be stimulated by and cardiovascular function through the exertion of Na
decrease in renal perfusion or a decrease in sodium (natriuresis), direct vasodilation and opposition of the
delivery to the distal portion of the renal tubules renin-angiotensin-aldosterone system
• Kidney response by secreting the renin into the • Responsible for water regulation
plasma, and the renin convert angiotensin 1 to • Atrial natriuretic peptide is a cardiac hormone that
angiotensin 2 help keep balance which can cause vasodilation or
• Increase in secretion of aldosterone may cause increased urinary excretion of sodium and water
sodium retention and potassium loss which may decrease blood volume
• Aldosterone causes the kidney to retain water and • Atrial natriuretic peptide suppresses the serum renin
sodium that may lead to increase in fluid volume and level, decrease aldosterone release from the atrial
sodium level gland, increase glomerular filtration, and increase
• If not regulated properly, aldosterone may contribute urine excretion of sodium and water
to the development and progression of cardiovascular • Decrease ADH releases from PPG and reduce
and renal disease vascular resistance by causing vasodilation
• Atrial natriuretic peptide tries to counteract the effects
of RAAS
• RAAS (Renin-Angiotensin Aldosterone System) – has
effect in decreasing blood pressure and reducing
intravascular blood volume
• When blood volume and blood pressure increase, it
stretches the atria then the ANF shuts the RAAS
which stabilizes blood volume and blood pressure
• Normal plasma: 20 – 77 picogram picogram/ml
Atrial Stretch Receptors Atrial Natriuretic Factor
• Triggered by increased • Produced by atria

venous return • Response to high BP
• Response to high BP • Reduces aldosterone
• Act to reduce BP  Increase water and salt
 By inhibiting ADH release excretion (Na+ & H2O
 By promoting secretion of reabsorption)
The picture above shows the difference of release of ADH ANF  Vasodilation effect
and aldosterone
Renal Regulation
• Regulates water balance through the adjustment in
urine volume and also regulates Na-K balance

• Thyroxin –  blood flow in body –  renal perfusion 

glomerular filtration rate,  urine output
• Thyroxine hormone decreases intestinal absorption
and kidney reabsorption of calcium
Parathyroid
• Parathyroid hormone (PTH) – regulates calcium level
in the ECF
• Parathyroid hormone draws calcium into the blood
and help move phosphorous to the kidney for
excretion
• Influence bone reabsorption, calcium absorption from
intestine and renal tubule
• Regulation of calcium and postural balance in
extracellular fluids
Skin
• Chief solutes in sweat are Na, Cl, K, and water
Other Mechanisms:
Baroreceptor – located in left atrium, carotid or aortic
arch
 May response to changes in circulating blood
volume, regulate sympathetic & parasympathetic
neural and endocrine activity
Renin aldosterone angiotensin system (RAAS) – act as
vasoconstrictor that increase arterial perfusion pressure
Gastrointestinal which may stimulate thirst
• Excrete and absorb fluid and electrolytes  Sympathetic nervous system is stimulated then
• Bulk of fluid is normally reabsorbed in the small aldosterone is released as a response to increase
intestine of renin
• Absorbs water and nutrients in a single day Antidiuretic hormone and osmoreceptors in
• 8 – 10 L of ECF is secreted into the GIT hypothalamus
• Drinking of water that result to distention of stomach
may stimulate nerve impulse that may inhibit tur Terms Related to Composition of Body Fluids
center Non-electrolytes
• Water is absorbed through the wall of the stomach, • No net electrical charge such as glucose and urea
small or large intestine in order for the osmotic • Organic molecules that do not dissociate in water
pressure of extracellular may return to normal
Electrolytes
Lungs
• Dissociated in water to ions: inorganic salts, acids and
• Regulate O2 & CO2 to maintain acid-base balance and bases and some proteins
hemostasis • Molecules split into ions when placed in water
• Through exhalation, the lungs may remove • Help regulate water distribution, manage in acid base
approximately 300 ml of water daily in normal adult balance, transmit nerve impulse, contribute to energy
• Abnormal condition that may increase loss includes generation and blood clotting
patient with abnormal deep breathing, continues • Ions are substances once in solution separates to its
coughing, or hooked to a mechanical ventilation which electrical charge
may cause decreased moisture
Cations
Thyroid and Parathyroid
• Positively-charged ions (Na, K, Ca, and Mg)
Thyroid • More protein than electron
• Thyroid is responsible for secretion of calcitonin that lowers • Extracellular fluid cation – Na
the elevated calcium level by preventing calcium release • Intracellular fluid cation – K, Ca, Mg
from the bone

Anions  Diabetes insipidus

• Negatively-charged ions  Hyperglycemia − causes the person to produce
• Bicarbonate large amount of diluted urine
• Extracellular fluid – chloride 4. Excessive skin losses
• Intracellular fluid – phosphate ion  Excessive diaphoresis, fever, severe wound
drainage
Fluid Volume Disturbances 5. Third space loses
 Ascites with liver dysfunction, initial face of burn
Fluid Volume Deficit
injury, HF, decrease in albumin, pleural effusion,
• Los of fluid of greater than 1% of body weight will lead
acute intestinal obstruction
to dehydration
• Kidney attempt to conserve body fluid leading to urine
output of less than 30ml per hour and become
1. Decreased skin turgor
concentrated
2. Dry mucous membrane
Dehydration 3. Orthostatic hypotension
• Loss of body fluid that cause the blood solute 4. Increase heart rate
 Rapid pulse may indicate low cardiac output
concentration to increase and serum sodium level to
5. Extreme thirst
rise
• In attempt to regain fluid balance between intracellular 6. Dizziness, weakness, and changes in mental status
and extracellular compartment, water molecule shifts 7. Renal shutdown – oliguria and concentrated urine
out of the cell into the more concentrated blood 8. Weight loss
9. Confusion
• The process above combined with increase water
10. Fever
intake and increase water retention in the kidney
usually restore the body fluid volume  Less fluid is available for perspiration which
• Any increase in fluid loss can lead to dehydration lower the body temperature
• Ex: Patients with diabetes insipidus – brain fail to 11. Low central venous pressure, delayed in capillary
refill, flattened neck vein
secrete ADH
12. Sunken eyes, cool clammy pale skin, muscle
 Inadequate ADH release may result to greater
amount of urine output (pathologic problem) cramps
• A person responds to thirst reflex by drinking fluid and
eating food that contain water Diagnostic Studies
• If water is inadequately replaced then the body cells 1. BUN – elevated
will lose more water, a condition called “dehydration”  The kidney is unable to function normally
resulting in a decreased renal perfusion
Hypovolemia 2. CBC
 If there’s a bleeding, there is a reduction in
• Loss of fluid and solutes from extracellular space
hemoglobin
• Excessive fluid loss like bleeding especially when
combined with reduced fluid intake  If there’s dehydration, the hematocrit level is
• Third space fluid shift – shifting of fluid from the elevated due to decreased plasma volume
3. Serum electrolyte
abdominal cavity (ascites) or patients who have
 Decreased potassium level: patients who have
pleural cavity, pericardial sac wherein there’s a
GI and renal loses
shifting of fluid from intravascular space but not into
intracellular space  Elevated potassium level: adrenal insufficiency
 May occur because of increase permeability of 4. Hyponatremia
capillary membrane or decrease in plasma colloid  Increased thirst and antidiuretic hormone
release: decrease in sodium level
osmotic pressure
 Elevations of sodium level may result from
increase in sensible loses and diabetes insipidus
Etiology
5. Urine specific gravity
1. Inadequate Fluid Intake  Increased of >1.020
2. Excessive GI fluid loss  The kidneys try to conserve fluid and decrease
 Vomiting, diarrhea, excessive suctioning, use of diabetes insipidus (< 1.05)
laxative, nasogastric drainage, abdominal  This test measures the ability of the kidney to
surgery (result to fluid volume deficit) excrete or conserve water
3. Excessive renal losses 6. Elevated urine osmolality
 Patients taking diuretic regimen or therapy  Compensate in conserving water

 Elevated urine osmolality (300 millimoles)  Decrease in peripheral perfusion − cold

extremities
Collaborative Management  Tissue turgor is best measured by gently
1. Fluid replacement pinching the skin over the sternum or inner
Oral route – intake of sodium-free drink because of aspect of the thigh or forehead
Na elevation  Tongue turgor is not affected by age, it is more
valid than evaluating skin turgor
Parenteral IV
4. Oral care
a. Isotonic solution – lactated ringer’s solution or
 Provide non-irritating fluids for oral discomfort
.09% sodium chloride, these are usually for
 If nauseated, give antiemetic drugs
treatment of hypotensive patients because they
 Small volume of oral rehydration fluid bay be
have the ability to expand circulating or plasma
given, it provides fluids, glucose, electrolytes in
volume.
concentrated form and are easily absorbed
b. Hypotonic solution – 0.45% sodium chloride is
5. Change position slowly to prevent orthostatic
used to provide electrolyte and water for renal
hypotension
excretion of metabolic waste
6. Maintain patent airway by providing oxygen therapy
− Avoid infusing/giving too quickly because the
7. Lower the head of the bed
fluid may move from vein into cell causing
edema
9. Assess for presence of diaphoresis
− Swelling of cell in brain can cause cerebral
 It might be the source of major fluid loss
edema
 Once fluid volume deficit occurs, the kidneys
− To avoid this problem, give it gradually over a
attempt to conserve body fluid leading to less
period of about 48 hours and watch for signs
urine (<30ml/hr) and may become concentrated
and symptoms of cerebral edema (headache,
10. Provide a safe environment
confusion, irritability, vomiting, wide pulse
 Patients at risk for seizure, and those who are
pressure)
confused and dizzy
c. Hypertonic solution − avoid giving this solution
because a patient’s hydrated blood is Fluid Volume Excess
concentrated
• Excess fluid in extracellular compartment
d. D5 water – should be carefully infused as it is
initially an isotonic and once it is being Water Intoxication
metabolized in the liver, it becomes hypotonic
• Occurs when excess fluid moves from extracellular
into the intracellular space
Nursing Management • Hypotonic − excessive low sodium fluid in
1. Maintain fluid balance extracellular space
 Accurate I & O  Because of this imbalance, fluid shifts by osmosis
 Monitor urine specific gravity – >1.020 indicates into the cell making the cell to swell
the kidney is conserving fluid  May occur as means of balancing concentration
 Monitor sodium level and urine osmolality of fluid between the two spaces called water
 Weigh daily to evaluate treatment progress intoxication
o 500 mL of fluid loss weigh approximately • Syndrome of inappropriate antidiuretic hormone
about 0.5g or half kilo grams or 1 pound (SIDA) – pathologic problem, abnormal antidiuretic
o 1L of fluid is approximately equivalent to 1 production causing the body to hold on fluids
kilogram • Other causes include rapid infusion of hypotonic
 Adequate hydration solution (D5 water), use of tap water in NGT irrigation,
2. Provide ongoing assessment enema
 VS − weak rapid pulse rate, orthostatic
hypotension, decreased capillary refill Hypervolemia
 LOC − severe fluid volume deficit may decrease
• Excessive fluid volume
cerebral perfusion (restlessness)
• Increase intestinal or intravascular compartment such
 CVP – low CVP indicates hypovolemia
as excessive sodium or fluid intake, fluid or sodium
 Breath sounds
retention, shift of fluid from intestinal space to
3. Maintain skin integrity – skin turgor, tongue and
intravascular space
mucous membrane
• When the compensatory mechanism fails to excrete
 Patients with fluid volume deficit have poor skin
excess fluid, it may increase extracellular fluid volume
turgor

Etiology  Both values are decreased due to plasma

1. Excessive fluid intake dilution
 IV replacement therapy using normal saline 3. Low Na
solution (NSS) or lactated ringer solution  Because of the increased water in the body due
 Blood or plasma replacement to excessive retention
 High intake of dietary sodium  The urine Na level is increased as the kidney
 Low dietary intake of protein may also result to attempts excrete excess volume
fluid volume excess 4. Low serum osmolality
2. Impaired ability to excrete fluid  Excessive retention of water
 Renal impairment 5. Low O2 level
3. Abnormal retention  Early tachypnea
 HF, corticosteroid therapy, liver cirrhosis or  Partial pressure of arterial carbon dioxide may
hyperaldosteronism be low which causes a drop in pH and respiratory
4. Fluid shifting into intravascular space alkalosis can occur because of the increase in
 Remobilization of fluid after burn treatment RR, removing excess CO2
 Administration of hypertonic fluid: mannitol or 6. Chest x-ray
hypertonic saline solution  Check for pulmonary congestion
 Use of plasma protein: albumin
Collaborative Management
Clinical Manifestations 1. Pharmacologic intervention
1. Weight gain Diuretics – remove excessive fluid. The choice of
 Because of the increased circulating blood fluid diuretics is based on the severity of hypervolemic
volume state, degree of impairment of the renal function, and
2. Increased BP, wide pulse pressure, central venous potency of the diuretic
pressure a. Thiazide (ex: Hydrodiuril) – blocks sodium
3. Tachycardia – rapid bounding pulse reabsorption in the distal tubules; the blood
4. Increased JVP (jugular venous pressure) volume may decrease and the aldosterone
5. Dependent/peripheral edema (feet, ankles, sacrum) increases, then there will be a loss in the
 Result of hydrostatic pressure that pushes the reabsorption of sodium and potassium
fluid out of the vessel forcing the fluid into the − Only 5-10% of filtered sodium is being
tissue (first visible in sacral area, ankle and feet) reabsorbed
 If the patient has a severe type of hypervolemia, b. Loop diuretics (Furosemide) – there is a great loss
there is a presence of a generalized edema of sodium and water because they block sodium
(anasarca) and water reabsorption in the ascending lymph of
6. Pulmonary the loop of Henle
 Dyspnea, SOB, tachypneic − As a result, the volume in the tubules
 Crackles – left side of the heart becomes increases and there is a decrease in blood
overloaded decreasing its pumping efficiency volume
o The fluid may back up into the lungs − More predictable so the physicians usually
o The hydrostatic pressure forces fluid out prescribe this drug
into the pulmonary blood vessel to the c. Potassium sparing diuretics (Aldactone) –
interstitial and alveolar area interfere with sodium and chloride reabsorption in
 Drop in SpO2 the tubules
 Pink frothy sputum – hallmark of pulmonary − Sodium, chloride, and water are excreted
edema and potassium is being spared and retained
7. Increased urine output in the body
8. Changes in LOC − The urine output increases
Potassium supplement – electrolyte imbalance
Diagnostic Studies (hypokalemia)
1. Low hematocrit a. Hypokalemia because of the effect of diuretics
 Due to hemodilution (except for spironolactone)
2. Low serum K and BUN b. Hyperkalemia may occur when diuretic works in
 Because of hemodilution the last distal tubule especially to patients with
 A high level indicates renal failure or impaired decreased renal function
renal prefusion Morphine and nitroglycerin to dilate blood vessels in
patients with pulmonary edema to reduce pulmonary

congestion and reduce amount of blood returning to  Related to diminished venous pooling and
the heart subsequent increase in effective circulating
Digoxin is used for HF to strengthen contraction and blood volume and renal perfusion
slow heart rate
2. Oxygen therapy SODIUM
 Since the pulmonary edema may affect • Major extracellular fluid cation which may affect the
pulmonary functions and patients may have SOB CNS
and dyspnea • There should be more fluid in the cell and less in the
3. Continuous renal replacement therapy (CRRT) or blood vessel
hemodialysis • Cerebral edema and hypovolemia can occur
 If drug agents cannot act efficiently to severely • When the Na level is low, the kidneys essentially hold
impaired renal function on to it
a. Peritoneal Dialysis – may remove the nitrogenous • When the Na level is high, the kidneys excrete the
waste, control potassium & acid base balance, excess through urine
and remove sodium and fluid • If the kidneys can’t eliminate enough Na, it will
b. CRRT – manage fluid and electrolyte imbalance accumulate into the bloodstream attracting and
in hemodynamically unstable patient with multiple holding water that results to increased blood volume
organ failure; renal failure cannot tolerate dialysis
4. Nutritional intervention Roles
 Low intake of Na and high protein intake Regulates osmotic forces − concerns with the moving of
 Albumin may increase protein intake fluid that influences fluid distribution
 Bottled water – has sodium content (0-1200 Activates neurotransmitters − transmits nerve impulse
mg/L) so it is important to teach or remind the and muscle fibers
patient to read the labels of food carefully Involves in the acid-base balance − it combines with
 Protein intake may hold oncotic pressure, they chloride and bicarbonate to regulate the balance)
try to pull out the water out the tissue to vessel Cellular-chemical reactions and membrane transport
for excretion by the kidney
Sodium Disturbances
Nursing Management:
Hyponatremia
1. Maintain normal fluid balance
• Hypo – low; Na – sodium; Tremia – blood
 Hourly take I & O, weigh daily
• Sodium Deficiency – craving for salt
 Monitor VS and assess for edema status
• Serum level below 135 mEq/L (N: 135-145)
 Monitor IVF regulation accurately
• Results from excessive sodium loss or excessive
 Rid bottled water free of sodium
water gain
2. Prevent/minimize edema
• Decrease in extracellular fluid, meaning the water is
 Assess lung sounds
being pulled from the extracellular fluid going inside
 Elevate HOB at least 30-45 degrees to provide
the cell (osmosis) causing the cell to swell
patent airway and lung expansion
• The fluid moves by osmosis from extracellular to
 EDBCE − encourage deep breathing coughing
intracellular with more fluid in the cell and less in the
exercise
blood vessels resulting in cerebral edema and
 TTS − turn side-to-side regularly to decrease or
hypovolemia
avoid skin breakdown, Q2h
• Therefore, there’s a decrease sodium in blood; too
 Administer diuretics as ordered
much water volume but decrease or low in sodium in
3. Family teaching
the body
 Sodium and water restriction as ordered
 Double check the OTC medications
 Some medications such as NSAIDS, Anti- Two Types
hypertensive agents, and Corticosteroids can Dilutional Hyponatremia – results from sodium loss and
cause edema excess water in the extracellular compartment without
 Health history edema
4. Offer emotional support Depletional Hyponatremia – there’s inadequate sodium
5. Physical care intake
 Provide oral care
6. Bed rest and proper positioning Etiology
 May favor diuresis of edematous fluid
1. Excessive fluid intake

2. Exercise-associated factors  Except for patients with azotemia wherein

 Prolonged exercise can cause a decrease in the there’s an accumulation of toxin
serum Na 3. Urine Na & specific gravity
3. Adrenal insufficiency  There’s a decrease if the cause is Na loss
 Decrease in the production of aldosterone  If less than 20 mEq/L, it suggests increase in
4. Renal losses proximal reabsorption of sodium secondary to
 Use of diuretics, patients with metabolic alkalosis extracellular volume deficit
due to excessive K loss  If the cause is SIADH (syndrome of inappropriate
5. Extrarenal or non-renal antidiuretic hormone), urine Na is > 20 mEq/L
 Vomiting, diarrhea, gastric suctioning, excessive and the specific gravity 1.012
sweating, burns, wound drainage
6. Medications Collaborative Management
 Anticonvulsants may increase the risk of
1. Sodium replacement
hyponatremia, sertraline (Zoloft)
 Must not exceed > 12 mEq/L in 24 hours to avoid
 In hypothyroidism, there is a low Na, limited fluid
neurological damage due to osmotic
excretion caused by the accumulation of fluids in
demyelination
the body
o This condition may occur when the serum
 Use of glucocorticoid therapy sodium concentration is over corrected
o If there’s a decrease in sodium in less than 48 exceeding 140 mEq/L too rapidly or in the
hours, it is usually associated with brain presence of hypoxia or anoxia
herniation or distraction of the mid brain o May produce lesion that show symmetric
structure myelin destruction affecting all the fiber
tracts that cause paraparesis, dysphagia,
Causes or coma
 Try to correct serum sodium by 1 mEq/L per hour
1. Excessive vomiting
 In severe hyponatremia use 3% saline
2. Diuretics
 If unable to consume sodium, a lactated ringer
3. Drinking too much water
solution or isotonic .09 normal saline, or sodium
4. Excessive diarrhea
chloride may be prescribed
5. Heart, kidney and liver problem
2. Water restriction – effective
6. Dehydration
3. Hypertonic solutions
7. Inadequate salt intake
 Small volume of hypertonic solution is given in
8. Fluid shift from ICF to ECF
severe neurological symptoms (seizure and
coma) or traumatic injury with the goal of
Signs and Symptoms
alleviating the cerebral edema
1. Neurological  Must be closely monitored to prevent circulatory
 Altered LOC, headache, seizures, confusion, overload and worsening of the neurologic status
coma  Hypertonic saline solution causes the water to
 Severe hyponatremia can cause permanent shift out of the cells which may lead to
neurologic damage intravascular volume overload and may cause a
 If the sodium level decrease less than 115 series of brain damage such as osmotic
mEq/L, it’s a sign if intracranial pressure demyelination
manifested by lethargy, confusion, muscle 4. Pharmacologic therapy
twitching, focal weakness, hemiparesis, and AVP receptor antagonist
seizure
 A new grant agent in order to treat hyponatremia
2. Cardiovascular
by stimulating the free water excretion causing
 Orthostatic hypotension due to the shifting of
water diuresis than salt diuresis by diluting the
fluid from IC to EC
urine and racing the serum sodium
 Weak, rapid pulse and decrease BP, CVP
IV conivaptan HCl (Vaprisol)
3. GI
 Contraindicated to patients with seizure,
 Anorexia, N/V, abdominal cramps
delirium, or coma
4. Muscle cramps, muscle twitching, tremors
Furosemide
 To prevent hypertonic overload
Diagnostic Studies
 C/I: seizure, delirium, or coma
1. Serum Na less than 135 mEq/L
2. Decrease in serum osmolality

Nursing Management  Pulmonary infection – loss of water vapor from

Maintain Fluid Balance the lungs through hyperventilation
1. Health history  Diabetes insipidus – experiences extreme thirst
 If using salt tablets (especially athletes), which and urinary loss (results from lack of ADH from
may decrease sweating thus the loss of sodium the brain and cannot concentrate urine
during prolong exercise 3. Reduced water replacement
 It is not recommended to use salt tablet as of a  Elderly, cognitive impaired and coma patients
study in 2015  Critically ill patients who are unconscious,
intubated, and sedated are at risk
2. Monitor I & O
4. Medications
3. Weigh daily
 Loop diuretics, certain antacid (Alka-seltzer), salt
4. Assess for s/s of fluid volume excess
tablet
 Observe for any circulatory overload, puffy
 Sodium bicarb given in cardiac arrest due to
eyelids, cough, dyspnea, presence of lung
metabolic acidosis
crackles, dependent edema, or weight gain in 24
5. Less common
hours
 Heat stroke, near-drowning in sea water,
5. Administer Na supplements
malfunctions of dialysis system, excessive use of
 Either orally, through NGT, or parenterally
NaHCO3 and hypertonic saline sol.
6. Monitor vital signs
 Sea water contains 500 mEq/L of sodium
 Blood pressure and pulse rate
concentration
 Watch out for tachycardia orthostatic
hypotension o Normally, the body thrives to maintain a normal
7. Infuse hypotonic solutions cautiously sodium level by secreting ADH hormone from
 May cause swelling of the cell the PPG
8. Water restriction if cause is fluid volume excess o This hormone causes the water to be retained
which helps in lowering the serum sodium level
Prevent Injury
1. Assess neurologic (LOC, muscle twitching, seizures)
Signs and Symptoms
and GI status (anorexia, NV, abdominal cramping)
2. Maintain seizure precautions – put up the side rails 1. Neurological
of the patient  Restlessness, irritability, lethargy, seizures,
confusion, coma, and tremors
 Earliest sign in hypernatremia in neurologic is
Hypernatremia
restlessness and agitation
• Sodium excess; craving for water
2. Pulmonary
• There’s an increased sodium, decreased water, and
 Dyspnea, pulmonary edema
increased osmolality
3. Cardiovascular
• Above serum Na level of 145 mEq/L
 Tachycardia, elevated BP, bounding pulse, and
• Result gain Na in excess of water or by loss of water
dyspnea
in
 Dry mucous membranes, dehydration, flushed
• Water moves out from intracellular fluid into
skin, orthostatic hypotension
extracellular fluid that may cause cellular dehydration
4. Thirst
 As the fluid leaves the cell, the cell becomes
 Primary symptoms of hypernatremia
dehydrated and streaked especially in the CNS
5. Integumentary
 When this occurs, patient may show signs of
 Decreased skin turgor, edematous dry skin and
neurologic impairment and hypervolemia
sticky mucous membrane
• Hypervolemia is fluid overload from increased
6. Low grade fever
intracellular fluid volume in the blood vessel, if the
7. Peripheral edema
overload is severe enough, subarachnoid
8. Decreased urine output
hemorrhage may occur
9. Increased deep tendon reflexes or muscle tone
Etiology
Diagnostic Studies
1. Excessive intake of Na in any routes
1. Elevated serum Na greater than 145 mEq/L
 Administration of hypertonic enteral feeding
2. Elevated serum osmolality greater than 295
without adequate water supplement
mOsm/kg
2. Water loss
3. Elevated urine specific gravity and urine osmolality
 Fever, heat stroke, diarrhea, vomiting, extensive
burns, hyperventilation

Collaborative Management • To keep the intracellular fluid electrically neutral, the

1. Infuse hypotonic electrolytes potassium ions move from the extracellular to
 E.g. 0.3% NaCl or isotonic non-saline solution intracellular which causes too little potassium in the
(D5 Water) blood stream, resulting to hypokalemia
 D5 water is to replace water without replacing
the sodium but be careful for cerebral edema Causes
 Hypotonic is safer than D5 water because it 1. Inadequate dietary intake of potassium
allows gradual reduction of sodium and  Elderly, alcoholism, anorexia nervosa, bulimia
decrease the incidence of cerebral edema 2. Excessive loss
− It is solution of choice in severe Medications
hyperglycemia with hypernatremia  Na Penicillin, amphotericin B, diuretics
2. Diuretics (Thiazides) (furosemide, digoxin), corticosteroid therapy,
 To decrease the free water loss in the kidney  Insulin to move potassium back to the cell and if
 Acts on the distal tubules to prevent sodium patient is receiving a lot of dextrose solution
reabsorption and increase the amount of tubular GI loss/disorders
fluid down the nephron
 Diarrhea, vomiting, gastric suction, fistula
3. Desmopressin acetate
 Loss of GI fluids may cause alkalosis and
 A synthetic ADH to treat diabetes insipidus if it is
hypokalemia
the cause of hypernatremia
Diaphoresis & renal disorders
Metabolic alkalosis
Nursing Management
 Increase in pH = decrease in hydrogen ion
1. Maintain normal fluid balance
 May cause the potassium to move in and
 Health history using OTC medications (Alka-
hydrogen to move out
Seltzer – high in Na content)
3. Mg depletion
 I & O accurately
 Causes renal potassium loss
 Weigh daily
 Must be corrected first otherwise the loss of
 Increase OFI (oral fluid intake) as appropriate
potassium in the urine will continue
 Use hypotonic solution cautiously
 Monitor serum Na level – check the lab test
Signs and Symptoms
 Restrict dietary sodium
2. Monitor changes in behavior 1. Alkalosis, Anorexia
3. Protect from injury 2. Shallow respiration
 Reposition frequently (every 2 hours) 3. Irritability
 Keep side rails up, bed in low position, call light 4. Confusion, drowsiness
within reach 5. Weakness, fatigue
 Secure all invasive lines 6. Arrhythmias – tachycardia or bradycardia
7. Lethargy
8. Thready pulse
POTASSIUM
9. Decreased intestinal motility, N/V, ileus, abdominal
• Potassium is the major intracellular cations
distention
• Normal: 3.5 mEq/L – 5.5 mEq/L
10. Muscle weakness, leg cramps or paresthesia –
numbness, tingling sensation, decrease muscle
Functions of Potassium strength and deep tendon reflexes
• Regulates the intracellular fluid volume
• Helps in conduction of nerve, Contraction of all
o Prolonged hypokalemia can lead to inability of
muscles, Cardiac cells, and metabolic processes.
the kidney to concentrate urine, causing diluted
• It also affects the acid base balance in relations to
urine, resulting to polyuria, nocturia, and
hydrogen ions
excessive thirst
o Potassium depletion suppresses the release of
Potassium Disturbances insulin and results to glucose intolerance
Hypokalemia
• Potassium deficiency
Diagnostic Studies
• Serum potassium < 3.5 mEq/L
1. Serum K+ <3.5 mEq/L
• In alkalosis, the hydrogen ions move from the
2. ECG: flattened T wave, prominent U wave,
intracellular fluid to the extracellular fluid
prolonged PR interval, depressed ST segments

3. Increase digitalis levels Hyperkalemia

4. ABG analysis • Potassium excess
 Metabolic alkalosis, elevated pH and • Serum K+ >5.5 mEq/L
bicarbonate levels • Due to acidosis – the hydrogen ion content in the
5. Decreased Mg level extracellular fluid increases, the ion will move into the
 Correct first the magnesium level before intracellular fluid
correcting hypokalemia • To keep the intracellular fluid electrically neutral, the
number of the potassium would leave the cell causing
6. Elevated serum glucose
hyperkalemia
Causes
1. Correct underlying condition
1. Age-related
2. Potassium replacement – diet, oral or IV replacement
 Premature infants are high risk of developing
3. If taking diuretics – switch medication to potassium-
hyperkalemia due to immature renal function.
sparing diuretics
Commonly within 48 hrs of life.
 Parenteral IV supplement is mandatory for
 Patients who are elderly are also high-risk in
potassium level of less than 2.5 mEq/L (if less
developing hyperkalemia because the renal
than 2.5 that’s the only time you will administer
function deteriorates with age. The flow of blood
parenteral IV supplement)
in the kidney is also decreased, and fluid intake
 To prevent or reduce toxic effect, the IV solution
is also decreased. Therefore, if there is decrease
concentration should not exceed 40 mEq/L. Rate
in urine flow rate, the plasma renin activity
is usually 10 mEq per hour. Rapid infusion may
aldosterone also decreases in age.
be used in severe cases, but it is very irritating
 Patients who are bedridden may be placed on
even diluted in IV fluids.
subcutaneous heparin which also decrease
 Calcium gluconate – to antagonize the effect of
aldosterone production thereby decreasing
cardiac conduction
potassium excretion.
2. Renal failure – decrease renal function
Nursing Management 3. Hypoaldosteronism
1. Monitor vital signs – pulse and BP, RR  Decrease in sodium retention and increase in
 Usually, hypokalemia is commonly associated potassium reabsorption
with hypovolemia due to diuresis which can 4. Acidosis
cause orthostatic hypotension 5. Severe tissue damage
2. Encourage potassium-rich foods  Burns, massive infection – may cause leakage of
 Banana, celery, orange, avocado, tomato potassium
3. Administer potassium replacement orally 6. Excessive intake of K supplement
 K durules or dilute the syrup in juices with full  when giving potassium, it should be diluted in IV
stomach to prevent perforation fluids, never give IV push, never give potassium
4. Infuse parenteral potassium supplement parenterally
 Diluted in at least 100 ml of solution, 7. Iatrogenic
administered through infusion pump or side drip,  Treatment induces hyperkalemia, not common
monitor ECG but dangerous because of the risk of cardiac
5. Never administer potassium per IV push or IM arrest
6. Monitor I&O, serum K 8. Blood transfusion
 1 liter of urine output = 40 mEq/L of potassium is  When there is a large amount of blood that is
being loss donated and has near expiration date, leakage
7. Assess for abdominal distention for any pain (GI of potassium from the cell may occur
bleeding) 9. Hemolysis
 Oral supplements can cause small bowel lesions  Lysis of the malignant cells after chemotherapy
so make sure to dilute the potassium with juices  Sometimes called Pseudo hyperkalemia
8. Prevent injury in client’s taking digitalis wherein there is increase potassium in the cell,
 If any injury occurs, the action of the drug that is why leukocytosis and thrombocytosis
potentiates and may lead to digitalis toxicity during coagulation causes the cell to lyse (lysis)
9. Auscultate bowel sounds and release potassium and seen in hemolysis
10. Safety precaution factor
 Provide safety environment by putting the side
rails up since muscles and the CNS are affected

10. Medications  Used in patients with impaired renal function.

Potassium sparing diuretics, NSAIDs and Heparin This may sit in the intestine, then sodium may
 May cause hyperkalemia by suppressing the move across the bowel-wall into the blood, and
aldosterone secretions, which may decrease the potassium move out of the blood into the
potassium excretion in the kidney intestine. Loose stool removes potassium from
ACE Inhibitor the body
 Inhibits shifting of potassium into the cell  Patients with paralytic ileus cannot use
Chemotherapy Kayexalate because intestinal perforation may
occur
 Causes cell death, and renal injury
 Kayexalate binds with other cation in the GI tract
11. Insulin deficiency
and contribute to the development of
 Decrease movement of potassium into the cell
hypomagnesemia and hypocalcemia. It may also
cause sodium retention, fluid overload, and
Signs and Symptoms
should be use with caution in patients who have
1. Cardiac arrhythmias heart failure
 Presence of tall peak narrow T wave, ST Calcium gluconate (10ml) or Calcium chloride (5ml)
segment depression, and shorten QT interval
 Effect on myocardium. It antagonizes the cardiac
 If PR interval becomes prolong and is followed
conduction. The calcium antagonizes the action
by disappearance of the P wave, and widening
of hyperkalemia on the heart, but it does not
of the QRS complex, patients may be at risk to
reduce the serum-potassium concentration
develop ventricular dysrhythmia and cardiac
 Calcium gluconate contains 4.5 mEq/L of
arrest may occur
calcium, while calcium chloride contains 13.6
2. Muscle weakness
mEq/L of calcium, so it cannot be used
 May lead to flaccid paralysis from legs to trunk,
interchangeably. Always read the label
which may involve respiratory muscle, or
 During calcium administration, patients might
paralysis or speech paralysis
develop bradycardia. If patient develop
 Paresthesia (early symptom because of
bradycardia, stop infusion
irritability), paralysis
Sodium bicarbonate – correct acidosis
3. Irritability and anxiety
Insulin or D50-50
4. Abdominal cramps with diarrhea – early sign
5. Muscle cramps  10 units of regular insulin of IV, so the drug may
6. Tingling sensation become active within 15 to 16 minutes and lasts
7. Decrease reflexes for 4 to 6 hours
8. Decrease cardiac contractility Beta-2 agonists – albuterol
9. ECG changes  Highly effective in decreasing potassium
10. Respiratory distress  May cause tachycardia and chest discomfort
11. Urine abnormalities – oliguria, anuria 3. Hemodialysis – renal failure
Diagnostic Studies Nursing Management

1. Serum K+ >5.5 mEq/L 1. Decrease intake of K+ rich food
2. ECG 2. Monitor ECG changes
 Tall, peak and narrow T waves, prolonged PR  Arrhythmias may be seen
interval followed by absent of P waves, and 4. Monitor vital signs
widening of QRS  especially BP (detection of hypotension from
rapid calcium gluconate administration)
3. ABG analysis
 HR (check for bradycardia)
 Decreased arterial pH indicates acidosis
5. Monitor CBG
 2 hours NPO before taking CBG for
Collaborative Management hypoglycemia
1. Restriction of dietary K and potassium-containing  S&S: hunger, diaphoresis, muscle weakness,
2. Pharmacologic therapy syncope
Loop Diuretic 6. Auscultate bowel sounds (for its character)
 Helps excrete water and prevent reabsorption of 7. Imposed safety measures
sodium-potassium chloride in the ascending loop 8. Monitor for ABG, BUN creatinine, and glucose
of Henle and in renal distal tubules 9. Do not prolong use of tourniquet in drawing blood
Sodium polystyrene sulfonate (Kayexalate)  Sometimes its mistaken for “pseudo
hyperkalemia” or false hyperkalemia because of

the tight tourniquet around an exercising Magnesium Disturbances

extremity while drawing a blood sample Hypomagnesemia
producing hemolysis of the sample for analysis • Magnesium deficiency
10. Measure the intake and output for the shift of the • Serum Mg <1.5 mEq/L
potassium in the cell • Causes muscle excitation
11. Assess for signs and symptoms of hyperkalemia • Normally, the Mg controls the calcium entry to the
myoneural junction. There are two gates in this:
• If the patient is receiving Kayexalate (Sodium  If there’s decrease in Mg, more calcium can enter
polystyrene sulfonate), a medication that exchanges the junction. Vice versa in hypermagnesemia, if
sodium for potassium in the colon and thus excreting there is a high level of Mg, less calcium can enter
potassium from the body, increase the sodium level or
intake but watch out for heart failure
Causes
• If patient is taking digitalis, then monitor for its toxicity.
1. Poor nutrition
Caution in the use of salt substitute and potassium-
 Lack of dietary intake of Mg
sparing diuretics
 Patients may receive total parenteral nutrition
• Renal functions should be monitored, if there’s a
because of insufficient magnesium
hyperactive bowel sounds, it may be a sign of
2. Decrease GI absorption
hyperkalemia
 Due to chronic alcoholism which alters the
absorption and increase urinary secretions
MAGNESIUM
because of diuresis
• Intracellular fluid cation; bff with potassium and  Malabsorption syndrome – patients may have
calcium steatorrhea, ulcerative colitis, or other celiac
• It may affect the CNS diseases and chrome diseases. These
• High concentration of magnesium is absorbed in the conditions may lead to a diminished absorption
distal part of the small intestine of Mg
• Most of the magnesium move freely as ionize or called 3. Excessive GI loss
the free form, and 30% of these binds with albumin.  Prolonged vomiting and diarrhea
Therefore, a decrease in albumin means there is also  More magnesium is found in the lower GIT,
a decrease in magnesium but the free magnesium meaning the distal small bowel is the major site
remains unchanged for Mg absorption. So, expect that when a patient
• Magnesium-rich food: green-leaf vegetables, whole has diarrhea, there is a decrease in Mg
grain, seafood, beans  Patients who have GI fistula, or suction, the
• Normal: 1.5-2.5 mEq/L overuse of laxatives.
4. Excessive loss from urinary tract
Role of the Magnesium  Patients who take diuretic medications
• Regulates muscle contraction; it acts on the  Normally, the Mg inhibits potassium secretion,
myoneural junction, the site where nerves and muscle but when Mg is decreased, more K is excreted
fibers meet. It affects the contractility of the cardiac  This also happens during the diuretic phase of a
and skeletal muscles. Therefore, it is important in kidney injury
maintaining cardiac rhythm 5. Surgery
• Helps in neurotransmission  Bowel resections or bypass will reduce the
• Necessary for the production of parathyroid hormone. potential absorption site by decreasing the
The parathyroid needs Mg in order to release PTH surface area within the GI tract
which causes the osteoclast to release calcium from 6. Other medical conditions
the bone. If there is a decrease in the Mg, the PTH will  DM − due to osmotic diuresis, an increase in
not be released in the gland glucose, meaning more glucose will be filtered
• Helps the body produce and use ATP for energy attracting large amounts of fluid that increases
• Magnesium-rich food: green-leaf vegetables, whole the urinary flow. With the fast urine flow, there
grain, seafood, beans will be not enough time for the Mg to be
• GI and urinary systems regulate magnesium by reabsorb, causing a shift of the Mg in the cell with
means of absorption, excretion, and retention. If the insulin therapy
there’s too much Mg, the GI excretes it through feces.  Hyperparathyroidism – the parathyroid needs
The kidney alters the reabsorption at the proximal Mg in order to release PTH which causes the
tubules and the loop of Henle, then excretes it through osteoclast to release calcium from the bone. If
urine. If too low, the GI reabsorbs it there is a decrease in the Mg, the PTH will not
be released in the gland

7. Decreased serum K and Ca  MgSO4 – give slowly; IV MgSO4 – administer by

an infusion pump at the rate of not exceeding
Signs and Symptoms 150 μg/min; 67 mEq over 8 hours
 Calcium gluconate – to treat hypocalcemia or
1. CNS
hypermagnesemia during administration
 Altered LOC causing hallucinations either by
visual or auditory
 Confusion Nursing Management
2. Neuromuscular irritability 1. Monitor VS, mental status changes
 Because the gate is open for the calcium to enter  Detect for any changes in cardiac rate/rhythm,
 This causes hyperactive deep tendon reflexes, hypotension, respiratory distress
(+) Trousseau (carpal spasm when the upper 2. Measure I&O
arm is compressed) and Chvostek signs (facial  Important before, during, and after
twitching when the facial nerve is administration of MgSO4
stimulated/tapped), tetany, tremors, twitching,  Notify the physician if UO is decreased to
and vertigo <100mL over 4 hours
3. Cardiovascular system  Don’t administer if UO is <100mL in 4 hours
  BP and HR  Excessive fluid loss is a risk in Mg deficiency and
 Arrhythmia − PVC, SVT, Torsades de pointes may become severe
(TdP), V fib, heart blocks 3. Evaluate neuromuscular status
 Dizziness  Hyperactive DTRs, Trousseau and Chvostek's
4. GI sign because of the decrease in Ca level
 Dysphagia, N/V, anorexia 4. Asses the swallowing ability
5. Behavioral changes  Prevent aspiration from dysphagia
 Insomnia, mood changes (apathy, depression), 5. Give MgSO4 slowly in IV push and through an
apprehension, extreme agitation infusion pump
6. Increased susceptibility to digitalis toxicity is 6. Discuss the misuse of diuretics and laxatives
associated with low serum magnesium level 7. Dietary sources of Mg
 Because the patient is receiving digoxin and  Nuts, whole grains, bananas
more likely to receive diuretic therapy, 8. Monitor ECG and pulse
predisposing them to renal loss of magnesium 9. Monitor Mg toxicity and digitalis toxicity
 N/V, bradycardia
Diagnostic Studies 10. Check serum Mg level
11. Monitor for s/s of magnesium toxicity
1. Serum Mg <1.5 mEq/L
 Hot flushed-skin, diaphoresis, anxiety or
2. Urine Mg after loading dose
lethargy, hypotension, laryngeal stridor
 Urine magnesium may help identify the cause of
12. Implement safety measures
depletion and measure the level after the loading
 Mental confusion and seizure precautions
dose of MgSO4 is given
3. ECG
 Flattened or inverted T wave, prominent U wave, Hypermagnesemia
and depressed ST segment, prolonged PR and • Mg excess
wide QRS • Serum Mg level >2.5 mEq/L
4. Nuclear magnetic resonance spectroscopy, Ion- • Muscles are too relaxed because of the restriction of
selective electrode calcium from entering the myoneural junction
 Sensitive and directly measures the ionized • If the serum Mg is elevated, the kidney will excrete the
serum magnesium level, but is very expensive excess through urine
5. Elevated digoxin level
6. Serum albumin level – decreased Causes
 Potassium, phosphorus, calcium level – these
1. Too much intake – dietary
are linked together, meaning, a decrease in one
 Milk of magnesia (laxative), Maalox (Mg-
of these, there is also a decrease in others
containing acid)
2. Poor renal excretion
Collaborative Management  Advanced age – inability to excrete magnesium
1. Diet therapy rich in Mg due to reduced renal function
2. Pharmacologic therapy

 Renal failure, oliguric phase of acute renal injury, Diagnostic Studies

or in patients who have adrenocortical 1. Serum Mg level >2.5 mEq/L
insufficiency 2. ECG
3. Continuous infusion of MgSO4  Peak T wave, prolonged PR, QT and QRS
 Pregnancy-induced hypertension (PIH) to treat interval and AV blocks
seizure and preterm labor 3. Creatinine clearance – decreased
4. Severe dehydration 4. Electrolytes – K and Ca are elevated
 As in DKA (diabetic ketoacidosis) when the 5. Platelet count and prothrombin time − delayed
catabolism causes the release of cellular Mg that
cannot be excreted because of the excessive
fluid volume depletion resulting in oliguria
1. Discontinue all parenteral and oral Mg salts
5. Hypoparathyroidism
2. Increase fluid intake to lower the Mg
3. Diuresis and dietary modifications
4. Pharmacological ways
 Loop diuretics
 IV calcium gluconate – Mg antagonist
5. Ventilator support
 May compromise respiratory function thus
proper monitoring
6. Monitor serum Mg level
7. Parenteral IV – treat hypotension
8. Enhance renal excretion through saline diuresis – LR
or 0.45% NSS
9. Hemodialysis
 With Mg free dialysate for renal dysfunction
Nursing Management
1. Monitor VS
 Watch out for hypotension, bradycardia,
The photo shows how magnesium works respiratory depression
2. Observe mental status, muscle strength and DTRs
o Potassium, Magnesium and Calcium are besties
(patellar reflexes)
o Magnesium is primarily regulated by the kidney but
3. Measure I&O
absorbed in the intestine
4. Monitor lab results
5. On cardiac monitoring to assess ECG tracing
Signs and Symptoms 6. Prepare for an emergency
1. CNS  Respiratory support – collaborate/coordinate
 Altered LOC − diminished; drowsiness, lethargic with the respiratory therapist to provide support
2. Neuromuscular for mechanical ventilator
 Due to decreased nerve function resulting to  Transcutaneous external pacemaker –
DTR, generalized muscle weakness, flaccid bradyarrhythmia
paralysis  Dialysis
3. Cardiovascular 7. Implement safety precautions – may alter the
 Bradycardia, BP, weak pulse, and cardiac sensations, mental status of the patient
arrhythmias 8. Monitor laboratory tests and report abnormalities
 Arrythmias may lead to diminished cardiac 9. Health teaching on antacid or cathartic use as well
output causing vasodilation, lowering the BP as OTC drugs containing Mg
4. Respiratory
 Slow and shallow respiration (depressed)
CALCIUM
 Respiratory arrest can occur that will require
• Major extracellular fluid cation
patients to be hooked to a mechanical ventilator
• About 99% of the body Ca is found in the skeletal
5. GI
muscles and is a major component of bones and
 N/V, diarrhea
teeth. Only 1% is found in serum and soft tissue. This
6. Hot, flushed skin, diaphoresis
1% is what matters in measuring Ca levels in the
7. Platelet clumping, or delayed thrombin formation
blood.

• Generally, 50% of the free ions in the circulation is bone and promote transfer of calcium in the plasma
termed as “ionized calcium”, 40% of the Ca binds with that will increase serum calcium level
albumin, and the remaining 10% binds with other  Parathyroid hormone acts on bone to stimulate
substances calcium to allow kidney to reabsorb more calcium
• The Ca in the extracellular fluid is split into: and not be loss in urine
Diffusible – small molecules that cross cell membrane  Synthesized calcitriol known as the active vitamin
Free ionized Ca – involves all cellular process D can cause intestine to increase absorption of
(neuron, action potential, muscle contraction, calcium and excretion of phosphorus at the same
hormone secretions, blood coagulation) time
Complex Ca – links to tiny molecules such as the
calcium oxalate, this is not used in cellular process Causes
Non-diffusible – the albumin are large molecules that 1. Advanced age
cross membranes but it is not involved in the cellular  Low intake
process. 41% is in the extracellular binding to a  Poor absorption (ex. in post-menopausal woman
protein, 9% is combined with non-protein ions there’s a of lack of estrogen)
(phosphate, citrate, and carbonate)  Reduced activity causes loss of calcium in the
• Calcium is absorbed in the small intestine and is bone
secreted in the urine and feces  Osteoporosis has normal serum count but stored
• Normal range of serum calcium level is 8.5-10.5 mineral level in bone is depleted
mEq/dl 2. Hyperparathyroidectomy
• Ionized serum level 4.5-5.5 mg/dl  Patients who have parathyroidectomy prevents
secretion of parathyroid hormone; patients who
had radical neck dissection during the first 24-48
Roles of Ca
hours
• Ca is involved in neurologic. Calcium transmits nerve  Patients who have this kind of surgery should be
impulses, regulate muscle contraction and relaxation, monitored for any neurologic symptoms of
which includes the cardiac, smooth and skeletal hypocalcemia
muscles 3. Lack of vitamin D
• Also involved in the blood clotting process or blood  Due to diet insufficiency which may reduce
coagulation calcium reabsorption
• Plays a role in cell membrane permeability where the  Alcoholism because of poor nutritional effect
cell receptor functions and membrane stabilization  Magnesium can also affect parathyroid hormone
occur secretions
• Also needed in hormone secretion  Malabsorption
• Serves as an instrument in activating the enzyme that  Lack of exposure to sunlight
stimulates many essential chemical reactions in the 4. Renal failure
body  Inability of the kidney to activate which may
affect calcium absorption
Factors that may influence the Ca in the body  Too much calcium leaving the blood
• Parathyroid gland which secretes PTH  Doesn’t reabsorb calcium and allow excretion of
• Thyroid gland that releases calcitonin calcium in urine
• Vitamin D from the ingested food and the exposure to  Kidney can filter and reabsorb Ca in the proximal
sunlight, this is needed to absorb calcium renal tubule. Therefore, calcium is being
excreted in the urine
 Frequent elevated phosphate level
Calcium Disturbances
5. Tissue damage-burn
Hypocalcemia  Tumor lysis syndrome wherein large number of
• Calcium deficiency cells die and release cellular phosphate in the
• Serum Ca of <8.5 mg/dL blood and bind with the ionized calcium
• Calcium stabilizes sodium during resting stage in phosphate making it insoluble and reduce total
order to prevent spontaneous depolarization calcium in the blood
• If there`s hypocalcemia, sodium becomes unstable 6. Inflammatory process
which allows the gate to open that depolarizes and  Pancreatic insufficiency causes malabsorption
easily excitable resulting to neurologic symptoms of calcium and be loss in feces
• Reduction of calcium can cause parathyroid gland to  Severe pancreatitis which is related to excess
stimulate parathyroid hormone that draws calcium in secretion of glucagon. Increase in glucagon can

cause release of calcitonin which prevents Laboratory and Diagnostic Test

calcium release from the bone 1. Total serum and ionized calcium − decreased
7. Other serum level 2. Ionized calcium is the definite method to diagnose
 Phosphate − elevation can reduce gastric acidity hypocalcemia
which may decrease the solubility of calcium and  Reduction in calcium level can be life threatening
reduce absorption 3. ABG – increase pH level (alkalosis)
 Magnesium − deficiency can cause decrease in  More calcium binds with albumin causing
parathyroid hormone secretion reduction in the ionized calcium
 Albumin – decrease can also lower calcium;  Total serum calcium is unchanged
increase level of pH can cause calcium to bind to 4. Low serum albumin level
albumin thereby decreasing the level of ionized  Lead to bound calcium, the free ionized calcium
level remains the same due to hormone regulation
8. Multiple blood transfusion caused by parathyroid hormone called as
 Causes transient hypocalcemia because of the “pseudo hypocalcemia”
citrate added to stored blood to prevent clotting  Total calcium is less but the free ionized calcium
and ionized calcium is remove from blood and is remains the same
bond with citrate 5. Low Mg and phosphorus level
9. Medication: Rifampicin  Identify possible causes of reduction in calcium
 Aluminum containing antacid, or loop diuretics 6. ECG
 Prolonged QT interval and ST, TdP
Signs and Symptoms  Patient is prone to Torsades de Pointes
1. CNS
 Irritability, confusion, hallucination, seizures Nursing Management
 Seizure occurs because of increased irritability 1. Monitor vital signs
of the CNS as well as the peripheral nerve  Specially BP because calcium replacement can
2. Neurological cause postural hypertension
 Tetany − involuntary muscle contraction; classic 2. Check IV patency
symptom)  Caution: tissue necrosis and sloughing
 (+) Trousseau and Chvostek sign (twitching of 3. Diet therapy – “dilis”, Vit. D
facial muscle by tapping the nerve) 4. Place on cardiac monitoring
 Hyperactive DTR because of irritability 5. Prepare resuscitation and tracheostomy set
 Paresthesia, which is the tingling sensation that 6. Regular exercise
occurs in the tips of finger especially around the 7. Monitor serum calcium
mouth and less common in feet 8. Caution in the Ca administration in patients taking
3. Cardiovascular digitalis
 cardiac rate, BP, ECG changes 9. Do not add Ca in solutions with bicarbonate or
 Decreased muscle contractility in which patient phosphorus
may experience angina and bradycardia 10. Safety precaution − seizure
 Prolonged QT interval and ST segments which 11. Check for Trousseau and Chvostek sign
causes patient to be at risk of torsades de 12. Oral supplement – 1-1 ½ hour after meal
pointes 13. Check Ca every 4 units of blood transfusion
 Patient can be also at risk of heart failure 14. Health teaching
4. Respiratory  Limit caffeine and alcohol intake because these
 Laryngospasm, bronchospasm limit calcium reabsorption
5. GI tract  Cigarette smoking may increase urinary
 Can cause hyperactive bowel sounds excretion of calcium
6. Musculoskeletal  Reduce intake of antacid as it reduces calcium
 Muscle spasm of the extremities of face absorption
 Prone to fracture
7. Abnormal clotting Collaborative Management
 Calcium is also responsible for blood
1. IV Ca replacement
coagulation, thus decreased calcium level can
 Calcium gluconate yields 4.5 mEq/L. This is
cause abnormal blood clotting
more common because calcium chloride has
 Can cause reduction of prothrombin time
higher ionized calcium level that can cause
irritation and sloughing of tissue infiltrate

 Calcium chloride provides 13.6 mEq/L. It is Signs and Symptoms

commonly used during cardiac arrest 1. CNS
 Be cautious in administration. Rapid  Decreased ability to concentrate, changes in
administration can cause cardiac arrest resulting mental status and LOC (lethargy, confusion,
to bradycardia coma, depression, slurred speech), sometimes
 Calcium is diluted in D5 Water may cause death
 Do not use 0.9 NSS because it can inhibit  Causes muscle weakness because of reduction
calcium absorption of smooth muscle (reduce muscle tone)
2. Magnesium therapy  Reduce muscle excitability because of
3. Aluminum hydroxide, Calcium acetate, calcium suppressed myoneural junction
carbonate antacids  Hypoactive deep tendon reflex − classic sign
 To lower elevated phosphorus levels before 2. Cardiovascular
treating hypocalcemia  Arrhythmias, bradycardia, hypertension
4. Nutrition – vitamin D supplement  Changes in ECG like shortening of QT interval
and ST segment
Hypercalcemia  Fatigue because of decreased membrane
excitability especially in the heart and skeletal
• Calcium excess
muscles
• Serum Ca >10.5 mg/dL
3. Musculoskeletal – muscle weakness, bone pain
• Gate become rigid so it is hard to depolarize, meaning
4. Gastrointestinal
patient have less excitability causing hypoactive deep
 Anorexia, N/V, abdominal cramps, constipation,
tendon reflex
decreased bowel sound
• Calcitonin produced by parathyroid gland can
5. Renal
antagonize parathyroid hormone
 Polyuria, polydipsia, hypercalciuria, calculi
• If calcium is too high, parathyroid will release
 17 mg/dl or higher
calcitonin to prevent bone reabsorption causing
 Hypercalciuria because kidney try to excrete
reduction of calcium amount in the body
calcium in the urine
 Prone to kidney stone and calcification
Causes 6. Bone pain
1. Hyperparathyroidism  Patients may experience deep pain over bony
 Overgrowth of parathyroid hormone which area and bone thinning
increases release of calcium from the bone and
increases intestinal and renal absorption of
Laboratory and Diagnostic Test
calcium
1. Serum calcium level − 
2. Malignancy
2. ECG
 Bone destruction as the cancer cells try to invade
 Heart blocks and shortening of QT interval and
the bone and release parathyroid hormone like
ST segment
substance that may increase the calcium level
3. PTH levels − decreased
3. Excessive calcium administration or intake
4. Bone x-rays
4. Osteoclastic bone absorption
 If there’s a pathologic fracture
 Osteoclastic bone reabsorption is most common
5. Sulkowitch urine test
causing break down of bone and release of
 Analyze the amount of Ca in the urine and
calcium in the blood
precipitation is observed
5. Decrease renal excretion due to renal failure
 Indirect measure of calcium stored in body by
6. Diuretics
examining the excreted amount of Ca in urine
 Thiazide can cause reabsorption in the distal
6. Ultrasound of the kidney
tubules which contribute to hypercalcemia
 To check for presence of calculi
Slight elevation of the calcium level by potentiating Nursing Management

the parathyroid hormone on the kidney and 1. Early ambulation
reducing the urinary calcium excretion. A false high  Participate in active and passive range of motion
level can be caused by prolonged blood draws with 2. Monitor HR and rhythm
excessive tight tourniquets or prolonged 3. Measure I & O
dehydration. Prolonged immobilization because of 4. Repositioning
bone fracture can also cause hypercalcemia 5. Participate in active and passive ROM exercise

