competency appraisal 1 reviewer-1

7/30/2019 Competency Appraisal 1 Reviewer-1

1/53

jcmendiola_Achievers2013 1

Competency Appraisal 1

(CA I)

REVIEW REVIEW!!!

Pediatric DisordersRESPIRATORY DISTRESS

SYNDROMEDefinition:

Formerly termedHyaline-membrane disease

Etiology: Preterm infants < 35 weeks Premenopausal mothers: Age >35 y/o Diabetic mothers

Cesarean births Meconium aspirated babies REMEMBER: Surfactant production 24 weeks, matures at

36th

week

MAIN CAUSE: Low level or absence of surfactant Pathologic Feature:

o Formation of hyaline-like membrane that forms froman exudate of the infants blood that lines the terminal

bronchioles, alveolar ducts and alveoli

o Which will prevent the exchange of carbon dioxideand oxygen and alveolar-capillary membrane

Signs and SymptomsCARDINAL SIGNS:

Low body temperature

Nasal flaring

Sternal and Subcostal retractions

Tachypnea (> 60 rpm)

Cyanotic mucous membranes (Central Cyanosis)

Diagnosis Chest Radiograph: Ground Glass (Haziness) ABGs: Respiratory Acidosis Blood Culture and CSF Culture: B-hemolytic, group B streptococcal infection

Nursing Diagnoses Impaired gas exchange Impaired spontaneous ventilation Impaired breathing pattern Ineffective tissue perfusion Risk for infection

Topics Discussed Here Are: P

1. Pediatric Disorders:a. Respiratory Distress Syndromeb. Megacolonc. Placenta Previa (Abruptio Placenta)d. Pregnancy Induced Hypertensione. Erythroblastosis Fetalis

2. Sensory Disordersa. Glaucomab. Cataractc. Retinal Detachmentd. Macular Degeneration

3. Neurologic Disordersa. Parkinsons Diseaseb. Multiple Sclerosis

4. Endocrine Disordersa. Hyperthyroidismb. Cushings Syndrome

5. Communicable Diseasesa. Rabiesb. Leptospirosis

6. Respiratory Disordersa. COPDb. Pneumoniac. Pulmonary Tuberculosis

7. Gastrointestinal + Diabetes Mellitusa. Crohns Disease (Ulcerative

Colitis)

b. Diabetes Mellitus8. Cardiovascular + Renal Disorders

a. Chronic Kidney Diseaseb. Myocardial Infarctionc. Tetralogy of Fallot

3

5

9

2

2

2

2

3

3

3

4

4

4

5

5

LOOKYHERE

As Distress Increase: Seesaw Respirations

Heart failure Due to UO and Edema

Pale gray skin

Periods of apnea

Bradycardia

Pneumothorax


2/53

2 jcmendiola_Achievers2013

Therapeutic Management Surfactant Replacement

o Spraying of synthetic surfactant (Via ET Tube)o Do not suction infant after administration

Oxygen Administrationo Used to maintain correct PO2 and pH Levels

o CPAP or PEEP Will exert pressure on alveoli at end of expiration to keep alveoli fromcollapsing

o Complication: Retinopathy of prematurity / Bronchopulmonary Dysplasia Ventilation

o Normal: Inspiration is shorter than Expiration (I/E Ratio 1:2)o Ventilator: I/E Ratio 2:1 to help facilitate inspiration

Extracorporeal Membrane Oxygenation (ECMO) Liquid Ventilation Nitric Oxide


3/53


MEDICATIONS: Indomethacin or Ibuprofen Used for closure of a Patent Ductus Arteriosus

o Indomethacin Known for AE such as; Renal function, Platelet count, Gastric irritation Pancronium (Pavulon) Muscle Relaxant to increase pulmonary blood flow

o Administered to abolish spontaneous respiratory actionso Antidote: Atropine or Injectible Neostigmine Methylsulfate

Nursing Interventions Keep infants warm

o Cooling increases acidosiso Warming infant reduces metabolic oxygen demand

Assist with insertion of NGT for nutrition (Breast milk) Allow parents to be participative Discharge Planning:

o Instruct to continue breastfeedingo Teach proper douching / suckling of infant

Prevention:o Assess for levels of Lecithin-Sphingomyelin Ratioo Prevent hypothermia (Provide neutral environment)o

Prevention of infection: Handwashing Prevent contact with people who have respiratory disorders Give immunizations

o Instruct mother that REGULAR CHECK-UP / PRENATAL CHECK-UP is needed

MEGACOLON (HIRSCHSPRUNGS DISEASE)Definition:

The absence of ganglionic innervations to the muscle of a section of the bowel Most common site: Lower portion of the sigmoid colon, just above the anus

Ways of Losing Heat Evaporation Dry the infant!

Conduction Line the sides of the cribwith pillows

Convection Do not place crib nearaircon

Radiation Imbalanced environment


4/53


Assessment Pathognomonic Sign: Ribbon-like Stools Meconium has not yet passed (24 hours of age) Increasing abdominal distention Thin and undernourshished (Deceptively) Does not become apparent until 6 12 months

o History of constipation (Ask for duration, ask parent definition of constipation)o Intermittent constipationo Diarrhea (Ask for consistency of stool)

Diagnostic Procedures Digital Rectal Examination: No stool in rectum Barium Enema: To outline the NARROW and NERVELESS portions of the bowel Biopsy: Of the affected segment Most definitive diagnosis (Shows the lack of innervations) Anorectal Manometry: Used to test the strength or innervations of the internal rectal sphincter by inserting

a balloon catheter in the rectum and measuring the pressure exerted against it

Therapeutic Management Pull-Through Operation

o Repair of the aganglionic Megacolon (Dissection and removal with anastomosis)o 1st Stage: Temporary colostomy is establishedo 2nd Stage: Bowel repair at 12 18 months of age

Nursing Diagnoses with Interventions (CNC) Constipation related to reduced bowel function

Outcome Evaluation: Child has a daily bowel movement through either a colostomy or by enema Interventions:

Daily enemas may be prescribed To achieve bowel movements Ensure to use Normal Saline (0.9% NaCl) and NOT TAP WATER (Hypotonic)

Teach parents how to prepare and administer saline enemas at home Mixing 2 tsp of noniodized salt to 1 quart of water

Imbalanced nutrition, less than body requirements related to reduced bowel function Outcome Evaluation: Child ingests a low-residue diet; weight follows a percentile curve on a growth

chart

Interventions: If patient has poor nutrition, may be returned home and get:

Minimal-residue diet, stool softeners, vitamin supplements or enemas until conditionimproves

Assist in giving TPN Teach parents about minimal-residue diets, or low in undigestible fiber, connective fiber and

residue

OMIT: Fried foods and seasoned foods

Help parents make a reminder sheet for the stool softener Tell parents to avoid giving new feeding methods (Cups, spoons) when special diet has started POSTOPERATIVE:

Will be in an:

Breakfast Lunch Dinner

C. strained fruit juice

1 serving refined cereal

1 egg

1 slice toast1 tsp. Butter or margarine

Jelly

Heavy cream

Hot beverage

Sugar

Salt

C. strained fruit juice and/or clear broth

2 oz. Meat

c. allowed potato substitute

Crackers1 tsp. butter or margarine

1 serving allowed dessert

Beverage

Sugar

Salt

C. strained fruit juice and/or clear broth

3 oz. Meat

C. allowed potato substitute

C. vegetables juice1 slice bread or roll

1 tsp. butter or margarine

1 serving allowed dessert

Beverage

Sugar

Salt


5/53


6/53



7/53


Nursing Diagnoses Altered tissue perfusion related to excessive bleeding causing fetal compromise

o Interventions: Frequently monitor mother and fetus Administer IVF as prescribed Position on side to promote placental perfusion

Administer O2 as face mask as indicated (8 10 per minute) Fluid volume deficit related to excessive bleedingo Establish and maintain a large-bore IV line, as prescribed and draw blood for type and screen for

blood replacement

o Position in a sitting position to allow weight of fetus to compress the placenta and decreasebleeding

o Maintain strict bed rest during any bleeding episodeo Prepare woman for cesarean deliveryo Administer blood or blood products protocol per institutional policy

Altered tissue perfusion related to excessive bleeding causing fetal compromiseo Frequently monitor mother and fetuso Administer IV fluids as prescribedo Position on side to promote placental perfusiono Administer oxygen as facemask as indicated (8 10 minute)

Risk for infection related to excessive blood losso Use aseptic technique when providing careo Evaluate temperature q4h unless elevated; then evaluate q2ho Evaluate WBC and differential counto Teach perineal care and hand washing techniqueso Assess odor of all vaginal bleeding or lochia

Anxiety related to excessive bleedingo Explain all treatments and procedureo Encourage verbalization of feelings by patient and familyo Provide information on a CS deliveryo Discuss the effects of long-term hospitalization or prolonged bed rest

Impaired fetal gas exchange related to altered blood flow, altered O2-carrying capacity of blood, decreasedsurface area of gas exchange at site of placental attachment

Fear related to outcome of pregnancy after episodes of bleedingo Explain all treatments and procedureo Encourage verbalization of feelings by patient and familyo Provide information on a CS delivery

Risk for deficient diversional activity Risk for deficient fluid volume

Complications Placenta accrete Immediate hemorrhage with possible shock and maternal death Increased risk for anemia secondary to blood loss and infection secondary to invasive procedures to

resolve bleeding Intrauterine growth restriction (IUGR)

Congenital anomalies Fetal mortality resulting from hypoxia in utero and prematurity

Risk Factors Previous placenta previa, delivery, cesarean delivery or abortion Woman who have previous pregnancies, especially a large number of closely spaced pregnancies, are at

higher risk


8/53


Women who have had previous pregnancies, especially a large number of closely spaced pregnancies are athigher risk

Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as theyget older

Women with larger placenta from twins or erythroblastosis are the higher risk Women who smoke or use cocaine may be at higher risk Race if a controversial risk factor, with some studies finding that people from Asia and Africa are at higher

risk and others finding no difference

Medical and Surgical Management Medical Management Surgical Management

IV access Laboratory examinations Blood typing and cross matching Administration of Betamethasone (Celestine)

Amniocentesis CS Section

Signs and Symptoms

CHARACTERISTIC Placenta Previa Abruptio Placenta

Onset Third trimester, commonly at 32weeks

Third trimester

Bleeding Mostly external small to profusein amount

Bright red

May be concealed External dark hemorrhage or

bloody amniotic fluid

Pain and Uterine Tenderness Usually absent Uterus is soft

Usually present Irritable uterus Progresses to board-like

consistency

Fetal Heart Tone Usually normal May be irregular or absent

Presenting Part Usually not engaged May be engaged

Shock Usually not present unlessbleeding is excessive

Moderate to severedepending on extent of

concealed and externalhemorrhage

Delivery Delivery may be delayeddepending on size of fetus and

amount of bleeding

Immediate delivery, usuallyby CS section


9/53


PREGNANCY INDUCED HYPERTENSIONDefinition: A condition in which vasospasms occurs during pregnancy in both small and large arteries Signs and Symptoms:

o Cardinal Signs: (PEH)

Proteinuria Edema Hypertension


10/53


AssessmentClassifications of PIH Gestational Hypertension

o Elevated BP (140/90 mm Hg)o NO PROTEINURIA and EDEMAo No drug therapy is necessary

Mild Pre-eclampsiao Elevated BP (140/90 mm Hg) Taken on 2 occasions 6 hours aparto Proteinuria (1+ or 2+)o Edema develops Due to loss of protein, sodium loss and lowered glomerular filtration rate

May develop into the upper part of the body Weight gain (Indicates abnormal tissue fluid retention):

>2 lb/wk in 2nd trimester

1 lb/wk in 3rd trimester Severe Pre-eclampsia

o Elevated BP (160/110 mm Hg) Taken on 2 occasions 6 hours apart Best position to assess BP (BED REST)

o Proteinuria (+3 or +4 / More than 5 g in a 24-hour sample)o Extensive edema

Palpated over bony surfaces Over tibia on anterior legs

Ulnar surfaces of the forearm

Cheekbones Edema on lower extremities and upper

extremities and face

Cerebral Edema: Visual disturbances (Blurred vision / seeing spots)

Severe head ache / marked hyperreflexia / ankle clonus Eclampsia

o Most severe classification of PIHo Cerebral edema that grand-mal seizure (tonic-clonic) or coma occurso Premature separation of placenta may occur (Abruptio Placenta)

Nursing Diagnoses Ineffective tissue perfusion related to vasoconstriction of blood vessels Deficient fluid volume related to fluid loss to subcutaneous tissue Risk for fetal injury related to reduced placental perfusion secondary to vasospasm Social isolation related to prescribed bed rest

Nursing InterventionsMILD PIH Monitor Antiplatelet Therapy

o Mild Antiplatelet agents: Low-dose aspirin Teach patient to not underestimate taking of aspirin

Promote Bed Resto Position the patient in a RECUMBENT POSITION (Prevents uterine vena cava pressure)

Sodium tends to be excreted faster Bed rest Best method of evacuation of sodium and encouraging diuresis

Promote Good Nutritiono Inform the woman to continue her usual pregnancy nutritiono No sodium restriction is needed, only moderate it

Provide Emotional Supporto Inform the mother of the seriousness of her conditiono Ask if there would be possible family members that can take care of her child (If has)o Make child care arrangements so mother can get rest

Edema Grading:1+ - Can be indented slightly

2+ - Moderate indentation

3+ - Deep indentation

4+ - Indentation remains after removal of finger


11/53


SEVERE PIH Patient is admitted to a health care facility Take amniocentesis to check for fetal lung maturity Support Bed Rest

o Restrict visitorso Minimize loud noises May trigger a seizure initiating eclampsiao

Raise the side rails to prevent injuryo Darken roomo Allow opportunities to express feelings

Monitor Maternal Well-beingo Monitor BP q4 hourso Obtain Blood Studies:

CBC, Platelet Count, Liver Function, BUN, Creatinine (Assess renal and liver function) and; Fibrin Degradation Products (For formation of DIC)

o Assess for premature separation of placentao Obtain daily weights of mothero Assist with insertion of indwelling urinary catheter To monitor I&O (Should be 600 mL/24hrs)

More than 30 ml/hr Monitor Fetal Well-being

o Assess with Doppler Auscultation q4 hourso Assess for non-stress test or biophysical profile done daily (To assess uteroplacental sufficiency)o Give Oxygen to the mother To prevent fetal bradycardia

Support Nutritious Dieto Diet needs moderate-to-high protein and moderate sodium, to compensate for protein lost

Administer Medications to Prevent Eclampsia

Drug Action Nursing Responsibilities

Hydralazine (Apresoline) Labetalol (Normodyne) Nifedipine

Act to lower bloodpressure by peripheral

dilatation

Assess for pulse and BP before andafter administration (Can cause

tachycardia)

Magnesium Sulfate CNS depressant thatblocks neuromuscular

transmission of ACh to

halt convulsions

Also halts premature laboras it relaxes smooth

muscles

Assess for maternal BP and fetal HRcontinuously

Assess for DTR q1-4 hours Monitor I&O (AE: UO)

Assess RR: Should be >12/min Assess LOC Obtain serum magnesium levels q6-8

hours

Keep calcium gluconate available May cause respiratory depression if

given close to birth

ECLAMPSIA Occurs when cerebral irritation from increasing cerebral edema becomes so acute that seizure occurs Can occur up to 48 hours after childbirth Tonic-Clonic Seizures:

o Muscles contract, back arches, arms and legs stiffen and jaw closes abruptly

o Tonic Phase, 20 seconds Respirations halt because her thoracic muscles are held in contractions

o Clonic Phase, 1 minute Bladder and bowel contract and relax, incontinence of urine and feces occur

o PRIORITY CARE: Maintain a patent airway: Oxygen by facemask Prevent aspiration: Turn on side to drain secretions Administer MgSO4 / Diazepam (Valium)

o Assess for O2 Saturation


12/53


o Continuously assess FHR and uterine contractionso Check for vaginal bleeding to detect placental separationo Postictal State

Semicomatose, cannot be roused except by painful stimuli (can initiate another seizure) Assess for premature separation of placenta May start labor, and woman cannot report contractions Keep woman on the side to pool secretions Give nothing to eat or drink Keep noise down Continuously monitor FHT and contractions Check for vaginal bleeding q15 minutes

Birtho If gestational age is >24 weeks, a decision must be made if birth will be madeo Unexplained reason, fetal lung maturity appears to advance rapidly with PIH

May be due to intrauterine stresso Cesarean birth may be hazardous for the fetus Due to retained lung fluid

A woman with eclampsia is not a good candidate for surgery Induction of pregnancy may be initiated if necessary

NURSING INTERVENTIONS DURING POSTPARTUM PERIOD

Postpartum Hypertension may occur up to 10 14 days after birtho May occur no more than 48 hourso Monitor BP and be alert for eclampsiao Urge who have had an elevated BP to return for postpartum check-up

ERYTHROBLASTOSIS FETALISDefinition Also known asHemolytic disease of the newborn It is a disease in the fetus / newborn caused by transplacental transmission of maternal antibody, usually

resulting from maternal and fetal blood group incompatibility

Rh incompatibility develop when a WOMAN who has Rh NEGATIVE blood becomes pregnant by a MANwith Rh NEGATIVE blood and conceives a FETUS with Rh POSITIVE blood

o In other words: () Woman + (+) Man = () Baby RBCs from the fetus leak across the placenta and enters the womans circulation throughout pregnancy with the

greatest transfer occurring at delivery This disease usually occurs greatly in the 2nd baby of the mother

IN SUCCEEDING PREGNANCIES

The antibodies reach the fetus via the placenta and destroy (lyse) the fetal RBCs The resulting anemia may be due to profound that the fetus may die in utero Reacting to the anemia; the fetal bone marrow may release immature RBCs / erythroblasts into the fetal

peripheral circulation causing Erythroblastosis Fetalis

Maternal fetal incompatibility of ABO blood types to neonatal erythroblastosis are less severe and less commonthan those of the Rh factor

2 Types

o Rh Incompatibilityo ABO IncompatibilityMost common

Clinical Manifestations Jaundice serum levels of unconjugated bilirubin (Hyperbilirubinemia) Anemia Due to hemolysis of erythrocytes Hepatosplenomegaly Hydrops Fetalis (Accumulation of fluids in body tissues) Other:


13/53


o level of insulino blood sugar

Nursing Diagnoses Impaired tissue perfusion related to destruction of red blood cells Ineffective family coping related to current condition of new born Risk for CNS involvement related to destruction of red blood cells

Diagnostic Examinations Before birth:

o Check mothers blood typeo For antibody screeningo Indirect Coombs Test = Measures the number of antibodies in the maternal bloodo PUBSo Amniocentesiso Ultrasound

After birth:o CBCo Bilirubin testo Direct Coombs Test = Which may get the level of maternal antibody attached to the babys RBCo Blood typing and Cross Matching

Medications and Treatment


14/53


Aqueous

Humor

Aqueous Humor Flow

Posterior

Chamber

AnteriorChamber

Trabecular

Meshwork

Canal of

Schlemm

Capillary

Network

Episcleral

Veins

Rhogam Given within 72 hours after birtho This immunoglobulin destroys any fetal blood cells in the mother preventing formation of Rh positive

(+) antibodies

o In cases where this precaution is not taken, antibodies are created and future pregnancies may becomplicated

o The preparation must be given after each pregnancy, whether it ends in delivery, or ectopic pregnancy Phototherapy

o Cover eyes to protect sclerao Cover genetaliao Expose entire body and be concerned about hydration of baby

