Medical surgical nursing-1 2nd year B.sc nursing blueprint question solution II LONG QUESTION 2024

Unit 4
Qn :1
a) Define Gastritis
b) Explain etiology and pathophysiology of Gastritis
c) Prepare a nursing care plan for Mr.X,who is suffering from acute Gastritis,based on
at least three prioritized nursing diagnoses
Ans)
Introduction
Gastritis is a common Gastrointestinal problem.It is a condition of the stomach where the
inner lining becomes inflammed.Gastric- refers to stomach and itis- refers to
inflammation.The term Gastritis used in a highly non specific manner by both lay persons
and health care personnels
a) Definition
• Gastritis is an inflammation, irritation or erosion of the lining of the stomach.
• Gastritis is an inflammation of gastric mucosa.
Types
• Acute Gastritis
Acute gastritis is short term inflammatory process lasting several hours to a few days
• Chronic Gastritis
Gastritis can occur from reflex of bile salts from the duodenum into the stomach as a
result of anatomical changes following surgical procedure such as gastroduodenostomy
and gastrojejunostomy.
• Erosive Gastritis
It is a type of gastritis that does not cause significant inflammation but can wear away
the stomach lining. It can cause bleeding, erosion or ulcer
b) Etiology
Diet
• Acute alcoholism
• Eating large quantities of spicy, irritating foods
• Excessive amount of tea,coffee,mustard,paprika, clove and pepper
• Food poisoning
• Foods with rough texture or those eaten at an extremely high temperature

Drugs
• Aspirin,NSAIDS, Cox -2 inhibitors, histamine receptors, antagonists,proton pump
inhibitor, corticosteroids
Disorders
• Uremia, shock, central nervous system lesions, hepatic cirrhosis, portal
hypertension and prolonged emotional tension
Pathophysiology
Due to etiological factors, the protective mechanism of the mucosa are overwhelmed
or breakdown in the normal gastric mucosal
Barrier
• Acid diffused back into mucosa
• Stimulation of Hcl
• Conversion of pepsinogen to pepsin
• Release of histamine from mast cells
• Edema, disruption of capillary walls with the loss of plasma into gastric lumen and
possible hemorrhage
c) Nursing Care Plan
I. Acute pain related to irritated stomach mucosa
Goal :
• Patient gets relief from pain
Interventions :
• Assess the intensity location, and duration of pain
• Avoid food and beverages that may be irritating mucosa
• Administer antacids and analgesics
II. Deficient fluid volume related to insufficient fluid intake and excessive fluid
loss

Goal :
• Patient maintains normal fluid volume in the body
Interventions:
• Assess the intake and output
• Administer iv fluids
• Always alert for sign of hemorrhage
III. Imbalanced nutrition less than body requirement related to inadequate
intake of nutrients
Goal:
• Patient maintains balanced nutrition as per body requirement
Interventions :
• Assess the nutritional status
• Provide physical and emotional support
• Keep the patient NPO until nausea and vomiting subsides
Conclusion
Gastritis is the most common illness associated to the stomach and can be
considered as the beginning of different complication that may led to peptic
ulcers disease and gastric adenocarcinoma.
(Book references : Brunner S L, Suddarth S D. ‘ Textbook of medical and
surgical nursing '. 11th
edition. Lippincott Williams and Wilkins. Newdelhi.
Vol 1. 1204-1208 )
UNIT-4
LONG ESSAY
2.a)Define peptic ulcer.
b)Enlist causes and clinical features of duodenal ulcer.
c)Enlist the medical and nursing management of Mr.Y, who is suffering from
duodenal ulcer.
ans)a)INTRODUCTION
Peptic ulcer disease is a condition characterized by erosion of the GI mucosa resulting
from the digestive action of Hcl acid and pepsin.
DEFINITION

A lesion in the lining (mucosa)of the digestive tract physically in the stomach or
duodenum caused by the digestive action of pepsin and Hcl.
b)CAUSES
Helicobacter pylori infection
Excessive secretion of Hcl
Regular use of pain reliever eg.aspirin ,ibuprofen,NSAIDs
Hereditary factors
Smoking
Alcohol consumption
Mental stress
Personality type :highly nervous ,emotional,aggressiveindividual are more
prone to get ulcers.
Irritants:excessive use of strong coffee,tea,spices,alcohol,tobacco.
CLINICAL FEATURES
1. Abdominal bloating
2. Abdopain in the upper middle part of abdomen
3. Minal burning
4. Heart burn
5. Belching
6. Feeling offullness
7. Loss of appetite
8. Nausea and vomiting
9. Weight loss
10. Bloody stool
11. Black or tarry stool
12. Vomiting blood or black material
13. Constipation
14. Diarrhoea.
c)MANAGEMENT
Medical management
→ proton pump inhibitons; such as omeprazole,pantoprazole, nabeprazole .
→ Arbeids: antacids relieve mild heartburn by neutralizing acid in the stomach.
Such aspirin, sodium bicarbonate,calciumcarbonate
→ Antibiotics: amoxicillin, clarithromycin
→ Non-steroidal anti-inflammatory drugs:Acetaminophen
→ H2 - recepton antagonists: these medications reduce the amount of acid in
the stomach.eg: Ranitidine, cemetidine
→ cytoprotective agents: helps to protect the tissuesthat line the stomach & intestine
eg: misoprostol, Bismuth subsalicylate
Nusing management

Assess the pain level
Administer prescribed medications
Avoid,spicy,irritant food and beverages,colas,tea,coffee,chocolates.
Encourages patient to eat regularly spaced meals in a relaxed atmosphere.
Obtain regular weight and encourage dietary modifications.
Drink adequate fluid
Monitor vital signs frequently
Monitor intake and output chart
Maintain an iv line for infusing fluid and blood
Monitor oxygen saturation and administer oxygen therapy.
Encourage family to participate in care and give emotional support.
CONCLUSION
Conclusion: Peptic ulcer disease is a common condition, early diagnosis, and
treatment, will not only treat your patient, rather, but it will also prevent serious and
life-threatening complications.
REFERENCE
Refered from suresh .k.sharma volume 2 871 page number
Unit 4 : Nursing management of patient with disorders of digestive system
Qn- 3. a) Definition hernia.
b) Enlist the types of hernias.
c)Explain the pre and post operative nursing management of Mr.
M who underwent Herniorrhaphy.
Ans.
HERNIA
Introduction
A hernia is an abnormal protrusion of an organ or a portion of it through
the containing wall of its cavity, beyond its normal confine.
Definition
Hernia is defined as a condition in which part of an organ or the
muscular wall of an organ is displaced and protrudes through the wall of cavity that
normally consists it
Types of hernia
1. Reducible Hernia
. It may appear as a new lump in the groin or other abdominal area
. It may ache but is not tender when touched

. Sometimes pain precedes the discovery of the lump.
. It may be reduced unless very large
2. Irreducible Hernias
. It may be an occasionally painful enlargement
. Some may be chronic without pain
. An irreducible hernia is also known as an incarcerated hernia
. It can lead to strangulation
3. Strangulated Hernias
. This condition is a surgical emergency
. The affected person may appear ill with or without fever
. Sometimes symptoms of bowel obstruction
. Pain is always present, followed quickly by tendernes
Causes
. Obesity
. Heavy lifting
. Persistentt coughing
.Straining with dedication or urination
.Diarrhea and constipation
. Ascites fluid in the abdominal cavity
.Peritoneal dialysis
.Ventriculoperitonial shunt
. Chronic obstructive pulmonary disease
. Family history
. Poor nutrition
. Smoking
Clinical manifestations
. Pain in abdomen , pelvis and testicle
. Abdominal discomfort
. Abdominal distension
. Groin discomfort
. Abdominal tenderness
. Swelling
. Difficulty in swallowing
. Chest pain
. Fatigue
Diagnostic evaluation
History collection
Physical examination

Complete blood count
Electrolytes , BUN
Urine analysis
Ultrasonography
CT scanning
Upright chest radiography
Management
Pharmacological management
Antibiotics , ampicillin , cefataxim
H2 receptors antagonist : rantidine , cemetidine
Proton pump inhibitor : omeprazole , rabeprazole , pantoprazole
Antacids : maganesium hydroxide , aluminimun hydroxides
Analgesics
Surgical management
Herniorrhapy : It involves restoring the displaced tissue to their proper position
Hernioplasty : Hernioplasty is used for large hernias . In this surgical
procedure plastic or steel mesh is added to the abdominal wall to repair and
reinforce weak spot
Laproscopic surgery : It is performed with general anaesthesia . A half inch or
smaller incision is made in theabdomen . A camera called laproscope is inserted
into the abdomen to visualize the hernia defect on the monitor
NURSING MANAGEMENT
➢Pre - Operative Management
● Collect detailed history
● Physical examination
●Signed informed consent form
● Monitor lab investigation report , blood test,blood grouping and cross matching,
urine analysis, ultrasound
● Maintain NPO
● Iv access for fluids ,medications such as sedatives, antibiotics
● Explain procedure to the client
● Prepare surgical site (shave and clean )
● Provide psychological support to the client
●Monitor vital signs
➢Post-Operative Management

●Provide comfortable position
●Monitor vital signs
●Administer oxygen
●Monitor blood oxygen saturation level
●Administration of Iv fluids
●Maintain input – output chart
●Follow aseptic dressing procedure
●Provide fluid diet until GI tract function become normal
●An antibiotics ointment prescribed for incision
●Administer analgesic for pain
●Avoid heavy weight lifting and strained activities
●Encourage movement and deep breathing exercises
●Instruct the client to avoid wearing tight clothes
●Administer laxatives or stool softener to avoid strainfuldefecation
Reference
Shamala mam’s notes
Unit 4:Nursing Management of Patient with Disorders of Digestive System
Qn-4
a) Define Intestinal obstruction
b) List the types of intestinal obstruction and clinical Manifestation
c) Explain the pre operative management of Intestinalobstruction Mr. B who
is posted for laparotomy.
Ans:
Intestinal obstruction
Introduction
A bowel obstruction can either be a mechanical orfunctional obstruction of
the small or large intestine. Overall, the most common cause of
mechanical obstruction are adhesions, hernias and tumors.
Definition
Intestinal obstruction is defined as significant mechanical impairment which is
partial or complete blockage of the bowel that result in the failure of the passage of
intestinal contents through the intestine.
Types
Two types of intestinal obstruction are:-

Mechanical obstruction: An intraluminal obstruction or a mural obstruction from
pressure on the intestinal walls occurs. Examples are intussusecption,polypoid tumors
and neoplasms, neoplasms, stenosis, strictures, adhesions, hernias and abscesses.
Functional obstruction: The intestinal musculature cannot propel the contents Along
the bowels Examples are amyloidosis, muscular dystrophy, endocrine disorders such
as diabetic mellitus and neurological disorders such as Parkinson’s disease. The
blockage can be also temporary and the result of manipulation of the bowel during
surgery.
Clinical features
• Abdominal cramping pain
• Constipation
• Nausea and vomiting
• Diarrhea
• Dehydration
• Anorexia
• Weight loss
• Shock
• Fecal vomiting
• Generalized malaise and aching
• Reverse peristalsis movement
• Swelling and distention of the abdomen
Inability to pass or to have a bow
Management
❖Medical management
➢Pharmacological management:
Analgesics:to relieve pain
Antiemetics:to relieve vomiting
Antibiotic:to treat bacterial growth
Anticholinergic:treat colicky pain
Non pharmacological management
Place iv line to replace the H2o,Na,K
Insert NG tube to suck out fluid,air.
Placing flexible catheter in the bladder to drain urine
Ambulation of the client
Nursing management
Assessment:-
•Assess the signs and symptoms of abdominal pain, indigestion, nausea and
vomiting.