6. Diet • Phosphorus also has something to do with energy

 High fiber, OFI metabolism. It metabolizes carbohydrates, proteins,
7. Safety precaution and fat
8. Monitor ECG changes • It also promotes energy transfer to cell in the form of
9. Educate the use of digitalis ATP
10. Emotional support • Provide structural support to bones and teeth, and has
something to do with platelet function
1. Treat underlying cause Phosphorus Disturbances
 Chemotherapy for malignancy Hypophosphatemia
 Partial parathyroidectomy • Phosphorus deficiency
2. Hydration • Serum Phosphorus < 2.5 mg/dL,
 Encourages diuresis • If it is less than 1mg/dl, the body cannot support its
 Saline solution is commonly used energy needs, hence may lead organ failure
3. Restrict dietary Ca intake  A decrease in phosphorus can affect the
4. Pharmacologic therapy musculoskeletal, CNS, and cardiac system
Loop diuretics • Since phosphorus requires a high energy (ATP) s/s
 Furosemide/Lasix which promote calcium may be related to energy store
excretion and inhibit calcium absorption
 Thiazide is not used because it can inhibit Causes
calcium excretion 1. Excess loss of phosphorus in urine –
Calcitonin hyperparathyroidism
 Inhibit osteoclast and lower serum calcium level  Too much parathyroid hormone
 Used for patient with heart disease or renal 2. Reduce GI absorption
failure  Alcohol, medication, poor diet (malnutrition,
 Reduce bone reabsorption starvation, anorexia nervosa) may impair the
 Increase calcium and phosphorus in bone absorption or slow down the metabolism
 Promote urinary excretion of calcium and 3. Hyperglycemia (DM)
phosphorus  Insulin will extract glucose and phosphorus from
blood into the cell, hence, phosphorus in the
Corticosteroids
blood will fall
 Reduce intestinal calcium absorption
4. Hyperventilation (respiratory alkalosis)
 Block bone resorption and block absorption of
 Causes the extracellular carbon dioxide in the
calcium from the GIT
blood to get out of the lungs to be well ventilated
5. Hemodialysis or peritoneal dialysis
and the intracellular carbon dioxide in the cell will
 To excrete calcium
diffuse out of the cell to increase the pH in the
6. Plicamycin
cell which may stimulate glycolysis which
 Chemotherapeutic drug that can decrease bone
requires phosphate
absorption of calcium
5. Renal excretion – use of diuretics
6. Other conditions
PHOSPHORUS  Anxiety, sepsis, heat stroke
• Intracellular ion, negatively charged
• 85% of the phosphorus combines with calcium to form Signs and Symptoms
hydroxyapatite to make bone harder 1. Musculoskeletal
• 1% is in the extracellular fluid and 14% is in the  Since there’s a lack of energy, patients may have
intracellular fluid muscle weakness, weak hand grasp, slurred
• Phosphorus is reabsorbed in the jejunum speech, osteomalacia or bone pain
• Normal range is 2.5 – 4.5 mg/Dl 2. CNS
 May alter the mental status of the patient causing
Roles of Phosphorus irritability, apprehension, confusion, seizure
• For cell membrane integrity  Without phosphorus, it cannot make enough
• Important for muscle and neurologic function energy resulting to malfunctioning of the CNS
• Forms a compound in RBC which facilitates the 3. Cardiovascular
release of oxygen from hemoglobin and maintenance  Low cardiac activity due to decreased energy
of acid-base balance store resulting to hypotension and CO which
may lead to cardiomyopathy

4. Respiratory failure from weak respiratory muscle, 3. Radiation treatment for cancer
poor contractions of diaphragm, and shallow 4. Excessive intake of phosphorus
respiration  Orally or phosphate-based laxative in enema
5. Hematologic effects 5. Tumor lysis syndrome
 RBCs, WBCs, platelet dysfunction which causes  Phosphorus is stored intracellularly, however,
mild GI bleeding when the cells die, the phosphorus are spilled in
6. Hypercalcemia symptoms the bloodstream
 Hyperactive DTRs  Cancer treatment – more cells die all at once
6. Acid-base imbalances (respiratory/metabolic
Diagnostic Studies acidosis)
 Carbon dioxide accumulation in the blood
1. Serum phosphorus level <2.5 mEq/L
 A person does not breath effectively
2. Skeletal X-rays – osteomalacia and rickets
 Carbon dioxide may diffuse into the cell, dissolve
3. Abnormal electrolytes – urine Mg, Ca
in water and form carbonic acid which may break
4. Alkaline phosphatase – osteoblastic activity
into proton and bicarbonate ion – lower pH which
may inhibit glycolysis
1. Correction and replacement of Phosphorus
Signs and Symptoms
 Through diet or parenteral route
1. Excitability can be seen in these patients
 In case of malnutrition, gradually increase caloric
 Neurons are excitable causing tetany, (+)
intake over several days to prevent refeeding
Chvostek and Trousseau signs, tingling around
syndrome
the mouth, decreased mental status, seizures
2. Observe for hypocalcemia
2. Calcifications
 Tetany and calcification in tissues
 Binding of calcium and phosphate to form
3. Add PO4 (phosphorus) in TPN
calcium (bone-like crystal) phosphate, deposits
in organ like heart, kidney, lungs, and soft tissue
Nursing Management 3. CV − Arrhythmia, tachycardia
1. Assess VS, s/s of apprehension, confusion, change 4. Decreased urine output
in LOC, Neuromuscular 5. Anorexia, N/V
2. Respiratory assessment 6. Muscle weakness, spasm, cramp, hyperreflexia
 Prevent hyperventilation 7. Hypocalcemia
3. Institute seizure precautions 8. Hyperactive reflexes
 Keep the bed in the lowest position, wheels are
locked, raise the side rales
4. Preventing infection since may alter granulocytes
1. Serum phosphorus level > 4.5 mEq/L (elevated)
 Follow strict sterile technique in changing
2. Decreased serum Ca level
dressing if any
3. Skeletal X-ray studies
 Observe signs of infection
4. Increased BUN and creatinine level
5. Introduce TPN gradually
 Reflect the worsening of kidney function
 To prevent rapid shift of PO4 into the cells
5. Decreased parathyroid hormone
6. Check IV patency and slow IV infusions
6. ECG changes
7. Measure I & O
 Prolonged QT interval
Hyperphosphatemia
• Phosphorus excess
1. Reduce food intake containing phosphorus
• Serum phosphorus > 4.5 mEq/L
2. Vit. D preparations (calcitriol)
3. Phosphate binding antacids (amphojel) with meals
Causes  Effective but can cause bone and CNS toxicity
1. Renal failure / injury with long-term use
 Common; lack of ability to excrete 4. IV and loop diuretic for healthy kidney
2. Hypoparathyroidism  To increase excretion called the “first diuresis”
 PT cannot produce enough hormone causing
reduction in calcium and increased reabsorption
Nursing Management
of phosphorus (patients with parathyroid
1. Low phosphorus diet
removal)

 Avoid foods high in phosphorus (hard cheese, 5. Low Na intake

cream, nuts, whole grains, dried foods, dried  Patients with diabetic ketoacidosis or cystic
vegetables) fibrosis
 No dairy products, soda, and meat 6. Metabolic alkalosis
2. Avoid phosphate containing substances
 Laxatives, enemas that contain phosphate Signs and Symptoms
3. WOF signs of hypocalcemia
1. Slow, shallow respirations
4. Measure I & O accurately
2. Neurological
5. Institute seizure precautions
 Hyperactivity of the muscles, tetany, DTRs,
6. Prepare for dialysis
hypertonicity, muscle cramps, twitching,
7. Keep flow sheet of daily lab results
weakness, tremors, and agitation
 BUN, creatinine, calcium and phosphorus
3. Cardiac arrhythmias – hypokalemia, hypotension
4. Seizure – hyponatremia
CHLORIDE 5. Metabolic alkalosis
• Abundant anion in the extracellular fluids; moves in  High pH and accumulation of HCO3 in ECF
and out with sodium and potassium
• Rich in CSF, bile, gastric, and pancreatic fluid Laboratory and Diagnostic Test
• Aldosterone secretions may increase sodium and
1. Electrolytes
chloride reabsorption because of the electrical
  serum chloride, sodium, and potassium
attraction
2. ABG analysis
 Sodium – positively charged
 Elevation of bicarbonate, increase pH
 Chloride – negatively charged
3. ECG
• High concentration of Cl is usually seen in canned
 Presence of arrhythmia
goods, egg, tomato, celery, lettuce, olives
• Chloride is absorbed in the intestine and mostly
produced in the stomach in the form of hydrochloric Collaborative Management
acid 1. IV fluid infusion
• Normal range is 97-107 mEq/L  0.9% NS, 0.45% NaCl (oral chloride replacement
through salty broth)
2. Discontinue diuretics if any
Roles of Cl
3. Ammonium chloride
• Maintains osmotic pressure and help gastric mucosal
 An acidifying IV agent to treat metabolic alkalosis
cells produce hydrochloric acid, assists in regulating
and effect will last for 3 days
acid-base balance, helps transport carbon dioxide to
 Should NOT give to patients with hepatic
RBC
diseases and renal impairment since ammonium
may metabolize in the liver
Chloride Disturbances
Hypochloremia Nursing Management
• Serum chloride <97 mEq/L 1. Monitor VS − RR and cardiac rhythm
• Usually, may occur with hyponatremia in which there’s 2. Monitor LOC and muscle strength
an elevated bicarbonate because of the decreased 3. Provide oral foods
chloride. The kidney retained bicarbonate, then the  Such as tomato juice, salty broth
level of bicarbonate is increased in the extracellular 4. Never give bottled water
fluid, hence the term hyperchloremic metabolic 5. Measure I & O
alkalosis – the chloride and bicarbonate have inverse  Especially if vomiting, with GI drainage
relationship 6. Provide safe and quiet environment
7. Institute seizure precaution
Causes
1. GI losses Hyperchloremia
 Prolonged vomiting, diarrhea, gastric surgery, • Serum chloride >107 mEq/L
suctioning, tube drainage like ileostomy • Sodium elevation, bicarbonate deficit; may be called
2. Severe diaphoresis as “metabolic acidosis”
3. Burns
4. Medications
Causes
 Laxatives, diuretics, corticosteroids, and
bicarbonate 1. Iatrogenic

 Relating to illness caused by medical Similar (If one is increase, the other will also increase)
examination or treatment • Calcium – Vitamin D
• Magnesium – Calcium
 Anastomosis of ureter or intestine • Magnesium – Potassium
 Administration of sodium chloride • Sodium – Chloride
2. Dehydration
 Increase water loss cause increase chloride and Normal Values of Electrolytes
sodium
Sodium 135 – 145 mEq/L
3. Conditions related to metabolic acidosis
Potassium 3.5 – 5.5 mEq/L
 Renal failure, diabetes insipidus, hypernatremia
4. Medications Calcium 8.5 – 10.2 mEq/L
 Kayexalate and carbonic anhydrase inhibitors Ionized Calcium 100 – 109

(acetazolamide) can cause sodium retention by Magnesium 4.5 – 5.1 mg/dL
increasing bicarbonate ion loss Phosphate 2.5 – 4.5 mg/dL
Chloride 97 – 107 mEq/L (serum)
Signs and Symptoms
Same as in hypervolemia and hypernatremia Acid–Base Balance
1. Respiratory Body acid are formed as end products of protein, carbs,
 Tachypnea, Kussmaul respiration, dyspnea and fat metabolism
2. CNS
 Diminished cognitive ability, lethargy, coma Acid
3. Cardiac arrhythmia, CO, tachycardia, HTN • Any substance that ionizes in water and forms
4. Pitting edema – fluid retention hydrogen ions (carbonic acid)
5. Weakness • Consist of molecules that release hydrogen ions such
6. Thirst and dehydration as the carbonic acid
7. Hypertension • Body acid exist in 2 forms:
8. High sodium level and fluid retention – pitting edema
Volatile − eliminated as carbon dioxide
Non-volatile − eliminated by the kidney
1. Electrolytes −  chloride and Na Base
2. Increased urine chloride excretion • Any substance that can bind or accept hydrogen ions
3. ABG –  pH and HCO3 (bicarbonate)
• Lungs, kidneys, and bone are the major organs
Collaborative Management involved in regulating acid-base balance
1. Hypotonic IV solution
 LR to convert lactate to bicarbonate Hydrogen Ion and pH
2. IV Sodium bicarbonate
Hydrogen
 Increases level of HCO3 leading to renal
• Maintains membrane integrity and speed the
excretion of Cl ions
enzymatic reactions
3. Diuretics
• Slight changes in the amount of hydrogen and
4. NaCl and fluids restriction
changes in pH can alter the biologic process in cells
and tissue
Nursing Management
• Hydrogen ions in the body are very small
1. Monitor VS, cardiac and respiratory rhythm,
neurologic status pH
2. Restrict fluid, Na and chloride
• Measures the hydrogen ion concentration and
3. Measure I & O
indication of the blood’s acidity and alkalinity
4. Document changes
• Plasma pH is an indicator of hydrogen ion
5. Provide safe, quiet environment to prevent injury
concentration
• Homeostasis mechanism keeps the pH within the
Electrolyte Relationships normal range
Inverse (Opposite – if one is increase, the other one will • Body fluid pH = 7.35-7.45
decrease, and vice versa)
• Sodium – Potassium
• Calcium – Phosphate
• Chloride – Bicarbonate
• Magnesium – Phosphate

On the picture, a decrease in pH, expect an elevation of

hydrogen concentration
Greater the H+ = more acidic = lower pH  Acidosis

Lesser the H+ = more alkaline = higher pH  Alkalosis
Mechanism of Regulation
The photo above shows the 20 parts bicarbonates and
Buffer System 1 part of carbonic acid
• First line of defense o Normal pH: 7.35 – 7.45
• Prevent changes in pH of body fluids by removing or o Acidosis: < 7.35
absorbing hydrogen (H+) o Alkalosis: > 7.45
• Located in the intracellular fluid and extracellular fluid o Respiratory component pertains to lungs
compartment and function in different rate o Metabolic component pertains to kidneys
• Phosphate which buffer and react with either acid or
base to form compound which slightly alter the pH
Respiratory System
 Effective in renal tubules where phosphate exists
in greater concentration • 2nd line of defense
• Hemoglobin binds with hydrogen to act as buffer and • Partial pressure of the arterial if carbon dioxide which
protein bind with the acid-base to neutralize reflect the adequacy of ventilation by the lugs; and
• Phosphate, hemoglobin, and protein are most bicarbonate level which reflect the activity of the
important intracellular buffer and 1st line of defense kidney in retaining or excreting bicarbonate
• Buffer system acts immediately to protect tissue and • Can make changes in seconds to minute to change in
cell pH
• Buffers combined with the imbalance acid or base to • If there’s  amount of carbonic acid, it may blow off
prevent changes of pH in the body fluids by removing carbon dioxide and leaving the water
or absorbing the hydrogen • The lungs compensate for changes in pH by
increasing or decreasing the concentration of CO 2
(carbonic acid) by changing ventilation
Carbonic Acid – Bicarbonate System
 Through hypoventilation or hyperventilation as
− Relationship between bicarbonate (HCO3) and needed to regulate excretion or retention of acid
carbonic acid is expressed as ratio 20:1 which within minutes
determines H concentrations of body fluids  Like a seesaw,  RR = in carbon dioxide
− Normally, 20 parts of bicarbonate = 1 part of  If there’s  in carbon dioxide in partial arterial
carbonic acid pressure =  RR
− If 20:1 was altered, the pH change   carbon dioxide =  level of carbonic acid leads
− Carbon dioxide is a potential acid when dissolved to  in pH
in water and becomes carbonic acid • Metabolic acidosis, RR  cause elimination of PaCO2
− Carbonic acid secretion is controlled by the lungs (to reduce the acid load)
o If CO2  then carbonic acid also  and vice • Metabolic alkalosis, RR  causing CO2 to retain
versa • Renal and respiratory adjustment to changes in pH
− Bicarbonate secretion is controlled by the kidneys known as compensation
• Metabolic disturbances – the primary cause of acid-
base imbalance. Therefore, the lungs will try to
compensate
• Lack of bicarbonate causes acidosis then the lungs 
the rate of breathing which blow off carbon dioxide
and health raise the pH to normal

• Excess of bicarbonate causes alkalosis then the lungs • Dibasic phosphate (HPO4) and ammonia (NH3) can
 the rate of breathing which retain carbon dioxide and attach H+ ion and excreted in the urine
health to lower the pH • In respiratory acidosis, the kidneys excrete hydrogen
(H+) and conserve bicarbonate (HCO3)
Human blood pH is 7.4 • In respiratory alkalosis, the kidneys retain hydrogen
and excrete bicarbonate
Effect of pH to CNS
Acidosis
• pH falls below 7.35
• Major effect: CNS malfunction − can become
comatose
• In normal conditions, blood pH is between 7.35 and Alkalosis

7.45 • pH increases above 7.45
• To maintain constant the blood pH, two organs play • Major effect: hyperexcitability of the nervous system
an essential role:
Lungs: breathing in removing carbon dioxide (CO2) Respiratory Component
has an effect on the blood pH Normal Values
Kidneys: eliminating protons (H+) and retaining
pH 7.35 – 7.45
bicarbonate (HCO3) has an effect on the blood pH
Partial Arterial Oxygen 80 – 100 mmHg
Partial Arterial Carbon Dioxide 35 – 45 mmHg
Kidneys and Lungs contribute to the maintenance of
acid-base balance of the body, but for various Bicarbonate 22 – 26 mEq/L
reasons, this balance can be broken (ACIDOSIS and

ALKALOSIS)
Respiratory Acidosis
•  PCO2 (> 45 mmHg)
Renal Buffering •  Carbonic acid
• 3rd line of defense •  H+ = low pH (< 7.35)
• Kidney regulates the bicarbonate level in the •  Bicarbonate − where the kidney tries to compensate
extracellular fluid in the dropping of pH
• Can reabsorb bicarbonate or regenerate new
bicarbonate from carbon dioxide and water Characteristic of Respiratory Acidosis
• Will take days or hours to restore the normal hydrogen
1. Alveolar hypoventilation (O/PCO2)
concentration
 pulmonary system is unable to rid body of
• Renal system tries to compensate by producing more
enough carbon dioxide to maintain healthy pH
acid or more alkaline urine to maintain 20:1, when
balance
ratio is altered, changes may occur in pH
 Decrease in oxygen, hemoglobin may pick up
• If the blood contains too much acid, the pH drops and
hydrogen and CO2 and decrease gas exchange
the kidney tries to reabsorb bicarbonate
 Ex: COPD, pneumonia, pulmonary edema
• Kidney also excrete hydrogen along with phosphate
2. Hypercapnia
or ammonia. Therefore, more bicarbonate will be
 There’s elevation in partial arterial carbon
formed in the distal renal tubules and eventually will
dioxide > 45 mm
retain in the body and will rise to make a more normal
 Elevation in PCO2 everything is elevated but
level of pH which may result to elevation of pH
there’s low pH
• Urine tends to be acidic because the body tries to
 Increased bicarbonate as kidney tries to
produce slightly more acid than the base. So, urine
compensate for drop in pH
become acidic than normal
• In metabolic acidosis, RR  causes greater elimination
of carbon dioxide to reduce the acid load Risk Factors for Respiratory Acidosis
• In metabolic alkalosis, RR  causing the retention of 1. Acute lung condition
carbon dioxide  Impair alveolar gas exchange
• The distal renal tubules regulate acid-base balance by  The problem can decrease partial arterial
secreting hydrogen (H+) into the urine and oxygen causing a decrease in pH and elevation
reabsorbing HCO3 into the plasma of PCO2

 Examples: pneumonia, pulmonary edema, 1.  PR and cardiac output

aspiration of foreign bodies, near drowning,  Patient may have hypoxemia because there’s
atelectasis, acute respiratory distress syndrome decrease in partial arterial oxygen
2. Chronic lung disease  Potassium in cell is shifted out to the
 Asthma, Emphysema bloodstream which may cause hyperglycemia
3. Overdose of narcotics or sedatives  Hydrogen may move from extracellular fluid into
 Because of depression that may impair gas an intracellular fluid compartment
exchange, there will be a high risk for acidosis 2. Arrhythmia
4. Depression of respiratory center 3. Hyperkalemia
 Brain injury, tumor – affect respiratory center and 4. Ventricular fibrillation
impair respiratory muscle that fail to respond 5. Expect for acidic urine
 Drugs  increase in partial arterial carbon dioxide
5. Paralysis of respiratory muscles (myasthenia gravis) stimulates kidney to conserve bicarbonate and
6. Disorder of the chest wall sodium in order to excrete hydrogen, some in the
 Kyphoscoliosis form of ammonia
 Broken ribs
Manifestations of Respiratory Acidosis

CNS
Carbon dioxide and hydrogen cause cerebral blood
vessel to dilate which increase blood flow to the brain
resulting to cerebral edema and depress central
nervous system activity
1.  LOC
2. Confusion
3. Lethargy, Restlessness
4. Convulsion
5. Coma When hypoventilation causes hypercapnia, blood pH falls. If this state persists,
respiratory acidosis results. Compensatory mechanisms can be initiated to return the
6. Headache pH to normal.
8. Diaphoresis Note:
9. Flush skin Respiratory Acidosis – increase BP
10. Increase intracranial pressure Respiratory Alkalosis – decrease BP
Neuromuscular
Signs and Symptoms of Respiratory Acidosis and
1. Depressed DTRs
Alkalosis
2. Muscle twitching and tremors
Respiratory
1. Rapid shallow RR
2. Increase amount CO2 and hydrogen that stimulate
respiratory center to increase RR but is shallow
 Increase RR can expel more CO2 and help
reduce CO2 level in blood and tissues
3. Patient may have a rapid shallow breathing, increase
RR and gradually become depressed
Cardiovascular
Lack of oxygen causes anaerobic production of lactic Diagnostic Studies to Check Blood Gases
acids depressing both neurologic and cardiac function 1. ABG
such as causing elevations of pulse rate. Presentation  Increase in pH
of ventricular fibrillation can cause respiratory acidosis  Expects there’s a decrease in pH less than 7.35
to patients receiving anesthesia. 2. Partial arterial greater than 45 ml
3. Chest X-ray

 Helps pinpoint the causes in patients with Characteristic of Respiratory Alkalosis usually results
pneumonia, COPD, pneumothorax, pulmonary from
edema 1. Alveolar hyperventilation ( O2)
4. Monitoring the serum electrolyte level 2. Hypocapnia – decrease in carbon dioxide
 Especially the potassium as it leaves the cell  In order to decrease the elimination of CO2
causing potassium elevation on the blood  pH >7.45 may cause an increase in RR causing
5. ECG lung to eliminate or blow off carbon dioxide
 For any cardiac involvement and screening for  Carbon dioxide – acid and eliminating it can
drug overdose cause a decrease in PCO2 along with the
increase in pH resulting to alkalosis
Management
1. Correct the underlying conditions Risk Factors
2. Supplement oxygen 1. Hyperventilation – anxiety, panic attack
3. Pulmonary hygiene measures 2. Hypermetabolic states
 Clear the respiratory mucous in the form of chest  Fever, liver failure, thyrotoxicosis
physiotherapy through coughing and breathing 3. Hypoxemia
exercise, incentive spirometer  High altitudes cause patient to breathe faster
4. Adequate hydration and deeper such as patients with pulmonary
 At least 2-3 L a day to keep mucous membrane disease, severe anemia, pulmonary embolism
moist therefore facilitate removal of secretions and hypotension
5. Pharmacologic agents 4. Over ventilation of mechanical ventilator causes the
 Bronchodilator lungs to blow more CO2 and a pulse rate greater than
 Thrombolytics for pulmonary embolism 100bpm
 Antibiotic and pain management to control pain 5. Hypoxia
and promote effective breathing 6. Salicylate overdose
6. Mechanical ventilation  Causes early sign of hyperventilation
Nursing Management Manifestations

1. Monitor vital signs, evaluate cardiac rhythm- CNS
 Respiratory acidosis may lead to cardiac arrest A decrease in PCO2 may increase cerebral and
2. CPT and encourage DBE (Deep Breathing Exercise) peripheral hypoxia from vasoconstriction therefore
3. Positioning patients may become
 Semi fowlers to facilitate expansion of the chest
1. Lightheadedness
wall
2. Difficulty concentrating
4. Diet – increase caloric intake
3. Anxiety
5. Bedrest
4. Restlessness
6. Proper use of bronchodilator agents
5. Seizure
7. Institute measures to prevent ventilator associated
6. Coma
pneumonia
7. Anxiousness
8. Monitor ABG level, pulse oximetry or serum
8. Dizziness due to reduction in cerebral blood flow
electrolyte levels
9. Diaphoresis
The oxygen saturation of patients with respiratory Neuromuscular

acidosis is increasing because of a decreased pH It inhibits calcium which causes increased nerve
level. The tendency of hemoglobin is to pick up the excitability and muscle contraction
hydrogen and carbon dioxide and release oxygen. 1. Tingling of the extremities
2. Carpopedal spasm
Respiratory Alkalosis 3. Hyperreflexia
4. Muscle weakness
•  PCO2 (< 35 mmHg)
•  Carbonic acid
•  H+ = high pH (>7.45) Respiratory
•  Bicarbonate When hypocapnia (reduced carbon dioxide in the blood,
deep and rapid breathing or hyperventilation) lasts for 6

hours then the kidneys increase the absorption of Nursing Management

bicarbonate and reduce the excretion of hydrogen 1. Anxiety reducing technique – promote relaxations
1. Dyspnea 2. Monitor VS, ABG and serum electrolytes
2. Decrease RR 3. Check ventilators setting frequently − if any
3. Cheyne-stokes respiration − alternating period of 4. Provide bed rest periods
apnea and hyperventilation 5. Stay with the patient
 Listen to the patient to lessen anxiety
Cardiovascular 6. Provide quiet and calm environment
Because of the low partial arterial carbon dioxide, it 7. Institute safety measures and seizure precaution as
stimulates the carotid and aortic body and medulla needed
causing an increased heart rate without an increase in 8. Document all care when charting
blood pressure
1. Tachycardia – most common Metabolic Acidosis
2. Angina •  H+ = low pH (<7.35) → acidosis
3. ECG changes •  Bicarbonate (HCO3)
 Prolonged PR interval, flattened P wave and • Heavier breathing causes  PCO2
prominent U wave • Secrete excess H+ in the renal tubules and ions
 This is because of the shifting of potassium into buffered by phosphate or ammonia and excreted in
the cell (causes hypokalemia) urine
• Respiratory compensation may occur
(hyperventilation or Kussmaul respirations) but it isn’t
enough to correct the imbalance
• Na and HCO3 are absorbed in the renal tubules
• Patient may have hyperkalemia (K moves out the cell)
• In over production of ketone acid, there is gaining of
acid but loss of base from the plasma. It may use up
its glucose supplies and grow on its fat store for
energy and convert this fatty acid to ketone bodies
• Lactic acidosis can worsen the metabolic acidosis that
can be secondary to heart failure, shock, or even
patients with pulmonary diseases
 Lactic acidosis is caused by poor perfusion or
hypoxemia
Diagnostic Test Signs and Symptoms of Metabolic Acidosis and

1. ABG analysis Alkalosis
 Serums and electrolytes show a decrease in
potassium characterized by a decreased LOC
and decreased Ca level
2. ECG
 Prolonged PR interval, flattened P wave and
Prominent U wave
Management
1. Treat underlying conditions
2. O2 supplement for hypoxia
3. Breathe into a paper bag or into cupped hands
 To counteract hyperventilation and allow the
CO2 to accumulate
4. Sedatives for anxiety attack Risk Factors
5. Adjust mechanical ventilator 1. Renal failure
 Refer to a respiratory therapist to lower the tidal  The kidneys are unable to excrete acid. So, the
volume and number of bpm
ions are buffered by phosphate or ammonia,
then excreted in the urine in the form of weak
acid

2. Overproduction of ketone bodies – DKA, severe  There’s an increase in respiratory rate, and
malnutrition patients may have Kussmaul respirations – rapid
 DKA – there is a gain in acid and loss in base depth breathing but fruity breath odor
from the plasma. It may use up the glucose  The odor stems from catabolism from the fats
supply, use the stored fat for energy, then and excretion of acetone through the lungs. This
converting the fatty acids into ketone bodies is a compensatory mechanism
3. Conditions that decrease bicarbonate
 Prolonged diarrhea, intestinal malabsorption GI
 Patients with ostomy or urinary diversions 1. Anorexia
 Use of diuretics inhibits the secretions of acid 2. Nausea and vomiting
4. Excessive infusion of chloride-containing IV fluids 3. Abdominal discomfort and diarrhea
(NaCl), or even parenteral nutrition without
bicarbonate
5. Patients who are chronic alcoholics
6. Poor dietary or carbohydrates intake
Manifestations
CNS –
Excess hydrogen may alter the normal balance of
calcium, sodium, potassium leading to reduced
excitability of nerve cells that may depress the CNS.
With regards to peripheral vasodilation, the patients
may have warm, dry, and cold clammy skin, especially
if shock develop.
1. Lethargy
2. Confusion Diagnostic Test for ABG
3. Alter LOC 1. Check serum potassium level
4. Coma 2. Blood glucose level – for any changes in glucose
5. Headache 3. Ketone level
4. Plasma lactate level – elevated
Neuro  Because of lactic acidosis
1. Decrease DTR  Since the tissue is hypoxic, the cell is forced to
2. Weakness switch to anaerobic metabolism and more lactate
3. Numbness is produced
4. Flaccid paralysis – weakness in muscle tone  When the lactate accumulates in the body faster
than it can be metabolized, then lactate acidosis
Renal may occur
1. Acidic urine 5. ECG monitoring
 Because the phosphate and ammonia are  Changes because of the hyperkalemia
secreted in the urine
Drug Therapy
Cardiovascular 1. Rapid-acting insulin
Release of potassium from the cell that cause a sign of  To reverse the diabetic ketoacidosis and drive
hyperkalemia the potassium back to the cell
1. Decrease PR, BP and CO 2. NaHCO3 (sodium bicarbonate)
 Because of decrease in pH  To neutralize the blood acidity in order to
2. Bradycardia decrease the bicarbonate and pH level
3. Arrhythmia 3. Antibiotic – to treat infection
4. Changes in the ECG 4. Anti-diarrhea – to induce bicarbonate loss
 Tall T wave, prolonged PR interval and wide 5. Acidosis and Dopamine
QRS complex  If administering dopamine to a patient and it is
not raising the blood pressure, try to investigate
Respiratory pH level of the patient, because below 7.1 level
1. Hyperventilation of pH may cause resistance to vasopressor
therapy

 Correct first the pH level, for the dopamine to process is known as the contraction
become effective alkalosis
3. Excessive adrenal corticoid hormones
Management  Cushing’s Syndrome − causes retention of
sodium and chloride, and the loss of hydrogen
1. Fluid replacement
and potassium in the urine
2. Monitor K level
 Hyperaldosteronism
 Potassium level may drop if the acidosis has
4. Excessive bicarbonate intake
been corrected and it may result in hypokalemia
 Antacids, parenteral NaHCO3, chronic use of
3. Dialysis – renal failure
milk and calcium carbonate
5. Renal artery stenosis
Nursing Management
 Usually in patients with kidney diseases
1. Monitor VS and assess cardiac rhythm 6. Hypocalcemia and hypochloremia
2. Measure I & O
3. Maintain patent IV access
Manifestations
4. Give vasopressor and antibiotics as prescribed
CNS
5. Prepare mechanical ventilator or dialysis as required
1. Lethargy
6. Flush IV line with NSS before and after giving
2. Diminished LOC
NaHCO3
3. Irritability, disorientation, aggressiveness
7. Reposition and safety precaution
 To promote chest expansion and ease in
breathing Neurologic Excitability
8. Monitor blood glucose The nerves are more permeable to sodium because of
the decrease in hydrogen and calcium. The movement
of sodium into the cell will stimulate a neural impulse
Metabolic Alkalosis
that may produce overexcitability of the peripheral
• Presence of more base than acid that cause increase
system and CNS.
in pH level and bicarbonate
1. Muscle twitching
• If untreated, can lead to arrythmia, coma or death
2. Tetany
• Metabolic Component
3. Hypokalemia (loss of reflexes)
•  H+ = high pH (>7.45)
 The hydrogen of the cell may move out to the
•  Bicarbonate (HCO3)
extracellular whereas the potassium move inside
• Lighter breathing causes PCO2
4. Numbness
• Hypokalemia – K move into the cells from blood
Renal
Risk Factors
Because of the alkaline urine, the glomerulus can no
1. Excessive acid losses
longer reabsorb excess amounts of bicarbonate and is
 Vomiting because of the loss of hydrochloric acid
being excreted in the urine while the hydrogen ions are
 Nasogastric suction because of the loss of
retained
hydrogen and chloride ions
1. Polyuria
 Pyloric stenosis in children may cause a loss of
 In order to maintain an electrochemical balance,
gastric juices
so the kidney may excrete excess sodium,
2. Excessive use of K-losing diuretics (Thiazide,
water, and bicarbonate
Furosemide)
2. Thirst, and dry mucous membrane
 Aside from losing K, it may also cause a loss in
 Sign of hypovolemia
hydrogen and chloride ions from the kidney
 Hypokalemia may produce alkalosis in 2 ways:
o The kidneys excrete hydrogen ions as they Cardiovascular
try to conserve K 1. K, Ca, arrhythmia, BP, changes in ECG, atrial
o The cellular potassium may move out of the tachycardia
cell as the hydrogen moves inside in an  As a compensatory action of the lungs from
attempt to maintain a near normal serum respiratory depression
level. With the fluid loss from diuresis, the 2. Ventricular disturbances
kidney attempts to conserve sodium and  Because of the decrease in potassium
water, and for the sodium to be reabsorbed, 3. Premature ventricular contractions, and presence of
the hydrogen ion must be excreted. This U waves in ECG, may sometimes cause death

Respiratory 4. Monitor I&O

1. Hypoventilation 5. Maintain IV patency
2. Slow & shallow respiration and depth 6. Administer diluted KCl with an infusion device
 May depress the chemoreceptors in the brain (infusion pump)
causing RR and elevation of partial arterial CO2 7. Institute seizure precautions
 If prolonged, it can lead to hypoxemia 8. Irrigate and NG tube with NSS
 To prevent loss of gastric electrolytes
Gastrointestinal
ABG Interpretation
1. Anorexia, N/V
 Because of the decrease in K • Performed to evaluate the client’s acid-base balance
and oxygenation
• Arterial blood provides a true reflection of gas
exchange in the pulmonary system. Though, there are
times that venous blood is used but mostly it’s the
arterial
Normal Values
pH 7.35 – 7.45
Partial Arterial Oxygen 80 – 100 mmHg
Partial Arterial Carbon Dioxide 35 – 45 mmHg
Bicarbonate 22 – 26 mEq/L
Base Excess -2 to + 2 mEq/L
When base is accumulated or acid is lost, the serum pH elevates. If this state persists,
metabolic alkalosis results. Compensatory mechanisms will usually be initiated to
attempt to return pH toward normal.
Acid-Base Imbalances
Diagnostic Studies
1. Project the ABG analysis
2. Monitor for the serum electrolytes (Ca,
Potassium chloride, bicarbonate) – expect elevation of
bicarbonate but there will be a decrease in K, Ca, and
chloride
3. ECG changes – diminished T-wave, or it could
merge with the P-wave
Management
1. Correct underlying cause
2. Restore fluid volume by administering NaCl solution
3. KCl replacement if hypokalemia occurs
4. Discontinue diuretics
5. H2 receptor antagonists – Cimetidine
 Reduce the production of gastric acid
6. Antiemetics if there’s a presence of n/v Note the mnemonic ROME:
7. Carbonic anhydrase inhibitor Respiratory is always Opposite
 Very useful in treating metabolic alkalosis in
• If there is an increase in pH, expect a decrease in
patients who cannot tolerate rapid volume
PCO2 (Partial Arterial Carbon Dioxide) = Alkalosis
expansion especially in patients who have heart
• If there is a decrease in pH, expect an increase in
failure
PCO2 (Partial Arterial Carbon Dioxide) = Acidosis
8. Acetazolamide
 Inhibits calcium and increase the renal excretion
Metabolic is Equal (similar)
of bicarbonate
• Increase pH then, HCO3 increases = Alkalosis
• Decrease in pH then, HCO3 decreases = Acidosis
Nursing Management
1. Monitor VS, cardiac rhythm and respiratory system
2. Assess LOC
3. Administer oxygen – treat hypoxemia

ACID  pH: 7.35 – 7.45  BASE Compensation Analysis

BASE  PCO2: 35 – 45  ACID Fully Compensated
ACID  HCO3: 22 – 26  BASE If pH is NORMAL, PaCO2 and HCO3 are both
abnormal
PaO2 (Partial Arterial Oxygen): 80 – 100 mm Hg
 − hypoxic Partially Compensated
 − hyperventilation If pH is ABNORMAL, PaCO2 and HCO3 are both
abnormal
Steps in ABGs Interpretation
Uncompensated
Step 1: Assess the pH
If pH is ABNORMAL, PaCO2 or HCO3 is normal but
a. If pH below 7.35 = acidosis
the other is abnormal
b. If pH above 7.45 = alkalosis
Step 2: Assess the PaCO2 level (pH opposite with Example of ABG Analysis
PaCO2) • pH – 7.2
a. PaCO2 RR = acidosis • PaCO2 – 50 mmHg
b. PaCO2 RR = alkalosis • HCO3 – 24
Step 3: Assess HCO3 value (pH = HCO3) Analysis: Uncompensated

Respiratory Acidosis
a. If below 22 = metabolic acidosis
b. If above 26 = metabolic alkalosis
Step 4: Assess for evidence of COMPENSATION

a. Respiratory acidosis: pH < 7.35
PaCO2 > 45 mmHg
If: HCO3 is above 26 mEq/L = kidneys maintaining
bicarbonate to minimize acidosis
= Renal Compensation
b. Respiratory alkalosis: pH > 7.45

PaCO2 < 35 mmHg
If: HCO3 is below 22 mEq/L = kidneys excreting
bicarbonate to minimize alkalosis
= Renal Compensation
c. Metabolic acidosis: pH < 7.35

HCO3 < 22 mEq/L
If: PaCO2 is below 35 mmHg = CO2 being “blown off”
to minimize acidosis
= Respiratory Compensation
d. Metabolic alkalosis: pH > 7.45

HCO3 > 26 mEq/L
If: PaCO2 is above 45 mmHg = CO2 being retained to
compensate for excess base
= Respiratory Compensation

URINARY AND RENAL DISORDERS
The primary purpose of renal and urinary system is to 11. Secretions of prostaglandin
maintain the body’s state of homeostasis by carefully
regulating fluid and electrolytes, removing wastes, and Structure of the Kidney
providing other functions
Capsule – a thin smooth layer of fibrous membrane that
covers the surface of the kidney
Kidney
Cortex – outer layer of the kidney
Main Function of Kidney Medulla – inner layer, consist of pyramids
Maintain Stable Internal Environment for Optimal Cell Pyramids – a triangular form that extends into the
and Tissue Metabolism renal pelvis which contains the loop of Henle and
• Balances the solute and water transport through collecting ducts
regulating the volume and composition of the Renal column – extensions of the cortex between the
extracellular fluid by filtration of the blood pyramid to the renal pelvis
 The filtered solute then can be reabsorbed or Papillae – apices of the pyramids through which the
secreted urine passes to enter the calyces
• Regulates acid base balance Calyx – where in this chamber receives urine from the
• Excretion of metabolic waste products such as urea, collecting duct and form that cause entry into the renal
creatinine, phosphate, sulfate and uric acid pelvis
• Conservation of nutrients Renal pelvis – funnel like structure that start from the
collecting system down to ureter
Endocrine Function
• Secretion of hormones such as renin, and
erythropoietin
• Kidney detects a decrease in oxygen tension in the
renal blood flow which may release erythropoietin that
can stimulate bone marrow to produce red blood cell
• Activation of the vitamin D is essential for the
absorption of calcium in the intestinal tract
Urine Formation
• Urine is formed in the nephron through complex 3
steps: glomerular filtration, tubular reabsorption and
tubular section
• The various substances filtered normally by the
glomerulus, reabsorbed by the tubules, and excreted
in the urine includes sodium, chloride, bicarbonate,
potassium, glucose, urea, creatinine, and uric acid
• The filtered urine or fluid is also known as filtrate or
ultrafiltrate
• Amino acid and glucose are usually filtered at the level
of the glomerulus and reabsorbed so that neither is to
be excreted in the urine
Function of Kidney
1. Regulate the volume and composition of ECF
2. Excrete waste products from the body – toxins, drug Nephron
metabolites, water soluble drugs • Each kidney has 1 million nephrons that are located
3. Secretes renin and erythropoietin within the renal parenchyma and are responsible for
4. Acid-base balance regulation the formation of filtrate that will become urine
5. Urine formation • Functional unit of the kidney responsible for initial
6. Regulation of electrolytes formations of urine, ultra-filtrations of the blood and
7. Control of water balance and blood pressure reabsorption / excretions of product in the subsequent
8. Renal clearance filtrate
9. Regulation of production of RBC • Main function is filtration, filtering plasma at the
10. Synthesis of vitamin D to active form glomerulus level. Then, reabsorb and/or secrete

different substances along tubular structure such as abundant protein in human urine. This protein
filtrate of the protein free fluid binds to uropathogens to prevent UTI and
protects the uroepithelium from injury, protects
Components of Nephron (microstructure of the against kidney stone formation
kidney)
Distal Convoluted Tubules
Mesangial Cells – lies between the capillaries, has
phagocytic ability similar to monocytes. It releases − Site from which filtrate enters the collecting tubule
inflammatory cytokines that can contract and regulate − Influenced by ADH permeable to water
glomerular capillary blood flow − Aldosterone acting on the distal tubule and
reabsorbed Na and water occurs
Juxtaglomerular Cells – located around the apparent
− Reabsorb water and concentrate urine as a result
arteriole where it enters the glomerulus
of antidiuretic hormones action and permeability
to water
The Nephron is Composed of − The principal cells that reabsorb sodium and
Glomerulus water and secrete potassium as a result of the
• A unique network of capillaries suspended between aldosterone
the afferent and efferent blood vessels which are
enclosed in an epithelial structure called Bowman’s Collecting Ducts – water permeable, releases urine
capsule – acts as a filter for urine
• A network of twisted capillaries that acts as a filter for
the passage of protein fee and red blood cell free
filtrate to the proximal convoluted tubules
• Filters fluid out of blood; the fluid is converted in urine
in the tubules
Tubular System
• Site of reabsorption of glucose, amino acids,
metabolites, and electrolytes from filtrate; reabsorbed
substances return to circulation
• Consists of 3 tubules:
Proximal Convoluted Tubules

− Contains microvilli that increase re-absorptive
surface area. Thus, reabsorbing water, urea,
glucose, amino acid and electrolytes back to Urine Formation
circulation • As fluid flows through the proximal tubules, water and
− Reabsorbs electrolytes, glucose, amino acids, Na solutes are reabsorbed (amino acid and glucose)
and other small proteins by active transport. While • Water and solutes that are not reabsorbed becomes
hydrogen and creatinine are secreted into the urine
filtrate • The process of selective reabsorption determines the
amount of water and solute to be excreted
Loop of Henle
− A U-shaped nephron tubule extending from the Process of Urine Formation
PCT to the DCT, site for further concentration of Glomerular Filtration
filtrate through reabsorption • Filter the blood (selective filtration)
− These are the cells of thick segments that • Electrolytes – Na, chloride and K
transport solute actively but not water in the thin • Organic molecules – creatinine, urea, glucose
segment with no active transport function • Hydrostatic pressure to Bowman’s capsule
− It contains concentration of salt and mostly the • Semipermeable membrane
sodium that pulls the sodium and chloride out of • Filtered fluid is known as filtrate or ultrafiltration
the filtrate and the absorb them in the descending • Normal GFR: 125 ml/min
lymph
− Responsible for concentration, conservation and
Tubular Function – reabsorption
dilution of urine filtrate
− The loop of Henle produces uromodulin (Tamm- • Substance moves from the filtrate back into the
Horsfall Protein [THP]) which is the most peritubular capillaries

Tubular Secretion • Unexplained anemia

• This stage helps with the elimination of K, hydrogen  Patients may have fatigue, SOB, exercise
ions, ammonia, uric acid, some drugs and other waste intolerance
• Filtrate becomes concentrated in the distal tubules  These conditions are the result from anemia of
and collecting ducts under hormonal influence and chronic disease
become urine then enter the renal pelvis, volume • Dysuria
depletion would rapidly occur  A burning sensation common in patients who
have urinary tract infection, urinary retention,
polyuria, anuria (no presence of urine output),
Urinary Structure
oliguria (urine is >400ml in 24hrs)
Ureter
• The lower portion of the renal pelvis and terminates in
Socio-Cultural Factors
the trigone of the bladder wall
• The lining of the ureter is made up of transitional cell • Take into consideration if the patient is an alcoholic or
epithelium which is called as “urothelium” that smoker
prevents reabsorption of urine
• Urine formed by the nephrons flows from the DCT, Family History
collecting ducts to renal papillae into calyces and • Genetic influence may influence renal conditions like
collected in the renal pelvis and funneled into the UTI and some renal disorder
ureters • Patients with diabetes with consistent hypertension or
with primary hypertension are at risk for renal
Bladder dysfunction
• A distensible muscle sac with a capacity of 400-500 • Older male client is at risk for prostatic enlargement of
ml and a total capacity of 1 liter the prostate gland which can cause urethral
• There is a retro vesicular junction that prevents reflux obstruction resulting in UTI or renal damage
of this urine from bladder towards the kidney
Physical Assessment
Urethra
Using IPPA technique including the digital rectal exam
• Extends from the inferior side of the bladder to the commonly done in male patients to check for any
outside of the body prostate enlargement
Assessment Inspection
Health History Skin
Review of Risk Factors • Check for pallor, scar ration, changes in the turgor,
• Multiparous with NSD, elderly is at risk for urinary bruises or texture
continence
• Patients with neurologic disorder: Parkinsonism often Mouth
have incomplete emptying of the bladder • For any presence of stomatitis, ammonia breath odor
• Urinary stasis that can result to urinary tract infection
and increase in bladder tension Face and Extremities
• Elderly male patient – risk for urinary enlargement • Check for any generalized or peripheral edema using
grading scale to determine the degree and severity
Reason of Consultation • Bladder distention, presence of masses or even
• Pain from obstructed urine flow, inflammation or enlarged kidney
swelling of the tissue
 Go over with the model of pain assessment Abdomen
• Changes in voiding • Check for presence of striae
 Frequency, urgency, dysuria, hesitancy, • Contour of abdomen for midline mass in the lower
incontinence, or presence of polyuria abdomen which indicates urinary retention
• GI symptoms
 Often associated with neurologic condition of the Weight gain
shared autonomic and sensory and the reno- • Due to edema and weight loss which is usually
intestinal reflexes associated with renal failure

General status
• Fatigue, lethargy and altered mental alertness of the
patient
Deep tendon reflex of the knee

• Important part in checking the urologic status of the
patients as it causes bladder dysfunction
• The sacral area which elevates the lower extremities
is the same peripheral nerve area responsible for
urinary incontinence
Herniation and Diverticula
Types of Herniation and Diverticula

Urethrocele – bulging of the anterior vaginal wall into the
urethra
Cystocele – herniation of the bladder wall into the
vaginal vault
Bladder Diverticula – herniation of bladder mucosa
between fibers of the detrusor muscle pH
• Evaluates the ability of the kidney to concentrate
solute in urine
Specific Gravity
• N: 1.010 - 1.025
• Measures the density of the solution compared to the
density of water which is 1.000
• Specific gravity is altered by the presence of blood or
protein that passed in the urine
Palpation – to locate the kidney. • In patients with renal disease, the urine specific
gravity does not vary with fluid intake, it can be fixed
Percussion – percuss for any distended bladder which
specific gravity
can be percussed as high as the umbilicus
• Specific gravity depends largely on hydration status.
Auscultation – renal arteries for bruit sounds which If fluid intake is decrease, specific gravity is elevated
indicates impaired blood flow to the kidneys and when the water intake is increase then specific
gravity is decreased
Laboratory and Diagnostic Tests • Conditions that decrease the urine specific gravity
Urinalysis includes diabetes insipidus, severe damage of the
• Common and repeatedly done in the hospital which renal or the kidney glomerulonephritis
provide clinical information about the kidney functions • Conditions that increase specific gravity includes
and help diagnose other diseases such as diabetes patients with diabetes mellitus and fluid deficit
Microscopic Examinations
• Determine the urine sediments to detect presence of
RBC termed as hematuria, common in women than in
men
• Hematuria is due to acute infections such as cystitis,
urethritis, prostatitis, and presence of stones and
neoplasms
• Other systemic disorders such as patients with
bleeding disorders, malignant lesions, taking warfarin
or heparin causes presence of RBC in urine
• WBC should be 0 or 1-2, but if there’s an elevation of
WBC in the urine, it indicates infection

• Casts, crystals and bacteria is also seen in aside from the tissue breakdown and fluid volume
microscopic examination changes
• Microalbuminuria – presence of albumin is a sign of • BUN has nothing to do with the kidneys because the
diabetic nephropathy ammonia is converted by the liver to urea which is
• There are some patients with transient proteinuria excreted
during times of stress like during exercise, fever,
prolonged standing and some medical conditions Prostate Specific Antigen (PSA)
such as malignancy, DM, pregnancy induced HPN,
• For male patients with hypertrophy of the prostate,
taking NSAIDS or ACE inhibitors
benign hyperplasia prostate
Urine Culture and Sensitivity Test

Radiographic Imaging
• To determine if bacteria are present in the urine, its
KUB (Kidney, Ureter, Bladder) Studies
strain and concentration
• X-ray study of the abdomen, kidneys, ureters and
• Through this, we can identify the antimicrobial therapy
bladder to delineate the size, shape and position of
that is best suited for the particular strain that is being
the kidneys and reveal urinary system abnormalities
identified
• Also reveal the presence of stones and other lesions
• Consist of a plain KUB or a contrast therefore check
Renal Function Test the creatinine level if contrast is needed
• Assess the status of patient’s kidney function • Some doctors may perform KUB prior to or before
performing a renal biopsy
24-hours Creatinine Clearance Test
• Measures volume of blood cleared of endogenous General UTZ
creatinine in 1 minute and approximation of
• Noninvasive, to detect abnormalities
glomerular filtration rate
• Requires full bladder
• More accurate wherein it determines the amount of
creatinine in the urine and check the functions of the
kidney Bladder UTZ
• Can detect and evaluate the progression of the renal • Noninvasive, measures urine volume in the bladder
disease • Indicated for urinary frequency, inability to void after
removal of a urinary catheter, post voiding residual
urine volume
Serum Creatinine Level
• Measure effectiveness of renal function
• The blood serum is common in the hospital, included CT and MRI
in the blood exam • Provide excellent view and contrast is used to
• Very effective to measure renal function with regards enhance visualization
to the glomerular filtration rate (GFR) • Evaluate presence of masses, kidney stone, chronic
• Creatinine is the end product of muscle energy renal infection, kidney/urinary tract trauma, metastatic
metabolism diseases, soft tissue abnormalities
• Low GFR is one reason for increase creatinine • If contrast is used, this is to enhance visualization
because it is not reabsorbed thus, check for the elevations of creatinine level and
• If there is a decrease, 50% of GFR is seen as elevated refer to the physician
creatinine
Nuclear Scans (Renal Perfusion Test)
Blood, Urea, Nitrogen (BUN) • Requires injection of a radioisotope (Tc99 or I123)
• Usually done together with creatinine test that serves  Provides information about kidney perfusion
as an index to determine the renal function including GFR
• Urea is a nitrogenous end product of protein • Evaluate acute and chronic renal failure, presence of
metabolism mass, blood flow before and after kidney transplant
• These test values are affected by the protein intake or • A radiotracer is being used to provide perfusion in the
dietary intake, tissue breakdown and fluid volume kidney including GFR
changes
• Between SCL and BUN, SCL is more accurate than Intravenous Urography / Pyelography (IVP)
BUN because creatinine is not affected by the dietary • Visualize the different layers of the kidney and its
intake unlike BUN that is affected by protein intake structures; differentiate solid masses or lesions from

the cysts. Can also visualize the urinary tract’s  To decrease pain and edema
position, size, shape, or the kidney, ureter and bladder 9. Observe for complications and refer accordingly
• Check if the patient has any allergies to seafood or  Such as hematoma formations, arterial
any iodinated containing substance; check creatinine thrombosis or even altered renal function
level
Urologic Endoscopic Procedures
Retrograde pyelography Cystoscopy
• A catheter is advanced through the ureter into the • Directly visualizes the urethra into the bladder by
renal pelvis by means of cystography magnifying and illuminating the view
• This visualizes the kidney, ureter and bladder after • Obtain a urine specimen to evaluate its function.
direct injections of contrast materials into the kidney
• It is performed if the IVP does not visualize the urinary
Bladder Function Test
tract
Urodynamic Test
• Check for any allergy to contrast materials or if
patients have a decrease in renal function • Evaluate the mechanism for how the urinary system
• Used for extracorporeal shock wave lithotripsy works, provide accurate diagnosis and treatment of
• It also served as a follow up care for patients with the urinary system; done as outpatient
neurologic cancer
• Possible complications include infection, perforations Cystometry
or hematuria of the ureter − Measure the bladder pressure and capacity
− Determine the cause of bladder dysfunction and
assess for the bladder neuromuscular function by
Cystography
measuring the efficiency of the detrusor muscle
• Evaluate vesicoureteral reflux and assess bladder
reflex
injury
Uroflowmetry
Renal Angiography − Measure time it takes to empty a full bladder of
• Provide image of the renal arteries and evaluate renal urine
blood flow is suspected − N: 20 – 30 mL/second
• There is a catheter that is threaded up to the femoral − Flow rate may be faster with urge incontinence
artery with a needle, the catheter is threaded up to the and slower to patients with prostate enlargement
femoral and iliac arteries to the renal artery or prostatic obstruction
• Contrast agent is injected in order to visualize the
renal structure Cystography
• This is to evaluate the renal blood flow if suspected − Evaluate vesicoureteral reflux and assess bladder
for renal trauma. injury
• It also evaluates any hypertension due to renal in
origin Post Void Residual Urine
• It is used preoperatively for renal transportation
− Measure residual urine in the bladder after
voiding
Nursing Responsibilities for Renal Angiogram / − Usually done together with ultrasound
Angiography − Residual of more than 200 is abnormal therefore
1. Obtain consent – it is invasive further evaluation is needed
2. Check for any allergies to seafood or iodinated
containing substances Leak Point Pressure
3. Laxatives to clean colon − Leak from bladder without warning
 So that it will not interfere with the visualizations
of the procedure Pressure Flow Study
4. Monitor vital signs – take BP on the opposite side − Pressure required to empty bladder
5. Monitor for presence of swelling and hematoma (post − May identify the bladder outlet obstruction that
procedure) may occur in prostate enlargement
6. Educate the presence of warm feeling along the
course of vessel when contrast is injected Electromyography
7. Assess for peripheral pulses for color and
− Measure nerve impulses and muscle activity in
temperature
the pelvic area
8. Apply cold compress to injection site

