up college of nursing 2005.doc

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P COLLEGE OF N RSING 2005

MEDICAL-SURGICAL NURSING

Cardiology, Respiratory, Gastrointestinal

Lecture Day #5: April 5, 2005

Lecturer: Mr. Ferdinand B. Valdez

CONGESTIVE HEART FAILURE

Inabilitiy of the heart to pump blood towards systemic circulation

I. LEFT-SIDED HEART FAILURE

1. PREDISPOSING FACTORS

1. 90% mitral !al!e stenosis

R"# $ antistreptolysis titer &'() $ *00 todd units

+enicillin, +'(', steroids

'ging

. -I

*. I"#

. "+/

. 'ortic !al!e stenosis

2. SIGNS AND SYMPTOMS

1. +ulmonary edemacongestion

#yspnea, +/#, * pillow orthopnea

+roducti!e cough &blood tinged)


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Rales

2ronchial whee3ing

. +ulses alternans

*. 'nore4ia and general body malaise

. +-I displaced laterally

. (* &!entricular gallop)

3. DIAGNOSTICS

1. C5R $ cardiomegaly

. +'+ $ pulmonary arterial pressure

-easures pressure in right !entricle

Re!eals cardiac status

*. +C6+ $ pulmonary capillary wedge pressure

-easures endsystolic and enddiastolic pressure

. 7chocardiograph $ re!eals enlarged heart chamber

. '2G analysis re!eals ele!ated +C and decreased + &respiratory acidosis)

8racheostomyfor se!ere respiratory distress and laryngospasm performed at bedside within 101 minutes

C+ re!eals fluid status: /ormal ; 10cm "o

'


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. +ulmonic stenosis

. left sided heart failure

2. SIGNS AND SYMPTOMS (Venous on!es"#on$1. >ugular !ein distention

. pitting edema

*. ascites

. weight gain

. hepatosplenomegaly

?. >aundice

@. pruritus urticaria

A. esophageal !arices

9. anore4ia

10. generali3ed body malaise

3. DIAGNOSTICS

1. C5R $ cardiomegaly

. C+ $ measures pressure in right atrium: / ; 10cc "

#uring C+B trendelenburg to pre!ent pulmo embolism and to promote

!entricular filling

lat on bed post C+

H%&o'oe)#*$ fluid challenge

H%&e+'oe)#*$ diuretics &loop)

*. 7chocardiography $ re!eals enlarged heart chamber

-uffled heart sounds cardiomyopathy

Cyanotic heart diseases

8 DtetE spells cyanosis with hypo4emia

8ricuspid !al!e stenosis

8ransposition of aorta

'cyanotic


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+#' $ machineliFe murmur

#CB indomethacin(7B corneal cloudiness

.


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?. 6eigh pt daily and assess for pitting edema

@. abdominal girth daily and notify -#

A. pro!ide meticulous sFin care

9. pro!ide a dietary intaFe which is low in saturated fats and caffeine

10. Institute bloodless phlebotomy

ROTATING TOURNIUET

Rotated e!ery 1 minutes to promote a decrease in !enous return

11. "ealth teaching and discharge planning

+re!ent complications

'rrhythmia

(hocF

8hrombophlebitis

-I

Cor pulmonale $ R hypertrophy

Regular adherence to medications

#iet modifications

Importance of ffup care

PERIPHERAL VASCULAR DISORDERS

I. A+"e+#* ue+s

1. 8hromboangitis obliterans 2uerger=s disease &feet)

. Reynaud=s +henomenon &hand)

II. Venous Ue+s

1. aricose !eins

. 8hrombophlebitis#8

ARTERIAL ULCERS


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I. THROMOANGITIS OLITERANS$ acute inflammatory condition affecting the smaller and medium

si3ed arteries and !eins of the lower e4tremities


1. "igh risF group men *0 years old abo!e

. Chronic smoFing

2. SIGNS AND SYMPTOMSConsistent to all arterial diseases

1. Intermittent claudication $ leg pain upon walFing

. cold sensiti!ity and sFin color changes

whitepallorbluishcyanosis redrubor

&) especially post smoFing

*. decreased peripheral pulses= !olume particularly in dorsalis pedis and posterior tibial