•Take the history of prolonged constipation and complaint of dysphagia and
abdominalPain.
•Assess for the diagnostic studies of the radiography of the flat and upright
abdomen.
• Assess for the abdominal distension through bowel sounds.
Decompression of the bowel through a nasogastric tube by the removal of gas,
and fluid, correction and relief of the obstruction. Decompression of the bowel is
done by inserting the NG tube or intestinal tube.
Nursing diagnosis
➢Ineffective breathing pattern related to abdominal distension, interfering
with normal lung expansion
Goal:-
▪Patient maintain normal breathing pattern
Interventions
▪Keep the patient in Fowler's position to promote ventilation.
▪Provide oxygenation to the patient. Monitor ABG level for oxygenation to
decompress.
Nursing diagnosis
➢Acute pain related to obstruction, distension, and strangulation
Goal:-
✓pt get relief from pain
Interventions
▪Provide supportive care during NG intubation to assist with
discomfort.
▪To relieve air-fluid syndrome, turn the patient from supine to prone
position ever 10 minutes until enough flatus is passed to
decompress the abdomen.
▪A rectal tube may be indicted. Administer prescribed analgesics.
Nursing diagnosis
➢Risk of fluid deficit volume related to impaired fluid intake, vomiting,
and diarrhea
Goal:-

✓Patient maintain fluid balance
Interventions
▪Measure and record all intake and output.
▪Administer IV fluid and parental nutrition as prescribed. . Measure and
record all intake and output.
▪Administer IV fluid and parental nutrition as prescribed
Nursing diagnosis
▪. Risk for electrolyte imbalance related to suctioning.
Goal:-
▪To maintain electrolyte balance
Interventions
▪Monitor electrolyte values to identify imbalances.
▪Monitor vital signs and watch for signs of electrolyte for imbalances such as
weakness accompanied by low potassium levels to identify imbalances for
prompt treatment.
▪Give ice chips sparingly if ordered by the physician melted ice increases
electrolyte and hydrochloric acid removal when suctioned from the
stomach, and electrolyte imbalance and metabolic alkalosis occur.
Conclusion:-
Intestinal obstruction is a digestive system disorder that may affect the
intestinal which are responsible formovement of digestive food
particles,faeces and gases
Reference:-
Text book of medical surgical nursing
Deepak Sethi
Page no:713-718
UNIT-4
Nursing management of patient (Adult including elderly )with disorder of digestive
system
5.a) Define appendicitis
b) enlist clinical manifestation of appendicitis

c) explain nursing management of Mr. A following appendicitis based on at
least three prioritized nursing diagnosis
Answer :
APPENDICITIS
INTRODUCTION
Appendicitis is a serious disorder of appendix, a finger-shaped pouch that projects
from colon on the lower right side of abdomen. Appendicitis causes pain in lower
right abdomen. However, in most people pain begins around the navel and then
moves.
DEFINITION
Appendicitis is defined as an inflammation of the vermiform appendix
b) Signs and symptoms of appendicitis
SIGNS
Rebound tenderness:
A doctor applying hand pressure to a patient abdomen. Pain felt upon release of
pressure indicates Rebound tenderness.
Rovsing’s sign:
A doctor tests for Rovsing’s ’s sign by applying hand pressure to the lower left side of
the abdomen. Pain felt on the lower side of the abdomen up on the release of pressure
on the left side indicates the presence of Rovsing’s ’s sign
pSoas sign:
A doctor can check for the “psoas sing” by applying resistance to the knee as the
patient tries to lift the right thigh while lying down. Positive psoas sign cause
abdominal pain.
Obturator sign :
Doctor test for the obturator sign by asking the patient to lay down with the right leg
bent at the knee, moving the bent kneeleft and right. requires flexing
the obturator muscle and will cause abdominal pain if the appendix is inflamed.
Aaron's sign:
Aaron’s sign is the pain felt in the epigastrium upon
continuous Firm McBurney point, it is indicate of chronic appendicitis
SYMPTOMS
Abdominal pain.
Abdominal tenderness.
Pain that worsens during coughing.
Nausea.

Vomiting.
Loss of appetite.
Fever.
Constipation.
Inability to pass gas /flatus.
Diarrhoea.
Abdominal swelling/ distension.
c) Patient named Mr. A admitted with appendicitis.
NURSING MANAGEMENT
Assessment
Assess the level of pain.
Assessment of Gastrointestinal disturbance,anorexia,vomiting, nausea.
Assessment of bowel pattern
Nursing diagnosis
1.Acute pain, right lower quadrant of abdomen related to obstructed appendix
as evidenced by painscale reading.
Goal: patient get relief from pain.
Intervention
Assess the general condition of the patient.
Check the pain level.
Monitor vital sign.
2.Risk for fluid volume deficit as evidenced by nausea or vomiting as evidenced
by observation
Goal:Patient experiences adequate fluid volume and electrolyte.
Intervention
Encourage patient to drink prescribed fluid amounts.
Obtain and maintain a large-bore IV
Observe input and output chart
3. Risk for infection related to rupture appendix as evidenced
Goal:Patient risk for infection is reduced through ongoing assessment
Intervention
Report signs of infection immediately to ensure prompt treatment and
prevent exacerbation of renal symptoms.
Provide comfort measures as needed

Protect patient from exposure to other infected patients.
CONCLUSION
Appendicitis is a condition that is prevalent in the developed world and
should have minimal complication. Surgical action should be taken without delay. If
left untreated there is a risk of peritonitis, which is the main complication of this
condition.
Reference:
Brunner’s and Suddartha’s
Textbook of Medical Surgical Nursing
Page No. 898-900
6.a. Define cholelithiasis.
.b. Describe pathophysiology and enlist clinical features
.c. explain the pre and post operative nursing management of Mrs .X. who is
suffering from cholelithiasis
ANSWER:
.a. DEFINITION
Cholelithiasis is defined as the presence of stone in gall bladder.
UpGall stone is a crystalline concentration formed within the gall bladder
by acceration of bile components causes obstruction for the bike flow into the
small intestine.
Types
• CHOLESTEROL STONE:light yellow to dark green or brown in colour.
• PIGMENT STONE: these are small and dark in colour.
•MIXED STONE : these are typically contain 20-80% of cholesterol .
.b. PATHOPHYSIOLOGY
*Due to etiology factor.
* Decrease bile acid synthesis.
* Increased cholesterol synthesis in liver
* super saturation of bile with cholesterol.
* formation of precipitate
* accumulation of gall stone
*Inflammatory changes
* Bile duct obstruction.
• CLINICAL MANIFESTATION
* pain in the abdomen

* abdominal swelling
* Abdominal distension
* Abdominal bloating
* Abdominal tenderness
* Gall bladder becomes distended
* Clay colored stool
* fever and chill
* Nausea and vomitting
* Sweating
• .c. PRE OPERATIVE NURSING MANAGEMENT
- Ensure that the client takes nothing by mouth .
- Remove nail polish , lipstick,and makeup to facilitate circulatory assessment
during and after surgery.
- Ensure that identification , blood,and allergy bands are correct
, legible,and secure.
- Complete part preparation as ordered.
- Administer preoperative medication as scheduled.
- Verify that the informed consent has been signed prior to
administering preoperative medications.
- Explain the procedure.
•POST OPERATIVE NURSING MANAGEMENT
1. Nursing diagnosis
Acute pain related to surgical incision as evidenced by verbalization
Goal- patients relieve from pain
Nursing interventions
-provide comfort position
-administer analgesics
-provide divertion therapy.
2. NURSING DIAGNOSIS
Risk for deficient fluid volume related to vomitting
Goal - patient maintain good skin turgor .
Nursing interventions
- Asses skin turgor
- Perform frequent oral hygiene.
- Advice to take plenty of water.
• .3 NURSING DIAGNOSIS

Imbalanced nutrition status ,less than body requirement related to inadequate bile
secretion.
• GOAL : patient get relief from vomitting.
• Nursing interventions
- Assess the abdominal distension
- Ambulate and increase activity as tolerated
- Provide parental feedings as needed.
UNIT-4 GASTRO INTESTINAL SYSTEM
7. A) Define ulcerative colitis.
b) Describe the pathophysiology and clinical manifestations of ulcerative
colitis.
c) Explain the nursing management of Mr. B who is suffering from ulcerative
colitis.
ANSWER
Introduction
➢Inflammatory bowel disease is a chronic inflammation of the GI tract.
➢Inflammatory bowel disease is classified either as Crohn’s disease or ulcerative
colitis based on clinical manifestations.
➢Ulcerative colitis is usually limited to the colon.
➢It commonly occurs during the teenage years and early adulthood, and have a
second peak in the sixth decade.
a) Definition
Ulcerative colitis is a chronic inflammatory bowel disease that affects the lining of
the large intestine and rectum. It’s a superficial inflammation of the large intestine,
not caused by bacteria, which results in ulceration and bleeding.
b) Pathophysiology
Due to etiological factors
⬇️
Affects or damage the superficial mucosa of the colon
⬇️
Multiple ulceration and diffused inflammation
⬇️

Mucous becomes edematous
⬇️
Abscess formation and infiltration to sub mucosa
⬇️
Inflammation starts in colons and spreads proximally to rectum
⬇️
Bowel becomes narrow shortens and thickens because of muscular dystrophy
and fat deposits.
Symptoms of ulcerative colitis primarily affect the digestive tract and
include appetite loss, diarrhoea, weight loss, rectal bleeding, nausea and
abdominal cramping. Persistent diarrhoea can cause malnutrition, weakness,
and electrolyte imbalances ; younger individuals may be small or experience
delayed growth.
❖Common symptoms
Bloody stools
Fatigue
Loss of appetite
Low red blood cell count
Nausea with or without vomiting
Nutritional deficiencies
Unexplained weight loss
❖Extraintestinal symptoms
Eye pain and redness
Joint aches and pains
Mouth ulcers
Skin rash or changes
Loss of body fluids
Liver disease
Rectal pain
❖Serious symptoms
Inability to pass gas or stool
Severe abdominal pain

Vomiting
Vomiting blood
Gastrointestinal bleeding
c) Nursing Management
✓Assessment
o Subjective data:-
i. Past health history: infection, autoimmune disorders
ii. Medications: Antidiarrheal medications
iii. Family history of ulcerative colitis
iv. Nutritional-metabolic: Nausea, vomiting; anorexia. Weight loss
v. Diarrhoea, blood mucus or pus in stool
vi. Lower abdominal pain which worse before defecation, cramping, tenesmus
o Objective data:-
i. Assess for intermittent fever, emaciated appearance, fatigue.
ii. Pale skin with poor Turner, dry mucous membranes, skin
lesions, anorectal irritation, skin tags, cutaneous fistulas should be
assessed.
iii. Assess for abdominal distension, hyperactive bowel sounds ,
abdominal cramps
iv. Assess tachycardia, hypotension
v. In diagnostic findings assess for anaemia, leukocytosis, electrolyte
imbalancesabnormal sigmoidoscopy, colonoscopic and barium
enema findings.
✓Nursing diagnosis
➢Diarrhoea related to bowel inflammation and intestinal
hyperactivity or malabsorption of bowel.
Goal: Patient reports reduction in frequency of stools, return to more
normal stool consistency.
Intervention:
▪Observe and record stool frequency, characteristics amount and
precipitating factors.
▪Promote bed rest, provide bedside commode.
▪Provide opportunity to vent frustration related to disease process
▪Restart oral fluid intake gradually offer clear liquids hourly, avoid
cold fluids.
➢Fluid volume deficit related to excessive diarrhoea and vomiting.
Goal: Maintain adequate fluid volume

