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I just wanted to share some of my Clinical Instructors lecture materials. I don't own this document, I wish to help you guys with the summary of Nursing MS.

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  1. 1. ABC ‘S OF PASSING LOCAL BOARD EXAM (ADDITIONAL BULLETS FOR MS)  Abdominal aortic aneurysm  Main problem :Local distention / outpouching of the artery wall usually in the thoracic or abdominal area  Initial manifestation :Initially asymptomatic; pulsating abdominal mass is a common sign, backache and auscultation of bruit are common manifestations ; abdominal or back pain  Laboratory Data : Elevated BUN and creatinine levels MRI, CT scan and X-ray. UTZ is the best test to confirm AAA  Nursing Diagnosis : Altered tissue perfusion  Nursing Interventions : Avoid abdominal palpation, prepare patient for surgery Monitor for possible rupture preoperatively(signs of shock) Monitor MIO and laboratory studies Administer medications to decrease hypertension and control pain Monitor peripheral pulses postoperatively  Acne Vulgaris  Inflammatory disease of sebaceous follicles due to blockage of sebaceous glands  Initial manifestation : Closed comedones( “ whiteheads “ ), open comedones ( “blackheads”)  Nursing Diagnosis : Body image disturbance  Nursing Interventions : Instruct patient to wash face gently with mild soap 1-2 times daily. Instruct patient to use benzoyl peroxide and never squeeze pimples Use of Isotretinoin ( Accutane ) for treatment can cause birth defects. Instruct patient to use contraceptives during the entire duration of the therapy unitl a month thereafter. Avoid exposure to sunlight and use sunblock when using these medications.  Acromegaly  oversecretion of growth hormone(anterior pituitary), long lasting stimulation affecting skeletal growth in adult by enlarging certain bones and tissues  Initial manifestation : coarse facial features, increased shoe size, increased intracranial pressure due to tumor headache and blindness  Laboratory Data : elevated serum human growth hormone and blood sugar levels  Priority Nursing Diagnosis : body image disturbance  Nursing Interventions : provide emotional support prepare client for surgery and deligently monitor VS and Neurologic Status post-op Monitor for signs and symptoms of diabetes octreotide ( Sandostatin) to decrease GH  Acute gastroenteritis ( AGE ) / Diarrhea
  2. 2.  Increase in fluid , frequency and volume of stool usually associated with rotavirus, clostridium deficile, salmonella  Initial manifestation : Frequent watery stool  Laboratory Data : Decrease in Na and K, (+) blood cultures usually for salmonella, rotavirus and clostridium defficile  Nursing Diagnosis : Fluid and electrolyte imbalance  Nursing Interventions : Priority ; fluid replacement Remember : fluid loss is more critical in younger patients because they have higher body fluid percentage. Monitor the patient’s fluid status, weight is a critical indicator of fluid loss, 1 gram of weight equals 1 ml of body fluid. Initially offer oral rehydration solution such as pedialyte then progress to non-carbonated drinks ( Gatorade) limit apple juice since it can cause diarrhea. BRAT diet  Acquired Immune Deficiency Syndrome ( AIDS)  Slow degeneration of the immune system( defect in T- cell mediated immunity caused by the HIV) with the development of opportunistic infections, malignancies and frequent impairment of the central nervous system  Initial Manifestation : Flu- like symptoms occur 2-4 weeks after infection  Laboratory Data : Diagnosis of AIDS is based on laboratory evidence of HIV infection coexisting with one or more indicator diseases such as Pneumocyctis carinii Pneumonia , Kaposis Sarcoma( most common malignancy), Cytomegalovirus , Candidal infection ,Herpes Simplex Virus or AIDS dementia HIV (+) on ELISA, confirmed by Western Blot HIV antibodies are detectable by routine tests, 3-6 months after infection so instruct the patient to have an initial test 3-6 months after exposure. Patients who are initially negative should have a retest 12 weeks or less since a possible exposure CD4 lymphocytes , 200 / cu .mm  Priority Nursing Diagnosis : Risk for infection  Nursing Interventions : Instruct patient to practice safe sex, avoid needle sharing.Maintain Satndard Precautions Monitor for opportunistic infections.Monitor respiratory status and laboratory values.Maintain diet/nutrition Use 10 % household bleaching solution to cleanse areas with blood stains from an HIV (+) patient Assess the patient for signs and symptoms of dementia like incoordination.  Addison’s Disease
  3. 3.      Adrenal hypofunction usually due to autoimmune disease Initial Manifestation :Hypotension; bronze skin pigmentation is a common sign Laboratory Data : Hyponatremia, hyperkalemia, hypoglycemia Nursing Diagnosis : Fluid volume deficit Nursing Interventions : Monitor fluid and electrolyte balance Explain the need for lifelong medications of glucocorticoids and mineralocorticoids Maintain high sodium, low potassium diet Advice patient to avoid infection , trauma or stress, it increases the risk for addisonian crisis( IV hydrocortisone and saline soln for addisonian crisis)  Anemia , aplastic  Main Problem : Bone marrow hypoplasia or aplasia resulting in pancytopenia( decreased WBC, RBC and platelets)  Initial manifestation – abnormal bleeding( purpura , petechiae, ecchymosis,epistaxis , melena and dyspnea)  Laboratory data: decreased WBC , RBC and Platelet Count  Nursing diagnosis: risk for infection; risk for injury  Interventions: prepare the patient for bone marrow transplant Assess for signs and symptoms of bleeding  Anemia , folic acid deficiency  Main Problem : Depletion of folate, which results to progressive anemia  Initial manifestation: fatigue  Laboratory data: decreased folate levels  Nursing diagnosis: activity intolerance  Interventions: teach patient to increase sources of folic acid in the diet like: green vegetables ( asparagus, broccoli and spinach), yeast , liver , organ meats and fresh fruits. Avoid overcooking of vegetables Teach the patient regarding oral folic acid replacement  Anemia , iron deficiency  Main Problem : Decreased oxygen carrying capacity of the blood. The condition is usually associated with nutritional deficiency of iron
  4. 4.  Initial manifestation: easy fatigability; poor sucking ( infants) chubby but pale babies ( milk babies)]  Laboratory data : decreased Hgb and Hct, microcytic, hypocromic RBC’s  Nursing Diagnosis:Activity intolerance  Interventions: Instruct patient to have frequent rest periods Increase iron in the diet( organ meat , egg yolk) milk is a poor source of iron Administer oral iron supplements as ordered  Anemia , Pernicious  Main Problem : Reduced vitamin B 12 Absorption due to the absence of the intrinsic factor usually related to gastrectomy and atrophy of the gastric mucosa  Initial manifestation : Fatigue ; beefy red tongue or glossitis a common sign  Laboratory Data : Schillings test reveals low value urinary excretion of ingested vitamin B12 < 10% in 24 hours  Nursing Diagnosis : Activity Intolerance  Nursing interventions : Teach patient monthly IM Vit B12 injections for life. Inform patient to report tingling sensation in the lower extremities indicating complication – peripheral neuropathy  ANAPHYLAXIS  Main Problem : Dramatic widespread acute atopic/allergic reaction which causes vascular collapse  Initial manifestation : Sudden onset of rapidly progressive urticaria , respiratory distress and hypotension which can lead to shock  Diagnostic data : Skin testing to determine allergen  Nursing Diagnosis : Risk for altered airway clearance related to bronchial edema  Nursing Intervention : Observe for respiratory complications (laryngeal edema ), watch out for signs and symptoms of shock. Maintain airway patency – prepare suction and intubation set Early stages – no loss of consciousness – epinephrine IM with loss of consciousness – epinephrine IV CPR for cardiac arrest After emergency give antihistamines [diphenhydramine(Benadryl) ] and corticosteroids Prevent recurrence by avoiding exposure to known allergens 1) A major nursing responsibility prior to initial administration of antibiotics specifically penicillin and sulfa drugs is : a) Skin testing b) Assessing for sensitivity to iodine c) Assessing for food allergies d) Suction equipment at bedside
  5. 5.  Answer : a - antibiotic therapy is done after negative skin test results to prevent occurrence of hypersensitivity reactions  Aphasia  Main problem an acquired disorder of communication resulting from brain damage.Speech difficulty /change usually caused by right sided hemiplegia(left brain involvement)  Initial manifestations : Expressive Aphasia – difficulty expressing self in understandable speech Receptive Aphasia – does not comprehend spoken or written word Global Aphasia – combination of both  Nursing Diagnosis : Impaired Verbal Communication  Interventions : Give the patient enough time to speak and respond and speak clearly and slowly while facing patient Provide visual cues like pictures and gestures when talking to the patient ( verbal and non-verbal) Approach on the visually unaffected side  Arrythmias  Main Problem : Abnormal electrical conduction or automaticity changes in the heart rate or rhythm which affects cardiac output and blood pressure  Initial manifestation : Hypotension and deteriorating level of consciousness  Diagnostic Data : ECG tracing reveals the following:  Atrial Fibrillation- irregular atrial rhythm > 400 beats / min. indiscernible PR interval and no P waves  Ventricular Tachycardia- ECG shows rate of 140 – 220 bpm, wide and bizarre QRS complex and no P waves  Ventricular fibrillation - ECG shows rapid and chaotic ventricular rhythm, wide and irregular QRS complexes and no visible P waves.  Premature Ventricular Contractions- irregular intervals between QRS complexes  Asystole – no atrial or ventricular rate  Nursing Diagnosis : Ineffective tissue perfusion: cardiopulmonary
