dec 2012 nle tips ms (a)

WHAT YOU SHOULD KNOW BEFORE THE PNLE

DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE

PERIOPERATIVE NURSING A. Major Types of Pathologic Process Requiring Surgical Intervention (OPET) Obstruction – impairment to the flow of vital fluids

(blood,urine,CSF,bile) Perforation – rupture of an organ. Erosion – wearing off of a surface or membrane. Tumors – abnormal new growths.

B. Classification of Surgical Procedure According to PURPOSE: Diagnostic – to establish the presence of a disease condition. (

e.g biopsy ) Exploratory – to determine the extent of disease condition ( e.g

Ex-Lap ) Curative – to treat the disease condition.

* Ablative – removal of an organ * Constructive – repair of congenitally defective organ. * Reconstructive – repair of damage organ Palliative – to relieve distressing sign and symptoms, not

necessarily to cure the disease. According to URGENCY

Classification Indication for Surgery

Examples

Emergent – patient requires immediate attention, life threatening condition.

Without delay

- severe bleeding - gunshot/ stab wounds - Fractured skull

Urgent / Imperative – patient requires prompt attention.

Within 24 to 30 hours

- kidney / ureteral stones

Required – patient needs to have surgery.

Plan within a few weeks or

months

- cataract - thyroid d/o

Elective – patient should have surgery.

Failure to have surgery not catastrophic

- repair of scar - vaginal repair

Optional – patient’s decision.

Personal preference

- cosmetic surgery

C. Inform Consent

Purposes: To ensure that the client understand the nature of the

treatment including the potential complications and disfigurement.

To indicate that the client’s decision was made without pressure.

To protect the client against unauthorized procedure. To protect the surgeon and hospital against legal action by a

client who claims that an authorized procedure was performed.

Essential Elements of Informed Consent the diagnosis and explanation of the condition. a fair explanation of the procedure to be done and used and

the consequences. a description of alternative treatment or procedure. a description of the benefits to be expected. material rights if any. the prognosis, if the recommended care, procedure is refused. Requisites for Validity of Informed Consent Written permission is best and legally accepted.

Signature is obtained with the client’s complete understanding of what to occur. - adult sign their own operative permit - obtained before sedation

For minors, parents or someone standing in their behalf, gives the consent. Note: for a married emancipated minor parental consent is not needed anymore, spouse is accepted

For mentally ill and unconscious patient, consent must be taken from the parents or legal guardian

If the patient is unable to write, an “X” is accepted if there is a witness to his mark

Secured without pressure and threat A witness is desirable – nurse, physician or authorized

persons. When an emergency situation exists, no consent is necessary

because inaction at such time may cause greater injury. (permission via telephone/cellphone is accepted but must be signed within 24hrs.)

D. Preoperative Meds. 5A’s Anxiolitics (Tranquilizers & Sedatives) * Diazepam ( Valium ) * Lorazepam ( Ativan ) * Diphenhydramine Analgesics * Nalbuphine ( Nubain ) Anticholinergics * Atropine Sulfate Anti-Ulcer (Proton Pump Inhibitors) * Omeprazole ( Losec ) * Famotidine Antibiotics E. Preoperative Teachings

Incentive Spirometry

Diaphragmatic Breathing

Coughing Turning

Foot and Leg exercise

Teaching should be done morning/afternoon before the day of surgery

Best Method: Return Demonstration

F. The Surgical Team Surgeon • Performance of the operative procedure according to the

needs of the patients. • The primary decision maker regarding surgical technique to

use during the procedure. Assistant Surgeon • Assists with retracting, hemostasis, suturing and any other

tasks requested by the surgeon to facilitate speed while maintaining quality during the procedure.

Anesthesiologist • Selects the anesthesia, administers it, intubates the client if

necessary, manages technical problems related to the administration of anesthetic agents, and supervises the client’s condition throughout the surgical procedure.

Scrub Nurse • Assists with the preparation of the room. • Scrubs, gowns and gloves self and other members of the

surgical team. • Prepares the instrument table and organizes sterile equipment

for functional use. • Assists with the drapping procedure. • Passes instruments to the surgeon and assistants by

anticipating their need. • Counts sponges, needles and instruments. • Keeps track of irrigations used for calculations of blood loss




Circulating Nurse • Responsible and accountable for all activities occurring during

a surgical procedure including the management of personnel equipment, supplies and the environment during a surgical procedure.

• Ensure all equipment is working properly. • Guarantees sterility of instruments and supplies. • Monitor the room and team members for breaks in the sterile

technique. • Handles specimens. • Coordinates activities with other departments, such as

radiology and pathology.