Intervention:
▪Monitor input and output chart
▪Observe for excessively dry skin and mucous membrane,
decreased skin Turner, slowed capillary refill.
▪Maintain oral restrictions, bed rest, avoid exertion.
▪Note generalized muscle weakness or cardiac dysrhythmia’s.
➢Altered nutritional status less than body requirement related to altered
absorption of nutrients
Goal:- Patient demonstrate stable weight and absence of signs of
malnutrition.
Intervention:-
▪Encourage bed rest and limit activity during acute phase of illness
▪Recommend rest before meals
▪Provide oral hygiene
▪Limit food that might cause abdominal cramping, flatulence(eg:
milk products)
➢Acute pain related to hyperperistalsis, prolonged diarrhoea, skin and
tissue irritation.
Goal:- Reported pain is controlled or relieved, Appear relaxed and able
to rest or sleep appropriately
Intervention:-
▪Encourage patient to report pain
▪Review factors that aggravates or alleviate pain
▪Provide comfort measures (eg:-backup, repositioning) and
diversional activities.
▪Provide sitz bath as appropriate.
Conclusion
Ulcerative colitis is a chronic disease which need long term management with primary
goal to induce then maintain remission and prevent complications.
Reference:-
Lewis's Medical Surgical Nursing Text
Volume-2,
3rd
South Asia edition
Chintamani and Mrinalini Mani
page no: 900-906
Nursing care plans

Marilynn E. Doenges
Mary Frances Moorhouse
Alice C. Ceissler,
F. A Davis Company. Philadelphia
Page no:471-485
Question No. 08
8.a)Define Pancreatitis.
b)Describe the pathophysiology and clinical
manifestation of pancreatitis.
c)Explain the medical and nursing management of Mr. A, who is admitted with acute
pancreatitis.
Answer :
INTRODUCTION
Pancreatitis is a serious disorder which affects pancreas. Pancreas is a long, large
and flat gland of about 6 inches (15.24 cm)that sits tucked behind the stomach in the
upper abdomen.
a.)DEFINITION
Pancreatitis is defined as an inflammation of the pancreas.
b.)PATHOPHYSIOLOGY
Due to etiological factors
⬇️
Premature activation of digestive enzymes in the pancreas.
⬇️
Trypsinogen ➡️ trypsin ➡️ Activation of digestive proenzyme.
⬇️
Release of enzymes into the pancreas and surrounding tissues.
⬇️

Tissue damage to pancreas and Retroperitoneum.
⬇️
Inflammation of the pancreas.
CLINICAL MANIFESTATIONS
● Severe abdominal and back pain, cramps.
● Abdominal tenderness
● Abdominal distension
● Nausea and Vomiting
● Ecchymosis (bruising)
● Fever
● Jaundice
● Mental Confusion
● Hypotension
● Acute renal failure
● Hypoxia
● Tachypnea, Tachycardia
● Dyspnea
● Respiratory distress
● Weight loss
● Steatorrhea
● Dehydration
● Skin rashes
● Clay- coloured stool
● Diarrhea
c.)There are two types of pancreatitis.
1. Acute pancreatitis
2. Chronic pancreatitis
● Acute Pancreatitis - It is a condition in which activated pancreatic enzymes leak
into the substance of the pancreas and initiate the auto - digestion of the gland.
● Chronic Pancreatitis - It is defined as permanent irreversible damage to pancreas
with histological evidence of chronic inflammation, fibrosis, destruction of
endocrine and exocrine tissues.
A patient named Mr. A, who is admitted with acute pancreatitis.
MEDICAL MANAGEMENT

1. Pharmacological Management
● Administration of antiemetic drugs to prevent nausea and vomiting.(Emset,
Domperidone, Dolastron )
● Administration of analgesics to relieve pain and inflammation.(Tramadol,
Morphine, zinconotide )
● Administration of antipyretics to reduce body temperature. (Paracetamol,
Acetaminophen )
● Enzyme supplement such as pancrealipase prescribed to help body absorb food
better.
● Multivitamins such as vitamin A, C, E, D and B-complex vitamins.
● Minerals such as magnesium, calcium, zinc.
● Omega -3 fatty acids to decrease inflammation and improve immunity.
● Histamine -2(H2) receptors antagonists. Ex:Ranitidine
2. Non - Pharmacological Management
● Provide bed rest to patient to prevent further complication.
● Provide wound care to prevent developing infections.
● Nutritional Support to the patient by maintaining healthy diet pattern.
● Provide range of motion to patient to maintain normal range of motion.
3. Surgical Management
● Pancreatectomy
● Pancreatico- jejunostomy
● Autotransplantation
NURSING MANAGEMENT
Assessment
● Assess level of pain.
● Assess GI distress, including nausea and vomiting and diarrhea.
● Assess for steatorrhea and malabsorption.
1. Acute pain in left upper and lower quadrant of abdomen related to inflammation
of pancreas.
Goal : Patient get relief from pain.
Interventions
● Assess the general condition of the patient.
● Check the pain level.

● Monitor vital signs.
2. Imbalanced nutrition less than body requirements related to loss of appetite.
Goal : Patient get relief from weakness.
Interventions
● Assess the nutritional status of the patient.
● Calculate BMI (Body Mass Index).
● Educate regarding the diet to be consumed.
3. Impaired thermoregulation, hyperthermia related to acute pancreatitis infection.
Goal : Patient get relief from nausea/
Vomiting.
Interventions
● Encourage client to have modified diet.
● Advice patient to avoid food that might cause abdominal cramps.
● Eliminate smell from the environment.
CONCLUSION
Acute Pancreatitis occurs suddenly and usually goes away in few days with
treatment.It is often caused by gall stones.Common symptoms are severe pain in the
upper abdomen, nausea and vomiting.Treatment is usually a few days in the hospital
for intravenous (IV) fluids, antibiotics and medicines to relieve pain.
Reference :
● Brunner's and Suddartha's
Textbook of Medical Surgical Nursing
Page No. 1003 - 1010.
9)Long essay
a)define cirrhosis of liver
A: Introduction

● Liver cirrhosis is a chronic , progressive degenerative disease of the liver
in which normal liver cells are damaged and then replaced by fibrous (scar tissue
)
● scar tissue replaces health healthy liver tissues particularly blocking the
blood flow through liver
● Liver is unable to function leads to liver failure
● Liver becomes hardened
Definition:
Liver cirrhosis is defined as degeneration of hepatocytes ,regenerative
(nodular)hyperplasia of the remaining or surviving hepatocytes and fibrosis. In
cirrhosis ,liver becomes small and shrunken
B)Mention the causes and clinical manifestations of cirrhosis of liver
A:. Causes
Alcohol is the commonest cause in the west but chronic HBV infection is the
commonest cause world wide .common causes are :
1. Alcohol (laennecs cirrhosis)-it is micronodular
cirrhosis
2. Chronic hepatitis (B,C)-it produces macrnodular
cirrhosis
3. Billiary cirrhosis-primaru or secondary
4. Autoimmune hepatitis

5. Haemochromatosis , Wilsons disease
6. Non-alcoholic fatty liver disease
7. Hepatic venous congestion
● Drugs eg .methotrexate ,oral contraceptive,isoniazid etc
Patients with Cirrohsis may be asymptomatic . Sometimes,the pattient may
present with mild hepatomegaly .
The earliest features pertain to GIT such as
● Nausea , vomiting
● Anorexia
● Weakness, lethargy,fatigue
● Weight loss
● Distension
Mainly the signs and symptoms are either due to portal hypertension and hepatic
insufficiency as follows
1)s/s of portal hypertension includes :
● Ascities

● Portasystemic shunting (caput medusae,oesophageal varices )and fetor
hepaticus (ammonical breath)
2)s/s of hepatic insufficiency include
● Jaundice
● Palmer erythema
● Spider angimata
● Clubbing of finger
● White nails anaemia
● Gynaecomastia
● Testicular atrophy in males Irregular menstruation in females
C)prepare a nursing care plan for Mr .a ,who is suffering from alcoholic
Cirrohsis of liver
Assessment:
The nursing assessment include history and physical examination to assess the
cause (alcohol, toxins, drugs, virus) and severity of cirrhosis
● Look for the signs of portal hypertension and hepatic encephalopathy.
● Assess the investigations and biochemical parameters for liver cell
decompensation when a client with cirrhosis of liver is hospitalised,
● use laboratory data and the client’s physical and psychosocial assessment
data to guide care planning
● Assess the client and his/her family for their knowledge about important
aspects of self-care.

Diagnosis :ineffective breathing pattern related to intra abdominal fluid
collection as evidenced by ascities:
Goal:maintain normal breathing pattern
Interventions:
1. Daily weight and abdominal girth
2. Keep head elevated ,position on side
3. Encourage frequent repositioning and deep
breath exercise
4. Monitor spo2 and ABG
5. Educate and assist the innovative spirometry
Evaluation: maintains a patent airway.
B)excessive fluid volume related to excessive sodium and fluid intake as
evidenced by edema :
Goals:relief from swelling
Interventions

1. Measure intake ,output and daily weight
2. Monitor bp and abdominal veins distension
3. Monitor for cardio arrhythmias
4. Assess degree of peripheral edema
5. Monitor the electrolyte balance
Evaluation:
Maintains adequate fluid and nutritional intake
C)imbalanced nutrition less than their body requirements related to inadequate
diet as evidenced by weight loss and poor muscle tone :
Goals :improve nutritional status
1. Measure the dietry intake by calories count
2. Tell the patient diet and encourage to eat food as body requirement.
3. Restrict intake of coffee ,spicy food and drinks
4. Monitor laboratory labs

Evaluation:improved nutritional status as evidenced by
D)deficiet knowledge related to lack of exposure as evidenced request for
information :
Goals :gain adequate knowledge
1. Review the disease process and future expectations
2. Discuss sodium and substitute rustication
3. Provide mind devotion activited
4. Emphasize the importance of good nutrition recommend avoid of high
protein diet
Evaluation
Demonstrates an adequate level of knowledge and performs self care adequately.
Conclusion
. Cirrhosis is a common end result of liver damage (Mostly caused by alcohol and
viral hepatitis)
Cirrhosis is a frequently encountered disease even among the young population.
. Cirrhosis prevalently affects male population.

• In its terminal stages, cirrhosis is frequently associated with other diseases and
may have fatal complications.
STOMACH CANCER
Introduction
Cancer of the stomach is the most common malignant disease more prevalent
among the lower economic class primarily living in urban areas. It is more
common in men than women. The most common cause is infection by the
bacteria HELICOBACTER pylori. Most cases of the stomach cancers are gastric
carcinomas
Definition
Stomach cancer is also called gastric cancer begins when cells in the stomach
become abnormal and grow uncontrollably.
Or
Stomach cancer is characterized by a growth of cancerous cells within the lining
of the stomach also called gastric cancer this type of cancer is difficult to
diagnose Because most people typically don’t show symptoms in the earlier
stages .
Incidence
1. According to the national Institute (NCI) approximately 7,60,000 cases of
stomachcancerarediagnosed worldwide.
2. Cancer of the stomach is 8th leading site of cancer overall. According to
department of health it is 6th among males and 10th among females.
3. Most 85%of cases of gastric cancer are adenocarcinomas that occures in the
lining of the stomach (Mucosa)
4. Approximately 40% cases develop in the lower part of the stomach (Pylorus)
5. 40% develop in the middle part (Body)

6. 15% develop in the upper part (Cardia)
Risk factors
• Family history
• Helicobacter pylori infection • Gastric polyp.
• Smoking and drug abuse.
• Chronic atrophic gastritis.
• Stomach injury .
• Pernicious anemia
Pathophysiology
(Diagram required )
Clinical features
• Discomfort or pain in the stomach area • Difficulty in swallowing
• Nausea and vomiting
• Weight loss
• GI bleeding
• Loss of appetite • Fatigue
Complications
• Hemorrhage
• Acute gastric distention • Nutritional problems
Diagnostic evaluation
• Through history and physical examination • Gastroscopic exam
• CT scan
• Complete blood count (CBC)
• Uper endoscopy • Biopsies
Explain the nursing management of Mr A. Who is suffering from carcinoma
stomach before and after total gastrectomy?
Nursing management
PREOPERATIVE CARE
• Consent must be taken prior to surgery
• The patients history of major illness ,previous surgeries, medication, alcohol
and tobacco is obtained.
• Bowel preparation must be done
• Catheterisation is provided before surgery.