  6. 6. Decreased cardiac output  Nursing Interventions : Watch out for hypotension and decreased urine output Assist with measures to treat underlying cause ( electrolyte replacement , oxygen therapy and pulmonary care) Hook on cardiac monitor and assess Level of consciousness, RR, PR , BP and fluid and electrolyte balance Perform ACLS measures Early defibrillation for VT and VF Cardioversion for atrial dysrhythmias Administer antiarrythmics (Lidocaine,Inderal,Cordarone) for arrythmias and PVC’s – hypotension common side effect Perform CPR and intubation prn prepare patient for possible pacemaker insertion 1) In a patient on antidysrhythmic drug therapy , the following intervention is necessary to monitor for the common side effect of the drug: a) Use of infusion pump for continous administration b) Ensure IV remains patent and check insertion site c) Check BP regularly d) Administer slowly and at a prescribed rate  Answer : c – major side effect of anti arrthmics is hypotension  Angina Pectoris  Main Problem _ Insufficient coronary blood flow results to inadequate oxygen supply causing intermittent chest pain  Initial Manifestation : squeezing , burning , pressing , chocking , aching or bursting left sternal chest pain lasting not more than 20 minutes. The patient often says , “It feels like gas or heartburn or indigestion “ .  Laboratory Data : ECG reveals ST segment depression  Nursing Diagnosis : Pain  Administer nitroglycerine sublingually to relieve the pain. Teach the patient that a burning sensation under the tongue after nitroglyvcerine indicates that the drug is potent. The drug may also cause facial flushing or headache Prepare patient for PTCA ( percutaneous Transluminal Coronary Angioplasty ) by informing the patient that a balloon tipped catheter will be introduced through a guide wire into a coronary vessel .  Appendicitis
  7. 7.  MAIN PROBLEM : Inflammation of the appendix due to obstruction of the intestinal lumen  Initial manifestation : right lower quadrant abdominal pain with rebound tenderness. Lessenignof pain indicates rupture of the appendix  Laboratory Data : Elevated WBC and urinalysis negative for UTI ( ruled out )  Nursing Diagnosis : Pain and Potential for injury  Interventions : Place patient in any position of comfort if appendix has not yet ruptured , if it is ruptured place patient in high fowler’s position to prevent upward spread of infection. Administer antibiotics as ordered . Avoid applying hot compress on the RLQ . No analgesics , antispasmodics and enema during observation phase.  Prepare patient for appendectomy and teach post op interventions/responsibilities.  Arthritis , gouty  Main Problem : Metabolic disorder of uric acid formation and excretion  Initial manifestation : Initially asymptomatic . A common sign is dusky red hot swollen joint(inflamed painful), usually the big toe. Pathognomonic : Formation of Tophi  Laboratory Data : Elevated urate crystals in synovial fluids and elevated serum uric acid  Nursing Diagnosis : Pain  Interventions : Teach patient to Maintain purine restricted diet ( avoid organ meats , alcohol , legumes, sardines). Increase oral fluid intake Avoid aspirin and diuretics as these interfere with uric acid excretion. Alkalanize urine – fruit, vegetables and milk. Use bed cradle to prevent linen from coming in contact with the inflamed joint which aggravates the pain Common Complication : Uric Acid Kidney stone formation Encourage compliance to anti gout medications: Allopurinol- blocks formation of uric acid, Colchicine – analgesic and anti-inflammatory, Probenecid – reduces uric acid Sulfinpyrazone – reduces uric acid in the blood  Arthritis , osteo  Degeneration of the articular cartilage in the joints  Initial Manifestation : Pain and swelling in a weight bearing joint, usually aggravated by activity  Laboratory Data : X – ray  Nursing Diagnosis : Pain  Interventions : Priority : Minimize Discomfort – Implement: W- eight control H- ot compress or ice packs
  8. 8. A – spirin use T – runk assistive devices – cane  Arthritis , Rheumatoid  Main Problem : systemic recurrent inflammation of the synovial lining of the joints, usually upper extremities.More common in women  Initial manifestation : Morning stiffness relieved by warm bath or soaks  Laboratory Data : elevated ESR and (+) rheumatoid factor  Nursing Diagnosis : Pain related to joint inflammation  Interventions : Teach patient to take aspirin regularly as ordered even in the absence of symptoms , instruct the patient that tinnitus is a side effect of aspirin. Apply moist heat for 15 – 30 minutes to reduce muscle spasm. Use ice packs during acute phase to decrease pain  Asthma  Main Problem : Abnormal Bronchial hyperactivity to certain substances and conditions  Initial manifestation : dyspnea and wheezing(asymptomatic between attacks)  Laboratory data : PFT’s during attacks show decreased forced expiratory volumes , elevated immunoglobulin E , ABG reveals respiratory Acidosis, peak flow levels below normal  Nursing diagnosis : Ineffective Breathing Pattern related to bronchospasm  Interventions : Assess precipitating factor and eradicate these sources Instruct patient to avoid 3 E’s ( exercise specially in cold weather, environmental factors like dust , emotional factors ) Position patient in orthopneic position and encourage patient to do pursed lip breathing Administer medications – Bronchodilators and corticosteroids usually via nebulization  Autonomic dysreflexia
  9. 9.  Main Problem : Exaggerated autonomic responses to local stimuli below the level of the spinal cord injury. Occurs in clients with lesions above T6 after spinal shock has subsided  Initial manifestation : Pounding headache or severe hypertension  Nursing Diagnosis : Urinary retention related to effects of spinal cord injury  Interventions : Catheterize the patient to prevent bladder distention. Relieve fecal impaction and pressure on skin which can precipitate attacks . Place patient in sitting position to help lower blood pressure . Administer antihypertensives  Benign prostatic hypertrophy  Main Problem : enlargement of the prostate gland resulting to narrowing of urethral opening  Initial manifestation : decreased force and amount of urine  Laboratory data :elevated Ph of prostatic fluid rectal examination shows enlarged prostate Cystoscopy shows enlarged prostate gland, obstructed urine flow and urinary stasis  Nursing Diagnosis: Altered bladder elimination related to enlarged prostate  Interventions : Force fluids Pre-op – assess understanding of procedure and anticipated postoperative course. Explain TURP ( Transurethral Resection Prostatectomy) will not involve any incision. Post – op assess for pain , discomfort and complications ( bleeding and infections ) Monitor continous bladder irrigations  Bleeding Esophageal Varices  Main Problem : bleeding of dilated veins in the lower esophagus  Initial manifestation : Hematemesis  Nursing Diagnosis : Fluid Volume Deficit  Interventions : Monitor the pateint’s airway Assist with the insertion of Sengstaken – Blakemore Tube ( keep a pair of scissors at the bedside, this is used to cut the port of the tube leading the balloon, to deflate it, in case aspiration occurs)  Bronchiectasis  Main Problem : Chronic abnormal dilation of bronchi and destruction of bronchial walls leading to multiple respiratory complications  Initial Manifestation : Chronic cough that produces copious, foul smelling, mucopurulent secretions, possibly totaling several cupfuls daily  Laboratory Data : Bronchoscopy helps identify source chest x-ray shows peribronchial thickening,
  10. 10. areas of atelectasis and scattered cystic changes Pulmonary Function tests detect decreased volumes  Nursing Diagnosis : Ineffective airway clearance related to secretions Impaired gas exchange related to alveolar exudate  Nursing Interventions :Assess respiratory status and level of consciousness to detect early signs of hypoxia and decompensation Administer antibiotics as necessary Teach and perform Respiratory Physiotherapy - deep breathing and coughing, postural drainage and chest percussion(done early morning and before bedtime) Teach importance of quitting smoking and avoidance of milk products 1) Priority nursing diagnosis for patient with bronchiectasis is: a) Altered breathing pattern b) Potential for infection c) Knowledge deficit d) Ineffective airway clearance  Answer: d - copious, foul smelling, mucopurulent secretions, possibly totaling several cupfuls daily  Buergers disease ( thromboangitis Obliterans )  Main Problem : Vasculitis of the small and medium sized veins and arteries usually in the lower extremities. It is more common in men and in smokers  Initial manifestation : Pain is an outstanding symptom, intermittent claudication is a common problem  Laboratory Data : leg arteriography reveals inflammatory lesions  Nursing Diagnosis : Altered peripheral Tissue Perfussion  Interventions : Instruct patient to stop smoking and administer calcium channel blockers and peripheral vasodilators as ordered.  Burns  Main Problem : Traumatic injury caused by thermal , electrical , chemical or radioactive agents  Initial Manifestations : 1st Degree – pinkish skin with pain 2nd degree – reddish with painful blisters 3rd degree – eschar , charred , painless  Laboratory Data : Hyperglycemia , anemia  Nursing Diagnosis : Decrerased cardiac output related to fluid shifts  Interventions : On strict MIO . Administer fluids as ordered during acute phase by fluid replacement calculations using body weight multiplied by BSA burned based on rule of nines. ½ of the