Sensory DisordersGLAUCOMA

Definition: Refers to a group of ocular conditions characterized by OPTIC NERVE DAMAGE The OPTIC NERVE gets damaged due to the increase in IOP; due to the congestion of aqueous humor in the

eyes which may lead to VISION LOSS NOTE: There is NO CURE

NORMAL PHYSIOLOGY

Aqueous humor flows between the IRIS and LENS which nourishes theCORNEA and LENS

Most of the fluid (90%) flows out through the ANTERIOR CHAMBERgoing to TRABECULAR MESHWORK and then to the CANAL OFSCHLEMM

About 10% flows through the CILIARY BODY going to theSUBCHOROIDAL SPACE and then to the VENOUS CIRCULATIONof the CILIARY BODY, CHOROID and SCLERA

IOP is determined by the rate of aqueous humor production N: 10 21 mm Hg

FACTORS that IOP:

- Time of day- Exertion- Diet- Medications- Blinking- Tight lid squeezing- Upward gazing- Diseases: Diabetes, Uveitis, Retinal Detachment


15/53


Refractive Errors Myopia my (Nearsightedness)

Hyperopia hy High (Farsightedness)

Astigmatism Blurred at any distance

Types of Glaucoma1. Open-Angle Glaucoma (Wide Angle Glaucoma)

Unclear Etiology Caused by a in outflow of Aqueous Humor into the Canal of Schlemm Usually affects both eyes (OU) Usually asymptomatic

2. Closed-Angle Glaucoma (Narrow Angle Glaucoma / Acute Angle Closure Glaucoma) Characterized by suddenly impaired vision due to intraocular tension caused by an imbalance in

production and excretion of Aqueous Humor

Results from abnormal displacement of iris against the angle of aqueous chamber Often unilateral, other eye may be affected Emergency treatment if necessary, IOP can exceed 30 mm Hg

3. Secondary Glaucoma Related to conditions that narrow the Canal of Schlemm

PATHOPHYSIOLOGY Theories in how the increase of IOP damages the Retina

Direct Mechanical Theory: IOP damages the retinal layer as it passes through the optic nerve head Indirect Ischemic Theory: IOP compresses the microcirculation in the optic nerve head leading to cell injury

and death


16/53


Clinical Manifestations: Open Angle Glaucoma (Wide Angle Glaucoma)

o Open Angle Glaucoma Mnemonic~ OPEN

O Occasionally sees HALOS AROUND LIGHTS

P Peripheral Vision is gradually lost (Progressive vision loss)

E Early stage is ASYMPTOMATIC

N NOT an EMERGENCYo Usually Bilateralo Slowly progressiveo Signs and Symptoms appear late as:

1. Mild aching in the eye2. Gradual loss of peripheral vision3. Seeing halos around lights4. Visual acuity, especially at night

Narrow Angle Glaucoma (Closed Angle Glaucoma)o Rapid onset, may consult an ophthalmologisto May feel eye pain, nausea and headacheo Vision is blurred and cornea appears bulging and cloudyo Pupil unresponsive to lighto Requires IMMEDIATE Treatment to prevent further damage

Assessment Demographic Profile Family History History of ocular surgeries, infections or trauma History of current medications

Possible Nursing Diagnoses Disturbed sensory perception

o Related to:

Altered sensory reception, Altered status of sense organ ( IOP / atrophy)o Evidenced by:

Progressive loss of visual field Anxiety

o Related to: Change in health status, Presence of pain, Reality of loss of vision, Unmet needs, Negative

self-talk

o Evidenced by: Apprehension, Uncertain and Expressed Concern regarding changes in life

Knowledge deficit Ineffective therapeutic regimen

Diagnostic Tests Tonometry

o Method of measuring the IOP using a calibrated instrument that flattens the corneal apexo Used to check for Glaucomao Performed yearly after 40 years oldo N: IOP = 10 21 mm Hg (Pero sabi sa Brunner 10 20 mm Hg)o Nursing Responsibilities:

Do not rub after procedure Contacts are REMOVED

Ophthalmoscopy


17/53


o Examine external structures and interior of eyes Gonioscopy

o Measures the angle of the anterior chambero Determines whether it is Open Angle Glaucoma or Closed Angle Glaucoma

Slit Lamp Examinationo Examination of anterior ocular structures under micromagnificationo Nursing Responsibilities:

Remove contacts Drops will make eyes blurred (40 minutes 2 hours) Advise to wear dark glasses

Medications B Beta Blockers

o Production of Aqueous Humor (Timolol, Betaxolol)

o Nursing Responsibilities: Contraindicated for patients with Asthma and COPD Assess for Bradycardia

A Anhydrase Inhibitorso Rate of formation of fluids (Acetazolamide)

o Side Effect: Anorexia H Hyperosmotics

o Rate of formation of fluids (Mannitol)

o Nursing Responsibilities: Check for BP Weight daily Monitor Signs and Symptoms of F&E imbalance

M Miotics

o Facilitates outflow of Aqueous Humor (Pilocarpine)o For constriction of pupilso Nursing Responsibility:

Can cause blurring of vision, advise to stop for a while

Surgical Procedures Laser Trabeculoplasty: Use of laser to create an opening in the Trabecular Meshwork to increase the outflow of

Aqueous Humor

Filtering Procedure:o Trephinateo To create an outflow channel from the anterior chamber to subconjunctival spaceo Aqueous humor is absorbed in the conjunctival spaces

Iridotomyo Formation of a new route for the flow of aqueous humor

NURSING RESPONSIBILITIESPRE OP

Prepare patient Explain procedure Waiting period 1 2 hours and WOF in IOP Ask a relative to accompany patient due to IOP

POST OP

Protect eyes from light Monitor frequently IOP


18/53


PATIENT EDUCATION Regular Exercise Medic-alert Card Compensate for reduced vision Stress importance of compliance to medications Read OTC Drugs, can IOP

Review signs and symptoms of infection andIOP

Rationalize for eye shields Avoid rubbing / pressure

CATARACT Definition:

o A cataract is a lens opacity or cloudiness

Clinical Manifestations Painless, blurry vision Dimmer surroundings (As if glasses need cleaning) Reduced contrast sensitivity Sensitivity to glares Visual acuity Myopic Shift (Return of ability to do close work) Astigmatism

Diplopia Color shift Brunescens (Color values shift to yellow-brown)

Assessment and Diagnostic Findings Snellen Visual Acuity Test Ophthalmoscopy Slit-lamp Biomicroscopic Examination

Medical Management

Characteristics of Cataract Cloudy, opaque lens

Acuity

No pain

Occurs gradually

Treatment:

Removal of lens with lens implant


19/53


No surgical treatment cures cataracts or prevents age-related cataracts Meaning SURGICAL INTERVENTION IS NEEDED

Surgical Management If reduced vision from cataract does not interfere with normal activities, surgery may not be needed Done in an outpatient basis and takes less than 1 hour with the patient being discharged 30 minutes or less

afterward

NURSING MANAGEMENT- Provide PreOp Care

1. Withhold anticoagulant 5 7 days before surgery2. Administer dilating drugs 10 minutes before surgery3. Administer antibiotics, corticosteroids, anti-inflammatory drugs, drops may be administered

prophylactically

- Administer mild analgesics PostOp- Administration of antibiotics, corticosteroids, anti-inflammatory drops may be administered PostOp- Provide written instructions for discharge

1. Wear glasses / metal eye shields at all times2. Wash before and after touching the eyes

3. Wipe the closed eyes with a single gesture from the inner to outer canthus4. Avoid lying on the affected side5. Keep activities light6. Avoid bending / lifting, pushing heavier than 15 lbs

REMEMBER:

- Cataract Glasses (Aphakic Glasses) magnify, so that everything appears about closer than it is- Use of contact lenses improves visual correction and better comments appearance- Intraocular Lens Implant

Alteration to cataract glasses and contact lenses

Made from polymethylmethacrylate, is implanted at the time of cataract extraction into the capsularsac

Main advantage of the implanted lens is better binocular vision

Possible Nursing Diagnoses- Disturbed visual sensory perception

Related to: Altered sensory reception, Status of sense organ, Therapeutically restricted environment

(Surgical procedure, patching)

Evidenced by: Diminished acuity, Visual distortions, Change in usual response to stimuli

- Risk for trauma

Risk Factors: Poor vision, Reduced hand/eye coordination

- Anxiety

Related to:

Alteration in visual acuity, Threat to permanent loss of vision Evidenced by:

Expressed concerns, Apprehension, Feelings of uncertainty- Knowledge deficit (Regarding ways of coping with altered abilities, therapy choices, lifestyle changes)

Related to: Lack of exposure/recall, Misinterpretations, Cognitive limitations

Evidenced by: Requests for information, Statement of concern, Inaccurate follow-through of instructions


20/53


RETINAL DETACHMENTDefinition: Refers to the separation of the RPE (Retinal Pigment Epithelium) from the sensory layer

TYPES OF RETINAL DETACHMENT

1. Rhegmatogenous RD Most common Hole or tear develops in the sensory retina Which allows seeping of vitreous liquid through the sensory retina and detach it from the RPE Possibly due to: S/p Cataract surgery, trauma and proliferative retinopathy

2. Traction RD Due to tension or apulling force Formation of fibrous scars on the retina due to conditions like; diabetic retinopathy, vitreous

hemorrhage, or retinopathy of prematurity The hemorrhages and fibrous proliferation exert a pulling force on the delicate retina

3. Combination of Rhegmatogenous and Traction4. Exudative RD

Due to production of serous fluid under the retina from the choroid Possibly due to diseases like; Uveitis and Macular Degeneration

