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Dec 2012 NLE TIPS MS (A)

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  • 1. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)PERIOPERATIVE NURSING Signature is obtained with the client’s complete understanding of what to occur.A. Major Types of Pathologic Process Requiring Surgical - adult sign their own operative permitIntervention (OPET) - obtained before sedation Obstruction – impairment to the flow of vital fluids For minors, parents or someone standing in their behalf, (blood,urine,CSF,bile) gives the consent. Note: for a married emancipated minor Perforation – rupture of an organ. parental consent is not needed anymore, spouse is accepted Erosion – wearing off of a surface or membrane. For mentally ill and unconscious patient, consent must be Tumors – abnormal new growths. taken from the parents or legal guardian If the patient is unable to write, an “X” is accepted if there is aB. Classification of Surgical Procedure witness to his mark Secured without pressure and threatAccording to PURPOSE: A witness is desirable – nurse, physician or authorized Diagnostic – to establish the presence of a disease condition. ( persons. e.g biopsy ) When an emergency situation exists, no consent is necessary Exploratory – to determine the extent of disease condition ( e.g because inaction at such time may cause greater injury. Ex-Lap ) (permission via telephone/cellphone is accepted but must be Curative – to treat the disease condition. signed within 24hrs.) * Ablative – removal of an organ * Constructive – repair of congenitally D. Preoperative Meds. 5A’s defective organ. Anxiolitics (Tranquilizers & Sedatives) * Reconstructive – repair of damage organ * Diazepam ( Valium ) Palliative – to relieve distressing sign and symptoms, not * Lorazepam ( Ativan ) necessarily to cure the disease. * Diphenhydramine AnalgesicsAccording to URGENCY * Nalbuphine ( Nubain ) Anticholinergics Classification Indication for Examples * Atropine Sulfate Surgery Anti-Ulcer (Proton Pump Inhibitors)Emergent – patient - severe * Omeprazole ( Losec )requires immediate Without delay bleeding * Famotidineattention, life threatening - gunshot/ stab Antibioticscondition. wounds - Fractured skull E. Preoperative TeachingsUrgent / Imperative – Within 24 to 30 - kidney /  Incentive Spirometrypatient requires prompt hours ureteral stones  Diaphragmatic Breathingattention.  CoughingRequired – patient Plan within a - cataract  Turningneeds to have surgery. few weeks or - thyroid d/o  Foot and Leg exercise months Teaching should be done morning/afternoon before the day ofElective – patient should Failure to have - repair of scar surgeryhave surgery. surgery not - vaginal repair Best Method: Return Demonstration catastrophicOptional – patient’s Personal - cosmetic F. The Surgical Teamdecision. preference surgery Surgeon • Performance of the operative procedure according to theC. Inform Consent needs of the patients. Purposes: • The primary decision maker regarding surgical technique to To ensure that the client understand the nature of the use during the procedure. treatment including the potential complications and Assistant Surgeon disfigurement. • Assists with retracting, hemostasis, suturing and any other To indicate that the client’s decision was made without tasks requested by the surgeon to facilitate speed while pressure. maintaining quality during the procedure. To protect the client against unauthorized procedure. Anesthesiologist To protect the surgeon and hospital against legal action by a • Selects the anesthesia, administers it, intubates the client if client who claims that an authorized procedure was necessary, manages technical problems related to the performed. administration of anesthetic agents, and supervises the client’s condition throughout the surgical procedure. Essential Elements of Informed Consent Scrub Nurse  the diagnosis and explanation of the condition. • Assists with the preparation of the room.  a fair explanation of the procedure to be done and used and • Scrubs, gowns and gloves self and other members of the the consequences. surgical team.  a description of alternative treatment or procedure. • Prepares the instrument table and organizes sterile equipment  a description of the benefits to be expected. for functional use.  material rights if any. • Assists with the drapping procedure.  the prognosis, if the recommended care, procedure is refused. • Passes instruments to the surgeon and assistants by anticipating their need. Requisites for Validity of Informed Consent • Counts sponges, needles and instruments. Written permission is best and legally accepted. • Keeps track of irrigations used for calculations of blood lossPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 2. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)Circulating Nurse Thrombophlebitis Early ambulation• Responsible and accountable for all activities occurring during Anti embolic stocking a surgical procedure including the management of personnel Encourage leg exercise equipment, supplies and the environment during a surgical Hydrate adequately procedure. Avoid any restricting devices• Ensure all equipment is working properly. that impaired circulation• Guarantees sterility of instruments and supplies. Avoid massage on the calf of• Monitor the room and team members for breaks in the sterile the leg technique. Initiate anticoagulant therapy• Handles specimens. URINARY• Coordinates activities with other departments, such as Urinary Retention Monitor I & O radiology and pathology. Interventions to facilitate voidingG. Principles of Surgical Asepsis Urinary Catheterization as needed Sterile object remains sterile only when touched by another Urinary Monitor I & O sterile object Incontinence Only sterile objects may be placed on a sterile field Urinary Tract Adequate fluid intake A sterile object or field out of range of vision or an object held Infection Early ambulation below a person’s waist is contaminated When a sterile surface comes in contact with a wet, Aseptic catheterization as contaminated surface, the sterile object or field becomes needed contaminated by capillary action Good perineal hygiene Fluid flows in the direction of gravity GASTRO-INTESTINAL The edges of a sterile field or container are considered to be Nausea and IV fluids until peristalsis contaminated (1 inch) Vomiting returns Progressive diet ( clear liquidH. PACU/RR Care then full fluids, soft then regular diet) Maintaining a Patent Airway Anti emetics as ordered Assessing Status of Circulatory System Hiccups NGT insertion as needed Maintaining Adequate Respiratory Function Hold breath while taking a Assessing Thermoregulatory Status large swallow of water Maintaining Adequate Fluid Volume Breath in and out on a paper Minimizing Complications of Skin Impairment bag Maintaining Safety Anti emetics as ordered Promoting Comfort Intestinal NGT insertion as needed Obstruction Administered IVF as orderedI. Parameter for Discharge from PACU/RR ( 3rd-5th day postop) Prepare for possible surgery Constipation Adequate hydration Activity. Able to obey commands High fiber diet Respiratory. Easy, noiseless breathing Encourage early ambulation Circulation. BP within 20mmHg of preop level Paralytic Ileus Encourage early ambulation Consciousness. Responsive WOUND Color. Pinkish skin and mucus membrane Wound Infection Keep wound clean and dryJ. Post Operative Complications Surgical aseptic technique when changing dressing Problem Nursing Intervention Antibiotic therapy Wound DehiscenceRESPIRATORY Apply abdominal binders Encourage high protein dietPneumonia Deep breathing exercises and Vit.C intake Coughing exercise Keep in bed rest Early ambulation Wound Evisceration Semi-Fowlers, bend knees toAtelectasis Deep breathing exercises relieve tension on the Coughing exercise abdominal muscles Early ambulation Splinting on coughingPulmonary Turning Cover exposed organ withEmbolism Ambulation sterile , moist saline dressing Anti embolic stockings Reassure, keep him/her quite Compression devises and relaxed Prevent massaging the lower Prepare for surgery and repair extremities of woundCIRCULATIONHypovolemia Fluid and blood replacementHemorrhage Fluid and blood replacement Vit.k and hemostat Ligation of bleeders Pressure dressingPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 3. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)ONCOLOGY NURSING  Yearly papanicolao (Pap) smear for sexually active females and any female over age 18A. Benign VS Malignant Neoplasm  At menopause, high-risk women should have an endometrial tissue sampleCharacteristic Benign Neoplasm Malignant NeoplasmSpeed Growth Grows slowly Usually grows rapidly 4. For detection of prostate cancer Usually continues Tends to grow relentlessly  At age 50, have a yearly digital rectal examination to grow throughout throughout life  At age 50, have a yearly prostate-specific antigen (PSA) test life unless surgically removed C. American Cancer Society’s seven warning signs of cancerMode of Grows by enlarging Grows by infiltrating (uses acronym CAUTION US):Growth and expanding surrounding tissues 1. Change in bowel or bladder habits Always remains May remain localized (in 2. A sore that does not heal localized; never situ) but usually infiltrates 3. Unusual bleeding or discharge infiltrates other tissues 4. Thickening or lump in breast or elsewhere surrounding 5. Indigestions or difficulty in swallowing tissues 6. Obvious change in wart or moleCapsule Almost always Never contained within a 7. Nagging cough or hoarseness contained within a capsule fibrous capsule Absence of capsule