  11. 11. total volume to be infused on the first 8 hours then the remaining ½ infused in the next 16 hours. Maintain a high calorie , high protein diet Treat pain with IV narcotics, provide tetanus prophylaxis and topical antimicrobial therapy. Institute reverse isolation in severe cases. Administer pain medications prior to ROM ,ambulation and whirlpool therapy  Cancer , Bladder  Main Problem : Presence of malignant cells in the bladder  Initial Manifestation : Painless hematuria  Laboratory data : Elevated Acid Phosphatase  Nursing Diagnosis: Altered urinary Elimination  Interventions : Prepare patient for surgery and chemotherapy Encourage patient to verbalize fears  Cancer Breast  Main Problem : Presence of malignant tumors usually in the upper outer quadrant of the left breast. It is associated with nulliparity or having the first child after age 35  Initial manifestation : skin dimpling and edema(peau d’ orange .Painless mass most common sign  Laboratory Data : Mammography reveals the presence of non – palpable lesion. Baseline mammography should be made between age 35 – 40 . Q2 years 40 – 50 years old if w/o predisposition ;yearly for high risk women;yearly after age 50.  Nursing Diagnosis : Knowledge deficit of breast cancer and mastectomy  Interventions : Prepare patient for chemotherapy , radiation and surgery. Teach patient how to perform Self Breast examinations. Done monthly , a week after menstruation since the breast are less tender at this time. The best position is lying down with pillow under shoulder of breast being examined. Inform the patient that Mammography will involve placing the breasts between two X-ray plates. Avoid use of deodorant ,lotions or powder In post mastectomy patient elevate affected arm to prevent lympedema and to avoid activities that increase infection like gardening and sewing. No BP taking , venipuncture and constrictive clothing on the affected arm  Cancer , Cervix  Main Problem : presence of malignant cells in the cervix associated with multiple sexual partners and history of sexually transmitted disease  Initial manifestation : initially asymptomatic , postcoital bleeding is common manifestation  Laboratory data : pap smear reveals presence of malignant cells  Nursing Diagnosis : Knowledge deficit of cervical cancer and chemotherapy
  12. 12.  Interventions : Instruct patient to avoid douching and sexual intercourse 24 hours before Paps’ Smear Stress the importance of lifelong follow up visits to detect response to treatment. Prepare patient for chemotherapy , radiation and surgery  Cancer , Esophagus  Main Problem : Malignant tumor in the esophagus related to alcoholism and smoking  Initial manifestation : Dysphagia – presenting symptom  Laboratory Data : Barium Swallow with fluoroscopy reveals large masses. CT scans may be employed to evaluate extent of tumor  Nursing Diagnosis : Altered Nutrition  Interventions : Prepare patient for surgery , radiation therapy and chemotherapy. Administer antacids and analgesics as ordered Prepare patient for tube or gastroctomy feedings and short course hyperalimentation Post operatively instruct patient to avoid overeating raw fruits and vegetables  Cancer ,Larynx  Main Problem : presence of malignant cells in the larynx associated with smoking and alcoholism  Initial Manifestations : Hoarseness or voice change, tickling sensation in the throat  Laboratory data : Laryngoscopy and Biopsy reveals malignant cells  Nursing Diagnosis : Knowledge deficit of laryngeal cancer  Interventions : Prepare patient for radiation , chemotherapy and surgery . teach patient to avoid cold air Instruct patient that swimming is not recommended post – laryngectomy. Institute alternative modes of communication  Cancer , Ovary  Main Problem : Gynecologic cancer associated with high fat diet and nulliparity  Initial Manifestation : Initial asymptomatic , vague abdominal discomfort like indigestion is a common symptom  Laboratory data : laparoscopy and Ultrasound reveals the presence of mass
  13. 13.  Nursing Diagnosis : Pain  Interventions : Prepare patient for surgery and chemotherapy Assist the patient to cope with change in body image Institute effective pharmacologic and non pharmacologic pain management  Cancer , Prostate  Main Problem : Malignant tumor in the prostate gland  Initial Manifestation : Decreased size and force of urinary stream  Laboratory data : Elevated Prostate Specific Antigen ( PSA ) , elevated acid phosphatase  Nursing Diagnosis : Pain related to tumor metastases to bone  Interventions : Support patient undergoing radiation therapy Inform the patient that radical prostatectomy, which involves the removal of the entire prostate gland, may cause impotence  Cancer , colon( colorectal Ca)  Primary or metastatic malignant tumor of the colon or rectum which infiltrate causing obstruction, ulceration and hemorrhage.  Change in bowel habits, character of stools, diarrhea and constipation- fecal oozing ( melena or hematochezia)  Barium enema locates mass, sigmoidoscopy / colonoscopy identifies and locates mass, positive for fecal occult blood and positive biopsy for Ca cells  Altered bowel elimination  Assess GI status, fluid and electrolyte studies, monitor for bleeding , infection and electrolyte imbalance Provide post-chemotherapeutic and post radiation therapy nursing care Provide adequate nutrition and administer antiemetics and anti - diarrheals Prepare for surgery and Teach ostomy self care Administer TPN as ordered 1) Among the following diagnostic results ,which is more suggestive of colorectal cancer? a) Painless hematuria b) Presence of occult blood in stool c) Increased level of acid phosphatase
  14. 14. d) Indigestion  Answer: b – lab test suggestive of colorectal cancer includes fecal occult blood and positive biopsy for Ca cells  Cancer , lung ( Bronchogenic Ca )  Development of a neoplasm in the respiratory tract(squamous cell-slow growing; large and small oat cell – fast growing).Presence of malignant tumor in the epithelium of the respiratory tract usually related to smoking or exposure to asbestosis  Chronic,nagging cough ( smokers cough)  Sputum cytology positive for cancer cells CXR shows a lesion or mass Bronchoscopy confirms a positive biopsy  Impaired gas exchange Impaired breathing pattern  Monitor respiratory status and pulse oximetry Check for cyanosis suggesting respiratory failure and increase in sputum production indicates infection Provide adequate pain control Increase oral fluid intake and IVF as ordered Provide increased CHON, high caloric diet( TPN or enteral,prn) Perform and teach Respiratory Physiotherapy Provide rest periods and mouth care Prepare patient for surgery and chemotherapy Elevate head of bed to prevent fluid collection in the upper body 1) All the following except one are diagnostic procedures done to confirm bronchogenic cancer: a) Sputum cytology b) Chest X- ray c) Bronchoscopy d) Pulmonary angiography  Answer : d - pulmonary angiography is the rapid injection of radiopaque dye into the pulmonary circulation useful in determining the site of pulmonary embolism, sputum cytology, CXRay and bronchoscopy are tests done to confirm lung cancer.  Cancer, Skin  Malignant primary tumor of the skin mainly caused by prolonged exposure to the sun or other carcinogenic agents  Squamous cell carcinoma- small red nodular lesion that begins as an erythematous macule or plaque
  15. 15.  Skin biopsy shows positive cytology  Impaired skin integrity  Assess lesion and monitor skin punch test site for bleeding Pre and post chemotherapy or radiation therapy nursing care Teach patient to avoid contact with chemical irritants. Use sunblock and layered clothing when outdoors 1) Nursing interventions for patients undergoing radiation therapy include all of the following except: a) Monitoring the punch test site for bleeding b) Teach patient to avoid contact with chemical irritants c) Using sunblock when outdoors d) Using layered clothing when sun exposure is possible Answer : a - skin punch test / skin biopsy is a diagnostic procedure to confirm the presence of skin cancer  Cancer , Testicular  Main Problem : Malignancy in the testes usually associated with cryptorchidism  Initial manifestations Painless swelling and enlargement of the testes , accompanied by sensation of heaviness in the scrotum  Laboratory data : Elevated HCG and alpha feto protein  Nursing Diagnosis : Knowledge deficit  Interventions : Prepare patient for surgery and chemotherapy Teach patient about testicular self examination .It should be done once a month while having warm bath or standing in front of mirror. Suspect cancer when spongy upon palpation  Cardiogenic shock  Main Problem : Extensive damage of the left ventricle due to Myocardial Infarction