• All pre medication should be done.
• Prepare the patient psychologically and reduce anxiety of the patient
• Patient should be NPO 12 hours before surgery.
Post operative care
• Monitor vital sign every 2 hourly.
• Inspect surgical site for redness itching etc.
• Asses complete blood count especially WBC level to check for infection.
• Monitor for complication like dumping syndrome .
• Monitor input and out put of the patient.
• Protect the airway.
• Monitor for gag reflexes .
• Provide comfort like semi Fowlers position.
• Manage drainage system
• Deacrecing the amount of food taken at one time and maintaining a eye protein
, high fat, low carbohydrate, dry diet.gastric emptying can be delayed by eating in
recumbent position or semi recumbent position lying down after meals
increasing the fat content in a diet and avoiding fluids one hour before or 2hours
UNIT-4
11.Mr.X is operated and admitted to post operative surgical ward with colostomy
a) Define colostomy
b) List the types of colostomy
c) Explain the postoperative nursing management of Mr X.
Ans:INTRODUCTION
Colostomy is an opening in the colon through which fecalmatters is eliminated.
The location of the colostomy affects characteristics of the fecal drainage,it
closer to rectum,the more formed the stool.
a)DEFINITION
Colostomy is an operation that create an opening for the colon or large intestine
through the abdomen.
b)TYPES
Single barrel colostomy

Double barrel colostomy
Loop colostomy
Single barrel colostomy:
➢It is usually permanent.
➢It removethe colon below the colostomy, include the rectum and anal opening.
Double barrel colostomy:
➢It is usually temporary and stoma may be adjacent or several inches a part.
➢Distil stoma connect to rectum and also called mucus fistula drains small
amount of mucus materials.
Loopcolostomy :
➢It is temporary and formed by bringing a loop of column through the abdominal
wall and the supporting it with the plastic brace.
➢The loop is opened up and stitched to your skin to form an opening called stoma.
c)NURSING MANAGEMENT
Nursing Assessment:
Assessment
Assess pain
Assess the integrity of skin.
Nursing diagnosis:
➢Acute pain:
Acute pain related to incisions.
Goals:
Verbalize pain is relieved.
Nursing intervention:
o Encourage use of relaxation techniques.eg;visualization, guide imagery.
o Provide comfort measures. eg;mouth care back rub.
o Assist with ROM exercises and encourage early ambulation.
➢Impaired skin integrity:
Impaired skin integrity related to absence of sphincter at stoma:
Goals:
Maintain skin integrity.
o Use a transparent,odor- proof drainable pouch.
o Support surrounding skin when gently removing appliance.
o Prescribed antifungal powder as indicated.

➢Risk for diarrhea:
Risk for diarrhea related to placement of ostomy in sigmoid colon.
Goals:
Maintain normal dehydration.
o Review dietary pattern and amount/type of fluid intake.
o Investigate delayed onset or absence of effluent.
o Demonstrate use of irrigation equipment per institution policy.
➢Disturbed sleep pattern:
Disturbed sleep pattern related to necessity of ostomy care.
Goals:
Increased sense of well-being and feeling rested.
o Restrict intake of caffeine-containing foods/fluids.
o Support continuation of usual bedtime rituals.
o Administer analgesics, sedatives at bedtime as indicated.
CONCLUSION
Colostomy is a surgically opening in the intestine. It may be temporary or
permanent. The pouch, skin and surrounding require care and maintenance by the
care giver or patient.
REFERENCE
NURSING CAREPLANS ,Guidelines for Planning and Documenting Patient Care
Marilynn E, Mary Frances Moorhouse, Alice C Geissler
3rd
Edition
Page no : 486 to 499
Unit 5
Q1
Mrs.R,35 years old suffering from Chronic lymphocytic Leukemia
a.list the types of leukemia
b.explain the clinical features of Chronic lymphocytic Leukemia
c.describe the management of leukemia
A).Introduction

Leukemia is a cancer that begins in the blood cells.normally cells grow and divide to
form new cells as the body needs them.
When cells grow old ,they die and new cells take their place some times it does not
work right.
Definition
Leukemia is a cancer of blood or bone marrow characterized by abnormal increase of
blood cells usually leucocyte (WBC).
Types of Leukemia
Acute lymphocytic Leukemia
Chronic lymphocytic Leukemia
Chronic myelogenous Leukemia
Acute myelogenous Leukemia
(1) Acute lymphocytic Leukemia:
It is atype of Leukemia that,all types of leukemia starts from white blood cells
in the bone marrow, the soft inner part of bones .it develops from cells called
lymphocytes ,types of WBCs central to immune system, an immature type of
lymphocyte.
Clinical manifestation
*fever
*pallor
*Bleeding
*Anorexia
*Fatigue
*weakness
*Bone joint and abdominal pain.
(2) Chronic lymphocytic Leukemia
It is atype of cancer of blood or bone marrow, normally bone make blood stem
cells (immature cells) that become mature blood cells over the time.
*usually their is no symptoms
*Chronic Fatigue, weakness, Anorexia,splenomegaly, hepatomegaly

* skin lesion
*anemia
*Thrombocytopenia
*The WBC count elevated to a level between 20,000 to 100,000
*increase blood viscosity and clotting episode.
(3) Chronic myelogenous Leukemia ( CML)
It is a type of cancer that starts in certain blood forming cells of the bone
marrow. And in this bone marrow produces too many white cells. It affects the
blood and bone marrow.
It occur between 25 -60 years of age. Peak 45 years and it is caused by benzene
exposure and high dose of variation.
*Fatigue, weakness, fever,sternal tenderness
*weight loss ,joint and bone pain
*massive splenomegaly and increase in sweating
*anemia and thrombocytopenia
(4) Acute myelogenous Leukemia (AML)
It is a fast growing cancer of blood and bone marrow where the bone
marrow makes many cancerous cells called Leukemia blasts ,normally blasts
develop into WBCs that fight infection, but in AML,Leukemia blast do not develop
properly and cannot fight infection. In there is proliferation of immature myeloid
cells.
B) Increased lymphocyte count(lymphocytosis )is always present.
The erythrocyte and platelet counts may be normal or in later stages of illness
decreased.
Enlargement of lymphocyte nodes (lymphadenopathy) is common. This can
be severe and sometimes painful. The spleen can also be enlarged (
splenomegaly)

Patients with CLL can develop B symptoms a constellation of symptoms
including fevers ,drenching sweats (especially in night) and unintentionally
weight loss.
T-cell function is impaired and may be the cause of tumor progression
and increased susceptibility to second maligancies and infections.
Viral infection such as herpes zoster can become widely disseminated
Defects in the complement system are also seen which results in Increased
risk of developing infection with encapsulated organisms.
Patients should receive an annual comprehensive skin examination and
screening guidelines for other cancers should be followed such as for breast,
colorectal,lung and prostate cancer .
(C) Medical Management
Chemotherapy: major form of treatment for Leukemia. This drug
treatment uses chemicals to kill Leukemia cells. Type of leukemia client may
receive a single drug or combination of drugs .these drugs may come in pill
form or they may be injected directly into the vein
Biological therapy: works by helping the immune system recognize and
attack Leukemia cells.
Targeted therapy:uses drugs that attack specific vulnerabilities with cancer
cells.
Radiation therapy: uses x-ray or other high energy beams to damage
Leukemia cells and stop their growth. Client may receive Radiation in 1
specific area of body we where there is collection of leukaemia cell orClient
may receive radiation over whole body
NON -PHARMACOLOGICAL
SURGICAL TREATMENT
Stem cell transplant: procedure to replace the diseased bone marrow with
healthy bone marrow
Before the stem transplant, client receives highdo doses of Chemotherapy or
radiation therapy to destroy diseased bone marrow.
The client receive an infusion of blood -forming stem cells that help to rebuild
the bone marrow
NURSING MANAGEMENT

History collection
Obtain patient family history, past Medical history
Ask for presence of exposure to any risk factors and etiology factors
Physical examination
Assessment for swollen lymph nodes ,spleen ,liver
Assessment for the client vital signs ,check client for presence of fever
Blood test
The lab does a complete blood count to check the number of white blood
cells ,red blood cells and platelets
Bone marrow aspiration
Thick hollow needle to remove sample of bone marrow The sample is taken
from the back of pelvic (hip)bone and with the help of needle small amount of
liquid bone marrow is sucked
DIAGNOSIS
1. Impaired tissue integrity related to high dose radiation therapy
GOAL
Patient maintain normal skin integrity
INTERVENTION
Avoid rubbing powders ,deodorants,lotions, or ointments.
Encourage the patiento keep the treated area clean and dry
Advise the Patient to bath the area gently with tepid water and mild soap
Encourage the Patient to wear loose fitting cloths
2. Risk for infection to decreased neutrophils, altered response to microbial
invasion, and presence of environmental pathogens
GOAL
Patient risk for infection to decreased neutrophils reduced through ongoing
assessment and early intervention.
ASSESSMENT
Inspect the Patient for the sign and symptoms of infection eg redness
Maintain a sepsis for Patient at risk
Instuct the Patient to take antibiotics as prescribed by doctor to prevent
microbial resistance.
Monitor granulocyte count ad WBC count to identify the presence of
infection.

3.impaired oral mucous membrane related to low platelet counts
GOAL
Patient maintain normal platelet count.
Assessment
Assist the Patient to select soft ,bland and nonacidic food to decrease irritation of
oral micosa
Advise the Patient to use soft toothbrush for removal of dental debris
Instuct the Patient to perform oral hygiene after eating and as often as needed to
avoid break down of oral mucosa
Advice the Patient to avoid use of lemon glycerin swabs to prevent excessive
drawing of mucosa.
CONCLUSION
Leukemia is a non tumorous cancer of the blood that develops exclusively in the
bone marrow of an individual. Lenalidomide consolidation improves the quality of
response in patients with CLL receiving first line induction. Longer follow up is
necessary in order to determine the clinical benefit with this strategy.
Reference: Brunner and Siddhartha
Vol 1
Page number:770-772
Deepak Sethi
Page number:217,220
-
LONG ESSAY
Unit 5 :
2. Mr.R 78 years old is admitted with congestive heart failure.
a) Define heart failure.
b) Explain the clinical features of heart failure.
c) Discuss in detail the medical and nursing management of heart
failure.