allows 8. Unexplained Anemia Capsule neoplastic cells to invade 9. Sudden loss of weight advantageous surrounding tissues because Surgical removal of tumor D. Internal Radiation Therapy (Brachytheraphy) encapsulated difficult tumor can be Sources of Internal Radiation removed surgically  Implanted into affected tissue or body cavityCell Usually well Usually poorly  Ingested as a solutioncharacteristics differentiated differentiated  Injected as a solution into the bloodstream or body cavity  Introduced through a catheter into the tumorRecurrence Unusual when Common following surgery Side Effects surgically removed because tumor cells spread  Fatigue into surrounding tissues  AnorexiaMetastasis Never occur Very common  ImmunosuppressionEffect of Not harmful to host Always harmful to host  Other side effects similar to external radiationNeoplasm unless located in Causes disfigurement, area where it disrupted organ function, Client Education compresses tissue nutritional imbalances  Avoid close contact with others until treatment is completed or obstructs vital May result in ulcerations,  Maintain daily activities unless contraindicated, allowing for extra organs sepsis, perforations, rest periods as neededPrognosis Very good Depends on cell type and  Maintain balanced diet Tumor generally speed of diagnosis  Maintain fluid intake ensure adequate hydration (2-3 liters/day) removed surgically Poor prognosis if cells are  If implant is temporary, maintain bedrest to avoid dislodging the poorly differentiated and implant. evidence of metastatic  Excreted body fluids may be radioactive; double-flush toilets after spread exists use Good prognosis indicated if  Radiation therapy may lead to bone marrow suppression cells still resemble normal cells and there is no Nursing Management evidence of metastasis  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,B. Recommendations of the American Cancer Society for Early and shieldingCancer Detection  Time: minimize time spent in close proximity to the1. For detection of breast cancer radiation source; a common standard is to limit contact time  Beginning at age 20, routinely perform monthly breast self- to 30 minutes total per 8-hour shift; examination  Distance: maintain the maximum distance 6 feet possible  Women ages 20-39 should have breast examination by a from the radiation source healthcare provider every 3 years  Shielding: use lead shields and other precautions to reduce  Women age 40 and older should have a yearly mammogram exposure to radiation and breast self-examination by a healthcare provider  Place client in private room  Instruct visitors to maintain at least a distance of 6 feet from the2. For detection of colon and rectal cancer client and limit visitors to 10-30 minutes  All persons age 50 and older should have a yearly fecal occult  Ensure proper handling and disposal of body fluids, assuring the blood test containers are marked appropriately  Digital rectal examination and flexible sigmoidoscopy should  Ensure proper handling of bed linens and clothing be done every 5 years  In the event of a dislodged implant, use long-handled forceps and  Colonoscopy with barium enema should be done every 10 place the implant into a lead container; never directly touch the years implant  Do not allow pregnant woman to come into any contact with3. For detection of uterine cancer radiationPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 4. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) If working routinely near radiation sources, wear a monitoring B. Heart Sound device to measure exposure  Tricuspid valve (lub) - RT 5th intercostal, medial Educate client in all safety measures  Mitral valve (lub) - LT 5th intercostal, lateral  Aortic semilunar valve (dub) - RT 2nd intercostalE. External Radiation Therapy (Teletheraphy)  Pulmonary semilunar valve (dub) - LT 2nd intercostals The radiation oncologist marks specific locations for radiation S1 - due to closure of the AV(mitral/tricuspid) valves treatment using a semipermanent type of ink S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves Treatment is usually given 15-30 minutes per day, 5 day per S3 – Ventricular Diastolic Gallop week, for 2-7 weeks Mechanism: vibration resulting from resistance to rapid The client does not pose a risk for radiation exposure to other ventricular filling secondary to poor compliance people S4 - Atrial Diastolic Gallop Mechanism: vibration resulting from resistance to lateSide Effects ventricular filling during atrial systole  Tissue damage to target area (erythema, sloughing, hemorrhage) Heart Murmurs  Ulcerations of oral mucous membranes  Incompetent / Stenotic Valve  GIT effects such as nausea, vomiting, and diarrhea Pericardial Friction Rub  Immunosuppression  It is an extra heart sound originating from the pericardial