This production of serous fluid detaches the RPE from the sensory layer

Surgical Management Scleral Buckle

o The compression of the sclera to indent the scleral wall from the outside of the eye and bring the tworetinal layers in contact

o Has a high success rate if with a very good surgeon, it causes less damage to the lens of the eye inphakic patients

o SE: Increased chance of Diplopia, induced myopia and postoperative pain


21/53


Pars Plana Vitrectomyo 1 4 mm incisions are made at the pars plana for the introduction of a light source and for the portal of

the vitrectomy instrument

Pneumotaxic Retinopexyo Used for repair of a rhegmatogenous retinal detachmento The most least invasive surgical treatment for retinal detachmento A gas bubble, silicone oil or perfluorocarbon and liquids may be injected in the vitreous cavity which

will help push the sensory retina against the RPE

Transconjunctival Sutureless Vitrectomyo Allows for self-sealing transconjunctival pars plana sclerotomies

Nursing Management Health Education and Supportive Care is the focus for patients with Retinal Detachment Post Operative (Pneumotaxic Retinopexy)

o Prone Position Because the injected bubble must float into a position overlying the area of detachment Which will give consistent pressure to reattach the sensory retina

o Inform patient of possibility of (2) eye patches after surgery Teaching About Complications

o

Advise patient for a follow-up check upo Teach patient signs and symptoms of increased IOP, endophthalmitiso Continuous blurring of vision despite surgeryo Give patients a telephone number of the ophthalmic team in case of emergencies

Possible Nursing Diagnoses Disturbed visual sensory perception

o Related to: Decreased sensory perception

o Evidenced by: Visual distortions Decreased visual field Changes in visual acuity

Knowledge deficit (Therapy, prognosis and or self-care needs)o Related to:

Lack of information/misconceptionso Evidenced by:

Statements of concerns Risk for impaired home maintenance

o Risk Factors: Visual limitations Activity Restrictions

MACULAR DEGENERATIONDefinition:

Characterized by tiny, yellowish spots called drusen beneath the retina Drusen Small clusters of debris or waste materials that lie deep within the RPE and if they are in maculararea, they affect vision

Common among 60 years old or older

SIGNS and SYMPTOMS

Central vision loss (Patients retain peripheral vision) Two Types:

o Dry Type: Non-neovascular, Non-exudative The outer layers of the retina slowly breakdown


22/53


With this breakdown, drusen appears

If it occurs outside the macula, no blurring

If it occurs within the macula, blurringo Wet Type: Neo-vascular, Exudative

Abrupt onset Proliferation of abnormal blood vessels

Report straight lines appear crooked and distorted Letters in words appear broken

Possible leakage of fluid, blood which elevate the retina

Medical Management There is no known cure for Dry Type of MD Administration of large doses of macronutrients Can slow the progression of the disease

o Antioxidants: Vitamin C, Vitamin E and Beta-caroteneo Minerals: Zinc oxide

Antiangiogenic Therapyo Treatment for Wet Type:

Pegaptanib sodium (Macugen)

VEGF (Vascular endothelial growth factor) antagonist Used to inhibit the ability ofVEGF to bind to cellular receptors

Ranibizumab (Lucentis) Designed to bind and inactivate all isoforms of VEGF Via intravitreal once a month

Bevacizumab (Avastin)

Monoclonal antibody, helpful in treatment of neovascular AMD

Nursing Management Instruct patient on how to use the Amsler Grid

Non-ne

ovas

cula

r,

Non

-exu

dativ

e Neovascular,

Exudative


23/53


o To monitor for a sudden onset or distortiono Can help determine the extent of the disease if getting worseo Encourage to look at the grid ONE EYE AT A TIME several times each week with glasses ono If change in the grid has been noticed, INFORM IMMEDIATELY

Neurologic DisordersPARKINSONS DISEASE (PD)Definition: Chronic slowly progressive neurologic movement disorder which leads to disability

Etiology Primary / Idiopathic PD

o Usually develops after age 60o Occurs on both genderso Probable causes are viruses or toxins on cells

Secondary PDo May be due to:

Encephalitis, Trauma, or Vascular Disease Drugs: Phenothiazines (e.g. Chlorpromazine)

Overview of Parkinsons Disease Also known as: Paralysis Agitans


24/53


Progressive neurodegenerative disease:o Progresses in a chronic period of timeo Emotionally incapacitatingo Change in the brain overtime

May be detrimental to the person Functioning of the brain

Debilitating:o Causes physical exhaustion for the persono Affects the emotional, physiological and psychological aspect of a person

Affects motor activity

4 Cardinal Symptoms for Parkinsons Disease (TRAP) T = Tremors (Resting Tremors) Different from MS (Intentional Tremors)

o Disappears with purposeful movemento Evident when motionless (Concentrating, feeling anxious)o Manifested as slow turning motion of forearmo Pill-rolling Motion of hands

R = Rigidity Resistance to passive limb movemento Lead-pipe or Cog-wheel movemento

Stiffness increases when another extremity is doing an actiono Patient complains of shoulder pain due to rigidityo Loss of arm-swinging

A = Akinesia / Bradykinesiao Overall slowing of active movemento Patients have difficulty initiating movement

P = Postural Instabilityo Patient stands with head bent forward and walks with a propulsive gaito Shuffling gait is evident, due to the persons effort to move faster and fastero Stooped posture

OTHER SIGNS and SYMPTOMS

- Mask-like appearance, decrease in blinking reflex- Uncontrolled sweating, paroxysmalflushing, orthostatichypotension, gastric and urinaryretention,

constipation and sexualdysfunction

- Psychiatric Changes:o Depression, Dementia, Delirium and Hallucinations (Auditory and Visual)

- Hypokinesia Abnormally diminished movement that appears after tremors- Micrographia (Small handwriting)- Dysphonia (Soft, slurred, low-pitched and less audible speech)- Dysphagia and drooling

STAGES of Parkinsons DiseaseSTAGE MANIFESTATIONS

Stage I Symptoms on one side of the body

Stage II Symptoms on both sides of the body; no impairment in balance

Stage III Balance impairment, mild to moderate disease; physically independentStage IV Severe disability, but still able to walk/stand unassisted

Stage V Wheel-chair bound/bed-ridden

Assessment and Diagnostic Findings There is no diagnostic procedure that can tell if the patient has Parkinsons Disease, but PET (Positron Emission

Tomography) and SPECT (Single Photon Emission Computed Tomography) can be helpful with the presence

of 2 or more of the cardinal signs and symptoms TRAP


25/53


Medical Management Treatment is directed at controlling symptoms and maintain functional independence Pharmacologic treatment is the mainstay of treatment

Pharmacologic Treatment Antiparkinsonian Drugs

o striatal dopaminergic activityo excessive influence of excitatory cholinergic neurons on the extrapyramidal tract which restores

dopaminergic and cholinergic activities

o Act on neurotransmitter pathways other than the dopaminergic pathway Levodopa (Larodopa)

o Most effective agent and the mainstay of treatment for PDo It is converted to dopamine in the basal ganglia which produces symptom reliefo Adverse Effects: Confusion, hallucinations, depression and sleep alterationso After 5 10 years of drug use:

Dyskinesia (Abnormal involuntary movements)

Facial grimacing

Rhythmic jerking movement of the hands

Head bobbing

Chewing and smacking movements Involuntary movements of the trunk and extremities

On-off Syndrome May occuro Neuroleptic Malignant Syndrome

Characterized by; severe rigidity, stupor and hyperthermia

Surgical Management Stereotactic Procedures

o Thalamotomy and Pallidotomy For patients who have Idiopathic

PD

With maximum doses ofAntiparkinsonian drugs

Done to interrupt the nervepathways which alleviates

tremor and rigidity

Pallidotomy:Destruction of partof the ventral aspect of the

medial globus pallidus which

will reduce rigidity,

bradykinesia and dyskinesia

o Stereotactic Frames will be used after theprocedure to help position the patients

head

Neural Transplantationo Transplantation of porcine neuronal cells,

human fetal cells and stem cells Deep Brain Stimulation

o Pacemakerlike brain implants are used to relieve tremorso A high-frequency electrical impulse is sent through a wire which blocks nerve pathways in the brain

that cause tremors

Nursing ProcessASSESSMENT

ABCDE of Parkinsons Disease MedicationsA = Amantadine (Symmetrel)

Antiviral and Antiparkinsonian Drug

Promotes availability of dopamine in receptor sitesB = Bromocriptine (Parlodel)

Used when Levodopa is already gone/faded away

Mimics effects of dopamine Does not need to be metabolized and converted

C = Carbidopa (Sinemet)

Prevents breakdown of Levodopa

Amino acid decarboxylase inhibitor ( CHON in diet)D = Dopar (Levodopa)

Causes longer periods of remission

AE: Confusion, hallucination, depression and sleepalteration

E = Entacapone (Comtan)

Used in psychiatric patients,

Hypersensitivity: History of MI and CVA

AE: Dystonia, hand tremors

SE: GI Upset


26/53


Observe for: Quality of speech, loss of facial expression, swallowing deficits (Drooling, poor head control, andcoughing), tremors, slowness of movement, weakness, forward posture, rigidity, mental slowness and confusion

POSSIBLE NURSING DIAGNOSES Impaired physical mobility related to muscle rigidity and motor weakness Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor and motor disturbance Constipation related to medication and reduced activity Imbalanced nutrition: less than body requirements, related to tremor, slowness in eating, difficulty in chewing

and swallowing

Impaired verbal communication related to decreased speech volume, slowness of speech, inability to movefacial muscles

Ineffective coping related to depression and dysfunction due to disease progression

PLANNING (MIB-NCC) After ______ of nursing interventions, the patient will be able to:

o Improve functional mobilityo Maintain independence in ADLso Achieve adequate bowel eliminationo Attain and maintaining acceptable nutritional statuso Achieve effective communicationo Develop positive coping mechanisms

NURSING INTERVENTIONS

Improving Mobility Give a progressive program of daily exercise

To increase muscle strength Improve coordination and dexterity Reduce muscular rigidity Prevent contractures