G. Principles of Surgical Asepsis Sterile object remains sterile only when touched by another

sterile object Only sterile objects may be placed on a sterile field

A sterile object or field out of range of vision or an object held below a person’s waist is contaminated

When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action

Fluid flows in the direction of gravity The edges of a sterile field or container are considered to be

contaminated (1 inch) H. PACU/RR Care Maintaining a Patent Airway Assessing Status of Circulatory System Maintaining Adequate Respiratory Function Assessing Thermoregulatory Status Maintaining Adequate Fluid Volume Minimizing Complications of Skin Impairment Maintaining Safety Promoting Comfort I. Parameter for Discharge from PACU/RR Activity. Able to obey commands Respiratory. Easy, noiseless breathing Circulation. BP within 20mmHg of preop level Consciousness. Responsive Color. Pinkish skin and mucus membrane

J. Post Operative Complications

Problem Nursing Intervention

RESPIRATORY

Pneumonia

Deep breathing exercises Coughing exercise Early ambulation

Atelectasis

Deep breathing exercises Coughing exercise Early ambulation

Pulmonary Embolism

Turning Ambulation Anti embolic stockings Compression devises Prevent massaging the lower

extremities CIRCULATION Hypovolemia Fluid and blood replacement Hemorrhage Fluid and blood replacement

Vit.k and hemostat Ligation of bleeders Pressure dressing

Thrombophlebitis

Early ambulation Anti embolic stocking Encourage leg exercise Hydrate adequately Avoid any restricting devices

that impaired circulation Avoid massage on the calf of

the leg Initiate anticoagulant therapy

URINARY Urinary Retention Monitor I & O

Interventions to facilitate voiding

Urinary Catheterization as needed

Urinary Incontinence

Monitor I & O

Urinary Tract Infection

Adequate fluid intake Early ambulation Aseptic catheterization as

needed Good perineal hygiene

GASTRO-INTESTINAL Nausea and Vomiting

IV fluids until peristalsis returns

Progressive diet ( clear liquid then full fluids, soft then regular diet)

Anti emetics as ordered Hiccups NGT insertion as needed

Hold breath while taking a large swallow of water

Breath in and out on a paper bag

Anti emetics as ordered Intestinal Obstruction ( 3rd-5th day postop)

NGT insertion as needed Administered IVF as ordered Prepare for possible surgery

Constipation Adequate hydration High fiber diet Encourage early ambulation

Paralytic Ileus Encourage early ambulation WOUND Wound Infection Keep wound clean and dry

Surgical aseptic technique when changing dressing

Antibiotic therapy Wound Dehiscence

Apply abdominal binders Encourage high protein diet

and Vit.C intake Keep in bed rest

Wound Evisceration Semi-Fowlers, bend knees to relieve tension on the abdominal muscles

Splinting on coughing Cover exposed organ with

sterile , moist saline dressing Reassure, keep him/her quite

and relaxed Prepare for surgery and repair

of wound




ONCOLOGY NURSING A. Benign VS Malignant Neoplasm Characteristic Benign Neoplasm Malignant Neoplasm Speed Growth Grows slowly

Usually continues to grow throughout life unless surgically removed

Usually grows rapidly Tends to grow relentlessly throughout life

Mode of Growth

Grows by enlarging and expanding Always remains localized; never infiltrates surrounding tissues

Grows by infiltrating surrounding tissues May remain localized (in situ) but usually infiltrates other tissues

Capsule Almost always contained within a fibrous capsule Capsule advantageous because encapsulated tumor can be removed surgically

Never contained within a capsule Absence of capsule allows neoplastic cells to invade surrounding tissues Surgical removal of tumor difficult

Cell characteristics

Usually well differentiated

Usually poorly differentiated

Recurrence Unusual when surgically removed

Common following surgery because tumor cells spread into surrounding tissues

Metastasis Never occur Very common Effect of Neoplasm

Not harmful to host unless located in area where it compresses tissue or obstructs vital organs

Always harmful to host Causes disfigurement, disrupted organ function, nutritional imbalances May result in ulcerations, sepsis, perforations,

Prognosis Very good Tumor generally removed surgically

Depends on cell type and speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis

B. Recommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer Beginning at age 20, routinely perform monthly breast self-

examination Women ages 20-39 should have breast examination by a

healthcare provider every 3 years Women age 40 and older should have a yearly mammogram

and breast self-examination by a healthcare provider 2. For detection of colon and rectal cancer All persons age 50 and older should have a yearly fecal occult

blood test Digital rectal examination and flexible sigmoidoscopy should

be done every 5 years Colonoscopy with barium enema should be done every 10

years 3. For detection of uterine cancer

Yearly papanicolao (Pap) smear for sexually active females and

any female over age 18 At menopause, high-risk women should have an endometrial

tissue sample 4. For detection of prostate cancer At age 50, have a yearly digital rectal examination