sac  Mechanism: Originates from the pericardial sac as it movesClient Education  Timing: with each heartbeat Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders C. ECG 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 Cardiac Action Potential promoting health and repair of normal tissues  Depolarization/Contraction/Systole - electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cellNursing Management  Repolarization/Resting/Diastole - return of the cell to the Monitor for adverse side effects of radiation resting state caused by re-entry of potassium into the cell Monitor for significant decreases in white blood cell counts while sodium exits and platelet counts Client teaching (refer to later sections for management of D. CARDIAC Proteins and enzymes immunosuppression, thrombocytopenia a. CK- MB ( creatine kinase)  Most cardiac specific enzymesCARDIOVASCULAR NURSING  Accurate indicator of myocardial dammage  Elevates in MI within 4 hours, peaks in 18 hours andA. Heart Circulation 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)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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 5. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)E. Cardiac Catheterization ( Coronary Angiography /  Keep the drug in a dryArteriography ) ECG: may reveals place, avoid moisture Insertion of a catheter into the heart and surrounding vessels ST segment and exposure to sunlight Is an invasive procedure during which physician injects dye depression  Change stock every 6 into coronary arteries and immediately takes a series of x-ray T wave inversion months films to assess the structures of the arteries  Offer sips of water Pretest: Ensure Consent, assess for allergy to seafood and before giving sublingual iodine, NPO, document weight and height, baseline VS, blood nitrates, tests and document the peripheral pulses Intra-test: inform patient of a fluttery feeling as the catheter NTG Nitrol or passes through the heart; inform the patient that a feeling of Transdermal patch warmth and metallic taste may occur when dye is  Avoid placing near hairy administered areas as it may decrease Post-test: Monitor VS and cardiac rhythm drug absorption Monitor peripheral pulses, color and warmth and sensation of  Avoid rotating the extremity distal to insertion site transdermal patches. Maintain sandbag to the insertion site if required to maintain Myocardial Chest pain Nursing Management pressure Infarction Usually radiates Goal: Decrease myocardial Monitor for bleeding and hematoma formation (MI) from neck, back, oxygen demand shoulder, arms,F. CVP ( Central Venous Pressure ) Death of jaw & abdominal  Administer narcotic Reflects the pressure of the blood in the right atrium. myocardial muscles analgesic as ordered: Engorgement is estimated by the venous column that can be cells from (abdominal Morphine observed as it rises from an imagined angle at the point of inadequate ischemia): severe  Administer oxygen low manubrium ( angle of Louis). oxygenation, crushing flow 2-3 L / min With normal physiologic condition, the jugular venous column often caused  Enforce CBR in semi- rises no higher than 2-3 cm above the clavicle with the client in by sudden Not usually fowlers position without a sitting position at 45 degree angle. complete relieved by rest or bathroom privileges blockage of a by nitroglycerine  Instruct client to avoid coronary forms of valsalva artery N/V maneuver Dyspnea  Monitor urinary output Characterized Increase in blood & report output of less by localized pressure & pulse than 30 ml / hr: formation of Hyperthermia: indicates decrease necrosis elevated temp cardiac output (tissue Skin: cool, clammy,  Resumption of ADL destruction) ashen particularly sexual NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg with Mild restlessness intercourse: is 4-6 weeks To Measure: subsequent & apprehension post cardiac rehab, post  Patient should be flat with zero point of manometer at the healing by CABG & instruct to: same level of the RA which corresponds to the mid-axillary scar formation ECG:  Instruct client to assume line of the patient or approx. 