  16. 16.  Initial manifestation : decreased systolic pressure  Laboratory Data : Elevated BUN , creatinine and liver enzymes  Nursing diagnosis : Altered cardiac Output ( decreased related to impaired contractility of the heart  Interventions : Monitor BP , MIO and weight . Evaluate serum electrolytes for hyponatremia and hypokalemia  Cataract  Main Problem : Opacity of the lens usually associated with aging , prolonged intake of steroids and chromosomal aberrations  Initial manifestation : painless blurring of vision  Laboratory data : Slit lamp test reveals milky white color of the pupils  Nursing diagnosis : potential for injury related to visual loss  Interventions : Prepare patient for surgery Postoperatively instruct patient to avoid activities that requires bending, report sudden eye pain, this indicates hemorrhage and increased IOP. Avoid lifting and rapid head movements Position in fowlers position or instruct patient to lie down on the unaffected side  Cerebrovascular Accident (CVA)  Sudden loss of brain function resulting from a disruption of blood supply to a part of the brain causing temporary or permanent dysfunction.(TIA warning sign of CVA – no neurovascular deficits / complete resolution of manifestation within 24 hours)  Initial Manifestation : depends on the site of brain involvement Middle cerebral artery : hemiparesis Internal Carotid artery : hemiplegia Right hemispheric lesion : spatial disorientation Left Hemispheric lesion : language disturbances Common manifestations: Hemiplegia and homonymous hemianopsia Emotional and personality disturbances Aphasia Dysphagia  Laboratory : Elevated Cholesterol Levels  Nursing Diagnosis : Ineffective Breathing Pattern Unilateral Neglect  Interventions : Maintain adequate airway Institute regular bowel and bladder training Establish means of communication
  17. 17.  Chest injury (Flail Chest )  Main Problem : Loss of stability of chest wall with subsequent respiratory impairment  Initial manifestation : Dyspnea , Paradoxical Chest Movement may occur ( detached part of the chest will be pulled in on inspiration and blown out on expiration )  Laboratory data : X ray reveals rib fractures  Nursing Diagnosis : Ineffective breathing pattern  Interventions : Stabilize the flail portion of the chest with hands or cover with impermeable dressing with three sides taped Turn patient on affected side to provide space for the unaffected lung to reexpand Place 10 pound sandbag at the site of flail  Cholecystitis / Cholelithiasis  Infection of the biliary tract associated with the presence of gallstones (Cholelithiasis) . Predisposing factors includes Fat, Female, Age Forty and above, and Fair skinned.  Intolerance to fatty foods and severe pain located on the RUQ of abdomen radiating to R scapula with nausea and vomiting. Indigestion, flatulence, belching, jaundice and clay colored stools  Hepatobiliary tract UTZ  Altered nutrition ; less than body requirements  Position in semi-fowlers,provide rest and limit activity Small frequent meals low fat, low calorie, high carbohydrate and fiber , no gas forming foods. NPO on acute phase. Administer IV fluids / TPN as ordered Prepare client for Extracorporeal Shock Wave Lithotripsy or cholecystectomy- T – tube for biliary drainage placed Teach post-op procedures and care(incentive spirometry and deep breathing) Give medications as ordered: Analgesics-Demerol ( morphine contraindicated) Antibiotics-Ceftazidine, Clindamycin , Gentamycin Anticholinergics- Probanthine Anti-emetic- Compazine Anti-pruritic- Benadryl NGT to low suction to decompress stomach 1) Management for patient post cholecystectomy includes: a) Adequate fat diet b) Maintain NPO for 3 days c) Place patient in supine position d) Instruct and encourage use of incentive spirometry
  18. 18.  Answer : d – management for clients post cholocystectomy includes maintaining high fowlers position, deep breathing and coughing, pain management, NPO until peristalsis returns, administer IVF and T – tube monitoring and care.  Cardiac Tamponade  Main Problem : Fluid Accumulation in the pericardial sac  Initial Manifestation : hypotension muffled heart sounds is a common sign  Laboratory data : ECG reveals ST and T wave abnormalities  Nursing Diagnosis : Altered cardiac Output  Interventions : prepare the patient for pericardiocentesis. Tjis involves aspirating the fluid or air from the pericardial sac. Assess for complications  Cor pulmonale  A chronic heart condition, is the hypertrophy of the heart, right ventricle and associated structure that results from diseases affecting the function and the structure of the lungs  Chronic productive cough , dyspnea on exertion, edema and fatigue  ABG- decreased Pa O2 < 70 mmHg CXR and UTZ – suggests R ventricular hypertrophy ECG- shows arrhythmia during severe hypoxia  Altered Tissue perfusion related to cardiopulmonary changes  Measure ABG levels and administer O2 by mask or cannula as ordered. Monitor serum K if on diuretics Low salt , fluid restricted , small frequent feedings Monitor digoxin level and check radial pulse prior to cardiac glycoside administration to avoid complications Reposition and provide meticulous respiratory care 1) Then following are diagnostic tests done to assess the presence of cor pulmonale except: a. CXR b. ECG c. UTZ d. Venogram  Answer : d – insertion of a dye into a vein for the purpose of outlining an obstruction or lesion.
  19. 19.  Chronic Bronchitis ( Blue Bloater )  Main problem : excessive mucus secretion with the airways and recurrent cough usually related to smoking , pollution and infection.  Initial Manifestation : Cough with copious sputum  Laboratory data : ABG reveals respiratory acidosis  Nursing Diagnosis : Impaired breathing pattern  Interventions : Increase Humidity Provide postural drainage before meals Relieve bronchospasm Teach the patient about breathing techniques like : blowing bubbles , blowing a trumpet , blowing a feather in the air  Complete Heart Block  Main Problem : altered transmission of wave impulses from the SA node to the AV node  Initial Manifestation : Bradycardia  Laboratory data : ECG reveals prolonged PR interval  Nursing Diagnosis : Altered tissue perfusion  Interventions : Monitor patients’ ECG Prepare patient for pacemaker insertion A common sign of pacemaker failure is hiccups Atropine Sulfate is given as a vagolytic  Congestive Heart failure  Main Problem : failure of the heart to pump blood to meet oxygen requirements.  Initial manifestations : Right sided edema , hepatomegaly Left sided : dyspnea , rales  Laboratory data : Elevated CVP above 12 mmHG for right sided failure. Elevated PAP and PCWP for left sided failure  Nursing diagnosis : altered cardiac output related to impaired contractility  Interventions : Maintain patient in semi – fowlers position Administer digitalis and diuretics as ordered Maintain low sodium and low cholesterol diet Monitor potassium levels  Crohn’s Disease ( Regional Enteritis)  Main Problem : Chronic Inflammatory Disease of the small intestines  Initial manifestation : Crampy abdominal pain in the right lower quadrant of the abdomen  Laboratory data : Barium Swallow reveals “string sign”  Nursing Diagnosis : Pain and alteration in bowel elimination ;diarrhea  Interventions : Maintain high protein , high carbohydrate , low fat diet Administer steroids as ordered
  20. 20. Provide small frequent feeding Monitor input and output  Cushing ‘s Syndrome  Main Problem : Hypersecretrion of the glucocorticoids by the adrenal glands  Initial Manifestation : Central type or truncal obesity with thin extremities, moon face , buffalo hump and hirsutism  Laboratory data : Elevated serum cortisol levels, hypernatremia , hypokalemia , hypertension , hyperglycemia  Nursing Diagnosis : Altered skin integrity related to impaired healing  Interventions : Maintain patient on high potassium and low sodium diet Instruct patient that treatment will involve lifelong administration of glucocorticoid synthesis inhibitors ( Mitotane ) Inform patient about slow wound healing  Cystitis  Main problem : inflammation of the urinary bladder  Initial Manifestation : Frequency and Urgency  Laboratory data : Culture and sensitivity tests reveal the presence of bacteria usually E coli  Nursing diagnosis ; Altered Urinary Elimination  Interventions : Increase Oral Fluid Intake Instruct the patient to avoid bubble baths , silk underwear. Cotton underwear is preferred. Maintain acid ash diet ; (cheese , cranberry , prunes , plums , poultry , eggs)  Diabetes Mellitus  Main Problem : Chronic disorder of cardohydrate , protein and fat metabolism characterized by an imbalance between insulin supply and demand. Type 1 – IDDM ( no insulin ) ; Type 2 – NIDDM ( little insulin or insensitivity of cells to insulin)  Initial manifestation : Polyuria , Polyphagia , Polydipsia and weight loss  Laboratory data ; elevated FBS level above 120 mg / dl  Nursing Diagnosis : Alteration in nutrition  Interventions : D-IET : 50-60%cho , 20-30% FATS , 10-20% CHON I – NSULIN – TYPE 1 A – NTIDIABETIC AGENTS –TYPE 2 B – LOOD SUGAR MONITORING E - XERCISE T – RANSPLANT OF PANCREAS