Walking, Stretching and ROM Exercises promote joint flexibility (Yoga, Taichi) Relaxes muscles Collaborating with a Physical Therapist can be helpful in developing an individualized exercise

program

Faithful adherence to an exercise and walking program delays progress of the disease Warm baths and massage Also helps relax muscles and relieve painful muscle spasms Balance may be affected:

Teach special walking techniques to offset shuffling gait Taught to concentrate on walking erect

Watch the horizon and use a WIDE-BASED GAIT Practice with marching music~

Perform breathing exercises while walking (Helps move the rib cage and aerate parts of the lungs Enhancing Self-Care Activities

Environmental modifications (To compensate for disabilities) Adaptive / assistive devices may be useful (Side-rails, overbed frame with trapeze) Collaborate with an Occupational Therapist

Improving Bowel Elimination

Establish a regular bowel routine Increase oral fluid intake (OFI) Eat foods with moderate fiber content DO NOT USE LAXATIVESMay impair the ability of the bowel to sense bowel fullness Raised toilet seat (Due to the difficulty of the patient in moving from a standing-sitting position)

Improving Nutrition Monitor weight on a weekly basis Give supplemental feedings to increase caloric intake An NGT (Nasogastric Tube) or PEG (Percutaneous Endoscopic Gastroscopy) may be inserted Collaborate with a dietitian regarding nutritional needs


27/53


Enhancing Swallowing Inform patient to eat in an upright position to improve swallowing Give a meal with SEMISOLID DIET with THICK LIQUIDS (Avoid THIN LIQUIDS) Inform patient of the Swallowing sequence

Put food on tongue Close lips and teeth Lift the tongue up and then back and SWALLOW

Encourage patient to chew first on one side, then on the other Massaging the face and neck may be beneficial

Encourage the Use of Assistive Devices Use of electric warming tray (To keep food warm) Use of special utensils Stabilized plate with nonspill cups Collaborate with the Occupational Therapist

Improving Communication Make an effort to speak slowly Remind the patient to face the listener, and EXAGGERATE the pronunciation of words Speak in short sentences Take a few deep breaths before speaking Collaborate with a Speech Therapist to help how to fully communicate with patient

Supporting Coping Abilities Help patient set achievable goals

Promoting Home and Community-Based CareTEACHING PATIENTS SELF-CARE- Do not overwhelm patient and family with too much information- Provide a clear explanation of the disease- Goal of assisting the patient to remain functionally independent as long as possible- Teach the side effects of medications and importance of reporting side effects

EVALUATION

MULTIPLE SCLEROSISDefinition: Immune-mediated, progressive demyelinating disease of the CNS Usually affects ages 20 40 years Affects women more than men

Etiology:

Idiopathic Genetics: Presence of Specific cluster (haplotype) oh Human Leukocyte Antigen (HLA) on cell wall Environmental exposures

Clinical Manifestationso Symptoms are mild and patients do not seek much treatment

o Relapsing Remitting (RR) Courseo 80 85% of patientso With each relapse, recovery is complete; however, residual deficits may occur and accumulate over

time which contribute to functional decline

o Primary Progressiveo May result in quadriparesis, cognitive dysfunction, visual loss and brain syndromeso Least common presentation, 5%o Relapses with continuous disabling progression between exacerbations

o Primary Symptoms:


28/53


o Fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance and pain (SIN:Scanning Speech, Intentional Tremors, Nystagmus)

o Visual disturbance: Lesions in optic nerves or their connections Blurring of vision, Diplopia, patchy blindness (scotoma), total blindness

o Fatigue: Most debilitating symptom Factors that exacerbate: Heat, depression, anemia, deconditioning and medications, therefore,

avoid hot temperatures

Effective treatment of depression and anemia and collaborating with PTs and OTs can helpcontrol fatigue

o Pain: Possible isolation Cause of pain is because of lesions on sensory pathways Additional sensory manifestations:

Paresthesias, dysesthesias, and proprioception loss Manage with: Analgesics, opioids, anti-seizure medications, anti depressants

o Spasticity: Muscle Hypertonicity andLoss of abdominal reflexes Due to involvement of main motor pathways (pyramidal tract) of the spinal cord

o Ataxia and Tremor Due to involvement of the cerebellum or basal ganglia

Assessment and Diagnostic Findings MRI: Presence of multiple plaques Electrophoresis of CSF: Presence of oligoclonal banding (Several bands of IgG)


29/53


Medical Management NO CURE EXISTS Only to RELIEVE and PROVIDE SUPPORT Goals of treatment:

o Delay progression of diseaseo Manage chronic symptoms

o Treat acute exacerbations

Pharmacologic Therapy:

DISEASE-MODIFYING THERAPIES

Action:o Reduce frequency of relapseo Reduce duration of relapseo Reduce number and size of plaques on MRI

All are injectables

Medication IM-GM Action Interferon beta-1a (Avonex, Rebif) Rebif administered: SubQ

Avonex administered: IM

SE: Flulike symptoms, liver damage, fetal anomalies, depression

Glatiramir acetate (Copaxone) Reduces rate of relapse in the RR course

Increases the time between relapses

Increases the antigen-specific suppressor T-cells

Administered: SubQ

Takes about 6 months for evidence of immune response Methylprednisolone Key agent for treating acute relapses in RR

Shortens duration of relapses

Exerts anti-inflammatory effects by acting on T cells and cytokines

Administered: IV

SE: Mood swings, weight gain, electrolyte imbalance Mitoxantrone (Novantrone) Reduce frequency of clinical relapses in patients with secondary-

progressive or worsening relapsing-remitting

Administered: IV SE: Cardiac toxicity

SYMPTOM MANAGEMENT THERAPIES

Medication Action Baclofen (Lioresal) Gamma-aminobutyric Acid (GABA) agonist

Medication of choice for SPASTICITY

Administered: Orally / Intrathecal

Benzodiazepines (Valium) Tizanidine (Zanaflex) Dantrolene (Dantrium)

Can also be used to treat SPASTICITY

Amantadine (Symmetrel) Pemoline (Cylert)

Fluoxetine (Prozac)

Used to treat fatigue that interferes with ADLs

Beta-adrenergic Blockers (Inderal) Antiseizure Agents (Neurontin) Benzodiazepines (Klonopin)

Used to treat ataxia

Anticholinergic agents Alpha-adrenergic blockers Antispasmodic agents

Used to treat bladder and bowel problems

Ascorbic Acid (Vitamin C) Used to treat UTI and ACIDIFY urine

Symptoms Needing Immediate Intervention

Spasticity

Fatigue

Bladder dysfunction

Ataxia


30/53


NURSING PROCESSAssessment- Assess for weakness, spasticity, visual impairment, incontinence and difficulty swallowing and in speech

Possible Nursing Diagnoses

Impaired bed and physical mobility related to weakness, muscle paresis, spasticity Risk for injury related to sensory and visual impairment

Impaired urinary and bowel elimination (urgency, frequency, incontinence, constipation) related to nervoussystem dysfunction

Impaired verbal communication and risk for aspiration related to cranial nerve involvement

Disturbed thought process (loss of memory, dementia, euphoria) related to cerebral dysfunction

Ineffective individual coping related to uncertainty of course of MS

Impaired home maintenance management related to physical, psychological, and social limits imposed by MS

Potential for sexual dysfunction related to lesions or psychological reaction

Planning and Goals (MIB-CCMS) After ____ of nursing intervention, the patient will have/be able to:

o Promote physical mobilityo Avoid injuryo Achieve bladder and bowel continenceo Improve cognitive functiono Develop coping strengthso Improve home maintenance managemento Adapt to sexual dysfunction

InterventionsPROMOTING PHYSICAL MOBILITY

Relaxation and coordination exercises Promotes muscle efficiency EXERCISES:

o Walking Improves gaito Instruct that assistive devices are available

MINIMIZING SPASTICITY AND CONTRACTURESo Spasticity:

Characterized by severe adductor spasms of the hips with flexor spasm of the hips and knees Use of warm packs are beneficial, AVOID HOT BATHS

o Contractures: Do daily exercises for muscle stretching Stretch-hold-relax routine

ACTIVITY AND RESTo Encourage to work and exercise to a point just short of fatigueo Take frequent rest periods (Lying down)

MINIMIZING EFFECTS OF IMMOBILITYo Assess and maintain skin integrityo Perform coughing and deep-breathing exercises

PREVENTING INJURY

Teach patient to walk with feet apart To widen the base of support Tell patient to watch feet while walking If loss of position sense occurs Use of assistive devices is available

ENHANCING BLADDER AND BOWEL CONTROL

Categories:o Inability to store urine (Hyperreflexic, uninhibited)


31/53


o Inability to empty bladder (Hyporeflexic, hypotonic)o Mixture of both

Ready the bed-pan near patients bed Establish a voiding time (Every 1.5 2 hours with gradual lengthening of interval) Instruct to drink a measured amount q2 hours and attempt to void Encourage to take prescribed medications Teach how to do intermittent self-catheterization Bowel problems:

o Adequate fluids, dietary fiber and bowel-training program

ENHANCING COMMUNICATION AND MANAGING SWALLOWING DIFFICULTIES

Collaborate with a speech therapist regarding speech and swallowing Have suction apparatus available, careful feeding and proper position the patient when eating

IMPROVING SENSORY and COGNITIVE FUNCTION

Vision

Eye patch / covered eyeglass lens Used to block visual impulses if has Diplopia Prism glasses Difficulty reading in a supine position

Cognition and Emotional Responses

Support of family and friends is a primary need

Instruct patient to remain as active as possibleStrengthening Coping Mechanisms

No two patients with MS have identical symptoms or course of illness Help alleviate anxieties Help define the problem, develop alternatives for management Collaborate with social services, speech therapists, PTs and home maker services if too complex a problem

arises

IMPROVING HOME MANAGEMENT

Other abilities are impossible to regain after they are lost Allow patient to be independent