5 cm below the sternum. & fibrosis ST segment a non weight bearing  Fluctuations follow patients respiratory function and will elevation position fall on inspiration and rise on expiration due to changes in T wave inversion  Client can resume sexual intrapulmonary pressure. Widening of QRS intercourse: if can climb  Reading should be obtained at the highest point of complexes or use the staircase fluctuation. The Most Critical PeriodG. Coronary Arterial Diseases 6-8 hours because majority of death occurs due toANGINA Coronary artery bypass arrhythmia leading toPECTORIS Levine’s Sign: surgery premature ventricular initial sign that  Greater and lesser contractions (PVC)4 E’s of shows the hand saphenous veins are *Lidocaine: DOC forAngina clutching the chest commonly used for arrhythmiaPectoris bypass graft procedures Chest pain: Excessive characterized by Percutaneuos F. Congestive Heart Failure physical sharp stabbing Transluminal Coronary Inability of the heart to pump blood towards systemic circulation exertion pain located at sub Angioplasty (PTCA) Exposure to sterna usually  Mechanical dilation of I. Left sided heart failure cold radiates from neck, the coronary vessel wall  90% - Mitral valve stenosis environment back, arms, by compresing the  Pulmonary Symptoms Extreme shoulder and jaw atheromatous plaque. emotional muscles II. Right sided heart failure response Nursing Management:  Tricuspid valve stenosis Excessive Dyspnea  Venous congestion symptoms intake of Tachycardia NTG Tablets(sublingual) foods or Palpitations Give 3 doses interval of 3- heavy meal Diaphoresis 5minutesPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 6. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)NURSING MANAGEMENT 5. BronchoscopyGoal: increase myocardial contraction  This is the direct inspection and observation of the Administer medications as ordered larynx, trachea and bronchi through a flexible or rigid  Cardiac glycosides bronchoscope.  Digoxin *Antidote: Digibind  Passage of a lighted bronchoscope into the bronchial tree  Loop diuretics for direct visualization of the trachea and the  Bronchodilators tracheobronchial tree.  Narcotic analgesics Diagnostic uses:  Morphine sulfate  To examine tissues or collect secretions  Vasodilators  To determine location or pathologic process and  Anti-arrhythmic agents collect specimen for biopsy Administer O2 inhalation at 3-4 L/minute  To evaluate bleeding sites Restrict Na and fluids  To determine if a tumor can be resected surgically Monitor strictly VS and IO and Breath SoundsWeigh pt daily and assess for pitting edema and abdominal girth daily and notify MD Therapeutic uses Provide meticulous skin care  To Remove foreign objects from tracheobronchial tree Provide a dietary intake which is low in saturated fats and caffeine  To Excise lesions  To remove tenacious secretions obstructing the tracheobronchial treeRESPIRATORY NURSING  To drain abscess  To treat post-operative atelectasisA. Diagnostic Evaluation Nursing Interventions BEFORE Bronchoscopy1. Skin Test: Mantoux Test or Tuberculin Skin Test  Informed consent/ permit needed  This is used to determine if a person has been infected or  Explain procedure to the patient, tell him what to expect, has been exposed to the TB bacillus. to help him cope with the unkown  This utilizes the PPD (Purified Protein Derivatives).  Atropine (to diminish secretions) is administered one  The PPD is injected intradermally usually in the inner hour before the procedure aspect of the lower forearm about 4 inches below the elbow.  About 30 minutes before bronchoscopy, Valium is given  The test is read 48 to 72 hours after injection. to sedate patient and allay anxiety.  (+) Mantoux Test is induration of 10 mm or more.  Topical anesthesia is sprayed followed by local  But for HIV positive clients, induration of about 5 mm is anesthesia injected into the larynx considered positive  Instruct on NPO for 6-8 hours  Remove dentures, prostheses and contact lenses2. Pulse Oximeter  The patient is placed supine with hyperextended neck  Non-invasive method of continuously monitoring he oxygen during the procedure saturation of hemoglobin  A probe or sensor is attached to the fingertip, forehead, Nursing Interventions AFTER Bronchoscopy earlobe or bridge of the nose  Put the patient on Side lying position  Normal SpO2 = 95% - 100%  Tell patient that the throat may feel sore with .  < 85% - tissues are not receiving enough O2  Check for the return of cough and gag reflex.  Check vasovagal response.3. Chest X-ray  Watch for cyanosis, hypotension, tachycardia,  This is a NON-invasive procedure involving the use of x-rays arrythmias, hemoptysis, and dyspnea. These signs and with minimal radiation. symptoms indicate perforation of bronchial tree. Refer  The nurse instructs the patient to practice the on cue to the patient immediately! 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 6. Sputum Examination  Pre-op meds: atropine SO4 and valium, topical  Indicated for microscopic examination of the sputum: anesthesia sprayed; followed by local anesthetic Gross appearance, Sputum C&S, AFB staining, and for injected into larynx. The nurse must have oxygen and Cytologic examination/ Papanicolaou examination anti spasmodic agents ready.  Nursing Interventions: Nursing Interventions AFTER Bronchogram  Early morning sputum specimen is to be  Side-lying position collected (suctioning or expectoration)  NPO until cough and gag reflexes returned  Rinse mouth with plain water  Instruct the client to cough and deep breathe client  Use sterile container.