− This is to diagnose the cause of urinary retention raising questions whether the defect is a tumor, stone,
and incontinence by measuring the electrical blood clot, etc.
potential generated by depolarizations of the • May include histologic examination which can
detrusor muscles and urethral sphincter differentiate glomerular form of tubular renal disease
− Done by a small sticky sensor placed in the • Doctor may also do renal biopsy to monitor progress
rectum and measures the coordination of muscles of the disorder and assess the effectiveness of the
and sphincter during emptying of the bladder therapy especially if the patient’s having a malignant
tumor
Direct Visualization Procedures • C/I: bleeding tendencies, uncontrolled HTN, sepsis,
large polycystic kidneys, UTI and morbid obesity
• Invasive therefore patient may stay in the hospital for
• Prone position with a sandbag under the abdomen
1-2 days to monitor and prepare the patient for the
• Local anesthetic agent – given for biopsy
procedure
• Post procedure: lie flat on his back for 12hrs and avoid
strenuous activity for 2 weeks
Cystoscopy • Monitor VS
• Directly visualize the urethra into the bladder,
magnifying and illuminating the view of the bladder
Extracorporeal Shock Wave Lithotripsy (ESWL)
• Obtain a urine specimen from each kidney to evaluate
• Uses shock waves to break a kidney stone into small
its function
pieces that can more easily travel through the urinary
tract and pass from the body
1. Hematuria, hematoma
2. Severe pain
3. Sometimes, unusual drop in blood pressure
Urinary and Renal Disorders

Nursing Responsibilities of Cystoscopy Procedure Acute Kidney Injury / Acute Renal Failure
1. Explain the procedure and obtain consent • Sudden decline in kidney function with a decrease in
2. NPO after midnight glomerular filtration and urine output with
 Because the patient may receive general accumulation of nitrogenous waste products in the
anesthesia blood
 To ensure that there is no involuntary muscle • Occurs abruptly and can be reversible
spasm when the scope is being passed through • Uremia and azotemia indicate accumulation of
the ureter or kidney nitrogenous waste products in the blood
3. Educate the expectation of some burning sensation Uremia – there is a decline in renal function to the
upon voiding and blood-tinged urine and urinary point that there is a manifestations or symptoms
frequency (post procedure) developing in multiple body system wherein patient
4. Moist heat to lower abdomen after 24hrs as per may have anorexia, fatigue, vomiting, pruritus and
doctor’s order even urologic changes
 Check doctor’s order because some doctors are Azotemia – accumulations of the nitrogenous waste
not comfortable to give moist heat to patients product characterized by elevations of BUN level and
fearing that it can cause bleeding but it depends serum creatinine. Meaning, the kidney is unable to
on the response of the patient excrete the daily load of toxin in the urine
5. Bedrest
 Prevent orthostatic hypotension and monitor VS Classification of Kidney Dysfunction
6. Medications: Flavoxate − antispasmodic Kidney Injury
 To relieve temporary urine retention • Sudden decline in the kidney function with a decrease
in glomerular filtration and urine output causing the
Biopsy / Percutaneous Renal Biopsy accumulations of these nitrogenous waste products in
• To diagnose and evaluate the extent of the disease the blood
• This provides specific information when there is an • It comes sudden and is reversible
abnormal x-ray finding of the ureter and renal pelvis

Kidney Failure • Due to external factors that cause reduction in renal

• Can be chronic and progress from chronic to end blood flow such as
stage kidney failure and can take over months or  Hypovolemia, cardiac insufficiency, reduced renal
years perfusion due to hypotension, decrease in cardiac
output
Renal Insufficiency  Renal vasoconstriction caused by NSAIDs or
• Declines in renal function of about 25% of the normal radiocontrast agents
• GFR is about 25- 30mL/min  Vasodilation from anaphylactic reactions or the
• Level of creatinine and urea is slightly elevated use of antihypertensive medications
• GFR and tubular reabsorption of Na and water
Rifle Criteria for Acute Kidney Dysfunction/Failure

Intrarenal (intrinsic)
Category GFR Criteria Urine Output Criteria
• The kidney itself is being damaged meaning, there’s
Risk Decrease >25% UO < 0.5 ml/kg/hr X 6hr a direct damage to the renal parenchyma causing
Injury GFR  >50% < 0.5 ml/kg/hr X 12hr damage to the filtering structure of the kidneys
< 0.5 ml/kg/hr X 24hr or
• Damage to filtering structures results to impaired
Failure GFR  >50%
anuria X 12hr nephron function
Persistent ARF = complete loss of kidney function > 4 Acute tubular necrosis (ATN) - common cause of AKI
Loss
weeks
wherein there is a disruption in the basement membrane
ESRD End-stage disease (>3 months)
of the tubular epithelium.
• The RIFLE comes from the first letter of each category
• For Loss, this is complete loss of kidney function of Causes
greater than 4 weeks Acute Tubular Necrosis (ATN)
 Hence, it’s called acute renal failure − Common cause of AKI
• ESR is considered chronic − There’s a disruption in the basement membrane of
the tubular epithelium
General Causes of AKI − It causes cell death probably from renal ischemia
1. Extracellular volume depletion or nephrotoxic injury
 Consists of severe fluid and blood loss. Infection
Hypovolemia, diarrhea, burns, severe − Acute glomerulonephritis, inflammation of the
dehydration, fluid and blood loss and excessive glomerulus
use of diuretics Vascular Changes
2. Reduced renal blood flow
− May cause endothelial dysfunction and
 Hypotension, reduced cardiac output and even
vasoconstrictions of the afferent arterioles which
patients with impaired insufficiency such as heart
increase adhesions of inflammatory cells like
failure, renal arteries or veins obstruction
neutrophils, aggravating inflammation
3. Toxic injury from chemicals or injury
 Nephrotoxic agents such as NSAIDS (Aspirin, Tubular Changes
Naproxen) or even the use of contrast dye during − There’s cells loss or damage in the cells due to
CT scan necrosis and later on, it will become apoptosis then
 Chemotherapy drugs can also damage and be it will become necrotic bodies which may cause
toxic to the kidney causing damage or injury to obstruction in the tube that result to the back
the organ leaking of the urine
 Constant infection can invade the kidney
resulting in damage, altering its function Post-renal
 Severe allergic reaction • Mechanical obstruction (bilateral) of urinary outflow
4. Direct injury to kidney causing an increased intraluminal pressure that may
 Kidney stone, tumor or blood clots upstream from the site of obstructions with a gradual
 Glomerulonephritis and lupus decrease in the GFR
• This type of failure can occur after the catheterization
Classification of AKI of the ureter
Prerenal • Common – BPH, prostate CA, calculi, tumor
• Decreased blood supply • Additional cause is medication that may interfere with
• Caused by inadequate kidney perfusion the normal bladder stricture, blood clot or abdominal
malignancy such as ovarian CA, colorectal CA

• There is extra renal tumor Phase 2: Diuresis

• Gradual increase in urine output (4-5L/day) that
Summary of AKI signals glomerular filtration has started to recover
Functionally • Excess water loss, potassium and sodium therefore
the patient is at risk for dehydration
It may decrease of the GFR or the patient. Expect a
 Monitor the intake and output of the patient
decrease in urine output, elevations of the
• Although diuresis is the recovery phase, the
nitrogenous waste product raising in the blood
laboratory result is still abnormal so continuous
including creatinine and urea
management is still needed
Structurally
May cause cell death due to necrosis and loss of
Phase 3: Recovery
adhesion due to the intrinsic renal cells resulting from
obstruction • Return to normal status, may take from 3-12 months
• Signals the improvement of renal functions
• Laboratory values may return to normal level
Phases of AKI
Initial – begins at the time of insult and signs and
Signs and Symptoms
symptoms become apparent (hours and days)
1. Oliguria
 Earliest sign, occurs 8-15 days <400cc/24hrs
Phase 1: Oliguria
• < 400 mL of urine in 24 hours, occur within 1-7 days Anuria
of causative event, there is no damage in the renal May also be present but it is rare especially
tissue during the early period. 70% of patients with
• Caused by decrease in circulating blood volume such AKI may experience it. The overlapping phases
as dehydration, burn, decrease in cardiac output of the clinical progression usually occur during
• Auto regulatory mechanisms may increase the initial stage wherein there is reduced
angiotensin II, aldosterone, norepinephrine and perfusion of toxicity in the kidney. Prevention of
antidiuretic hormone which attempts to preserve the injury is possible during this phase.
blood flow to the essential organ Oliguric
• Vasoconstriction may occur along with the sodium The period established kidney injury
and water retention dysfunction after initiating the event has been
 There will be elevations in the potassium and resolved may last from weeks to months. Urine
phosphate causing metabolic acidosis output is lowest during this phase. Serum
• Intrarenal failure (intrarenal cause of oliguria) creatinine and BUN level is both increased.
 The normal specific gravity will be fix to 1.010 Polyuric or recovery phase
 There will be high sodium concentration meaning,
The glomerular function returns but
there is an injury to the tubules that cannot
regenerating tubules cannot concentrate the
respond to auto regulatory mechanism
filtrate. Diuresis is common during this phase
• Mechanism of oliguria due to altered renal blood flow
with a decline in serum creatinine and urea
 The afferent arteriolar vasoconstriction may be
concentration. Watch out during the diuresis
released by intrarenal release of angiotensin and
period, observe for dehydration and monitor the
the redistribution of the blood from the cortex to
potassium level.
the medulla
• Autoregulation of blood flow may be impaired 2. Hypertension
resulting in reduced GFR  Common with AKI together with fluid overload
 Changes in glomerular permeability can also  Check for any distended neck vein with pounding
decrease the GFR which is the ischemia pulse of presence of edema
• Tubular obstruction is another mechanism due to the 3. Fluid overload
necrosis of the tubules causing sloughing of cells, pus 4. Metabolic acidosis
formation, ischemic edema that may result to tubular 5. Uremic breath
obstruction which can cause a retrograde increase in  May have a Kussmaul breathing
pressure and reduce in GFR 6. Lethargy and stupor
• Usually, renal failure can occur within 24 hours  If the metabolic acidosis is not treated
• Tubular back leak with the glomerular filtration 7. Tetany and tingling sensation
remains normal but the tubular reabsorption of filtrate  Due to hypercalcemia and hyperphosphatemia
is accelerated as a result of permeability cause by
ischemia from the obstruction

 Low calcium results from decreased serum GI  Supplement multivitamins to replace the daily
absorption of the calcium recommended allowances needed
 Calcium is being absorbed in the GIT so  If with kidney injury, no banana, citrus fruits,
activated of vitamin D must be present by a juices and coffee
functional kidney  During diuresis phase, may start increasing
8. Hematologic disorder calories and protein
 Anemia is common because of impaired 2. Fluid restriction
erythropoietin production  About 600 to 800mL of fluid is allowed per day
 It is also compounded by platelet abnormalities 3. Monitor electrolytes
that could lead to bleeding from multiple sources  To detect for any hyperkalemia
9. Pruritus 4. Parenteral IV fluid
 Deposit of calcium and phosphate  May give LR solution to treat hypovolemia
10. Arrhythmia due to hyperkalemia 5. Dialysis
 If the AKI is caused by massive tissue trauma,  If failed to correct the uremic symptoms
the damaged cell releases additional potassium
into the extracellular fluid Drug Interventions
 Bleeding and blood transfusion can cause
1. Sodium bicarbonate − to correct acidosis
cellular destruction releasing more potassium
2. Insulin / Dextrose 50%
into the extracellular fluid
 To correct hyperkalemia by driving the
11. Diarrhea or constipation
potassium from the vascular system into the cell
 Because they share autonomic and sensory
3. Na polystyrene sulfonate (Kayexalate)
innervation and reno-intestinal reflexes
 To remove the potassium using exchange renin
12. Dry mucous membrane
 Administered orally or as retention enema
 It is effective as most sodium potassium occurs
Diagnostic Tests in the colon
1. BUN and creatinine 4. Mannitol (furosemide) − to  diuresis
 Elevated and indicates renal failure because it’s 5. Antibiotics – as needed for infection
not significantly altered by other factors 6. Multivitamins – to replace daily needs
2. 24hrs urine − best method
3. Urinalysis Nursing Management
  specific gravity unless the kidney is already
1. Monitor VS
damaged
 If the patient is on dialysis or fistula, don’t take
 Presence of protein or pus may also be included
blood pressure on the affected site
in the urinalysis
 If not undergoing dialysis, then VS can be
4. Proteinuria
monitored in any part of extremities
5. CBC
2. Monitor I & O
  Hgb and Hct as it is related to erythropoietin
3. Weigh daily
6. ABG −  pH and HCO3
4. Replace blood component
 Patient may have a metabolic acidosis  Don’t use full blood if patient is at risk for heart
7. Electrolytes – K and P, Na normal or decreased failure
8. Renal scan 5. Watch out for S/S of pericarditis or any pericardial
9. Radiographic imaging, CT scan, MRI or retrograde friction, inadequate renal perfusion such as
pyelography hypotension or acidosis
 Pyelography – catheters advanced through the 6. Maintain nutritional status
ureters into the renal pelvis by means of  High calorie, low sodium, potassium and protein
cystography + vitamin supplement
7. Monitor ECG changes
Medical Management  To follow up tracing which may indicate increase
Goal: Re-establish effective renal function, if possible, or peak T-wave and widening of the QRS
to maintain the consistency of the internal environment segment and disappearance of the P-wave due
despite of the transient renal failure to hyperkalemia
1. Diet – high calories, low CHON, K and Na 8. Provide Bedrest
 Carbohydrate has a protein sparing effect 9. Assist in turning, coughing and deep breathing
preventing ketone effect  To promote lung expansion and prevention of
atelectasis and respiratory tract infection
10. Practice strict asepsis

 Especially if there’s a dressing, catheter or Signs and Symptoms of CKD

invasive line Skeletal
11. Provide skin care – bathing, trim fingernails 1. Bone pain
12. Provide emotional support 2. Spontaneous fractures and deformities of the low
bone
Chronic Renal Failure 3. Bone inflammation with fibrous degeneration related
• Characterized by diminished / progressive loss of to hyperparathyroidism
renal function due to parenchymal renal damage
• Irreversible, destruction of nephron in both kidneys Cardiopulmonary
• Affects all major body system, requires dialysis and 1. Pulmonary edema because of fluid overload
transplant 2. Kussmaul respiration from metabolic acidosis
• Loss of nephron and glomerular hyperfiltration 3. Cough reflex may be depressed
Etiologic Factors of CKD Cardiovascular

1. Acute Renal Failure 1. HTN
 Prerenal and post-renal problems (chronic 2. Left ventricular hypertrophy due to the extra volume
urinary obstruction, ureteral stricture, calculi, expansion and hypersecretion of renin which is
neoplasms, SLE) associated with HTN
2. Hypertension 3. HR, CAD, arrhythmia, pericardial effusion
 Includes renal artery stenosis
 Hypertension causes thickening of the BV, Neurologic
narrowing the lumen therefore there is less blood 1. Muscle twitching, seizure and coma, asterixis.
entering the kidney to the nephron, decreasing 2. Encephalopathy, reduced attention span, difficulty in
the GFR problem solving
 Decrease in GFR and blood flow in the nephron,  Due to the presence of the waste product in the
the cell may be detected and stop producing CNS
renin subsequently and activation of the RAAS
which will further increase the BP and HR then Hematologic
will eventually result to glomerulosclerosis which 1. Anemia
can cause thickening and hardening of the  Patients with anemia may also reduce the
vessel in the Bowman’s capsule erythropoietin secretions which causes
3. Diabetes Mellitus reduction in the production of RBC
 Cause changes in patients with diabetic 2. Decrease EPO
nephropathy due to the proliferation and 3. Bleeding tendencies
expansion of the mesangial cells
 Hypertrophy and atrophy can be seen in the GI
monocytes and the thickening of the glomerular 1. N/V, stomatitis, metallic taste, pancreatitis
basement membrane and even sclerosis 2. GI bleeding
4. Kidney disease  Bleeding tendency may alter the function of the
 Includes polycystic kidney disease platelet
3. Uremic fetor – urine odor of breath
Stages of CKD
GFR Integumentary
Stage Description S/S
(ml/min)
1. Yellow-gray discoloration
Kidney damage with • Usually none  Due to the absorption of the urinary pigment that
1 >90
normal or high GFR • HTN – common
may cause retention in the skin
Mild decrease in • HTN
2 60-80
GFR • Increased crea and urea 2. Expect a decrease in all sweat gland activities
Moderate, decrease causing patients to have dry and brittle hair
3 30-59 • Mild as above
in GFR
3. Uremic frost
• Moderate: erythropoietin
deficiency anemia,  Rare condition in which the urea crystallizes in
Severe kidney hyperphosphatemia, the skin and the BUN is extremely high
4 15-29
damage hyperkalemia, Na-water
retention, metabolic
acidosis
End-stage kidney Immunologic
disease (ESRD) –
5 kidney failure <15 • Severe as above
1. Risk of infection sometimes resulting to death
Renal replacement
needed

Reproductive 2. Fluid restriction – 600-800 mL/day

1. Amenorrhea, impotence and decrease in libido  Depending on the daily urine output
 There will be dysfunction on the ovaries, testes,  Gelatin and ice cream should be counted as fluid
presence of neuropathies intake
3. Continuous Renal Replacement Therapy (CRRT)
GIT
1. Oliguria, anuria Drug Therapy
2. Proteinuria, pyuria, hematuria Should be symptomatic treatment so avoid drugs that
contain magnesium because a failing kidney can
Metabolic Imbalances accumulate Mg and cause severe neurologic problem
1. Hyperglycemia 1. Kayexalate – remove the potassium
 Due to altered carbohydrate metabolism 2. Antihypertensive agents − ACE inhibitors
 Patients with diabetes who become uremic may  Delay the progression of the renal failure and
require less insulin than before the onset of renal decrease proteinuria
disease because the insulin is dependent on the 3. Beta-adrenergic blockers and calcium channel
kidney for excretion, it may remain in the blockers
circulation longer so the adjustment of the insulin 4. Cardiovascular agents
is needed 5. Diuretics – furosemide
2. Elevated triglycerides 6. Anticonvulsant
 The insulin stimulates the liver to produce  Administer depending on the symptoms of the px
triglyceride so uremia develops hyperlipidemia 7. Erythropoietin
with elevated very low-density lipoprotein  It can cause HTN during the early stage of
treatment and increase clotting on the vascular
Diagnostic Tests of CKD access site, sometimes cause seizure and
1. Renal scan – GFR  depletion of the body stored iron
2. 24hrs creatinine clearance – decreases 8. Sodium carbonate
3. Serum creatinine and BUN – increases  Given in order to treat hyperphosphatemia but
4. Electrolytes be cautious for the risk of hypercalcemia
 Hypocalcemia, hyperphosphatemia, 9. Aluminum hydroxyl
hyperkalemia  Not used for the treatment of hyperacidity in
5. CBC – decrease in hemoglobin patients with chronic renal kidney disease
6. High level of PTH  This is to bind the phosphate of ingested foot
7. Triglycerides – elevated  Usually given with or immediately after meal or
8. CXR – shows interstitial edema snacks
9. ECG – dysrhythmias
10. Renal ultrasound Nursing Management
1. Monitor VS, weigh daily
Medical Management 2. Monitor fluid status through I and O
1. Diet – low CHON, low phosphorus, low Na and K, 3. Dietary program
supplement amino acids (ketoanalogues), high  To ensure nutritional status within the limits of
calcium, vitamin B complex, C and D, iron treatment regimen
 Low protein because of the urea, uric acid, and 4. Self-care and independence
organic acid 5. Provide education
 High biological value protein like egg, dairy  Information concerning ESKD, treatment options
products may provide complete protein supply, and potential complications
the essential amino acid necessary for growth 6. Provide emotional support
and cell repair 7. Institute safety measure and seizure precaution
 Low sodium and potassium due to the fluid 8. Prepare for dialysis or transplantation
overload, no banana citrus fruit, juices and
coffee Dialysis
 Supplement amino acid in the form of • A technique in which substances move from the blood
ketoanalogue and high calcium due to through a semipermeable membrane into a dialysate
hypocalcemia (dialysis solution)
 Supplement of vitamin B complex, C, D and iron • Work on the principle of diffusion and osmosis of
solutes and fluid across a semipermeable membrane

• Type of dialysis include: hemodialysis, peritoneal Who needs dialysis?

dialysis and continuous renal replacement therapy 1. Advance or end stage renal disease
(CRRT) 2. High or increasing serum potassium or calcium level
3. Fluid overload
Principles of Dialysis 4. Impending pulmonary edema
Diffusion 5. Increasing acidosis
6. Advance uremia
• Works from higher to lower concentration
7. Hepatic encephalopathy
• It is the movement of solutes (particles) from blood
shift toward the waste-free dialysate with the net effect It can remove toxic medication from the blood which
to lower the blood concentration does not respond to the other treatment
• In renal failure, creatinine, uric acid and, electrolytes
like potassium and phosphate, moves from the blood A − Acid base problems
to the dialysate with the effect of lowering their E − Electrolyte imbalance
concentration in the blood
I – Intoxication
• If RBC, WBC, plasma and protein are too large to
O − Overload fluid
diffuse to the pores of the membrane, it means it
cannot be filtered out U − Uremic symptoms
• Bacteria and viruses present in the dialysate are too
large to migrate into the pores to the blood Hemodialysis
• Vascular access is needed in order to remove the
Osmosis toxic nitrogenous substance from the blood and
• Movement of fluid from area of lesser to greater remove excess fluid
concentration of solutes so excess fluid is removed • To obtain a vascular access, it requires a large blood
from the blood by osmosis vessel to allow a very rapid blood flow
Ultrafiltration
• Water and fluid removed through a process by which
a pressure is applied to remove excess fluid from the
blood
• The pressure either on the membrane that contain
blood which push the fluid out of the body to the
dialysate
• While for the dialysate site of the membrane, it pulls
the fluid out from the blood
Peritoneal Dialysis
• Excess fluid is removed by increasing the osmolality
of the dialysate
 The excess fluid can be removed by creating a
pressure that is differential between the blood and
the dialysate solution
 It can be a combination of a positive rate in the Types of Vascular Access
blood compartment and a negative pressure in
External Shunt
the dialysate compartment
• Constant replacement of dialysate • Rarely used except for CRRT due to various
 The dialyzer is a form of artificial kidney therefore complications
it should be replaced because it could cause • A U-shaped silastic tube divided at the midpoint with
accumulation of these solutes in the dialysate each end placed in the artery and a vein
 It should be kept low in the side of the membrane  Usually, an external shunt visible and covered
• Dialysis of solution HCO 3 slightly higher than in with dressing
normal blood to neutralize the metabolic acidosis • Prone to infection and clotting causing erosion of the
 Maintain body’s buffer system using a dialysate skin around the insertion site
both make up of HCO3 • Prevention of physical trauma and avoidance of some
• Anticoagulant heparin prevents blood clotting in the activities, such as swimming. Thus, limitation of some
extracorporeal dialysis circuit physical activity

Types of Dialysis Access Arteriovenous Graft (AVG)

Peritoneal Access – dialysis inserted in the • A synthetic material is used
peritoneum to form a “bridge” between
Arteriovenous Fistula − preferred method for the arterial and venous
permanent vascular access. You can see the blood supply
anastomosis of the artery to the vein • Brachial and antecubital
Graph − form a synthetic material to form a breech access / site can be used
• Self-healing, prone to
infection and thrombogenic
• Prone to stenosis and
thrombosis
• Used for compromised
vascular system like patient
with diabetes since the
nature of their vessel may
not be suitable for AVG
• Required 2-4 weeks to
mature allowing the graft to
heal
Internal Shunt Catheter

Arteriovenous Fistula (AVF) • Temporary vascular access that requires
• Created surgically in the forearm with an anastomosis percutaneous cannulation of the internal jugular or
between an artery and a vein femoral vein is performed
• Arterial segment of the fistula is used for arterial flow • Usually has a double external lumen with an internal
to the dialyzer and the venous segment for the septum separating the two internal segments
infusion of the dialyzed blood  One lumen is for removal and the other is for
• Needle is inserted into the vessel fusing an artery and blood return
a vein • Catheter can be left in place for about 1-3 weeks
• Arterial blood flow is essential to provide rapid blood • Femoral vein cannula can remain in place up to 1
flow which is required during dialysis and this increase week
pressure of the arterial blood to the vein dilates the • Jugular vein cannulation has a low incident of
vein and become tough and be amenable for repeated thrombosis compared to subclavian vein that can
venipuncture cause central stenosis, pneumothorax or hemothorax
• The vein is accessed using a 2 large gauge needle • The disadvantage of the femoral catheter is that it only
• Not possible for severe HTN, peripheral vascular can be used for a short time and the location of the
disease, DM, prolonged IV drug use or previous catheter is easily kinked and the groin is not a clean
multiple IV procedures in the forearm site
• Required 4-6 weeks to mature • Common complication of the femoral site is that it can
• As the AVF matures, the venous segment dilates and cause femoral vein thrombosis, pulmonary emboli,
toughen due to increased blood flow coming directly infection, immobility and hematoma formation
from the artery • No medication should be administered into the
 It takes about 2-3 months catheter by a non-dialysis staff to minimize infection
Semi-permanent (PermCath)
− A type of tunneled central venous catheter, with
two lumens which have unequal length
− No needle stick needed, can be used immediately
but with high infection rate and circulation rate
− Commonly used when waiting for the fistula
placement or a long-term access when other form
of access has failed

 Examples are patients with HTN, medications

such as antihypertensive drugs can cause
hypotension during dialysis causing low BP
 Adjust the daily antihypertensive drugs and not
before the dialysis
Complication of Hemodialysis
Hypotension
• Rapid removal of vascular volume
• Usually after completion of dialysis due to rapid
removal of vascular amount causing hypovolemia,
Nursing Management decrease in CO and decrease in systemic vascular
resistance
1. Protection of vascular access
• Check the VS first
 To promote patency
• Apply pressure on the site after the discontinued
2. Do not measure BP or obtain blood specimens, tight
hemodialysis
dressings, restraints or jewelry over the vascular
• Drop of BP may precipitate lightheadedness, nausea,
access site
vomiting, seizure because of the rapid removal of the
3. Assess and evaluate “bruit or thrill” over the venous
vascular volume
access site
• Treatment is to decrease the volume of fluid being
 Absence of these indicates blockage or clotting
removed and infusion of 0.9% normal saline and can
in the vascular access
be referred to the physician
4. Integrity of dressing and change as needed done by
a trained dialysis nurse
5. Monitor VS, I & O Muscle cramps
6. Monitor for CV, respiratory complications • Rapid removal of Na and water
7. Monitor dietary intake • Or from neuromuscular hypersensitivity
 Minimize uremic symptoms and fluid and • The reduction of the ultrafiltration rate and infusion of
electrolyte imbalance, to maintain a good hypertonic saline solution may decrease the
nutritional status through adequate high complications
biological value protein, calorie, vitamins and
mineral intake but restriction of dietary protein, Loss of blood
sodium, potassium, phosphate and fluid intake • From not being completely rinse from dialyzer, so
8. Manage pruritus, pain secondary to neuropathy
accidental separations of blood tubing or dialysis
 By trimming the nail
membrane rupture
9. Skin care
• Patient who receives too much heparin or has clotting
 Moisturized using bath oils, superfatted soap,
problem may cause a loss of blood
creams or lotions • Rinse back all blood and closely monitor
10. Prevent infections, pneumonia and site infection
heparinization to avoid excess anticoagulant and hold
 Because patients in end stage renal disease
firm but not too occlusive pressure
have a low WBC count, they have decreased
phagocytic ability, low RBC count and impaired
RBC function Hepatitis
11. Provide emotional support • Adherence to precaution to blood transfusion and
 Most often patients may have financial problems cause of hepatitis B and C so in dialysis should be
 Sometimes they have the fear of dying that can observed
also alter in terms of lifestyle like food, fluid • Treatment is putting the patient in an isolation room if
restriction positive from hepatitis B and C and have hepatitis
 It is normal for patient to have depression or vaccine and use disposable equipment
anger therefore counseling and therapy may be
helpful Sepsis
12. Medications • R/T infection of the vascular access site, so aseptic
 There are medications that are removed from the technique is important
blood during hemodialysis therefore the dosage,
timing of medication of administration may
require adjustment

Disequilibrium Syndrome • Prophylactic antibiotics are given for peritonitis,

• Rapid removal of urea from blood reverse osmosis potassium chloride for hypokalemia but make sure
with water moving into the brain cell, can be caused that it is being incorporated in 100 cc of plain NSS
of cerebral edema resulting to the shift of fluid into the • 7-14 day before the start of PD
brain causing cerebral edema • Persol solutions with glucose concentration of 1.5% to
• Because too rapid changes in the compositions of the 2.5%
extracellular fluid may create a high osmotic radian in  The presence of the glucose in the peritoneal
the brain dialysis solution may become hypertonic
a. Rapid removal of urea from blood  The greater the osmotic pressure for
b. Reverse osmosis with water moving into brain ultrafiltration, the greater the amount of fluid that
cells is being removed
c. Cerebral edema
Manifestations / Complications of Disequilibrium

Syndrome
1. Headache
2. Restlessness
3. Confusion
4. N/V
5. Twitching and jerking and seizures
Treatment
1. STOP dialysis
2. Infuse hypertonic solutions
3. Albumin and mannitol
 To draw fluid from the brain cells back to
systemic circulation Indications
1. Unable to undergo HD or kidney transplant
Peritoneal Dialysis 2. Rapid fluid & electrolyte and metabolic changes
occur during HD
• Made use of the peritoneum to remove toxic
 There are instances where patients may
substance and metabolic waste and reestablish
undergo HD then suddenly, they will shift to PD
normal electrolytes fluid balance by transfer across
because of metabolic changes
the peritoneum
3. Diabetes
 Peritoneal membrane will serve as the
4. Cardiovascular diseases
semipermeable membrane that allows removal of
5. Elderly cannot undergo HD
urea and creatinine through the process of
6. Risk for adverse effects of systemic heparin
diffusion and osmosis
7. Severe HTN and pulmonary edema not responsive
• Catheter that is being attached in the abdomen.
to usual treatment
Which is a silicon rubber tubing which is about 60cm
with 2 Dacron cuffs on the subcutaneous and
peritoneal portion of the catheter Phases of Peritoneal Dialysis Cycle
• Removal of bod’s solute substances and water by Intermittent PD
transferring across the peritoneum, utilizing a dialysis Inflow (filling phase)
solution which is intermittently introduced into and • Infused 1-2 L/cycle of warmed dialysate into
removed from the peritoneal cavity peritoneal cavity
• Tenckhoff catheter – a silicone catheter placed on the • Inflow time: 5-10 minutes
peritoneal cavity allowing fluid to flow in and out of the • Flow can be decreased if there is a presence of pain.
catheter Therefore, you need to warm the solution but do not
 Catheter is being irrigated with heparinized overwarm because it may cause burns to the patient
dialysate
 Therefore, it can be given with heparin in order to Dwell (equilibrium)
clear the blood and fibrin to prevent fibrin
• Diffusion and osmosis occur in this phase between
formation and result to the occlusion of the
patient’s blood and peritoneal cavity
peritoneal catheter
• Dwell time: 20-30min (manual); 10-20min (automatic)
• You allow the fluid to stay for about 20-30 mins.

Outflow (drain) Outflow Problem

• If manual, after 20-30 minutes, you may start draining, During her clinical days, ma’am handled a patient
which will take 15-30 minutes and an average of 20 who had an outflow problem. What they did was to
min to allow the flow of urine check the tunnel segment, then turn the patient side
 To facilitate the flow, you may gently massage the to side, also gentle massage may also help improve
abdomen and change position the outflow
• 30 cycles in 24 hours is ideal
• Turn side to side to increase return
Nursing Management
1. Monitor VS (as often as possible)
Contraindications of Peritoneal Dialysis
2. Weigh daily
1. History of multiple abdominal surgery procedures 3. Monitor fluid balance
2. Pathologic changes – pancreatitis 4. Warmed dialysate solution to body temperature to
3. Recurrent abdominal hernia avoid discomfort and abdominal pain
4. Excessive obesity  Soaking the bag of solution in warm water is not
5. Severe obstructive pulmonary disease recommended, because it might introduce
bacteria to the exterior of the bag of solution
Complications which may increase the chance of peritonitis.
1. Peritonitis  Heating it in a Microwave oven is not
 Due to the contaminated dialysate recommended as well, because it might cause
 You can see through the effluent, there will be a burns to the peritoneum
cloudy peritoneal effluent with the WBC count of 5. Institute strict aseptic technique
over 100 cells per unit liter, particularly the 6. Provide psychosocial needs
neutrophil  Altered body image, sexual dysfunction
2. Site infection 7. Education
 Because of Staphylococcus aureus or  S.E., schedule and frequency, catheter care
Staphylococcus epidermidis from the skin flora 8. Diet
3. Leakage  High fiber to prevent constipation that may
 This can be avoided by gradually increasing impede the flow of dialysate in and out of the
small amount of dialysate peritoneal cavity
4. Abdominal pain  High CHON
 Because of the low pH of dialysate solution and 9. K, Na and fluid not restricted
at the same time, because of the peritoneal
irritation displacement of the catheter Hemodialysis Peritoneal Dialysis (PD)
o Change the position to correct this problem
 Or maybe it’s because you might have infused Hemodialysis circulates the blood through
special filters that are outside the body. Blood
Peritoneal Dialysis (PD)
uses the peritoneal
the solution too rapidly flows across the dialyzer with solutions that membrane located inside
help remove the toxins. Blood flows from the the abdomen. Solutions
5. Bleeding body to the dialysis machine via a fistula that that remove the toxins are
 Check BP or hematocrit has been surgically placed in the patient’s put into the abdomen via a
vein. Blood goes from the fistula to the dialysis catheter that is both inside
 Those patients who are menstruating or machine. The dialysis machine then corrects and outside the body. The
my chemical imbalances or impurities before solution remains in the
ovulating, there will be some blood efflux returning the blood back to the body. Typically, abdomen for a specific
because of the hypertonic fluid pooled blood this is done three times a week. Each dialysis amount of time. Then it is
session usually lasts 3-4 hours at a time. This drained out. This type of
from the uterus through the opening in the type of dialysis has to be done at a dialysis dialysis is performed daily
center. and is done at home.
fallopian tube into the peritoneal cavity, so no
interventions needed
6. Triglycerides and CHO abnormalities Continuous Ambulatory Peritoneal Dialysis (CAPD)
 The dialysate contains glucose (1.5% - 2.5%), it • Almost the same with PD, the only difference is that
can be absorbed in the peritoneum CAPD uses machines to provide fluid exchange. It is
 Continuous absorption of these glucose may already programmed to deliver a certain amount of
result in insulin secretions, and the level of solution that will dwell in the peritoneal cavity for a
insulin in the plasma may be elevate period of time until it will be drained from the
 Elevation of insulin may stimulate the liver to peritoneal via gravity
produce triglycerides • Dialysis solution is infused into peritoneum three
times daily and once before bedtime
• Dwell time: 5 hours for each daily exchange,
overnight for the fourth (8 hours)

• Indwelling peritoneal catheter is connected to solution  Since there’s a little change in cardiac output and
bag at all times − serves to fill and drain peritoneum the mean arterial pressure
Continuous Renal Replacement Therapy (CRRT) Continuous Venous Hemofiltration.

• This is used to manage fluid and electrolyte • Patient’s blood enters the hemofilter from a line that is
imbalances in hemodynamically unstable patients connected to one lumen of a venous catheter
with multiple organ failure or renal failure who can’t  It may flow through the hemofilter and may return
tolerate hemodialysis to the patient through the second lumen of the
 If the patient cannot undergo HD or PD, then she catheter
may undergo CRRT or sometimes they call it • At the first pump, may add anticoagulant, then the
Hemofiltration second pump moves the dialysate through the
• A process, similar to hemodialysis, by which blood is hemofilter, then the third pump may add replacement
dialyzed using ultrafiltration, and usually to remove a fluid if needed
specific product of fluid volume
• Can be continued as long as 30-40 days Kidney Transplant
• It is a gradual removal of fluid in the body, but the
• Involves transplanting a kidney from a living or
hemofilter should be changed every 24-45 hours
deceased (someone who just died) donor to a
because of loss of filtration efficiency or clotting
recipient who no longer has a renal function
• The living donor should be well matched with the ABO
Indications compatibility and HLA
1. Clinically unstable for traditional hemodialysis  Should be tested first before transplantation is
2. Patients with fluid overload secondary to oliguric done
3. Patients whose kidneys cannot handle their acutely
high metabolic or nutritional needs Contraindications (recipient and donor)
1. DIC
CRRT Basic Components 2. Severe irreversible extra renal disease
1. Solutions 3. Chronic respiratory disease
2. Hemofilter 4. Recent malignancy
3. CRRT system 5. Active infection (HIV, Hepatitis B & C)
 Blood warmer 6. Hypertension and diabetes
 Vascular Access 7. Active or chronic infection
 Anticoagulation/anticoagulant 8. Current substance abuse
Difference of CRRT from HD

1. Continuous rather than intermittent
2. Large volume can be removed over days
3. Solute removal occurs by convection there is no
dialysate required in addition to osmosis
4. Less hemodynamic instability
 Patients with hypotension may undergo CRRT
unlike in HD, if there is a hypotension, they
cannot undergo HD
5. Does not need constant monitoring by a specialized The existing kidneys are not usually removed because
HD nurse but it does require a trained ICU nurse this has been shown to increase the rate of surgical
6. Not required complicated HD equipment but a morbidity. So, the donated kidney is placed in a position
modified blood pump different from the original ones. Usually in the Iliac
 Just the hemofilter and the CRRT system fossa, the anterior to the iliac crest because it allows
7. It has precise control of fluid volume easier access to the blood supply needed to perfuse the
kidney.
Nursing Management
1. Monitor fluid and electrolyte balance Postoperative Care of Kidney Transplant
2. Monitor VS and hemodynamic status Goal: Promote uncomplicated recovery of recipient
3. Monitor I & O hourly 1. May see large amounts of urine (3-20 L) in early
4. Assessment and care of the vascular access site postoperative periods from sodium diuresis, or the

kidney may not work for a week or more and dialysis 4. Psychological concerns
will be needed within 24-48 hrs. 5. Monitor potential complications
2. Strict reverse isolation 6. Education on self-care
 To prevent the transmission of microorganisms
to the patient Complications of Kidney Transplant
3. Position − back to non-operatic sides, semi fowler’s
Hyperacute Rejection
4. Indwelling catheter care − report gross hematuria,
• Occurs within 24 hours after transplantation
heavy sediment, clots
• Can be caused by an immediate antibody mediated
5. Diet
reaction that leads to generalized glomerular capillary
 Regular, liberal amounts of protein
thrombosis or necrosis
 Restrict fluids since kidney is not yet working
 Sodium and potassium will be regulated only if
the patient is oliguric Acute Rejection
• 3 days to 14 days or after many years
Management of Kidney Transplant • The T lymphocytes or the T cytotoxic lymphocytes
attack the foreign kidney
1. Screening test prior to surgery – ABO compatibility,
• The patient may experience tenderness at the site of
HLA, Rh BT, tissue typing, antibody screening
transplantation
2. Immunosuppressive therapy
• Decrease serum creatinine value
 Suppress immune response to prevent the
• patient might have fever, body malaise, oliguria
rejection of the transplanted kidney while
• This is common with cadaver kidney but reversible by
maintaining sufficient immunity
increasing the corticosteroid doses and
 To prevent overwhelming infection through a
immunosuppressive therapy
combination of the corticosteroids and
immunosuppressive agents which may affect the
actions of lymphocytes to minimize the body Chronic Rejection
reactions to transplanted organs • Over months and years and irreversible
a. Azathioprine (Imuran) • The kidney is filtered with a large number of T-cells
Side effects: GI bleeding, bone marrow and B-cells characterized by ongoing low grade
depression, leukopenia, anemia, infection, immune mediated injuries
liver damage  That means there is a gradual occlusion of the
b. Prednisone renal blood flow
• Patients may have proteinuria, hypertension,
Side effects: stress ulcer, hyperglycemia,
increasing serum creatinine levels
muscle weakness, osteoporosis, moon face,
• That is why kidney transplant really needs financial
acne, depression and hallucinations
assistance because prior to transplantation, there are
 Monitor the patient for the possible side effects
several tests that the patient has to undergo, then
of these drugs
even after kidney transplant there are several things
3. Monitor risk of infection
that the patient has to observe, maintain medications
4. Psychological evaluation
 The ability of the recipient to adjust from the
transplant (coping strategies, social history and Infection
support, financial resources because transplant • Due to the suppression of the body’s normal defense
is expensive not only before but also after mechanism by surgery
transplant) • The use of immunosuppressive drugs and the effect
 Psychiatric illnesses are often aggravated by the of end stage renal disease
corticosteroid needed for immunosuppression  Commonly these are Pneumonia and wound
after transfusion infection
Nursing Management Cardiovascular Disease

1. Assess for transplant rejections • May increase the incidence of atherosclerosis,
 Check for signs of transplant rejection such as hypertension, DM, and even the increase in the
fever, oliguria, weight gain, edema, elevated BP, homocysteine level that may result in coronary artery
or tenderness of the transplant site disease
2. Prevent infections
 Through strict aseptic techniques
3. Monitor urinary function

Malignancy  Retrograde movement of gram (-) bacilli from

• The immunosuppressant may suppress the immune urethra to bladder
system and also suppress the ability to fight infection  More common in women
and productions of abnormal cells such as cancer  Sexually active and pregnant
cells
Risk Factors
Corticosteroid Related Complications 1. Sexual intercourse also called Honeymoon cystitis
2. Higher risk for women
Lower Urinary Tract Infections  Because of shorter urethra than men
3. Post-menopausal women
For the infections to occur, the bacteria can gain
 Decrease in the level of estrogen, which can
access to the bladder, attach to and colonize the
cause the normal protective vaginal flora to be
epithelium of the urinary tract to avoid being washed out
lost
with voiding. It may invade the defense mechanism of
4. Presence of catheter in urethra, which can also
the client and initiate inflammation.
introduce pathogens
It shows the slow shedding of bacteria epithelial
5. Uncircumcised infants
cells. So, the bladder could clear a large number of
6. Impaired bladder emptying that causes urinary stasis
bacteria. The reflux with coughing, sneezing and
 Urine sits in the bladder allowing the bacteria to
straining, may increase the pressure in the bladder
have the chance to adhere and colonize the
which may force the urine from the bladder into the
bladder
urethra. Then the pressure returns to normal, the urine
will flow back into the bladder bringing the bacteria back
to the bladder from the anterior portions of the urethra. Signs and Symptoms
Uropathogenic bacteria is another cause of lower 1. Dysuria
urinary tract infection. UTI is the infection of the urinary 2. Suprapubic and low back pain
tract which includes the upper portion consisting of the 3. Hematuria, cloudy urine
kidneys and ureter and the lower portion, bladder and 4. Frequency and urgency
urethra. 5. Burning and urination
6. Voiding in small amounts
7. Inability to void
Cystitis
8. Incomplete emptying of the bladder
• Inflammation of the bladder and common site of UTI 9. Foul dark smelling urine
• The inflammation of the bladder results from mucosal 10. Fever
inflammation and congestion 11. N/V
Causes Diagnostic Studies

Ascending infection where the bacteria from the rectum 1. Urinalysis
move into the urethra then into the bladder. If it is a 2. Urine C&S
descending infection, the bacteria from blood goes to  This is the GOLDEN STANDARD
the kidney way down to the bladder through urethra. 3. Cellular studies
1. Bacterial Infection – E. coli and Staphylococcus  Microscopic hematuria, pyuria
saprophyticus (most common), Schistosomiasis,  Microscopic presence of white blood cells and
Enterobacter, Pseudomonas pyuria, presence of stones or interstitial nephritis
 A normal urine is sterile, no bacteria or even patients with renal tuberculosis
 The composition of urine is high in urea 4. Urine dipstick test
concentrations and a low pH, which bacteria  Test positive for the leukocyte esterase/nitrates/
cannot survive or settle in reductase for sexually transmitted organisms
 The direction of urinary flow during urination  It can be a diagnosis for uncomplicated UTI
keeps the bacteria from entering the bladder and 5. Radiographic studies – CT, UTZ
urethra but some bacteria are surviving and  Detect obstruction, abscess, tumor or cysts
resistant that may stick into the bladder and 6. Renal scan
colonize the bladder mucosa  To detect any renal scarring
2. Chemical Irritants  Presence of pyuria means that there’s an
3. Fungal infection elevation of WBC in the urine
4. Foreign Bodies like renal stones  The urine may appear cloudy and there’s a high-
5. Trauma power field of the microscope of greater than 5

 Proper technique of urine catching is important • All types except

corn and lentils
• Beets, beet
greens, Swiss
Management Vegetables • Corn, lentils Vegetables chard, dandelion
greens, kale,
1. Encourage increased oral Fluid Intake mustard greens,
 This is the best choice spinach, turnip
greens
2. Medications
• All types except
 Analgesics Fruits
• Cranberries, plums,
Fruits
cranberries,
prunes plums, prunes
 Antispasmodics to prevent the bladder irritability • Molasses
and pain • Plain cakes,
Desserts Sweets • Molasses
 Antibiotics − Bactrim forte cookies
3. Acid ash diet

 The use of cranberry juice can help prevent and
control symptoms
 Requires drinking CBJ longer, not just in 1
drinking
4. Strict asepsis
5. Application of heat to the perineum
 Help relieve pain and spasm but make it sure
that it is warm, in order to not to burn the patient
6. Avoid urinary irritants
 Coffee, tea or cola, alcohol
7. Empty bladder completely and regularly
 The lower the urine bacterial count may reduce Upper Urinary Tract Infections
urinary stasis and prevent re-infection Pyelonephritis
8. Education
• Inflammation due to bacterial infection of the
 Educate the patient with regard to the early signs
parenchyma and pelvis of the kidney
and symptoms of cystitis
• Begin with colonization and infection from the lower
9. Proper hygienic measures
urinary tract via ascending urethral route from
 To prevent catheter associated UTI if the patient
vesicoureteral reflux such as retrograde or backflow
is on a urinary catheter
movement of the urine from the lower urinary to the
 Do perineal care
upper urinary tract. Like BPH or urinary stone
 Some patients with genetic influence are prone
• 95% of cases are caused by gram-negative enteric
to develop cystitis
bacilli (E. coli), Enterobacter, Klebsiella that causes
nephron destruction
Prevention • Leads to impaired sodium reabsorption (salt wasting),
1. Wipe from front to back inability to concentrate urine, progressive renal
2. Avoid bubble bath failure, and hypertension
3. Void every 2 to 3 hours to empty the bladder • Inflammation of the renal pelvis, as shown in the first
4. Wear cotton pants, instead of nylon pants. few slides, a funnel-like structure of the kidney
5. Acid and alkaline ash foods • Usually it may affect 1 kidney (unilateral)
 Acid ash foods may acidify your urine, but if your • The bacteria may adhere on the epithelial of the renal
urine is too acidic, you may eat alkaline ash tubules which may trigger inflammatory response
foods • Acute pyelonephritis may start in the renal medulla
and spread to adjacent cortex
 Recurring of this episode can lead to scar which
Acid-Ash Foods Alkaline-Ash Foods
may affect the function of the kidney so it may
• Meat, fish, fowl,
Meat
shellfish, egg cause chronic pyelonephritis.
• All types of cheese • Milk and milk • Urosepsis is a systemic infection that arises from
Dairy and
• Peanut butter Dairy products urologic sources. It needs immediate diagnosis and
other protein
• Peanuts • Butter milk
effective treatment because it may lead to septic
• Nuts (almonds,
• Bacon, nuts (Brazil, shock or death.
Fat Fat chestnut,
filberts, walnuts)
coconuts)
• All types esp. whole
wheat
• Crackers, cereal,
Starch
macaroni,
spaghetti, noodle,
rice

Risk Factors / Causes of Pyelonephritis Signs and Symptoms

1. Obstruction – kidney stones 1. Fever, chills
 Obstruction and stasis of the urine may 2. Low back pain, flank pain
contribute to bacteriuria, even hydronephrosis 3. Nausea and vomiting
and irritations of the epithelial lining with the 4. Headache
entrapment of the bacteria 5. Frequency, urgency and painful urination
2. Vesicoureteral reflux 6. Leukocytosis, bacteriuria
 Chronic reflux of urine, the backflow of urine from 7. Tenderness in costovertebral angle (CVA)
the bladder going up to the kidney  Pay attention that there is a tenderness in the
 It can happen in the vesicoureteral orifice costovertebral angle, usually on the affected site
 May be caused by a congenital defect of the
valve or orifice or there is an obstruction in the Chronic Signs and Symptoms
bladder outlet which causes the pressure on the
1. NO symptoms
bladder that may affect the valve
2. Fatigue
3. Neurogenic bladder
3. Headache
 Neurologic impairment that may interfere with
4. Poor appetite
the normal bladder contraction with residual
5. Polyuria
urine and causes ascending of infection
6. Excessive thirst
4. Pregnancy
7. Weight loss
 Urethral relaxation caused by high progesterone
8. Persistent and recurring infection
level
 Produce scarring of the kidney resulting to CKD
 Pregnancy may also cause obstruction from
enlargement of the uterus
5. Instrumentation Collaborative Management
 Catheterization wherein introduction of 1. Specific antibiotics agents (2-weeks course)
organisms into the urethra, bladder or 2. Hydration – oral & IV fluids
endoscopes that is introduced into the urinary  About 1500-2000ml per day to flush out the
tract for diagnostic purposes bacteria to reduce pain and discomfort
6. Female sexual trauma 3. Urine C&S 2 weeks after completion of antibiotic
7. Hematogenous infection therapy
 The infection from the blood may result in 4. Monitor temperature
pyelonephritis. There is a possibility however, 5. Education
this is not common  Increase fluid intake, emptying bladder regularly
6. Meticulous perineal care
 Goal is to combat infection, prevent recurrence
Diagnostic Studies
and alleviate the symptoms
1. Urinalysis
2. Urine C&S
 Presence of WBC casts in pus indicates Complications
involvement of renal parenchyma but not always 1. Renal abscess
present 2. Recurrent infection
3. WBC count – leukocytosis  This is very common for those with anatomic
 Although they have to evaluate further in order to problems which allows bacteria to cause
determine which part of the urinary tract is infection
affected 3. Chronic pyelonephritis
4. Imaging studies 4. Papillary necrosis
 Not usually done because of the contrast 5. ESRD
materials to prevent possible spread of infection  Progressive loss of nephrons secondary to
5. Ultrasound chronic inflammation and scarring
 Identify abnormalities or presence of obstructing 6. Hypertension
stone 7. Formation of stones
6. IV pyelogram
 If functional and structural renal abnormalities is Polycystic Kidney Disease
suspected • Genetic disorder characterized by cystic formation
7. Radionuclide imaging and hypertrophy of the kidneys which lead to cystic
 Identify sites of infection rupture, infection formation of scar tissue, and
damage nephrons

• Leads to kidney failure  This is a stone inhibitor like potassium citrate, the
• Usually does not have any cure, so the treatment is Tamm-Horsfall protein, and magnesium are
more supportive which includes control of BP, pain capable of inhibiting crystal growth
control and prescription of antibiotic agents to resolve  Therefore, reducing the use of calcium phosphate
infection or calcium oxalate may precipitate in urine and
prevent stone formation
Signs and Symptoms
1. Hematuria Risk Factors
2. Polyuria 1. Age and gender
3. Hypertension  Common in male and obese patient
4. Develop renal calculi associated with UTIs  Common in American and Asian due to high
5. Proteinuria protein diets and salt intake
6. Abdominal fullness and flank pain o Avoid eating salty food
7. Palpable mass o Increase fluid intake because if there is
reduction in fluid intake this may be
Diagnostic Studies susceptible in renal stone formation
2. Diet and fluid intake
1. Physical assessment by palpating the abdomen
3. Occupation
 Reveals enlarged cystic kidneys
4. Changes in urine pH and concentration
2. ultrasound imaging
 May precipitate crystal formation such as uric
acid calcium salt − alters calcium metabolism
Management 5. Infection – UTI
1. Monitor for hematuria 6. Urinary stasis
2. Increase sodium and water 7. Immobility
3. Provide bed rest 8. Metabolic – PKD, chronic stricture
4. Prepare for percutaneous cyst rupture – under strict 9. Medications
aseptic technique  Antacids, high doses of aspirin, acetazolamide
5. Administer anti-hypertensive (Diamox)
 PKD patients may have hypertension  Some form of cancer
6. Genetic counseling  Excessive intake if vit. D
 Because this is a genetic disorder
7. Renal transplant and dialysis
Type of Stones
 If the nephron is severely damaged
Calcium Oxalate
• 70% - 80% – dietary intake
Renal Calculi
• This is due to hypercalciuria, higher absorption of
• Urolithiasis and nephrolithiasis refer to stone (calculi) dietary calcium and decreased renal calcium
in the urinary tract and kidneys reabsorption. Additionally, patients with hyperpara-
 The calculi are masses of crystals, protein or thyroidism and bone demineralization are also at risk.
other substances that are common of urinary tract However, the use of oxalate in the diet may risk the
obstruction in adults formation of calcium stone/bone formation
• Located in the kidneys, ureters and urinary bladder • Idiopathic/unknown cause
• Formation of renal calculi depending on the salts in • The stone forms freely in the supersaturated urine or
urine, this means the amount of substance, the ionic detaches from the intestinal side within tubules near
strength and pH of the urine the tip of the renal papillae
• Supersaturation is the presence of higher • Food containing oxalate, such as spinach, french
concentration of salt within the fluid than the volume fries, nuts, potato chips, and large amount of vit. C
of the salt that is able to maintain the equilibrium • Take a lot of fluid to flush this out
• Another cause is the precipitation of the fluid from the
solid state. Human urine contains many ions capable
Uric Acid
of forming solutions and a variety of salt. Salt form
crystal that retains in the stone • 5% - 10% with gout and myeloproliferative disorders
• Although supersaturation is essential for stone • Uric acid is by product of the endogenous urine and
formation it does not necessarily remain continuously secondary affected by the consumption of uric in the
supersaturated for renal stone to grow diet
• Absence or presence of stone inhibitor also known as
neuromodulator, Tamm-Horsfall protein

Struvite Management of Renal Calculi

• (15%) – alkaline, ammonia-rich urine that contains Goal is to reduce pain, promote passage of the stone,
magnesium ammonium phosphate and vary in reduce size of the stone and prevent formation of new
different levels in the matrix stone
• Matrices form by producing bacterial pathogens such
as klebsiella pseudomonas Nutritional Therapy
• The struvite may grow large and stagnant • Restrict calcium intake, take liberal fluids and the use
configurations that may lay on the collecting ducts of thiazide diuretics which is beneficial in reducing
• Common in patients with URT infection calcium loss in urine and lowering elevated
parathyroid hormones
Cystine • Food that is high in purine such as shellfish,
• Rare, from amino acid metabolism in the body asparagus and organ meats should be avoided
• This is a genetic disorder from the presence of low • Allopurinol may be prescribed in order to reduce the
urine pH of 5.5 or less serum uric acid level and excretion
• For oxalate stone, food that contains spinach,
chocolate, wheats, peanuts must be avoided as well
Sign and Symptoms
to prevent formation of oxalate stone
1. Pain • Acid dash diet that consists of a large amount of meat,
 Depends on the location of obstruction fish, cereal with minimal quantity of meal. When
 Deep ache of the costovertebral region, or what catabolize, it may lead in to acid residue to de
we called renal colic and described as moderate excreted
to severe pain, often felt in the flank and radiate • Alkaline dash diet, consist of fresh fruits and
to the bone area. This may indicate obstruction vegetables, except of cranberry and plum
on the renal pelvis or proximal ureter
2. Hematuria, pyuria
Fluid Intake
3. Fever, chills
4. Nausea and vomiting • At least 2 liters per day unless contraindicated like in
5. Diarrhea and abdominal discomfort patients with heart failure
6. Urine frequency
 Sometimes unable to void, then when able to Opioid Analgesic Agent
void, it has pus and blood due to abrasive action • NSAIDs to prevent shock that may result in severe
of the stone pain
 Stones of 0.5 to 1 cm in diameter will be able to • NSAID is effective in treating stone pain and inhibits
pass out but more than 1 cm in diameter must be prostaglandin to reduce swelling and facilitate
removed or fragmented through lithotripsy to passage of the stone
pass it out spontaneously
7. Pallor and sweating
Warm Bath to flank area to reduce spasm
Diagnostic Studies
Extracorporeal Shock Wave Lithotripsy (ESWL)
1. Urinalysis include pH
• Patients may have discomfort due to multiple shocks
2. Blood chemistry
• Observe any infection that may result in blockage of
3. 24-hour urine test
the stone fragment in the urinary tract
 To identify whether calcium oxalate, citrate, or
other constituents such as uric acid, and
creatinine increase crystal formation and other Percutaneous Nephrolithotomy
organic substances • Introduced to renal parenchyma and extract by
 Determine abnormal pH whether acidic or forceps or stones retrieval basket
alkaline, and • Stones may be removed by the small puncture into
4. CT scan – non contrast the kidney, suitable for stones that are greater than 2
5. Stone analysis cm that present around the renal pelvis
6. Ultrasonography
7. IV pyelography Chemolysis Stone Dissolution
• use of chemical infusion such as alkaline agents,
acidifying agents, to dissolve the stone
• Ureteroscopy is the insertion of scope into the ureter
to utilize the stone to break it

• Stent may also be placed and will stay for about 48 Cutaneous ureterostomy – ureter directed to
hrs. or more after procedure to keep the ureter patent abdominal wall and attach to open skin
Nephrostomy – catheter is inserted through renal
Surgery: Nephrectomy incision in the flank or by a cutaneous catheter placed
• Removal of the kidney, especially if this is not already into the kidney
functioning Vesicostomy – suture the bladder that creates an
opening through the abdominal wall and bladder wall
for urinary drainage
Nursing Management for Renal Calculi
1. Pre-operative care of for surgery
2. Monitor VS Continent
3. Nutritional therapy • A portion of the intestine is used to create a new
 Low purine and avoid protein to decrease the reservoir for urine
urinary excretion of the calcium and uric acid Indian pouch
 Limit sodium intake Ureterosigmoidostomy – transplantation of the ureter
 Careful for low calcium intake, unless for true to the sigmoid colon allowing urine to flow through
absorptive hypercarotenemia and if their low colon and out of the rectum. Performed to patients
calcium intake may lead to bone density loss with extensive pelvic irradiation, previous small bowel
particularly to postmenopausal women resection or with small bowel diseases.
4. Increase fluid intake
5. Avoid activities that lead to excessive sweating and
Ileal Conduit
dehydration but may ambulate to promote passage
• Implanting the ureter into a loop of ileum led out
of the stone except during acute colic attack then
through the abdominal wall.
place in bed rest
• An ileostomy bag is used to collect urine
6. Consent for invasive procedures
• Complication: wound infection, wound dehiscence,
7. Check lab result
urinary leakage, and gangrene of the stoma so
8. ESWL – observe for any bleeding
assessment of stoma is important
9. Strained urine to monitor if there is presence of
• Stents may be placed in the ureter to prevent
stone, deliver it to the laboratory
occlusion secondary to post-surgical edema and will
10. Monitor signs of infection
leave for 10-21 days
Urinary Diversion
Nursing Management
• To divert urine from the bladder to a new exit site,
1. Stoma care
usually through a surgically created opening (stoma)
 Healthy stoma color is pink and red
in the skin
 If there are changes, this may compromise the
• Common method for urinary diversion, also known as
vascular supply
Bricker’s procedure
2. Inspect the color and viability
• Performed in the bladder tumor
3. Inspect for bleeding of the stoma, encrustation, skin
irritation
Indications 4. Inspect for wound infection
1. Congenital anomalies of the bladder 5. Observe for moisture of bed linens, clothing, odor of
2. Neurogenic bladder urine
3. Mechanical obstruction to urine flow 6. Changing the appliance
4. Severe cystitis  Appliance application and emptying – do not
5. Trauma to lower urinary tract remove each day, change appliance every 4-5
6. Pelvic malignancy days or when leaking
7. Birth defects 7. Cleaning and deodorizing appliance
8. Strictures  Rinsed in warm water and soaked in 3:1 ratio of
water and white vinegar
Cutaneous  Avoid putting appliances in direct sunlight, this
• Urine drains through an opening created in the may cause cracking of the pouch or even hot
abdominal wall and skin water should be avoided
8. Control odor
Conventional ileal conduit – common; urine is diverted
 Avoid strong odor food such as asparagus,
by implanting the ureter with a loop of ilium that leads
cheese, egg
out to the abdominal wall

 Vit. C may acidify urine and suppress urine • For instance, in a patient with an intact urinary system,
output this agent may affect the alpha urinary receptor that is
9. Encourage fluids responsible for the urinary bladder causing pressure
10. Provide emotional support • Once the medication is being stopped, this may
11. Diet management resolve the problem.
 Acid-ash diet
 Avoid asparagus, tomatoes Mixed
 Avoid gas-forming food
• Common to women with a combination of overactive
12. Salt intake restriction
stress
 To prevent hyperchloremic acidosis and
increase K in continent urinary diversions
13. Provide hygiene Risk Factors
14. Monitor complication 1. Age-related changes in the urinary tract
15. Empty the urine from the intestine 2. Cognitive disturbances
 To lower rectal pressure and minimize the 3. Diabetes
absorption of urinary constituents from the colon 4. High-impact exercise
5. GUT surgery
 Such as prostatectomy that causes loss of
Urinary Incontinence
urethral compression
• Involuntary loss of urine from the bladder that affects
6. Immobility
all ages but more common in elderly or multiparous
7. Incompetent urethra
women
 Due to trauma or sphincter relaxation
8. Medications
Types of Urinary Incontinence  Sedatives, diuretics, hypnotics agents, opioids
Age related, cognitive disturbances, like Parkinson 9. Pelvic muscle weakness
disease, or dementia. 10. Pregnancy
11. Stroke
Stress Incontinence
• Leakage of urine due to increased intraabdominal Assessment and Diagnostic Findings
pressure such as sneezing, coughing, and changing 1. History taking
positions so there will be involuntary loss of urine 2. Fluid intake and output
• This may affect women who have vaginal deliveries 3. Medications taken
and male patients due to radical prostatectomy due to 4. Bedside test – residual urine, stress maneuver
prostate cancer 5. Extensive urodynamic test
6. Urinalysis
Urge Incontinence 7. Urine culture
• Overactive bladder, associated with strong urge to
void that cannot be suppressed this may cause Management
involuntary loss of urine 1. Behavioral therapy – first choice to eliminate urinary
• Seen with patients who have neurologic dysfunction incontinence
which damages nerve control muscles that help the  Kegel’s exercise
urinary flow  Bladder training or double voiding
 Scheduling of toilet trip every 2 hours
Functional 2. Pharmacologic therapy
• For instance, lower urinary tract function is intact but Anticholinergic – inhibit bladder contraction, consider
other functions have severe cognitive impairment like first line medication for urge incontinence
Alzheimer's dementia that make it difficult for patient Tricyclic antidepressant – decrease bladder
to identify the needs to void or impossible for them to contraction and increase bladder neck resistance
reach the CR to void due to physical inactivity Pseudoephedrine sulfate (Sudafed) – treat stress
incontinence but cautiously given with patients who
Iatrogenic have hypertension, and prostatic hyperplasia. This is
• Due to extrinsic medical factors like alpha adrenergic an alpha-adrenergic receptor that causes urinary
agent that decreases blood pressure retention
3. Surgery intervention
 Anterior vaginal repair with stress incontinence.