  21. 21. E – NSURE ADEQUATE FOOD INTAKE S – CRUPULOUS FOOT CARE STRICT MONITORING FOR COMPLICATIONS( DKA for IDDM and HHNKS for NIDDM)  Diabetes Insipidus  Main Problem : Hyposecretion of antidiuretic hormone  Initial manifestation : Polyuria , polydipsia  Laboratory data : fluid deprivation test confirms the disorder  Nursing Diagnosis : Fluid Volume Deficit  Interventions : Maintain Adequate fluid intake Monitor urine specific gravity Administer Desmopressin acetate or Vasopressin intranasally as ordered  Dementia , Alzheimers  Irreversible progressive impairment in the patients cognitive functioning, memory and personality  Confusion, easy forgetfulness and memory loss( cannot retain or recall recent information)( confabulates to cover up memory loss)  Cognitive assessment- deterioration of cognitive ability Mental status exam – reveals disorientation and recall difficulty. Functional Dementia Scale shows some degree of dementia Cortical atrophy seen on MRI / CT scan  Altered thought processes  Group therapy and increase social interaction - reminiscence therapy to increase self esteem ) Provide for a safe , highly structured environment. Maintain consistency and provide constant orientation When agitated – redirect focus Simplify communications , tasks and routines Diet adequate in folic acid and provide adequate fluids and nutrition Palliative medical management with: Anticholinesterase – Tacrine(Cognex), Donepezil (Aricept) Antipsychotics, Benzodiazepines,Antidepressants and Vitamin E supplements 1. Clinical manifestations more typical of dementia include all of the following except: a. wandering:becoming lost b. impairment of cognitive functioning c. memory impairment d. no personality changes
  22. 22.  answer : d - in dementia there is personality changes that interfere with ADL.  Delirium  Acute reversible disturbance of consciousness accompanied by a change in cognition not attributed to pre-existing dementia lasting several hours or days  Altered psychomotor activity such as apathy, withdrawal and agitation with disorientation  Result of a physiologic condition, metabolic imbalance, intoxication, substance withdrawal, toxic exposure, prescribed medicines or combination . No specific laboratory test. Multiple tests to rule out or confirm underlying factors  Altered cerebral perfusion and high risk for injury  Assess and correct underlying physiologic problem  Create a structured safe environment  Decresase sensory stimulation and administer medications as ordered:  Tranquilizer  Benzodiazepines  Cholinesterase inhibitors  Antipsychotics  Risperidone(risperdal) 1) Clinical manifestations not typical of delirium : a) Slowed thought processes , confusion and disorientation b) Misperception of stimuli and incoherent speech c) “ sundowner’s syndrome” and dream like state d) memory impairment , aphasia and apraxia  answer : d - memory impairment , aphasia and apraxia more associated with dementia  Compartment Syndrome  Pressure within a muscle and its surrounding structures increases causing circulation impairment or interruption caused by application of dressing, tight casting, burns, closed fractures and crushing injuries  Pain increased with stretching and unrelieved by narcotic analgesics Paresthesias, pallor, pulseless and paralysis  No specific diagnostic test  Risk for peripheral neurovascular dysfunction  Position the affected extremity lower than the heart to increase circulation to the area
  23. 23. Bivalving or removal of dressings and constrictive coverings from area Monitor affected extremity and perform neurovascular checks. 1) In patient with complaining of intense pain on the casted extremity unrelieved by analgesics the nurse would : a) Ask the patient to wiggle the fingers or toes of the extremity b) The nurse would refer to patient to the AP for increase in narcotics c) check for distal pulses and elevate the extremity d) prepare the client for possible bivalving  answer d : in compartment syndrome emergency bivalving is the most appropriate intervention done  Disseminated Intravascular Coagulation ( DIC )  Main Problem : Wide spread coagulation all over the body resulting to subsequent depletion of clotting factors  Initial Manifestation : petechiae and ecchymosis on the skin , mucous membrane , heart lungs and other organs  Laboratory Data : Prolonged PT and PTT  Nursing Diagnosis : Risk for Injury  Interventions : Monitor for signs of bleeding ( tarry stool , hemoptysis , nosebleeding ) Administer heparin as ordered.heparin inhibits thrombin thus preventing further clot formation and allowing coagulation factors to accumulate. Administer Blood transfusion as ordered Instruct patient to avoid aspirin and aspirin containing compounds  Diverticulitis  Main Problem _ Inflammation of a pouch or saccular dilation in the colon ( diverticula)  Initial Manifestation : Left lower Quadrant Pain  Laboratory data : Sigmoidoscopy confirms the diagnosis  Nursing Diagnosis : Pain  Interventions : Provide Low Fiber Diet ( avoid vegetables) in diverticulitis, high fiber in Diverticulosis Administer Metamucil as ordered Administer meperidine for relief of pain  Dumping Syndrome  Main Problem : Rapid emptying of the stomach contents into the small intestine usually a complication of gastric surgery
  24. 24.     Initial manifestations : 3 D’s ( Diarrhea , Diaphoresis , Drowsiness) Laboratory data : non – specific Nursing Diagnosis : Altered Elimination Interventions : Maintain patient on supine position after Meals and withold fluids during meals Maintain high fat , high protein , dry diet, low in simple sugars ( fat delays emptying of the stomach  Emphysema (Pink Puffer)  Main problem : destruction of the alveoli , narrowing of small airways and trapping of air resulting in loss of lung elasticity  Initial manifestation : shortness of breath ; barrel chest ( increase in anteroposterior diameter of the chest ) is a late sign  Laboratory data : ABG reveals Respiratory Acidosis  Nursing Diagnosis : Ineffective breathing Pattern  Interventions : Keep the patient in orthopneic position / sitting Administer low flow oxygen Encourage patient to do pursed lip breathing Instruct patient to avoid powerful odors , extremes of temperature, pets , fireplace and feather pillows  Endocarditis  Main Problem : Infection of the inner lining of the heart caused by direct invasion of bacteria leading to deformity of the valve leaflets  Initial Manifestation : Fever  Laboratory data : elevated ESR  Nursing Diagnosis : Altered Cardiac Output  Interventions : Record daily weight Evaluate jugular vein distention, as this signifies the development of CHF Instruct the patient to take antibiotics before dental procedures that can cause bleeding Avoid sharing of needles Teach the women in child bearing years the risks of using IUD’s or other birth control ( source of infection )  Epileptic Seizure  Main Problem : Abnormal sudden excessive discharge of electrical activity within the brain  Initial Manifestation : Impaired Consciousness  Laboratory Data : EEG ( abnormal brain waves ) , CT scan reveals brain lesions
  25. 25.  Nurisng Diagnosis : Altered tissue Perfusion  Interventions: (On seizure precautions) Maintain Patent Airway Protect from injury Do not restrain Administer valium,drug of choice as prescribed ; & other anticonvulsants Oxygen equipment and suction at bedside  Fractures  Break in the continuity of the bone due to trauma, bone tumors and osteoporosis  Acute pain, cyanosis, loss of function, swelling , deformity and crepitus  Antero posterior lateral X-ray of the area  Acute pain and impaired physical activity  Rest Immobilize Cold compress and control bleeding Elevate Alleviate pain by giving adequate analgesics/narcotics except in presence of head injury Prepare patient for reduction and alignment ( Splinting , casting, application of traction and surgical fixation (CRIF/ORIF) Provide adequate care for clients with traction T-rapeze bar overhead R – equires free – hanging weights A – nalgesics is given to relieve pain C – heck circulation (pulse) T – emperature monitoring I – nfection prevention O – utput and intake monitoring N – utrition( appropriate diet) S – kin must be checked frequently 1) In management for fractures by closed reduction the bones are:
  26. 26. a) b) c) d) Realigned through surgical means May involve removal of damaged bone Bone replacement with prosthesis Bones realigned without surgery and cast applied to hold bones in alignment  Answer : d – closed reduction – bone realignment without surgery  Glaucoma  Main problem: increased intraocular pressure due to accumulation of aqueous humor  Initial manifestation : Tunnel Vision , Gun Barrel Vision Closed angle – with pain  Laboratory Data : Tonometer reading of 25 mm Hg and above  Nursing Diagnosis : Potential for Injury related to visual impairment  Interventions : Explain to the patient that glaucoma cannot be cured but it can be controlled Administer Miotics ( pilocarpine ) Mydriatics contraindicated(ATSO4) Instruct patient to avoid activities that can contribute to increased IOP Teach patient about trabeculoplasty – creation of an opening in the trabecular meshwork to increase the outflow of aqueous humor.  Gastritis  Acute and chronic inflammation of gastric mucosa causing edema, hemorrhage and erosion  Abdominal cramping, epigastric discomfort, hematemesis and indigestion  Occult blood in stool and vomitus, decreased Hgb and Hct Upper GI endoscopy confirms diagnosis when performed within 24 hours of bleeding  Acute and chronic pain Risk for fluid volume defict Altered nutrition less than body requirements  Give IVF and antiemetics. Monitor MIO Provide bland diet in smaller frequent meals Administer antacids(between meals) and H2 blockers to promote healing, anticholinergics and Vit B12 Angiography with vasopressin infused in NSS during bleeding