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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 7. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)  Sputum specimen for C&S is collected before  Auscultate lungs to assess for pneumothorax the first dose of anti-microbial therapy.  Monitor oxygen saturation (SaO2) levels  For AFB staining, collect sputum specimen for  Bed rest three consecutive mornings.  Check for expectoration of blood6. Pulmonary Function Test / Studies C. Chronic Obstructive Pulmonary Diseases  Non-invasive test  Measurement of lung volume, ventilation, and diffusing Chronic Bronchitis Smoking  Consistent productive capacity (Blue Bloaters) Air cough Inflammation of the pollution  Dyspnea on exertion bronchi due to with prolonged hypertrophy or expiratory grunt hyperplasia of goblet  Anorexia and mucous producing cells generalized body leading to narrowing of malaise smaller airways  Cyanosis  Scattered rales/rhonchi Bronchial Asthma Allergens  Cough that is productive Reversible inflammatory  Dyspnea lung condition caused by  Wheezing on expiration hypersensitivity to  Tachycardia, allergens leading to palpitations and narrowing of smaller diaphoresis airways  Mild apprehension, restlessness  Cyanosis Bronchiectasis Recurrent  Consistent productive7. Arterial Blood Gas Permanent dilation of LRTI cough  Assessment of arterial blood for tissue oxygenation,  Dyspnea the bronchus due to Congenital ventilation, and acid-base status  Presence of cyanosis destruction of muscular disease  Arterial puncture is performed on areas where good pulses  Rales and crackles and elastic tissue of the Presence are palpable (radial, brachial, or femoral). Radial artery  Hemoptysis alveolar walls of tumor is the most common site for withdrawal of blood specimen  Anorexia and Chest Nursing Interventions: trauma generalized body  Utilize a 10-ml. Pre-heparinized syringe to prevent malaise clotting of specimen   Soak specimen in a container with ice to prevent Pulmonary Smoking  Productive cough hemolysis Emphysema Pollution  Dyspnea at rest  If ABG monitoring will be done, do Allen’s test to assess Terminal and Hereditary  Prolonged expiratory for adequacy of collateral circulation of the hand (the irreversible stage of Allergy grunt ulnar arteries) COPD characterized by :  Resonance to hyperresonance8. Thoracentesis Inelasticity of alveoli  Decreased tactile  Procedure suing needle aspiration of intrapleural fluid or air Air trapping fremitus under local anesthesia  Decreased breath Maldistribution of  Specimen examination or removal of pleural fluid sounds gasses Nursing Intervention BEFORE Thoracentesis  Barrel chest Overdistention of  Secure consent  Anorexia and thoracic cavity  Take initial vital signs generalized body (Barrel chest)  Instruct to remain still, avoid coughing during malaise insertion of the needle  Rales or crackles  Inform patient that pressure sensation will be felt on  Pursed-lip breathing insertion of needle Nursing Intervention DURING the procedure: Nursing Management:  Reassess the patient  Enforce CBR  Place the patient in the proper position:  Low inflow O2 admin; high inflow will cause respiratory arrest  Upright or sitting on the edge of the bed * most accurate: venturi mask  Lying partially on the side, partially on the  Administer medications as ordered back Bronchodilators Antimicrobials Nursing Interventions after Thoracentesis Corticosteroids (5-10 minutes after bronchodilators)  Assess the patient’s respiratory status Mucolytics/expectorants  Monitor vital signs frequently  Force fluids  Position the patient on the affected side, as ordered,  Nebulize and suction client as needed for at least 1 hour to seal the puncture site  Provide comfortable and humid environment  Turn on the unaffected side to prevent leakage of  Avoidance of smoking and allergens fluid in the thoracic cavity  Check the puncture site for fluid leakagePOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 8. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)C. PNEUMONIA  Administer bronchodilators 15-30  Inflammation of the lung parenchyma leading to pulmonary minutes before procedure consolidation because alveoli is filled with exudates  Stop if pt. can’t tolerate the procedure  Provide oral care after procedure as it I. Etioilogic Agent may affect taste sensitivity 1. Streptococcus pneumoniae (pneumococcal  Contraindications: pneumonia)  Unstable VS 2. Hemophilus influenzae (bronchopneumonia)  Hemoptysis 3. Klebsiella pneumoniae  Increased ICP 4. Diplococcus pneumoniae  Increased IOP (glaucoma) 5. Escherichia coli 12. Provide pt health teaching and d/c planning 6. Pseudomonas aeruginosa  Avoidance of precipitating factors  Prevention of complications II. Predisposing