Nursing Management Strategies for Promoting Urinary Clinical Manifestation

Continence 1. Bladder fullness
1. Avoid bladder irritants 2. Sensation of incomplete bladder emptying
 Caffeine, alcohol, and aspartic 3. Signs and symptoms of URT infection
2. Avoid taking diuretic agents after 4 pm
3. Perform all pelvic floor muscle exercises Complications
4. Coughing due to smoking increases incontinence
1. Renal stones
5. Take steps to avoid constipation
2. Pyelonephritis
 Drink adequate fluids
3. Sepsis
 Eat high in fiber
4. Hydronephrosis
 Exercise regularly
 Take stool softener
6. Void regularly about every 2-3 hours Management
 First thing in the morning, before each meal, and 1. Analgesic agent
before going to bed, and one time during night  Given after surgery especially to
time, if necessary hemorrhoidectomy patients or childbirth due to
pain in the perineal that causes voiding difficulty
2. Urinary catheterization
Urinary Retention
 To prevent over distention of the bladder
• Inability to empty bladder completely during attempts
3. Observe for complications
to void that can lead to chronic infection, calculi
formation, hydronephrosis, pyelonephritis, cystitis
• Residual urine – urine remains in the bladder after Nursing Management
voiding 1. Encourage normal voiding patterns
2. Provide privacy
3. Body position conducive to voiding
Causes
4. Apply warmth to relax the sphincter
1. Trauma – pelvic injury
5. Use of bedside commode
 About 50-100 ml of residual may remain after
6. Offer hot caffeine-free beverages
each voiding due to decreased contractility of the
7. Do trigger techniques
detrusor muscle
8. Aseptic technique during catheterization
2. Prostate enlargement
9. Wearing clothes easy to remove quickly
3. Urethral pathology – infection, tumor, calculus
4. Pregnancy
5. Neurological disorders – stroke, spinal cord injury, Neurogenic Bladder
Multiple sclerosis, Parkinson's disease • A bladder dysfunction caused by neurologic disorder
6. Medications that leads to urinary incontinence
 Occur in post op patient if the surgery affects the • Also caused by spinal cord injury, spinal tumor,
perineal or anal region herniated vertebral disc, multiple sclerosis, congenital
 Usually, to patients with post hemorrhoidectomy disorders
 General anesthesia reduces bladder muscle and
suppresses the urge to void and may intend Types of Dysfunctions
bladder emptying Spastic Bladder (Reflex Bladder)
• Lesions develop in the upper motor neuron of the
Assessment and Diagnostic Findings voiding reflex arc; common type
1. Neurodynamic studies
 To identify the types of bladder dysfunction and Flaccid
to determine appropriate treatment
• caused by a lower motor neuron lesion that results
2. Bladder fullness
from trauma
3. Signs and symptoms of UTI
• Lesion seen on the sacral area of the spinal cord that
4. Urodynamic studies
results in hypotonic bladder function often with loss of
5. Ultrasonography
bladder sensation
 Assess to post void residual urine, normally
• Also seen patients who have DM, bladder continuous
more than 50 ml amount of residual urine
to fill and become distended, over-floor incontinence
occurs
 Difficulty to empty the bladder
• Patient muscles do not forcefully contract at any time

Diagnostic Study 9. Western diet

1. Neurodynamic studies  Due to high intake of animal fats and protein and
2. Fluid intake low intake of fiber
3. Urine output and residual urine volume
4. Urinalysis Sign and Symptoms
1. Bladder outflow and obstruction
Common Complication 2. Spectrum of lower urinary tract symptoms
1. Renal calculi 3. Residual urine
2. Urinary incontinence or retention 4. Hematuria
5. Bladder or kidney function
6. Bladder calculi
Management
7. Hydronephrosis
1. Continuous, and subsequent, intermittent or self-
8. Renal insufficiency
catheterization and use of external condom-type
9. Progressive bladder distention
catheter
2. Diet – low in calcium to prevent calculi
3. Encourage mobility and ambulation Diagnostic Studies
4. Liberal fluid intake 1. Medical history and physical examination
 To reduce urinary bacterial count, reduce stasis, 2. Digital rectal exam (DRE)
decrease the concentration of calcium in the 3. Prostate specific antigen (PSA)
urine, and minimize the precipitation of urinary 4. Transrectal ultrasound (TRUS)
crystals and subsequent stone formation  To determine bladder and prostate volume and
5. Bladder retraining program size of prostate and any residual urine
 Treating spastic bladder or urine retention 5. Urinalysis
6. Pharmacologic therapy – bethanechol (Urecholine) 6. Serum creatinine and BUN
 Help to  the contraction of the detrusor muscle 7. Uroflowmetry
7. Surgery 8. Postvoid residual urine (PRV)
 Correct bladder neck contractures or 9. Cystometry
vesicoureteral reflux  Detect kidney and bladder function
 Perform a urinary diversion procedure  This is a definitive test performed before the
surgery and helps determine what best
procedure will be done to the patient
Benign Prostatic Hyperplasia
• Hyperplasia of the prostate gland due to increased
prostatic tissue that compresses the urethra where it Treatment
passes through urethra resulting in frequency of lower Conservative Therapy
UTI infection and symptoms 1. Prostate massage
• Link to hormonal activity of male patients that 2. Sitz bath
produces hydrogenic hormones that causes 3. Fluid restriction to prevent bladder distention
imbalance between androgen and estrogen levels 4. Antimicrobial to prevent infection
and high levels of testosterone
Pharmacologic Therapies
Risk Factors 1. Alpha-1-adrenergic blockers

 Relax smooth muscles of the bladder and
1. Family history
prostate and also improve urine flow and relieve
2. Race − African-American
the symptoms
3. Obesity
2. Antiandrogen agents – 5 alpha reductase inhibitors
 With central fat distribution around the abdomen
 To prevent conversion of testosterone to
that increases the risk of BPH
dihydrotestosterone and decrease prostate size
4. Advanced age
5. Androgen hormones Alternative and Complementary Therapy
 Dihydrotestosterone is necessary for normal
1. Serenoa repens, commonly known as saw palmetto
development.
berry – African plum
 Its role in BPH remains unclear
2. Pumpkin seeds
6. Smoking, consumption of alcohol
7. Physical inactivity
8. Underlying conditions such as HTN, heart diseases,
DM

Surgery
Transurethral Radiofrequency Procedures (TUNA)
• Low frequency energy that is delivered through tiny
needles that are placed in the prostate gland
• Produce localized heat and destroy the prostate
tissue while sparring the other tissues
Transurethral Microwave Thermography

• Application of heat to the prostate tissues could be
high or low energy thru insertion of the endoscope into
the urethra
• Microwave is directed to the prostate tissue
Transurethral Resection of the Prostate (TURP)

• Surgical treatment for BPH
• Involves surgical removal of the inner portion of the
prostate through an endoscope
• There is no internal skin incision that is performed with
ultrasound guidelines
• If a prostate weighs 2 ounce or 57.2 grams they may
do the TURP
TURP Bladder Irrigation

− connected to triple lumen catheter
− one lumen is connected to the irrigating solution
similar with IV plastic solution
− Another tube is inflating the balloon
− Another tube is draining the urine
− Irrigating solution is through the use of 0.9 normal
saline solution, you need to check the level
carefully, because the IV plastic solution is almost
same appearance of this normal saline solution
− Measure intake and output every hour
− Doctors may order do not manipulate the
irrigation

COMMUNICABLE DISEASES
Communicable Disease Disinfectant − use of chemical agents that is applied to

• It is an illness caused by an infectious agent or its toxic inanimate or non-living objects and is too toxic when
products that are transmitted directly or indirectly to a applied to tissue (e.g. Cidex, concentrated Lysol,
well person through an agent, vector or inanimate formalin)
object Sterilization – use of physical or chemical agents that
• Caused by bacteria, viruses, parasites, and fungi that cause complete destruction of all microorganism
can be spread directly or indirectly from one person to Antiseptic – chemical used on living tissue such as skin
another and mucous membrane free from pathogenic
• Some are transmitted through bites from insects while microorganism (e.g. betadine, hexidine)
other are caused by ingesting contaminated food or Bacteriostatic – reduces microorganism
water
 Inhibit bacterial multiplication without killing them
 Relapses can occur after discontinuations of a drug
Types of Communicable Disease  e.g. macrolides, clindamycin, chloramphenicol
Infectious − not easily transmitted by ordinary contact Bactericidal – kills microorganism and inactive bacteria
but require a direct inoculation through a break in the (e.g. metronidazole, vancomycin, aminoglycosides)
previously intact skin or mucous membrane Isolation – the separation and restriction of movement
Contagious − easily transmitted from one person to and activities of an ill persons from other persons with
another through direct or indirect means contagious disease or communicable disease for the
purpose of preventing disease transmission
o All contagious diseases are infectious but not
Quarantine – limitation of freedom of movement of
all infectious diseases are contagious
persons which have been exposed to communicable
diseases for a period of time equivalent to the longest
Terminologies
incubation period of that disease
Disinfection
• Destruction of pathogenic microorganism outside the
General Principles
body by directly applying physical or chemical means
1. Pathogens move through spaces or air current
• Process that reduces the number of contaminating
2. Pathogens are transferred from one surface to
microorganisms, particularly those liable to cause
another whenever objects touch
infections to the level which is no longer harmful to the
 Microbes can survive outside the body for
health
several hours
• Kills microbe microorganism except for bacterial
3. Hand washing removes microorganism
endospore but it kills the vegetative forms of bacteria
 Key measure to prevent the spread of infection
Concurrent – method of disinfection done
4. Pathogens are released into the air on droplet nuclei
immediately after the infected individual
when person speaks, breaths, sneezes
discharges infectious material/secretions. This
 Keep distance from infected person
method of disinfection is when the patient is still the
5. Pathogens are transferred by virtue of gravity
source of infection
6. Pathogens move slowly on dry surface but very
 Immediate process wherein the applications of quickly through moisture
disinfection measures as soon as possible
after discharge of infectious materials or
Infection
secretions from the body such as urine, feces,
contaminated blood, clothes, gloves/hands, or • Invasion of an organism's body tissues by disease-
bed linen causing agents, their multiplication, and the reaction
of host tissues to the infectious agents and the toxins
Terminal – applied when the patient is no longer
they produce resulting to signs and symptoms as well
the source of infection
as immunologic response
 Application of disinfection measures after the
• May injures the patient by
patient has died or has ceased to be a source
 Competing with the host’s metabolism (in patients
of infection sell it can be done in the
with ascariasis)
convenience time such as cleaning of the bed,
 Cellular damage produced by the microbes
IV stands, and BP apparatus
 Intracellular multiplication
Prophylactic – preventive measure to prevent the
spread of infection such as boiling of water, proper
hand washing, chlorination of water, even
pasteurization of milk

Factors Influencing the Extent and Severity of • Skin and mucous membranes, natural microbial flora,
Infection enzymes, and complement protein
Pathogens • “Microbial antagonism principle” enables the
a. Dose – number of invading microorganisms indigenous microflora to serve as a beneficial wall
b. Virulence – ability of the microorganism to produce preventing other microbes from colonizing the body
disease  Resident bacterial flora prevents the colonization
c. Route of entry of pathogenic bacteria
 One example is the vagina flora which maintains
Host
a pH of 3.5-4.5 to prevent to overgrowth of
a. Immune status – ability to resist infection
amoebiasis albicans
b. General health and nutritional status
c. Genetic influence Second
• Inflammatory response
Disease Occurrence in Population • Broad, internal defense
Sporadic • Phagocytic cells and WBC to destroy invading
S Disease that occur occasionally and irregularly in a small area with no
specific pattern (scattered and isolated cases). microorganism manifesting the cardinal signs
Endemic
Those that are present in a population or community at times.
E Regular number over a period of time in a certain geographical Third
location.
E.g. malaria in Africa • Immune response − Natural/Acquired: active/ passive
Epidemic • Lymphocytes and antibodies (B cells & T cells)
Diseases that occur in a greater number than what is expected in a
E specific area over a specific time.
Widespread outbreak affecting large areas.
Pandemic Risk Factors
P An epidemic that affects several countries or continents.
E.g. SARS, COVID, AIDS 1. Age, sex, and genes
 Very young and very old
Causes of Infection 2. Nutritional status, fitness, environmental factors
1. Some bacteria develop resistance to antibiotics  Maintain a well balance diet to decrease the risk
 Concurrent use of antibiotics is not advisable of infection
2. Some microbes have so many strains that a single  Maintain a clean environment
vaccine can’t protect against all of them 3. General condition, emotional and mental state
 Influenza and COVID 4. Immune system
3. Most viruses resist antiviral drugs  Encourage patients to take zinc supplements
4. Opportunistic organisms can cause infection in 5. Underlying disease (diabetes mellitus, leukemia,
immunocompromised patients transplant)
 Especially AIDS patients who are prone to these 6. Treatment with certain antimicrobials (prone to
opportunistic microorganisms like pseudomonas fungal infection), steroids, immunosuppressive drugs
and klebsiella etc.
5. Most people have not received vaccinations
6. New infectious agents occasionally arise such as Classification of Infection
HIV & Corona virus Primary − initial infection with organism in the host
7. Some microbes localize in areas of the body that Re-infection − subsequent infection by the same
may treatment difficult (e.g. bones, CNS) organism in a host after recovery
8. Increased air travel can cause the spread of virulent
Superinfection – infection of the same organism
microorganism to heavily populated area in hours
occurring after or on top of an earlier infection
9. Use of biological toxins (warfare and bioterrorism)
with organisms such as Anthrax and plaque is an Secondary Infection – the resistance of a person is
increasing threat to public health and safety lowered by a pre-existing infectious disease causing a
throughout the world new organism to set up in an infection
10. Use of immunosuppressive drugs and invasive Cross Infection – when a person is suffering from a
procedures increase the risk of infection disease and a new infection set up from another host or
external source
Subclinical Infection – asymptomatic which produces
Three Lines of Defense
effects that are not detectable by the usual clinical test
First
 Not clinically apparent or does not show signs and
• Mechanical barriers
symptoms but may lead to immunity or non-
• Broad, external defense
immunity

 E.g. Hepatitis A in children

Clinical Infection – characterized by the presence of the
cardinal signs and symptoms
Chain of Infection
Mode of Transmission – means by which the

infectious agent passes through the portal of exit of the
reservoir to the susceptible host. This is the easiest way
to break the infection through proper handwashing
Contact Transmission – common mode
Direct Contact – person to person
Infectious Agent − is able to survive and multiply and Indirect Contact – inanimate object or fomites
also produce itself in a manner that can be transmitted Droplet Spread – from coughing, sneezing or
to man talking by an infected person which can travel up
to 3 ft. to 1 meter
Carrier – infected hosts who are potential sources of  Organism is not suspended in the air but rather
infection for others settled on a surface
Active Carrier – has overt clinical case of disease Air-Borne Transmission – occurs by particles that are
suspended in the air (TB, chicken pox, measles)
Convalescent Carrier – has recovered but continuous
to harbor large number of pathogens Vehicle Transmission – through articles or
substances until it is being ingested or inoculated into
Healthy Carrier – harbors the pathogen but is not ill
the host
Incubatory Carrier – is incubating the pathogen in
Salmonellosis through contaminated food
large numbers but is not yet ill
Shigellosis through contaminated water and food
Intermittent Carrier – occasionally shed the
pathogenic microorganism Bacteremia from infusion of contaminated drugs or
blood products (hepatitis B or non-AB hepatitis)
Sustained/Chronic Carrier – always have the
infectious organism Vector-Borne – infection through arthropods such as
mosquitoes, fleas, flies and ticks
o Animals are responsible for infestation with
trophozoites like amoeba
o Fomites are from garden soil or street dust
Portals of Exit – way in which the organism leaves the

reservoir
Respiratory Tract – coughing, sneezing, spitting
(influenza, TB)
Gastrointestinal Tract − feces (typhoid fever,
salmonella, cholera) and saliva (rabies virus, herpes
simplex)
Genitourinary Tract − urine and vaginal secretions
Skin and Mucous membranes – superficial lesions
and percutaneous site
Blood − biting arthropods and needles/syringes

Portal of Entry – pathogens may find a venue wherein Emerging Problems in Infectious Diseases
it gains entrance into the susceptible host 1. Increasing number of different organisms
 Which develops resistance to increasing number
of available antimicrobials
2. Serious disease exposed to aggressive surgical
procedure
3. Developing resistance to antibiotics e.g. anti-TB
drugs, MRSA
4. Increasing numbers of immunosuppressed patients
(CA and leukemia)
5. Use of indwelling lines and implanted foreign bodies
has increased (e.g. urinary catheterization)
Infection Control Measures

Susceptible Host – if the defenses of the host is good, • These are measures practiced by healthcare
there is no infection that will take place however, if the personnel to prevent spread and transmission of
host is weak, microbes will launch an infectious disease infections between patients and healthcare providers
Low Immunity – patients undergone transplant,
receiving chemotherapy, AIDS) Universal Precaution – all blood, blood products and
Poor Physical Resistance – burn patients who have secretions from patients are considered as infected
impaired skin integrity that is a good source of In order to avoid discrimination, treat aft bodily fluids and
infection fetal matter as though they may be infected and observe
Surgical Procedure – abrasion the following precautions:
Age – very young and very old 1. Use barrier protection by covering up any open
Nutritional Status – malnourished wounds or sort; before proceeding
Underlying Diseases

2. Wear gloves when handling bodily fluids or Control Measures

contaminated materials and other waste 1. Masking
3. Wear a face mask/gown  Patients with infectious respiratory diseases
4. Use caution when handling sharp objects, needles, should wear mask (pneumonia, TB)
and waste  N95 mask should be worn when caring for
5. Discard contaminated materials by following patients with COVID
biohazard procedures for disposal 2. Handwashing
6. Clean area thoroughly with disinfectant  With the use of soap and water
7. Wash hands thoroughly with soap and water for at  Before and after patient contact and after
least 20 seconds removing the gloves
8. Wash clothing in hot water 3. Gloving
 Wear gloves for all direct contact with patients
Work Practice Control  Changing of gloves and handwashing every after
1. Handwashing each patient is a must
2. Protective equipment shall be removed immediately 4. Gowning
upon leaving the work area  During procedure since it may likely to generate
 Apron must be folded properly and placed in a splashes of blood or body fluid secretions
plastic bag 5. Eye protection (goggles)
 Mask, gloves etc. should be removed and  To prevent splashes and aerosols
discarded properly; placed in designated area or 6. Environmental
container for washing, decontamination or  Clean surfaces with disinfectants like 70%
disposal alcohol or diluted bleach
3. Used needles and sharps SHALL NOT be bent,  Clean the room after discharge
broken, recapped
 Used needles must not be removed from Isolation Precaution
disposable syringes • Separation of patients with communicable diseases
4. Eating, drinking, smoking, applying cosmetics or from others so as to reduce or prevent transmission
handling contact lenses are prohibited in work areas of infectious agents
 If it cannot be avoided, handwashing must be
performed Categories Recommended in Isolation
5. Foods and drinks shall not be stored in refrigerators,
Strict Isolation – to prevent highly contagious through
freezers where blood or other infectious materials
handwashing, infectious materials must be discarded,
are stored
use of single room, use of mask, gloves and gowns
 Blood should be stored in the blood bank not in
the refrigerator  Prevent spread of infection from patient to patient or
6. All procedures involving blood or other potentially staff
infectious materials shall be performed in such a  Wash hands after every contact
manner as to minimize splashing, or spraying Contact Isolation – prevent spread by close or direct
contact
Respiratory Isolation – prevents transmission through
air
TB Isolation – for (+) TB or CXR suggesting active PTB
Enteric Isolation – direct contact with feces
 Proper handwashing and proper disposal
Drainage / Secretion Precaution – prevent infection
through contact with materials or drainage from infected
person
 Such as fistula and discharges from the body
Universal Precaution – for handling blood and body
fluids (bloods, pleural fluid, peritoneal fluid etc.)
 This precaution is applied to px who have HIV,
hepatitis B&C, also intended to prevent parenteral
mucous membrane exposure of nurses to blood-
borne pathogen

Preventive Aspect of Care in Patient with − Acquired through administration of vaccine and
Communicable Disease toxin
Health Education – educate the family about: − E.g. During pregnancy when we have our duty in
1. Immunization outpatient, we are able to give tetanus toxoid to a
 Educate regarding the availability and pregnant woman which is one form of artificial
importance of prophylactic immunization active immunity
2. Mode of transmission Artificial Passive Immunity
 To avoid the spread through proper − Preformed antibodies in immune serum are
handwashing, isolation, and precaution introduced by injection
technique − Through administration of antitoxin, anti-serum, or
3. Environmental sanitation receiving gamma globulin
 Clean the breeding places of mosquito − E.g. Hepatitis B vaccination
 Proper disposal of feces
4. Importance of seeking medical advice for any health
problem
 If there is S/S, they have to seek consultation
instead of self-medicating
 Discourage the patient to self-medicate
5. Preventing contamination of food and water
 Proper supervision of cleanliness and infections
of food handler such as proper food handling,
food preservation, storage of perishable goods in
a refrigerator, significance of milk pasteurization,
proper sterilizing the food through the means of
heat, and importance of meat inspection
Natural and Acquired Immunity

Natural Immunity
• A non-specific immunity present at birth
• Responses to a foreign invader are very similar from
Factors Affecting Vaccine
one encounter to the next
1. Maintain vaccine potency by preventing from
• Present at birth meaning it is a genetically coded
 Heat and sunlight
immunity so person may not suffer any illness
 Freezing
because of inborn immunity
2. Antiseptic/ disinfectants/ detergents lessen the
Natural Active Immunity
potency of vaccines
− Antigens enter the body naturally; body induces  Use water only when cleaning the freezer/ref
antibodies and specialized lymphocytes
− Acquired thru immunization and recovery from Cold Chain System – maintenance of correct
certain diseases like measles and chicken pox temperature of vaccines, starting from the
Natural Passive Immunity manufacturer, to regional store, to district hospital, to the
− Antibodies pass from mother to fetus via placenta health center to the immunizing staff and to the client
or to infant via the mother’s milk
Nursing Responsibilities on Health Education
Acquired/Adaptive Immunity The community health nurse is in the best position to do
• Specific immunity develops after birth health education such as
• Increases in intensity with repeated exposure to the 1. Develops material for environmental sanitation
invading agent  For utilization and distribution
• Immunity may develop after the host has been 2. Provides group counselling, holding community
exposed to antigen or after the transfer of these assemblies and conferences
antibodies’ lymphocytes from an immune donor 3. Creates programs for sanitation
Artificial Active Immunity  Act as advocator to families and communities
− Antigens are introduced in vaccines; body 4. Coordination and collaboration with other agencies
produces antibodies and specialized lymphocytes 5. Be a role model

Communicable Diseases Acquired Through

Respiratory Inhalation
Meningitis
• Inflammation of the meninges usually some
combination of headache, fever, stiff neck, and
delirium
• Inflammation of the meninges of the brain and spinal
cord as a result of viral or bacterial infection
• It may involve the 3 meningeal membranes, the dura
mater, pia mater, and arachnoid
AKA: Meningococcemia: cerebrospinal fever

Etiologic agent: Neisseria meningitidis
Incubation: 2 – 10 days
MOT:  Respiratory droplet through nasopharyngeal
mucosa
 Direct invasion through otitis media
 Trauma or procedures penetrating the head
(wounds, scalp fracture, lumbar puncture)
o Classic triad of diagnostic sign of meningitis:

nuchal rigidity, sudden high fever, spiking fever
o For meningococcemia: altered mental status
Acute Meningococcemia
• Invade the bloodstream without involving the
meninges but may cross blood-brain barriers
 Wherein the causative agent may invade the
bloodstream even with or w/o involving
meninges
Classification of Meningitis • Starts with nasopharyngitis followed by sudden onset
Aseptic Meningitis of high-grade fever with chills, N/V, headache and
malaise
• Viral meningitis wherein there is an inflammation of
• Patients develop petechial or purpuric hemorrhage
the meninges but there is no causative organism can
over the entire body or mucous membrane
be found
• The combination of meningococcemia and adrenal
medullary hemorrhagic is known as Waterhouse
Bacterial Meningitis
Friederichsen Syndrome – rapid onset development
• Inflammation of the arachnoid which may progress to
of petechiae to purpuric and ecchymotic spots in
congestion of adjacent tissue which may eventually
association with shock
destroy some nerve cells
• Common among children 6 months to 1 y/o or even
• The 3 meningeal membranes may be involved overcrowded places
• Incubation period of about 3-4 days
Acute Meningococcemia • The bacteria may spread through bloodstream to joint,
• Wherein the causative agent may invade the skin, adrenal gland, CNS, and even lumps
bloodstream even with or w/o involving meninges
Waterhouse Friederichsen Syndrome

Clinical Manifestations  This is to detect the nature of the foreign

1. Infectious signs substance that is present and it could also be
 Sudden onset of fever x 24h, tachycardia, chills therapeutic to reduce the ICP due to excess CSF
2. Meningeal irritation
a. Stiff neck or nuchal rigidity – pathognomonic sign
wherein when you try to flex the neck of patient,
there is resistance or stiff neck
b. Opisthotonus − the body is bent backward and
stiff usually characterized by hyperextensions of
the back and neck muscle with retractions of the
head and arching forward to the trunk
c. Kernig’s sign − resistance to full extensions of the
leg at knee when the hip is flexed
d. Brudzinski sign − wherein there’s a severe stiff
neck that causes the patient’s hip and knees to
flex when the neck is being flexed
2. CSF Examination
 High WBC marks leukocytosis
 High CHON content in the CSF and low glucose
content
 Fluid is turbulent or purulent which may mark
increased number of cells usually more than
1,000 cubic mm
3. Gram stain
 To detect the causative agent
4. Blood test
 To detect for any leukocytosis and serum
electrolytes abnormalities
5. Culture and Sensitivity Test
 Blood, urine, nose and throat secretions
6. Latex Agglutination
 Although the counter current
immunoelectrophoresis is not widely available in
our country, latex agglutination is being used
instead
 It is able to determine the specific bacterial
antigen
3. Neurologic signs – altered LOC (delirium, stuporous,  Cerebrospinal fluid, collected from the thecal sac
coma), neurologic deficit, cranial nerve palsies, that surrounds the spinal cord
ataxia, seizure, throbbing headache
4. Increased ICP
a. Bulging fontanel in infants (Macewen’s sign)
1. Antibiotics
b. Nausea and vomiting (projectile)
a. Rifampicin – drug of choice for prophylactic
c. Severe frontal headache
treatment
d. Blurring of vision, photophobia
b. Ceftriaxone – commonly used
e. Alteration in sensorium
c. Penicillin in high doses is almost always effective
5. Petechial, purpuric rashes
2. Repeat lumbar tap 24 – 48 hours after therapy is
 That cover the skin and mucous membrane
started
6. Waterhouse Friedrichsen Syndrome
 To determine whether response to drugs used is
 Results from endothelial damage and vascular
adequately treating the patient depending on the
nephrosis caused by the bacteria
CSF finding
 Usually returns into normal in 1-2 weeks
Diagnostic Study 3. Reduction of intracranial pressure
1. Lumbar tap / lumbar puncture a. Mannitol − very effective
 Insertion of a needle into the lumbar b. Dexamethasone
subarachnoid space and withdrawal of CSF 4. Supportive therapy
 Maintain fluid and electrolytes balance

 Blood transfusion Etiologic agent: Corynebacterium Diphtheriae (Klebs

 Plasma for shock loffer bacillus)
 Mechanical ventilator if there is respiratory Incubation period: 2 – 5 days
failure Period of communicability: variable, average: 2 – 4
5. ABG weeks (if untreated), 1 – 2 days (if treated)
 To check for pH level
MOT – Droplet, direct or intimate contact, fomites,
6. Monitor cerebral perfusion pressure
discharge from nose, skin, eyes, and even lesions on
7. Avoid straining
other parts of the body
 Laxative may be given to prevent increased ICP
Types and Manifestations of Diphtheria

Nursing Management
Pseudomembrane
1. Administer prophylactic antibiotics
 Rifampicin − drug of choice • Grayish white, smooth,
2. Prevent the occurrence of further complications leathery and spider web like
 Priority: AIRWAY, SAFETY structure that bleeds when
 Maintain aseptic technique when dressing and detached in the tonsils and
assisting in lumbar puncture pharynx
 Monitor VS
 Administer O2 inhalation to prevent respiratory Types of Respiratory Diphtheria
distress Nasal
 Change position frequently • Foul smelling discharges
 Protect patient’s eye from bright light and noise • There is no toxemia present because of poor
as patient may have photo sensitivity absorption of toxin
 Observe S/S of ICP • Serous to serosanguinous purulent discharge
3. Maintain seizure precaution • Pseudo membrane on septum
 Lower the bed, put up the side rails, and lock the • Dryness/ excoriation on the upper lip and nares
wheels
4. Prevent spread of disease
Pharyngeal
 Proper disposal of secretions
 Wear facial masks since microorganisms are • Pharyngeal pseudomembrane
commonly found in discharges from nose and  Small yellowish white spot appears on the
throat reddened tonsils
 Place the patient in an isolation room and explain • Bull neck (cervical adenitis)
it to the patient and family  Swollen cervical lymph nodes
5. Respiratory precaution  Neck tissues are edematous that result to
6. Prevent constipation disappearance that is a very toxic infection
 Use of laxatives to prevent increased ICP  There is some degree of toxemia
7. Nutrition – vitamin C, protein, CHO, low fat  Patient may have dysphagia and noisy breathing
 Avoid gas forming food with nasal voice
 Small supplementary feedings are given • Difficulty swallowing
between meals  Presence of regurgitation of fluid to the nose due
 Maintain fluid intake of 2500ml/day, but do not to palatal weakness or paralysis
overload because of danger of cerebral edema
8. Observe for any deteriorations Laryngeal
 Increased temperature of 38.9o and above, there • Extension of the pharyngeal form
will be altered LOC, onset of seizure, and altered  Very common in infant
respiration  Presence of soreness, hoarseness with barking
cough
Diphtheria • Sore throat, pseudo membrane
• Acute contagious disease characterized by • Croupy cough, husky characters (noisy breathing)
generalized toxemia coming from localized • Patient may have aponia (absence of pain)
inflammatory process • There is a marked dyspnea with supraclavicular
• Characterized by the formation of pseudo membrane retraction
in the tonsils, pharynx, or nasal cavity, it is capable of
damaging the muscles especially cardiac, nerve,
kidney, and other tissue

Diagnostic Studies  Nutrition – increase fluid intake, salty food, fruit

1. Nose and throat swabs juices with vitamin C (to maintain alkalinity of the
 Culture of specimen from beneath membrane blood and increase resistance of the patient)
 Negative result does not rule out diphtheria  Complete bedrest – for 2 weeks and avoid
2. Virulence test exertion during defecation to conserve energy
 To test the ability of pathogens to produce and decrease the workload of the heart
disease  Apply ice collar in the neck
3. Schick’s Test  Tracheostomy – if there is a presence of
 Test for susceptibility to diphtheria laryngeal obstruction
 Injecting diphtheria toxin intradermally  Isolation – until free negative culture
 Read result within 48-72 hours 4. Preventive measures
 Positive reaction: reveal local circumscribe area  Case reporting to DOH or hospital is mandatory
of redness usually about 1-3 cm in diameter  Isolation − minimum of 14 days from the onset of
4. Moloney’s Test disease until free negative culture
 Test for hypersensitivity to diphtheria  Avoid contact w/ children and avoid handling
 Should be done in older children and adult food until bacteriologic examination of culture is
before the toxic is given in order to avoid severe negative
reaction  Immunization − booster dose of DPT vaccine,
 Develop within 24 hrs. of injection tetanus vaccine under 5 y/o is mandatory
Things to Remember During Vaccination

1. Moderate and severe fever can be vaccinated as
soon as they have recovered
2. Minor illness like upper respiratory tract infection with
or without fever can be vaccinated
3. Immunosuppressive therapies can be given for
cancer as they may not develop the same response
to a normal person unless discontinuation of the
drugs, usually for about 1 month
4. Patients who developed encephalitis within 7 days of
DPT immunization should not receive additional
immunization containing pertussis vaccine
5. Immunization should be completed using the
diphtheria tetanus vaccine so postpone further doses
until child’s neurologic status become fair
Complications
Toxemia
Toxic Myocarditis
Management − First 10 – 14 days, ECG changes
1. Antibiotics − Due to action of the toxin in the heart muscle
 Penicillin G − usual drug given via IV or IM − Arrythmia may also be seen manifested by
 Erythromycin − orally for 7-10 days elevated ST segment, prolong PR interval and
2. Serum therapy evidence of heart block
 Diphtheria Antitoxin after a positive skin test; skin Neuritis
test is necessary prior to this diphtheria antitoxin − Absorption of toxin in the nerve that causes
 Fractional Desensitization given at an interval of paralysis of the palate
15 mins if there is no reaction notice, and if there − Extraocular muscle paralysis may occur which
is reaction then an hour is allowed to elapse and results to blurring of vision during the 5th week
the last dose which is not being reactive is given
Toxic Nephritis
again
− Albuminuria, cast, edema
3. Supportive
 O2 therapy

Intercurrent Infection
Bronchopneumonia
− Usually with laryngeal type secretion tends to
stagnate due to the paralysis of the diaphragm
Respiratory Failure
Pertussis (Whooping Cough)

• Repeated attacks of spasmodic coughing with series
of explosive expirations ending in long drawn force
inspiration
• Patient may produce a characteristic of growing Diagnostic studies
sound called the whoop and is usually followed by 1. CBC − Elevated WBC (20,000 to 50,000 mm3)
vomiting  More than 60 – 90% of lymphocyte appear near
the end of the catarrhal stage
Etiologic agent: Bordetella pertussis or Haemophilus 2. Nasopharyngeal swab
pertussis (common) 3. Sputum culture
Incubation period: 7 – 14 days (the whole course of
disease = 6 weeks) Complications
Period of communicability: 7 days post exposure to 3 1. Otitis media
weeks post disease onset  Most dangerous and common in young infant
MOT: Droplet 2. Acute bronchopneumonia
Sources: Nose and throat secretions of infected  Most dangerous and common in young infant
persons 3. Atelectasis or emphysema
Incidence: Infants  Air passages are obstructed by mucus plugs
4. Rectal prolapse, umbilical hernia
 Due to straining
Three Distinct Stages of Manifestations
5. Convulsions
Catarrhal – slight fever in PM, colds, watery nasal  Brain damage may cause asphyxia, hemorrhage
discharge, teary eyes, nocturnal coughing, 1-2 weeks
 Most communicable
 Last about 1 – 2 weeks
1. Prevention DPT
 Similar with colds
 DPT immunization then isolate the patient for
 Cough may become irritating, hacking, and severe
about 4 to 6 weeks from the onset of illness
Paroxysmal – spasmodic stage; 5-10 successive
 Public indications for immunizations and early
forceful coughing ending with inspiratory whoop,
diagnosis is important
involuntary micturition and defecation, choking spells,
2. Drug therapy
cyanosis; end of 2nd weeks
a. Erythromycin − drug of choice
 5-10 successive rapid forceful coughing in one b. Gamma globulin – effective in patients <2 y/o
inspiration ending in a high-pitched whoop 3. Supportive therapy
 a. Parenteral fluid − replacement of fluid and
 Convulsion may occur as a result intracranial electrolyte
hemorrhage b. Adequate ventilation, avoid dust, smoke to avoid
 Cough may be provoked by crying, eating, drinking trigger coughing
or physical exertion c. Isolation – do not bring the patient outdoor
Convalescent – 4 to 6th weeks; diminish in severity, d. Bedrest
frequency, vomiting ceases e. Prone position during attack
 Marked by gradual decrease in paroxysmal cough f. Abdominal binder for support as it may cause pain
both in frequency and severity in the abdominal muscles during coughing
 6th week from the onset, the attack may subside because of the characteristic of the disease which
is spasmodic coughing
g. Gentle aspiration of secretions
h. Expose to sunshine and fresh air but should be
protected from draft

Measles  Maculopapular rashes appear 2-7 days after the

• A contagious exanthematous disease of acute onset onset
most often affect children and the chief symptoms is  Appear first on the cheeks, bridge of the nose,
referable to the upper respiratory passages along the hairline, and ear lobe
• A single attack usually confers a lasting immunity, so 2. Rash is fully developed by 2nd day
8 days as shortest and 20 days as longest  All symptoms are at the maximum at this time
3. High grade fever – on and off
4. Anorexia, irritability, throat is sore
AKA: Rubeola, 7-day measles, Morbilli
 When examining the mucosal area/cavity, it is
Etiologic agent: Morbilli Paramyxoviridae virus
reddish in color
Incubation period: 10-12 days 5. Diarrhea, pruritus, and occipital lymphadenopathy
Period of communicability: 3 days before and 5 days
after the appearance of rash Convalescence (7-10 days)
MOT: Airborne (coughing and sneezing), vector-borne 1. Rashes fade in the same manner as they appeared
(articles that is contaminated with respiratory secretion from the face downward, so leaving a dirty
from patient) pigmentation or fine granular which may be noted for
Sources of infection: Secretions from eyes, nose and several days
throat 2. Desquamation of the skin
Pathognomonic sign: Koplik’s spots 3. Appetite is restored
4. Fever may subside as eruption disappear
Koplik’s Spots
• Wherein there is an inflammatory
lesion on the mucus plug with
superficial nephrosis
• Occur in the inner chip opposite
to the second collar
• Occur 1-2 days before the
measle rashes appear
Classified into Stages

Pre-Eruptive/Prodromal Symptoms – it is highly
communicable
Eruptive – appearance of rashes on the 2nd day Diagnostic Studies
Convalescence – fading of rashes from face downward, 1. Nose and throat swab
leaving dirty brown pigmentation  Microorganisms can be obtained from the
respiratory passages
2. Urinalysis
Clinical Manifestations According to Stages
 Obtained 4 days after the onset or eruption
Pre eruptive stage / Prodromal (10-11 days) 3. CBC – leukopenia, leukocytosis, lymphocytes
1. Fever, catarrhal symptoms (Coryza, rhinitis,  Decreased WBC and sometimes may be
conjunctivitis, photophobia elevated
 3 early symptoms: runny nose, cough and  Presence of atypical lymphocytes
reddened eyes 4. Complement fixation or hemagglutination test
2. Respiratory symptoms  Detect the presence of specific antibodies or
 Common cold, persistent coughing antigens in the patient’s serum
3. Enanthema signs: Koplik’s Spot  Confirmatory test for measles and even fro
 Whitish pinpoint dots in the inner cheek patients with influenza, because virus and RBC
4. Stimson’s line or are mixed which may not agglutinate, that is why
 Transverse line of the inflammation along the it is called hemagglutination indication test
margin of the eyelid
Eruptive Stage
1. Maculopapular rashes
 The Koplik’s spot is an enanthema sign
(exanthema sign is the eruption of skin rashes)

Hemagglutination Inhibition Prophylaxis

Active Immunity – measles vaccine at 9 months, MMR
15 months and then 11-12 years; defer if with fever,
illness
 A slight measle like may develop a week after
vaccination
 Not given to pregnant mothers, active TB, leukemia,
lymphoma or depressed immune system
Passive Immunity – gamma globulin
 Infant under 6 months usually acquired temporary
transplacental immunity from the mother
German Measles
Treatment
• Mild viral illness caused by rubella virus
1. Antibiotics – if with complications • Associated with rashes and presence of joint pain
2. Antiviral drugs – Isoprinosine • Has a teratogenic effect on the fetus
3. Supportive – O2 inhalation, IV fluids • Highly communicable if the infant with congenital
4. Symptomatic − Vaseline can be applied on the edge rubella may shed virus for months and even after the
of the eyelid to prevent them from sticking together birth
5. Antipyretic − if there is fever
6. Immunoglobulin – prophylaxis for no symptoms
AKA: Rubella, 3-Day Measles
Incubation period: from exposure to rash 14-21d
Period of communicability: one week before and 4
1. Otitis media
days after onset of rashes
2. Pneumonitis
MOT: Droplet, nasal secretions, transplacental in
3. Sinusitis
congenital
4. Laryngotracheobronchitis
5. Blindness
Nursing Management
1. Isolation – contact/respiratory
 Room must be quiet, well ventilated, subdued
light
 Quarantine is not necessary because by the time
a diagnosis of measle is made, siblings and
playmates of the patient have already been
Rashes in measles (confluence, group together) is
contaminated
different from German measles (scattered, separated at
 Highest contagious period is about 1 week
first then runs together)
before rashes appear
2. TSB, Skin care – daily cleansing wash
Manifestations
 Water should be comfortably warm
 TSB during febrile period Prodromal
3. Oral and nasal care 1. Low grade fever
4. Eye care 2. Headache
 Sensitive to light, therefore position the patient 3. Body malaise
where direct glare of light is avoided 4. Colds
 Keep eyes free of secretions 5. Lymph node involvement on 3rd to 5th day (post-
5. Nutrition: Plenty of fluids, fruit juices, milk auricular and suboccipital)
 If febrile, limit the diet to fruit juices, milk, and
water Eruptive
 If vomiting, give iced juices in small amount and 1. Forscheimer’s spots
more frequently  Pinkish rash on soft palate
6. Ear care  Rash on face, spreading to the neck, arms and
 Observe for any s/s of early mastoid infection trunk
7. Change position every 3-4 hours

 Last 1 – 5 days with no pigmentation or Period of communicability: 1 day before eruption up

desquamation (fades) to 5 days after the appearance of the last scab
2. Muscle/joint pain MOT: airborne, direct (shedding vesicles), indirect
3. Young adults may experience testicular pain (linens or fomites)
4. Transient polyarthritis may occur occasionally in
children
Treatment
1. Symptomatic treatment
Complications
1. Encephalitis
2. Neuritis, arthritis, arthralgia
3. Rubella syndrome – microcephaly, mental
retardation, deaf mutism, congenital heart disease Clinical Manifestations
1. Pre eruptive: Mild fever and malaise
2. Eruptive
Risk for congenital malformation
a. Rash starts from trunk
1. 100% when maternal infection happens in the first b. Lesions – red papules then become milky and pus
trimester of pregnancy like within 4 days
2. 4% in second or third trimester c. Pruritus – itchy
d. “Celestial map” – all stages are present
o 90% of the congenital rubella cases will excrete simultaneously before all are covered with scabs
the virus at birth and are therefore infectious
Stages of Skin Affectations

Teratogenic Triad
Macule − lesion is not elevated above the skin surface
1. Deafness
Papule – elevation of lesion is about 3mm
2. Cataract
3. Mental retardation of the infant Vesicle − pop like eruption filled with fluid that dries up
in 3-5 days
Pustule − infected vesicle filled with pus and may be
Nursing Management
scarred, big, and wide afterwards
1. Isolation
Crust – scab (secondary lesion), drying on the skin
2. Bed rest and darkened room
 To avoid photophobia
3. Nutrition – encourage fluids
4. Ice irrigation with normal saline
 To relieve irritations
5. Similar with measles treatment
 Good ventilation, prevention of transmission
6. Prevention
 MMR, Pregnant women should avoid exposure
to rubella patients
 Administration of Immune serum globulin one
week after exposure to rubella
Chicken Pox
• Acute and highly contagious viral disease
characterized by vesicular eruptions on the skin
• Remains highly contagious until the skin has fully
crusted
Management of Chickenpox
1. Symptomatic
Infectious agent: Herpes zoster virus or Varicella
2. Drug therapy
zoster
a. Oral antihistamine – pruritus
Incubation period: 10-21 days b. Calamine lotion – ease itchiness

c. Antipyretics − acetaminophen or ibuprofen Incubation period: unknown but believe to be about 1

d. Zovirax 500 mg/tb BID for 7 days – 2 weeks
e. Oral acyclovir 800 mg TID for 5 days Period of communicability: 1 day before the
 To lessen the severity of the disease appearance of the 1st rash and until 5 – 6 days after the
 Given within 24 hours after the rashes first last crust
appear MOT: Direct and Indirect – airborne
o Patient with chicken pox should not be given

salicylate because it can lead to Reye’s
syndrome
Preventive Management
1. Active immunization with life attenuated varicella
vaccine is necessary
 Varicella zoster immunoglobulin may be given
96 hours post-exposure Pathogenesis
2. Avoid exposure to infected person Virus lies inactively in the nerve tissue near the spinal
cord and brain that is why there is involvement of dorsal
Nursing Management ganglia of the posterior nerve roots and the peripheral
1. Strict isolation until all vesicle scabs disappears segmental distribution
2. Linens must be disinfected
 Under the sunlight or through boiling Risk Factors
3. Attention should be given to nasopharyngeal 1. Elderly 50 years and above
secretions and discharges 2. Patients with weak immune system (CA)
4. Hygiene care of patient
 To prevent secondary infection
5. Cut finger nails short Diagnostic Studies
 To minimize bacterial infections from scratching 1. Hx of previous chickenpox
(pruritis) 2. Pain and burning sensation over lesions of vesicles
 For infants: wear mittens along nerve pathway
6. Prevention: Live attenuated varicella vaccine 3. Tissue cultures of vesicle fluid
7. VZIG (varicella immunoglobulin) 4. Electron microscopy
 Effective if given 96h post exposure  To visualize the virus
5. Smear of vesicle fluid
 Giant cells and intranuclear inclusion bodies
Complications
6. Giemsa-stained scraping
1. Pneumonia  Multinucleated giant epithelial cells
2. Sepsis
3. Meningoencephalitis
4. Secondary infections (cellulitis, skin abscess) Manifestations
1. Appearance of herpes zoster comes in cluster
2. Burning, itching, pain then erythematous patches
Herpes Zoster
followed by crops of vesicles
• Acute inflammatory disease known to be caused by  Patient is sensitive to touch, with headache,
herpesvirus varicellae or V-Z virus along the sensory photophobia, and fever
nerve pathway 3. Eruptions are unilateral
• Acute viral infection of the sensory nerve caused by  One sided rashes/blister
variety of chicken pox virus and is very painful  May developed as a striped of blisters that may
• Affect only a single line of the nerve pathway wrapped around
• Occurs as reinfection of VZ virus 4. Lesions may last 1-2 weeks
5. Fever, regional lymphadenopathy
AKA: V-Z virus, shingles 6. Paralysis of cranial nerve, vesicles at external
Incidence: older children and adults auditory canal
 Infant is not an exemption, but it is less commonly  5th cranial nerve: trigeminal/ophthalmic –
seen in children less than 10 years of age Gasserian ganglionitis
Infectious agent: Varicella-zoster (V-Z) virus