PROMOTE SEXUAL FUNCTIONING

Collaborate with patient, family and health care for supporting intimacy

Alternatives for methods of sexual expressions

Promoting Home and Community-Based CareTeaching Self Care- Self-care education

o Assistive devices, self-catheterizations, medication administration- Teaching plan about IM or SQ administration

Evaluation


32/53


Endocrine DisordersHYPERTHYROIDISM

Definition: It is the excessive secretion of TH

Affects women more than males Occurs in the ages between 20 and 40 years old

Etiology and Risk Factorso Graves Disease (Toxic, Diffuse Goiter)Most

common form of Hyperthyroidism

o An autoimmune disorder mediated byimmunoglobulin G (IgG) antibody that binds to and

activates TSH receptors

o 3 Principal Hallmarkso Hyperthyroidismo Goiter (Thyroid Gland Enlargement)o Exophthalmos (Abnormal protrusion of eyes)

Clinical ManifestationsAssessment Hyperthyroidism Assessment Goiter / Heart Ds Assessment Exophthalmos Extremely agitated (Irritable) Resting hand tremors Ravenous appetite but still has

weight loss

Loose bowel movements Heat intolerance (Profuse

diaphoresis)

Tachycardia Incoordination

Warm, smooth and moist skin Thin and soft hair Changing moods Fatigue and depression*SEE PATHOPHYSIOLOGY

Enlarged neck Due to hyperplasia and

hypertrophy of thyroid cells

because of the TH release

Heart Disease

Administration of Beta-adrenergic blockers

Occurs due to the autoimmunityagainst retro-orbital tissues

Protruding eyes Fixed stare Gritty sensation in eyes Photophobia Lacrimation Inflammatory changes Dyslogia Impaired ability to

express ideas verbally*Does not regress with therapy

Medical Interventions:

Diuretics Glucocorticoids (Prednisone) Methylcellulose Eye drops Radiation Therapy Surgical Decompression

Nursing Interventions:

Wear dark eye glasses Avoid dust / dirt in eyes

Wear sleeping mask / tape Elevate HOB at night Restrict salt intake

Medical ManagementTo Curtail Excessive Secretion of TH Propylthiouracil (PTU)

o Most commonly used antithyroid medicationo Corrects hyperthyroidism by impairing TH synthesis

Thyroid Storm (Thyrotoxicosis) High fever

Severe tachycardia

Delirium

Dehydration Extreme irritability

Treatment:

Hypothermia blankets

IVF

Suppressing hormone release

Inhibiting hormone synthesis

Blocking conversion of T4 to T3

Inhibiting effects of TH on body tissues

Treating precipitating cause


33/53


o Toxic SE: Agranulocytosis (Deficiency of granulocytes in the blood)o Less Severe SE: Allergies, rash and pruritus

Iodine Therapy:o Given to:

Reduce vascularity of the thyroid gland before subtotal or total thyroidectomy Treat thyroid storm

o Act temporarily to prevent release of TH into the circulation by increasing the amount of TH stored inthe gland

o Must be given only for 10 14 days before surgeryo Iodine Medication of Choice:

Potassium Iodide Lugols Solution

Radioactive Iodine (131I)o For middle-age and older adultso Advantage: Simple to administer and is economical, can be given on an out-patient basiso Action:

Thyroid gland is unable to distinguish between REGULAR IODINE ATOMS andRADIOIODINE ATOMS

If patient receives 131I, thyroid gland picks up RADIOIODINE and concentrate it asREGULAR IODINE

As a result, cells that concentrate 131I to make T4 are destroyed by local irradiationo Manifestations of Hyperthyroidism subside within 6 12 weeks after

Prevent and Treat Complications Adrenergic Blocking Agents (Propranolol)

o Helps lessen manifestations of: Palpitations Tachycardia Tremors and Nervousness

Diet:o High calorie diet (4000 5000 calories)o High protein diet To compensate for hypermetabolic state and prevent a negative nitrogen balance

and weight loss

Nursing ProcessAssessment- Complete History:

o Weight, appetite, activity, heat intolerance and bowel activityo Enlarged thyroid gland (Soft and pulsating, thrill can be palpated, bruit is heard)

- Diagnostic Test:o Based on the symptomso Serum TSH: Decreasedo T4: Increasedo Radioactive Iodine Uptake: Increased

Planning and Goals After ___ of nursing intervention, the patient will have:

o Improved nutritional statuso Improved coping abilityo Improved self-esteemo Maintenance of normal body temperatureo Absence of complications

Nursing Diagnoses and Interventions


34/53


Imbalanced nutrition: less than body requirements related to exaggerated metabolic rate, excessive appetite, andincreased gastrointestinal activity

o Appetite is increased Give several, well-balanced meals of small sizes (6 meals a day)o Diarrhea: Discourage highly seasoned foods and stimulantso Encourage high-calorie, high-protein foodso Give a quiet atmosphere for eatingo Record weight and dietary intake

Ineffective coping related to irritability, hyperexcitability, apprehension and emotional instabilityo Reassure about emotional reactions are because of disorder, can be controlledo Use a calm, unhurried approacho Minimize stressful experiences

Give a private room Minimize noises (Music, conversations, equipment alarms)

o Encourage relaxation techniqueso Repetition of instructions for Preoperative teaching may be required

Low self-esteem related to changes in appearance, excessive appetite and weight losso Nurse conveys an understanding of patients concern about problemso Cover/remove mirrors (If disturbing for the client)o Explain that with effective treatment, symptoms will disappearo If patient is embarrassed with eating large meals, leave the room avoid commenting

Altered body temperatureo Normal room temperature may be too WARMo Maintain environment at a COOL, COMFORTABLE temperatureo Change linens and clothing as neededo Cool baths / cool fluids may give reliefo Explain the reason for discomfort

Surgical InterventionsThyroidectomy Removal of the thyroid gland:

o Total Thyroidectomy To remove completely due to thyroid cancer (Need hormone replacement)o Subtotal Thyroidectomy Removal of 5/6th the gland (Does not need hormone replacement)

Nursing Interventions:

Preoperative Care: Patient is EUTHYROID Manifestations of THYROTOXICOSIS are diminished / absent Client appears RESTED and RELAXED Weight and nutrition are normal (Lost weight was regained) Cardiac problems are under control

Postoperative Care: Assemble needed equipment at bedside

BP Cuff with stethoscope

Additional pillows

Oxygen with suction equipment

Intubation supplies

Tracheostomy Set

Ampules of Calcium Gluconate Monitor and Treat Hypocalcemia

Assess for muscle twitching and hyperirritability

Monitor Chvosteks and Trousseaus Signs

Home Care Instructions Neck Exercises: - Teach client how to support weight of the head and neck when sitting up Medications:

Explain self-administration of thyroid medications Explain lifelong replacement therapy

Follow-up Monitoring: Make an appointment after discharge At least twice a year

Promote Wound Healing Use lanolin or Vitamin E cream to soften wound and minimize scarring


35/53



36/53


CUSHINGS SYNDROME (HYPERCORTISOLISM)Definition: Overactivity of the adrenal glands, hypersecretion of glucocorticoids Occurs more frequently to women (Age 20 and 40 or 60)

Clinical Manifestations1. Central Nervous System:

Emotional lability2. Sleepiness / sleeplessness3. Psychosis4. Skin: Blood vessels become fragile

Easy bruising Straie Poor wound healing Acne Facial hair

5. Cardiovascular System Abnormal sodium and water absorption

(Retention) Hypervolemia = BP and HR Edema

6. Musculo-Skeletal System Muscle weakness Easy fatigability Abnormal absorption of Calcium =

Osteoporosis

7. Abnormal fat metabolism Moon face Buffalo Hump

8. Immune System Immunocompromised

9. Glucose Slow circulation of glucose

Increased due to increased cortisol andgluconeogenesis10. No menstrual flow

Nursing ProcessAssessment History taking

Level of activity Ability to carry out routine and self-care activities

Physical Assessment: Skin: Trauma, infection, breakdown, bruising / edema Changes in physical appearance Responses to the changes are noted

Mental function: Mood, Responses, Awareness, Level ofdepression

Diagnostic Tests CT Scan / MRI = Tumor Blood Culture Urine Specimen Saliva Cortisol Level

Nursing Diagnoses Risk for injury related to weakness Risk for infection related to altered protein metabolism and inflammatory response

Self-care deficit related to weakness, fatigue, muscle wasting and altered sleep patterns Impaired skin integrity related to edema, impaired healing, and thin and fragile skin Disturbed body image related to altered physical appearance, impaired sexual functioning and

decreased activity level

Disturbed thought processes related to mood swings, irritability and depression

Planning and GoalsAfter ____ of nursing intervention, the patient will be able have:

Decreased risk of injury Decreased risk of infection

Mnemonic for

Immunocompromised

Patients

C Cushings Syndrome

A Agranulocytosis

S SteroidsH HIV


37/53


Increased ability to carry out self-care activities Improved skin integrity Improved body image Improved mental function Absence of complications

Interventions Risk for injury related to weakness Establish protective environment (Prevent falls, fractures and other injuries) Give assistance when ambulating Encourage foods high in CHON, Ca and Vitamin D To minimize muscle wasting and

osteoporosis Collaborate with dietitian if necessary

Risk for infection related to altered protein metabolism and inflammatory response Avoid exposure to others with diseases Assess for subtle signs of infection (Anti-inflammatory signs may be masked)

Self-care deficit related to weakness, fatigue, muscle wasting and altered sleep patterns Encourage client to do ADLs Despite weakness, fatigue, and muscle wasting To prevent

complications of immobility

Promote self-esteem Plan and space rest periods throughout the day Promote a relaxing, quiet environment for rest and sleep

Impaired skin integrity related to edema, impaired healing, and thin and fragile skin Give meticulous skin care To avoid traumatizing the patients skin DO NOT USE ADHESIVE TAPES Assess skin and bony prominences Change position of client every 2 hours to prevent skin breakdown