Factor  Atelectasis 1. Smoking  Meningitis 2. Air pollution  Regular compliance to medications 3. Immunocompromised  Importance of ffup care  (+) AIDS  Kaposi’s Sarcoma  Pneumocystis Carinii Pneumonia HEMATOLOGY NURSING  DOC: Zidovudine (Retrovir)  Bronchogenic Ca A. Blood Cellular Components 4. Prolonged immobility (hypostatic pneumonia) 5. Aspiration of food (aspiration pneumonia) RBC 4-6 6. Over fatigue million/mm3III. Signs / Symptoms * Hemoglobin Ave. 12 - 18 iron-containing protein of RBC, 1. Productive cough, greenish to rusty g/dL delivers oxygen to tissue 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia, general body malaise * Hematocrit F: 36-42% red cell percentage in whole 4. Cyanosis M: 42-48% blood 5. Pleuritic friction rub 6. Rales/crackles on auscultation 7. Abdominal distention  paralytic ileus WBC N = 5,000- 10,000/mm3IV. NURSING MANAGEMENT 1. Enforce CBR (consistent to all respi disorders) *Neutrophils Most common  First line of defense, 2. Strict respiratory isolation type of  Helpful in localizing the 3. Administer medications as ordered leukocyte but a infection and in  Broad spectrum antibiotics short lifespan immobilizing the  Penicillin – pneumococcal infections of only 10-12 pathogens until other  Tetracycline hours WBCs arrive  Macrolides  Anti-pyretics  Mucolytics/expectorants *Eosinophils Lifespan=  Allergic Reaction and 4. Administer O2 inhalation as ordered hours to 3 days Parasitic Invasion 5. Force fluids to liquefy secretions 6. Institute pulmonary toilet – measures to promote *Basophils  they are mediators in expectoration of secretions inflammatory process.  DBE, Coughing exercises, CPT (clapping/vibration), Turning and *Monocytes  largest WBC repositioning (macrophage) 7. Nebulize and suction PRN *Lymphocytes B Cells 8. Place client of semi-fowlers to high fowlers T Cells  Antibody response 9. Provide a comfortable and humid environment NK Cells  Immunity 10. Provide a dietary intake high in CHO, CHON, Calories  Anti tumor and Vit C 11. Assist in postural drainage Platelets N = 150-450 Promotes hemostasis →  Patient is placed in various position to drain thousand mm3 prevention of blood loss → secretions via force of gravity promote clotting mechanisms  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 DBEPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 9. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)B. Blood Disorder is water soluble and is easily excretable; oral forms might develop tolerance.IRON DEFICIENCY  Monitor for signs of bleeding of all hema  Increase caloric intake, CHON, CHO, Fe,ANEMIA (IDA) – test including urine, stool and GIT Vit Cchronic microcytic  Enforce CBR so as not to overtire patient  Encourage client to use soft bristledanemia due to  Encourage increased iron diet toothbrush and avoid irritatinginadequate  Avoid tannates in tea and coffee mouthwashes (remember there areabsorption of iron  Administer medications as ordered mouthsores!)leading to Oral iron preparations (300mg OD)  Avoid heat application (there ishypoxemic tissue NURSING MANAGEMENT numbness remember?)  may lead toinjury 1. Administer with meals to lessen burns GIT irritation 2. Use straw for liquid form 3. Administer with orange juice or vitamin C to facilitate absorption GUT NURSING 4. Inform client of SE/monitor for a. Anorexia A. Causes of Acute Renal Failure 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 chillsAPLASTIC  Enforce complete BRANEMIA – stem  Administer O2 inhalation Acute Renal Failure Chronic Renal Failurecell disorder  Reverse isolation Sudden inability of the Irreversible loss of kidneyleading to bone  Monitor for signs of infection kidneys to excrete functionmarrow  Avoid IM, SQ or any venipuncture sites nitrogenous wastedepression   instruct: use electric razor when shaving products, leads to azotemia PREDISPOSING FACTORSpancytopenia (all  Medications as ordered DM and HPN (commonblood cells Immunosuppressants via central STAGES causes)decreased)  venous catheter Recurrent pyelonephritisanemia, Anti-lymphocyte globulin (ALG) – Oliguric phase – passage Exposure to renal toxinsleucopenia, given within 6 days – 3 weeks to of urine (1-2 weeks) Tumorthrombocytopenia achieve maximum therapeutic effect  UO: <400 ml/cc  Hyperkalemia STAGESPERNICIOUS  Hypernatremia  Diminished renal reserveANEMIA – chronic  Headache, dizziness, dyspnea, palpitation,  Hyperphosphatemia volume – asymptomatic,anemia resulting cold sensitivity, pallor and generalized body  HYPOCALCEMIA normal BUN and CREAfrom deficiency of malaise  Hypermagnesemia  Renal insufficiencyintrinsic factor  GIT changes: Mouth sores, Red beefy  Metabolic acidosis  End-stage renal diseaseleading to tongue, Dyspepsia or indigestion, Weight  Elevated BUN, Crea (ESRD) – presence ofhypochlorhydria loss, Jaundice oliguria, azotemia(decreased