 7th cranial nerve: facial • Syndrome occurs when geniculate ganglion is

– Ramsay Hunt involved due to reactivation
syndrome can cause • Classical triad:
facial rashes with fluid  Ipsilateral facial paralysis
filled blister, facial  Ear pain / hearing loss
paralysis or weakness,  Vesicles in pinna
and hearing loss in the • Sensation of spinning
affected ear • Tinnitus
7. Paralytic ileus, bladder
paralysis, encephalitis Mumps
• Acute viral disease manifested by swelling of one or
Treatment both of the parotid glands, with occasional
1. Symptomatic involvement of other glandular structures
2. Antiviral drugs – acyclovir • It is referred to as “beke” in tagalog
3. Analgesics to control pain • Self-limiting
 For weeks or months after the blister have dried • 20% of person infected with the virus do not show
up and disappear can cause neuralgia symptoms
 Neuralgia – sharp, stabbing, burning, and often  Possible to be infected and spread the virus
severe pain due to an irritated or damaged nerve without knowing
4. Anti-inflammatory or steroids • Human is the only natural reservoir
 To reduce severely painful cases
 Short regimen of high dose steroids to boost the AKA: Infectious Parotitis, Epidemic Parotitis
effect of antiviral drugs in Ramsay Hunt
Etiologic agent: paramyxovirus group usually found in
syndrome
saliva of infected person
5. VZ vaccination
Incubation period: 14 -25 days
Period of communicability: 6d before and 9d post
o Zoster immune globulin is not effective and not
onset of parotid gland swelling
given to herpes zoster patients
o Antimicrobial drugs are not indicated, only  48 hours period immediately prior to onset of
antiviral drugs swelling is considered the time of highest
communicability
 Conferred and lifelong immunity
Nursing Management
MOT: direct, indirect - droplet, airborne
1. Strict isolation
 Avoid physical contact with newborn, pregnant Pathology: Generalized disease that affect glandular
women, and immunosuppressed patients structure, also affect renal and nervous tissue
2. Apply cool and wet dressing
 With normal saline solution to pruritic lesions
3. Prevent bacterial invasion and secondary infection
 Cutting nails
4. Analgesics, sedatives – weeks to mos.
5. Encourage proper disposal of secretions and usage
of gown and mask
6. Diversional activities
Complications 1. Sudden headache – 1st symptom
1. Encephalitis 2. Earache, loss of appetite
2. Paralytic ileus and bladder paralysis 3. Swelling of the parotid gland
3. Ophthalmic herpes – may lead to blindness because  Reaches its peak for about 2 days and
of damage of Gasserian ganglion continuous for 7-10 days
4. Geniculate herpes – deafness because of infection 4. Fever may reach 40 ºC during acute stage
of 7th CN 5. One gland may be affected first
 3 days later, the other side may become involved
Herpes Zoster Oticus  Patient may have sore face and ears, and dry
mouth
• Caused by varicella zoster
• Infection along facial nerve near inner ear

 Avoid spicy and irritating food since parotid gland

is inflamed
 Increase fluid intake to prevent dehydration
5. Isolation
 Respiratory isolation in an open ward by medical
aseptic technique
6. Report cases to health authorities like DOH
Complications
1. Orchitis – testes are swollen and tender upon
palpation for several days after the onset parotid
swelling
2. Oophoritis – pain and tenderness of the abdomen
3. Deafness may happen − complete and permanent
hearing loss
4. Nuchal rigidity − headache, lethargy, convulsion,
delirium
5. Pancreatitis − epigastric pain, vomiting, chills,
frustration
Communicable Diseases Acquired Through

Gastrointestinal Tract
Typhoid Fever
• Infection of the GIT affecting the lymphoid tissues
Diagnostic Studies (ulceration of Peyer’s patches) of the small intestine
There is no confirmatory test for mumps • Bacterial infection transmitted by contaminated water,
1. Viral culture milk, shellfish, or other food
 From saliva; mouth swab or urine of associated
with meningoencephalitis (CSF) AKA: Enteric fever, Typhus Abdominalis
 Isolation of virus should be done few days before Etiologic Agent: Salmonella typhosa and typhi,
and at least 5 days after parotid swelling is done Typhoid bacillus, Salmonellosis
2. Complement fixation test Incubation period: 5 – 40 days (mean: 1- 20 days)
 Show presumptive evidence of infection
Period of communicability: as long as the patient is
3. Hemo-agglutination inhibition test
excreting the microorganism
 Used to determine immune status of patient
 Important source of the infection is the stool of the
4. Serum amylase
patient
 Useful for making early presumptive diagnosis
5. Blood test MOT: fecal-oral route, contaminated water, milk or other
 WBC count leukopenia with relative food; flies (vector)
lymphocytosis Incidence: world-wide distribution that occur anytime of
the year
Treatment Modalities
1. Antiviral drugs Sources of Infection
2. NSAIDS – Acetaminophen 1. A person who recovered from the disease can be
 To relieve pain from parotid swelling potential carrier
3. Prevention: MMR Vaccine  It may spread the bacillus for years
2. Ingestion of shellfish taken from waters
contaminated by sewage disposal
Nursing Management
3. Stool and vomitus of infected person are sources of
1. Symptomatic
infection
2. Comfort measures
 Application of warm/ cold compress
3. Oral care, warm salt water gargle Pathogenesis
4. Diet – semi solid, soft food easy to chew • The organism may gain access to the bloodstream
through the bowel

• Principally, it may infect the Peyer’s patches which is  To determine if the patient have typhoid fever
the lower ileum of the lymphoid tissue  Based on the presence of specific IgM and IgG
1st week: lymph nodes are swollen antibodies
2nd week: they may form a slough which is often  Salmonella usually needs 2-3 days of infection
black color 2. WBC – elevated
 To detect for any leukocytosis
3rd week: the slough may separate and leave an
3. Blood Culture – (+) S. typhosa
ulcerated surface
 Positive during the 1st week if there’s a presence
• Hemorrhage and perforation may occur due to the
of S. typhosa
extension of the lesion and continuous erosion of the
4. Stool Culture (+)
epithelial lining of the small intestine
 May be positive after the 1st week or throughout
• Since the toxin may be absorbed by the bloodstream
the course of illness
and almost all organs of the body are affected,
 Can be done through rectal swabbing
commonly the heart, liver, and the spleen
5. Urine culture (+)
• The mesenteric lymph gland is red and swollen
 During the first 2nd week, the organism may or
may not be presence
Clinical Manifestations of Typhoid Fever 6. Widal test – blood serum agglutination test
Onset  To detect specific antibodies in the serum
1. Ladder-like fever  Usually, it is positive by the end of the 2nd week
 Fever may be higher in the morning than it was which shows a rising titer on the 2nd to 3rd week
in the afternoon of disease
2. Nausea, vomiting, abdominal pain and diarrhea  The time recommended is about 8-10 days and
3. RR is fast, skin is dry and hot, abdomen is distended may be repeated by the 4th week
4. Headache, aching all over the body  Diagnostic value – if “O” antigen titer is >1:160,
5. Worsening of symptoms on the 4th and 5th day it is considered as an active typhoid stain
6. Rose spots
 Slightly raised, rose-red spots, which fade on Complications
pressure 1. Hemorrhage
 Usually, visible only on white skin  Appear pallor and thirst due to hypovolemia
 Appear on the 2nd week where symptoms  Rapid pulse
become more aggravated and more prominent  Low BP
2. Perforation
 Rupture of blood vessel of the intestine during
the 3rd week
 Sudden onset of constant abdominal pain for
about 2 weeks
3. Peritonitis
 From perforation
4. Pneumonia
Typhoid State 5. Heart failure
6. Sepsis
1. Sordes
 Teeth and lips accumulate a dirty-brown
collection of dried mucus and bacteria Management
2. Coma Vigil – stare blankly Drug Therapy
3. Subsultus Tendinum 1. Chloramphenicol – drug of choice
 Twitching of the tendon in the wrist  Check the intactness of the IV because it is very
4. Carphologia oily and irritating
 The patient may have picking behavior at his bed 2. Ampicillin
clothes with his finger in continuous fashion  For premature and newborn babies
 Describes the action of picking or grasping at 3. Ciprofloxacin
imaginary objects, as well as the patient’s own 4. Paracetamol
clothes or linens  For fever
Diagnostic Studies and Complications Nursing Care

1. Typhidot – confirmatory 1. Restore fluid and electrolyte balance

 Increase the fluid intake of the patient Pathogenesis

 Monitor VS
2. Safety precaution – from fall
 Especially for patients with typhoid psychosis
 Place the patient in bed rest
3. Personal and oral hygiene
 Mouth care because the dry mucus may stick on
the tongue of the patient
4. Bedrest
5. Enteric precaution
6. WOF intestinal bleeding – bloody stool, sweating,
pallor
 Due to the erosion of blood vessels or ulceration
of the small intestine
Clinical Manifestation
 Cooling measures during febrile state
7. Preventive and health education 1. Acute, profuse, watery diarrhea with NO tenesmus
 Teach enteric precautions 2. Initial stool is brown and contains
 The proper disposal of excreta fecal material then becomes “rice
 Proper supervision of food handling through water”
hand washing 3. Nausea/ Vomiting
 Adequate protection and provision of safe  Vomiting may occur after diarrhea has been
drinking water supply established
 Report the case to the health authorities 4. Diarrhea
 Typhoid vaccine can be given via SC followed by Causes fluid loss amounting to 1 – 30 liters per day
2nd injection or more weeks later owing to subsequent dehydration and electrolyte
 Immunization may reduce the risk of active loss
diseases 5. S/s of Dehydration
 Poor tissue turgor
 Sunken eyes
Cholera 6. Changes in vital signs
• An acute bacterial disease of the GIT characterized  Pulse is low or difficult to obtain
by profuse diarrhea, vomiting, massive loss of fluid  BP is low and later unobtainable
and electrolytes  RR are rapid and deep
• Diarrhea may take 1-30 liters of fluid per day 7. Washer-woman’s-hand
• Imbalance of fluid and electrolytes may result to  Cold, wrinkled fingers
hypovolemic shock, acidosis, and death 8. Cyanosis – later
9. Voice becomes hoarse
AKA: El Tor  Speaks in whisper
Etiologic agent: Vibrio cholerae, V. comma 10. Diminished peripheral circulation
11. Oliguria or anuria
 Produces toxins which alters the electrolyte balance
 Due to diarrhea and vomiting
in the epithelial cell
12. Conscious, later drowsy
 Can survive in an ordinary temperature and can
13. Deep shock
survive longer in refrigerated food
14. Death may occur as short as four hours after onset
Pathognomonic sign: rice watery stool
 Usually 1st or 2nd day if not treated properly
Incubation period: few hours to 5 days; usually 2– 3
days
Principal Deficits
Period of Communicability: entire illness, 7-14 days
1. Extracellular volume deficit – loss of fluid lead to
MOT: fecal oral route from contaminated food, water
a. Severe dehydration
and milk
− Manifest as washer-woman’s-hand,
 Flies, soiled hands, or utensils may also be able to restlessness, and excessive thirst
transmit the infection b. Circulatory collapse or hypovolemic shock
2. Metabolic acidosis – Kussmaul respirations
 Because of loss of large volume of bicarbonate-
rich in stool that may result to rapid respiration
with intervals of apnea

3. Hypokalemia 4. Sanitary disposal of human excreta

 Because potassium is loss in the stool 5. Environmental sanitation
 Patient may have abdominal distention attributed 6. Cholera vaccination
to the paralytic ileus
Shigellosis
Diagnostic Exams • Acute bacterial infection of the intestine characterized
1. Fecal microscopy by diarrhea and fever
2. Rectal swab • In cholera there is no tenesmus but in shigellosis there
3. Stool exam is a presence of tenesmus (abdominal cramps)
4. CBC
 Expect that there are hemoconcentration which AKA: Bacillary Dysentery, bloody flux
means the hematocrit is elevated
Etiologic Agent: Shigella group (Group B/Shigella
5. ABG
flesneri (common in PH), Group C/Shigella boydii,
 Because of metabolic acidosis
Group D/S. connei, S. dysenteria
6. Electrolytes
Incubation period: 7 hrs. to 7 days (3-5 days)
 Check the potassium because of massive loss in
the stool Period of communicability: during acute infection until
the feces are (-)
 Some patients remain a carrier for 1 – 2 yrs.
Management
MOT: fecal-oral route, contaminated water, milk, food;
1. IVF − rapid replacement
flies, contaminated objects of infected person
 Intravenous infusion containing Na, K, chloride,
and bicarbonate ions Source of Infection: contaminated food, water; flies,
 Usually, the use of plain LR swimming in polluted water
2. Oral rehydration – Oresol, Hydrites May be sexual in origin
 Unless it is contraindicated or if the patient is not
vomiting Clinical Manifestations
 If the patient is vomiting, cannot use oral 1. Fever especially in children
rehydration because it needs IV replacement  Initial manifestation
3. Strict I and O 2. Nausea, vomiting and headache
 There’s an extracellular volume deficit 3. Anorexia, body weakness
 Measure the I and O strictly and accurately 4. Cramping abdominal pain (colicky)
4. Antibiotics – Tetracycline, Cotrimoxazole, 5. Diarrhea
Chloramphenicol  Bloody and mucoid feces
 Tetracycline 500mg Q6 6. Tenesmus
 This may shorten the period of diarrhea and  Abdominal cramps
hospitalization 7. Dehydration and weight loss
 Straining during defecation may lead to rectal
Nursing Management prolapse particularly in malnourished children
1. Medical Asepsis
2. Enteric precaution Diagnosis
3. VS monitoring 1. Fecalysis
4. I and O  Microscopic examination of stool
5. Good personal hygiene 2. Rectal swab/culture
 Including the buttocks by keeping it dry and 3. Hemogram – WBC elevated
clean  Leukocytosis and lymphocytosis
6. Proper excreta disposal
4. Blood culture
7. Concurrent disinfection
 If there’s vomit or presence of loose bowel
8. Environmental sanitation Treatment
1. Antibiotics
Prevention  Ampicillin (common)
 Cotrimoxazole
1. Protection of food and water supply from fecal
 Tetracycline (severe cases)
contamination
2. IVF – normal saline (with electrolyte)
2. Water should be boiled / chlorinated
3. Milk should be pasteurized

 Plain lactate ringer solution to prevent • Disease of the lower motor neuron
dehydration • Affect all ages but mainly children under 3 years of
3. Diet – low residue – recommended age
 Since patient is having diarrhea
4. Anti-diarrheal are contraindicated AKA: Acute anterior poliomyelitis, Heine-medin
 Delay fecal excretion that can prolong fever disease, infantile paralysis
 In pediatric cases, there’s a lack of benefit if the
Etiologic Agent: Poliovirus (Legio Debilitans)
doctor use anti-diarrheal, risks of side effect may
Incubation period: 7-14 days ave (3-21 days)
occur such as ileus, drowsiness and nausea
5. Avoid giving anti-motility drugs – Lomotil Period of communicability: 7-16 days before and
 Stop effect of antibiotics few days after onset of s/s
 Increase bladder capacity and decrease the urge MOT: fecal-oral
of continence
3 Types Poliovirus Associated with Paralytic
Disease
Type 1 – most frequent
Type 2 – next most frequent
Type 3 – least frequent
3 Strain That Affect Man Alone

1. Brunhilde
2. Lansing
3. Leon
Nursing Management
1. Maintain fluid and electrolyte balance
 To prevent severe dehydration
2. Restrict food until nausea and vomiting subsides
 Through medical aseptic technique
4. Excreta must be disposed properly
5. Concurrent and terminal disinfection
6. Prevention
 Sanitary provision of food processing and
preparation especially when food is eaten raw
 Provision of adequate safe washing facilities
 Fly control
 Isolation during acute stage
Poliomyelitis
• An acute infectious disease caused by any of the 3
types of poliomyelitis virus which affects mainly the
anterior born cells of the spinal cord and the medulla, Predisposing Factors
cerebellum and the midbrain 1. Age
• Characterized by changes in the CNS which result  60% is under 10 years of age
from pathological reflexes, muscle spasm, and  It affects all ages but mainly children under 3
paralysis years of age

2. Gender  Patient may have problems involving the

 Male are more prone than female respiratory and vasomotor center
3. Environmental and hygienic condition • Pulmonary edema
• Hypothalamus dysfunction
Manifestation According to Forms  Patient may have impaired temp regulation
• Hypertension
Abortive Type – does not invade the CNS; recovers
 As a result of medullary involvement
within 72 hours
• Encephalitic s/s
1. Headache and sore throat
 Facial weakness, dysphagia, difficulty chewing,
2. Slight – moderate fever
inability to swallow or expel saliva, regurgitation of
3. Low lumbar pain
food through nasal passage
Non-Paralytic Type – all the above signs; it usually lasts

for a week but if with meningeal irritation, it persists for Bulbospinal
about 2 weeks • Combination of neuron of brain stem and spinal cord
1. Spasm of the muscles of the hamstring
2. Changes in deep and superficial reflexes o Cardiac arrest – most common leading cause
of death because it is attributed to excessive
3. Inability to place the head in between the knees
catecholamine production or direct action of
4. Pandy’s test – (+) tetano-spasm or tetano-lysin on the
 Tests the cerebrospinal fluid to detect elevated myocardium
level of globulins (proteins)
 If (+) cloudy if (–) translucent
Diagnostic Test
Paralytic – all sign and symptoms listed above 1. Throat swab – early phase
2. Stool culture – throughout the disease
1. Hoyne’s sign – (+)
3. Lumbar puncture – cerebrospinal fluid
 Head will fall back when in supine and shoulder
are elevated
 Legs is unable to be raised at full 90 degrees Treatment
2. Paralysis occurs 1. Analgesic
3. Kernig and Brudzinki test – (+)  Relieve headache, back pain and leg spasm
4. Muscle weakness, urine retention, constipation  Morphine is contraindicated because of danger
5. Hypersensitivity to touch of additional respiratory suppression or
depression
Types of Paralysis 2. Moist heat application
 Reduce muscle spasm and pain
Spinal Paralytic
3. Bed rest – necessary
• Flaccid Paralysis
4. Rehabilitation
 Paralysis may occur in muscle reverted by motor
 If it is paralytic polio, with the use of physical
neuron of the spinal cord
therapy, braces, corrective shoes or in some
 Asymmetry of one or both lower extremities
cases, orthopedic surgery
• Autonomic Involvement
 Excessive sweating
• Respiratory Difficulty Nursing Interventions
1. Supportive, Preventive
 Immunization of oral polio vaccine (south and
Bulbar Form
Sabin vaccine)
• Rapid & serious
2. NO morphine
 When it multiplies in the nervous system, the virus
3. Moist heat application for spasms
may destroy the nerve cells affecting the motor
 As per doctor’s order
neuron activating the skeletal muscles and may
4. Airway: tracheotomy
lose their function due to lack of nervous
5. Footboard to prevent foot drop
innervation
6. Observe for paralysis or other neurologic damage
• Glossopharyngeal and Vagus nerves affected (9th and
7. Maintain fluid and electrolytes
10th nerve)
8. Bedrest
 Patients may have paralyzed facial, pharyngeal or
9. Enteric and strict precautions
ocular muscles
 Isolation
• Cardiac and respiratory reflexes altered
 Occur in later part

Amoebiasis • The cyst remains viable and infective in moist cool

• Protozoal infection of human being environment for at least 12 days and 30 days in water
• Initially involves the colon that may spread to soft • May cause intestinal lesions and travel to the liver
tissue, most commonly, the liver or lungs by lymphatic through the circulatory system causing hepatic
spread or dissemination abscess
• Involves the colon in general but may involves the • Cyst is also resistant to the level of chlorine which are
liver or lungs as well normally used for water purifications, but they are
rapidly killed if the temperature is below 5 and above
40 degrees
Etiologic agent: Entamoeba histolytica
 Common in unsanitary area
 Common in one climate Clinical Manifestations
 Acquired through swallowing 1. Intermittent fever
 May survive for few days outside the body 2. Nausea, vomiting, weakness
 As the cyst passes through the large intestine, it 3. Later: anorexia, weight loss, jaundice
may hatch into thropozoid into the mesenteric vein 4. Diarrhea
to the portal vein affecting the liver thereby forming  Watery and foul-smelling stool often containing
an amoebic liver abscess blood streaked mucus
Incubation: average cases 3 – 4 weeks 5. Colic and abdominal distention
6. Intestinal perforation – bleeding
 3 days for severe infection
 Several months in sub-acute or chronic form
Period of communicability: duration of illness Diagnostic Exam
MOT: fecal-oral route (direct or indirect) 1. Fecalysis/Stool Exam (cyst, amoeba+++)
2. WBC – elevated
 Indirect − ingestion of food contaminated with E.
Histolytica cysts, polluted water supply, exposure to
flies, unhygienic food handlers Treatment
 Direct – sexual contact by oro-genital, oro-anal 1. Amoebacides – Metronidazole (Flagyl)
activity  Drug of choice for patients with Amoebiasis
 800mg TID X 7days
Pathogenesis 2. Bismuth gylcoarsenilate combined with Chloroquine
3. Antibiotic – ampicillin, tetracycline, chloramphenicol
4. Fluid replacement – IVF, oral
Nursing Management
2. Health education
 Boil drinking water (20-30 mins)
 Use mineral water
3. Cover leftover food
4. Avoid washing food from open drum/pail
5. Wash hands after defecating and before eating
6. Observe good food preparations
7. Fly control
• When a person ingested an infective cyst from
contaminated water or food, it may cause the Ascariasis
organism to exist in the intestines • Helminthic infection of the small intestine caused by
• Initially in the stomach or in an acidic environment, it Ascaris Lumbrecoides
does not show any activities but when it reaches the
alkaline medium of the intestine, it begins to move
within the cyst wall AKA: Roundworm Infection
• The amoeba may be swept down into the cecum Incubation period: 4-8 weeks
which serves as the 1st opportunity for the organism Communicability: as long as mature fertilized female
to colonize and make contact with the mucosa worms live in intestine
• The productions of trophocytes multiply and colonize MOT: fecal-oral
in the large intestine

Clinical Manifestation Complications

1. Stomachache 1. Energy / Protein malnutrition
2. Nausea/Vomiting  Due to the damage in intestinal mucosa which
3. Passing out of worms or intestinal obstruction impairs the absorption of nutrients,
 Caused by bolus of entangled worms which are 2. Anemia
palpable 3. Intestinal obstruction
4. Loss of appetite  Due to perforation and secondary peritonitis
 Because the larva penetrates the wall of the
intestine especially the duodenum Communicable Diseases Acquired Through the
5. Peri-umbilical pain Skin
 The larva picked up by lymphatic or blood stream
Tetanus
aggravated by cold stimulation or the Nakamura
• An acute, often fatal, disease characterized by
Sign
generalized rigidity and convulsive spasms of skeletal
muscles caused by the endotoxin released by C. Teta
• It may produce a potent exotoxin that may cause a
prominent systemic neuromuscular manifestation
such as generalized spasmodic contraction of the
skeletal muscle
• These spores are introduced to the body when an
injured become contaminated with street dust, animal,
human feces, and contaminated soil
Diagnostic Exam
1. Hx of passing out of worms (oral or anal)
AKA: Lockjaw
2. Microscopic identification of eggs in stool
3. CBC – increase eosinophilia Etiologic Agent: Clostridium Tetani
4. Abdominal X-ray “dot” sign Characteristics of C. Tetani
 There’s a light strand of spaghetti dot sign 1. Anerobic Spore forming – microbes cannot live in
the presence of oxygen
Treatment 2. Gram positive rod
1. Drug therapy Organism may release two types of toxins:

 Pyrantel Pamoate 1. Tetanospasmin – responsible for muscle spasms
 Piperazine Citrate 2. Tetanolysin – responsible for destruction of RBC
 Mebendazole, Tetramizole – most effective Incubation period: 3 days – 3 weeks (ave:10 days)
 Dicyclomine Hcl, NSAIDS − abdominal pain  Tetanus is fatal up to 60% of those who are not
2. For intestinal obstruction immunized usually within 10 days of onset
 Decompression  When symptoms develop within 3 days the
 Fluid and electrolyte therapy prognosis is poor
 If persistent, laparotomy
MOT:
3. FF up stool exam 1-2 weeks after treatment
✓ Direct or indirect contact to wounds
4. Periodic mass treatment/ Deworming
✓ Traumatic wounds and burns
 Every 4 months or 3 times a year
✓ Umbilical stump of the newborn – particularly in rural
 Very common in children
deliveries attempted by unlicensed midwife using
primitive method in cord dressing
Nursing Intervention ✓ Dirty and rusty hair pins
1. Isolation − not needed ✓ GIT- port of entry – rare
2. Enteric precaution ✓ Circumcision/ear piercing/dental extraction
3. Handwashing  If the patient is to enter a dental extraction, the
4. Proper nutrition instruments must be sterilized, same with
5. Maintenance of hydration / fluid balance / boil of circumcision and ear piercing
water Sources: Animal and human feces, soil and dust,
6. Improve personal hygiene plaster, unsterile sutures, rusty scissors, nails and
7. Proper food preparation and handling
pins
8. Deworming
 Especially in children because it is common on
them so its recommended

4. Jaw becomes so stiff that baby cannot suck or

swallow
5. Tonic or rigid muscular contraction, spasm or
convulsion provoked by stimuli
Complications
Laryngospasm – involvement of respiratory muscle
1. Hypostatic pneumonia
 Respiratory obstruction from secretions due to
poor changing position
2. Hypoxia
 Due to laryngospasm and decrease in oxygen
and there’s possibility that result to atelectasis
3. Atelectasis
 Due to hypoxia and laryngospasm
Trauma
1. Lacerations of tongue and buccal mucosa
Onset – sudden muscular spasms and cramp-like pain 2. Intramuscular hematoma
around the site of inoculation 3. Fractures of spine and ribs – rare
1. Muscular spasm and cram-like pain
 The microorganism may release toxin Septicemia
(Tetanospasmin) causing muscle spasm or 1. Nosocomial infections
cramp-like pain in the site of inoculation  From grossly contaminated wound can occur
coincidentally
Sequelae – rigidity of muscles, muscle spasms of flexor
and extensor muscle groups
Diagnostic Procedure
1. Trismus or lockjaw
1. Blood tests – elevated WBC
 Neck and jaw muscles show stiffening or rigidity
2. CFS or cerebrospinal fluid examination – normal
2. Opisthotonus
 Arching of the trunk (from spasms) which are
very prominent in patients with tetanus Management
3. Risus sardonicus Specific
 Grinning expression 1. Wounds should be cleaned
 There’s a sardonic sign, sneering smile or  Necrotic tissue or foreign material should be
distorted grin produced by the spasm of the face removed
4. Hypertonicity, hyperactive DTR, tachycardia, painful 2. Within 72 hours give ATS, TIG, TAT
involuntary muscle contractions, fever, sweating a. Tetanus Immune Globin
5. Difficulty in swallowing − About 3000- 6000 units IM
6. Rigidity of abdominal muscles − This is to neutralize the toxins and prevent
neurotoxin release into the circulation during
Excitants − recurrent generalized spasms precipitated debridement from being attached to the nerve
by the slightest stimulus (5 – 10 seconds) ending
1. Recurrent generalized spasms precipitated by the − Especially given if patient does not have any
slightest stimulus such as bright light, noise and previous immunization
movement of the patient that may last for 5 – 10 b. Tetanus Anti-Toxin
seconds with stiffening of the whole body − The TAT or horse serum antitoxin
− 50,000-100,000 units IM
Neonatal Tetanus – a form of generalized tetanus that − Nurses must inject it in separate arm
occurs in newborn infants, usually those with c. Anti-tetanus Serum (ATS)
contaminated umbilical stamp in rural areas − For horse serum antitoxin, skin testing is
1. Feeding and suck difficulty necessary
2. Cry excessively − Higher doses do not seem to be effective
3. An attempt to suck results in spasm and cyanosis − Intraspinal administration has also been
recommended

d. Tetanus Toxoid 8. Close monitoring of vital signs and muscle tone

− 0.5cc IM given in standard schedule given in 9. Provision of optimum comfort measures
3 doses 10. Maintain fluid and electrolytes balance so
3. Pen G Na (penicillin G sodium) parenteral nutrition through NGT feeding
 To control infection  Aspiration is very common so be careful
 Tetracycline – not recommended 11. Observe for development of fractures of the
vertebral bodies which may occur during severe
4. Muscle Relaxants
spasm
 To decrease muscle rigidity spasm
12. Wash and clean the wound- most important step in
the prevention of tetanus
Non-specific 13. Encourage patient to keep an up-to-date record of
1. Oxygen inhalation immunization status
 Especially to patients with laryngospasm 14. Active immunization with tetanus toxoid for adult
2. Gavage feeding and DPT vaccine
3. Tracheostomy  To control and prevent tetanus
 For presence of prolong spasm of respiratory  Observe for adverse reaction like local reaction,
muscle and inability to swallow due to erythema, fever, and duration
obstruction or laryngospasm  Systemic symptoms and any exaggerated local
4. Adequate fluid, electrolyte, caloric intake reactions are not common
 Initially, intravenous fluid is being administered
especially when spasms become less frequent Immunization Series
thus, gavage feeding
1st dose – specific date
5. During convalescence
2nd dose – given 4 – 8 weeks after the 1st dose
 Determine vertebral injury – because patient is
having opisthotonos 3rd dose – given 6 – 12 months after the 2nd dose
 Attend to residual pulmonary disability Booster dose – with tetanus and diphtheria every 10
 Physiotherapy years is recommended
 Give Tetanus Toxoid
Rabies
Nursing Care • Severe viral infection of the
1. Maintain adequate airway central nervous system
2. Provide cardiac monitoring • Highly fatal viral
 To prevent cardiovascular and respiratory encephalomyelitis which is
complication transmitted to man by the bite
3. Maintain an IV line for medications and emergency of a rabid animal, through the
care if necessary saliva of an infected animal
4. Carry out efficient wound care especially wildlife animals like
 Proper wound care through debridement by the racoon, bats, ox, and cattle
doctor prescribing anti-microbial to eradicate
toxoid and stop production of new toxins AKA: Hydrophobia, Lyssa
 Tetanus toxoid may be given in a separate Etiologic agent: Rhabdovirus
syringe in separate side
Pathognomonic Sign: Negri bodies in the infected
5. Avoid stimulation
neurons
 Even very minimal stimulation may cause spasm
Incubation period: 4 – 8 weeks; 10 days – 1 year
 Warn visitors not to upset or overly stimulate the
patient  Incubation period in dogs is usually 1 week to 7 ½
 Even tactile stimulation may promote spasm so months but varies depending on the case
place the patient in a quiet semi dark room to  Incubation period depends upon the following
avoid stimulating reflex spasm factors:
 Sudden stimuli and lights may trigger 1. Distance of the bite to the brain
paroxysmal spasm 2. Extensiveness of the bite
6. Avoid contractures and pressure sores 3. Species of the animal
 Change the position of patient from prolonged 4. Richness of the nerve supply in the area of the
immobility bite
7. Watch out for urinary retention 5. Resistance of the host
 Occurs when perineal muscles are affected

Period of communicability: 3 – 5 days before the 4. Difficulty swallowing, and pain in the actual site of the
onset of s/s until the entire course of disease bite
MOT: contamination of a bite of infected animals
2nd Stage: Stage of Excitement
Diagnostic Procedure 1. Marked excitation, apprehension
1. History of exposure 2. Delirium, nuchal stiffness, involuntary twitching
2. PE/assessment of s/s 3. Painful spasms of muscles of mouth, pharynx, and
 The characteristics s/s of rabies is increased larynx on attempting to swallow food or water or the
sensitivity to sensory stimuli with muscle spasm mere sight of them – hydrophobia
and onset of hydrophobia 4. Aerophobia – fear of air
3. Microscopic examination of Negri bodies in the dog’s 5. Precipitated by mild stimuli – touch or noise
brain using Seller’s May-Grunwald and Mann Strains 6. Death – spasm from or from cardiac / respiratory
4. Fluorescent Rabies Antibody technique or Direct failure
Immunofluorescent test
 Most definite diagnosis for rabies 3rd Stage: Terminal Phase or Paralytic Stage
1. Quiet and unconscious
Pathogenesis 2. Loss of bowel and bladder control
3. Tachycardia, labored irregular respiration, steady
rising temp
4. Spasm, progressively increasing paralysis
5. Death due to respiratory paralysis
6. Peripheral WBC count shows leukocytosis for about
20,000 to 30,000
7. Slight elevation of protein but CSF is normal
• Virus enters the body through animal bite, scratching,

or licking of an impaired skin
• The virus may stay in the skeletal muscle and
replicate
• This period between inoculation and nerve invasion is
the only time when prophylactic vaccine is effective
• Because the virus stays in the muscle, it binds with
the acetylcholine receptors at the neuromuscular
junction
• The virus may travel within the axons in the peripheral
nerve, and it may travel to the brain through the dorsal
root ganglion wherein it replicates in the motor neuron
of the spinal cord infecting the brain
• The infection of the brain neurons with the neuron
dysfunctions that may cause spread along the nerve
to the salivary gland, skin, cornea, and other organs
1st Stage: Prodromal Phase / Stage of Invasion
Treatment
1. Myalgia, numbness, tingling, burning or cold
1. No cure
sensation along nerve pathway; dilation of pupils
 But can provide care based on symptoms /
2. Fever, anorexia, malaise, sore throat, copious
supportive care
salivation, lacrimation, perspiration, irritability,
2. No specific – symptomatic/ supportive
hyperexcitability, restlessness, drowsiness, mental
 Directed toward alleviation of spasm
depression, marked insomnia
3. Employ continuing cardiac and pulmonary
3. Sensitive to light, sound, and changes in temperature
monitoring

4. Assess the extent and location of the bite – biting 1. Vaccination against rabies
incident/ status of the animal 2. WHO recommends mass immunization campaign for
a. Severe exposure – multiple bites, deep all dogs 3 months to 1 year
puncture wounds, located in the face, head,
neck, arms, hands or finger Malaria (Ague)
b. Mild exposure – scratches, single bite,
• Acute and chronic disease transmitted by an infected
laceration on the other areas of the body other
mosquito bite confined mainly to tropical areas
than those mentioned above
because of rainfall, warm temperature, and presence
5. Tetanus prophylaxis
of stagnant water
 Check first the immunization status of the patient
 Tetanus toxoid may be necessary
 Anti-tetanus serum around the wound or may Etiologic agent: Protozoa of genus Plasmodia
also be through IM after negative skin test
6. Anti-rabies vaccine Species
 Both passive and active depending on the site Plasmodium Falciparum (malignant tertian)
and extensivity of the bite • Most common in the Philippines
7. Antibiotics – bacterial set in • Most serious malarial infection because of the
8. Suturing of open wounds should be avoided development of hyper parasitic density in the RBC,
there is a tendency to agglutinate and form micro
Rabies Vaccine emboli
Both active and passive immunization if bitten in the
eyes, ears, face, fingers and any part of the head P. Vivax
• Non-life threatening except for the very young and old
Active Immunization • Manifests chills every 48 hrs. on the 3rd day onward if
• Administered 3 years duration not treated
• Used for lower extremity bites
• Lyssavac (purified protein embryo) = Imovax, Anti- P. malarie (Quartan)
rabies vaccine • Less frequent, non-life threatening, fever and chills
 Lyssavac is given IM in the deltoid area once a occur every 72 hrs. on the 4th day of onset
day for 14 days
 Imovax may be given one vial through deltoid, P. ovale – rare
buttocks IM and given 3 doses
 If the dog die, it needs 6 doses, usually from 0, 3, Incubation period: 12 days P. falciparum, 14 days P
7, 14, 30, to 90 (booster dose) days vivax and ovale, 30 days P. malariae
 Anti-rabies vaccine is administered in the
Period of communicability: If not treated/ inadequate
abdominal wall 2ml SC for 14 days
– more than 3 yrs. P malariae, 1-2 yrs. P. vivax, 1 yr. -
P. falciparum
Passive Immunization
MOT: mosquito bites, blood transfusion, and in
• 3 months
contaminated syringe or needle
• Rabuman, Hyper Rab, Imogam
Vector: female Anopheles mosquito
 Breeds in clear, flowing and shaded streams usually
Nursing Management
in the mountains
1. Isolate the patient  Bigger in size than the ordinary mosquito
2. Provide emotional and spiritual support  Brown in color
3. Provide optimum care  Night-biting mosquito
 Place padding on the bed side or use restrain  Does not bite a person in motion
 Clean and dress wound with the use of gloves  Assumes a 36° position when it alights on wall,
 Wipe saliva or provide sputum jar trees, curtains and the like
4. Darken the room and quiet environment
5. Do not bathe or any running water in the room
6. Electric fan and windows should be closed Pathogenesis
7. IVF should be wrapped and securely anchored • The parasites enter the mosquito's stomach through
8. Concurrent and terminal disinfection the infected human blood obtained by biting or during
blood meal, the parasites undergo sexual conjugation
• After 10 to 14 days, the young parasites are release
Control
which went their way into the salivary gland of the

mosquito, and the organisms are carried in the saliva

into the victim when the mosquito bite again
• When the mosquito injects the parasite to the human
through bites, it may travel and the sporozoites will
reach the liver through blood vessels and they will
reproduce asexually in the liver cells causing the
bursting of the RBC and release into the blood
• Therefore, the patient will develop cycle of fever and
other symptoms
• The released parasites may also infect the new RBC
wherein the sexual stages may develop in the RBC
Diagnostics
1. Malarial smear
 Film of blood is placed on a slide, stained and
examined
2. Rapid diagnostic test (RDT)
 Done in field or outside the laboratory
 10-15 mins result blood test
 This test detects malaria parasites antigens in
the blood
3. Polymerase chain reaction (PCR)
 Detects malaria DNA
Management
Medical
1. Antimalarial drugs
 Chloroquine – drug of choice for all species
except P. Malarie
 Quinine − depends on the type of plasmodium or
species
1. Rapidly rising fever with severe headache
 Sulfadoxine − resistant P falciparum
2. Shaking chills and diaphoresis
 Primaquine − relapse P. vivax/ovale
3. Myalgia
2. RBC replacement/ erythrocyte exchange transfusion
 For rapid production of high-level parasites in the
5. Orthostatic hypotension
blood
6. In children: convulsions and GI symptoms
7. In Cerebral malaria: changes in sensorium,
Nursing
Jackonian or grand mal seizure may occur
1. Closely monitor
 If the infected blood vessels are destroyed, the
2. Measure I & O
BV will stick into the wall of the small BV and
 To prevent pulmonary edema
thereby sequestering the parasites from the
3. TSB, ice cap on the head
general circulation and spleen
 During the febrile stage to lower the temperature
 Therefore, the sequestered RBC can breach the
of the patient
blood brain barrier causing cerebral malaria
4. Provide comfort and psychological support
 This can cause high-grade fever, seizures, and
5. Monitor vital signs
impairment in consciousness
 Retinal hemorrhage or nystagmus can also
7. Kept bedding and clothing dry
occur
8. Watch out for neurologic toxicity
 Appearance of the anopheles can also be seen,
 Muscular twitching, delirium, confusion,
usually in 30 degrees slant position and brown in
convulsion
color
9. Watch out for abnormal bleeding
10. Evaluate degree of anemia
11. Use mosquito net and insect repellents
 To irradicate mosquitoes

12. Screening: People who live in a malaria infested mosquitoes), stagnant water or water stored within
area should NOT donate blood for at least 3 years household / standing water in the premises
and blood donors should be properly screened  The breeding of this mosquito in flowing water, clear
13. Case finding/tracing for the care of an exposed and shaded stream
person Usual dissemination: schools and hospitals
Complication of P. Falciparum Difference Between Dengue Fever and Chikungunya

1. GIT • Chikungunya patients may have polyarthritis unlike in
 Bleeding from GUT dengue fever where patients may have myalgia of the
 N/V, diarrhea, abdominal pain lower back
 gastric,  In chikungunya, patients may experience
 typhoid, choleric, dysenteric polyarthritis even after a year
2. CNS or Cerebral Malaria • The distribution of rash in chikungunya is on the face
 Changes in sensorium and trunk while for dengue fever is in the limbs and
 Severe headache face
 N/V
3. Hemolytic
 Lysis of the RBC
4. Blackwater fever
 Reddish to mahogany colored urine due to
hemoglobinuria
 Anuria – death
5. Malarial lung disease
Dengue Fever
• Is an acute febrile disease cause by infection with one
of the serotypes of dengue virus which is transmitted
Signs and Symptoms
by mosquito (Aedes aegypti)
• Dengue hemorrhagic fever – fatal characterized by Signs and Symptoms of Chikungunya and Dengue Fever
bleeding and hypovolemic shock Chikungunya Dengue fever
Incubation one to 12 Incubation three to seven

Typical time
days. Duration one to days. Duration four to
AKA: Chikungunya, O’ nyong nyong, west nile fever course
two weeks. seven days.
Etiologic agent: Arbovirus group B (4 species)
Fever, arthralgia,
Incubation period: 3-14 days; common minimum 3 myalgia, headache, Fever, arthralgia, rash,
Initial symptoms
conjunctival injection, headache.
days and maximum of 10 days photophobia, rash.
Incidence:
Polyarthritis, symmetrical
 Age – occur at any age but common in children typically involving the
Severe myalgia of the
lower back, arms and
Arthralgia and smaller joints (e.g. hands
between 4-9 years old myalgia and feet), with swelling.
legs. Arthralgia,
especially of the knees
 Gender – both equally affected Pain is worse in the
and shoulders.
mornings.
 Location – prevalent in communities
 Season – usually during rainy seasons Flushing on face and
trunk. Widespread rash
Period of communicability: one day before febrile Distribution of
(50% of cases) on trunk
and limbs that can also Limbs and face.
period up to the end rash
affect face, palms and
feet accompanied by
 The mosquito becomes infective from days 8-12 pruritus.
after the blood meal then remains infective all
Severe dengue fever
throughout its life Around 5–10% of
may cause shock,
patients will develop
respiratory distress,
MOT: Bite of infected mosquito – Aedes Aegypti Complications chronic arthritis. Rarely
hemorrhagic
neurological
complications and organ
 Mosquito is domestic, day biting with low and limited complication.
impairment.
flying movement
 Day biting appears 2 hours after sunrise & 2 hours
Diagnostic Tests
before sunset
1. Tourniquet test – screening test
Sources of infection: infected person (virus is present
 By occluding the arm vein for about 5 minutes to
in the blood and will be the reservoir when sucked by
detect for any capillary fragility

 About 5cm in diameter of circle in the area under Classification of Dengue Fever
pressure is counted Grade 1
 Normally it is <15 petechiae but If it’s >15, it may • Fever and nonspecific constitutional symptoms
indicate capillary fragility • Prodromal symptoms wherein positive tourniquet test
2. Platelet Count – decreased and confirmatory test is only hemorrhagic manifestation
(<100,000 mm3)
3. Hematocrit – hemoconcentration Grade 2
 Elevation of about 20% of the normal value)
• Grade 1 manifestations + spontaneous bleeding from
4. Leukopenia to mild leukocytosis with lymphocytosis
nose, gums, and GIT
5. Coagulation studies
 PT is prolonged
Grade 3
 Fibrinogen, factor assay 8, 12, and antithrombin
• Signs of circulatory failure (rapid/weak pulse, narrow
3 is reduced
pulse pressure, hypotension, cold/clammy skin)
6. Occult blood
7. Hemoglobin determination
Grade 4
8. NS1 (nonstructural protein 1) test
 Usually done in the community wherein the • Profound shock (undetectable pulse and BP)
protein secreted into the blood during the acute
phase of dengue infection Management
 Done in 0-7 days, beyond this is not Medical
recommended 1. No specific antiviral therapy for dengue
 it is entirely symptomatic
Manifestations 2. Analgesic – not aspirin for relief of pain
Prodromal Symptoms 3. IV fluid
1. Malaise and anorexia up to 12 hrs. 4. Blood transfusion or platelet concentration as
2. Fever and chills, headache, muscle pain necessary
3. Nausea and vomiting  For severe bleeding
 Replacement of plasma if bleeding occurs
Febrile Phase 5. O2 therapy
 Indicated to all patients in shock
1. Fever persists (39-40 °C)
6. Close monitoring of BP, HCT, Hgb, platelet
 Non-remitting and persists for 3-7 days
2. Rash
Nursing
 More prominent on the extremities and trunk
3. (+) tourniquet test 1. Kept in mosquito free environment to avoid further
 Petechiae more than 15 transmission
4. Skin appears purple with blanched areas with varied 2. Keep pt. at rest
sizes (Herman’s sign – pathognomonic) 3. VS monitoring every hour
5. Generalized or abdominal pain 4. Ice bag on the bridge of nose and forehead
6. Hemorrhagic manifestations – epistaxis, gum  If nose bleeding occurs – cold compress
bleeding 5. Observe for signs of shock – VS (BP low), cold
clammy skin
Circulatory Phase
1. Fall of temp on 3rd to 5th day Prevention
2. Restless, cool clammy skin Early detection and treatment to avoid worsening of the
3. Profound thrombocytopenia patient’s condition
 Decrease in platelet / thrombocytes 1. Mosquito net with insecticides
4. Bleeding may be very evident and shock 2. Eradication of breeding places of mosquito:
5. Pulse – rapid and weak  House spraying
6. Untreated shock – coma – death  Change water of vases
7. Metabolic acidosis  Scrubbing vases once a week
 Occurs within 2 days and if treated, may recover  Cleaning the surroundings
in 2-3 days  Keep water containers covered
 Avoid too many hanging clothes inside the house

Leptospirosis Clinical Manifestations

• Infectious bacterial disease carried by animals whose Septic Stage
urine contaminates water or food which is ingested or Bacteria is present in blood and CSF which is
inoculated thru the skin characterized by flu-like symptoms
Early – Fever (40 °C), tachycardia, skin flushed,
AKA: Weil’s disease, mud fever, Swineherd’s disease warm, petechiae
Etiologic agent: spirochete Leptospira interrogans  Fever may last for 4 to 7 days
found in river, sewerage, floods Severe – Multiorgan failure, conjunctival affectation,
Incubation Period: 6 -15 days jaundice, purpura, ARF, hemoptysis, headache,
Period of Communicability: found in urine between abdominal pain, jaundice
10-20 days
MOT: contact with skin of infected urine or feces of Toxic Stage
wild/domestic animals; ingestion, inoculation With or w/o jaundice, meningeal irritation, oliguria–
shock, coma, CHF
Source of infection: Rats, dogs, mice
1. Bacteria may be present in urine
2. Presence of meningeal irritation such as
Pathogenesis
disorientation and convulsion
• After appearing in blood, it invades all tissues and 3. CSF findings shows aseptic meningitis
organs particularly affecting the liver and kidneys  Because the bacteria are only present in the
• The invasion is cleared by the body by the host’s urine but not in the blood or other organs but
immune response there is CNS involvement
• It settles in the kidney in the convoluted tubule of the
kidney and being shed in urine the for a few weeks, Convalescence – recovery
months or even longer
• Once it is cleared in the urine, then it will also be
o Relapse may occur during 4th and 5th week
cleared in kidneys and other organs
Diagnostic Test
1. History of exposure to Leptospira and clinical
manifestations
2. Culture
 Blood during first week may be seen and CSF
from 5th to 12th days
 Uremic after the first week until the period of
convalescent
3. Liver and Kidney function test – creatinine, BUN,
SGPT, SGOT
 10% of the patients may develop enteric
diseases like jaundice, renal and liver failure
 Severe hemorrhage and hypotension may occur
due to vascular collapse and myocarditis
Treatment
1. IV antibiotic – Pen G Na, Tetracycline, Doxycycline
2. Dialysis – peritoneal
 If renal failure occurs
3. IVF and electrolytes as indicated
4. Supportive care based on symptoms of patient
5. Symptomatic
Nursing Management
1. Isolation of patient – urine must properly dispose
 Especially during toxic stage because the
Leptospira is present in the urine

2. Care of exposed persons – keep under close Diagnostic test: ova seen in fecalysis
surveillance
3. Supportive and symptomatic Pathogenesis
4. Control measures
 Cleaning of the environment/ stagnant water
 Eradicate rats and rodents
 Avoid bathing or wading in contaminated pool of
water
 vaccination of animals (cattle, dogs, cats, pigs)
 Advocate Information-dissemination campaign
Prevention
Schistosomiasis
• Larva penetrate the skin or mucus membrane and
• Parasitic disease caused by Schistosoma japonicum, finds a way to the liver
S. mansoni, S. Hematobium • It matures in the portal vessels for at least 1-3 months
• Chronic wasting disease among farmers and their and as the worm matures in the liver, it might migrate
families in certain part of the Philippines to other parts of the body
• Female cercariae lay eggs in the blood vessels
Species surrounding the large intestine or bladder
Schistosoma japonicum • Ulceration may occur in the mucosa then and eggs
• One type of species that infects the intestinal tract might escape into the lumen of the intestine and be
(gathiya disease) and the only type that can be found excreted in the feces
in the Philippines • Some of the eggs carried by the portal circulation and
• Also called oriental schistosomiasis because it is also is being filtered in the liver were small lesion and
found in China, Japan and Thailand granulomas are found
• These granulomas are replaced with fibrous tissues
S. mansoni while the ulceration in the intestine are healed causing
• Also affects the intestinal tract and commonly seen in scar formation
some part of Africa • As the disease progress, the liver may enlarge due to
increase fibrosis and the flow of blood will be
S. Haematobium compromise in the intrahepatic portion therefore
• Affects the urinary tract that can be found in some part resulting into portal hypertension
of middle east like Iraq and Iran • Fluid may accumulate in the patient’s abdomen that
may cause distension or bulging
AKA: Bilharziasis, Snail fever
Incubation period: 2-6 weeks (at least 2 months) Clinical Manifestations
MOT: bathing, swimming, wading in water 1. Swimmer’s itch
 Because of pruritic rashes that develop at the
Vector: intermediary tiny snail called Oncomelania
site of penetration
quadrasi
 Cercariae: most infective stage

 There’s a presence of redness and facio(?) Nursing Intervention

formation 1. Administer prescribed drugs as ordered
2. Low grade fever, fatigue, myalgia and cough 2. Prevent contact with cercaria-laden waters in
3. Abdominal discomfort endemic areas like streams
4. Diarrhea 3. Proper sanitation or disposal of feces
 Bloody-mucoid stool “dysentery-like” 4. Creation of a program on snail control – chemical or
 Comes on and off for weeks changing snail environment
5. Icteric and jaundice  Building a footbridge in snail infested stream
6. Eosinophilia – extremely high eosinophil granulocyte
count
Leprosy
7. Colonic polyposis with bloody diarrhea
• Chronic systemic infection characterized by
8. Portal hypertension with hematemesis and
progressive cutaneous lesions
splenomegaly (S. mansoni, S. japonicum)
• May transmit from one man to another affecting the
9. Cystitis and ureteritis with hematuria  bladder
skin and mucus membrane and nervous tissue
cancer
eventually producing deformities
10. Pulmonary hypertension (S. mansoni, S.
japonicum, more rarely S. haematobium)
11. Glomerulonephritis and CNS lesions AKA: Hansen’s Disease
Etiologic agent: Mycobacterium leprae (gram+)
Diagnostic Studies  Acid fast bacilli attached to cutaneous tissues and
1. Fecalysis peripheral nerves producing skin lesions,
 Identification of eggs anesthesia, infection and deformities
2. Liver and rectal biopsy Incubation period: 5 1/2 mos. – eight years
 Lesions can cause granulomas in the liver that Period of communicability: presence of open lesions
may cause fibrosis Source of infection: discharges from mucocutaneous
3. Kato-Katz technique lesion containing large number of mycobacteria
 Another diagnostic test used to identify eggs MOT: respiratory droplet, inoculation through break in
4. Cercum Ova Precipetin Test (COPT) skin and mucous membrane
 Confirmatory diagnostic test that detects
antibodies against schistosomiasis
 Gold standard for schistosomiasis Forms of Leprosy
5. Enzyme link immunosorbent assay (ELIZA) Lepromatous Leprosy
 Detects and measure antibody in the blood that • Most infectious wherein there will be damage in
relate to certain infectious disease of conditions respiratory system, eyes, testes, nerves and skin
• Skin lesion contains large amounts of Hansen`s
Complications bacillus then there will be gradual thickening of the
skin with the development of granuloma`s condition
1. Pulmonary hypertension
• There will be a gradual loss of sensation in some
2. Cor pulmonale
degree
3. Myocardial damage
• Skin and muscle can be atrophied but when the doctor
 As this goes into the circulation
does the lepromin test, it is negative
4. Portal hypertension and liver cirrhosis
• Lepromin test is done by giving intradermal injection
5. Renal failure
of lepromin in order to classify the stage of leprosy
based on the lepromin reactions or sometimes called
Specific Chemotherapy Treatment “Mitsuda antigen”
Effective when given early in the course of the disease
1. Praziquantel tablet for 6 months Tuberculoid Leprosy
 BID X 3 mos.; OD for another 3 mos. • Lepromin test is positive meaning, there’s
 Commonly given lepromatous tissue of dead lepra bacilli.
2. Trivalent antimony • Macules are elevated with a clearing at the center
 Tartar emetic – administered thru vein • Loss of sensation is present in the peripheral nerve
 Stibophen (FUADIN) – given per IM
3. Niridazole
Borderline Leprosy
• Characteristic of lepromatous and tuberculoid leprosy

Clinical Manifestations Nursing Intervention

1. Corneal ulceration, photophobia – blindness 1. Isolation of patient – until causative agent is still
2. Lesions are multiple, symmetrical and erythematous present
– macules and papules 2. Medical asepsis
3. Later lesions enlarge and form plaques on nodules 3. Moral support and encouragement
on earlobes, nose eyebrows and forehead 4. Help educate in terms of mode of transmission
4. Foot drop and claw hand 5. Care of exposed persons
5. Raised large erythematous plaques appear on skin  Household contact needs to take
with clearly defined borders Diaminodiphenylsulfone for 2 years
 Rough hairless and hypopigmented  Observe carefully for symptoms of the disease
 Leaves an anesthetic scar
6. Loss of eyebrows/eyelashes Communicable Disease Acquired Through Sexual
7. Loss of function of sweat and sebaceous glands Contact
8. Epistaxis
Gonorrhea
• A curable infection caused by the bacteria Neisseria
Signs and Symptoms – additional gonorrhea
1. Loss of temperature sensation • Sexually transmitted bacterial disease which may
2. Numbness involve the mucosal lining of the genitourinary tract,
3. Large ulceration rectum and pharynx
4. Muscle weakness
5. Progressive disfigurement
AKA: Clap, Flores Blancas, Drip, G. vulvovaginitis
Incubation period: 3 to 10 days from initial
Diagnosis Test manifestations
1. Identification of S/S Period of communicability: considered infectious
 Via history and PE
from the time of exposure until treatment is successful
2. Tissue biopsy
 The infected person remains communicable if the
3. Tissue smear
organism is present in the secretions and
 To determine the presence of organism
discharges
4. Hemogram – increased ESR
5. Lepromin skin test MOT: transmitted during vaginal, anal, and oral sex
 To determine cross sensitivity TB infection
 There are two reactions: Clinical Manifestations
Mitsuda reaction Female
Fernandez reaction – positive lepromin skin test 1. Burning sensation and frequent urination – female
because reaction occurs within 48hrs of injection 2. Yellowish purulent discharges
of lepromin only in the tuberculoid form of 3. Redness and swelling of the genitals
leprosy –erythema induration of 10-30 mm 4. Itching of genitals
6. Mitsuda reaction 5. Urethritis or cervicitis
 Delayed granulomatous lesion which occur 3-4  Pelvic pain
weeks after injection of lepromin and induration 6. Fever
is about 3-5 mm in diameter 7. Nausea and vomiting
8. Abdominal tenderness
Treatment 9. Endometriosis and salpingitis
1. Multiple drug therapy  Symptoms of uterine invasion which may lead to
 Sulfone therapy – effective infertility
2. Rehab – occupational 10. Swelling of the Bartholin glands, and discharges
 If patient have some form of disability can be seen
3. Isolation 11. Neonates have gonorrheal conjunctivitis acquired
4. Prevention from the discharges in the birth canal
 Report cases and suspects of leprosy
 BCG vaccine may be protective if given during
the first 6 months