  27. 27. Teach importance of smoking cessation , avoid spicy foods and caffeine, taking steroids with milk, foods or antacids and to avoid aspirin containing compounds 1) Complications of gastritis include a) gastric carcinoma and pernicious anemia b) bleeding and dehydration c) a and b d) b only  answer : b - gastric carcinoma , pernicious anemia, bleeding and dehydration are complications of gastritis  Guillain – Barre Syndrome  Main Problem : acquired acute inflammatory disease of the peripheral nerves  Initial Manifestation : ascending paralysis , weakness at first  Laboratory Data :CSF exam reveals elevated total protein  Nursing Diagnosis: Ineffective Breathing Pattern  Interventions : Maintain a patent airway Monitor for respiratory involvement Instruct patient to avoid crowded areas Keep tracheostomy and suction equipment at bedside  Hemophilia  Main Problem : Deficiency of clotting factors. Sex –linked recessive trait ( type A and B ) more common in males. Von Willebrands disease is transmitted to both male and female offsprings of a carrier  Initial Manifestation: Hemarthrosis ( bleeding joints)  Laboratory Data : prolonged Bleeding Time  Nursing Diagnosis: Altered tissue perfusion  Interventions : Avoid Aspirin Control by : Rest Immoblize Cold Compress Elevate  Hepatic encephalopathy / coma  Main Problem : Decreasing level of consciousness related to accumulation of ammonia  Initial manifestation : personality changes ; flapping tremors (asterexis) common sign
  28. 28.  Laboratory Data : Elevated serum ammonia  Nursing Diagnosis : Altered Thought Process  Interventions : Monitor LOC Maintain low CHON diet  Hiatal Hernia  Main Problem :A portion of the stomach is herniated through the esophageal hiatus of the diaphragm  Initial Manifestation: initially asymptomatic , heartburn is a common complaint  Laboratory Data: Endoscopy reveals herniation of a part of the stomach  Nursing Diagnosis : Altered Nutrition  Interventions : Maintain the patient in an upright position after meals Instruct patient to avoid bending Provide small frequent meals Avoid anticholinergic drugs and coughing  Hip Fracture  Main Problem : Break in the continuity of the hip bone  Initial manifestation: Shortening and external rotation of the affected leg  Laboratory : Hip X – ray  Nursing Diagnosis : Impaired Physical Mobility  Interventions : Prepare the patient for surgery Postoperatively maintain the legs in abduction by placing a wedge pillow between legs Monitor for signs and symptoms of complications ( petechiae over chest indicates fat embolism)  Hyperparathyroidism  Main Problem : hypersecretion of the parathyroid hormone  Initial manifestation : bone pain  Laboratory Data : elevated serum calcium levels  Nursing Diagnosis : Risk for Injury  Interventions : Prepare the patient for Surgery Increase oral fluid intake Provide low calcium diet Strain all urine Complication : renal calculi
  29. 29.  Hypertension  Main Problem : Persistent BP above 140 / systolic and 90 / diastolic  Initial manifestation : Asymptomatic , occipital headache is a common complaint  Laboratory data : elevated BP  Nursing Diagnosis : Altered Tissue Perfusion  Interventions: Avoid Stimulants Low salt , low fat diet Stress reduction techniques Lifestyle , dietary and behavioral modification Compliance to HPN pharmacotherapy Specially maintenance meds  Hyperthyroidism  Main Problem : Hypersecretion of thyroid hormones  Initial manifestation : Fine hand tremors , intolerance to heat is a common symptom  Laboratory Data : Elevated T3 and T4  Nursing Diagnosis : Risk for Injury  Interventions : Maintain a high calorie , High CHON Diet Provide adequate rest Provide acool environment Elevate head of bed Propylthiouracil medication is lifetime Prepare patient for thyroidectomy Post thyroidectomy – assess for hemorrhage by slipping the hand behind the neck  Hyperlipidemia  Increased serum levels of two plasma lipids; cholesterol and triglycerides above 200 mg/ dl. Factor causation of atherosclerosis and conductive to arteriosclerosis  Initially asymptomatic  Lipid Profile Test – elevated  Non compliance to therapeutic regimen  Instruct patient to eat salmon and tuna at least several times a week and increase intake of high fiber foods Administer antilipidemic drugs with meals – Clofibrate ( Atromid-S) and Cholestyramine ( Cuemid) 1) Management for patients with hyperlipidemia: a) Diet low in cholesterol and saturated fats
  30. 30. b) Carbohydrate restricted diet c) A and b d) A only  Answer : c – low saturated fat and low cholesterol diet can maintain serum cholesterol below 140 mg/dl. Carbohydrate restriction can lower serum triglyceride levels by reducing lipoprotein derived from carbohydrate  Hypoparathyroidism  Main Problem : Hyposecretion of parathyroid hormone  Initial manifestations : Tingling sensation around the lips and upper extremities  Laboratory Data : Decreased serum calcium levels  Nursing Diagnosis : Potential ; altered cardiac output  Interventions : Assess for increased signs of neuromuscular irritability ( Chvosteks’ and Trousseau’s Sign) Provide a quiet room , no stimulus Provide high calcium , low phosphorus diet  Hypothyroidism  Main Problem : Hyposecretion of thyroid hormone  Initial Manifestation : Fatigue , facial edema is a common sign  Laboratory Data : Decreased T3 and T4 levels  Nursing Diagnosis : Activity Intolerance  Interventions : Maintain low calorie , low cholesterol and low saturated fat diet Provide warm environment and avoid sedatives Provide frequent rest periods Instruct patient that administration of synthroid is lifelong  Hypovolemic shock  Main Problem : Loss of effective circulating blood volume leading to circulatory collapse resulting to inadequate tissue perfusion  Initial manifestation : narrowing pulse pressure  Diagnostic data ; Decreased BP and Decreased CVP  Nursing Diagnosis : altered Tissue Perfusion  Interventions : Maintain patent airway
  31. 31. Keep patient in modified trendelenburg position Start fluid replacement immediately Administer vasopressors as ordered  Hemorrhoids  Varicosities or outpouching of the veins of the hemorrhoids plexus  Internal- painless bleeding in defecation External – intense rectal itching with bleeding and pain upon defecation  Rectal examination  Pain related to irritation, pressure, sensitivity in recto-anal area  Conservative treatment: Application of hot and cold compress Analgesic ointment(nupercaine) Hot sitz bath Prepare patient for treatment by ligation, injection of sclerosing agent or preop and post –op care for hemorroidectomy Position prone post hemorroidectomy, Watch out for hemorrhage 24 hours to 10 days post-op when sutures are sloughing off. Administer laxative, full diet until few hours before anesthetic is given. Stool softeners and bulk formers(Metamucil) Increase bulk and fluids 1) Post hemorrhoidectomy nursing care monitoring for potential complication includes observation for: a) Bleeding and urinary retention b) Bleeding and atelectasis c) Respiratory complications and urinary retention d) None of the above  Answer : a – bleeding and urinary retention are possible complications of hemorrhoidectomy  Increased intracranial pressure  Main problem : increase in amount of CNS tissue or CSF fluid leading to an ICP greater than 15 mmHg  Initial Manifestation : Widening pulse pressure , decreasing LOC  Laboratory Data : elevated Blood pressure ( systolic)  Nursing diagnosis : Potential for ineffective breathing pattern  Interventions : Keep the patient in high – fowler’s position Administer dexamethasone and mannitol as ordered to decrease cerebral edema Monitor level of consciousness  Liver Cirrhosis  Main Problem : Normal liver tissues are replaced with scar tissues
  32. 32.     Initial manifestation : edema Laboratory data : elevated SGOT / SGPT ; AST / ALT Nursing Diagnosis: Altered Fluid Volume Interventions : Maintain A low protein diet Assess the patient for bleeding Prepare the patient for paracentesis Weigh the patient daily Asterixis indicates hepatic encephalopathy  Meniere’s Disease  Main Problem: Dilation of the endolymphatic system causing degeneration of the vestibular and cochlear hair cells in the inner ear . It affects cranial nerve VIII  Initial Manifestations : Vertigo usually described by patients as “ I feel like I’m spinning “ , I feel as if the room is revolving “  Laboratory Data : Caloric Stimulation test reveals moderate nystagmus  Nursing Diagnosis : Risk for Injury  Interventions : Priority Safety Keep the patient in supine position during the attack Maintain low sodium diet Encourage the patient ot stop smoking Keep the room dark when photophobia is present  Multiple Sclerosis  Main Problem : Chronic Progressive disease of the CNS characterized by small patches of demyelination in the brain and spinal cord  Initial Manifestations : Intentional Tremors and Diplopia  Laboratory Data : MRI reveals small plaques scattered throughout the CNS  Nursing Diagnosis : Impaired Physical Mobility related to nuscle weakness ; Risk for injury  Interventions : Promote safety of the client Teach the patient certain stress management techniques Encourage daily exercise  Myasthenia Gravis  Main Problem ; Faulty Neuromuscular transmission of the voluntary muscles of the body due to a deficiency in acetylcholine receptor sites in the myoneural junction  Initial Manifestation : Descending muscle weakness initially manifested by ptosis  Laboratory Data : CT scan reveals hyperplasia of the thymus gland. Tensilon test ; increased muscle strength 30 seconds after administration of Endrophonium