At age 50, have a yearly prostate-specific antigen (PSA) test C. American Cancer Society’s seven warning signs of cancer (uses acronym CAUTION US): 1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump in breast or elsewhere 5. Indigestions or difficulty in swallowing 6. Obvious change in wart or mole 7. Nagging cough or hoarseness 8. Unexplained Anemia 9. Sudden loss of weight D. Internal Radiation Therapy (Brachytheraphy) Sources of Internal Radiation Implanted into affected tissue or body cavity Ingested as a solution

Injected as a solution into the bloodstream or body cavity

Introduced through a catheter into the tumor

Side Effects

Fatigue Anorexia

Immunosuppression

Other side effects similar to external radiation

Client Education Avoid close contact with others until treatment is completed Maintain daily activities unless contraindicated, allowing for extra

rest periods as needed

Maintain balanced diet Maintain fluid intake ensure adequate hydration (2-3 liters/day)

If implant is temporary, maintain bedrest to avoid dislodging the

implant. Excreted body fluids may be radioactive; double-flush toilets after

use

Radiation therapy may lead to bone marrow suppression

Nursing Management Exposure to small amounts of radiation is possible during close

contact with persons receiving internal radiation: understand the

principles of protection from exposure to radiation: time, distance, and shielding

Time: minimize time spent in close proximity to the

radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift;

Distance: maintain the maximum distance 6 feet possible

from the radiation source Shielding: use lead shields and other precautions to reduce

exposure to radiation

Place client in private room Instruct visitors to maintain at least a distance of 6 feet from the

client and limit visitors to 10-30 minutes

Ensure proper handling and disposal of body fluids, assuring the containers are marked appropriately

Ensure proper handling of bed linens and clothing

In the event of a dislodged implant, use long-handled forceps and

place the implant into a lead container; never directly touch the

implant

Do not allow pregnant woman to come into any contact with radiation




If working routinely near radiation sources, wear a monitoring

device to measure exposure

Educate client in all safety measures

E. External Radiation Therapy (Teletheraphy) The radiation oncologist marks specific locations for radiation

treatment using a semipermanent type of ink

Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7 weeks

The client does not pose a risk for radiation exposure to other people

Side Effects

Tissue damage to target area (erythema, sloughing, hemorrhage) Ulcerations of oral mucous membranes GIT effects such as nausea, vomiting, and diarrhea

Immunosuppression

Client Education Wash the marked area of the skin with plain water only and pat

skin dry; do not use soaps, deodorants, lotions, perfumes, powders

or medications on the site during the duration of the treatment; do not wash off the treatment site marks

Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor

Wear soft, loose-fitting over the treatment area

Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15

Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues

Nursing Management Monitor for adverse side effects of radiation

Monitor for significant decreases in white blood cell counts and platelet counts

Client teaching (refer to later sections for management of immunosuppression, thrombocytopenia

CARDIOVASCULAR NURSING A. Heart Circulation

B. Heart Sound Tricuspid valve (lub) - RT 5th intercostal, medial Mitral valve (lub) - LT 5th intercostal, lateral Aortic semilunar valve (dub) - RT 2nd intercostal Pulmonary semilunar valve (dub) - LT 2nd intercostals

S1 - due to closure of the AV(mitral/tricuspid) valves S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves S3 – Ventricular Diastolic Gallop Mechanism: vibration resulting from resistance to rapid ventricular filling secondary to poor compliance S4 - Atrial Diastolic Gallop

Mechanism: vibration resulting from resistance to late ventricular filling during atrial systole

Heart Murmurs Incompetent / Stenotic Valve Pericardial Friction Rub It is an extra heart sound originating from the pericardial sac Mechanism: Originates from the pericardial sac as it moves Timing: with each heartbeat C. ECG

Cardiac Action Potential Depolarization/Contraction/Systole - electrical activation of

a cell caused by the influx of sodium into the cell while potassium exits the cell

Repolarization/Resting/Diastole - return of the cell to the resting state caused by re-entry of potassium into the cell while sodium exits

D. CARDIAC Proteins and enzymes

a. CK- MB ( creatine kinase) Most cardiac specific enzymes Accurate indicator of myocardial dammage Elevates in MI within 4 hours, peaks in 18 hours and

then declines till 3 days Normal value is 0-7 U/L or males 50-325 mu/ml

Female 50-250 mu/ml b. Lactic Dehydrogenase (LDH)

Most sensitive indicator of myocardial damage Elevates in MI in 24 hours, peaks in 48-72 hours

Return to normal in 10-14 days Normally LDH1 is greater than LDH2

c. Troponin I and T Troponin I is usually utilized for MI Elevates within 3-4 hours, peaks in 4-24 hours and

persists for 7 days to 3 weeks! Normal value for Troponin I is less than 0.6 ng/mL REMEMBER to AVOID IM injections before obtaining

blood sample! Early and late diagnosis can be made!