Complications
1. Upper genital tract infection
Male – prostatitis, seminal vasculitis
Female – sterility, pelvic infection
2. Anorectal infection
3. Pharyngeal infection
4. Gonorrheal conjunctivitis for neonates
1. Case finding
2. Health teaching on importance of monogamous
sexual relationship
3. Treatment should be both partners to prevent
reinfection
4. Instruct possible complications like infertility
5. Educate about S/S and importance of taking
antibiotic for the entire therapy
o All information should be considered

confidential and the patient should be isolated
until recovery
Syphilis
Male • A curable, bacterial infection, that left untreated will
1. Dysuria and purulent discharge from urethra progress through four stages with increasingly serious
 It’s about 2-7 days after exposure symptoms
2. Yellowish purulent discharges • Chronic infectious sexually transmitted disease that
 If there is no visible usually begins in the mucous membrane and
discharge, gently massage becomes systemic
the urethral from the ventral • Acquired through sexual contact
part of the penis towards the
meatus and a thick AKA: Lues Venereal, Morbus Gallicus
yellowish-greenish mucus discharge can be Etiologic agent: Treponema pallidum
seen
Incubation: 10 – 90 days; average of 3 weeks
3. Pain or burning while passing urine
MOT:
4. increased frequency of urination
5. swelling and redness in the urethral meatus ✓ Through sexual contact/ intercourse, kissing,
6. Prostatitis, pelvic pain and fever abrasions
7. Rectal infection – homosexuals ✓ Can be passed from infected mother to unborn child
(transplacental)
Diagnosis
1. Culture & Sensitivity – gram staining
2. Blood tests for N. gonorrhoeae antibodies 1st Stage: Primary Syphilis (10 – 90 days after infection)
1. Chancre – a firm, painless skin ulceration localized
at the point of initial exposure to the bacterium
Treatment
appear on the genitals
1. Antibiotics
 Can also appear on the lips, tongue, and other
 Penicillin
body parts
 Single dose Ceftriaxone IM + doxycycline PO
 Disappears after 3-6 weeks even without a
BID for 1 week
treatment
 Prophylaxis: Silver nitrate, Tetracycline,
 Women with chancre are often overlooked
Erythromycin
because it often develops in the internal surface,
the cervix and the vaginal wall

 As a nurse, one should be alert, syphilis should Diagnostic Studies

be suspected an indolent painless ulceration 1. Venereal Disease Research Laboratory (VDRL) test
appears in the body  To detect for the presence of bacteria by
determining the antibody response to antigen
Chancre Congenital Syphilis
produced by cell damaged by bacteria
2. Fluorescent treponemal antibody absorption (FTA –
Abs)
 To check for presence of antibodies to
Treponema pallidum bacteria
3. Micro hemagglutination test (MHA - TP)
Tibia Syphilis 4. CSF examination
2nd Stage: Secondary Syphilis (last 2 – 6 weeks)

1. Syphilis rash – an infectious brown skin rash that
typically occurs on the bottom of the feet and the
palms of the hand
2. Condylomata lata – flat broad whitish lesions, occur
in warm moist area of the body like perineum, vulva,
scrotum, the lesion is enlarged and erode that
produce contaminated pink or grayish white lesions
3. Influenza like symptoms: Fever, sore throat, Treatment
headache, lacrimation, nasal discharges, 1. Syphilis is easily treatable when early detected
hoarseness, generalize lymphadenopathy, swollen 2. Penicillin & other antibiotics
glands, and hair loss can also be experienced 3. Prevention
(alopecia)  Practicing monogamous relationship
4. Abstinence
Syphilis Rash Condylomata Lata
5. Mutual monogamy
6. Latex condoms for vaginal and anal sex
1. Case finding
2. Health teaching and guidance along preventive
measures
3rd Stage: Latent – symptoms tend to recede even 3. Utilization of community health facilities
without treatment 4. Assist in interpretation and diagnosis
No clinical manifestations but serologic test prove to be 5. Reinforce follow up treatment
reactive due to the degree of immunity, but the patient 6. VD control program participation
is not cured 7. Medical examination of patient’s contacts
8. Ask to participate in sexually transmitted controlled
program
4th Stage: Late Syphilis – manifest 1 – 10 years after the
9. Reinforcement of follow up treatment
infection, clinically destructive but not infectious
 Especially if patient have some contact, they
1. Gummas – soft, tumorlike growths have to seek medical examination as soon as
 Seen in the skin and mucous possible
membranes – occurs in bones, joint
and bone damage
2. Numbness in the extremities, difficulty
in coordinating movements, and blindness

Skin Chemical irritants – strong acids or alkalis

• As a protective interface between internal organs and Microorganisms – bacteria and viruses
the environment, the skin encounters a host of toxins,
pathogenic microorganisms, and physical stresses Major Events in the Local Inflammatory Response
• To combat these attacks on the cutaneous
microenvironment, the skin functions as more than a
physical barrier, it is an active immune organ
• Immune responses in the skin involves an
armamentarium of immune competent cells and
soluble biologic response modifiers including
cytokines
• The verse bionetwork of lymphatic and blood vessels
determines that it contains most of the lymphocyte in
the skin, other migrant leukocytes, mast cells, and
1. At the site of injury, chemicals signal release by
tissue macrophages
activated macrophages and mast cells causing
• Although the epidermis has no direct access to the
nearby capillaries to widen and become more
blood or lymphatic circulation, it is equipped with
permeable
immune competent cells
2. The fluid, antimicrobial protein, and clotting elements
• Forms mechanical barrier that prevents entry of
move from the blood to the site of injury then the
pathogens and other harmful substances into body
clotting begins
Acid mantle – skin secretions (perspiration and
3. Chemokines released by various kinds of cells attract
sebum) make epidermal surface acidic, which
more phagocytic cells from blood to the injury site
inhibits bacterial growth; sebum also contains
4. Neutrophils and macrophages phagocytose
bactericidal chemicals
pathogens and cell debris on the site and the tissue
Keratin – provides resistance against acids, alkalis
heals
and bacterial enzymes
5. In healing resolution of inflammation and
regeneration of tissue or replacement with scar
tissue
Decubitus Ulcers / Pressure Ulcers

• Any lesion caused by unrelieved pressure that causes
local interference with circulation and subsequent
tissue damage (tissue ischemia or anoxia)
• A.k.a. bedsore or pressure sores
• Initial sign – ERYTHEMA
• Injury to the skin (abrasions, cuts, incisions, burns,
etc.) or penetration (insect bites, splinters, needle Contributing Factors
sticks, stabs) can, of course, breach the barrier and Immobility (bed and chair bound clients)
provide a portal of entry for infectious agents • Post-stroke patients
• Pressure is exerted on the skin and subcutaneous
tissue by objects on which the person rests such as a
mattress, chair seat, and cast
• The development of pressure ulcers is directly related
to the duration of immobility
• If pressure continues long enough, small vessel
thrombosis and tissue necrosis may occur resulting to
• The inflammatory response (inflammation) occurs pressure ulcer
when tissues are injured by bacteria, trauma, toxins, • Weight-bearing and bony prominences are most
heat, or any other cause susceptible to pressure ulcer development because
• The damaged cells release chemicals including they are covered only by skin and small amounts of
histamine, bradykinin, and prostaglandins subcutaneous tissue
 This helps isolate the foreign substance from • Most susceptible areas include the sacrum and
further contact with body tissues coccygeal areas, ischial tuberosities (especially in
• Causes of inflammatory response: people who sit for prolonged periods), greater
Physical irritants – trauma or a foreign body

trochanter, heel, knee, malleolus, medial condyle of • Friction is the force of rubbing two surfaces against
the tibia, fibular head, scapula, and elbow one another and is often caused by pulling a patient
over a bedsheet commonly known as “sheet burn” or
from a poorly fitted prosthetic device
• Shear is the result of gravity pushing down on the
patient’s body and the resistance between the patient
and chair or bed
• Shear occurs when tissue layers slide over one
another
 Blood vessels stretch and twist and the
microcirculation of the skin is disrupted
Impaired sensory perception or cognition
• Pressure ulcer from friction and shear occur when the
• Patients with sensory loss, impaired level of patient slides down in bed or when positioned and
consciousness, or paralysis may not be aware of the moved improperly (dragged up in bed)
discomfort associated with prolong pressure on the • Sacrum and heels are the most susceptible to the
skin effects of shear
• May not change their position to relieve pressure
• Prolonged pressure impedes blood flow, reducing
nourishment of the skin and underlying tissues
• A pressure ulcer may develop in a short period of time
Increased moisture
Prolong contact with moisture from perspiration,
urine, feces, or drainage produces maceration
(softening), irritation, breakdown of the skin
Decreased tissue perfusion

• Conditions that reduce the circulation and Microorganisms invade broken skin
nourishment of the skin and subcutaneous tissue like Foul smelling infectious drainage is present

altered peripheral tissue perfusion increases the risk
Lesion enlarges, extends deep into the fascia,
of pressure ulcer development muscle, and bone
• DM patients – compromised microcirculation 
• Edema patients – impaired circulation & poor SEPSIS
nourishment of the skin tissue
• Lesion enlarge and allow a continuous loss of serum
• Obese patients – large amounts of poorly
which may further deplete the body of essential
vascularized adipose tissue which is susceptible to
protein needed for tissue repair and maintenance
breakdown
• The lesion may continue to enlarge and extend deep
with multiple sinus tracts radiating from the pressure
Decreased nutritional status ulcer
• Nutritional deficiencies − protein – tissue wasting • With extensive pressure ulcers, life threatening
and inhibited tissue repair infections and sepsis may develop, frequently from
• ↓Vit C and trace minerals – tissue maintenance and gram-negative organisms
repair
• Anemia − hemoglobin Assessment
• Metabolic disorders
Braden Scale for Predicting Pressure Ulcer Risk
• Poor nutritional status can prolong the inflammatory
• The Braden Scale for Predicting Pressure Ulcer Risk,
phase of pressure ulcer healing and can reduce the
is a scale to help health professionals, especially
quality and strength of wound healing
nurses, assess a patient's risk of developing a
pressure ulcer
Friction and shear
• Each category is rated on a scale of 1-4 excluding the
• Mechanical forces also contribute to the development friction and shear category which is rated on a 1-3
of pressure ulcers scale

Stages of Pressure Ulcer

Suspected Deep Tissue Injury
• Purple or maroon localized area of discolored intact
skin or blood-filled blister due to damage of underlying
soft tissue from pressure and/or shear
• The area may be preceded by tissue that is painful,
firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue
• The evolution may include a thin blister over a dark
wound bed and the wound may further evolve and
become covered by thin eschar
• Evolution may be rapid exposing additional layers of
tissue even with optimal treatment
Detecting a Change
Note that the skin appears intact in the left
photograph, but infrared imaging (right) reveals a
suspected deep tissue injury
Scoring with the Barden Scale

Range of score 6-23 Visual Image Infrared Image
Score 19-23 – no risk for developing a pressure ulcer (early identification) (early identification)
Score 15-18 – mild risk
Score 13-14 – moderate risk Stage 1
Score 10-12 – high risk • Area of intact skin that is reddened, or deep pink
Score 6-9 – very high risk/severest risk for developing • Erythema does not blanch with pressure
a pressure ulcer • Skin temperature elevated
• Tissue swollen and congested
• Patient complains of discomfort
Pressure Mapping
• Erythema progress to dusky blue gray
• A pressure map is a computerized clinical tool for • Area may be painful, firm, soft, and warmer or cooler
assessing pressure distribution as compared to adjacent tissue
• Measurement and visual reporting of pressure
between two contacting surfaces
• Helps identify areas of high pressure
How to use:
1. Place a thin, sensor mat on a wheelchair seat or a
mattress surface
2. Have patient sit or lie on the mat, a computer screen
displays a map of pressure, using colors, numbers, Stage 2
and a graphic image of the patient • Partial thickness wound or loss of dermis
• Red-pink wound bed without slough
• Skin breaks (epidermis and/or dermis)
• Abrasion, blister or shallow crater
• Shiny or dry shallow ulcer without slough or bruising
 Bruising indicates suspected deep tissue injury
• Area surrounding damaged skin is reddened
Red – areas of higher pressure • Edema persists
Blue or green – areas of lesser pressure • Ulcer drains
• May present as an intact or open ruptured serum filled
blister

• Infection may develop (does not include skin tears,

perineal dermatitis, maceration, excoriation)
Stage 3
• Ulcer extends into subcutaneous tissue
 Subcutaneous tissue becomes visible
• Slough may be present but does not obscure the
depth of tissue loss
 May include undermining and tunneling Documentation
• Necrosis and drainage continue 1. Pressure ulcer – measured and documented
• Infection develops 2. Characteristic of wound
• Full thickness wound 3. Signs of an infected ulcer include
 A foul odor from the ulcer
 Redness and tenderness around the ulcer
 Skin close to the ulcer is warm and swollen
4. Exudates if present
 Purulent – with pus
 Serosanguinous – with serum and blood
5. Color exudate and its corresponding pathogen
Stage 4
• Ulcer extends to underlying muscle and bone Color Exudate Probable Pathogen
• Deep pockets of infection develop Beige (light brown) with a
Proteus
• Ulcer can be fishy odor
 Dry, black, and covered with accumulation of Brown with a fecal odor Bacteroides
necrotic tissue Creamy yellow Staphylococcus
 Wet, oozing dead cells, purulent exudates Green blue with a fruity
• Full thickness wound Pseudomonas
odor
Management
1. Relieving pressure
 Change position or by turning and repositioning
the patient
 Shifting weight allows the blood to flow into the
ischemic area
Unstageable: Depth Unknown  Attention should be paid to patient migration,
• Full thickness tissue loss in which the base of the moving down into the bed in those on bed rest
ulcer is covered by slough (yellow, tan, gray, green, particularly when the head of the bed is elevated
or brown) and/or eschar (tan, brown, or black) in the
wound bed Pushes down on armrest and raises buttocks
Push ups
of the seat of the chair
• Until enough slough or eschar is removed to expose
Repeats the push up on the right side and
the base of the wound, the true depth, and therefore One half
then the left, pushing up on one side by
push up
stage, cannot be determined pushing down on the armrest
• Stable (dry, adherent, intact without erythema or Moving side Moves from one side to the other while sitting
to side on the chair
fluctuance) eschar on the heels serves as “the body’s
Bends forward with the head down between
natural (biologic) cover” and should not be removed Shifting the knees (if able) and constantly shift in the
chair
2. Positioning the patient

 Position – lateral, prone, dorsally in sequence
 Shift weight every 15-20 mins and move
independently

 Repositioning every 2 hours or more frequently

To reduce friction and shear, the following is
 Bridging technique – support client with pillows recommended:
30 degrees on a side lying position over bony
✓ Use draw sheets for repositioning
prominences ✓ Encourage use of trapeze if possible
 Small rolled towel under the shoulder or hip ✓ Keep head of bed elevated at 30o, if tolerated
3. Using pressure relieving devices ✓ Elevate foot of bed slightly, if condition permits
 Pillows, sheepskin, foam padding, and powders ✓ Use pillow or wedge to support hip, side-lying,
 Gel type flotation pads and air fluidized beds lateral position
✓ Utilize lifts and transfer devices
 Oscillating or kinetic beds change pressure by
✓ Rehabilitation or restorative care if indicated
rocking movements – multiple trauma patients
4. Improving mobility
9. Minimize irritating moisture
 Active and is ambulated whenever possible
 Pay attention to skin folds
 Active and passive exercises – increase
 Perspiration, urine, stool, and drainage must be
muscular, skin, and vascular tone
removed from the skin promptly
5. Improving sensory perception
 Soiled skin washed immediately with mild soap
 Encourage to participate in self-care
and water and blotted dry with a soft towel
 Support the client’s efforts towards active
 Skin may be lubricated using a lotion
compensation for loss of sensation
 Topical barrier ointments may be helpful in
o Paraplegia – lifting from the sitting position
protecting the skin in incontinent patient
every 15 minutes
 Drying agents and powders are avoided
o Quadriplegia – should be weight shifted
 Absorbent pads – to absorb drainage
every 30 minutes while sitting in a wheel
10. Promote pressure ulcer healing
chair
 Debridement – wet to damp dressing changes,
 Decreased sensation – inspect potential
mechanical flushing (for necrotic and infective
pressure areas visually (AM/PM) using a mirror
exudate), surgical dissection
6. Improving tissue perfusion
 Culture and sensitivity to guide the selection of
 Activity, exercise, and repositioning
antibiotic
 Massage of erythematous area is avoided
 After pressure ulcer is clean – topical treatment
because damage to the capillaries and deep
to promote granulation
tissues may occur
 Do not massage the area of the ulcer, massage
can damage tissue under the skin
7. Improving nutritional status
 Maintain positive nitrogen balance
 Eat well-balanced meals
 Drink plenty of water (8 to 10 cups) every day
 High protein diet Size
 Iron preparations – to raise the hemoglobin Measurement
concentration (maintain oxygen levels at Length – from top edge to the bottom edge (head
acceptable limits) to toe) at longest point
 Ascorbic acid – for tissue healing, promotes Width – from edge-to-edge perpendicular to the
collagen synthesis length at widest point
 Vit. A and B, zinc, sulfur – for healthy skin Depth – straight in, perpendicular to the base, at
8. Reducing friction and shear deepest point
 Shear occurs when the patient is pulled, allowed Undermining/Tunneling
to slump or move by digging heals or elbows into Using the “clock concept” (12 o’clock is in the
the mattress direction of the patient’s head and 6 o’clock is
 Semi-reclining position is avoided toward the feet)
 Raising the HOB by even a few cm can increase Where does it star and where does it end
shearing force in the sacral area (clockwise direction)
Tunnel depth is at its deepest point
Location of deepest point
o Measure widest width of the pressure ulcer side

to side perpendicular (90o angle) to length
o The depth of this pressure ulcer is
approximately 3.7 cm

Pressure Ulcer Scale for Healing (Push) Tool

• Categorizes ulcer
Score of 0 – wound healed
Score of 17 – wound not healed
Hyperbaric Medicine / Hyperbaric Oxygen Therapy

(HBOT)
• Involves the application of either topical oxygen at an
increased pressure directly to the wound or placing
the patient into a hyperbaric oxygen chamber
• The medical use of oxygen at a level higher than
atmospheric pressure
• The equipment, pressure chamber, delivers 100%
oxygen
• Promotes healing by stimulating new vascular
growths and aids in the preservation of damaged
11. Prevent recurrence
tissues
 Teach patient to increase mobility
 Follow a regimen of turning, weight shifting, and
repositioning
Management (Devices)
Patient Transfer Assistant
• Reducing the heavy physical burden of moving
patients required in caretaking
Negative-Pressure Wound Therapy (NPWT)

• A method of drawing out fluid and infection from a
When complications like fistula exist and does not
wound to help it heal
respond to treatment:
• A special dressing (bandage) is sealed over the
wound and a gentle vacuum pump is attached 1. Surgical debridement
• Controlled application of sub-atmospheric pressure to 2. Incision and drainage
the local wound environment 3. Bone resection
• The continued vacuum draws out fluid from the wound 4. Skin Grafting
and increases blood flow to the area
Care and Treatment
• Pulls the skin together to promote the growth of new
tissue Deep tissue injury
• The vacuum may be applied continuously or 1. Immediate pressure relief to affected area
intermittently
Stage 1
• Antibiotics and saline can be pushed into the wound
when needed 1. Remove pressure
• Dressing is changed 2-3 times per week 2. Prevent moisture, shear, friction
3. Promote proper nutrition, hydration
Stage 2
1. Clean with sterile saline
2. Semipermeable occlusive dressings, hydrocolloid
dressings, or wet saline dressings provide moist
healing environment

Stage 3 and 4 9. Caution against removing the radiator cap from a hot
1. Debridement to remove infected, necrotic tissues car engine
 Wet to damp dressing 10. Recommend avoidance of overhead electrical wires
 Enzyme preparations and underground wires when working outside
 Surgical debridement 11. Advise that hot irons and curling irons be kept out of
2. Topical treatment to promote granulation of tissue the reach of children
3. Surgical interventions may be required 12. Caution against running electric cords under
 Bone resection carpets or rugs
 Skin grafting 13. Recommend storage of flammable liquids well away
from a fire source
14. Advocate caution when cooking, being aware of
loose clothing hanging over the stove top
15. Recommend having a working fire extinguisher in
the home and knowing how to use
Types of Burns
Burn Injuries
Thermal Burn
• Burns are tissue damage that results from heat,
overexposure to the sun or other radiation, or • Caused by exposure to flames, hot liquids, steam or
chemical or electrical contact hot objects
• Most burns occur in the home a. Residential fires
• Greatest Risk b. Automobile accidents
 Very young and very old c. Playing with matches
 Infirm (not physically or mentally strong, d. Improper handling of firecrackers
especially through age or illness) e. Improper handling of gasoline
 Firefighters f. Scalding and kitchen accidents
 Metal smelters g. Abuse (most common in children and elderly
 Chemical workers patients)
• Drugs and alcohol play major role h. Self-inflicted
i. Clothes that catch fire
Health Promotion / Burn Prevention
1. Advise that matches and lighters be kept out of the Chemical Burns
reach of children • Caused by tissue contact with strong acids, alkalis or
2. Emphasize the importance of never leaving children organic compounds
unattended around fire or in bathroom/bathtub • Systemic toxicity from cutaneous absorption can
3. Advise the installation and maintenance of smoke occur
detectors on every level of the home, changing • Are commonly seen in the home but especially in the
batteries annually on birthday workplace.
4. Recommend the development and practice of a • These chemicals can produce local tissue injury and
home exit fire drill with all members of the household some have potential to be absorbed resulting in body
5. Advise setting the water heater temperature no poisoning
higher than 120F a. Sulfuric acid as found in toilet cleaners
6. Caution against smoking in bed, while using home b. Sodium hypochlorite as found in bleach
oxygen, or against falling asleep while smoking c. Halogenated hydrocarbons as found in paint
7. Caution against throwing flammable liquids onto an remover
already burning fire
8. Caution against using flammable liquids to start fires

Acid Burn Alkali Burn
How to Treat a Chemical Burn

1. Remove the cause of the burn safely. If the
chemical is dry, brush off any excess
2. Remove any contaminated clothing or jewelry
3. Rinse the chemical off of the skin with cool, gently Lighting Burn
running water for at least twenty minutes. Apply
• Result from energy caused by lightning strikes, and
wet cool compresses to relieve the pain
are characterized by a unique pattern of skin lesions
4. Wrap the burned area loosely with a dry sterile
• These tree-like lesions resemble feathering or ferning,
dressing. Take an over-the-counter pain reliever
and are also called “Lichtenberg figures
Seek emergency medical assistance if:
1. Person shows signs of shock
2. Burn penetrated the first layer of skin or is more
than 3 inches in diameter
3. Burn occurred on the eye, hands, feet, face, groin,
buttocks, or over a major joint
4. Pain cannot be controlled
Radiation Burns
• Exposure to UV light, x-rays or radioactivity
Burn Size
Electrical Burn Small Burns
• Caused by heat generated by electrical energy as it • Localized to the injured area
passes through the body.
• The damage may be minor skin damage or may Large or extensive burns
cause damage to internal organs • 25% or more of the total body surface area
• Devastating effects can cause lifelong neurovascular • Response of the body to the injury is systemic
problem • Burn affects all major systems of the body
• High voltage (more than 100,000 volts) injury can
cause tissue and bone destruction resulting in
amputations and possible loss of life as a result of
cardiac and respiratory abnormalities
• There is an entrance and exit wound
• Accidental electrical contact with faulty electrical
wiring or high voltage lines
• Most of the damage is beneath the skin surface and
therefore the actual injury can easily be
First Aid for Minor Burns
underestimated
1. Run cool water over the burn continuously for 10 -
• Prone to acute renal failure - release of myoglobin
15 min
from the destruction of muscle and tissue.
2. Apply cool compresses if continuous water flow is
Myoglobin is released into the bloodstream
not available
• Myoglobin – can occlude the renal tubules, acute
3. Do not apply ice, ice water, butter or ointments
tubular necrosis and acute kidney injury will occur
4. Do not pop blisters
• Neurovascular complications for as long as 2 years
5. Cover loosely with a sterile gauze bandage
after the incident can occur
6. Take ibuprofen or acetaminophen for pain

Zones of Burn Injury • Healing time – 3-5 days (discomfort 48 hrs.) no

Each burned area has three zones of injury. The inner scarring occurs
zone or "Zone of Coagulation" is where cellular death • Grafts required – no,
occurs and sustains the most damage. The middle area • Example: sunburn, flash burns
or "Zone of Stasis" has a compromised supply of blood,
inflammation, and tissue injury. The outer zone or "Zone
of Hyperemia" sustains the least damage.
Superficial Partial Thickness – 2nd degree

• Injury deeper into the dermis, blood supply is reduced
• Color – pink to red, broken epidermis with wet, shiny
and weeping surface
Central Inner Zone (Zone of Coagulation or necrosis)
• Edema – mild to moderate
• This forms the inner layer of the visible burn eschar • Blisters – yes, may cover an extensive area
• If left, the eschar separates within 3 weeks leaving • Pain – yes, sensitive to cold air
either a bed of granulation tissue (in full thickness • Eschar – no
burns) or re-epithelialization bed (in partial thickness • Healing time – approximately 2 weeks
burns) • Grafts required – no
Intermediate Zone (Zone of Stasis) • Example: scalds, flames, brief contact with hot objects
• This zone surrounds the zone of coagulation

• It contains viable tissues that may die over the next 48
hours postburn, if tissue oxygenation and adequate
nutrition are not maintained
Outer Zone (Zone of Hyperemia)

• This area contains inflammatory mediators
(prostaglandins, histamine and kinins), which
contribute to the formation of tissue edema Deep Partial Thickness – 2nd degree
• Tissue in this zone normally recover within 7-10 days • Extends deeper into the dermis
unless subjected to infection • Color – red to white
• Edema – moderate
• Blisters – rare
• Pain – yes
• Eschar – yes, soft and dry
• Healing time – 2-6 weeks
• Grafts required – can be used if healing is prolonged
• Example: scalds, flames, prolonged contact with hot
objects, tar, grease, chemicals
Classification of Burns According to Depth
Superficial Thickness – 1st degree
• Involves injury to the epidermis, blood supply to the
dermis is still intact
• Color – pink to red (mild to severe erythema)
• Edema – mild
• Blisters – no
• Pain – yes with tingling
• sensation, eased by cooling Full Thickness – 3rd degree
• Eschar – no
• Injury and destruction of the epidermis and dermis
 Piece of dead tissue that is cast off from the
• Color – black, brown, yellow, waxy white, red
surface of the skin, particularly after a burn injury,
• Edema – severe, under the eschar

• Blisters – no Inhalation Injuries

• Pain – yes and no, sensation is reduced/absent due • Smoke inhalation injury is a respiratory injury that
to nerve ending destruction occurs when the victim is trapped in an enclosed, hot
• Eschar – yes, dry, hard and inelastic smoked filled space
• Healing time – weeks to mos.
• Grafts required – yes, may develop scarring and Carbon Monoxide Poisoning
wound contractures − Smoke poisoning caused by the inhalation of the
• Example: scalds, flames, prolonged contact with hot byproducts of combustion
objects, tar, grease, chemicals, electricity − Carbon monoxide is a colorless, odorless, and
tasteless gas that binds to hemoglobin 200 times
more avidly than oxygen, thereby limiting the ability
of hemoglobin to transport oxygen
− The toxicity of CO is directly related to the
percentage of hemoglobin it saturates
− Oxygen molecules are displaced and carbon
monoxide reversibly binds to hemoglobin to form
carboxyhemoglobin → tissue hypoxia
− Treatment is based on the ability of increased
Deep Full Thickness – 3rd degree concentrations of oxygen to increase the rate at
• Injury extends beyond the skin into the underlying which CO is diffused
fascia and tissues, and muscle, bone, and tendons − A concentration of 100% oxygen increases the rate
are damaged of CO diffusion from hemoglobin from 4 hours to
• Color – black 45 minutes
• Edema – absent
• Blisters – no (%) of CO in Hemoglobin Symptoms
• Pain – absent
0-10 None
• Eschar – yes, hard and inelastic
• Healing time – weeks to mos. 10 – 20 Headache, confusion
• Grafts required – yes 20 – 40

Disorientation, fatigue, nausea,
and visual changes
• Example – flames, tar, grease, chemicals, electricity
Hallucinations, combativeness,
40 – 60
coma, and shock
> 60 Mortality > 50%
Burn Location
Head, neck and chest – associated with pulmonary
Assessment
complications
1. Facial burns
Face – corneal abrasions
2. Erythema
Ear – auricular chondritis
3. Swelling of oropharynx and nasopharynx
Hands and joints – require intensive therapy to prevent 4. Singed nasal hairs
disability 5. Flaring nostrils
Perineal area – prone to auto-contamination by urine 6. Stridor, wheezing and dyspnea
and feces 7. Hoarse voice
Circumferential burns of the 8. Tachycardia
Extremities – compartment syndrome 9. Agitation and anxiety
Thorax – inadequate chest wall expansion,
pulmonary complications Methods to Estimate Total Body Surface Area
(TBSA) Burned
Rule of Nines
• This method divides the body into 11 areas, each
counting for 9% of the total body area, plus an

additional area surrounding the genitals accounting Pathophysiology

for 1% of the body surface area. • Does not exceed 20% TBSA (local response)
• It is used for early assessment • Exceeds 20% TBSA (Local and systemic response)
• Vasoactive substances are released
• Increased capillary permeability (plasma seeps into
the surrounding tissue)
• Capillary permeability decreases in 18-26 hours after
the burn, but does not normalize until 2-3 weeks post
injury)
• Extensive burns → generalized body edema and a
decrease in circulating blood volume
Fluid loss

Decrease organ perfusion
A client sustained burns on his entire back and left 
arm. Using the Rule of Nines, what percentage of Plasma loss: increase Hct and K, decrease Na
his body is involved? 
Heart rate increases, cardiac output decreases
Answer: 27% and BP drops

Hemodynamic instability: tissue hypoperfusion
Lund and Browder Method and organ hypofunction
• A method for estimating the extent of burns that allows
for the varying proportion of body surface in persons • The initial systemic event after a burn injury is
of different ages hemodynamic instability which results from the loss of
• Children and infants capillary integrity and a subsequent shift of fluid, Na,
and CHON from the intravascular space into the
interstitial space producing hypovolemic shock
Cardiovascular Alterations
↓Cardiac output, ↓BP

Sympathetic nervous system releases
catecholamines – vasoconstriction

Fluid is reabsorbed in the vascular compartment –
blood volume increases

Heart rate increases, cardiac output decreases and
BP drops

Renal and cardiac function adequate

Urine output increases
Fluid and Electrolyte Alterations

Palm Method • Edema forms rapidly after burn injury
• This method used the patient's hand-size to estimate  Avoid excessive fluid administration during the
the percent TBSA of SMALL BURNS. The palmar early postburn period
surface of the hand (palm and fingers) equals roughly • Circulating blood volume decreases
1% TBSA in all age groups • Evaporative fluid loss
• In scattered burns • Hyperkalemia – massive cell destruction –
• Clean piece of paper is cut to the size of hand and immediately after burn
through that percentage of burns is assessed • Hypokalemia – latter, fluid shifts, inadequate fluid
• Use of the hand as a measurement tool is acceptable replacement
to measure burn surface areas which are <15% or • Hyponatremia may be present as a result of plasma
(>85% measuring non-burned area) loss, occur during the 1st week of acute phase as
water shifts from the interstitial space to the vascular
space

• Edema forms rapidly after a burn injury. A superficial 4. Presence of soot and charring in the airway
burn will cause edema to form within 4 hours after  Soot is a black powdery or flaky substance
injury, while a deeper burn will continue to form over consisting largely of amorphous carbon,
a longer period of time up to 18 hours postinjury produced by the incomplete burning of organic
 This is caused by increased perfusion to the matter
injured area and is reflective of the amount of
vascular and lymphatic damage to the tissue
Pulmonary Alterations
Inhalation injury
• Trapped in a burning structure, explosion 5. Tissue sloughing
• They may be coughing up carbonaceous sputum 6. Carbonaceous material in the airway
• Three elements of inhalation injury
 Thermal Renal Alterations
 Asphyxiation Inadequate blood volume to kidneys
 Toxic- induced lung injury 
• Fiber optic bronchoscopy (FOB) is the standard Hemoglobin and myoglobulin occlude the renal
tubules
technique for diagnosis of inhalation injury, it is readily 
available and allows a longitudinal evaluation Acute tubular necrosis and renal failure
Immunologic Alterations
Altered Immunologic defenses

↑ Risk of infection and sepsis
Thermoregulatory Alterations
Loss of skin

Inability to regulate body temperature
(Exhibit low body temperatures in the early
hours after injury)

Upper airway injury Hypothermia
• Severe upper airway edema, caused by direct thermal
injury or face and neck burns which can cause upper Gastrointestinal Alterations
airway obstruction from ET or nasotracheal
Paralytic Ileus
intubation, including the pharynx and larynx, in the
• The occurrence of intestinal blockage in the absence
early hours postburn
of an actual physical obstruction
Injury below the glottis • This type of blockage is caused by a malfunction in
• Loss of ciliary action, hypersecretion severe mucosa the nerves and muscles in the intestine that impairs
edema, bronchospasms - E.T. digestive movement
• The pulmonary surfactant is reduced, resulting in • Decrease peristalsis and bowel sounds due to burn
atelectasis (collapse of alveoli) trauma  gastric distension and nausea and vomiting
• Needs gastric decompression (NGT)
Smoke inhalation injury
• Inhale noxious gases (carbon monoxide) → tissue Curling’s Ulcer (Gastric or Duodenal Erosion)
hypoxia • An acute gastric erosion resulting as a complication
• Early intubation and mechanical ventilation from severe burns when reduced plasma volume
leads to ischemia and cell necrosis (sloughing) of the
Bronchoscopic Findings gastric mucosa
1. Airway edema • GIT bleeding due to massive physiologic stress –
 Early intubation is required if features of airway occult blood in the stool, regurgitation of coffee brown
edema seen as it will increase in the first 24 ground material from the stomach or bloody vomitus
hours
2. Inflammation Goals Related to Burn
3. Mucosal necrosis 1. Prevention of infection and wound care

2. Institution of lifesaving measures for the severely − All burn patients are treated as traumatized
burned person patients
3. Pain management − Assess for associated trauma
4. Prevention of disability and disfigurement through − Conserve body heat
early specialized and individualized care − Cover burns with sterile or clean cloths
5. Rehabilitation through reconstructive surgery and − Remove constricting clothing, jewelry and piercing
rehabilitation programs to prevent constriction secondary to rapidly
developing edema to prevent torniquet effect
3 Phases of Management − Assess the need for IV fluids
Emergent Phase / Resuscitative Phase − Transport to the Emergency department
• From onset of injury to completion of fluid Minor Burns
resuscitation − Administer pain medications as prescribed
• Duration usually 48 – 72 hours − Administer tetanus prophylaxis
• Includes prehospital care and emergency room care − Wound care – cleansing, debriding loosse tissue,
• GOAL: to prevent hypovolemic shock and preserve topical antimicrobial cream, sterile dressing
vital organ functioning − Instruct client in follow up care. Wound care
On the Scene Care treatments
− Preventing injury to the rescuer is the first priority Emergency Department Care: Major Burns
of on the-scene care. If needed, fire and − Evaluate the degree and extent of the burn
emergency medical services should be requested − Treat life-threatening situations
at the first opportunity − Ensure a patent airway, administer 100% oxygen
− Prevent injury to rescuer. Do not become a victim − Monitor for respiratory distress. Assess the need
yourself! for intubation
− Turn off gas / pump / electric power, etc. if possible, − Assess oropharynx for blisters and erythema
remove patient from heat source (push with dry − Monitor ABG and carboxyhemoglobin levels
nonconductive material if in contact with electricity) − For an inhalation injury, administer 100% oxygen
− Immediately move patient from vicinity if danger of via a tight-fitting non-rebreather face mask
explosion − Initiate peripheral IV access to nonburn skin
− Keep low to avoid smoke; use protective breathing proximal to any extremity burn, or prepare a central
apparatus if available venous line
− Put fire out; extinguish burning clothing (H2O or − Assess – hypovolemia. IVF to maintain fluid
CO2 extinguisher) balance
− Stop injury: extinguish flames (stop, drop and roll), − Monitor VS
smother flames (blanket, coat). Disconnect − Insert a foley catheter, maintain UO – 30 -50 ml/hr
electrical source − Maintain an NPO status
− Position airway; start O2 and / or CPR if needed − Insert NGT – remove gastric secretions, prevent
− Get off all potentially affected clothing aspiration
− Soak clothing or burn area if heat transfer still − Administer tetanus prophylaxis as prescribed
possible; continue to copiously irrigate if chemical − Administer pain medications IV as prescribed
burn − Prepare the client for an escharotomy or
− Ventilate area if smoke present fasciotomy as prescribed
− Arrange transport
− Immobilize neck & back, etc., if needed
Compartment Syndrome
Prehospital Care • A condition of marked increase in venous pressure
− Immediate survey ABCDEs: because of the constriction of edematous tissue within
Airway with cervical spine stabilization – a muscle compartment – Impaired Circulation
A
electrical burn • Compartments are enclosed spaces located in the
B Breathing muscles of extremities and are made up of muscle,
C Circulatory and cardiac status bone, nerves and blood vessels wrapped by a fibrous
membrane or fascia
Disability including neurologic deficit, level
D
of consciousness, GCS • Internal pressure – bleeding or edema into a
compartment
Exposure – expose and examine while
E
maintaining a warm environment

− Sodium traps in edema fluid and shifts into cells as

potassium is released: hyponatremia
− Begin initiation of fluid
− Amount of fluid administered based on client’s
weight and extent of injury
− GOAL: Prevent shock by maintaining adequate
circulating blood volume and maintaining vital
organ perfusion
American Burn Association Fluid Resuscitation Formula

Adults: within 24 hours Post Thermal or Chemical Burn
Formula: 2 ml Lactated Ringers (LR) x weight in kg x %
Management
TBSA
Surgical fasciotomy
GIVEN: 70 kg patient with a 50% TBSA burn
 To decrease pressure
 Fasciotomy or fasciectomy is a surgical procedure 2ml x 70 kg x 50 TBSA = 7000 ml/24 hours
where the fascia is cut to relieve tension or Plan to administer:
pressure commonly to treat the resulting loss of First 8 hours = 3500 ml (half is given first 8 hours)
circulation to an area of tissue or muscle or 437 ml/h
 A limb-saving procedure when used to treat acute Next 16 hours = 3500 ml, or 219ml/h
compartment syndrome
Adults: within 24 hours Post Electrical Burn
Formula: 4 ml Lactated Ringers (LR) x weight in kg x %
TBSA
GIVEN: 70 kg patient with a 50% TBSA burn
4ml x 70 kg x 50 TBSA = 14,000 ml/24 hours
Plan to administer:
First 8 hours = 7000 ml (half is given first 8 hours)
or 875 ml/h
Next 16 hours = 7000 ml, or 437ml/h
− The pH and osmolality of Lactated Ringer’s

solution closely resembles human plasma
− IV access is used for small burns whereas central
venous line is used for extensive burns
− Successful fluid resuscitation – stable VS,
adequate UO palpable peripheral pulses and clear
sensorium
− Foley catheter is inserted to monitor hourly urine
output and provide data to determine whether fluid
resuscitation is adequate
Escharotomy − 30ml/hr – minimum acceptable urine flow for adults
 Surgical incision into the eschar (devitalized tissue − Burgundy-colored urine
resulting from the burn) to relieve the constricting suggests the presence of
effect of the eschar tissue hemochromogen and
 Inflexible eschar and underlying tissue edema can myoglobin resulting from
also prevent chest wall motion and, thus, limit muscle damage
ventilation o This is associated with
deep burns caused by electrical injury or
Fluid and Electrotype Shifts prolonged contact with flames
− Generalized dehydration − Glycosuria, a common finding in the early postburn
− Reduced blood volume and hemoconcentration hours, results from the release of stored glucose
− Decreased urine output from the liver in response to stress
− Trauma causes release of potassium into
extracellular fluid: hyperkalemia

Nursing Intervention Observation Explanation

1. Monitor for tracheal/laryngeal edema
Blood cell concentration is diluted as
2. Monitor ABG Hemodilution fluid enters the intravascular
3. Elevate head of the bed to 30 degrees – burns of the (decreased hematocrit) compartment; loss of red blood
face and head destroyed at burn site
4. Shave or cut body hair around wound margins Fluid shift into intravascular
Increased urinary compartment increases renal blood
5. Monitor gastric output, auscultate bowel sounds output flow and causes increased urine
6. Monitor stools for occult blood formation
7. Address pain With diuresis, sodium is lost with
Sodium (Na) deficit
8. Pain meds – opioid analgesics serum
water; existing sodium is diluted by
 Only IV medication should be administered water influx
(morphine) Potassium (K) deficit

Beginning on the fourth or fifth
 Medicate clients before painful procedures (occurs occasionally in
postburn day, K shifts fluid into cells
this phase)
9. Nutrition – proper nutrition to promote wound healing
maintain an NPO status until the bowel sounds are Loss of sodium depletes fixed base;
Metabolic acidosis relative carbon dioxide content
heard increases
10. Encourage patient to cough – to remove secretions
by suctioning
Management
11. Bronchodilators and mucolytic agents administered
12. Edema of the airways – endotracheal tube, Debridement
Mechanical ventilation • The goals of, debridement, the removal of devitalized
13. Contact lenses removed tissue, are:
14. Clean sheets to protect the burn from contamination a. Removal of tissue contaminated by bacteria and
15. Patient is stabilized and condition is continually foreign bodies, thereby protecting the patient
monitored from invasion of bacteria
16. Patients with electrical burns should have ECG b. Removal of devitalized tissue or burn eschar in
17. Psychosocial consideration and emotional support preparation for grafting and wound healing
should be given to patient and family
18. Transferred to a burn unit Types of Debridement
Surgical Debridement (Sharp)
Burn Unit – a specialized facility usually affiliated • Excision of eschar or necrotic tissue via surgical
with a hospital that provides advanced care and
treatment for patients with severe burn procedure in the operating room
Mechanical Debridement
Acute Phase / Intermediate Phase • By irrigation, hydrotherapy, wet-to-dry dressings, and
• Begins when the client is hemodynamically stable, an abraded technique
capillary permeability is restored and diuresis has • This technique is cost-effective, can damage healthy
begun to near completion of wound closure tissue, and is usually painful
• Usually begins 48-72 hours after time of injury
Enzymatic Debridement
• Focus is on infection control, wound care, wound
closure, nutritional support, pain management, • Performed by the application of a prescribed topical
physical therapy agent that chemically liquefies necrotic tissues with
• GOAL: Placed on restorative therapy and the phase enzymes
• These enzymes dissolve and engulf devitalized
continues until wound closure is achieved
tissue within the wound matrix
• Prevention or treatment of infection or complication
 Burn wound is an excellent medium for bacterial • Enzymatic debriding agents
growth a. Accuzyme
 Infection impedes wound healing by promoting b. Collagenase (Santyl)
c. Granulex
excessive inflammation and damaging tissues
 Use of cap, gown, mask and gloves d. Zymase
Autolytic Debridement
Fluid and Electrolyte Changes in the Acute Phase • Uses the body's enzymes and natural fluids to soften
• Fluid remobilization phase (state of diuresis) bad tissue
Interstitial fluid  plasma • This is done with a moisture-retaining dressing that is
typically changed once a day. When moisture

accumulates, old tissue swells up and separates from Classification

the wound. Autographs – tissue is obtained from the patient’s own
• Only necrotic tissue is liquefied skin
• It is also virtually painless for the patient Allograph (allogenic, homograft) – tissue obtained from
• Hydrocolloids, hydrogels and transparent films a donor of the same species
Xenograft (Heterograph) – tissue obtained from another
Burn Wound Care specie
• Wound cleaning: hydrotherapy – cleansed by
immersion, showering, or spraying
Hydrotherapy
• Uses warm running water to help the healing process
of a burn injury
• We use it to clean patient wounds and assess the
healing progress
Topical Agents
a. Silver Sulfadiazine (Silvadene) – water soluble
cream, wide antimicrobial coverage, minimal
penetration of eschar – S.E. Leukopenia
b. Mafenide acetate (Sulfamylon) – gram positive and
negative bacteria Types of Skin Grafts
c. Silver nitrate – bactericidal, does not penetrate Pinch Graft
eschar • Very small squares of skin are attached to the area
d. Acticoat – gram positive and negative bacteria that needs to be covered
• These small pieces of skin will then grow to cover
Skin Grafting injured sites
• A technique in which a section of skin is detached • These will grow even in areas of poor blood supply
from its own blood supply and transferred as free and resist infection
tissue to a distant(recipient) site
• Commonly used to cover areas denuded of
skin(burns)
Split-Thickness Graft
• Involves removing the epidermis and dermis
• These layers are taken from the donor site, which is
the area where the healthy skin is located
• Split-thickness skin grafts are usually harvested from
the front or outer thigh, abdomen, buttocks, or back
A: A 38-year-old woman, who suffered thermal burn caused by

alcohol, with a full-thickness burn covering 30% TBSA;
B: injured area after eschar removal
C: reconstruction with 210 cm2 of dermal matrix and autografts.
She presented 5-cm2 graft loss that was treated with autologous
keratinocyte cultures
D: the picture shows the appearance at 9 months Full-Thickness Graft
postoperatively. TBSA: total body surface area
• Involves removing all of the epidermis and dermis
from the donor site

• These are usually taken from the abdomen, groin,

forearm, or area above the clavicle
• For weight-bearing portions of the body and friction
prone areas such as, feet and joints
• Contains all of the layers of the skin including blood
vessels
• Blood vessels will begin growing from the recipient
area into the transplanted skin within 36 hours
Pre-Operative
1. Recipient and donor sites must be free of infection
and have a stable blood supply
2. Success of a skin graft can be determined within 72
Equipment hours of the surgery – no rejection
Dermatome
• A surgical instrument used to produce thin slices Donor Site Care
of skin from a donor area, in order to use them for 1. Absorbent gauze dressings
making skin grafts  To absorb blood or serum from the wound
• Dermatomes can be operated either manually or 2. Membrane dressing (Opsite)
electrically (oscillating blade, micrometers)  Transparent, allows the wound to be observed
• Electrical dermatomes are better for cutting out without disturbing the dressing
thinner and longer strips of skin with a more  Permits the patient to shower without fear of
homogeneous thickness saturating the dressing from water
3. Keep it clean and dry

4. After healing, keep the donor site soft and pliable
Free-Hand Knives (lanolin, olive oil) 6-12 mos.
• These are manual dermatomes and the term knife or 5. Protect donor site and grafted area from
scalpel is used to describe them  Exposure to extremes of temperature
• Their disadvantages are harvesting of grafts with  External trauma
irregular edges and grafts of variable thickness  Sunlight (at least 6 mos.)
• The operator has to be experienced to their use of
optimal result Conditions for the Graft to Survive
1. There is enough blood supply
2. Graft must be in close contact with its bed to avoid
accumulation of blood or fluid between the graft and
recipient site
3. Graft must be fixed firmly
4. Area must be free of infection
1. Keep affected part immobilize as possible
 Face – avoid strenuous activity
 Hand or arm – may be immobilized with a splint

 Lower extremity – elevate g. Vocational counseling and support groups may

 Ambulation permitted – elastic stockings to assist the patient
counter balance venous pressure
2. Inspect the dressing daily Burn Scar Contractures
 Report unusual drainage or an inflammatory • Refers to the tightening of the skin after a second- or
reaction around the wound margin third-degree burn
3. After 2-3 weeks, apply lanolin cream to moisten the • When skin is burned, the surrounding skin begins to
graft pull together, resulting in a contracture
4. Bowel Management System • It needs to be treated as soon as possible because
 Soft catheter is inserted the scar can result in restriction of movement around
into the rectum for fecal the injured area
management to contain
and divert fecal waste Complication of Contracture
 Prolonged diarrhea 1. Hypertrophic Scar
5. Pain Management  A cutaneous condition characterized by deposits
 Most severe forms of acute pain of excessive amounts of collagen which gives
 Pain accompanies care, and treatments such as rise to a raised scar, but not to the degree
wound cleaning and dressing changes observed with keloids
 Analgesics 2. Keloid Formation
a. IV use during emergent and acute phases  A type of raised scar
b. Morphine – PCA (patient-controlled  They occur where the skin has healed after an
analgesia) injury
 Role of anxiety in pain  They can grow to be much larger than the
 Effect of sleep deprivation on pain original injury that caused the scar
 Nonpharmacologic measures
6. Nutritional Support
Burn injuries:
 Enteral route is preferred
 Jejunal feedings
 Goal of nutritional support is to promote a state
of nitrogen balance and match nutrient utilization
Other Major Care Issues

1. Pulmonary care Management
2. Psychological support of patient and family 1. Burn Pressure Garments
3. Patient and family education  Pressure garments are worn after a burn to
4. Restoration of function control scarring, to help the scar mature, and to
improve the look of the injured skin
Rehabilitative Phase  Compression minimizes the development of
• Overlaps acute phase of care scars by interfering with the production of
• Extends beyond hospitalization collagen and helping to realign the collagen
• Rehabilitation is begun as early as possible in the fibers
emergent phase and extend for a long period after the 2. Psychological support
injury  Grief and loss – physical injury, loss of control
• GOAL: client can gain independence and achieve from the forced dependency on others, loss of
maximal function family members/friends who may have perished
• Focus is upon in the injury, loss of homes and possessions
a. Wound healing (Residential Fire)
b. Psychosocial support  PTSD – Post traumatic stress disorder
c. Self-image  Promote a healthy body image
d. Lifestyle 3. Reconstructive Burn Surgery
e. Restoring maximal functional abilities so the  The goals are to improve both the function and
patient can have the best quality life, both the cosmetic appearance of burn scars
personally and socially
f. Reconstructive surgery to improve function and
appearance

4. Rehabilitation
 Physical and occupational exercises to prevent
muscle atrophy and to maintain the mobility
required for daily activities

HIV AND AIDS
HIV Infection and AIDS • I984 – the HIV antibody test, enzyme immunoassay
• Most commonly known immunodeficiency disorders (EIA) formerly called enzyme linked immunosorbent
• When first identified in 1981, HIV and AIDS was a fatal assay (ELISA) became available
disease and the only treatments available were
comfort measures and hospice care for several years o Freddie Mercury (QUEEN) was diagnosed with
• As of today, there is still no cure, but there are now HIV in 1987 and died in 1991
o Earvin "Magic" Johnson Jr. is an American
close to 40 U.S. food and drug administration, FDA
retired professional basketball player
approved medications for treating HIV/AIDS announced in 1991 that he contracted HIV
• If HIV positive patients are compliant with their HIV
treatment, including routine testing to monitor overall First Decade
health status and managing the effects of the chronic − Recognition and treatment of opportunistic
disease, it can be controlled and a good quality of life diseases
can be maintained − Introduction of prophylaxis against opportunistic
• The epidemic remains a critical public health issue in infections (OIs)
all communities across the country and around the Second Decade
world
− Progress in the development of highly active
• Prevention, early detection, and ongoing treatment
antiretroviral drug THERAPIES (HAART)
remain important aspects of care for people with HIV
− Progress continued in the treatment of
infection and AIDS
opportunistic infections
• Nurses in all settings encounter people who are
Third Decade – Focused on:
positive for HIV infection; therefore, nurses need an
− Issues of preventing new infections
understanding of the pathophysiology, knowledge of
− Adherence to antiretroviral therapy (ART)
the physical and psychological consequences
− Development of second-generation combination
associated with the diagnosis, and expert assessment
medications that affect different stages of the viral
and clinical management skills to provide optimal care
life cycle
for people with HIV infection and AIDS
− Continued need for an effective vaccine
HIV (Human Immunodeficiency Virus)

Epidemiology
• Can only infect human beings
• Attacks the body’s immune system by weakening its • In the fall of 1982, after the first 100 cases were
defenses against diseases or infections reported, the Centers for Disease Control and
• An organism, a characteristic of which is that it Prevention (CDC) issued a case definition of AIDS
reproduces itself, taking over the machinery of the • AIDS cases were reported to the CDC using a uniform
human cell surveillance case definition and case report form
• Late 1990s, many more states in the U.S.
AIDS (Acquired Immunodeficiency Syndrome) implemented HIV case reporting in response to the
• Transmitted from person to person, not hereditary changing epidemic and the need for information on
• It affects the body’s immune system, part of the body the numbers and characteristics of people with HIV
which usually works to fight off germs such as bacteria infection who had not yet developed AIDS
and viruses • End of 2014 – WHO projected approximately 36.9
• It makes the immune system work improperly million people living with HIV
• Someone with AIDS may experience a wide range of • July 2015 – White House released the National
different diseases and opportunistic infections HIV/AIDS Strategy for the United States: Updated to
2020
• Strategic goals:
History
1. Reducing new infections
• I981(June) – HIV was first reported by the Centers for 2. Increasing access to care and improving health
Disease Control (CDC) outcomes for people living with HIV
• The condition was named GRIDS (Gay Related 3. Reducing HIV related health disparities and
Immune Deficiency Syndrome) before since all of its health inequities
first cases were homosexual men suffering from 4. Achieving a more coordinated national
general immune deficiency response to the HIV epidemic
• 1982 – the term AIDS replaced GRIDS when it • 2015 – A growing number of adults aged 50 and older
became apparent that the disease was not just limited have HIV/AIDS. Many were diagnosed with HIV in
to gay men their younger years and are benefitting from effective
• It can occur in a person of any age treatment

HIV AND AIDS
• New York City has the oldest and the largest epidemic
in the Western world
Predictions for the leading causes of disability and

mortality in 2030
World 1 HIV/AIDS
2 Unipolar depressive disorder
3 Ischemic heart disease
High-income countries 1 Unipolar depressive disorder
2 Ischemic heart disease
3 Alzheimer
Middle-income 1 HIV/AIDS
countries 2 Unipolar depressive disorder
3 Cerebrovascular
Low-income countries 1 HIV/AIDS
2 Perinatal disorder
3 Unipolar depressive disorder
Several factors put older adults at risk for HIV infection

1. Many older adults are sexually active but do not use
History in the Philippines condoms, viewing them only as a means of
1984 – the first case of AIDS was identified unneeded birth control
1985 – DOH began serological surveillance of HIV 2. Many older adults do not consider themselves at risk
1986 – HIV/AIDS was declared a notifiable disease for HIV infection
3. Older gay men, who grew up and lived in an era
1987 – the National AIDS prevention and Control
when disclosure of their sexual orientation was not
Committee
acceptable and who have lost long-time partners,
1991 – National Sentinel Surveillance initiative to may begin new relationships with younger men
monitor trends of HIV/AIDS in high-risk groups and 4. Older adults may be intravenous (IV) injection drug
determines its spread in low-risk groups users
1992 – National AIDS Prevention and Control Program 5. Older adults may have received HIV-infected blood
Surveillance and Education Activities through transfusions before 1985
6. Normal age-related changes include a reduction in
immune system function, which puts the older adult
at greater risk for infections, cancers, and
autoimmune disorders. Many older adults also
experience the loss of loved ones, resulting in
depression and bereavement, factors that are
associated with depressed immune function
• In a healthy immune system, the T-cells that have the

protein CD4 on their surface are known as CD4
positive and as T-helper cells
• CD4 cells are sometimes also called T-cells, T-
lymphocytes, or helper cells
• Normally, CD4 and T-cells, activate B-cells, natural
killer cells, and phagocytes
• These cells participate in both cellular and humoral
immunity

HIV AND AIDS
• HIV primarily attaches to the CD4 cell wall receptors Reverse transcriptase – copies RNA into DNA
found on lymphocytes and some monocytes (Reverse transcription)
• The virus must go through several stages before it can Integrase – incorporates the reprogrammed DNA
effectively infect a host cell Protease – cuts the long chains, freeing the
• Once infected with HIV, the host cell and the ability of replicated viral particles into the cytoplasm of the
the cell-mediated immune response is seriously cell
impaired
• Once infection occurs in the CD4 lymphocytes and
produces HIV, the CD4 cell itself dies
The transformed DNA provides the blueprint for

making clones of HIV
HIV Life Cycle

Attachment/Binding – glycoproteins of HIV bind with the
host’s uninfected CD4 receptor and chemokine
Etiology coreceptors, usually which results in fusion of HIV with
• HIV is a retrovirus the CD4 T-cell membrane
• Cannot replicate outside of living host cells.
• Contain only RNA; no DNA Uncoating/Fusion – only the contents of HIV’s viral core
• Differs from other viruses because of an enzyme (reverse transcriptase, integrase, and protease) are
called reverse transcriptase which help the virus emptied into the CD4 T-cell
replicate and place its genetic material in the DNA synthesis − HIV changes its genetic material from
deoxyribonucleic acid (DNA) of the host cell RNA to DNA through action of reverse transcriptase,
• Results in the replication of as many 2 billion viral resulting in double-stranded DNA that carries instruction
particles/day released from the host cell into the for viral replication
circulatory system, infecting other cells in the body
Integration − new viral DNA enters the nucleus of the
2 HIV Subtypes CD4 T-cell and through action of integrase is blended
with the DNA of the CD4 T-cell, resulting in permanent,
HIV-1 − found around the world, mutates easily and
lifelong infection
frequently, producing multiple sub-strains
HIV-2 − found mainly in small area in West Africa and is Transcription − when the CD4 T-cell is activated, the
less transmittable and the development of AIDS is double-stranded DNA forms single-stranded
longer messenger RNA (mRNA), which builds new viruses
Translation − the mRNA creates chains of new proteins