  33. 33.  Nursing Diagnosis : Ineffective Breathing Pattern  Interventions : Maintain Patent Airway Instruct the patient to avoid quinidine , morphine and antibiotics since these may trigger muscle weakness. Instruct the patient to avoid prolonged talking over the phone especially before meals since this will weaken the facial muscles which are also used for eating.  Intestinal obstruction  Blockage of intestinal lumen causing gas, fluid and digested material substance to accumulate near the obstruction and increase peristalsis.H2O and electrolytes are then secreted into the blocked bowel causing inflammation and inhibiting absorption  Abdominal distention, cramping pain, decreased or absent bowel sounds  Abdominal X-ray – increased amount of gas in the bowel  Acute pain related to abdominal distention Constipation related to inability of stool to pass through obstructed area  Place patient on NPO and fluid and electrolyte replacement through IVF infusion Assess bowel sounds,mio,vs and labs- stoll exams and measure abdominal girth to assess for distention Semi-fowlers for comfort , bedrest and quiet envt. Administer analgesics( Demerol)and antibiotics(Gentamycin) Teach and monitor pre-op and post –op care for bowel resection with or without anastomosis Avoid constipating food GI decompression using NGT, Miller abbott or cantor tubes maintained position and low intermittent suction 1) The priority nursing diagnosis for patients with bowel obstruction are Constipation related to inability of stool to pass through obstructed area and: a) Fluid volume deficit, potential for b) Pain c) High risk for infection d) Potential for non – compliance  Answer : b : pain is an immediate problem the other choices are potential problems.  Myocardial Infarction  Main Problem : Destruction of the cardiac tissue due to reduced coronary blood flow  Initial Manifestation : lower sternal pain not relieved by rest and nitroglycerine , characterized as crushing or excruciating  Laboratory Data : Elevated CPK and Troponin , ECG reveals ST segment elevation or depression and T wave inversion
  34. 34.  Nursing Diagnosis : Pain related to decreased tissue oxygenation Interventions: Morphine / Demerol to relieve pain Oxygen Administration Nitroglycerine Aspirin Position in semi-fowler’s Maintain low fat , low cholesterol and low sodium diet  Osteoporosis  Main Problem : Loss of bone matrix leading to bone weakness predisposing it to fractures. Usually associated with smoking , menopause , immobility and hyperparathyroidism  Initial manifestation : asymptomatic  Laboratory Data : X- ray reveals decrease in bone density  Nursing Diagnosis : Potential for Injury  Interventions ; Increase Vit D and Calcium in the diet Estrogen replacement therapy for post menopausal women Encourage patient to perform active weight bearing exercises like brisk walking , jumping rope , hiking , tennis and bal;lroom dancing. Swimming does not meet criteria for resistance needed for prevention of osteoporosis  Metabolic acidosis  state of excess acid accumulation and deficient base bicarbonate  drowsiness and Kussmauls respiration, CNS depression, lethargy and stupor  ABG reveals pH < 7.35 and HCO3 level < 24 mEq / L  Impaired gas exchange  Assess and correct underlying cause Watch out for increased serum potassium,frequent monitoring of vital signs , labs and level of consciousness Keep sodium bicarbonate ready and institute seizure precautions. Teach urine and blood tests for sugar or acetone. Encourage strict adherence to OHA or insulin therapy 1) Hyperglycemia in patients with IDDM can cause what metabolic imbalance: a) Metabolic acidosis b) Metabolic alkalosis c) All of the above d) None of the above  Answer : a – excess production of metabolic acids such as hyrglycemia in patients with IDDM warrants use of fats which liberates ketone bodies which is a metabolic acid precipitates metabolic acidosis.
  35. 35.  Metabolic Alkalosis  Clinical state marked by decreased amounts of acid and increased amounts of base bicarbonate  Confusion, hypoventilation, irritability, picking at bedlinens and twitching  ABG pH . 7.45 and Bicarbonate level > 28 mEq / L  High risk for injury related to metabolic alkalosis Alteration in tissue perfusion and Impaired gas exchange  Assess and Treat underlying cause  Measure I and O and watch out for tachycardia and hypotension indicating hypokalemia Avoid the use of alkaline agents such as antacids, bicarbonate of soda and no administration of IVF with increased concentration of bicarbonate or lactate Acidifying agent- ammonium Chloride IV and potassium Chloride – supplements IV ( not given to clients with hepatic and renal diseases and given on slow infusions to prevent hemolysis) 1) Most appropriate nursing intervention to correct metabolic alkalosis is to: a) infuse Potassium chloride b) Use of antacids and bicarbonate of soda c) IVF with bicarbonates and lactate d) All of the above  Answer : a - Infusion of acidifying agents are beneficial to counteract metabolic alkalosis  Respiratory alkalosis  Deficiency of CO2 in the blood as indicated by decreased PaCO2 caused by alveolar hyperventilation which elevates blood Ph.  Deep rapid breathing > 40 bpm( cardinal) Circumoral or peripheral paresthesias Carpopedal spasms and lightheadedness  ABG – Pa CO2 < 35 mHg  Impaired gas exchange Ineffective breathing pattern  Eradicate underlying condition by treatment of CNS disease, fever, sepsis or removal of ingested toxins Teach effective deep breathing into a paper bag Watch out for twitching and cardiac arrythmias Monitor ABG’S and serum electrolyte levels
  36. 36. 1) Common management for respiratory alkalosis includes: a) Oxygenation by nasal cannula b) Oxygen delivery by face mask at 10 LPM c) Teach deep breathing in a paper bag d) Encourage patient to breathe deeply in a pursed lip manner  Respiratory Acidosis  Acid – base disturbance characterized by excess CO2 in the blood( hypercapnia) >45 mmHg resulting from reduced alveolar ventilation  Restlessness and confusion  ABG – Ph below normal < 7.35 ; pCO2 > 45  Impaired gas exchange Ineffective breathing pattern  Monitor pulmonary function tests  Prepare patient for intubation and /or mechanical ventilation if with hypoxemia, decreased level of consciousness and respiratory distress. Administer antibiotics, sodium bicarbonate and bronchodilators as needed Chest physiotherapy, suctioning and O2 with humidification Eradicate underlyingt cause by intubation and Mech. Ventilation, removal of foreign body and dialysis to remove toxic drugs. 1) Respiratory acid – base imbalance caused by retention of CO2 which combines with H2O to form carbonic acid H2CO3 includes the following disorders except: a) COPD and Asthma b) hyperventilation c) CNS depression d) Pulmonary edema and respiratory paralysis  Answer : b – hyperventilation causes alkalosis  Pancreatitis  Main Problem : Autodigestion of the pancreas  Initial Manifestation : Periumbilical Pain  Laboratory Data : Elevated Serum Amylase  Nursing Diagnosis : Pain
  37. 37.  Interventions : Administer Demerol to relieve pain. Morphine contraindicated as it causes spasm of the spincter of oddi Maintain low fat diet , patient on NPO during acute phase Instruct patient to avoid coffee and alcohol  Parkinson ‘ s Disease  Main Problem : Progressive Neurologic Disorder affecting the brain centers responsible for control and regulation of movement due to depletion of dopamine  Initial manifestation : Bradykinesia  Laboratory data : No Specific  Nursing Diagnosis : Risk for Injury  Interventions ; Maintain Exercise program Maintain a low protein diet at daytime and high protein at night because absorption of levodopa which is usually taken at daytime is slowed down by intake of high protein foods and vitamin B6 Institute safety measures ( rubber soled shoes , low heels and grab bars ) Prepare patient for stereotaxic thalamotomy , surgery done to decrease tremors  Peptic Ulcer Disease , Duodenal  Main Problem : Increased in HCL acid levels in the stomach  Initial manifestation : Right Epigastric Pain which occurs 2-3 hours after meals usually at night and is relieved by eating  Laboratory Data : Gastric Analysis reveals elevated HCL  Nursing diagnosis : Potential for fluid volume deficit  Interventions : Maintain high fat , high carbohydrate and low protein diet. Instruct patient to avoid spicy and caffeine containing foods , alcohol and smoking  Peptic Ulcer Disease , Gastric  Main Problem : Weak Gastric Mucosa  Initial Manifestation : Left epigastric pain which occurs 30 minutes – 1 hour after meals usually at day time and is relieved by vomiting  Laboratory Data : Endoscopy reveals ulcer usually in the lesser curvature of the stomach  Nursing Diagnosis : Potential for fluid volume deficit  Interventions ; Maintain High fat , high carbohydrate and low protein diet Instruct the patient to avoid spicy , caffeine containing foods , alcohol and smoking
  38. 38. Administer antacids separately from other drugs that the patient is taking , as ordered. Prepare patient for surgery ( Billroth 1 , 2 or gastrectomy or vagotomy)  Raynauds disease  Main Problem : VAsospastic condition of arteries of the hands tha occurs with exposure to cold or stress  Initial Manifestation : Intermittent arteriolar vasoconstriction  Laboratory Data : Allen’s test reveals circulatory problems  Nursing Diagnosis : Altered Tissue Perfusion  Interventions : Avoid cold weather  Wear leather gloves when getting anything from the refrigerator  Stop smoking  Administer vasodilators as ordered  Renal Colic ( Urolithiasis)  Main Problem : Presence of renal stone in the urinary system  Initial manifestation : Sudden severe pain that leads to shock, unrelieved by analgesics  Laboratory Data : IVP reveals the presence of stone  Nursing diagnosis : Pain  Interventions : Strain all patients urine , to assess if the patient is passing out stones Increase Oral Fluid Intake Prepare Patient for Extracorporeal Shock Wave Lithotripsy- area submerged in water and electrically generated shock wave directed to the location of the stone. Pain medications given to minimize pain Maintain patient on low sodium , low protein diet  Renal Failure , Acute  Main Problem : Abrupt reversible cessation of renal function as a result of trauma , allergy and kidney stones  Initial Manifestation : Oliguria ( U.O. , 400 ml / 24 hours )  Laboratory data : elevated BUN and creatinine  Nursing Diagnosis : Alteration in Urinary Elimination Fluid and electrolyte imbalance