d. Serum Lipids Lipid profile measures the serum cholesterol,

triglycerides and lipoprotein levels Cholesterol= 200 mg/dL Triglycerides- 40- 150 mg/dL LDH- 130 mg/dL HDL- 30-70- mg/dL NPO post midnight (usually 12 hours)




E. Cardiac Catheterization ( Coronary Angiography / Arteriography ) Insertion of a catheter into the heart and surrounding vessels Is an invasive procedure during which physician injects dye

into coronary arteries and immediately takes a series of x-ray films to assess the structures of the arteries Pretest: Ensure Consent, assess for allergy to seafood and iodine, NPO, document weight and height, baseline VS, blood tests and document the peripheral pulses Intra-test: inform patient of a fluttery feeling as the catheter passes through the heart; inform the patient that a feeling of warmth and metallic taste may occur when dye is administered Post-test: Monitor VS and cardiac rhythm

Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion site

Maintain sandbag to the insertion site if required to maintain pressure

Monitor for bleeding and hematoma formation

F. CVP ( Central Venous Pressure ) Reflects the pressure of the blood in the right atrium. Engorgement is estimated by the venous column that can be

observed as it rises from an imagined angle at the point of manubrium ( angle of Louis).

With normal physiologic condition, the jugular venous column rises no higher than 2-3 cm above the clavicle with the client in a sitting position at 45 degree angle.

NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg To Measure:

Patient should be flat with zero point of manometer at the same level of the RA which corresponds to the mid-axillary

line of the patient or approx. 5 cm below the sternum.

Fluctuations follow patients respiratory function and will fall on inspiration and rise on expiration due to changes in

intrapulmonary pressure.

Reading should be obtained at the highest point of fluctuation.

G. Coronary Arterial Diseases ANGINA PECTORIS 4 E’s of Angina Pectoris Excessive

physical

exertion

Exposure to

cold

environment

Extreme emotional

response

Excessive intake of

foods or

heavy meal

Levine’s Sign: initial sign that shows the hand clutching the chest Chest pain: characterized by sharp stabbing pain located at sub sterna usually radiates from neck, back, arms, shoulder and jaw muscles Dyspnea Tachycardia Palpitations Diaphoresis

Coronary artery bypass surgery Greater and lesser

saphenous veins are

commonly used for

bypass graft procedures

Percutaneuos Transluminal Coronary Angioplasty (PTCA) Mechanical dilation of

the coronary vessel wall by compresing the

atheromatous plaque.

Nursing Management: NTG Tablets(sublingual) Give 3 doses interval of 3-5minutes

ECG: may reveals ST segment depression T wave inversion

Keep the drug in a dry place, avoid moisture and exposure to sunlight

Change stock every 6 months

Offer sips of water before giving sublingual nitrates,

NTG Nitrol or Transdermal patch Avoid placing near hairy

areas as it may decrease drug absorption

Avoid rotating transdermal patches.

Myocardial Infarction (MI) Death of myocardial cells from inadequate oxygenation, often caused by sudden complete blockage of a coronary artery Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation & fibrosis

Chest pain Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles (abdominal ischemia): severe crushing Not usually relieved by rest or by nitroglycerine N/V Dyspnea Increase in blood pressure & pulse Hyperthermia: elevated temp Skin: cool, clammy, ashen Mild restlessness & apprehension ECG: ST segment elevation T wave inversion Widening of QRS complexes

Nursing Management Goal: Decrease myocardial oxygen demand Administer narcotic

analgesic as ordered:

Morphine

Administer oxygen low flow 2-3 L / min

Enforce CBR in semi-fowlers position without bathroom privileges

Instruct client to avoid forms of valsalva maneuver

Monitor urinary output & report output of less than 30 ml / hr: indicates decrease cardiac output

Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac rehab, post CABG & instruct to:

Instruct client to assume a non weight bearing position

Client can resume sexual intercourse: if can climb or use the staircase

The Most Critical Period 6-8 hours because majority of death occurs due to arrhythmia leading to premature ventricular contractions (PVC) *Lidocaine: DOC for arrhythmia

F. Congestive Heart Failure Inability of the heart to pump blood towards systemic circulation I. Left sided heart failure

90% - Mitral valve stenosis

Pulmonary Symptoms

II. Right sided heart failure

Tricuspid valve stenosis Venous congestion symptoms




NURSING MANAGEMENT Goal: increase myocardial contraction Administer medications as ordered

Cardiac glycosides Digoxin *Antidote: Digibind

Loop diuretics Bronchodilators Narcotic analgesics

Morphine sulfate Vasodilators Anti-arrhythmic agents

Administer O2 inhalation at 3-4 L/minute

Restrict Na and fluids

Monitor strictly VS and IO and Breath SoundsWeigh pt daily and assess for pitting edema and abdominal girth daily and notify MD