Disturbed body image related to altered physical appearance, impaired sexual functioning anddecreased activity level

Encourage verbalization of feelings by the patient regarding condition they have had Modify weight gain and edema by giving:

LOW CARBOHYDRATE LOW SODIUM

HIGH PROTEIN Disturbed thought processes related to mood swings, irritability and depression

Explain to patient and family about cause of emotional instability Report any psychotic behavior by the patient Encourage further verbalization of feelings by patient and family

Health Teaching Do not let the patient and family abruptly stop the corticosteroid medication Emphasize the need to ensure an adequate supply of corticosteroids Stress the need for dietary modification Teach family on how to take:

Blood pressure Blood glucose levels

Weight

Communicable DiseasesRABIES (HYDROPHOBIA / LYSSA) A specific, acute, viral infection communicated to man by the saliva of an infected animal


38/53

38

ETIOLOGIC AGENT Rhabdovirus (DNA and RNA Creates a protection)

o A bullet-shaped filterable virus with strong affinity for the CNSo Sensitive to sunlight, UV light, ether, formalin, mercury, and nitric acido Resistant to phenol, merthoilate and common antibacterial agents

INCUBATION PERIOD 1 Week 7 Months in Dogs

10 Days 15 Years in Humans

Depends on the following factors1) Distance of the bite to the brain2) Extensiveness of the bite3) Species of the animal4) Richness of the nerve supply5) Resistant to host

PERIOD OF COMMUNICABILITY The client is communicable 3 5 days

BEFORE the onset of the symptoms until the

entire course of illness

CLINICAL MANIFESTATIONS

(3 Phases)1. Prodromal / Invasion Phase

o Fever, anorexia, malaise, sore throat,copious salivation (microorganism

grows and multiplies in the salivary glands), Lacrimation, perspiration, irritability,

hyperexcitability, apprehensiveness, restlessness, drowsiness, mental depression,

melancholia and marked insomnia

o Pain / tingling sensation at original site and different body parts, HA, nauseao Sensitive to light, sound and temperatureo Anesthesia, numbness, burning and cold sensations may be felt along the peripheral

nerves involvedo Mild difficulty in swallowing

2. Excitement or Neurological Phaseo Marked excitability apprehension and even terror may occuro Delirium associated with Nuchal rigidity, involuntary twitching or generalized

convulsions

o Maniacal behavior, eyes are fixed and glossy, skin is cold and clammyo Severe and painful spasms of the muscles of the mouth, pharynx and larynx on attempt to

swallow water or food or even the mere sight of them

(Amygdala Organ for emotion. Pain, fear, climax)

o Aerophobia / fear of air3. Terminal / Paralytic Phase

o Client becomes quiet and unconscious

o Loss of bowel and urinary controlo Spasms cease with progressive paralysiso Tachycardia, labored irregular respirationo Death occurs due to respiratory paralysis, circulatory collapse / heart failure

DIAGNOSTIC PROCEDURES1. Virus Isolation From clients saliva or throat2. Fluorescent Rabies Antibody (FRA) Provides most definitive diagnosis3. Negri Bodies Found in dogs brain

Incubation Period 1 week 8 months (Dog) 1 year 19 years (Man)

Types of Canine Rabies Viruses

1. Furious Type: Tame to wild Frantically runs biting anyone Salivation: Foaming, thick and

sticky

Dog refuses to eat Restless

2. Dumb Type Depressed, dark and quiet Far away look Dropping jaw, hanging tongue Continuously salivating Rejects food Sudden death


39/53


MODALITIES OF TREATMENT1. Wash wounds from bite and scratches with soap and running water for 3 minutes (As FIRST AID)2. Immunization status (Tetanus Toxoid if needed)3. Tetanus antiserum infiltrated around the wound or given IM after a negative (-) skin test4. Anti-rabies vaccine

5. Prepare a Dakins Solution (Bleach)a. Ethanol 70%b. Povidone-Iodine

NURSING MANAGEMENT1. Isolate the patient and LEASH the dog2. Emotional and spiritual support to the client and the family to help them cope with clients

symptoms

3. Optimum comfort4. Darken room and provide quiet environment5. Client should not be bathed, no running water in the room, within the hearing distance of the

patient

6. If IV is given, wrap it!

7. Continuous monitoring of heart and respiration8. Administer:

a. PCEC (Purified Chick Embryo Cell Vaccine)b. PVRV (Purified Vero Cell Rabies Vaccine)

PREVENTION and CONTROL1. Vaccination of all dogs2. Pick-up and DESTRUCTION of stray dogs3. 10 14 Day confinement of dog that bit a person4. Availability of labs5. Providing public education

NURSING DIAGNOSES and INTERVENTIONS

Nursing Diagnosis Nursing InterventionsHyperthermia related to increased metabolic rate,

and increased body temperature as manifested by

complaints of headache and a low-grade fever

Assess VS, note for the value of temperature forbaseline comparison

Perform tepid sponge bath Administer medications to treat underlying cause

(Antibiotics)

Administer replacement fluid and electrolytes tosupport circulating volume and tissue perfusion

Maintain bed rest to reduce metabolic demandsand oxygen consumption

Categories of ExposureCategory I No vaccine needed

Feeding / touching an animal(Wash with soap/water)

Licking of intact skin(No vaccine needed / RIG)

Category II Contact

5 doses (Days)

0, 3, 14, 28 and 30

If S/Sx arise, STOPmedication

Category III

Give RIG

Same management asCategory II

Program Jointly Implemented

By: Department of Agriculture Department of Health Department of Education,

Culture and Sports

Department of Interior andLocal Government and Non-

Government Organizations

REMEMBER: RA 9482


40/53

40

Monitor respirations (WOF: Respiratorydistress)

Acute pain related to biological agents as

manifested by verbal reports of pain in the

abdomen, chest, and changes in muscle tone

Assess clients level of pain (Pain scale) Including PQRST of pain Observe non-verbal cues and other objective

defining characteristics as noted

Monitor skin / color, temperature, check VSwhich are usually altered in acute pain Provide comfort measures:

Providing quiet environment Darken the room Provide calm activities

Encourage relaxation techniques: Deep-breathing Exercises Listening to soft music Guided imagery

Administer analgesics as indicated to maintainacceptable levels of pain

Encourage adequate rest periods to preventfatigue

Evaluate clients response to pain managementImpaired skin integrity Assess blood supply and sensation of affected

areas Assess skin color, texture and turgor Palpate skin lesions for size, shape, consistency,

texture, temperature and hydration

Determine degree / depth / injury damage to theintegumentary system

Monitor progress of wound healing Keep the wound area clean, dry, and carefully

dress the wound

Apply appropriate dressing Avoid use of plastic materials

Remove wet / wrinkled linens promptly


41/53


LEPTOSPIROSIS

(Weils Diseases/Canicola Fever/Hemorrhagic Jaundice/Mud Fever/Swine Herd Disease) Zoonotic infectious bacterial diseases carried by animals, both domestic and wild Water / Food is contaminated by the infected which causes diseases when ingested / inoculated

through the skin

ETIOLOGIC AGENT- Leptospira interrogans Spirochete genus ofLeptospira

INCUBATION PERIOD- 6 15 DAYS

PERIOD OF COMMUNICABILITY Leptospira Urine (10 20 Days after onset)

SOURCE OF INFECTION

Rats L. icterohaemorrhagiae,L. bataviae Dogs L. canicola Mice L. grippotyphosa

MODE OF TRANSMISSION- Direct contact (Skin / mucous membranes) ANIMALS, Human transmission is RARE

Eyes, nose, mouth, semen / breaks in skin

CLINICAL MANIFESTATIONS1. Septic Stage

Febrile (4 7 Days)

Abrupt onset of remittent fever, chills, HA, anorexia

Abdominal pain and severe prostration

Respiratory distress2. Immune or Toxic Stage

With or without Jaundice (4 30 Days)

If SEVERE: Death occurs in 9th 16th Day1. Anicteric Phase (Without Jaundice)

Low-grade fever with rash2. Icteric Phase (With Jaundice)Wet Syndrome

Hepatic and renal manifestations (Prominent)o Oliguria / Anuria


42/53

42

LABORATORY DIAGNOSIS1. BUN and Creatinine2. Agglutination Test done after 2nd /3rd Week

a. Microagglutinationb. Macroagglutinationc. Indirect Hemoagglutination

3. Impaired liver and kidney Tests

ORGANS OF THE BODY INVADED BY THE ORGANISM1. LIVER = After gaining entrance, it multiplies in the bloodstream and invades this organ

causing JAUNDICE (Icteric Gives an orange-colored skin)

2. KIDNEYS = Inflammation of the nephrons and tubular necrosis resulting in RENALFAILURE

3. Leptospira = May affect the muscles, causing PAIN and or EDEMA4. EYES = Conjunctivitis, orange-colored sclera due to Icteric

TREATMENT (MANAGEMENT)1. Medical

a. Suppression of causative agentb. Fighting possible complications

1. Aetiotropic Drugs Penicillin, Doxycycline, Ampicillin, Amoxicillin

Doxycycline 100 mg PO q12 hrs (1 week)2. Peritoneal Dialysis If client has kidney failure3. Administration of F&E and blood as indicated

2. Nursinga. Isolate (Proper disposition of urine)b. Darken room (Irritating to clients eyes)c. Skin care to ease pruritus No ointments on skin, except Calamine Lotiond. Close surveillancee. Keep homes cleanf. Eradicate rats and rodents

g. Health education on modes of transmissionh. Encourage OFI (Oral fluid intake)

PREVENTION and CONTROL1. Sanitation in homes, workplaces and farms2. Need for proper drainage system and control of rodents (40% - 60% infected)3. Animals must be vaccinated (Cattle, dogs, cats and pigs)4. Infected human and pets should be treated5. Information dissemination campaign