A:
A) INTRODUCTION:
Heart failure is an abnormal clinical condition involving
impaired cardiac pumping. It results in the characteristic
pathophysiologic changes of vasoconstriction and fluid
retention.
DEFINITION:
Heart failure is a clinical syndrome resulting from structural or
functional cardiac disorders that impair the ability of ventricles
to fill or eject blood.
Heart failure, often referred to as congestive heart failure
(CHF), is the inability of the heart to pump sufficient blood to
meet the needs of the tissues for oxygen and nutrients.
ETIOLOGY :
Coronary artery disease
Hypertension
Cardiomyopathy
Valvular disorders
Renal disfunction
Atherosclerosis of the coronary artery
Nutritional deficiencies
Anemia
B ) CLINICAL FEATURES:
There are 2 types of heart failure:
Left – sided heart failure
Right – sided heart failure.
Left -sided heart failure causes different manifestations than right -
sided heart failure.
Clinical features of Left -sided heart failure :
- Dyspnea
- Decrease in oxygen saturation may occur.

- Blood flow to the kidney decrease causing decreased
perfusion and reduced urine output.
- Crackles( pulmonary edema)
- Restlessness, confusion
- Fatigue, weakness.
- Dry , hacking cough
- Nocturia
Clinical features of right- sided heart failure:
- Jugular venous distention.
- Weight gain.
- Increase in heart rate
- Hepatomegaly ( liver enlargement)
- Ascites
- Anorexia
- Nausea
- Anxiety, depression
- Weakness.
DIAGNOSTIC EVALUATION :
History collection
Physical examination
An echocardiogram is usually performed to confirm the
diagnosis of HF.
Chest x ray and an electrocardiogram (ECG)
Laboratory studies usually performed during
the enitial workup include serum electrolytes, blood
urea nitrogen (BUN) , creatinine, liver function tests,
complete blood count and routine urine analysis.
Cardiac stress testing and cardiac catheterization.
C)Management
MEDICAL MANAGEMENT:
- Treatment options vary according to the severity of the
patients condition and may include:

- Oral and intravenous medications
- Major lifestyle changes such as include restriction of dietary
sodium, avoidance of smoking, avoidance of excessive fluid
and alcohol intake, weight reduction when indicated and
regular exercise.
- Patient must also known how to recognisesigns and
symptoms that need to be reported to the primary provider.
PHARMACOLOGICAL MANAGEMENT:
- Pharmacological management:
*Angiotensin – converting enzyme
inhibitors eg: lisinopril,enalapril. These drugs decreases
BP and afterload . Relieves signs and symptoms of HF .
*Angiotensin receptor blockers eg: balsartan,losartan .
Prevents progression of HF .
*Beta blockers eg: bisoprolol,metoprolol. dilates blood
vessels And improves exercise capacity.
*Diuretics eg: loop diuretic (eg: furosemide)
Thiazide diuretics (eg: metolazone).Decreases fluid volume
overload. Decreases signs and symptoms of HF.
*Digitalis eg: digoxin. Improves cardiac contractility.
- Non pharmacological management
*Diet which has low sodium.
*Avoidance of excessive amount of fluid.
*Oxygen therapy may become necessary as HF progresses.
SURGICAL MANAGEMENT:
- Cardiac transplantation:
A heart transplant is an operation in which a failing heart is replaced
with a healthier donor heart. Heart transplant is a treatment that’s usually
reserved for people whose condition hasn’t improved enough with
medications or other surgeries.
NURSING MANAGEMENT:

- Assessment:
*history collection: •History collection focuses on the signs
and symptoms of HF such as dyspnea, fatigue and edema.
•Sleep disturbance
•Nurses assess the patients understanding of HF , self-
management strategies, and the patients ability and
willingness to adhere to those strategies.
*Physical examination:
•the rate and depth of respiration are assessed along with
the effort required for breathing.
•the lungs are auscultated to detect crackles and wheezes.
•blood pressure is carefully evaluated.
•heart rate and rhythm are also documented.
•the feet and lower legs are examined for edema.
•the abdomen is examined for tenderness and
hepatomegaly.
•intake and output records are rigorously maintained
and analyzed.
1) •Nursing diagnosis:
Activity intolerance related to fatigue secondary to cardiac
insufficiency and pulmonary congestion as evidenced
by dyspnea, shortness of breath, weakness, increase in heart rate
on exertion.
•Goal :
Will achieve a realistic program of activity that balances
physical activity with energy -conserving activities.
• Intervention:
- Encourage alternate rest and activity periods to reduce
cardiac workload.

- Provide calming diversionary activities to promote
relaxation to reduce O2 consumption and to relieve dyspnea
and fatigue.
Excess fluid volume related to cardiac failure as evidenced
by edema , dyspnea on exertion, increased weight gain.
•Goal :
Experiences reduced edema or absence of edema .
•Intervention:
- Monitor renal function and intake and output to monitor
fluid balance.
- Monitor respiratory pattern for symptoms of respiratory
difficulty for early recognition of pulmonary congestion.
Impaired gas exchange related to increased preload ,
mechanical failure, or immobility as evidenced by
increased respiratory rate, shortness of breath,dyspnea on
exertion.
•Goal:
Maintains adequate respiratory rate and rhythm for
activities of daily living.
•Intervention:
- Monitor rate, rhythm, depth, and effort of respirations to
evaluate changes in respiratory status
- Administer supplemental oxygen as ordered to maintain
oxygen level.
- Position to alleviate dyspnea eg: semi fowler position.

- Introduction – Lewis page no:820
- Definition – Brunner and suddarths south asian edition page
no: 615. Brunner and suddarths 10th
edition page no:789
- ETIOLOGY – Brunner
and suddarths south asian edition page no: 616 .
- Clinical features – Lewis page no: 824. Brunner
and suddarths 10th
edition page no: 794 – 795
- Diagnostic evaluation – Brunner and suddarths 10 th edition
page no: 795-796.
- Medical management – Brunner
and suddarths south asian edition page no: 620.
- Pharmacological management – Brunner
and suddarths south asian edition page no 621 – 623 .
- Nursing management – Lewis page no: 835 -836.
Unit 5 : cardiovascular problems
Question no 3 : Mr.S , 60 yrs old man is admitted with heart failure.
a) Explain the causes of heart failure
b) List the signs and symptoms of right sided heart failure
c) Explain the nursing management of this patient with based on 3 nursing
diagnosis
Ans)
Introduction
❖Heart failure is a long terms condition in which your heart
can't pump blood will enough to meet your body's needs all the time
❖It is also known as congestive heart failure is
recognized as clinical syndrome characterized by signs and symptoms of fluid
overload or of inadequate tissue perfusion
Definition
❖Heart failure is the inability of heart to pump sufficient Blood to meet the
Needs of the tissue for oxygen and nutrients
❖The term heart failure indicates myocardial disease in which there is a
problem with contraction of heart ( Systolic Dysfunction ) or filling of the

heart(diastolic dysfunction) that may or may not cause pulmonary or systemic
congestion
❖It may occur at any age
a) Causes of heart failure
Systemic diseases are usually one of the most common cause of heart failure
*Coronary artery disease :
Atherosclerosis of the coronary arteries is the primary cause of heart failure and
coronary artery disease is found in more than 60% of the patients with heart failure
*Ischemia :
Ischemia deprives heart cells of oxygen and leads to acidosis from the
accumulation of lactic acid
*cardiomyopathy :
Heart failure due to cardiomyopathy is usually chronic and progressive
*systemic or pulmonary hyper tension :
Increased in afterload results from hyper tension which increased the workload of
the heart and leads to hypertrophy of myocardial muscle fibers
*Valvular heart disease :
Blood has increasing difficulty moving forward increasing pressure within the heart
and increasing cardiac workload
b) Signs and symptoms of Right sided heart failure
∆ Heart failure are two type
Right sided heart failure
Left sided heart failure
Right sided heart failure
➢When the right ventricle fails,congestion in the peripheral tissue
and viscera predominates
➢The right side of the heart cannot eject and cannot accommodate all the blood
that normally returns to it from the venous circulation
➢Increased venous pressure leads to JVD and increased capillary
hydrostatic pressure throughout the venous system
Signs and symptoms
o Enlargement of the liver result from venous enlargement of the liver
o Accumulation of fluid in the peritoneal cavity may increase pressure on
the stomach and intestines and causes gastrointestinal distress
o Loss of appetite results from venous engo garment and venous stasis within the
abdominal organ
Left sided heart failure
➢Left sided heart failure or left ventricular failure have different manifestation with
right sided heart failure

➢Pulmonary congestion occur when the left ventricle cannot effectively pump
blood out of the ventricle into the aorta and the systemic circulation
Signs and symptoms
Dyspnea or shortness of breath
Cough(dry and nonproductive)
Pulmonary crackle
Low oxygen saturation level
C) Nursing management
✓Assessment
The nursing assessment for the Patient with heart failure focus on observing for
the effectiveness of therapy and for patients ability to understand and implement self
management and strategies
Asses the signs and symptoms such as dyspnea,shortnessof breath,fatigue and
edema
Physical Examination
o Auscultate the lungs for presence of crackles and wheezes
o Auscultate the heart for the presence of an S3 heart sound
o Asses JVD for the presence of distension
o Evaluate the sensorium and level of consciousness
o Asses the dependent part of the patient body for perfusion and edema
o Asses the liver for hepatojugular reflux
o Measure the urinary output carefully to establish a baseline against which to asses
the effect of the diuretic therapy
o Weight
✓Nursing diagnosis
1. Decreased cardiac output related to of heart rate as evidenced by decreased heart
rate
➢Goal : patient demonstrate the increased cardiac output
➢Intervention
Asses the general condition of the patient
Check for any alternation in level of consciousness
Asses the patient vital signs
Asses the oxygen saturation
2. Acute chest pain related to heart failure as evidenced by pain scale reading
➢Goal : patient get relief from pain
➢Intervention:
Asses the general condition of the patient
Provide comfortable measures including repositioning


To provide diversional therapy to the patient
Provide a calm and quite environment
3. Impaired breathing patterns, dyspnea related to mucus secretion as evidenced by
decreased breathing pattern
➢Goal : patient get effective airway clearnce
➢Intervention:
Provide proper position,semi-fowler's position
Give deep breathing exercises
Perform suctioning
Provide warm water
Conclusion
❖When an understanding of all these elements is achieved,better care can be
given to the patient experiencing heartfailure, and mortality and morbidity can be
reduced
[ For reference : Medical-Surgical Nursing 3rd South Asia Edition (1
Volume set) 2018 By Chintamani and mrinalini page no : 692 -709 ]
Unit-05 : Nursing Management Of Patient with Blood & Cardiovascular System
Qno.04: a) Define Angina Pectoris
b) List the types of angina
c) Explain the medical and nursing management of patient with Angina pectoris
Introduction
Angina pectoris or simply angina is chest pain or discomfort that keeps coming back. It
happen when some part of your heart doesn't get enough blood and oxygen.Angina can be a
symptom of coronary artery disease(CAD).
a) Definition
Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms
of pain or pressure in the anterior chest.
b) Types
1) Stable angina: predictable and consistent pain that occurs on exertion and is relieved by
rest.