Provide meticulous skin care

Provide a dietary intake which is low in saturated fats and caffeine

RESPIRATORY NURSING A. Diagnostic Evaluation 1. Skin Test: Mantoux Test or Tuberculin Skin Test This is used to determine if a person has been infected or

has been exposed to the TB bacillus. This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner

aspect of the lower forearm about 4 inches below the elbow. The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is

considered positive

2. Pulse Oximeter Non-invasive method of continuously monitoring he oxygen

saturation of hemoglobin A probe or sensor is attached to the fingertip, forehead,

earlobe or bridge of the nose Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2

3. Chest X-ray This is a NON-invasive procedure involving the use of x-rays

with minimal radiation. The nurse instructs the patient to practice the on cue to

hold his breath and to do deep breathing Instruct the client to remove metals from the chest. Rule out pregnancy first.

4 . Indirect Bronchography A radiopaque medium is instilled directly into the trachea

and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray.

It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis. Nursing Interventions BEFORE Bronchogram Secure written consent Check for allergies to sea foods or iodine or anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4 and valium, topical

anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready.

Nursing Interventions AFTER Bronchogram

Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe client

5. Bronchoscopy This is the direct inspection and observation of the

larynx, trachea and bronchi through a flexible or rigid bronchoscope.

Passage of a lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree. Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process and

collect specimen for biopsy To evaluate bleeding sites To determine if a tumor can be resected surgically

Therapeutic uses To Remove foreign objects from tracheobronchial tree To Excise lesions To remove tenacious secretions obstructing the

tracheobronchial tree To drain abscess To treat post-operative atelectasis

Nursing Interventions BEFORE Bronchoscopy

Informed consent/ permit needed

Explain procedure to the patient, tell him what to expect, to help him cope with the unkown

Atropine (to diminish secretions) is administered one hour before the procedure

About 30 minutes before bronchoscopy, Valium is given

to sedate patient and allay anxiety.

Topical anesthesia is sprayed followed by local

anesthesia injected into the larynx

Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses

The patient is placed supine with hyperextended neck

during the procedure

Nursing Interventions AFTER Bronchoscopy Put the patient on Side lying position

Tell patient that the throat may feel sore with .

Check for the return of cough and gag reflex.

Check vasovagal response. Watch for cyanosis, hypotension, tachycardia,

arrythmias, hemoptysis, and dyspnea. These signs and

symptoms indicate perforation of bronchial tree. Refer the patient immediately!

6. Sputum Examination

Indicated for microscopic examination of the sputum: Gross appearance, Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaou examination

Nursing Interventions:

Early morning sputum specimen is to be collected (suctioning or expectoration)

Rinse mouth with plain water Use sterile container.




Sputum specimen for C&S is collected before the first dose of anti-microbial therapy.

For AFB staining, collect sputum specimen for three consecutive mornings.

6. Pulmonary Function Test / Studies

Non-invasive test Measurement of lung volume, ventilation, and diffusing

capacity

7. Arterial Blood Gas Assessment of arterial blood for tissue oxygenation,

ventilation, and acid-base status Arterial puncture is performed on areas where good pulses

are palpable (radial, brachial, or femoral). Radial artery is the most common site for withdrawal of blood specimen

Nursing Interventions: Utilize a 10-ml. Pre-heparinized syringe to prevent

clotting of specimen Soak specimen in a container with ice to prevent

hemolysis If ABG monitoring will be done, do Allen’s test to assess

for adequacy of collateral circulation of the hand (the ulnar arteries)

8. Thoracentesis Procedure suing needle aspiration of intrapleural fluid or air

under local anesthesia Specimen examination or removal of pleural fluid

Nursing Intervention BEFORE Thoracentesis Secure consent Take initial vital signs Instruct to remain still, avoid coughing during

insertion of the needle Inform patient that pressure sensation will be felt on

insertion of needle

Nursing Intervention DURING the procedure: Reassess the patient Place the patient in the proper position:

Upright or sitting on the edge of the bed Lying partially on the side, partially on the

back

Nursing Interventions after Thoracentesis Assess the patient’s respiratory status Monitor vital signs frequently Position the patient on the affected side, as ordered,

for at least 1 hour to seal the puncture site Turn on the unaffected side to prevent leakage of

fluid in the thoracic cavity Check the puncture site for fluid leakage

Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood

C. Chronic Obstructive Pulmonary Diseases Chronic Bronchitis (Blue Bloaters) Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways

Smoking Air pollution

Consistent productive

cough

Dyspnea on exertion with prolonged

expiratory grunt

Anorexia and

generalized body

malaise

Cyanosis Scattered rales/rhonchi

Bronchial Asthma Reversible inflammatory lung condition caused by hypersensitivity to allergens leading to narrowing of smaller airways