Pathophysiology and enzymes (polyproteins) that contain the
• HIV requires a living host cell for survival and components needed in the construction of new viruses
duplication
• HIV enters the body through transmission of infected Cleavage − the HIV enzyme protease cuts the
blood or body fluids, carries its genetic information in polyprotein chain into the individual proteins that make
RNA and infects cells which have the CD4 antigen up the new virus
• Capsid is a double layer of lipid material with surface Budding − new proteins and viral RNA migrate to the
binding protein called GP120 and projects in all membrane of the infected CD4 T-cell, exit from the cell,
directions from the lipid layer and start the process all over
• Inside the capsid are strands of RNA and 3 important
 When the buds rupture, they release many copies
enzymes:
of the virus, which reinfect other T-cells

HIV AND AIDS
dissemination of HIV throughout the body, and

destruction of CD4 T-cells resulting to a dramatic drop
in CD4 T-cell counts, which are normally 500 to 1500
cells/mm3 of blood
• During this time the immune system reacts to the virus
by developing antibodies, this is referred to as
seroconversion
• When the body's immune system puts up a fight, it is

called acute retroviral syndrome (ARS), viremia,
which often is mistaken for flu
Symptoms
Early symptoms of infection disappear on their own
within weeks
1. Fever (most common)
Stages of HIV Diseases 2. Headache
2014 CDC Case Definition for HIV Infection Among Adolescents and
3. Lymphadenopathy
Adults 4. Pharyngitis
CD4 5. Skin rash (red rash that doesn't itch, usually on the
Stage CD4 Count Clinical Evidence
%*
Stage 0 Early HIV infection torso)
6. Myalgias/arthralgias
Stage 1 ≥500 cells/mm3 ≥26 No AIDS-defining condition
3
7. Diarrhea
Stage 2 200-499 cells/mm 14-25 No AIDS-defining condition
8. Night sweats
or Documentation of AIDS-
Stage 3 <200 cells/mm3 <14
defining condition
and No information on
Stage
No data No data presence of AIDS-defining
Unknown
condition
*Use CD4 percentage only if no data available for CD4 count
Stage 0: Primary Infection (Acute/Recent HIV Infection,

Acute HIV Syndrome)
• The period from infection with HIV to the development
of HIV-specific antibodies (within 2 to 4 weeks after
infection with HIV)
• Window period – is the time it takes for the body to
produce HIV antibodies after being exposed to HIV
• During this stage an HIV-positive person tests
negative on the HIV antibody blood test, although he
Stage 1: HIV Asymptomatic /Chronic HIV infection
or she is infected and highly infectious, because his
(More Than 500 CD4 T Lymphocytes/mm3)
or her viral load is very high
• During this very early period, HIV infection may not be • Stage is free from symptoms; person may look and
detected by testing. This is because most HIV tests feel well but HIV is continuing to weaken his immune
look for antibodies rather than the virus system
• Increased viral replication occurs 2-4 weeks after • Level of HIV in the blood drops to very low levels
exposure to HIV followed by widespread • HIV neutralizing antibodies are detectable in the blood

HIV AND AIDS
• Patient may have persistent generalized occurs on the surface lining of the cervix or endocervical
lymphadenopathy (PGL), painless, non-tender canal
enlarged lymph nodes (lymphadenopathy) in at least
two areas of the body for at least 3 months
• Viral set point is a state in which a patient’s primary
infection with HIV has subsided and an equilibrium
now exists between HIV levels and the patient’s
immune response. The remaining amount of virus in
the body after primary infection
• The higher the viral load of the set point, the faster the
virus will progress to AIDS; the lower the viral load of
the set point, the longer the patient will remain in
clinical latency. The only effective way to lower the set
Constitutional symptoms − such as fever (38.5C) or
point is through highly active antiretroviral therapy
diarrhea exceeding 1 month in duration
Hairy leukoplakia – is a white patch on the side of the

tongue with a corrugated or hairy appearance. It is
caused by Epstein-Barr virus (EBV)
Stage 2: HIV Symptomatic (200 to 499 CD4 T- Oral Herpes zoster (shingles) − involving at least two
Lymphocytes/mm3) distinct episodes or more than one dermatome. Herpes
• The immune system becomes damaged and zoster is viral infection, a painful but self-limited
weakened by HIV and symptoms develop dermatomal rash caused by reactivation of varicella
• The symptoms are caused by the emergence of zoster virus which remained dormant in the body within
opportunistic infections (illness caused by various the dorsal root ganglia often after decades after initial
organisms, some of which usually do not cause exposure
disease in people with normal immune system
• It is typically at this point that the person seeks health Idiopathic thrombocytopenic purpura – is
an immune disorder in which the blood doesn't clot
Examples of conditions normally and can cause excessive bruising and
Bacillary angiomatosis – neovascular proliferation in the bleeding particularly in the legs
skin or the internal organs and presenting as tumor-like
masses due to infection with Bartonella henselae or
Bartonella quintana
Listeriosis − a serious infection caused by the germ

Listeria monocytogenes through eating contaminated
ready-to-eat meat and dairy products. High risk foods
include bologna, vienna, and other sausages
Candidiasis, oropharyngeal (thrush) or vulvovaginal
(persistent, frequent, or poorly responsive to therapy)
Cervical dysplasia (moderate or severe) – a

precancerous condition in which abnormal cell growth

HIV AND AIDS
Pelvic inflammatory disease − particularly if complicated

by tubo-ovarian abscess and caused by a complication
of an STD resulting to a great damage in the uterus,
ovaries, fallopian tube, and other organs
Peripheral neuropathy – loss of blood flow causing

nerve damage
Wasting syndrome − refers to unwanted weight loss of

more than 10 percent of a person's body weight, with
either diarrhea or weakness and fever that have lasted
at least 30 days
 For a 150-pound man, this means a weight loss of
15 pounds or more Stage Unknown
 Weight loss can result in loss of both fat and • Refers to a person with laboratory confirmation of HIV
muscle infection, but no information about CD4 cell count or
percentage (and no information about the presence of
Stage 3: AIDS (Fewer Than 200 CD4 T AIDS-defining clinical conditions)
Lymphocytes/mm3)
Stage
• Significantly impaired Immune system and the body Stage 0 Stage 1 Stage 2 Stage 3
Unknown
can’t fight off opportunistic infections Asymptomatic With
Severe laboratory
• The illness becomes more severe leading to an AIDS (No Mild Advanced
symptoms of confirmation
symptoms of Symptoms symptoms
AIDS
diagnosis HIV disease) of HIV
infection,
Rapid but no
Short, flu-like
The immune Decline in
If preventive medications not started the HIV infected illness occurs Average 10
system the number
information
1-6 weeks years about CD4
person is at risk for after infection
deteriorates of CD4 T- cell count or
cells percentage
Pneumocystis Carinii Pneumonia (PCP) Opportunistic
Infected HIV blood Opportunistic infections
– A cause of diffuse pneumonia in person can drops to infections become
immunocompromised hosts Even in fatal cases, infect other very low (OI) start to severe and
people levels appear cancer may
the organism and the disease remain localized to develop
the lung Antibodies
are
detectable
Cryptococcal Meningitis in the blood
− A type of meningitis caused by a fungus

called Cryptococcus Assessment
− This type of meningitis mainly affects people with 1. Take a health history, especially noting any “high
weakened immune systems due to another illness risk” exposures
Out Patient
Toxoplasmosis  Having unprotected anal or vaginal sex
− A disease that results from infection with  Having another sexually transmitted infection
the Toxoplasma gondii parasite, one of the world's (STI) such as syphilis, herpes, chlamydia,
most common parasites gonorrhea and bacterial vaginitis
− Infection usually occurs by eating undercooked Many STIs produce open sores on genitals.
contaminated meat, exposure from infected cat These sores act as doorways for HIV to enter the
feces, or mother-to-child transmission during body
pregnancy  If client appears very uncomfortable and pauses
for long periods before answering the nurse’s
questions, tell him to take his time. Realize that
this is a very private topic to talk about
 Give time to collect his or her thoughts and
composure before answering questions
In Patient
 Shared contaminated needles, syringes
 Received unsafe injections, blood transfusions
and tissue transplantation, and medical

HIV AND AIDS
procedures that involve unsterile cutting or • Respiratory failure can develop within 2 to 3 days after
piercing the initial appearance of symptoms
 Accidental needle stick injuries • PCP can be diagnosed definitively by identifying the
2. Risk reduction counseling – discussion of sexual organism in lung tissue or bronchial secretions
history Procedures:
 The patient’s support network can be assessed, a. Sputum induction
readiness for anti-retroviral therapy can be b. Bronchial-alveolar lavage
evaluated c. Transbronchial biopsy (fiberoptic bronchoscopy)
 The nurse should begin with an assessment of
the client’s comfort level with the topic when Mycobacterium Avium Complex (MAC)
completing a health history for a client and
• A group of bacteria related to tuberculosis, these
begins to obtain a sexual history
germs are very common in food, water, and soil
 Opening question: How do you feel about
• When a person has a strong immune system, it
answering questions about your sexual history?
doesn’t cause problems but they can make people
3. The initial evaluation and the focus of the first visit
with weaker immune systems, like those with HIV very
should take into account whether the client is newly
sick
diagnosed with HIV or has established HIV and is
new to the clinic Signs and Symptoms
 In some instances, the client may have active 1. Fever
HIV-related issues that needs to be immediately 2. Sweating
addresses and these issues make take priority 3. Weight loss
and dominate the first visit 4. Fatigue
4. In general, while obtaining the initial history, the 5. Diarrhea – loose, watery stools, which would
clinician should obtain information from the client in increase the risk for perineal skin breakdown
an open, nonjudgmental manner 6. Shortness of breath
 The initial encounter forms the basis of the client- 7. Abdominal pain
provider relationship and should be informed by 8. Anemia
a patient centered multidisciplinary approached
Tuberculosis
Comprehensive Patient History
• Caused by Mycobacterium tuberculosis in which it
1. Date of diagnosis of HIV infection
primarily attacks the lungs but can also damage other
2. Identified risk factors related to HIV acquisition
parts of the body
3. Prior HIV-associated complications and
• Spreads through the air when a person with TB
comorbidities
coughs, sneezes or talks
4. Past medical history
5. Past surgical history Signs and Symptoms
6. Psychiatric history 1. Loss of appetite and unintentional weight loss
7. Residence and travel history 2. Fever and chills
8. Medication history 3. Night sweats
9. Allergies and intolerances to medications 4. A cough that lasts more than three weeks
5. Cough up some blood
A complete physical examination should be  Place the patient on respiratory isolation and
performed at the initial encounter, with particular
attention given to the oral, integumentary, and inform the physician
lymph node examinations
Management
1. Sputum exam and x-ray
Opportunistic Infections 2. Meds – 4 drug combinations: isoniazid, rifampin,
Respiratory Manifestations pyrazinamide and ethambutol
Pneumocystis Pneumonia (PCP)
• Most common infection in people with AIDS Gastrointestinal Manifestations
• Without prophylactic therapy, 80% of all people ✓ Loss of appetite
infected with HIV will develop PCP ✓ Nausea and vomiting
• Nonspecific signs and symptoms – non-productive ✓ Oral and esophageal candidiasis – creamy-white
cough, fever, chills, shortness of breath, dyspnea, patches in the oral cavity
hypoxemia, and occasionally chest pain ✓ Difficult and painful swallowing
✓ Chronic diarrhea – profound weight loss

HIV AND AIDS
Wasting Syndrome 4. Progressive 6. Psychosis and hallucinations

confusion 7. Tremor and seizures
• Profound involuntary weight loss exceeding 10% of 5. Psychomotor slowing 8. Incontinence
baseline body weight and either chronic diarrhea for 6. Apathy ataxia 9. Mutism
more than 30 days 10. Death
Oncologic Manifestations Cryptococcal Meningitis

Kaposi’s Sarcoma • A fungal infection that causes neurologic disease
• A type of cancer that can form masses in the skin, • Characterized by symptoms such as fever, headache,
lymph nodes, or other organs malaise, stiff neck, nausea, vomiting, mental status
• The skin lesions are usually purple in color changes, and seizures
• They can occur singularly, in a limited area, or be • Ask the client to place his chin on his chest to assess
widespread the presence of nuchal rigidity
 Nuchal rigidity is an inability to flex the neck
forward due to rigidity of the neck muscles if
present it confirms the diagnosis
• Diagnosis is confirmed by CSF analysis
Interventions-Seizure Precautions
1. Side rails up
2. Side lying position
Neurologic Manifestations
3. Seizure pads against the side rails
HIV-Associated Dementia
4. Pillow under head
• Occurs when the HIV virus spreads to the brain 5. Suction available
• Symptoms include loss of memory, difficulty thinking, 6. Bed in low position
concentrating, and or speaking clearly, lack of interest 7. Curtain for privacy
in activities and gradual loss of motor skills
Progressive Multifocal Leukoencephalopathy (PML)
HIV-Associated Peripheral Neuropathy • Disease of the white matter of the brain, caused by a
• Also called “Distal Sensory Polyneuropathy (DSPN)” virus infection that targets cells that make myelin
• Occurs in advanced HIV disease as a result of • People may become clumsy, have trouble speaking,
immunosuppression, antiretroviral drug toxicity, and and become partially blind, and mental function
mitochondrial toxicity declines rapidly
• It can lead to significant pain and decreased function
Depressive Manifestations
HIV Encephalopathy
• People with HIV/AIDS who are depressed may
• It is a clinical syndrome that is characterized by a experience irrational guilt and shame, loss of self-
progressive decline in cognitive, behavioral, and esteem, feelings of helplessness, worthlessness, and
motor functions suicidal ideation
• People with HIV suffer from depression caused by
Manifestations
shame, trauma, substance abuse
Early Manifestations Later Stages
1. Memory deficits 1. Global cognitive impairments
2. Headache 2. Delay in verbal responses Integumentary Manifestations
3. Difficulty 3. A vacant stare Generalized Folliculitis
concentrating 4. Spastic paraparesis
5. Hyperreflexia • Hair follicles become inflamed

HIV AND AIDS
• It's usually caused by a bacterial or fungal infection During Pregnancy, Delivery or through Breast-Feeding
• At first it may look like small red bumps or white- • Infected mothers can pass the virus on to their babies
headed pimples around hair follicles, the tiny pockets • Mothers who are HIV-positive and get treatment for
from which each hair grows the infection during pregnancy can significantly lower
the risk to their babies
Seborrheic Dermatitis
• Skin disease that causes an itchy rash with flaky Kissing
scales • Inflammation and breaks in the skin or mucosa, if
• It causes redness on light skin and light patches on even the smallest amount of blood is present
darker skin (membranes of mouth are thin enough for HIV to enter
straight into the body)
Molluscum Contagiosum
Organ Transplants
• Viral infection characterized by deforming plaque
• Receiving organ transplants with HIV infected blood
formation
 Lesions in the groin and thigh
or blood products
areas on presentation of a 25-
year-old, HIV-seropositive Sharing Razors – if blood is present
man with molluscum
contagiosum virus infection
 Extensive, ulcerating lesions Tattoos/Body Piercing – if equipment is not clean
were accompanied by peri
nodular scarring
Prevention
Gynecologic Manifestations Advise all patients to:
Vaginal Candidiasis 1. Abstain from exchanging of sexual fluids
2. Have monogamous relationship
Ulcerative Sexually Transmitted Diseases (STDs)  Be faithful to one partner
• Chancroid, syphilis, and herpes are more severe in 3. Always use latex condoms
women with HIV infection  If the patient is allergic to latex, nonlatex
condoms should be used, however they will not
Human Papillomavirus (HPV) protect against HIV infection
• Causes venereal warts and is a risk factor for cervical 4. Avoid reusing condoms
intraepithelial neoplasia, a cellular change that is 5. Educate people on the proper use of condom
frequently a precursor to cervical cancer
How HIV Spreads

Unprotected Penetrative Sex
• Have vaginal, anal or oral sex with an infected partner
whose blood, semen or vaginal secretions enter the
body
• The virus can enter the body through mouth sores or
small tears that sometimes develop in the rectum or
vagina during sexual activity
• Through sexual partners of infected persons, multiple
sexual partners without condom, or men having sex
with men without condom (MSM)
6. Avoid using cervical caps or diaphragms without
Sharing Needles using a condom as well
• Sharing contaminated IV drug paraphernalia (needles 7. Always use dental dams for oral–genital or anal
and syringes) puts you at high risk of HIV and other stimulation
infectious diseases, such as hepatitis  A dental dam is a thin, flexible piece of latex that
protects against direct mouth-to-genital or
Blood Transfusions mouth-to-anus contact during oral sex
• In some cases, the virus may be transmitted through  This reduces your risk for sexually transmitted
blood transfusions (contaminated blood and blood infections (STIs) while still allowing for clitoral or
products) anal stimulation
8. Avoid anal intercourse because this practice may
injure tissues

HIV AND AIDS
 If not possible, use lubricant appropriate hygiene, or is at increased risk of acquiring

 There are water and silicone-based products infection or developing adverse outcome following
designed for anal sex infection
9. Avoid manual–anal intercourse (“Fisting”)
Respiratory Hygiene/Cough Etiquette: Instruct
10. Do not to ingest urine or semen
symptomatic people to cover mouth and nose when
11. Educate patients about nonpenetrative sexual
sneezing or coughing
activities, such as body massage, social kissing
 Use tissues and dispose in no-touch receptacle
(dry), mutual masturbation, fantasy, and sex films
 Observe hand hygiene after soiling of hands with
12. Advise patients to avoid sharing needles, razors,
respiratory secretions
toothbrushes, sex toys, or blood-contaminated
 Wear surgical mask if tolerated
articles
13. Inform previous, present, and prospective sexual
and drug-using partners of their HIV positive status Prophylactic Measures
 If the patient is concerned for his or her safety, Pre-Exposure Prophylaxis (or PrEP)
advise the patient that many states have • A way for people who do not have HIV but who are at
established mechanisms through the public very high risk of getting HIV to prevent HIV infection
health department in which professionals are by taking a pill every day
available to notify exposed contacts • The pill (brand name Truvada) contains two
14. Avoid having unprotected sex with another HIV- medicines (tenofovir and emtricitabine) that are used
seropositive person in combination with other medicines to treat HIV
 Cross-infection with that person’s HIV can
increase the severity of infection Post-Exposure Prophylaxis (PEP)
15. Advise HIV-seropositive patients to avoid donating • Means taking HIV medicines within 72 hours after a
blood, plasma, body organs, or sperm possible exposure to HIV to prevent HIV infection
• After an unintended exposure to the blood or body
Standard precautions to reduce the risk of exposure of fluids of a person who either is HIV positive or whose
health care workers to HIV HIV status is unknown, the need for post-exposure
Hand Hygiene: Use after touching blood, body fluids, prophylaxis (PEP) must be assessed within 2 hours
secretions, excretions, or contaminated items; • Exposure can be large bore needle stick, significant
immediately after removing gloves; and between patient mucosal contact with body fluids, contact with body
contacts fluids via break in the skin
Personal Protective Equipment (PPE): gloves, gowns,
and masks should be worn in the care of patients with Post Exposure Prophylaxis for Health Care Providers
HIV • It includes taking antiretroviral medicines ASAP, but
no more than 72 hours (3 days) after possible HIV
Soiled Patient Care Equipment: Handle in a manner that
exposure
prevents transfer of microorganisms to others and to the
• 2 or 3 drugs are usually prescribed which must be
environment by wearing gloves if visibly contaminated
taken for 28 days
and performing hand hygiene
 Retrovir (zidovudine) and Epivir (lamivudine) for
Environmental Control: Develop procedures for routine 28 days
care, cleaning, and disinfection of environmental • Occupational exposures – needle stick injury
surfaces, especially frequently touched surfaces in
patient care areas Diagnostic and Laboratory Findings
Textiles and Laundry: Handle in a manner that prevents HIV Diagnostic Tests:
transfer of microorganisms to others and to the Nucleic Acid Tests (NAT) aka RNA Test
environment • Looks for the actual virus in the blood
Needles and Other Sharps: Do not recap, bend, break, • Test can either tell if a person has HIV or tell how
or hand-manipulate used needles much virus is present in the blood (known as an HIV
viral load test)
Patient Resuscitation: Use mouthpiece, resuscitation • Very expensive and not routinely used for screening
bag, and other ventilation devices to prevent contact  Unless patient recently had a high-risk exposure
with mouth and oral secretions or a possible exposure and have early symptoms
Patient Placement: Prioritize for single-patient room if of HIV infection
patient is at increased risk of transmission, is likely to • Can usually tell you if you have HIV infection 10 to 33
contaminate the environment, does not maintain days after an exposure

HIV AND AIDS
Antigen/Antibody Tests – There is a phone number included with a HIV self-

• Looks for both HIV antibodies and antigens test for anyone to call to get help with conducting
• If you have HIV, an antigen called p24 is produced the test
even before antibodies develop
• Can usually detect HIV infection 18 to 45 days after
an exposure
Antibody Tests
• HIV antibody tests only look for antibodies to HIV in
the blood or oral fluid
• Can take 23 to 90 days to detect HIV infection after an
exposure
Rapid HIV Testing
– Offer highly accurate information within as little as
20 minutes
– These tests look for antibodies to HIV using
either:
a. A sample of blood, drawn from a vein or a
finger prick
b. Fluids collected on a treated pad that is
rubbed on your upper and lower gums
– A positive reaction on a rapid test requires an
additional blood test to confirm the results
– Remind the patient about the need to return for
retesting to verify the results
FDA Approved Home Testing Kits

Home Access HIV 1 Test System
– A laboratory test sold over-the-counter (OTC) that
uses fingerstick blood mailed to the testing EIA (Enzyme Immunoassay) Test
laboratory – Formerly referred to as the ELISA (enzyme-linked
– Procedure: immunosorbent assay)
1. Prick finger – Identifies antibodies directed specifically against
2. Place blood on sample card HIV
3. Mail blood sample to designated lab – Can use, blood, saliva or urine
4. Identification number – Antibody assays do not detect HIV antibody in the
– Test results are obtained through a toll-free earliest stages of the infection
telephone number using the PIN, and post-test – HIV antibody may be detected normally from 2
counseling is provided by telephone when results weeks to 6 mos. after the acute infection
are obtained – False positives and false negatives can occur
a. A false-positive result indicates you have a
OraQuick In-Home HIV condition when you actually don’t
– Swab own mouth to collect an oral fluid sample b. A false-negative result indicates you don’t
and use a kit to test it have a condition when you actually do
– Once the device is inserted into the test tube, the c. Because of this, patient may be asked to
oral fluid mixes with the liquid and travels up the repeat the EIA again in a few weeks
test stick – If positive, the enzyme immunoassay test will
a. If C-line turns dark, it confirms the test is need to be repeated to verify the results and must
working properly be confirmed by Western Blot (WB) test
b. If no C-line appears, the test is not working – The Western blot test detects antibodies to HIV
c. If only C-line appears, the test is negative and is used to confirm the EIA test results
d. HIV antibodies collecting at the T-line
indicates a positive test result
– Results can be read in 20-40 minutes

HIV AND AIDS
Additional Diagnostic and Laboratory Findings Genotype Test Phenotype Test

Western Blot
• The Western blot test separates the blood proteins Tests for virus mutations Measures how well the virus
associated with resistance to can reproduce in the
and detects the specific proteins (called HIV a particular drug presence of different drugs
antibodies) that indicate an HIV infection
• The Western blot is used to confirm a positive EIA, Recommended as 1st
Provides more information
than genotype test about
and the combined tests are 99.9% accurate resistance test for people
which drugs will work against
who are new to treatment
• Can take up to 2 weeks to obtain results your virus
• Normal value – negative
Screening for Sexually Transmitted Diseases
Polymerase Chain Reaction (PCR) Syphilis
• Used to detect HIV's genetic material, called RNA – All persons with HIV should undergo screening for
• These tests can be used to screen the donated blood syphilis at the initial visit and periodically
supply and to detect very early infections before thereafter if ongoing risk factors exist
antibodies have been developed – High rates of syphilis in persons with HIV,
especially among men with HIV who have sex
Immunofluorescent Antibody Assay with man
• HIV infected cells are fixed onto a clean glass slides – This phenomenon may be linked to
and then reacted with serum followed by fluorescein methamphetamine use, changing patterns of
conjugate anti-human gamma globulin social networks and serosorting
• Apple green fluorescence appear in the positive test Routine STD Screening in Women:
under fluorescent microscope – All women should be screened for Neisseria
• Normal value = negative gonorrhoeae, Chlamydia trachomatis, and
Trichomonas vaginalis at baseline and thereafter
CD4 Cell Count with Percentage depending on the risk and prevalence of STDs in
• Helps to establish the risk of specific HIV-associated the community
complications and the need for prophylaxis against – Retesting in 3 months is indicated for women
opportunistic infections found to be positive for any of these infections on
• For persons with HIV infection, measurement of CD4 initial screening because of high reinfection rates
cell count serves as the best laboratory indicator of Routine STD Screening in Men:
immune function – All men should be screened for gonorrhea and
• Identifies what stage of HIV infection patient may be chlamydia at baseline and at least annually
in thereafter depending on the risk and prevalence
• Determines when to start antiretroviral therapy (ART) of STDs in the community
and prophylactic therapy for opportunistic infections – Retesting in 3 months is indicated for men found
• Should be obtained every 3 to 6 months thereafter to to be positive for gonorrhea and chlamydial
assess immune and/or therapeutic response and infections because of high reinfection rates
evaluate need for starting ART
Pregnancy Test
Quantitative Plasma HIV RNA Level (viral load) • Pregnancy testing should be performed in women at
• The plasma HIV RNA level defines a baseline viral initiation or modification of antiretroviral therapy, since
load, which can predict rapidity of disease, with higher certain medications may be teratogenic, such as
HIV RNA levels clearly correlating with more rapid efavirenz (Sustiva) and possibly dolutegravir
progression of disease and greater risk of developing
AIDS Cervical Cancer Screening
• Every 3 to 4 months thereafter in the untreated person • Sexually active women with HIV infection should
undergo cervical cancer screening at initial entry to
HIV Drug-Resistance Testing HIV care and again 12 months later if the initial test
• Two types of HIV drug-resistance tests are widely was normal
available: genotypic and phenotypic tests
• Baseline HIV drug-resistance testing assesses Routine Laboratory Tests
transmitted drug resistance • Complete Blood Count (CBC) with Differential
• Basic Chemistry Panel and Calculated Creatinine
Clearance
• Hepatic Aminotransferase Levels

HIV AND AIDS
• Urinalysis Non-nucleoside reverse transcriptase inhibitors

• Fasting Lipid Panel (Total cholesterol, HDL, LDL, (NNRTIs) turn off a protein needed by HIV to make
Triglycerides) copies of itself
• Fasting Plasma Glucose or Hemoglobin A1c efavirenz (Sustiva)
• Serum Testosterone: Men with HIV infection, rilpivirine (Edurant)
particularly those with advanced immunosuppre-
doravirine (Pifeltro)
ssion, have increased risk of developing
hypogonadism
Protease inhibitors (PIs) inactivate HIV protease,
another protein that HIV needs to make copies of itself
Nursing Diagnoses
atazanavir (Reyataz)
1. Ineffective airway clearance
2. Impaired skin integrity darunavir (Prezista)
3. Imbalanced nutrition less than body requirements lopinavir/ritonavir (Kaletra)
4. Diarrhea
5. Risk for infection Integrase inhibitors work by disabling a protein called
6. Social isolation integrase. It prevents viral DNA from integrating into
7. Deficient knowledge hosts DNA
8. Activity intolerance bictegravir sodium/emtricitabine/tenofovir
9. Acute and chronic pain alafenamide fumar (Biktarvy)
10. Chronic confusion
raltegravir (Isentress)
11. Grieving
dolutegravir (Tivicay)
Medical / Therapeutic Management
• Antiretroviral Therapy (ART) is usually a combination Entry or fusion inhibitors block HIV's entry into CD4 T-
of three or more medications from several different cells
drug classes maraviroc (Selzentry)
• This approach has the best chance of lowering the enfuvirtide (Fuzeon)
amount of HIV in the blood Fuzeon is available only as a subcutaneous injection
• Daily use of a combination of HIV medicines to treat and can cause injection site reactions and nodules. The
• HIV client should be taught the subcutaneous technique,
• ART saves lives, but does not cure HIV including rotation of sites
 Reduces the amount of HIV in the blood
 Reduces risk of HIV transmission
• Adherence to ART is defined as a patient's ability to
 Prevents HIV from advancing to AIDS
follow a treatment plan, take medications at
 Protects the immune system
prescribed times and frequencies, and follow
• The goals of treatment include
restrictions regarding food and other medications
 Maximal and sustained suppression of viral load
• Factors associated with non-adherence include
to a non-detectable level
 Active substance abuse
 Restoration or preservation of immunologic
 Depression
function
 Lack of social support
 Improved quality of life
• Before the initiation of antiretroviral therapy (ART)
 Reduction of HIV-related morbidity and mortality
assess patient's ability to comply with art schedule
• Results of therapy are evaluated with viral load tests
Classes of Antiretroviral Drugs Include  Viral load levels should be measured immediately
Nucleoside or nucleotide reverse transcriptase before initiation of antiretroviral therapy and again
inhibitors (NRTIs) are faulty versions of the building after 2 to 8 weeks, because in most patient’s
block that HIV needs to make copies of itself adherence to a regimen of potent antiretroviral
abacavir (Ziagen) agents should result in a large decrease in the
tenofovir (Viread) viral load by 2 to 8 weeks
emtricitabine (Emtriva)  The viral load should continue to decline over the
following weeks, and in most individuals, it will
lamivudine (Epivir)
drop below detectable levels (currently defined as
Zidovudine (Retrovir) less than 50 RNA copies/mL) by 16 to 20 weeks
Combination drugs also are available, such as
emtricitabine/tenofovir (Truvada) and emtricitabine/
tenofovir alafenamide (Descovy)

HIV AND AIDS
Adverse effects associated with all HIV treatments Cryptococcal Meningitis

1. Hepatotoxicity • Current primary therapy is IV lipid formulation of
2. Nephrotoxicity amphotericin B in combination with fluconazole
3. Osteopenia (Diflucan)
4.  Risk of CVD and MI • Serious potential adverse effects include anaphylaxis,
5. Metabolic alterations – dyslipidemia, insulin hepatic and renal impairment, electrolyte imbalances,
resistance anemia, fever, and severe chills
6. Fat redistribution syndrome (Lipodystrophy) • 2 weeks therapy
Lipoatrophy – localized subcutaneous fat loss in • Lumbar puncture – CSF negative
the face, arms, legs and buttocks
Cytomegalovirus Retinitis
• Cytomegalovirus retinitis, also known as CMV
retinitis, is an inflammation of the retina of the eye that
can lead to blindness
• Occurs predominantly in people whose immune
system has been compromised, 40-50% of those with
AIDS
Lipohypertrophy – central visceral fat accumulation • Leading cause of blindness in patients with AIDS
in the abdomen, possibly in the breast, • Oral valganciclovir, IV ganciclovir, followed by oral
dorsocervical region (buffalo hump) and within the valganciclovir
muscle and liver • Reaction to valganciclovir is severe neutropenia
Antidiarrheal Therapy
• Therapy with octreotide acetate (Sandostatin), a
synthetic analogue of somatostatin, has been shown
to be effective in managing chronic severe diarrhea
• A stool culture should be obtained to determine the
possible presence of microorganisms that cause
7. Facial wasting – sinking of the cheeks, eyes and
diarrhea
temples caused by the loss of fat tissue under the
skin, may be treated by injectable filters such as poly-
l-lactic acid (Sculptura) Chemotherapy
 Can disturb body image, leading to patient Kaposi’s Sarcoma
declines/stops ART • Management of KS is usually difficult because of the
variability of symptoms and the organ systems
involved
• The treatment goals are
 To reduce symptoms by decreasing the size of
the skin lesions
 To reduce discomfort associated with edema and
ulcerations
• Radiation therapy is effective as a palliative measure
to relieve localized pain due to tumor masses
Treatment of Opportunistic Infections
Pneumocystis Pneumonia Lymphoma
• Trimethrophim – sulfamethoxazole (TMP-SMZ) is the • Successful treatment of AIDS-related lymphomas has
treatment of choice been limited because of the rapid progression of these
• Adjunctive corticosteroids should be started as early malignancies
as possible and certainly within 72 hours after starting • Combination chemotherapy and radiation therapy
specific PCP therapy regimens may produce an initial response, but it is
usually short-lived
Mycobacterium Avium Complex
• Clarithromycin (Biaxin) is the preferred first agents Antidepressant Therapy
• Azithromycin (Zithromax) can be substituted when • Involves psychotherapy integrated with
there is drug interaction / intolerance to clarithromycin pharmacotherapy
• Ethambutol is the recommended 2nd drug

HIV AND AIDS
• If depressive symptoms are severe and of sufficient  High Fowler’s or semi-Fowler’s position to
duration, treatment with antidepressants may be facilitate breathing and airway clearance
initiated 2. Administer oxygen and respiratory treatments as
imipramine (Tofranil) prescribed
desipramine (Norpramin)  Humidified oxygen may be prescribed, and
fluoxetine (Prozac) nasopharyngeal or tracheal suctioning,
intubation, and mechanical ventilation may be
• These medications also alleviate fatigue and lethargy
necessary to maintain adequate ventilation
that are associated with depression
• Psychostimulant Ritalin, which may be used in low
doses in patients with neuropsychiatric impairment Prevent the Spread of Infection
1. Monitors laboratory test results that indicate
Nutrition Therapy infection, such as the white blood cell count and
differential count
• Malnutrition increases the risk of infection and the
 Cultures of specimen from wound drainage, skin
incidence of opportunistic infections
lesions, urine, stool, sputum, mouth and blood
• Nutrition therapy should be tailored to meet the
are obtained to identify pathogenic organisms
nutritional needs of the patient whether by oral diet,
and the most appropriate antimicrobial therapy
enteral tube feedings, or parenteral nutritional support
2. The patient is instructed to avoid others with active
if needed
infections such as upper respiratory infections
• For patients with diarrhea, diet low in fat, lactose,
insoluble fiber, and caffeine
• The goal is to maintain the ideal weight and, when Improving Activity Tolerance
necessary, to increase weight 1. Monitor ability to ambulate and perform activities of
Appetite stimulants: daily living
Megestrol acetate (Megace)  Patients may be unable to maintain their usual
levels of activity because of weakness, fatigue,
Dronabinol (Marinol)
shortness of breath, dizziness, and neurologic
• Megestrol acetate (Megace), a synthetic oral
involvement
progesterone preparation promotes significant weight
 Measures such as relaxation and guided
gain and inhibits cytokines synthesis. In patients with
imagery may be beneficial in decreasing anxiety
HIV infection, it increases body weight primarily by
which contributes to weakness and fatigue
increasing body fat stores
2. Assist in planning daily routines that
• Dronabinol (Marinol), a synthetic tetrahydro carbinol,
 Maintain a balanced routine activity and rest may
the active ingredient in marijuana is used to relieve
be necessary
nausea and vomiting associated with cancer
3. Instruct about energy conservation techniques
chemotherapy
 Such as sitting, while washing dishes, or while
• Oral supplements may be used to supplement diets
preparing meals
that are deficient in calories and protein
 Personal items that are frequently used should
• Advera is a nutritional supplement that has been
be kept within the patient’s reach
developed
• Parenteral nutrition is the final option because of its
Maintaining Thought Processes
prohibitive cause in associated risk including risk of
infection 1. Instruct to speak to the patient in simple, clear
language and give the patient sufficient time to
respond to questions
Nursing Interventions
2. Orient the patient to the daily routine by talking about
Improving Airway Clearance
what is taking place during daily activities
1. Provide respiratory support 3. Provide the patient with a regular daily schedule for
 Pulmonary therapy (coughing, deep breathing, medication administration, grooming, eating, and
postural drainage, percussion, and sleeping and awakening time
vibration) is provided as often as every 2 hours 4. Post a schedule in a prominent area (eg, on the
to prevent stasis of secretions and to promote refrigerator), provide night lights for the bedroom and
airway clearance bathroom
 Any cough and the quantity and characteristics  Planning safe leisure activities, allow the patient
of sputum are documented to maintain a regular routine in a safe manner
 Sputum specimens are analyzed for infectious 5. Activities that the patient previously enjoyed are
organisms encouraged
6. Around-the-clock supervision

HIV AND AIDS
 Strategies can be implemented to prevent the 8. Sitz baths or gentle irrigation may facilitate cleaning
patient from engaging in potentially dangerous and promote comfort
activities like driving, using the stove, or mowing  The area is dried thoroughly after cleaning
the lawn 9. Topical lotions or ointments may be prescribed to
promote healing
Relieving Pain and Discomfort 10. Wounds are cultured if infection is suspected
1. Assess quality and severity of pain associated with  To initiate appropriate antimicrobial treatment
impaired perianal skin integrity
 The lesions of Kaposi’s Sarcoma and peripheral Improving Nutritional Status
neuropathy 1. Monitor weight, dietary intake, and serum albumin,
 In addition, the effects of pain in elimination, BUN, protein, and transferrin levels
nutrition, sleep, and communication are explored 2. Assess for factors that interfere with oral intake
along with exacerbating and relieving factors  Anorexia, oral esophageal candida, nausea,
2. Cleaning the perianal area to promote comfort pain, fatigue, lactose intolerance, and so on
3. Topical anesthetic medications or ointments may be 3. Consult the dietitian to determine the patient’s
prescribed nutritional requirements
4. Use of soft cushions or foam pads may increase 4. Encourage the patient to rest before meals if fatigue
comfort while sitting and weakness interfere with intake
5. Avoid foods that act as bowel irritants 5. Schedule meals so that they do not occur
 Anti-spasmodic and anti-diarrheal medications immediately after a painful or unpleasant procedure
may be prescribed to reduce the discomfort and if the patient is hospitalized
frequency of bowel movements 6. Avoid foods that stimulate intestinal motility and
6. Pain management abdominal distention
 NSAIDs and opioids plus non-pharmacologic  For patient with diarrhea and abdominal
approaches such as relaxation techniques cramping
7. Adequate rest is essential to minimize energy
expenditure and prevent excessive fatigue Promote Usual Bowel Patterns
1. Bowel patterns are assessed for diarrhea
Promote Skin Integrity 2. Monitor the frequency and consistency of stools and
1. Medicated lotions, ointments, and dressings are patient’s reports of abdominal pain or cramping
applied to affected skin surfaces as prescribed associated with bowel movements
 Applying Dinitrochlorobenzene (DNCB) lotion to 3. Assess factors that exacerbate frequent diarrhea
an HIV/AIDS patient with Kaposi's Sarcoma 4. Measure the quantity, volume of liquid stools to
2. Assist to change position every 2 hours if patient is document fluid volume losses
immobile 5. Stool cultures are obtained to identify pathogenic
 Devices such as alternating pressure mattresses organisms
and low air loss beds are used to prevent skin
breakdown Coping with Grief
3. Encourage to avoid scratching; to use nonabrasive, 1. Provide psychosocial support as needed
nondrying soaps; and to apply non-perfumed skin  Help the patient verbalize feelings and explore
moisturizers to dry skin and identify resources for support and
4. Adhesive tape is avoided mechanisms for coping
5. Keep bed linens free of wrinkles and avoiding tight or  Encourage to maintain contact with family,
restrictive clothing friends, and coworkers and to use local or
 Skin surfaces are protected from friction and national AIDS support groups and hotlines
rubbing 2. Identify loss and address it
6. If with foot lesions advise to wear cotton socks and 3. Encourage patient to continue usual activities
shoes that do not cause the feet to perspire whenever possible
 Anti-pleuritic, antibiotic, and analgesic agents 4. Consultation with a mental health counselor is useful
are administered as prescribed for many patient
7. Perianal area is cleaned after each bowel movement
 With non-abrasive soap and water to prevent
further excoriation, breakdown of the skin, and
infection
 If the area is very painful, soft cloths or cotton
sponges may be less irritating than wash cloths

HIV AND AIDS
3. Patients with pets are encouraged to have another

person clean areas soiled by animals, such as bird
cages and litter boxes
 If this is not possible, patients should use gloves
and should wash their hands after they clean the
area
4. Patients are advised to avoid exposure to others who
are sick or recently have been vaccinated
5. Avoid smoking, excessive alcohol, and over-the-
counter and street drugs is emphasized
6. Instruct not to donate blood
7. Caregivers in the home are taught how to administer
medications, including IV preparations
Decreasing the Sense of Isolation 8. Continuing care
 Community based organizations that provide a
1. Provide an atmosphere of acceptance and
variety of services for people living with HIV
understanding for people with AIDS and their families
infection and AIDS
and partners
 During home visits, the nurse assesses the
2. Encouraged to express feelings of isolation and
patient’s physical and emotional status and
loneliness, with the assurance that these feelings are
home environment
not unique or abnormal
 Assess for progression of disease and for
 May harbor feelings of guilt because of their
adverse side effects of medications
lifestyle or because they may have infected
 Remind that food handlers must maintain good
others in current or previous relationships
hand washing and hygiene practices
 May feel anger toward sexual partners who
 Drink purified bottled water if living in areas with
transmitted the virus to them
unsafe drinking water
3. PAC Community Program for Clients with HIV/AIDS
or who are HIV-impacted: direct care and support:
 Volunteer visitation HIV and AIDS in the Philippines
 Personal advocacy for adults and youth with • The Philippines is a low-HIV-prevalence country with
HIV/AIDS 0.1% of the adult population estimated to be HIV
 Social service coordination positive but the rate of increase in infections is one of
 Counselling / Spiritual Care the highest
 Facilitated peer support module groups for • As of August 2019, the Department of Health (DOH)
adults AIDS Registry in the Philippines reported 69,629
 HIV/AIDS training modules for volunteers and cumulative cases since 1984
partnership projects • Government agencies responsible for educating the
public about HIV AIDS in the Philippines
Improving knowledge of HIV a. Department of Interior and Local
Government (DILG)
1. Educate about HIV infection, means of preventing
b. Philippine National AIDS Council (PNAC)
HIV transmission, ART and appropriate self-care
c. Research Institute for Tropical Medicine (RITM)
measures
d. STI/AIDS Cooperative Central Laboratory
(SCCL)
Promoting Home and Community-Based Care
1. Teaching patients self-care
 Patients and their families or caregivers must
receive instructions about how to prevent
disease transmission
 Handwashing, proper disposal of soiled items
with body fluids
 Clear guidelines regarding avoiding and
controlling infection, regular health care
appointments, and symptom management
2. Kitchen and bathroom surfaces should be cleaned
regularly with disinfectants

HIV AND AIDS
HIV/AIDS Support Groups

1. Pinoy Plus Association (PPA+)
2. The Positive Action Foundation Philippines, Inc.
3. Action for Health Initiatives, Inc.
4. B-Change Group
5. The Red Whistle (TRW)
6. AIDS Society of the Philippines
7. The Love Yourself Group (TLY)
World AIDS Day, observe December 1 each year, is

dedicated to raising awareness of the AIDS
pandemic caused by the spread of HIV infection
Coronavirus (COVID-19) and HIV

• Coronavirus lockdown could spark rise in HIV
infections
• If lockdowns and stay at home orders: problems
getting tested for sexually transmitted diseases,
because thousands of centers that used to provide
them have closed down. These people still having sex
and have no idea of their status is a potential ticking
bomb
Preparing for COVID-19 if you’re living with HIV

1. Take action to avoid COVID-19
 Follow the general prevention advice
2. Continue your treatment
 Take your ART to keep your immune system
healthy
3. Stock up on ART
 Have a 30-day supply of your ART, ideally 3
months
4. Check if you’re up to date with your immunization
5. Have a plan in place for if you feel unwell and need
to stay at home
6. Look after yourself
 Eat well, exercise, and look after your mental
health

ONCOLOGIC DISORDERS
Cancer Nursing (Oncology Nursing) Two Types of Cancer Genes

• A nursing specialty that seeks to reduce the risks, Oncogenes
incidence, and burden of cancer by encouraging • A gene that has the potential to cause cancer
healthy life- styles, promoting early detection, and • In tumor cells, these genes are often mutated, or
improving the management of cancer symptoms and expressed at high levels
side effects throughout the disease trajectory • Most normal cells will undergo a programmed form of
• An oncology nurse is a registered nurse who cares rapid cell death (apoptosis) when critical functions are
for and educates patients who have cancer. Oncology altered and malfunctioning
nurses work in a multi-disciplinary team, in a variety  Most of the time, cells are able to detect and
of settings, from the inpatient ward, to the bone repair DNA damage. If a cell is severely damaged
marrow transplant unit, through to the community and cannot repair itself, it usually undergoes
“programmed cell death”
Medical Oncology (Chemotherapy) Unit
• Provides for the clinical treatment and management Tumor Suppressor Genes
of patients undergoing chemotherapy treatment for • These genes normally function to prevent cell
cancer growth/division, repair DNA mistakes, or tell cells
• The function of the unit may include: when to die
✓ Chemotherapy administration • Normal genes that slow down cell division, repair DNA
✓ Administration of blood products and/or other mistakes, or tell cells when to die (a process known
supportive therapies as apoptosis or programmed cell death)
✓ Blood collection • When tumor suppressor genes don't work properly,
✓ Clinical procedures and examination cells can grow out of control, which can lead to cancer
✓ Patient and family education and support
✓ Clinical trial management An important difference between oncogenes and
✓ Coordination of care tumor suppressor genes is that oncogenes result
from the activation (turning on) of proto-
oncogenes, but tumor suppressor genes cause
Oncologic Disorders cancer when they are inactivated (turned off)
• A complex problem in health care delivery and public
policy
• Cancer can affect people of all nationalities and age Types of Neoplasia/Tumor
groups
Neoplasia refers to an abnormal cell growth or
tumor, a mass of new tissue functioning
Cancer independently and serving no useful purpose
• A disease process whereby cells proliferate
abnormally, ignoring growth-regulating signals in the Benign Neoplasm
environment surrounding the cells
• Slow growing, localized and encapsulated and
• Normal cells are under direct supervision and their
encapsulated nonmalignant growths with well-defined
growth, proliferation and cell division are supervised
borders
through signal transduction
• They are usually removed
• However, cancer cells develop autonomous
• They generally do not cause tissue damage or other
mechanism for its growth and proliferation
complications unless they interfere with tissue
function or circulation
Carcinogenesis • Grows only locally and cannot spread by invasion or
• The formation of a cancer, whereby normal cells are metastasis
transformed into cancer cells
• There are some factors which are responsible for Malignant Neoplasm
change of normal cell into cancer cell, those factors or • Aggressive growths that invade and destroy
agents are known as carcinogens surrounding tissues, can lead to cell death unless
• The process is characterized by changes in the interventions are taken
cellular, genetic, and epigenetic levels and abnormal • Cells invade neighboring tissues, enter blood vessels
cell division and metastasize to different sites
• Clinically, there are many types of cancer but • Rate of growth correlates inversely with level of
biologically, the origin of cancer is similar which is due differentiation
to a defect in the gene expression  Poorly differentiated tumors grow more rapidly

ONCOLOGIC DISORDERS
Invasion vs Metastasis Ovary Liver, lung, peritoneum

Invasion Pancreas Liver, lung, peritoneum
• Refers to the direct migration and penetration by Prostate Adrenal gland, bone, liver, lung
cancer cells into neighboring tissues Rectal Liver, lung, peritoneum
Stomach Liver, lung, peritoneum
Metastasis
Thyroid Bone, liver, lung
• Refers to the ability of cancer cells to penetrate into
lymphatic and blood vessels, circulate through the
bloodstream, and then invade normal tissues Grading and Staging
elsewhere in the body • Grading and staging are methods used to describe
• Spread of cancer cells to new areas of the body, often the tumor; these methods describe:
by way of the lymph system or bloodstream  The extent of the tumor
• One that has spread from the primary site of origin, or  The extent to which malignancy has increased in
where it started, into different areas of the body size
 The involvement of regional nodes, and
Routes of Metastasis metastatic development
Local Seeding Grading
• Distribution of shed cancer cells occurs in the local • Classifies the cellular aspects of the cancer
area of the primary tumor • Tumor grade describes a tumor in terms of how
• A primary tumor is a tumor growing at the anatomical abnormal the tumor cells are when compared to
site where tumor progression began and proceeded normal cells
to yield a cancerous mass • A low-grade cancer is likely to grow more slowly and
be less likely to spread than a high grade one
Bloodborne Metastasis Grade 1 – the cancer cells look very similar to normal
• Tumor cells enter the blood, which is the common cells and are growing slowly (low grade)
cause of cancer spread Grade 2 – the cells don't look like normal cells and are
a. Cancer cells invade surrounding tissues and growing more quickly than normal (intermediate
blood vessels grade)
b. Cancer cells are transported by the circulatory
Grade 3 – the cancer cells look very abnormal and are
system to distant sites
growing quickly (high grade)
c. Cancer cells reinvade and grow at new location
• Example: colorectal cancer Grade 4 – cells are immature and undifferentiated; cell
of origin is difficult to determine
Lymphatic Spread
• Primary sites rich in lymphatics are more susceptible Differentiation
to early metastatic spread • Another way of describing the cells by how
• Malignant cells infiltrate into lymphatic ducts then differentiated they are
carried to draining (regional) lymph nodes (from a • Differentiation refers to how well developed the tumor
tumor deposit), and subsequently spreads further cells are how cancer cells are organized in the tumor
through the lymphatics tissue
• E.g., Breast cancer of upper outer quadrant of breast Well Differentiated – when cells and tissue structures
will spread to the axillary lymph nodes and eventually are very similar to normal tissues. These tumors tend
from a palpable mass to grow and spread slowly.
• Example: breast carcinoma, gastric cancer, ovarian Poorly Differentiated – or an undifferentiated
cancer tumor, the cells look very abnormal and are not
arranged in the usual way wherein normal structures
Common Sites of Metastasis and tissue pattern are missing
Cancer Type Main Sites of Metastasis
Staging
Bladder Bone, liver, lung
• Classifies the clinical aspects of the cancer and
Breast Bone, brain, liver, lung
degree of metastasis at diagnosis
Colon Liver, lung, peritoneum
• The process which measures how far cancer has
Kidney Adrenal gland, bone, brain, liver, lung spread
Lung Adrenal gland, bone, brain, liver, other lung • Stage of cancer helps us understand:
Melanoma Bone, brain, liver, lung, skin, muscle

ONCOLOGIC DISORDERS
 How serious the client’s cancer is and what are − The numbers are stages between I to IV, and
his survival chances usually, it is referred to with Roman numerals
 To plan the best treatment for the client
 The other treatment option is to Identify clinical Stage 0
No cancer, only abnormal cells with the potential to
become cancer. referred to as “In- Situ cancer”
trials
Cancer is small and spot only in one area and it has
• There are two main methods that form the basis for Stage 1 not spread to any lymph nodes or other body areas.
the more specific or individual cancer type staging This is called “early-stage cancer”
Cancer is larger or has grown into nearby tissues or
Stage 2&3
lymph nodes
TNM Staging
Cancer has spread to other parts of the body called
Stage 4
− This system describes the size of the primary tumor, “advance or metastatic cancer”
whether cancer has spread to the lymph nodes, and
whether it has spread to a different part of the body Classification of Cancer
− The TNM staging system classifies cancers Carcinomas
according to:
• This type of cancer arises from epithelial cells or
Tumor (T): Primary tumor size and/or extent
ectodermal tissues lining the internal surface of the
Nodes (N): Spread of cancer to lymph nodes in the various organs
regional area of the primary tumor • For example: breast cancer, lung cancer, skin cancer,
Metastasis (M): Spread of cancer to distant sites brain cancer, cancer of pancreas and mouth,
away from the primary tumor esophagus, stomach and intestine
− A number is added to each letter to indicate the size
or extent of the primary tumor and the extent of Sarcomas
cancer spread (higher number means bigger tumor • These cancers arise from connective and muscular
or more spread) tissue derived from mesoderm
• For examples: bone tumors, muscle tumors, cancer of
TNM staging system: lymph nodes
Primary Tumor (T)
TX – Primary tumor cannot be evaluated Lymphomas or Leukemia
T0 – No evidence of primary tumor • It is the malignant growth of leucocytes (WBC)
• Persons affected with this cancer show the excessive
Tis – Carcinoma in situ (CIS; abnormal cells are
production of leucocytes (blood cancer) and cancer of
present but have not spread to neighboring tissue;
bone marrow
although not cancer, CIS may become cancer and is
• In addition, kidney, brain, and eye tumor is seen in
sometimes called pre-invasive cancer)
infants and children due to a malignant growth of
T1, T2, T3, T4 - Size and/or extent of the primary
primitive embryonic tissues
tumor
Regional Lymph Nodes (N) Etiological Agents That Induce Cancer

NX – Regional lymph nodes cannot be evaluated 1. Environmental factors
N0 – No regional lymph node involvement  Tobacco, smokes, diets, environmental
pollutants etc.
N1, N2, N3 – Involvement of regional lymph nodes
 Heavy smoking cause lung, oral cavity and
(number of lymph nodes and/or extent of spread)
esophageal cancer
Distant Metastasis (M)  Excessive intake of alcohol cause liver cancer
2. Chemical carcinogen
MX – Distant metastasis cannot be evaluated (some
 Nickel compounds, cadmium, arsenic,
clinicians do not ever use this designation)
nitrosamines, trichloroethylene, arylamines,
M0 – No distant metastasis
benzopyrene, aflatoxins, reactive oxygen
M1 – Distant metastasis is present radicals etc.
3. Physical carcinogen
Consequently, a person's cancer could be listed  UV rays (ultraviolet), ionizing radiation (x-rays
as T1N2M0, meaning it is a small tumor (T1), but and gamma rays)
has spread to some regional lymph nodes (N2), 4. Biological carcinogen
and has no distant metastasis (M0)
a. Virus: Virus has also been associated with
various types of cancers. These viruses are called
Numbering Cancer Stage System (Roman numeral) oncoviruses
− Used stages to identify how far cancer has spread

ONCOLOGIC DISORDERS
− (Oncovirus); Human papilloma virus (HPV), Early Detection

Epstein-Barr Virus, (EBV), Hepatitis B virus, Mammography
Herpes virus • The process of using low-energy X-rays to examine
− Hepatitis B and C virus is casually related the human breast for diagnosis and screening
with hepato-cellular carcinoma (liver cancer) • The goal of mammography is the early detection of
− Cytomegalovirus (CMV) is associated with breast cancer, typically through detection of
Kaposi’s sarcoma characteristic masses or microcalcifications
− Human papilloma virus (HPV) is a chief • In mammography, each breast is compressed
suspect of cervix cancer horizontally, then obliquely and an x-ray is taken of
b. Bacteria: Helicobacter pylori – gastric cancer each position
5. Endogenous factors
 Mutations, change in DNA replication, metabolic
reactions generating reactive oxygen radicals,
Immune system defects, ageing
• Breast calcifications are calcium deposits within

breast tissue, they appear as white spots or flecks on
a mammogram
• Calcifications that are irregular in size or shape or are
tightly clustered together, are called suspicious
calcifications
General Etiology and Pathogenesis
Recommended:
Screening Mammography that women who are
o Ages between 40 and 49 should have
mammography every one to two years
o Ages 50 and older – annual mammography
Pap Smear
• Also called a Pap test, is a procedure to test for
cervical cancer in women
• Involves collecting cells from the cervix and the lower
narrow end of the uterus
• Detecting cervical cancer early with a pap
smear gives the person a greater chance at a cure
Age Pap Smear Frequency