2) Unstable angina: it is also called preinfarction angina or crescendo angina. Symptoms
occur more frequently and last longer than stable angina.
3) Intractable or refractory angina: severe incapacitating chest pain.
4) Variant angina: It is also called prizme tails angina. Pain at rest with reversible ST-
segment,caused by coronary artery vasospasm.
5) Stent Ischemia: Objective evidence of ischemia,but patient reports no symptoms.
c) Management
1) Medical management
● Pharmacological management
The three major types of medications used in angina pectoris are:
1).Vasodilators
a.Short acting nitrates(sublingual and intravenous nitroglycerin).
b.Long acting nitrates (isosorbide dinitrate , nitroglycerin ointment).
2).Beta-adrenergic blocking agents: It inhibit sympathetic stimulation of receptors that
are located in the conduction system of the heart (eg: propranolol)
3).Calcium channel blockers: It inhibit movement of calcium within the heart muscle and
coronary vessels ( eg: nifedipine, verapamil, diltiazem).
● Non-pharmacological management
● Complete bed rest
● Assess pain
● Check for nitroglycerine side effects
● Administer O2, 3liter by nasal cannula
● Obtain ECG and vital signs
● Cardiac monitoring
2).Surgical management
● Percutaneous transluminal coronary angioplasty:
A balloon- tippid catheter is placed in a coronary vessel narrowed by plaque.The
Rballoon is inflated and deflated to stress the vessel wall and flatten the plaque.blood flows
freely through the unclogged vessel to the heart.

● Stent placement:
A diamond mesh tubular device
is placed coronary vessel.
● Artherectomy:
A blade- tipped catheter is
guided in to a coronary vessel to the site of the plaque.
● Laser angioplasty
● CABG (coronary artery bypass graft)
3).Nursing management
Diagnosis
1) Acute pain related to an imbalance in oxygen supply and demand.
Goal
● Reports of pain varying in frequency, duration andintensity
Intervention
1) Place patient at complete rest during anginal episodes
2) Elevate head of bead if patient is short of breath
3) Monitor heart rate and rhythm
4) Assess and document patient response to medication
Diagnosis
2) knowledge deficit regarding self administration of nitroglycerine
Goal
● Give the following learning or teaching guidelines to people taking nitroglycerin
Intervention
1) Carry nitroglycerin tablets at all times
2) Repeat the drug dosage every five to ten minutes until obtaining relief
Diagnosis
3) Anxiety related to chest pain,uncertain prognosis and threatening environment
Goal
● Report anxiety is reduced to a manageable level
Intervention

1) Explain purpose of tests and procedure
2) Encourage family and friends to treat patient as before
3) Administer sedatives ,tranquilizer,as indicated
4) Promote expressions of feeling and fears
Diagnosis
4) Risk for decreased cardiac output
Goal
● Report or display decreased episodes of dyspnea,angina and dysrhythmias
Intervention
1) Monitor vital signs and cardiac rhythm
2) Auscultate breath sounds and heart sounds
3) Provide adequate rest periods
4) Assess for signs and symptoms of heart failure
Conclusion
Angina still affects almost one quarter of patients with chronic coronary syndrome.
Anginal symptoms resolve the majority of patients over time,without revascularization.
Reference:
● Lippincott textbook of medical surgical nursing
● Page no:930-934
-
UNIT 5
Long Essay
Q,:7
a)Define Hypertension
b) Explain the pathophysiology of hypertension
c) Discuss in detail the medical and nursing management of patient
with hypertension Ans:
INTRODUCTION

Hypertension (HTN) also known as high blood pressure (HBP) is a long term
medical condition in which the blood pressure in the arteries is persistently
elevated
The SBP will be more than or equal of 140mmHg and DBP will be more than or
equal of 90mmHg
DEFINITIONS
High blood pressure, is generally defined as a persistent elevation of systolic blood
pressure above 140 mm of Hg diastolic pressure above 90 mm Hg.
The American College of cardiology and American Heart association published
new guidelines
Normal: less than 120/8
Elevated systolic between 120-129 and diastolic less than 80
Stage 1: Systolic between 130-139 and diastolic 80-89
Stage 2: Systolic 140 or higher and diastolic at 90 or higher
Hypertensive crisis: Higher than 180 for systolic and diastolichigher than 120
ETIOLOGY:
Primary HTN: It is the elevation in BP with out an identified couse.
Secondary HTN: It is the elevation in BP with an exact couse.This type
account for 5-10% of total cases
The couses of secondary HTN
•congenital narrowing of aorta
•Renal disease.
•Endocrine disorder like Cushing’s syndrome
•Neurological disorders like brain tumours and injury
RISK FACTORS:
•Age chances of after 50 yrs of age.
•Alcohol, Smoking and DM
•Excessive dietary intake of sodium.
•Gender
•Obesity
• Sedentary life style.
•stress
PATHOPHYSIOLOGY
•The normal blood pressure is maintained by four mechanisms.
•Sympathetic nervous system activities of vascular endothelium
•Activities of renal system.
•activities of endocrine system
Explanation:
Blood pressure rises with any increase in CO or SVR. Increased CO is some
times found in the person with prehypertension. Later in the course of hypertension,

the SVR rises and CO returns to normal. The hemodynamic hallmark of hypertension
is persistently increased SVR. The persistent elevation in SVR may occur in various
ways. Table 29-4 presents factors that relate to the development of primary
hypertension or contribute to its consequences. Abnormalities of any of
the mechanisms involved in the maintenance of normal BP can result in hypertension
CLINICAL FEATURES:
•Some time high blood pressure does not couses and symptoms. So that it is known as
silent killer disease.
•In some patients the symptoms will develop like
Severe headache.
Dizziness
Blurred vision
Nausea
Vomiting
fatigue.
Chest pain.
Shortness of breath
Irregular heartbeat
Diagnostic Elevation
•History collection.
•medical history of diabetic mellitus.
•complete blood count
•chest – x ray
•ECG
MANAGEMENT
Mainly the management of hypertension is possible by two way
Life style modification and pharmacological ttherapy
1 LIFE STYLE MODIFICATION:
•DASH diet (Dietary approaches to stop hypertension).
•Reduce alcohol
•Exercise
•Stress management
2 PHARMACOLOGICAL THERAPY :
•a) various groups of drugs are used for the treatment of hypertension collectively
these drugs are called as Anti Hypertensive drugs which includes
•b) Diuretics: It helps the kidney to inhibit the sodium reabsorption in the distal
convoluted ascending limb and Loop of Henley eg: Chlorothiazide furosemide
•c) Beta blockers : These medications reduce the work load of the heart and blood
vessels and cousing the heart to beat slowly with less force eg: Atenolol, Propranolol.
•d) Alpha blockers: couse the peripheral vasodilation of blood vessels eg: prazoin

•e) Vasodialators: These medications acting directly on the muscles in the Wall of
arteries and preventing the muscles from lighting and arteries from narrowing eg:
Nitroglycerin
•f) ACE inhibitors:
•g) Calcium channel blockers
Alternative therapies which are helpful to regulate blood pressure
includes acupuncture relation techniques and diversional therapies
NURSING MANAGEMENT
•NURSING ASSESMENT
1.Assess BP at frequent intervals
2.Assess for signs and symptoms that indicates target organ damage
3.Note the apical and peripheral pulse rate, rhythm and character
4.Assess extent to which hypertension has affected patient personally, socially
and economically
NURSING DIAGNOSIS
•1 Risk for decreased cardiac tissue perfusion
GOAL: Maintain adequate tissue perfusion
NURSING INTERVENTIONS
Check for optimal fluid balance. Administer IV fluids as ordered.
• optimal cardiac output.
•Consider the need for potential embolectomy, heparinization, vasodilator therapy,
•2 Deficit knowledge regarding the relationship between the treatment regimen and
control of the disease process
GOAL: To gain knowledge regarding hypertension
•1. Emphasize the concept of controlling hypertension (with lifestyle changes and
medications) rather than curing it
2. Arrange a consultation with a dietitian help to develop a plan for improving nutrient
intake or weight loss.
3. Advise patient to limit alcohol intake and avoid use of tobacco.
Complications
Heart attack or stroke. …
Aneurysm. …
Heart failure. …
Kidney problems. …
Eye problems. …
Metabolic syndrome. …
Changes with memory or understanding. …
Dementia.
Bibliography

Lewis ‘s
Medical surgical nursing
3rd
south asia edition (p.g.no:636-655)
-Long Essay
Qn.6
Mr.R ,64 years old is admitted to the hospital with the diagnosis of Acute
Myelogenous leukemia
a)Define Leukemia
b) Explain the clinical manifestations of Leukemia
d) Explain the medical and nursing management of Mr.R based on his problem
Ans:
INTRODUTION
. All cancers begin in cells of the body, and laukemia is a concen that begins in
blood cells.
.Normally cells grow and divide to Form as the body needs them.
. Leukemia is production of abnormal white blood cells from bone marrow and
lymphatic tissues.
DEFINITION
“Leukemia(greek word leukes means “white” aima means “blood”) is a cancer of
the blood or bone marrow characterized by an abnormal increased to blood
cells”
Types of Leukemia

1)Acute lymphatic Leukemia(ALL)
3) Acute myelogenous leukemia (AML)
3)Chroni lymphatic leukemia (CLL)
4) Chronic myelogenous leukemia (CML)
1)Acute lymphatic leukemia (ALL):
*Clinical ManManifestations :
. Fever
. Bleeding
. Fatigue
.Bone,joint and abdominal pain
2)Acute myelogenous leukemia (AML)
*Clinical Manifestations:
. Weakness
. Fatigue
.High fever
3)Chronic lymphatic leukemia (CLL)
.Usually there is no symptoms
. Chronic fatigue, weakness, anorexia,

.Skin lesions
. Anemia
. Thrombocytopenia
5) Chronic myologenous leukemia (CML):
. Fever, fatigue,sternal tenderness
. Weight loss, joint and bone pain
. Massive splenomegaly and increase in sweating
MANAGEMENT:
MEDICAL MANAGEMENT:
. PHARMACOLOGICAL MANAGEMENT:
. Chemotherapy: major form of treatment for Leukemia. This drug treatment
uses chemicals to kill Leukemia cells. Type of leukemia client may receive a
single drug or combination of drugs .these drugs may come in pill form or they
may be injected directly into the vein
. Biological therapy: works by helping the immune system recognize and attack
Leukemia cells.
. Targeted therapy:uses drugs that attack specific vulnerabilities with cancer
cells.
. Radiation therapy: uses x-ray or other high energy beams to damage Leukemia
cells and stop their growth. Client may receive Radiation in 1 specific area of
body we where there is collection of leukaemia cell orClient may receive
radiation over whole body
NON -PHARMACOLOGICAL

SURGICAL TREATMENT:
. Stem cell transplant: procedure to replace the diseased bone marrow with
healthy bone marrow
. Before the stem transplant, client receives highdo doses of Chemotherapy or
radiation therapy to destroy diseased bone marrow.
. The client receive an infusion of blood -forming stem cells that help to rebuild
the bone marrow
NURSING MANAGEMENT:
. History collection
. Physical examination
. Obtain patient family history, past Medical history
. Ask for presence of exposure to any risk factors and etiology factors
. Assessment for swollen lymph nodes ,spleen ,liver
. Assessment for the client vital signs ,check client for presence of fever
Blood Test:
. The lab does a complete blood count to check the number of white blood cells
,red blood cells and platelets
. Bone marrow transplantation:
. Thick hollow needle to remove sample of bone marrow The sample is taken
from the back of pelvic (hip)bone and with the help of needle small amount of
liquid bone marrow is sucked

DIAGNOSIS:
2) Impaired tissue integrity related to high dose
radiation therapy
GOAL:
. Patient maintain normal skin integrity
INTERVENTIONS:
. Avoid rubbing powders ,deodorants,lotions, or ointments.
. Encourage the patiento keep the treated area clean and dry
. Advise the Patient to bath the area gently with tepid water and mild soap
. Encourage the Patient to wear loose fitting cloths
3) Risk for infection to decreased neutrophils, altered
response to microbial invasion, and presence of
environmental pathogens
GOAL:
. Patient risk for infection to decreased neutrophils reduced through ongoing
assessment and early intervention.
ASSESSMENT:
. Inspect the Patient for the sign and symptoms of infection eg redness
. Maintain a sepsis for Patient at risk
. Instuct the Patient to take antibiotics as prescribed by doctor to prevent
microbial resistance.
. Monitor granulocyte count ad WBC count to identify the presence of infection.