Allergens Cough that is productive

Dyspnea

Wheezing on expiration Tachycardia,

palpitations and

diaphoresis Mild apprehension,

restlessness

Cyanosis

Bronchiectasis Permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the alveolar walls

Recurrent LRTI Congenital disease Presence of tumor Chest trauma

Consistent productive

cough

Dyspnea Presence of cyanosis

Rales and crackles Hemoptysis

Anorexia and

generalized body malaise

Pulmonary Emphysema Terminal and irreversible stage of COPD characterized by : Inelasticity of alveoli

Air trapping

Maldistribution of gasses

Overdistention of thoracic cavity

(Barrel chest)

Smoking Pollution Hereditary Allergy

Productive cough Dyspnea at rest Prolonged expiratory

grunt Resonance to

hyperresonance Decreased tactile

fremitus Decreased breath

sounds Barrel chest Anorexia and

generalized body malaise

Rales or crackles Pursed-lip breathing

Nursing Management: Enforce CBR

Low inflow O2 admin; high inflow will cause respiratory arrest * most accurate: venturi mask

Administer medications as ordered

Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after bronchodilators) Mucolytics/expectorants

Force fluids

Nebulize and suction client as needed

Provide comfortable and humid environment Avoidance of smoking and allergens




C. PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary

consolidation because alveoli is filled with exudates

I. Etioilogic Agent

1. Streptococcus pneumoniae (pneumococcal pneumonia)

2. Hemophilus influenzae (bronchopneumonia) 3. Klebsiella pneumoniae 4. Diplococcus pneumoniae 5. Escherichia coli 6. Pseudomonas aeruginosa

II. Predisposing Factor

1. Smoking 2. Air pollution 3. Immunocompromised

(+) AIDS Kaposi’s Sarcoma Pneumocystis Carinii Pneumonia

DOC: Zidovudine (Retrovir) Bronchogenic Ca

4. Prolonged immobility (hypostatic pneumonia) 5. Aspiration of food (aspiration pneumonia) 6. Over fatigue

III. Signs / Symptoms

1. Productive cough, greenish to rusty 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia, general body malaise 4. Cyanosis 5. Pleuritic friction rub 6. Rales/crackles on auscultation 7. Abdominal distention paralytic ileus

IV. NURSING MANAGEMENT 1. Enforce CBR (consistent to all respi disorders) 2. Strict respiratory isolation 3. Administer medications as ordered

Broad spectrum antibiotics Penicillin – pneumococcal infections Tetracycline Macrolides

Anti-pyretics Mucolytics/expectorants

4. Administer O2 inhalation as ordered 5. Force fluids to liquefy secretions 6. Institute pulmonary toilet – measures to promote

expectoration of secretions DBE, Coughing exercises, CPT

(clapping/vibration), Turning and repositioning

7. Nebulize and suction PRN 8. Place client of semi-fowlers to high fowlers 9. Provide a comfortable and humid environment 10. Provide a dietary intake high in CHO, CHON, Calories

and Vit C 11. Assist in postural drainage

Patient is placed in various position to drain secretions via force of gravity

Usually, it is the upper lung areas which are drained

Nursing management: Monitor VS and BS Best performed before meals/breakfast

or 2-3 hours p.c. to prevent gastroesophageal reflux or vomiting (pagkagising maraming secretions diba? Nakukuha?)

Encourage DBE

Administer bronchodilators 15-30 minutes before procedure

Stop if pt. can’t tolerate the procedure Provide oral care after procedure as it

may affect taste sensitivity Contraindications:

Unstable VS

Hemoptysis

Increased ICP

Increased IOP (glaucoma) 12. Provide pt health teaching and d/c planning

Avoidance of precipitating factors Prevention of complications

Atelectasis Meningitis

Regular compliance to medications Importance of ffup care

HEMATOLOGY NURSING A. Blood Cellular Components RBC * Hemoglobin * Hematocrit

4-6 million/mm3 Ave. 12 - 18 g/dL F: 36-42% M: 42-48%

iron-containing protein of RBC, delivers oxygen to tissue red cell percentage in whole blood

WBC *Neutrophils *Eosinophils *Basophils *Monocytes *Lymphocytes

N = 5,000-10,000/mm3 Most common type of leukocyte but a short lifespan of only 10-12 hours Lifespan= hours to 3 days B Cells T Cells NK Cells

First line of defense, Helpful in localizing the

infection and in immobilizing the pathogens until other WBCs arrive

Allergic Reaction and

Parasitic Invasion they are mediators in

inflammatory process. largest WBC

(macrophage) Antibody response Immunity Anti tumor

Platelets

N = 150-450 thousand mm3

Promotes hemostasis → prevention of blood loss → promote clotting mechanisms




B. Blood Disorder IRON DEFICIENCY ANEMIA (IDA) – chronic microcytic anemia due to inadequate absorption of iron leading to hypoxemic tissue injury