  39. 39.  Interventions : Monitor Intake and output Maintain a low protein , high carbohydrate , low sodium diet and fluid restricted during the oliguric phase and high protein , high calorie and fluid replacement during diuretic phase  Renal Failure , Chronic  Main Problem : Irreversible slow or progressive failure of the kidneys to function that results in death unless treatment is instituted  Initial manifestation : GI manifestations like anorexia , nausea and vomiting  Laboratory Data : Elevated serum creatinine level and low urine creatinine clearance  Nursing Diagnosis : Alteration in urinary elimination Fluid Volume Excess  Interventions : Maintain low protein , low sodium , low potassium diet Prepare patient for hemodialysis / peritoneal dialysis and monitor for complications Monitor for signs and symptoms of anemia Administer Epogen , diuretics and antihypertensives as ordered  Pulmonary Embolism  Obstruction of blood flow to pulmonary vessels by an undissolved substance( air, fat, emboli,thrombus) resulting in pulmonary hypertension and possible iinfarction  Sudden onset of dyspnea, tachypnea, crackles and chest pain  ABG – hypoxemia; pulmonary angiography shows location of embolism and filing defect CXR – shows pneumoconstriction pulmonary arterial dilation Lung scan shows VQ mismatch  Impaired gas exchange Ineffective tissue perfusion; cardiopulmonary  Monitor ABG and watch out for respiratory distress and assess cardiovascular status and CVP Irregular pulse – arrhythmia caused by hypoxemia Hyperthermia – pulmonary embolism caused by thrombophlebitis
  40. 40. Monitor lab studies – maintain PTT at 1 ½ to 2 times control in patient with heparin – PT at 1 ½ to 2 times control or INR at 2 -3 in patient receiving coumadin Place patient in fowlers position, suction and administer IVF, analgesics, anticoagulants, diuretics and fibrinolytics as ordered 1) The nursing diagnosis with least significance for patients with pulmonary embolism is: a) Altered pattern of breathing related to dyspnea b) Impaired gas exchange related to decreased diffusion c) Pain related to pleural irritation d) Anxiety related to hypoxia  Answer : d – physiological needs first  Pulmonary Edema  A condition characterized by excessive amount of fluid in the alveoli and pulmonary interstitial tissues which tends to interfere with effective diffusion of gases  Dyspnea, orthopnea, crackles paroxysmal nocturnal dyspnea and pink frothy sputum  Pulmonary function tests decreased VQ ratios, ABG’s indicate hypoxemia  Impaired gas exchange related to right to left shunting and decreased V/Q ratios Fluid volume excess related to left ventricular failure in cardiogenic pulmonary edema Decreased cardiac output related to left ventricular failure in cardiogenic pulmonary edema  Monitor blood gases If on ventilator , suction frequently. Maintain oxygenation with ventilator( on PEEP) or nasal cannula Restrict fluids and sodium for edema Administer inotropic drugs(Dopamine and dobutamine) and diuretics in cardiogenic pulmonary edema Prevent pulmonary infection with strict asepsis Maintain nutrition with parenteral or enteral feedings 1) An example of a drug used in pulmonary edema to decrease circulating fluid volume a) Dopamine ( Intropin) b) Dobutamine ( Dobutrex) c) Lasix( Furosemide) d) Digoxin ( Digitoxin)  Answer : c – furosemide is a diuretic which decreases fluid volume by increasing renal water excretion
  41. 41.  Pneumothorax  A restrictive respiratory disease occurs when air enters the pleural space as a result of pulmonary lesion, neoplasms, accidental or surgical opening through the chest wall. Collapse of the lung due to air in the pleural space.  Hemothorax – blood  Hydrothorax – water  Pyothorax – pus and exudates  Acute symptoms of dyspnea and paradoxical chest movement( absent or restricted movement on the affected side with decreased or absent breath sounds , may lead to mediastinal shift)  Lung scan shows VQ ratio mismatches  CXR showing decreased perfusion ABG showing hypoxemia  Impaired gas exchange  Monitor PFT’s and prepare patient for thoracentesis and observe for complications of chest tube placements ( constant bubbling in the water seal chamber– indicates leak; 3 days post insertion can indicate lung re-expansion) Place patient in high fowlers position and place on O2 therapy as indicated. Instruct patient to do valsalva maneuver during chest tube removal. 1) The following are measures to promote adequate respirations and maintain proper function of the drainage bottle system: a) Prevent movement to prevent displacement of the tube b) Keep drainage bottles below chest level and position patient flat on bed c) Constant clamping of the tubes d) Milking not routinely done  Answer : d – patient is positioned in semi- fowlers,drainage bottles below chest level, milking not routinely done as it increases negative pressure, clamping of the tube done only when bottles are broken or must be raised above the chest.  Systemic Lupus Erythematosus  Chronic autoimmune multi-system disorder with periods of exacerbation and remission and increased production of antibodies to cellular DNA results in inflammatory process involving veins and arteries causing pain swelling and tissue damage.  Pancytopenia and butterfly rash on the face, palmar erythema, psychosis and impaired cognitive function migratory pain and swelling, hypertension & carditis  Positive rheumatoid factor and ANA test positive  ESR elevated and serum globulins elevated
  42. 42. Urine chemistry – proteinuria and hematuria  High risk for injury  Diet high in iron , CHON, vita.C Hemodialysis and kidney transplant if renal failure occurs Increase rest and sleep Monitor musculo skeletal, renal and cardiopulmonary status Administer antiemetics , and antidiarrheals Encourage expression of body image change Avoid infections, injury, sunlight exposure, OTC meds, oral contraceptives, hair spray and color Give medications as ordered – analgesics , anti-emetics, anti-rheumatics, cytotoxic drugs, steroids and NSAIDS. 1) Complications of SLE includes peripheral vascular disease which can be a cause of a. Loss of limbs b. COPD c. Congestive heart failure d. Stroke  Answer : a – PVD as a complication of SLE can lead to peripjeral tisuue necrosis which warrants amputation  Urinary Tract Infection  Infection of the urinary tract as a result of urethral ascend of bacteria usually caused by E. Coli. Cystitis – inflammation of the urinary bladder Pyelonephritis  inflammation of the kidney and its pelvis  Flank pain, with frequency,burning and urgency Chills , muscle spasm, dysuria  Urinalysis and urine C/ S confirms causative agent  Pain alteration in comfort  Stress the importance of medication compliance and bedrest during acute phase Relieve flank pain with analgesics , rest massage and external heat application Sulfonamides and broad spectrum antibiotics, urinary antiseptics ( Bactrim , Septra) and urinary analgesics ( Pyridium) Increase oral fluid intake up to 4 liters per day and follow up urinalysis every two weeks for a month then monthly until urine is sterile.
  43. 43. 1.)the following statement is true about pyelonephritis except a. may follow cystitis b. clinical manifestation includes costovertebral angle tenderness c. most commonly caused by E coli d. all of the above  answer : d – all statements are descriptive of pyelonephritis  Retinal Detachment  Main Problem : Separation of the sensory retina from the pigment epithelium of the retine  Initial manifestation : Visual floaters described by patients as cobwebs or curtain in eyes  Nursing Diagnosis : Potential for Injury  Interventions : Immediate Bedrest Position patient with the affected side towards the bed , so gravity may help put the detached retina back into place . Avoid coughing ,sneezing and straining prepare the patient for eye surgery.  Spinal Cord Injury  Main Problem : Partial or complete disruption of nerve tracts and neurons resulting in paralysis and sensory loss  Initial manifestation : Depends on the level of injury Cervical : Quadriplegia Thoracic : Paraplegia Lumbar : Paraplegia  Laboratory Data : X – Ray reveals the location and extent of injury  Nursing Diagnosis : Ineffective Breathing Pattern , Impaired Physical Mobility  Interventions : Avoid hyperflexion and hyperextension of the spine . log roll the patient Keep a catheter at the bedside to prevent bladder distention which may stimulate autonomic dysreflexia  Syndrome of Inappropriate antidiuretic Hormone (SIADH)  Main Problem : Inappropriate continued release of antidiuretic hormone resulting in water intoxication
  44. 44.  Initial Manifestation : Mental Confusion  Laboratory Data : Hyponatremia – Na , 120 mEq / L  Nursing Diagnosis : Fluid Volume Excess Fluid and electrolyte imbalance  Interventions : Fluid Restriction Assess for signs and symptoms of hyponatremia  Ulcerative Colitis  Main Problem : Ulceration of the mucosa of the lower colon and rectum  Initial manifestation : Bloody Mucoid Diarrhea  Laboratory data : Barium enema reveals lesions  Nursing Diagnosis : Pain Altered Bowel Elimination ; diarrhea  Interventions : Avoid dairy products Maintain Low Residue and High protein Diet , avoid cold fluids Teach patients about familial predisposition GOODLUCK AND GOD BLESS…JLO