4) Impaired oral mucous membrane related to low
platelet counts
GOAL:
Patient maintain normal platelet count.
ASSESSMENT:
Assist the Patient to select soft ,bland and nonacidic food to decrease irritation of
oral micosa
Advise the Patient to use soft toothbrush for removal of dental debris
Instuct the Patient to perform oral hygiene after eating and as often as needed to
avoid break down of oral mucosa
Advice the Patient to avoid use of lemon glycerin swabs to prevent excessive
drawing of mucomuc
CONCLUSION:
Leukemia is a non tumorous cancer of the blood that develops exclusively in the
bone marrow of an individual. Lenalidomide consolidation improves the quality
of response in patients with CLL receiving first line induction. Longer follow up is
necessary in order to determine the clinical benefit with this strategy.
Reference: Brunner and Siddhartha
Vol 1
Page number:770-772
Deepak Sethi

Page number:217,220
UNIT 5
Long Essay
Q,:7
a)Define Hypertension
b) Explain the pathophysiology of hypertension
c) Discuss in detail the medical and nursing management of patient
with hypertension
INTRODUCTION
Hypertension (HTN) also known as high blood pressure (HBP) is a long term
medical condition in which the blood pressure in the arteries is persistently
elevated
The SBP will be more than or equal of 140mmHg and DBP will be more than or
equal of 90mmHg
DEFINITIONS
High blood pressure, is generally defined as a persistent elevation of systolic blood
pressure above 140 mm of Hg diastolic pressure above 90 mm Hg.
The American College of cardiology and American Heart association published
new guidelines
Normal: less than 120/8
Elevated systolic between 120-129 and diastolic less than 80
Stage 1: Systolic between 130-139 and diastolic 80-89
Stage 2: Systolic 140 or higher and diastolic at 90 or higher
Hypertensive crisis: Higher than 180 for systolic and diastolichigher than 120
ETIOLOGY:
Primary HTN: It is the elevation in BP with out an identified couse.
Secondary HTN: It is the elevation in BP with an exact couse.This type
account for 5-10% of total cases
The couses of secondary HTN
•congenital narrowing of aorta
•Renal disease.
•Endocrine disorder like Cushing’s syndrome
•Neurological disorders like brain tumours and injury
RISK FACTORS:
•Age chances of after 50 yrs of age.

•Alcohol, Smoking and DM
•Excessive dietary intake of sodium.
•Gender
•Obesity
• Sedentary life style.
•stress
PATHOPHYSIOLOGY
•The normal blood pressure is maintained by four mechanisms.
•Sympathetic nervous system activities of vascular endothelium
•Activities of renal system.
•activities of endocrine system
Explanation:
Blood pressure rises with any increase in CO or SVR. Increased CO is some
times found in the person with prehypertension. Later in the course of hypertension,
the SVR rises and CO returns to normal. The hemodynamic hallmark of hypertension
is persistently increased SVR. The persistent elevation in SVR may occur in various
ways. Table 29-4 presents factors that relate to the development of primary
hypertension or contribute to its consequences. Abnormalities of any of
the mechanisms involved in the maintenance of normal BP can result in hypertension
CLINICAL FEATURES:
•Some time high blood pressure does not couses and symptoms. So that it is known as
silent killer disease.
•In some patients the symptoms will develop like
Severe headache.
Dizziness
Blurred vision
Nausea
Vomiting
fatigue.
Chest pain.
Shortness of breath
Irregular heartbeat
Diagnostic Elevation
•History collection.
•medical history of diabetic mellitus.
•complete blood count
•chest – x ray
•ECG
MANAGEMENT
Mainly the management of hypertension is possible by two way

Life style modification and pharmacological ttherapy
1 LIFE STYLE MODIFICATION:
•DASH diet (Dietary approaches to stop hypertension).
•Reduce alcohol
•Exercise
•Stress management
2 PHARMACOLOGICAL THERAPY :
•a) various groups of drugs are used for the treatment of hypertension collectively
these drugs are called as Anti Hypertensive drugs which includes
•b) Diuretics: It helps the kidney to inhibit the sodium reabsorption in the distal
convoluted ascending limb and Loop of Henley eg: Chlorothiazide furosemide
•c) Beta blockers : These medications reduce the work load of the heart and blood
vessels and cousing the heart to beat slowly with less force eg: Atenolol, Propranolol.
•d) Alpha blockers: couse the peripheral vasodilation of blood vessels eg: prazoin
•e) Vasodialators: These medications acting directly on the muscles in the Wall of
arteries and preventing the muscles from lighting and arteries from narrowing eg:
Nitroglycerin
•f) ACE inhibitors:
•g) Calcium channel blockers
Alternative therapies which are helpful to regulate blood pressure
includes acupuncture relation techniques and diversional therapies
NURSING MANAGEMENT
•NURSING ASSESMENT
1.Assess BP at frequent intervals
2.Assess for signs and symptoms that indicates target organ damage
3.Note the apical and peripheral pulse rate, rhythm and character
4.Assess extent to which hypertension has affected patient personally, socially
and economically
NURSING DIAGNOSIS
•1 Risk for decreased cardiac tissue perfusion
GOAL: Maintain adequate tissue perfusion
Check for optimal fluid balance. Administer IV fluids as ordered.
• optimal cardiac output.
•Consider the need for potential embolectomy, heparinization, vasodilator therapy,
•2 Deficit knowledge regarding the relationship between the treatment regimen and
control of the disease process
GOAL: To gain knowledge regarding hypertension

•1. Emphasize the concept of controlling hypertension (with lifestyle changes and
medications) rather than curing it
2. Arrange a consultation with a dietitian help to develop a plan for improving nutrient
intake or weight loss.
3. Advise patient to limit alcohol intake and avoid use of tobacco.
Complications
Heart attack or stroke. …
Aneurysm. …
Heart failure. …
Kidney problems. …
Eye problems. …
Metabolic syndrome. …
Changes with memory or understanding. …
Dementia.
Bibliography
Lewis ‘s
Medical surgical nursing
3rd
south asia edition (p.g.no:636-655)
-
Unit 05: Nursing Management Of Patient With Blood And Cardiovascular Problems
Q.8 a)Explain the clinical manifestations based on pathophysiology of infective
endocarditis.
b)Explain the medical and nursing management of infective endocarditis.
Ans:Definition
1) Infective endocarditis is a microbial infection of the heart.
2) Heart murmur
3) Fever
4) Osler nodes - small , painful nodules present in pads of fingers or toes
5) Janeway lesions - irregular, red or purple, painless flat macules present on fingers and
toes
6) Roth spots - hemorrhages with pale centers caused by emboli observed in fundi of the
eyes

7) Petechiae - appear in conjunctiva and mucous membranes
8) Cardiomegaly - enlarged heart
9) Tachycardia - fast heart rate
10)Splenomegaly - enlarged spleen
11)Heart failure
12)Headache
Pathophysiology
Injury to valve/bacteremia
Adherence of microorganisms to the endocardium and valve surface
Bacterial growth and multiplication
Fibrin platelet vegetation (may embolize to other tissues)
Fibrin thrombus calcification
Valve destruction, embolization
Symptoms depend on infected valve
Heart failure
● Tubulent blood flow disrupts valve surface (endocardium) to produce suitable (sticky)
site for bacterial attachment.
● Platelet deposition + fibrin may lead to non bacterial thrombas or vegetation.
● Bacteraemia delivers organisms to the damaged (sticky) endocardial surface resulting in
adherence and colonisation.
● Eventual invasion of valve leaflets results in infected vegetation.
b)Medical management
● Pharmacological management
1) Streptococcal endocarditis - IV penicillin or IM gentamycin
● Enterococcal endocarditis - IV ampicillin
● Staphylococcal endocarditis - IV nafcillin
● Fungal - IV amphtericin

● Non pharmacological management
1) Urine culture obtained after 48 hours to assess efficiency of drug therapy
2) Repeat blood culture obtained after 48 hours to assess efficiency of drug therapy
3) Close follow up by cardiologist
4) Supplemental nutrition
● Surgical management
1) Valve debridement
5) Debridement of vegetations
6) Debridement and closure of an abscess
7) Closure of a fistula
8) Aortic or mitral valve debridement
9) Replacement
Nursing management
Assessment
2) Assess for hemodynamic stability
3) Level of comfort, coping ability, support from significant others
4) Potential for self care
Diagnosis
● Alteration in comfort due to fever and malasie
Goal
The person will be as comfortable as possible
Intervention
● Administer antibiotics
● Treat fever with cooling measures
● Encourage to eat nutritious diet and to drink sufficient fluids
● To rest mentally and physically
Diagnosis
5) Alteration in cardiac output decreased due to cardiac valve dysfunction
Goal

The person will utilise effective coping strategies
Intervention
6) Do not enforce complete bed rest unless fever or signs of heart damage develop
7) Auscultate daily for heart murmur
8) Assess for rapid pluse,dyspnea
9) Monitor the persons physical response to exercise
Diagnosis
● Ineffective individual coping due to the chronic nature of infective endocarditis
Goal
There will be restoration and maintenance of hemodynamic status
Intervention
● Encourage compliance with the intervention program
● Give clear instructions concerning the disorder
● Delivering consistent encouragement
● Give reason for lengthy intervention
Diagnosis
● Knowledge deficit regarding infective endocarditis and it's management
Goal
The person and significant others will have an understanding of the disease
Intervention
● The cause of infectious endocarditis and it's course
● The purpose of long term antibiotic administration
● The need for prophylactic antibiotics
● The importance of ongoing assessment
Reference
● Lippincott textbook of medical surgical nursing
Page no: 972 - 976
● Brunner and suddarths textbook of medical surgical nursing
Page no:606 - 609

Mr. S, 48yrs old is admitted to the hospital with hypertension a Define hypertension b
list the modified and non modified risk factors of hypertension c Explain the
pharmacological management of hypertension
INTRODUCTION
Hypertension or elevated blood pressure is a serious medical condition that significantly
increases the risk of heart, brain kidney and other diseas
Blood pressure is the force of blood pushing up against the blood vessels walls. The
higher the pressure the harder the heart has to pump
DEFINITION
Persistent diastolic blood pressure is greater than 90 mm Hg and systolic blood pressure
is greater than 140mm Hg
OR
A condition in which the force of the blood against the artery walls is too high
NON MODIFIABLE RISK FACTORS
∆ Age : advanced age
∆ Gender : males are at risk until the age 55 yrs, between 55-74 yrs the risk is equal in
both male and female. After 74 yrs the woman are at risk
∆ Race : more prevalent in black people

∆ Family history: The genetic predisposition that makes certain families more
susceptible to hypertension
MODIFIABLE RISK FACTORS
∆ Stress : stimulate sympathetic nervous system
∆ Obesity : need more blood to supply oxygen and nutrients leads to increase in BP
∆ Atherosclerosis: narrowing of arteries leads to hypertension
∆ Smoking: nicotine constricts blood vessels
∆ High salt diet : sodium causes water retention, increasing blood volume ∆
Alcohol : increases plasma catecholamines
PHARMACOLOGICAL MANAGEMENT
The primary goal is to maintain a systolic blood pressure of less than 140 mm Hg and a
diastolic blood pressure of less than 90 mm Hg
•Diuretics
∆Thiazide diuretics
Eg : chlorthiazid, hydrochlorothiazide
Block sodium absorption in acsending tubule, water excreted with sodium producing
decreased blood volume
∆Loop diuretics