Warning Signs of Cancer: CAUTION
<21 years old None needed
C Change in bowel and bladder habits
A A sore that does not heal 21-29 Every 3 years
U Unusual bleeding or discharge Every 3 years or an HPV test every 5
T Thickening or lump 30-65 years or a Pap test and HPV test together
I Indigestion or difficulty swallowing every 5 years
O Obvious change in wart or mole
65 and older You may no longer need Pap smear tests
N Nagging cough or hoarseness

ONCOLOGIC DISORDERS
• If patients have certain risk factors, primary health • In premenopausal women, the best time for breast
care provider may recommend more-frequent Pap self-examination is seven days after the menstrual
smears, regardless of age period begins when breasts are least congested
• Risk factors:
 A diagnosis of cervical cancer or a Pap smear that
showed precancerous cells
 HIV infection
 Weakened immune system due to organ
transplant, chemotherapy or chronic
corticosteroid use
 A history of smoking
Stools for Occult Blood

• The fecal occult blood test (FOBT) is a lab test used
to check stool samples for hidden (occult) blood
• Occult blood in the stool may indicate colon cancer or
polyps in the colon or rectum
• A positive fecal occult blood test means that blood has
been found in the stool
For a guaiac smear test (gFOBT), client will most likely

need to:
1. Collect samples from three separate bowel
movements
2. For each sample, collect the stool and store in a
clean container
3. Make sure the sample does not mix in with urine or
water from the toilet Testicular Self Examination
4. Use the applicator from test kit to smear some of the • Testicular self-examination is a procedure for
stool on the test card or slide, also included in the kit checking for early testicular cancer, where a man
5. Label and seal all samples as directed examines his own testicles and scrotum for possible
6. Mail the samples to health care provider or lab lumps or swelling, performed on a regular basis
starting from puberty
• It is usually undertaken after a warm bath or shower
while standing at home
• The person examines each testicle gently with both
hands by rotating the testicle between the thumb and
the forefinger followed by finding the epididymis, and
looking for any lumps or irregularities, any changes in
size, shape, or texture
Skin Inspection
Colonoscopy
• An exam used to detect changes or abnormalities in
the large intestine (colon) and rectum
• During a colonoscopy, a long, flexible tube
(colonoscope) is inserted into the rectum
• A tiny video camera at the tip of the tube allows the
doctor to view the inside of the entire colon
Breast Self-Examination
• Breast self-examination is a screening method used
in an attempt to detect early breast cancer
• The method involves the woman herself looking at
and feeling each breast for possible lumps, distortions
or swelling

ONCOLOGIC DISORDERS
Diagnostic Exam
Biopsy (Histopathology)
• A sample of tissue taken from the body in order to
examine it more closely
• A doctor should recommend a biopsy when an initial
test suggests an area of tissue in the body isn't normal
Incisional biopsy – only a small part will be taken
Excisional biopsy – tumor and some of the normal
surrounding cells will be removed Magnetic Resonance Imaging
• Medical imaging technique used in radiology to form
Bone Marrow Examination pictures of the anatomy and the physiological
• Refers to the pathologic analysis of samples of bone processes of the body
marrow obtained by bone marrow aspiration and bone • MRI scanners use strong magnetic fields, magnetic
marrow biopsy (often called a trephine biopsy) field gradients, and radio waves to generate images
 Bone marrow is a soft, gelatinous tissue that fills of the organs in the body
the medullary cavities in the centers of bone
Chest X-Ray
• A chest X-ray of someone with lung cancer may show
a visible mass or nodule
• This mass will look like a white spot on the lungs,
while the lung itself will appear black
• However, an X-ray may not be able to detect small or
early-stage cancers
Types of Cancer Treatment
Chemotherapy
• Chemotherapy is a type of cancer treatment that uses
one or more anti-cancer drugs as part of a
standardized chemotherapy regimen
• Chemotherapy may be given with a curative intent, or
it may aim to prolong life or to reduce symptoms
• It disrupts the cell cycle in various phases, interfering
with cellular metabolism and reproduction
• A fixed percentage of cells are killed by
chemotherapy, leaving some tumor cells remaining;
this necessitates the repeated doses of
chemotherapy in order to reduce the number of cells,
Complete Blood Count allowing the body’s immune system to destroy the
• A group of tests that evaluate the cells that circulate remaining tumor cells
in blood, including red blood cells (RBCs), white
blood cells (WBCs), and platelets (PLTs)
• The CBC can evaluate the client’s overall health and
detect a variety of diseases and conditions, such as
infections, anemia and leukemia
Computed Tomography
• Refers to a computerized x-ray imaging procedure in
which a narrow beam of x-rays is aimed at a patient
and quickly rotated around the body, producing
signals that are processed by the machine's computer Major Classes of Chemotherapeutic Agents
to generate cross-sectional images or “slices” of the Class Mechanism Examples
body
Platinums (cisplatin,
carboplatin, oxaliplatin),
Alkylating DNA damage, not
nitrogen mustard derivatives
Agents phase specific
(Cytoxan, chlorambucil),
alkyl sulfonates, nitrosourea

ONCOLOGIC DISORDERS
(carmustine, lomustine), 6. Inform all healthcare providers of chemotherapy

triazines
and /or radiation treatments
7. Avoid aspirin and aspirin containing products
Pyrimidine analogues 8. Safety precautions for oral hygiene; use soft
DNA/RNA
(gemcitabine, 5-fluoracil, toothbrushes, and do not floss
replication in S
Anti- capecitabine), methotrexate,
phase of cell
metabolites gemcitabine-gemzar, 6
division
mercaptopurine, cytarabine Nursing Management
Interfere with Doxorubicin-Adriamycin,

1. There is a high risk for spontaneous hemorrhage
Anti-tumor when platelet count is < 20,000; precautions are
enzymes needed danorubicin, mytomycine C,
Antibiotics
for DNA replication bleomycin necessary for platelet count < 50,000
Interfere with 2. Assess for bleeding, monitor stools and urine for
Isomerase
enzymes needed Topotecan, irinotecan occult blood
Inhibitors
for DNA replication
3. Assess skin for ecchymoses, petechiae, and
Taxanes-TAXOL, Taxotere, trauma
Plant alkaloids that
Mitotic vinca alkaloids (vincristine,
inhibit mitosis in 4. Educate client about bleeding safety precautions
Inhibitors vinblastine), etramustine-
tumor cells
emcyt 5. Avoid intramuscular injections and limit
venipunctures
Side Effects of Chemotherapeutic Agents
Bone Marrow Suppression c. Decreased Hemoglobin and Hematocrit Count
(Anemia)
a. Decreased WBC count (Immunosuppression)
Client Education
Gastrointestinal Effects: anorexia, nausea, vomiting,
1. Risk for infection is high when WBC count is low
2. Avoid crowds, people with infections, and small and diarrhea
children when WBC is low
3. Use meticulous personal hygiene to avoid Stomatitis (inflammation of the mouth) and Mucositosis
infection Client Education
4. Wash hands before and after eating, after 1. Use a soft toothbrush, mouth swabs may be needed
toileting, and after contact with other people and for acute episodes
pets 2. Avoid mouthwashes containing alcohol, do not use
5. Consume a low bacteria diet; avoid undercooked lemon glycerin swabs or dental floss
meat and raw fruits and vegetables 3. Consider using chlorhexidine mouthwash (Peridex)
6. Be aware of signs and symptoms of infection and to decrease risk of hemorrhage and protect gums
report them immediately to primary care provider from trauma
4. Assess daily lesions, infection, bleeding or irritation
Nursing Management
5. For xerostomia (dry mouth), apply lubricating and
1. Monitor laboratory values: CBC with differential, moisturizing agents to protect the mucous
platelets, BUN, liver enzymes membranes from trauma and infection
2. Assess for infection; monitor vital signs for early
indication of infection: fever, tachycardia and Nursing Management
tachypnea 1. May consider using “artificial saliva” (Salivart) and
3. WBC suppression, malnutrition, and presence of hard candy or mints to help with dryness
disease increase the risk of infection 2. Avoid smoking and alcohol, which can further irritate
4. Utilize neutropenic precautions (low bacteria diet, oral mucosa
no fresh plants or flowers in room, no pets, no 3. Teach signs and symptoms of oral infection and to
visitors with infections) when WBC level falls report to primary healthcare provider
below predetermined level (such as 2,000 mm3) 4. Drink cool liquids, and avoid hot and irritating foods
b. Decreased Platelet Count (Thrombocytopenia) Inadequate Nutrition, Fluid and Electrolyte Imbalance
Client Education
Client Education
1. Monitor stools and urine
2. For shaving, use electric razor only 1. Eat frequent small, low-fat meals
3. Avoid contact sports and other activities that may 2. Avoid spicy and fatty foods
cause trauma 3. Avoid extremely hot foods
4. If trauma does occur, apply ice to area and seek 4. Perform oral hygiene before and after meals
medical assistance 5. Maintain fluid intake as prescribed
5. Avoid dental work or other invasive procedures

ONCOLOGIC DISORDERS
6. Take nutritional supplements as prescribed External Therapy

(vitamins, liquid nutrition) − The radiation oncologist marks specific locations
7. Maintain a daily journal of food and fluid intake for radiation treatment using a semipermanent
type of ink
Nursing Management a. Treatment is usually given 15-30 minutes/day,
1. Assess for adequate hydration; for duration of 5 days/week, for 2-7 weeks
treatment, encourage daily fluid intake of 2-3 liters b. The client does not pose a risk for radiation
unless contraindicated exposure to other people
2. Administer antiemetics prior to chemotherapy − With a watertight seal that stays securely in place
3. Weigh client routinely, monitor weight loss for up to 4 weeks, patients do not have to alter their
4. Monitor lab. Values indicative of nutritional status routine or their daily living
(hgb, hct, albumin, prealbumin)
5. Monitor for diarrhea or constipation, and nausea and
Side Effects of External Radiation Therapy
vomiting
1. Tissue damage to target area (erythema, sloughing,
6. Encourage adequate nutritional intake with meals
hemorrhage)
that are served attractively, and environment free of
2. Ulceration of the mucous membranes
noxious stimuli (bedpan, urinal, odors)
3. Gastrointestinal effects – nausea, vomiting and
diarrhea
Fatigue
4. Radiation pneumonia
Client Education 5. Fatigue
1. Assess client that fatigue is a normal response to 6. Alopecia
chemotherapy and it does not indicate progression 7. Immunosuppression
of disease
2. Encourage client to continue daily activities as much Client Education for External Radiation
as possible, allowing for rest periods in between
1. Wash the marked area of the skin with plain water
3. Assist client in self-care needs when indicated
only and pat dry; do not use soaps, deodorants,
4. Allow for periods of rest, cluster activities
lotions, perfumes, powders or medications on the
site during the duration of the radiation treatment; do
Alopecia (hair loss) not wash off the treatment site marks
Nursing Management 2. Avoid rubbing, scratching, or scrubbing the treatment
1. Inform patient that the hair loss is temporary and will site; do not apply extreme temperatures (heat or
grow back, usually beginning about a month after cold) to the treatment site; if shaving use only electric
completion of chemotherapy razor
2. Encourage the client to choose a wig before hair loss 3. Wear soft, loose-fitting clothing over the treatment
occurs in order to match texture and hair color area
3. Care of hair and scalp includes washing hair 2 or 3 4. Protect skin from exposure during the treatment and
times a week with a mild shampoo; pat dry, and do for at least 1 year after the treatment is completed;
not use a blow dryer when going outdoors, use sun-blocking
4. Allow client to express feelings concerning altered 5. Agents with sun protection factor (SPF) of at least 15
body image 6. Maintain proper rest, diet, and fluid intake as
essential to promoting health and repair of normal
Radiation Therapy tissues
• A type of cancer treatment that uses beams of intense 7. Hair loss may occur; choose a wig, hat, or scarf to
energy to kill cancer cells cover and protect the head
• Radiation therapy most often uses X-rays, but protons
or other types of energy also can be used Nursing Management for External Radiation
• The term "radiation therapy" most often refers to 1. Monitor for adverse side effects of radiation
external beam radiation therapy ✓ Hair loss ✓ Diarrhea
• It is used to kill a tumor, reduce the tumor size, relieve ✓ Appetite changes ✓ Nausea and
✓ Mouth and throat vomiting
obstruction, or decrease pain changes ✓ Urinary and bladder
• Causes lethal injury to DNA, so it can destroy rapidly ✓ Trouble swallowing changes
multiplying cancer cells, as well as normal cells Swelling ✓ Sexual changes
(collateral damage) ✓ Coughing
• Can be classified as internal radiation (brachytherapy)  Most side effects go away within 1–2 months
or external radiation therapy (teletherapy) after you have finished radiation therapy

ONCOLOGIC DISORDERS
2. Monitor for significant decreases in white blood cell Verrucae: Warts

counts and platelet counts • Common benign skin tumors caused by infection with
the human papillomavirus
Surgery a. Plantar wart – rough papules on the soles of the
How Surgery Works against Cancer feet.
b. Filiform wart – long spiny projections from the skin
• Depending on the type of cancer and how advanced
surface
it is, surgery can be used to:
c. Flat warts – flat topped, smooth surface lesions
Remove the entire tumor
(found on face, neck, arms, back of hands, and
− Surgery removes cancer that is contained in one
legs)
area
d. Venereal warts – genital mucosa
Debulk a tumor
− Condylomata acuminata – warts on the
− Surgery removes some, but not all, of a cancer genitalia and perianal areas
tumor − Sexually transmitted
− Debulking is used when removing an entire tumor
might damage an organ or the body
− Removing part of a tumor can help other
treatments work better
Ease cancer symptoms
− Surgery is used to remove tumors that are causing
pain or pressure Angiomas
• Benign vascular tumors that
Skin Cancer involved the skin and
• Skin tumors are abnormal growths of tissue that can subcutaneous tissues
be malignant (cancerous) or benign (harmless) • Present at birth may occur as flat,
• Skin tumors become extremely common as people violet red patches (port wine) or
get older raised, bright red nodular lesions
• Cherry angiomas are due to aging
Benign Skin Tumors
Cyst Pigmenti Nevi: Moles
• A closed sac, having a distinct • Moles are a common type of skin
membrane and division compared to growth
the nearby tissue • They often appear as small, dark
• It may contain air, fluids, or semi- brown spots and are caused by
solid material clusters of pigmented cells
• Pilar cyst – sebaceous cyst of the
scalp Keloids
• Treatment: surgical removal; excision of cyst • Benign overgrowths of fibrous
tissue at the site of scar or trauma
Seborrheic Keratoses (Senile Warts) • Treatment: Excision,
• Benign wart like lesions that • Intralesional corticosteroid therapy
originates from keratinocytes
• Most common in the face, Dermatofibroma
shoulders, back and chest are seen • Benign tumor of connective tissue
more often as people ages that occurs predominantly on the
extremities
Actinic Keratoses
• Premalignant skin lesions that Neurofibromatosis: Von Recklinghausen’s Disease
develop in chronically sun-exposed • Tumors grow on nerves, affects its growth and
areas of the body development
• Removed cryotherapy or shave • A hereditary condition – pigmented patches
excision • Develops anywhere near the nervous system
including the brain, spinal cord, and nerves

ONCOLOGIC DISORDERS
• Melanoma is often called "the most serious skin

cancer" because it has a tendency to spread
• Melanoma signs include:
 A large brownish spot with darker speckles
 A mole that changes in color, size or feel or that
bleeds
 A small lesion with an irregular border and
Malignant Skin Tumors portions that appear red, pink, white, blue or blue-
Basal Cell Carcinoma black
• Comes from the basal cell in the lowest part of the  A painful lesion that itches or burns
epidermis (majority of skin cancers)  Dark lesions on the palms, soles, fingertips or
• Most common type of skin cancer toes, or on mucous membranes lining the mouth,
• Frequently develops in people who have fair skin nose, vagina or anus
• Often look like a flesh-colored round growth, pearl-like
bump, or a pinkish patch of skin
• A flat, flesh-colored or brown scar-like lesion
• A bleeding or scabbing sore that heals and returns
• Usually develop after years of frequent sun exposure
or indoor tanning
• Are common on the head, neck, and arms; however, • 2 Forms of Malignant Melanoma
they can form anywhere on the body, including the a. Superficial spreading
chest, abdomen, and legs b. Nodular
Squamous Cell Carcinoma (SCC) Assessing the ABCDE’s of moles

• Comes from Keratinocytes, the skin cells that make
Normal Cancerous
up the top layer of the skin
• SCC is the second most common type of skin cancer “A” for ASYMMETRY
• Most likely to develop light skin If you draw a line through the
middle of the mole, the halves
• A sore that heals and then re-opens of a melanoma won’t match in
• A firm, red nodule size
• A flat lesion with a scaly, crusted surface
“B” for BORDER
The edges of an early
melanoma tend to be uneven,
crusty or notched
“C” for COLOR

Healthy moles are uniform in
color. A variety of colors,
especially white and/or blue, is
bad
“D” for DIAMETER

Melanomas are usually larger in
diameter than a pencil eraser,
although they can be smaller
“E” for EVOLVING

When a mole changes in size,
Malignant Melanoma shape, or color, or begins to
bleed or scab, this points to
• Comes from pigment-creating skin cells called danger
melanocytes. Although less prevalent, melanoma is
the most dangerous, rapidly

ONCOLOGIC DISORDERS
Risk Factors Stage I

1. Excessive exposure to sunlight is the main cause of • In stage I, cancer has formed and the tumor is
skin cancer 2 centimeter or smaller
2. UV rays alter the genetic material in skin cells,
causing mutations
3. Sunlamps, tanning booths, and X-rays also generate
UV rays - cause malignant cell mutations
4. Exposure to certain substances, such as arsenic,
may increase the risk of skin cancer
Diagnosis
1. Skin Examination
 Determine whether skin changes are likely to be
skin cancer
 Further testing may be needed to confirm that
diagnosis Stage II
2. Skin biopsy • In stage II, the tumor is larger than 2 centimeters but
 Remove a sample of suspicious skin for testing not larger than 4 centimeters
 A skin biopsy is a procedure in which a doctor
cuts and removes a small sample of skin to have
it tested
Punch biopsy − A hollow, circular scalpel is used to
cut into a lesion on the skin. A small sample of tissue
is removed to be checked under a microscope. The
instrument is turned clockwise then
counterclockwise to cut down about 4mm to layer of
fatty tissue below the dermis
Incisional biopsy − scalpel is used to remove part of
a growth
Excisional biopsy − scalpel is used to remove the
entire growth
Stages of Skin Cancer

Stage III
Stages are used for basal cell carcinoma and squamous
• Nonmelanoma skin Cancer of The Head and Neck
cell carcinoma of the skin that is on the head or neck
• The tumor is (a) larger than 4 centimeters; or cancer
has spread to (b) tissue covering the nerves below the
Stage 0 (Carcinoma in situ) dermis; or (c) below the subcutaneous tissue; or (d)
• Abnormal cells are found in the squamous the bone and the bone has minor damage
cell or basal cell layer of the epidermis
• These abnormal cells may become cancer and
spread into nearby normal tissue
• Stage 0 is also called carcinoma in situ
• Cancer may have spread to one lymph node on the

same side of the body as the tumor and the node is 3
centimeters or smaller, and cancer has not spread

ONCOLOGIC DISORDERS
through to the outside covering of the lymph node (not − Tumor, along with some of the
shown) normal tissue around it, is cut from the skin.
• The tumor is 4 centimeters or smaller. Cancer has − Treatment of choice for small, superficial
spread to one lymph node on the same side of the lesions
body as the tumor and the node is 3 centimeters or − Wide local excision
smaller − For deeper lesions, skin grafting may be
necessary
Mohs Micrographic Surgery
− The tumor is cut from the skin in thin layers
− During the procedure, the edges of the tumor
and each layer of tumor removed are viewed
through a microscope to check for cancer cells
− Layers continue to be removed until no more
cancer cells are seen
− This type of surgery removes as little normal
tissue as possible
− It is often used to remove skin cancer on the
face, fingers, or genitals and skin cancer that
Stage IV
does not have a clear border
• The tumor is any size
• Cancer may have spread to the bone and the bone
has minor damage, or to tissue covering the nerves
below the dermis, or below the subcutaneous tissue
• Cancer has spread to: (a) one lymph node on the
same side of the body as the tumor, the node is 3
centimeters or smaller, and cancer has spread
through to the outside covering of the lymph node; or
(b) one lymph node on the same side of the body as
the tumor, the node is larger than 3 centimeters but
not larger than 6 centimeters, and cancer has not
spread through to the outside covering of the lymph
node; or (c) more than one lymph node on the same
side of the body as the tumor, the nodes are 6
centimeters or smaller, and cancer has not spread
through to the outside covering of the lymph nodes; or
(d) one or more lymph nodes on the opposite side of
the body as the tumor or on both sides of the body,
the nodes are 6 centimeters or smaller, and cancer
has not spread through to the outside covering of the
lymph nodes
• The surgeon removes the visible portion of the tumor

exposing the underlying surface "roots" of the skin
cancer
• Has the capacity to remove skin cancer with very
narrow surgical margin and a high cure rate for basal
cell carcinoma
Medical Management
1. Surgery
Simple Excision

ONCOLOGIC DISORDERS
Care of the Patient with Malignant Melanoma

1. Inspect skin carefully
2. Ask specific questions about pruritis, tenderness,
pain, changes in moles, or new pigmented lesions
3. Assess knowledge level and risk factors
4. Assess coping and anxiety
5. Provide emotional support
6. Pain management
Signs and Symptoms
1. Bone pain
Prevention
2. Swelling and tenderness near the affected area
1. Use sunblock or lotion 3. Weakened bone, leading to fracture
 SPF (solar protection factor), indicates how 4. Fatigue
much longer a person can stay in the sun before 5. Unintended weight loss
the skin begins to reddened
 SPF 30 – reapply every 2 hours
Exams and Tests
 4 (weakest)
1. Blood tests
 50 (strongest)
2. Bone scan to see metastasis
2. Wear protective clothing, such as broad-brimmed hat
3. CT scan of the chest - spread to the lungs
 Remind patients that up to 50% of UV rays can
4. CT scan of the affected area
penetrate loosely woven clothing
5. Open biopsy (at time of surgery for diagnosis)
3. No oils before or during sun exposure
6. X-ray of the affected area
4. Use a lip balm that contains an SPF of 15 or higher
5. Remind client that UV light can penetrate cloud
Advise patient: TNM Classifications
 No tanning T stages of bone cancer
 No unnecessary exposure to the sun (10am - TX – primary tumor can’t be measured
4pm) the sun's rays are strongest between about T0 – no evidence of the tumor
10 a.m. and 4 p.m.
T1 – tumor is 8 cm (around 3 inches) or less
 Schedule outdoor activities for other times of the
T2 – tumor is larger than 8 cm
day, even in winter or when the sky is cloudy
6. Avoid sunburns T3 – tumor is in more than one place on the same bone
7. Apply sunscreen/day to block harmful sunrays
8. Use sunscreen with an SPF of 15 or higher Bone Tumors
9. Reapply water resistant sunscreen after swimming, Abnormal and uncontrollable neoplastic growth of the
heavy sweating bones that can be form a mass or lump of tissue, mostly
10. Avoid using tan lamps for indoor tanning and benign
commercial tanning booths
11. Periodic skin self-examination Primary Tumors
• Benign tumors are more common, generally slow
Bone Cancer growing, and present few symptoms
• Can begin in any bone in the body, but most
commonly affect the pelvis or the long bones in the Osteochondroma
arm, and legs • Most common benign tumor, large projection of bone
• Rare, accounting only 1% of all cancers in the end of long bones (shoulder, knee)
• Non-cancerous bone tumors are more common than • These tumors form near the actively growing ends of
cancerous ones long bones, such as arm or leg bones
• Specifically, these tumors tend to affect the lower end
of the thighbone (femur), the upper end of the lower

ONCOLOGIC DISORDERS
leg bone (tibia), and the upper end of the upper arm • The vertebrae can collapse, which is known as a
bone (humerus) compression fracture
• These tumors are made of bone and cartilage
Osteoclastoma
• Giant-cell tumor of the bone, also known
as osteclastoma, is a relatively uncommon tumor of
the bone
• It is characterized by the presence of multinucleated
giant cells
• Giant cell tumors are normally benign but locally
aggressive
 May undergo malignant transformation and
metastasize
• Giant cell tumor, hemorrhagic, soft
• Common in young adults
Enchondroma Malignant Tumors

• Common tumor of the hyaline cartilage that develops • Arise from connective and supportive tissue cells or
in the hand, femur, tibia, or humerus bone marrow elements
Osteosarcoma (Osteogenic sarcoma)

• Most common and most fatal
primary malignant bone tumor
• The cancerous cells produce bone
• Occurs most often in children and
young adults, in the bones of the
leg or arm
• Osteosarcoma tends to occur in
the bones of the:
Osteoid Osteoma  Shin (near the knee)
• Most common of the benign tumors involving the bone  Thigh (near the knee)
of the spine  Upper arm (near the shoulder)
• Commonly occur in the legs, hands, finger, and spine
• Found during adolescence
• Scoliosis or curvature of the spine
• Aching pain that does not ease up, and is worse at
night or when waking up
• Problems with movement and sensation

ONCOLOGIC DISORDERS
Symptoms of Osteosarcoma − The goal of this procedure is to improve quality of

1. Persistent pain, swelling or a firm lump on a bone, life and increase high functional performance
especially on an arm or leg − The lower part of the leg is rotated and reattached
2. A limp (if the tumor affects the leg) so that the ankle
3. Pain or difficulty breathing (if the tumor affects the becomes the new knee,
ribs) and a prosthetic device is
4. A bone fracture that occurs spontaneously or after a attached to replace the
minor bump ankle and foot
A pathologic fracture is a bone fracture caused by

weakness of the bone structure that leads to
decrease mechanical resistance to normal
mechanical loads due to pathologies such as a
bone cyst or cancer
3. Amputation
− Removal of the limb
4. Hip disarticulation
− Surgical removal of the entire lower limb by
transection through the hip joint
Management
1. Limb Sparing Surgery
− Removes the cancerous tumor and bone,
replacing it with either a graft or prosthesis to
make the limb as functional as possible
− Surgery to remove a tumor in a limb (arm or leg)
without removing the whole limb
− The bone and tissue around the tumor may also
Chondrosarcoma
be removed, and an implant may be used to
replace the part of the limb removed • Malignant cancer whose tumor cells produce a pure
− Limb-sparing surgery is done to help save the use hyaline cartilage that results in abnormal bone and/or
and appearance of the limb cartilage growth
2. Rotationplasty (Van Nes rotation) • Usually occurs in the pelvis, legs or arms in middle-
− The surgery involves surgical resection of the aged and older adults
shaft/ distal end of the femur bone and proximal
tibia
− The tibia is then rotated 180 degrees, to form a
functional knee joint, which is reattached to the
remaining femur
− This gives the appearance of a short leg with the
foot on backwards. This will allow the patient to
wear a more functional and customized below
knee prosthetic

ONCOLOGIC DISORDERS
Ewing’s Sarcoma Clinical Manifestations

• The second most common form of bone tumor in Classical Triad: headache, vomiting, papilledema
children and adolescents 1. Increased ICP
• Most commonly arise in the pelvis, legs or arms of  The effect is a disruption of the equilibrium that
children and young adults exists between the brain, the CSF, and the
cerebral blood
 As the tumor grows, compensatory adjustments
may occur through compression of intracranial
veins, reduction of CSF volume (by increased
absorption or decreased production), a modest
decrease in cerebral blood flow, or reduction of
intracellular and extracellular brain tissue mass
 When these compensatory mechanisms fail, the
patient develops signs and symptoms of
increased ICP, most often including headache,
Treatment nausea with or without vomiting, and
1. Chemotherapy papilledema
2. Radiotherapy 2. Headache
3. Surgery  Most common in the early morning and is made
4. Amputation worse by coughing, straining, or sudden
 The removal of a limb by surgery movement
 As a surgical measure, it is used to control pain  Described as deep or expanding or as dull but
or a disease process in the affected limb, such unrelentingVomiting unrelated to food intake
as malignancy 3. Vomiting
 Unrelated to food intake, is usually the result of
The goal of rehabilitation after an amputation is to irritation of the vagal centers in the medulla
help the patient return to the highest level of 4. Papilledema
function and independence possible, while  Edema of the optic nerve, causes visual
improving the overall quality of life—physically, disturbances ( visual acuity and diplopia)
emotionally, and socially
5. Seizures (focal and generalized)
 Occurs in 60% of cases, initially or throughout
Brain Cancer the disease process
• Produces a unique set of nursing challenges 6. Changes in mental status
• A localized intracranial lesion that occupies space 7. Focal neurologic deficits
within the skull growing as a spherical mass or  Aphasia, hemiparesis, sensory problems
diffusely infiltrating tissue 8. Cranial nerve dysfunction (vision), motor deficits
• Cancer cells invade and destroy intracranial tissues (walking difficulty)
• Tumors may be benign (not cancerous) or malignant  If there is a parietal lobe tumor, it may cause
(cancerous) deceased sensation on the opposite side of the
• Effects of brain tumor are caused by inflammation, body or generalized seizures
compression, and infiltration of tissue 9. Deficits in cognition, learning & memory
Types Types of Primary Brain Tumors

Primary – originates in the brain tissue (e.g., glioma, Gliomas
meningioma) • Glial tumors, the most common type of intracerebral
Secondary – metastases from tumor elsewhere in the brain neoplasm, are divided into many categories
body (e.g., lung, breast) Astrocytomas
− The most common type of glioma and are graded
from I to IV, indicating the degree of malignancy
Cause
− The grade is based on cellular density, cell
1. Unknown mitosis, and appearance
2. Genetic factor − Usually, these tumors spread by infiltrating into
3. Exposure to environmental toxins the surrounding neural connective tissue and
4. Possible link to radiation to the head therefore cannot be totally removed without
5. Viruses – HIV infection causing considerable damage to vital structures
6. Cigarette smoking

ONCOLOGIC DISORDERS
Oligodendrogliomas Common Brain Tumor Sites

− Represent 20% of gliomas and are categorized as
low grade or high grade (anaplastic)
• The histologic distinction between astrocytomas and
oligodendrogliomas is difficult to make but important,
because oligodendrogliomas are more sensitive than
astrocytomas to chemotherapy
Meningioma
• Common benign encapsulated tumors of arachnoid
cells on the meninges
• They are slow growing and occur most often in
middle-aged adults (more often in women)
• Meningiomas most often occur in areas proximal to
the venous sinuses
• Manifestations depend on the area involved and are
the result of compression rather than invasion of brain
tissue
• Preferred treatment for symptomatic lesions is
surgery with complete removal or partial dissection
Diagnostic Exams
Acoustic Neuroma 1. Physical Exam
2. Skull x-ray
• Tumor of the eighth cranial nerve (hearing and
 To confirm the presence of tumor
balance)
3. Brain Scan
• An acoustic neuroma may grow slowly and attain
 To confirm the presence and size of the tumor
considerable size before it is correctly diagnosed
4. CT Scan
• The patient usually experiences loss of hearing,
5. MRI
tinnitus, and episodes of vertigo and staggering gait
6. EEG
• As the tumor becomes larger, painful sensations of
7. Routine Lab Tests
the face may occur on the same side, as a result of
a. Analysis of blood and electrolytes
the tumor’s compression of the fifth cranial nerve
b. Liver function tests
c. Blood coagulation profile
Pituitary Adenoma
• Pituitary tumors represent about 10% to 15% of all
Medical Management
brain tumors and cause symptoms as a result of
Specific treatment depends upon the type, location, and
pressure on adjacent structures or hormonal changes
accessibility of the tumor
such as hyperfunction or hypofunction of the pituitary
1. Surgery
 Goal is to removal of tumor without increasing
Angioma
neurologic symptoms or to relieve symptoms by
• Masses composed largely of abnormal blood vessels decompression
are found either in or on the surface of the brain  Craniotomy, transsphenoidal surgery.
• They occur in the cerebellum in 83% of cases Stereotactic procedures
• Occasionally, the diagnosis is suggested by the 2. Radiation therapy
presence of another angioma somewhere in the head  External beam radiation
or by a bruit (an abnormal sound) that is audible over  Brachytherapy
the skull 3. Chemotherapy
• Because the walls of the blood vessels in angiomas  Referral to a neurooncologist – cancer specialist
are thin, these patients are at risk for hemorrhagic 4. Gamma knife to perform radiosurgery
stroke  Multiple narrow beams then deliver a very high
 In fact, cerebral hemorrhage in people younger dose of radiation
than 40 years of age should suggest the  Allow treatment of deep, inaccessible tumors,
possibility of an angioma often in a single session
 Precise localization of the tumor is accomplished
 No surgical incision is needed

ONCOLOGIC DISORDERS
Craniotomy Post-Op Intervention

• Is a type of a brain surgery 1. Monitor VS & neurovascular status every 30-60
• It entails surgical extraction of bones from skull so that minutes
part of brain is exposed to help the doctor in 2. Monitor for increased ICP
determining presence of brain tumor 3. Monitor for decreased level of consciousness, motor
weakness or paralysis, aphasia, visual changes, and
personality changes
Supratentorial Infratentorial Transsphenoidal
4. Maintain mechanical ventilation and slight
Site of Surgery hyperventilation for the 1st 24-48 hours as prescribed
Below the
Sella turcica and  To prevent increase ICP
Above the tentorium tentorium, brain
stem
pituitary region 5. Assess orders regarding client’s positioning
Incision Location 6. Avoid extreme hip or neck flexion, and maintain the
Above the area to Made beneath the head in a midline neutral position
Made at the nape of
be operated on;
the neck, around
upper lip to gain 7. Provide a quiet environment
usually located access into the
the occipital lobe 8. Monitor the head frequently for signs of infection
behind the hairline nasal cavity
9. Mark the area of drainage at least once each nursing
Selected Nursing Interventions
shift for baseline comparison
1. Maintain HOB 1. Maintain neck in 1. The patient will
elevated 30-45 10. Monitor the Jackson Pratt or Hemovac drain which
straight not be able to
degrees, with alignment brush teeth may be in place for 24 hours
neck in neutral
alignment
2. Avoid flexion of because of  Maintain suction on the drain
the neck to incision
2. Position patient prevent possible 2. Maintain nasal  Measure drainage every 8 hours, record amount
on either side or
back (Avoid
tearing of the packing in place and color, report if  normal amount 30-50
suture line and reinforce as
positioning 3. Position the needed
ml/shift
patient on patient 3. Instruct patient to 11. Excessive amounts of drainage/saturated head
operative side if a
 Flat in bed avoid blowing the dressing – report immediately to the physician
large tumor has (prone) nose
been removed)  On either side 4. Provide frequent 12. Monitor fluid and electrolyte status
but not on oral care  Maintain accurate I and O
back 5. Keep HOB
 Check elevated to  Restrict fluids to 1500 ml/day as ordered to
surgeon’s promote venous decrease cerebral edema
preference for drainage and
positioning of drainage from the
 Avoid overly rapid infusions
patient surgical site  Watch for signs of diabetes insipidus (severe
thirst, polyuria, dehydration) or SIADH (urine
output, hunger, thirst, irritability)
Pre-Op Intervention
13. Administer medications as ordered
1. Explain the procedure to the patient and family  Corticosteroids to decrease cerebral edema
2. Ensure that an informed consent has been obtained  Anticonvulsants to prevent seizure
3. Provide emotional support, explain post-op  Stool softeners to prevent straining
procedures  Mild analgesics
 Head will be shaved, there will be a large 14. Apply ice to swollen eyelids and lubricate lids and
bandage on head areas around the eyes with petroleum jelly
 Possibly temporary swelling and discoloration 15. Refer client for rehabilitation for residual deficits
around the eye on the affected side 16. Enhancing self-image
 Possible headache  Encourage verbalization
4. Shave hair (usually done in the OR)  Encourage social interaction and social support
5. Evaluate and record baseline VS and neuro checks  Attention to grooming
6. Avoid enemas unless directed (straining increases  Cover head with turban and later a wig
ICP)
7. Give pre-op steroids as ordered
Colorectal Cancer
 To decreased brain swelling
 Dexamethasone (Decadron) • Intestinal tumors are malignant lesion that develop in
8. Give antiseizure medication as prescribe: the cell lining the bowel wall or develop as
 Phenytoin (Dilantin) adenomatous polyps in the colon or rectum
 Phenytoin metabolite (Cerebryx) • Tumors are spread by direct invasion through the
9. Immediately before/during surgery lymphatic and circulatory system
 Mannitol and furosemide (Lasix) – if tend to • A colon polyp is a small clump of cell that forms on the
retain fluid lining of the colon

ONCOLOGIC DISORDERS
 Most colon polyps are harmless but over time, Pre-Procedure

some colon polyps can develop into colon cancer • Low residue-diet for 1-2 days
• Clear liquid diet and laxative or suppository the
Risk Factors evening before the test
• NPO after midnight the day of the test or 8
1. Age 50 y/o or older hours pretest
2. Family history of colorectal cancer • Enemas until clear the morning of test
3. Previous colorectal cancer
During Procedure
4. Previous colorectal polyps
• May assume different position
5. History of chronic inflammatory disease of the bowel • Radiologist may press firmly on your abdomen
6. History of ovarian or breast cancer and pelvis – for better viewing
• Usually takes 30-45 minutes, x-ray images are
Assessment taken
• Cramping
1. Rectal bleeding or blood in the stool (most common)
2. Anorexia, vomiting and weight loss Post-Procedure
3. Anemia • Laxatives/fluids to assist in expelling barium
4. Abnormal stool 5. CT Scan
 Ascending colon tumor: diarrhea  Type of x-ray that uses a computer to make
 Descending colon tumor: constipation or some image inside the body
diarrhea, or flat ribbon like stool caused by partial  Scanning may or may not require injection of a
obstruction dye
 Rectal tumor: alternating constipation and 6. Sigmoidoscopy, Colonoscopy
diarrhea  Colonoscopy is an exam used to detect changes
5. Late signs: or abnormalities in the large intestine (colon) and
 Guarding or abdominal distention, abdominal rectum
mass  During a colonoscopy, a long, flexible tube
 Cachexia, a “wasting” disorder that causes (colonoscope) is inserted into the rectum, a tiny
extreme weight loss and muscle wasting, and video camera at the tip of the tube allows the
can include loss of body fat doctor to view the inside of the entire colon
 Enema
Diagnostic Exams  Clear liquid diet day before the test
1. Stool for Occult Blood Positive  NPO at midnight
 Wait 3-5 mins after applying the same until  Consent form
developing the test to allow adequate time for  Sedation
sample to penetrate the test paper Pre-Operation
 Open back of slide and apply 2 drops od • Routine pre-op preparations
hemoccult developer to guaiac paper directly • Consult enterostomal therapist to help identify
over each smear optimal placement of ostomy
 Read results within 60 seconds • Instruct to eat a low-fiber diet for 1-2 days
 Any trace of blue on or at the edge of the smear before the surgery
is positive for occult blood • Administer:
 Guaiac test detects the presence of fecal occult a. Intestinal antiseptics and antibiotics as
blood. positive guaiac test shown on right, as prescribed to cleanse the bowel and to
would be seen for this patient. decrease the bacterial content of the colon
2. Hgb and Hct decreased b. Laxatives and enemas as prescribed
3. CEA positive
 A carcinoembryonic antigen (CEA) test is a Post-Operation
blood test used to help diagnose and manage • Bedrest
certain types of cancer • Bleeding, perforation
 The CEA test is used especially for cancers of
the large intestine and rectum Medical Management
 Normal serum levels are less than 2.5 ng/ml 1. Chemotherapy
 Borderline: 2.5-5.0 ng/ml  Reduce metastasis and control its
 Elevated if greater than 5.0 ng/ml manifestations
4. Barium Enema (Lower GIT Studies) 2. Radiotherapy
 Barium is instilled into the colon by enema  To decrease tumor growth
3. Surgery: Colorectal

ONCOLOGIC DISORDERS
4. Abdominal perineal resection (APR) Breast Cancer

 A surgery in which the anus, rectum, and • Cancer that forms in the cells of the breast
sigmoid colon are removed • After skin cancer, breast cancer is the most common
5. Colostomy cancer diagnosed in women in the United States
• Breast cancer can occur in both men and women, but
Colostomy it`s far more common in women
• A pouch (or appliance) is placed over the stoma to Cancerous Non-Cancerous
collect the stool as it is passed out of the body
Firm, irregular margins, Squishy, defined
• Beltlines, waistlines, skin folds and bony or scarred Feel
immobile margins, mobile
areas are avoided because these can affect how well Mammogram Spiky, fuzzy, or lumpy Uniform, round or oval
the colostomy bag or pouch sticks to the abdomen Slow to light up,
MRI Rapid light-up and fade
• Is a surgical creation of an opening into the colon that doesn’t fade
allows for drainage fecal matter from the colon to the Biopsy
Cell clusters, irregular
Same as normal cells
nuclei
outside of the body
• Primary surgeon moved to a position between the
patient’s legs and began the perineal dissection with Stages of Breast Cancer
a perianal incision Stage Description
Survival
Rate
Abnormal cells in duct lining or sections of
Nursing Considerations 0 the breast. Increased risk of developing 100%
After Surgery cancer in one or both breasts.
1. Perform meticulous supportive care Cancer in breast tissue. Tumor is less that
1 98%
2. Keep the NGT patent one inch across in size.
3. Clear liquid diet Cancer in the breast tissue. Tumor is less
4. Continue teaching stoma care 2 than two inches across in size. Cancer 88%
5. Note the normal stoma color is pink to bright red and may spread to the auxiliary lymph nodes.
shiny, indicating high vascularity Tumor is larger than two inches across in
 Pale pink – low hemoglobin count and size and cancer has spread to auxiliary.
3 52%
Possible dimpling, inflammation or skin
hematocrit level color change.
 Purple black– compromised circulation,
Cancer has spread beyond the breast to
requiring physician notification 4 16%
other nearby areas of the body.
6. Administer analgesic and antibiotic as prescribed
7. Ischemia – complication of intestinal stomas
Risk Factors
8. Instruct the patient to avoid foods that cause excess
gas formation 1. Atypical hyperplasia
9. Teach good stoma care  In previous biopsies – increased risk
10. Wash the skin around the stoma with soapy water  Proliferative breast changes without atypia –
and fry it thoroughly smaller risk
11. Apply karaya gum around the stoma`s base to avoid 2. Race/ethnicity
irritation and make a water tight seal  Non-Hispanic White Women – Higher Rates of
12. Empty the pouch when it is 1/3 full Breast Cancer.
 Squeeze the contents into the toilet 3. Postmenopausal hormone replacement therapy
 Clean the pouch`s lower opening 4. Breast density
 Rinse the pouch  High breast density d/t incomplete involution of
13. Dietary advice to ostomates lobules at the end of each menstrual cycle
 Take low fiber food to reduce bulk in stool and causes increased number of cells potentially
help prevent intestinal obstruction susceptible to neoplastic transformation
 Avoid celery, popcorn, corn, coconut 5. Radiation exposure
 Avoid vegetables known to result in offensive  To chest – d/t cancer therapy, atomic bomb
odors: radish, cabbage, garlic, cucumber exposure, or nuclear accidents
 To reduce flatus, avoid: carbonated beverage, 6. Carcinoma of the contralateral breast of
chewing gums, smoking endometrium
 Chew food well  1% of women with breast cancer − second
 Drink adequate amounts of water contralateral breast carcinoma/year
 Sports drink – Gatorade  Risk is higher for women with germline mutation
in BRCA1 and BRCA2
7. Geographical influence

ONCOLOGIC DISORDERS
 Higher incidence in United States and Europe Surgical Interventions

8. Diet 1. Lumpectomy
 Alcohol consumption causes higher estrogen  Partial mastectomy, breast-conserving surgery,
levels and lower folate levels breast-sparing surgery, and wide incision
9. Obesity  Is the surgical removal of a cancerous or
 Post-menopausal obese women – increased noncancerous breast tumor
synthesis of estrogen in fat depots  Removing a small amount of normal breast
10. Breastfeeding tissue around a cancerous tumor
 The longer women breastfeed, the greater the 2. Simple mastectomy
reduction of risk  Breast tissue and nipple removed
11. Environmental toxins  Lymph nodes are usually left intact
 Organochlorine pesticides − estrogenic 3. Modified Radical Mastectomy
12. Tobacco and cigarette smoking  Breast tissue, nipple and lymph nodes are
removed
Signs and Symptoms  Muscles are left intact
1. Mass felt during BSE 4. Transverse Rectus Abdominis Myocutaneous
 Mass is usually in the upper outer quadrant (TRAM) Flap Surgery
beneath the nipple or in axilla  The tissue remains attached to its original site,
2. A breast lump or thickening that feels different from retaining its blood supply
the surrounding tissue  The flap, consisting of the skin, fat, and muscle
3. Asymmetry with the affected breast being higher. with its blood supply, is tunneled underneath the
Change in the size, shape, or appearance of a breast skin to the chest creating a pocket for an implant
4. Skin edema or peau d` orange skin – or in some cases, creating the breast mound
 Orange peel appearance of the skin of the breast itself
caused by cutaneous lymphatic edema, which
causes swelling Post-Operative Interventions
5. Skin dimpling, retraction or ulceration 1. Monitor VS
6. Nipple retraction or elevation 2. Position to semi-fowlers position, turn from the back
7. Bloody or clear nipple discharge to the unaffected side, with the affected arm elevated
8. Axillary lymphadenopathy above the level of the heart
 Also known as adenopathy, describes changes  To promote drainage and prevent lymphedema
in the size and consistency of lymph nodes in the 3. Encourage coughing and deep breathing
armpit (axilla) 4. If a drain (usually a Jackson Pratt) is in place,
9. Early detection – monthly BSE maintain suction and record the amount of drainage
and drainage characteristics, teach the client about
Diagnostic Examination home management of the drain
1. Mammography 5. Assess operative site for infection, swelling and or
 Can reveal tumor that is too small to palpate presence of fluid collection under the skin flaps or in
2. Chest x-ray can pinpoint metastases in the chest the arm
3. Fine needle biopsy and excision provides cell for 6. Monitor incision site for restriction of dressing,
histological examination that may confirm the impaired sensation or color change in the skin
diagnosis 7. If breast reconstruction was performed, the client will
return from surgery with a surgical brassiere and a
Non-Surgical Interventions prosthesis in place
8. Provide the use of pressure sleeves as prescribed if
1. Chemotherapy
edema is severe
2. Radiotherapy
9. Maintain fluid and electrolyte balance, administer
a. External beam radiation (high intensity x-ray
diuretics and provide a low salt diet as prescribed for
beamed from several angles)
severe lymphedema
b. Brachytherapy (internal radiation therapy;
10. Consult with the physician and physical therapist
radiation delivered through catheters in the
regarding the appropriate exercise program and
breast)
assist client with prescribed exercise
c. Proton beam therapy (protons beamed only to
11. Instruct the client about home care measures
tumor)
12. No IVs, injections, blood pressure measurement
and no venipuncture should be done in the arm on
the side of the mastectomy

ONCOLOGIC DISORDERS
 This arm should be protected and any Rod or Broomstick Lifting

interventions that could traumatize the affected Grasp a rod with both hands, held
arm is avoided about 2 feet apart. keeping the
arms straight, raise the rod over
Home Care Measures the hand. Bend elbows to lower the
1. Avoid overuse of the arms during the first few months rod behind the head. Reverse
2. Keep the affected arm elevated to promote fluid maneuver, raising the rod above
drainage via lymphatic and venous pathways the head, then return to the starting
 To prevent lymphedema position.
 Ex. Elevating the arms on two pillows
3. Provide incision care with an emollient Rope Turning
 To soften and prevent wound contractures Tie a light rope to a doorknob.
4. Encourage to perform breast self-examination with Stand facing the door. Take
the unaffected breast the free end of the rope in the
5. Protect the affected hand and arm hand on the side of surgery.
6. Avoid strong sunlight on the affected area Place the other hand on the
 Ex. Tanning in the beach= sunburn hip. With the rope-holding arm
7. Do not let the affected arm hang dependent extended and held away from
8. Do not carry a pocketbook or anything heavy on the the body (nearly parallel with the floor), turn the rope,
affected arm making as wide swings as possible. Begin slowly at first,
9. Avoid cuts, trauma, bruises, or burns to the affected speed up later.
side
10. Avoid wearing constricting clothing or jewelry on the
Pulley Tugging
affected side
11. Wear gloves when gardening Toss a light rope over a shower
12. Use thick oven mitts when cooking. curtain rod or doorway curtain
13. Use a thimble when sewing- for finger protection rod. Stand as nearly under the
14. Apply hand cream several times a day rope as possible. Grasp an end
15. Call the physician if signs of inflammation occur in in each hand. Extend the arms
the affected arm straight and away from the body.
16. Wear a medic alert bracelet stating which arm is Pull the left arm up by tugging
lymphedematous down with right arm, then the
right arm up and the left down in a see-sawing motion.
o Lymphedema is caused by the inability of the
arm to remove even normal excess fluid after Lung Cancer
nodes have been removed from under the arm. • Type of cancer that begins in the lungs
It can occur even many years after nodal
• Leading cause of cancer deaths worldwide
surgery; there is no time limit.
o Tattoos help breast cancer patients heal after • The risk of lung cancer increases with the length of
mastectomy. time and number of cigarettes you have smoked
Causes
Post-Mastectomy Exercise
1. Cigarette smoking, also exposure to passive tobacco
Wall Climbing with Hand
smoking
Stand facing the wall with feet apart 2. Exposure to environmental and occupational
and toes as close to the wall as pollutants.
possible. with elbows slightly bent,  Air pollution from vehicles, industry, and power
place the palms of the hand on the wall plants can raise the likelihood of developing lung
at shoulder level. By flexing the fingers, cancer in exposed individuals
work the hands up the wall until arms
are fully extended. Then reverse the
Signs and Symptoms
process, working the hands down to the
1. A new cough that doesn`t go away
starting point.
2. Coughing up blood, even a small amount
3. Shortness of breath
4. Chest pain
5. Hoarseness

ONCOLOGIC DISORDERS
6. Weight loss without trying 7. Monitor pulse oximetry

7. Bone pain 8. Administer as prescribed:
8. Headache  Bronchodilator and steroids to decrease
bronchospasm, inflammation and edema
Diagnostic Exam 9. Provide a high calorie, high protein, high vitamin diet
1. Imaging Tests 10. Provide activity as tolerated, rest periods and active
 X-ray image of your lungs may reveal an and passive ROM exercises
abnormal mass or nodule
 CT scan can reveal small lesions in your lungs Non-Surgical Interventions
that might not be detected on an x-ray 1. Radiation therapy for localized intrathoracic lung
2. Sputum Cytology cancer and for palliation of hemoptysis, obstruction
 Refers to the examination of sputum (mucus) and pain
under a microscope to look for abnormal or 2. Chemotherapy for non-resectable tumors
cancerous
3. Tissue sample (biopsy) Preoperative Interventions
 A sample of abnormal cell may be removed in a 1. Explain the potential postoperative need of chest
procedure called a biopsy bronchoscopy tubes
Stages of Lung Cancer Surgical Interventions

Stage 1 − less than 3cm, no metastasis 1. Thoracentesis and pleurodesis
Stage 2 − tumor is less than 6cm, single metastasis  To remove pleural fluids and relieve hypoxia
observed 2. Thoracotomy
Stage 3 − tumor is more than 6cm, metastasis in the 3. Wedge resection
lymph nodes  To remove a small section of the lungs that
Stage 4 − the tumor passed to other organs contains the tumor along with a margin of healthy
tissue
4. Segmental resection
Stages and Treatment for NSCLC (Non-Small Cell
 To remove a larger portion of the lung, but not an
Lung Cancer)
entire lobe
Stage Description Survival Rate 5. Lobectomy
 To remove the entire lobe of one lung
Tumor of any size is found only in
I Surgery 6. Pneumonectomy
the lung
 To remove an entire lung
Tumor has spread to lymph nodes
II Surgery
associated with lungs
Postoperative Interventions
Tumor has spread to the lymph Chemotherapy
III A nodes in the tracheal area, followed by 1. Monitor VS
including chest wall and diaphragm radiation 2. Assess cardiac and respiratory status, monitor lung
Tumor has spread to the lymph Combination of
sounds
III B nodes on the opposite lung or in chemotherapy 3. Maintain the chest tube drainage system which
the neck and radiation drains air and blood that accumulates in the pleural
Tumor has spread beyond the space; monitor for excess bleeding
IV Chemotherapy
chest 4. Administer oxygen as prescribed
5. Check doctor’s order − positioning, avoid complete
Interventions lateral turning
6. Monitor pulse oximetry
1. Monitor VS
7. Provide activity as tolerated
2. Monitor breathing pattern and breathing sounds and
8. Encourage activity range of motion exercises of the
for signs of respiratory impairment, monitor for
operative shoulders as prescribed
hemoptysis
3. Assess for tracheal deviation
4. Pain management − analgesics
5. Place in fowler’s position
 To help ease breathing
6. Administer oxygen as prescribed and humidification
as prescribed
 To moisten and loosen secretions

Cancer Pain

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PAIN CONCEPTS

Pain Quality of Life Activities Affected by Chronic Pain

Client exhibits behavior indicative of Pain behavior often absent

GERICKA IRISH HUAN CO 2

Phantom limb pain is actual pain felt in a body

Gate Control Theory

Visceral Pain Intense concentration

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Transduction • Are located in the skin and responds to strong

Muscle Spasm Stimulation of pain receptors

Tissue destruction; stimulation of

Pain Receptors (Nociceptors) – carry pain impulses by

2 Main types of fibers (Nociceptors)

GERICKA IRISH HUAN CO 4

Other endogenous opioids: serotonin & epinephrine

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Characteristics of Pain Behavioural Pain (FLACC) Scale

No particular Occasional grimace Frequent to constant

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Personal Meaning of Pain Cutaneous Stimulation and Massage

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− Contraindicated in cases of acute injury because Distraction

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Alternative Therapies Example: Xylocaine 1-2%

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Unpredictable Pain – administer medications on a Side Effects:

Examples: Tylenol, Tempra

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a. Opioid Agonist – produce analgesia but also Nausea and Vomiting

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Sedation • It is programmed so that the patient can decide when

Intramuscular Route – may be used to administer

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f. Benzodiazepines – for muscle spasm and anxiety Spinal Cord Stimulation

Example: Instead of 15 mg of morphine to relieve a

Pro re nata (PRN)

Neurologic and Neurosurgical Procedures for Pain

GERICKA IRISH HUAN CO 14

Cordotomy − interruption of pain-conducting 6. Relieved anxiety and fears.

Expected Patient Outcomes for the Patient with Pain

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Perioperative Nursing 3. To cure a disease by removing the diseased tissue

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According to URGENCY Prefixes Meaning

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Roots Meaning How Operations Are Named

cysto urinary bladder otomy cutting into an organ/tissue Laparotomy, Thoracotomy

dent teeth pexy fixation or suturing in place Orchidopexy

dermat skin restoration of a lost part/ piece

gastro stomach rraphy repair, suturing of

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• Mouth condition − presence of dentures, dental Immunocompetence

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Antihypertensive agents interact with Alcoholism

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Manifestations of Fear Preadmission Procedures

Culture Electrocardiogram (ECG)