. 8rophic changes

. ulceration

?. gangrene formation

3. DIAGNOSTICS

1. os#o)e"+%$ re!eals a decrease in peripheral pulse !olume

. Do&&e+ u"/$ decrease in blood flow to affected e4tremity

*. *n!#o!+*&0%$ site and e4tent of malocclusion

,. NURSING MANAGEMENT

1. encourage slow progressi!e physical acti!ity

walFing *4day

out of bed *4day

. medications as ordered

analgesics

!asodilators

anticoagulants

*. instruct patient to a!oid smoFing and e4posure to cold en!ironment


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. institute foot care management

a!oid barefoot walFing

straight nails

lanolin cream for feet

&) constricting clothes

. 'ssist in surgeryB 2K'

II. REYNAULDS DISEASE$ characteri3ed by acute episodes of arterial spasms in!ol!ing the digits of

hands and fingers


1. high risF group women 0 years old up

. smoFing

*. collagen diseases

(


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. ulceration

. gangrene formation

3. DIAGNOSTICS1. oscillometry $ re!eals a decrease in peripheral pulse !olume

. angiography $ site and e4tent of malocclusion


1. 'd minister medications as ordered

'nalgesics

asodilators

. encourage pt to wear glo!es

*. instructB a!oid smoFing and e4posure to cold en!ironment

VENOUS ULCERS

I. VARICOSE VEINS$ abnormal dilation of the !eins of the lower e4tremities dt incompetent !al!es

leading to increased !enous pooling and !enostasis decreased !enous return


1. "ereditary

. congenital weaFness of !eins

*. thrombophlebitis

. cardiac diseases

. pregnancy

?. obesity

7. prolonged immobilityprolonged standing and sitting



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1. pain after prolonged standing

. dilated tortous sFin !eins which are warm to touch

*. hea!iness in the legs

3. DIAGNOSTICS

1. enography

2. trendelenburg=s test $ re!eals that !eins distend MuicFly N * seconds incompetent

!al!es

,. NURSING MANAGEMENT (ons#s"en" "o * 'enous ue+s$

1. ele!ate legs abo!e heart le!el increased !enous return &* pillow ele!ation)

. measure circumference of leg to determine swelling

*. antiembolic stocFing, full support panty hose

4. medications as ordered analgesics

. assist in surgery

!ein stripping and ligation

sclerotherapy

for spiderweb !aricosities

cold solution in>ection

(7B thrombosis

II. THROMOPHLEITIS DEEP VEIN THROMOSIS (DVT$


1. smoFing

. obesity

*. prolonged use of C+s

. chronic anemia

. diet high in saturated fats

?. #-


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@. C"

A. -I

9. postcannulation &insertion of !arious catheters)

10. postsurgical operation

11. sedentary lifestyle


1. pain at the affected e4tremity

. presence of cyanosis

*. dialted tortous !eins

4. ($ HOMAN4Spain on calf on dorsifle4ion

3. DIAGNOSTICS

1. !enography

. #oppler ut3

*. angiography

,. NURSING MANAGEMENT1. ele!ate the legs abo!e heart le!el

. apply warm moist pacF to relie!e lymphatic congestion

*. measure circumference of leg muscles to determine if it is swollen

. antiembolic stocFings

. administer medications as ordered

analgesics

anticoagulants $ heparin

?. pre!ent complications

pulmonary embolism

RESPIRATORY SYSTEM


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+ost lobectomy unaffected side to promote lung e4pansion

+leura

+arietal

isceral

DIAPHRAGM$ primary muscle for respiration

INTERCOSTAL MUSCLES$ secondary muscle for respiration

ALVEOLI&'cinar cells) $ site for gas e4change &!ia diffusion)

VENTILATION$ mo!ement of air in and out of the lungs

RESPIRATION$ lungs to cells

Internal

74ternal

A'eo*+ "%&e II es$ secretes surfactants

SURFACTANTS$ en3ymes made up of lipoproteins which decrease surface tension thereby pre!enting

collapse


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. #iplococcus pneumoniae

. 7scherichia coli

2. HIGH RIS7 GROUPS

1. children less than yo

. elderly


1. (moFing

. air pollution

*. immunocompromised

&) 'I#(

bronchogenic Ca

. prolonged immobility &hypostatic pneumonia)

. aspiration of food &aspiration pneumonia)