Eg: furosemide
Block sodium and water reabsorption in medullary portion of asending tubule causes
rapid water depletion
∆Potassium sparing diuretics
Eg: spironolactone
Inhibits aldosterone, sodium excreted in exchange for potassium
•Adrenergic Inhibitors
∆ beta adrenergic drugs
Eg: atenolol, propranolol
Block beta adrenergic receptors of sympathetic nervous system, decreasing heart rate and
blood pressure
∆Centrally acting alpha blockers
Eg:clonidine
Activate central receptors that suppress vasomotor and cardiac centers causing decrease
in peripheral resistance
∆Peripheral acting adrenergic antagonists
Eg: reserpine
Block norepinephrine release from adrenergic nerve endings.
• Adrenergic inhibitors ∆alpha I adrenergic blockers
Eg : Prazosin
Reduce peripheral resistance by dilating arterioles and venules
∆Combined alpha and beta adrenergic blockers

Eg: labetatol
•Vasodilators
Eg: hydralzine
Dilate peripheral blood vessels by directly relaxing vascular smooth muscle
•ACE Inhibitors
Eg : enalpril, ramipril
Inhibits conversion of angiotension to angiotension II, thus blocking the release of
aldosterone thereby reducing sodium and water retension
•Angiotension II Receptor blockers
Eg : Avapra
Block the effect of angiotension II at the receptor.
•Calcium channel blockers
Eg : nifedipine, verapamil
Inhibits influx of calcium into muscle cells, act on vascular smooth muscles to reduce
spasms and promote vasodilatatio
OTHER TREATMENT
Life style modification which includes
*Weight loss
• Diet : restriction of salt and saturated fat, high fiber diet
• Cessation of smoking

• Restrictions of alcohol beverages
• Activity 30-45 min exercises at least 3-4 times in a week
COMPLICATIONS
*Left ventricle dilation and hypertrophy
• Left ventricle failure
• Arteries may rupture
• Thrombosis
CONCLUSIONS
Hypertension is the commonest cardiovascular disorder. It can be diagnosed by
monitoring blood pressure. This disease can be prevented by modifying diet and change
in a life style etc.
Qn 9 : Mr . Somu 48 yrs old is admitted to the hospital with myocardial infarction
a) Define myocardial infarction
b) Explain the pathophysiology and clinical manifestations of MI
c) Write the pharmacological and nursing management of MI
Question number :9

Introduction
Myocardial infarction reffers to the process by which areas of myocardial cells in the
heart are permanently destroyed. It occurs when myocardial tissues are abruptly and
severely deprived of oxygen.
a) Definition
MI is defined as a disease condition which is caused by reduced blood flow in a coronary
artery due to atherosclerosis and occlusion of an artery by an embolus or thrombus
b) Pathophysiology
• Marked reduction or loss of blood flow through one or more of the
coronary arteries resulting in cardiac muscle ischemia and over a finite
period, resulting in necrosis
• Occurs most often due to coronary artery disease
• Cellular ischemia and necrosis can affect the heart rhythm, pumping
action and blood circulation
• Other problems may also ensure, such as heart failure life threatening
arrhythmias and death
• Delay in seeking treatment is the largest barrier to receving therapy
• Chest pain
• Dyspnea
• Fatigue
• Weakness
• Nausea
• Palpitation
• Light headedness
• Anxiety
• Sleeplessness
• Hypertension

• Hypotension
• Arrhythmia
C). Pharmacological management
a) Thrombolytic agents
Eg :Urokinase
b) Anticoagulants
Eg : Heparin
c) Antiplatelet drugs
Eg: Aspirin
d) Antihypertensive agents
Eg : Atenolol, Labetalol
e) Vasodilators
Eg : Losartan
Nursing Management
Nursing assessment
•Assess for chest pain not relieved by rest or medications.
•Monitor vital signs, especially the blood pressure and pulse rate.
•Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.

•Assess for nausea and vomiting.
• for decreased urinary output.
•Assess for the history of illnesses.
•Perform a precise and complete physical assessment to detect complications and changes
in the patient’s status.
•Assess IV sites frequently
Nursing diagnosis
a) Ineffective cardiac tissue perfusion related to reduced coronary blood flow
Goal : Maintenance or attainment of adequate tissue perfusion
Interventions :
• Check for optimal fluid balance and administer IV fluids
• Maintain oxygen therapy as ordered
b)Acute pain related to tissue ischemia
Goal : To relieve pain
Interventions:
• monitor and document characteristics of pain
• provide calm and quiet environment
• administer analgesics
b) Activity intolerance, fatigue related to inadequate oxygen supply
Goal : To relieve fatigue

Interventions :
• Encourage bedrest
• Encourage fluid intake
• Limit activities
Conclusion
Myocardial infarction is a life threatening disease caused by many factors. Health
education must given to the patients with predisposing or risk factors to prevent it. Early
diagnosis is also very important for saving the life of the patient
10. a) Define cardiac catheterization.
c) List the indications For cardiac catheterization.
d) Describe the pre procedural and post procedural management of a client
undergoing cardiac catheterization.
Ans: a) INTRODUCTION
Cardiac catheterization is a procedure to examine how well your heart is working. A
thin, hollow tube called a catheter is inserted into a large blood vessel that leads to your
heart.
DEFINITION
Cardiac catheterization is done by inserting a radio opaque catheter into the right or left
side of the heart. For the right side of the heart a catheter is inserted through an arm vein
or a leg vein.
Left-sided heart catheterization is done by inserting a catheter into a femoral, brachial, or
radial artery. The catheter is passed in a retrograde manner up to the aorta, across the

aortic valve, and into the left ventricle.
c) INDICATION :
DIAGNOSTIC INDICATIONS:
• UNSTABLE ANGINA
• ACS
• MYOCARDIAL INFARCTION
• CONGENITAL DEFECTS
• ABNORMAL STRESS TEST
• PLANNED VALVE SURGERIES
• CARDIOGENIC SHOCK
• VENTRICULAR ARRHYTHMIAS
THERAPEUTIC INDICATIONS:
• PERCUTANEOUS CORONARY ANGIOGRAM
• PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
• VALVULOPLASTY
• VALVOTOMY
d) PRE PROCEDURAL :
• Check for sensitivity to contrast media.
• Withhold food and fluids for 6 to 1 hours before procedure.
• Give sedative and other drugs if ordered.
• Inform patient about use of local anesthesia, insertion of catheter, feeling
of warmth when dye is injected, and possible fluttering sensation of heart
as catheter is passed
• Note that patient may be instructed to cough or take a deep breath when
due is injected and that patient is monitored by ECG throughout
procedure.
POST PROCEDURAL:

• After procedure, frequently assess circulation to extremity used for
catheter insertion
• Check peripheral pulses, color, and sensation of extremity per agency
protocol
• Observe puncture site for hematoma and bleeding
• Place compression device over arterial site to achieve hemostasis, if
indicated
• Monitor vital signs and ECG
• Assess for hypotension or hypertension, dysrhythmias, and signs of
pulmonary emboli (e.g., respiratory difficulty)
CONCLUSION:
• Cardiac catheterization is a common outpatient procedure.
• It involves insertion of catheter into heart to obtain information about
oxygen levels and pressure readings within heart chambers.
• Contrast medium is injected to assist in seeing structures and motion of
heart
• Procedure is done by insertion of catheter into a vein( for right side of
heart) or an artery ( for left side of heart ).
11. a, define anaemia
B, list out causes and clinical manifestations of anemia
C, describe the management of anemia

A), DEFINITION
• It is a condition in which the Hemoglobin concentration is lower than
normal
• Anemia is reflects the presence of fever than the normal number of
erythrocytes within the circulation
Types
1.Hyper proliferative anemia: in hyper proliferative anemia the marrow cannot produce
adequate number of erythrocytes
2.Hemolytic anemia: There is premature destruction of erythrocytes that result in the
liberation of hemoglobin from the erythrocytes into the plasma the released hemoglobin
is then converted into bilirubin.
3.Bleeding anemia : Bleeding anemias are caused by the loss of erythrocytes
CLASSIFICATION
• Microcytic anemias
1. Iron deficiency
2. Thalassemia
3. Anemia of chronic diseases
• Normocytic anemias
1. Anemia of chronic diseases
2. Iron deficiency

3. Anemia of renal diseases
4. Hypothyroidism
• Macrocytic anemia
1. Megaloblastic anemia
2. Hemolytic anemia
3. Liver diseases
4. Hypothyroidism
B) CAUSES OF ANEMIA
A diet lacking in certain vitamin and minerals a diet consistently low in iron, vitamin
B12, folate and copper increased risk of anemia
iron deficiency
kidney disease
excessive bleeding
Stomach acid low
Enzyme deficiencies
Infections
vitamin B12 deficiencies

CLINICAL FEATURES
Feeling weak or tired
shortness of breath
Increased susceptibility of The infection
cold hands or feet
Pallor
Pica
SIGNS AND SYMPTOMS
Fatigue
Weakness
pale or yellowish skin
Irregular heart beat
shortness of breath
Dizziness
Chest pain
Brittle nails
C) MANAGEMENT OF ANEMIA

Medical management
Investigate the causes of the anemia
Monitoring the vital signs
providing semi fowlers position
Oxygen therapy
Transfusion therapy of The platelets and RBC
administration of pencillin and analgesics
A device for the intake of the high protein add high caloric diet
administration of the ferrous agents
oral iron therapy
Ferrous sulphate, ferrous gluconate, ferrous fumarate,
supplemental iron is needed to replenish lost iron stores
ferrous iron is most easily absorbed
Treatment with oral iron should be continued for three to six months to correct
the anemia and replenish iron stores
Nursing management

ASSESSMENT
• Take the health history
Careful diet history to identify any deficiencies
Evidence of Eating clay, Ice ,paste
• Observe for manifestations of anemia
Muscle weakness
easy fatigability:
Frequent resting
Shortness of breath
Poor sucking(infants)
NURSING DIAGNOSIS
1)Imbalanced nutrition less than body requirement related to inadequate intake of
essential nutrition as evidenced by skin integrity colour and body weight
GOAL
• Improve nutrition level
INTERVENTION
A health diet should be encouraged
Avoid alcoholic beverages

Dietary teaching session should be individualized including culture aspect related
to food preference and food preparation
2)Activity intolerance related to lower level of hemoglobin in body as evidenced by the
Weakness fatigue and malaise
GOAL
• Improve the activity intolerance
INTERVENTION
Assist the patient to prioritize the activities and a established balance between the
activity and rest that is realistic and feasible from the patient perspectives
Patient with chronic anemia need to mandane some physical activity and exercise
to prevent the deconditioning that result from the inactivity
3)Ineffective tissue perfusion related to less blood volume as evidence to buy skin
color(pallor)
GOAL
Improve tissue perfusion
INTERVENTION
The nails monitor the vital signs closely
Monitor the vital signs closely lost volume replaced with blood transfusion or IV
fluids
supplemental oxygen may be necessary but it is rarely needed on a long term
basis
other medication such as anti hypertensive agent may be needed to be adjusted
CONCLUSION

Anemia is a preventable global disease.anemia is still the commonest cause of maternal
morbidity and mortality in spite of easy diagnosis and treatment. Anemia during
pregnancy factors the development of iron deficiency anemia is infant and young children
Anemia is not a disease but a Condition caused by various underlying pathology
processes. A Proper history and physical examination Is more important in an easy way
of approaching a child with anemia all causes of anemia are not necessary to be
Transfused

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