HCl  CNS changes – PA is the most dangerous Diuretic Phase (2-3secretion); form of anemia, Tingling sensation, weeks) Paresthesia, Ataxia, Psychosis  Increased passage of urine DIAGNOSTICS  Hyperkalemia SCHILLING’S TEST – indicates decreased  Hyponatremia reabsorption of vitamin B12; confirms  Metabolic acidosis presence of pernicious anemia Convalescent phase (3-12 NURSING MANAGEMENT months)  Enforce complete bed rest (consistent to  Improvement in all types of anemia) passage of urine  Administer Vit B12 injections at  Characterized by MONTHLY intervals for lifetime as complete diuresis ordered; common site: dorso and ventrogluteal, no drug toxicity because itPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 10. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)NURSING MANAGEMENT ARF/CRF ENDOCRINE NURSING  Enforce CBR  Admin oxygen inhalation as ordered A. Thyroid Gland Disorders  High CHO diet low CHON, fats, High vit and minerals HYPOTHYROIDISM HYPERTHYROIDSM  Provide meticulous skin care Decreased T3 and T4 Increased T3 and T4  Wash with warm water Early Signs 1. Hyperphagia – increased  Soap irritates and dries skin 1. Weakness and fatigue appetite  Meds as ordered 2. Loss of appetite but 2. (+) weight loss d/t  anti-HPN agents (+) weight gain d/t increased metabolism  Hydralazine (appresoline) increased lipolysis 3. heat intolerance  SE: orthostatic hypotension 3. Dry skin 4. moist skin  NaHCO3 4. Cold intolerance 5. diarrhea  Kayexelate enema 5. Constipation 6. increased VS  Hematinics 6. Menorrhagia 7. CNS changes  Antibiotics Late Signs a. Irritability  Supplementary vitamins and minerals 1. Brittleness of hair b. agitation  Phosphate binders 2. Non-pitting edema c. Tremors  Calcium gluconate 3. Hoarseness of voice d. Restlessness 4. Decreased libido e. Insomnia 5. Decreased VS f. HallucinationsB. Nursing Management on Hemodialysis 6. CNS changes 8. Goiter a. Lethargy 9. Exophthalmos  Secure consent and explain procedure to client b. Memory 10. Amenorrhea  Maintain strict aseptic technique impairment  Obtain baseline data – before and q30 during c. Psychosis procedure 1. Monitor STRICTLY VS, 1. Monitor VS and IO strictly  VS IO to determine to determine presence of  Wt presence of THYROID STORM/Crisis  Blood exams – secure all pre-procedure MYXEDEMA COMA a 2. Administer medications  I/O complication of severe as ordered hypothyroidism a. Anti-Thyroid Agents:  Have client void pre-procedure characterized by: PTU  toxic effects is  Inform pt about bleeding (blood is heparinized) a. Severe AGRANULOCYTOSIS  Monitor for signs of complications (BEDSSH) hypotension fever and chills, sore  Bleeding b. Bradycardia throat (throat CS  Embolism c. Bradypnea pls!), LEUKOCYTOSIS  DISEQUILIBRIUM SYNDROME – results from rapid d. Hypoventilation (CBC pls!) loss of nitrogenous waste products particularly UREA e. Hypoglycemia b. Methimazole from the brain f. Hyponatremia (Tapazole)  HPN g. Hypothermia 3. High calorie diet to  Disorientation – initial sign 2. Administer isotonic correct weight loss  Nausea and vomiting fluids as ordered 4. Provide comfortable and  Anorexia 3. Administer cool environment  Headache medications as 5. Institute meticulous skin ordered – thyroid care  Paresthesia, peripheral hormones or agents 6. Maintain side rails  Numbness (may cause insomnia 7. Bilateral eye patch to  Septicemia and heat intolerance) prevent drying of eyes  Shock 4. Provide dietary intake 8. Assist in surgical  Hepatitis low in calories to procedure: subtotal  Avoid BP taking, phlebotomy, IV meds at the site of prevent weight gain thyroidectomy fistula, blood extraction to prevent compression 5. Institute meticulous  Maintain patency of shunt/fistula: skin care PRE-OP  Palpate for thrills, auscultate for bruits 6. Provide comfortable Administer lugol’s solutions/  Instruct that minimal bleeding is expected since blood and warm SSRI to promote decreased is heparinized environment vasculature and promote  Avoid use vasodilators, sedatives, and tranquilizers to 7. Forced fluids atrophy of the thyroid gland to prevent hypotension unless ordered prevent/minimize bleeding  Prepare at bedside bulldog clips to prevent embolism and hemorrhage  Auscultate for bruits and palpate for thrills (if (+)  patent) 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 ofPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE
  • 11. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESSPART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) 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 braceletB. Insulin TherapyI. 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 hoursII. 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, hyperglycemiaPOSSIBLE 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 onthe possible topics that might be part of the upcoming Dec 2012 PNLE