NURSING DIAGNOSIS Body image disturbance

High risk for injury

Anxiety Altered nutrition: Less than body requirements

Impaired physical mobility

Impaired skin integrity

Knowledge deficit


43/53


Causative Agent:

Leptospira interrogans

Reservoir:Animals (Rats, Dogs,

Cattle, Livestock)

Portal of Exit:

Urine of infected

Mode of Transmission:

Exposure to the urine

Portal of Entry:

Splashing in eyes

Swallowing of

contaminated waterBite / Wound Breaks

Susceptible Host:

Man

CHAIN OF INFECTION

FOR LEPTOSPIROSIS


44/53

44

Respiratory Disorders

CHRONIC OBSTRUCTIVE PULMONARY

DISEASE (COPD)COPD is Characterized By:

Airflow limitation that is not FULLY REVERSIBLE! :oo ASTHMA IS SEPRATED FROM COPD because it is REVERSIBLE

RECURRENT OBSTRUCTION of airflow in the pulmonary airways Obstruction is usually PROGRESSIVE and May be accompanied by HYPERACTIVITY of GOBLET Cells / mucus secreting cells Problem with lung recoil / chronic inflammation

Mechanism:

Involves multiple pathogenesis

Includes INFLAMMATION and FIBROSIS (Stiffening) of the bronchial wall, hypertrophy of the

submucosal glands and HYPERSECRETION of mucus There is a LOSS OF ELASTIC FIBER and ALVEOLAR tissue

Pathophysiology of COPD

1.2. Chronic Bronchitis

Airway obstruction caused by INFLAMMATION of major or small airway Commonly seen on middle-aged men and associated with chronic irritation and recurrent

infections

Types of COPD1. Emphysema

Characterized by: LOSS of lung elasticity and Abnormal ENLARGEMENT of the air

spaces distal to the terminal bronchioles

with DESTRUCTION of alveolar wall and

capillary beds

Etiology: Smoking

Genetic: Absence of Alpha1 anti-trypsinResponsible for synthesis of ELASTIC

FIBER

PATHOPHYSIOLOGY of Emphysema


45/53


Etiology or Risk Factors: Smoking, Gender, Age Viral / bacterial cause History of recurrent RTI Exposure to irritants

Medical Management Depends on the stage of the disease Administration of PHARMACOLOGIC TREATMENTS

1. Bronchodilators2. Adrenergic Drugs3. Anticholinergics Drugs4. Theophylline5. Corticosteroids

Administer Corticosteroids (Prednisone) Administer Antibiotics (INFECTIONS) Lung resection for distended areas of the lungs

LETS DIFFERENTIATE EMPHYSEMA and CHRONIC BRONCHITIS

Characteristics Emphysema (Pink Puffer) Chronic Bronchitis (Blue Bloater)Smoking Usual Usual

Age of Onset 40 50 30 40Barrel Chest After Maybe present

Weight Loss May be severe / advanced stage Infrequent

SOB Absent in early stage Predominant early sign!!

Breath Sounds Characteristic (Alveolar wall distention) Variable

Wheezing ABSENT Variable

Rhonchi Absent/minimal Other prominent

Sputum May be absent / may develop Frequent early manifestation!!

Cyanosis Advanced stage Often dramatic

Blood Gases Relatively normal until later in the disease Hypercapnia!

Cor Pulmonale Only in advanced stages Frequent in peripheral edema

Polycythemia Advanced cases Frequent

Prognosis Slowly debilitating case Life-threatening due to acute exacerbation

IRREVERSIBLE IRREVERSIBLE


46/53

46

Nursing ProcessAssessment

Health Historyo Exposure to risk factors (Intensity and durations)o Past Medical history (Past respiratory problems/diseases)

o Family history of COPD / other Respiratory diseaseso History of exacerbationso Current medical treatment

Nursing Diagnoses and Interventions with Planning Impaired gas exchange related to decreased ventilation and mucus plugs

o Outcomes: The client will maintain adequate gas exchange evidenced by normal ABGvalues

o Interventions: Monitor respiratory rate, pulse oximetry, ABG and manifestations of

hypoxia/hypercapnia

Administer low-flow O2 therapy (1 3 L/min) Position client: High-fowlers position

Administer medications: Bronchodilators as needed Ineffective airway clearance related to excessive secretions and ineffective coughing

o Outcomes: The client will have improved airway clearance as evidenced by effectingcoughing techniques and a patent airway

o Interventions: Monitor lung sounds q 4 8 hours before and after coughing episodes Encourage drinking 8 10 glasses of water per day Encourage coughing exercises Teach on how to use incentive spirometry 10 times per hour Teach/perform CPT Assess condition of oral mucous membranes Give oral care q 2 hours

Anxiety related to breathing difficulties and fear of suffocation

o Outcomes: The client will express an increase in psychological comfort and demonstrateuse of effective coping mechanisms

o Interventions Remain with client Provide quiet, calm environment Give adequate space during acute episodes (Limit external stimuli) Encourage breathing exercises and relaxation techniques Give sedatives / tranquilizers as needed

Activity intolerance related to inadequate oxygenation and dyspneao Outcomes: The client will have improved activity intolerance as evidenced by

maintaining a realistic activity level

o Interventions: Monitor dyspnea and O2 saturation Stop / slow activities that change respiratory rate Maintain O2 therapy as needed during activity Schedule active exercises after respiratory treatment Avoid activities that increase O2 demand Teach on how to do pursed-lip breathing and diaphragmatic breathing

techniques

Imbalanced nutrition: less than body requirements related to reduced appetite, decreased energylevel and dyspnea

o Outcomes: The client will eat 75% of served foods during the acute phase and maintainbody weight within normal limits and lab values will be within normal values


47/53


o Interventions: Give oral care before meals as needed Advise to eat small, frequent meals (High in CHON and Low in CHO) Advise to avoid gas-producing foods (Beans & Cabbage) Instruct in the use of high calorie liquid supplements Advise to use oxygen via nasal cannula during meals Suggest methods to make meal preparations more convenient Collaborate with dietitian to assist for food choices Monitor food intake, weight and serum hemoglobin

Disturbed sleep pattern related to dyspnea and external stimulio Outcomes: The client will report feeling adequately restedo Interventions:

Promote relaxation by providing a darkened, quiet environment; adequate roomventilation

Schedule care activities Avoid use of sleeping pills

Interrupted family processes related to chronic illness of a family membero Outcomes: The family will verbalize their feelings, participate in the care of the ill family

member, and seek external resources as needed

o Interventions:

Encourage patient in participation of planning process Assess family communication patterns Encourage social support networks

PNEUMONIA- It is an inflammation of the lung parenchyma caused by various microorganisms- Classifications of Pneumonia

o Community Acquired Pneumoniao Hospital Acquired Pneumoniao Aspiration Pneumonia

- It may develop as a primary acute infection / secondary to another respiratory / systemic condition

Community Acquired Pneumonia Occurs in community setting or within the 1st 48 HOURS after hospitalization Commonly causative factors are as follows:

1. S. Pneumoniae2. H. Influenzae3. Legionella4. Pseudomonas Aeruginosa5. Other gram negative rods

Hospital Acquired Pneumonia Nosocomial infection Defined as the onset of pneumonia symptoms more than 48 HOURS after

admission in clients without evidence of infection at the right time of admission

Client in the hospital are exposed to potential bacterial invasion

Aspiration Pneumonia Refers to the pulmonary consequences resulting from entry of endogenous /

exogenous substances into the lower airway

RISK FACTORS

Client with mucous / bronchial obstruction Smoking


48/53

48

Immunocompromised clients Prolonged immobility Depressed cough reflex Incompetent epiglottis Client with NGT, ET Tube, use of suction machine Advanced age Improper isolation technique Systemic infection

PATHOPHYSIOLOGY (OLD)

Cough

Crackle

s

DIAGNOSTIC PROCEDURES

- Chest X-Ray- Sputum / Blood Cultures- Physical Examination

Types of Pneumonia Involving Different Parts of the Lungs

Segmental Pneumonia: One or more lobe segments

Lobar Pneumonia: One or more entire lobes

Bilateral Pneumonia: Lobes in both lungs

Based on Location and Radiologic Appearance Bronchopneumonia (Bronchial Pneumonia): Terminal bronchioles and

alveoli

Interstitial Pneumonia (Reticular Pneumonia): Inflammatory responseswithin lung tissue surrounding air spaces / vascular structures

Alveolar Pneumonia (Acinar Pneumonia): Fluid accumulation in lungsdistal air spaces

Necrotizing Pneumonia: Death of a portion of lung tissue


49/53


Medical ManagementPharmacologic Management

Antibiotic / Anti-infectives Mucolytics Antipyretic Nasal Decongestants Antihistamines

Nursing Management- Assess for SYMPTOMS such as:

o Fevero Chillso Night Sweatso Respiratory Function Use of accessory muscleso Pleuritic-type paino Fatigueo Coughing and Purulent Sputum

RUSTY COLORED SPUTUM Productive COUGH

- Conduct respiratory assessment (q4 Hours)

- For elderly, assess for mental status, dehydration, excessive fatigue and heart failure- For clients with methicillin resistance Methicillin Sensitive Staphylococcus Aureus

(MRSA) Isolated in room, contact precaution

Nursing Responsibility- When transporting, clients must apply appropriate precaution- For VIRAL PNEUMONIA Support Management- Provide Health Education on prevention of pneumonia Vaccine for elderly clients

o Pneumococcal Vaccine (65 Years Old)


50/53

50

Nursing Process:

Nursing Diagnoses and Interventions Ineffective airway clearance related to copious tracheobronchial secretions

Suction clients secretion as needed Encourage water intake (2 3 L/day) Humidified oxygen may help loosen secretions Encourage coughing exercises, deep breathing exercises and diaphragmatic exercises Teach client or significant other about chest physiotherapy

Sputum retention not responding to coughing History of pu

competency appraisal 1 reviewer-1

Documents