,. SIGNS AND SYMPTOMS

1. producti!e cough, greenish to rusty

. dyspnea with prolong e4piratory grunt

*. fe!er, chills, anore4ia, general body malaise

. cyanosis

. pleuritic friction rub

?. ralescracFles on auscultation

7. abdominal distention paralytic ileus

8. DIAGNOSTICS1. (putum gscs confirmatory: type and sensiti!ity: &) to cultured microorganism

. C5R $ &) pulmonary consolidation

*. C2C

ele!ated 7(R &rate of erythropoeisis) / ; 0.1.%

ele!ated 62C


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. '2G $ + decreased

9. NURSING MANAGEMENT

1. enforce C2R

. 'dminister medications as ordered

2road spectrum antibiotics

+enicillin $ pneumococcal infections

8etracycline

-acrolides

'3ithromycin 4 *days)

1. too costly

. not much (7

*. only (7B ototo4icity $ transient hearing loss

'ntipyretics

-ucolyticse4pectorants

*. 'dminister inhalation as ordered

. force fluids to liMuefy secretions

. institute pulmonary toilet

#27

Coughing e4ercises

C+8

8urning and repositioning

?. nebuli3e and suction +R/

@. place client of semifowlers to high fowlers

A. pro!ide a comfortable and humid en!ironment

9. pro!ide a dietary intaFe high in C", C"/, Calories and it C

10. 'ssist in postural drainage

/ursing manatementB

-onitor ( and 2(


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2est performed before mealsbreaFfast or * hours p.c. to pre!ent

gastroesophageal reflu4 or !omiting

7ncourage #27

'dminister bronchodilators 1*0 minutes before procedure

(top if pt. can=t tolerate the procedure

+ro!ide oral care after procedure as it may affect taste sensiti!ity

ContraindicationsB

nstable (

"emoptysis

Increased IC+

Increased I+ &glaucoma)

11. pro!ide pt health teaching and dc planning

a!oidance of precipitating factors

pre!ention of complications

atelectasis

meningitis

regular compliance to medications

importance of ffup care

II. PULMONARY TUERCULOSIS (7OCHS DISEASE$$ infection of the lung parenchyma caused by

in!asion of mycobacterium tuberculosis or tubercle bacilli &gram negati!e, acid fast, motile, aerobic, easily

destroyed by heatsunlight)

1. PRECIPITATING FACTORS

1. malnutrition

. o!ercrowding

*. alcoholism

depletes it 21 &thiamin) alcoholic beriberi malnutrition

. physical and emotional stress

. ingestion of infected cattle with mycobacterium bo!is


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?. !irulence &degree of pathogenecity)

2. MODE OF TRANSMISSIONB 'irbornedroplet infection


1. producti!e cough &yellowish)

. low grade afternoon fe!er, night sweats

*. anore4ia, malaise, weight loss

. chestbacF pain

. hemoptysis

,. DIAGNOSTICS

1. (Fin testing

M*n"ou5 "es" : PPD

Induration width &within A@ h)

;-1< )) (DOH$

1


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?. nebuli3e and suction +R/

@. pro!ide comfortable and humid en!ironment

A. institute short course chemotheraphy

In"ens#'e &0*se

I/"

(7B peripheral neuritis &increase !it 2? or pyrido4ine

Rifampicin

(7B red orange color of bodily secretions

+J'

(7B allergic reactions: hepatoto4icity and nephroto4icity

I/" and Rifampicin is gi!en for months, a.c. to facilitate absorption

8hese * drugs are gi!en simultaneously to pre!ent de!elopment of

resistance

S"*n>*+> Re!#)en

(treptomycin in>ection &aminoglycoside)

/eomycin

'miFacin

Gentamycin

1. common (7B AthC/ damage tinnitus hearing

lossototo4icity

. nephroto4icity

1. 2/ &/ ; 100)

. CR7' &/ ; A10)

9. "ealth teaching and dc planning

'!oidance of precipitating factors

+re!ention of complications

'telectasis

-ilitary 82

(trict compliance to medications


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#iet modifications


III. HISTOPLASMOSIS$ acute fungal infection caused by inhalation of contaminated dust with histoplasma

capsulatum from birds= manure


Inhalation of contaminated dust


+roducti!e cough

e!er, chills, anore4ia, generali3ed body malaise

Cyanosis

Chest and >oint pains

#yspnea

"emoptysis

3. DIAGNOSTICS

"istoplasmin sFin test is &)