Monitor for signs of bleeding of all hema test including urine, stool and GIT

Enforce CBR so as not to overtire patient Encourage increased iron diet Avoid tannates in tea and coffee Administer medications as ordered Oral iron preparations (300mg OD) NURSING MANAGEMENT

1. Administer with meals to lessen GIT irritation

2. Use straw for liquid form 3. Administer with orange juice or

vitamin C to facilitate absorption 4. Inform client of SE/monitor for

a. Anorexia b. Nausea and vomiting c. Abdominal pain d. Diarrhea/constipation e. Melena

Parenteral Iron Preparations NURSING MANAGEMENT

1. Administer using z-tract method to prevent discomfort, discoloration and leakage

2. Avoid massaging of injection site instead encourage pt. to ambulate to facilitate absorption

3. Monitor SE a. Pain at injection site b. Localized abscess c. Lymphadenopathy d. Fever and chills

APLASTIC ANEMIA – stem cell disorder leading to bone marrow depression pancytopenia (all blood cells decreased) anemia, leucopenia, thrombocytopenia

Enforce complete BR Administer O2 inhalation Reverse isolation Monitor for signs of infection Avoid IM, SQ or any venipuncture sites instruct: use electric razor when shaving Medications as ordered

Immunosuppressants via central

venous catheter

Anti-lymphocyte globulin (ALG) –

given within 6 days – 3 weeks to

achieve maximum therapeutic effect

PERNICIOUS ANEMIA – chronic anemia resulting from deficiency of intrinsic factor leading to hypochlorhydria (decreased HCl secretion);

Headache, dizziness, dyspnea, palpitation,

cold sensitivity, pallor and generalized body malaise

GIT changes: Mouth sores, Red beefy

tongue, Dyspepsia or indigestion, Weight loss, Jaundice

CNS changes – PA is the most dangerous

form of anemia, Tingling sensation, Paresthesia, Ataxia, Psychosis

DIAGNOSTICS SCHILLING’S TEST – indicates decreased reabsorption of vitamin B12; confirms presence of pernicious anemia

NURSING MANAGEMENT Enforce complete bed rest (consistent to

all types of anemia) Administer Vit B12 injections at

MONTHLY intervals for lifetime as ordered; common site: dorso and ventrogluteal, no drug toxicity because it

is water soluble and is easily excretable; oral forms might develop tolerance.

Increase caloric intake, CHON, CHO, Fe, Vit C

Encourage client to use soft bristled toothbrush and avoid irritating mouthwashes (remember there are mouthsores!)

Avoid heat application (there is numbness remember?) may lead to burns

GUT NURSING A. Causes of Acute Renal Failure

Acute Renal Failure Chronic Renal Failure Sudden inability of the kidneys to excrete nitrogenous waste products, leads to azotemia STAGES

Oliguric phase – passage of urine (1-2 weeks) UO: <400 ml/cc

Hyperkalemia

Hypernatremia Hyperphosphatemia

HYPOCALCEMIA

Hypermagnesemia Metabolic acidosis

Elevated BUN, Crea

Diuretic Phase (2-3 weeks) Increased passage of

urine Hyperkalemia

Hyponatremia

Metabolic acidosis

Convalescent phase (3-12 months) Improvement in

passage of urine Characterized by

complete diuresis

Irreversible loss of kidney function

PREDISPOSING FACTORS DM and HPN (common

causes)

Recurrent pyelonephritis

Exposure to renal toxins

Tumor

STAGES Diminished renal reserve

volume – asymptomatic,

normal BUN and CREA Renal insufficiency

End-stage renal disease

(ESRD) – presence of oliguria, azotemia




NURSING MANAGEMENT ARF/CRF Enforce CBR

Admin oxygen inhalation as ordered

High CHO diet low CHON, fats, High vit and minerals Provide meticulous skin care

Wash with warm water

Soap irritates and dries skin Meds as ordered

anti-HPN agents Hydralazine (appresoline)

SE: orthostatic hypotension NaHCO3 Kayexelate enema Hematinics Antibiotics Supplementary vitamins and minerals Phosphate binders Calcium gluconate

B. Nursing Management on Hemodialysis

Secure consent and explain procedure to client Maintain strict aseptic technique Obtain baseline data – before and q30 during

procedure VS Wt Blood exams – secure all pre-procedure I/O

Have client void pre-procedure Inform pt about bleeding (blood is heparinized) Monitor for signs of complications (BEDSSH)

Bleeding Embolism DISEQUILIBRIUM SYNDROME – results from rapid

loss of nitrogenous waste products particularly UREA from the brain

HPN

Disorientation – initial sign

Nausea and vomiting

Anorexia

Headache

Paresthesia, peripheral

Numbness Septicemia Shock Hepatitis Avoid BP taking, phlebotomy, IV meds at the site of

fistula, blood extraction to prevent compression Maintain patency of shunt/fistula:

Palpate for thrills, auscultate for bruits Instruct that minimal bleeding is expected since blood

is heparinized Avoid use vasodilators, sedatives, and tranquilizers to

prevent hypotension unless ordered Prepare at bedside bulldog clips to prevent embolism Auscultate for bruits and palpate for thrills (if (+)

patent)

ENDOCRINE NURSING A. Thyroid Gland Disorders

HYPOTHYROIDISM HYPERTHYROIDSM Decreased T3 and T4 Increased T3 and T4 Early Signs 1. Weakness and fatigue 2. Loss of appetite but

(+) weight gain d/t increased lipolysis

3. Dry skin 4. Cold intolerance 5. Constipation 6. Menorrhagia Late Signs 1. Brittleness of hair 2. Non-pitting edema 3. Hoarseness of voice 4. Decreased libido 5. Decreased VS 6. CNS changes

a. Lethargy b. Memory

impairment c. Psychosis

1. Hyperphagia – increased appetite

2. (+) weight loss d/t increased metabolism

3. heat intolerance 4. moist skin 5. diarrhea 6. increased VS 7. CNS changes

a. Irritability b. agitation c. Tremors d. Restlessness e. Insomnia f. Hallucinations

8. Goiter 9. Exophthalmos 10. Amenorrhea

1. Monitor STRICTLY VS, IO to determine presence of MYXEDEMA COMA a complication of severe hypothyroidism characterized by: a. Severe

hypotension b. Bradycardia c. Bradypnea d. Hypoventilation e. Hypoglycemia f. Hyponatremia g. Hypothermia

2. Administer isotonic fluids as ordered

3. Administer medications as ordered – thyroid hormones or agents (may cause insomnia and heat intolerance)

4. Provide dietary intake low in calories to prevent weight gain

5. Institute meticulous skin care

6. Provide comfortable and warm environment

7. Forced fluids

1. Monitor VS and IO strictly to determine presence of THYROID STORM/Crisis

2. Administer medications as ordered

a. Anti-Thyroid Agents: PTU toxic effects is AGRANULOCYTOSIS fever and chills, sore throat (throat CS pls!), LEUKOCYTOSIS (CBC pls!)

b. Methimazole (Tapazole)

3. High calorie diet to correct weight loss

4. Provide comfortable and cool environment

5. Institute meticulous skin care

6. Maintain side rails 7. Bilateral eye patch to

prevent drying of eyes 8. Assist in surgical

procedure: subtotal thyroidectomy

PRE-OP Administer lugol’s solutions/ SSRI to promote decreased vasculature and promote atrophy of the thyroid gland to prevent/minimize bleeding and hemorrhage POST-OP WOF signs of THYROID STORM agitation, hyper-thermia, HPN. If (+) thyroid storm: administer anti-pyretics and beta-blockers; VS, IO and NVS strictly, siderails up, provide hypothermic blanket WOF: inadvertent or accidental removal of




parathyroid gland hypocalcemia or tetany [(+) trousseu’s signs, (+) chvostek’s Give Ca Gluc slowly to prevent arrhythmia and arrest WOF accidental laryngeal nerve damage hoarness of voice instruct client to talk immediately post-op if (+) notify MD WOF signs of bleeding (+) feeling of fullness at incision site, (+) soiled dressings at back or nape area, notify MD WOF signs of laryngeal spasm DOB and SOB prep trache set 9. Hormonal Replacement

therapy for life 10. importance of FFup care 11. wearing of medic-alert

bracelet B. Insulin Therapy I. Types of Insulin

A. Rapid (SAI) – clear, peak: 2-4 hours , Regular insulin B. Intermediate AI – NPH (Non-Protamine Hagedorn) –

cloudy, peak : 6-12 hours C. Long AI – Ultra lente – cloudy, peak 12-24 hours

II. Nursing Management

A. Administer insulin at room temp to prevent lipodystrophy atrophy/hypertrophy of SQ tissue

B. Insulin only refrigerated once opened C. Avoid shaking insulin, roll between palms only D. Accuracy of administration is important E. Rotate insulin sites to prevent lipodystrophy F. Use short bore needle gauge 25-26 G. No need to aspirate H. Administer insulin 45/90 degrees angle depending on

amount to pt’s SQ tissue I. Most accessible route: abdomen J. Aspirate CLEAR before CLOUDY to prevent

contamination and promote accurate calibration K. Monitor for local complications:

1. Allergic reactions 2. Lipodystrophy 3. SOMOGYI’S PHENOMENON – rebound effect of insulin

characterized by hypoglycemia, hyperglycemia

dec 2012 nle tips ms (a)

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