'2G analysis re!eals p low

,. NURSING MANAGEMENT 7nforce C2G

'dminister meds as ordered

'ntifungal agents

'mphotericin 2 &ungi3one) (7B nephroto4icity and

hypoFalemia


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Corticosteroids

'ntipyretics


'dminister o4ygen inhalation as ordered

orced fluids

+re!ent complications

2ronchiectasis

+re!ention of spread

(praying of breeding places

Kill bird and ownerL "eheL

COPD

1. Chronic 2ronchitis

. 2ronchial 'sthma

*. 2ronchiectasis

. +ulmonary 7mphysema

I. CHRONIC RONCHITIS&2lue 2loaters) $ Inflammation of the bronchi due to hypertrophy or

hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways


1. (moFing

. air pollution


1. producti!e cough

. dyspnea on e4ertion

*. prolonged e4piratory grunt

. anore4ia and generali3ed body malaise


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. cyanosis

?. scattered ralesrhonchi

@. pulmonary hypertension

peripheral edema

cor pulmonale

3. DIAGNOSTICS

1. '2G analysisB decreased +, increased +C, respiratory acidosis: hypo4emia

cyanosis


1. enforce C2R


bronchodilators

antimicrobials

corticosteroids

mucolyticse4pectorants

*. low inflow admin: high inflow will cause respiratory arrest

. force fluids

. nebuli3e and suction client as needed

?. pro!ide comfortable and humid en!ironment

@. health teaching and dc planning

a!oidance of smoFing

pre!ent complications

C narcosis coma

Cor pulmonale

+leural effusion

+neumothora4

Regular adherence to meds



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II. RONCHIAL ASTHMA$ re!ersible inflammatory lung condition caused by hypersensiti!ity to

allergens leading to narrowing of smaller airways


1. E5"+#ns#&'topic'llergic 'sthma)

+ollens, dust, fumes, smoFe, fur, dander, lints

. In"+#ns#&/on'topic/on'llergic)

#rugs &aspirin, penicillin, 2blocFers)

oods &seafoods, eggs, chicFen, chocolate)

ood additi!es &nitrates, nitrites)

(udden change in temperature, humidity and air pressure

Genetics

+hysical and emotional stress

3. M#5e> "%&ecombination of both


1. cough that is producti!e

. dyspnea

*. whee3ing on e4piration

. tachycardia, palpitations and diaphoresis

. mild apprehension, restlessness

?. cyanosis

3. DIAGNOSTICS1. +8 decreased !ital lung capacity

2. '2G analysis+ decreased


1. enforce C2R


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bronchodilatorsadminister first to facilitate absorption of corticosteroids

inhalation

-#I

Corticosteroids


-ucomyst

'ntihistamine

*. administer o4ygen inhalation as ordered

. forced fluids

. nebuli3e and suction patient as necessary

?. health teaching and dc planning

a!oidance of precipitating factors

pre!ention of complications

status asthmaticus

epinephrine

aminophylline drip

emphysema

regular adherence to medications

importance of ffup care

III. RONCHIECTASIS$ permanent dilation of the bronchus due to destruction of muscular and elastic

tissue of the al!eolar walls


1. recurrent lower respiratory tract infection

histoplasmosis

. congenital disease

*. presence of tumor


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. chest trauma


1. consistent producti!e cough

. dyspnea

*. presence of cyanosis

. rales and cracFles

. hemoptysis

3. DIAGNOSTICS

1. '2G analysis re!eals low +

. 2ronchoscopy $ direct !isuali3ation of bronchi lining using a fibroscope

+reop

(ecure consent

74plain procedure

/+

-onitor ( and breath sounds

+ostoperati!e

eeding initiated upon return of gag refle4

Instruct client to a!oid talFing, coughing and smoFing as it may irritate

respiratory tract

-onitor for ss4 of franF or gross bleeding

-onitor for signs of laryngeal spasm

#2 and (2

*. (egmental lobectomy

. +neumonectomy


1. enforce C2R



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bronchodilators

antimicrobials

corticosteroids



. force fluids






C narcosis coma

Cor pulmonale

+leural effusion

+neumothora4



I. PULMONARY EMPHYSEMA$ terminal and irre!ersible stage of C+# characteri3ed by B

Inelasticity of al!eoli

'ir trapping

-aldistribution of gasses

!erdistention of thoracic ca!ity &2arrel chest)


1. smoFing

. air pollution

3. hereditaryB in!ol!es alpha1 antitrypsin for elastase production for recoil of the

al!eoli


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. allergy

5. high risF group elderly degenerati!e decreased !ital lung capacity and thinning

of al!eolar lobes


1. producti!e cough

. dyspnea at rest

*. prolonged e4piratory grunt

. resonance to hyperresonance

. decreased tactile fremitus

6. decreased breath sounds & if &) 2(lung collapse)

@. 2arrel chest

A. anore4ia and generali3ed body malaise

9. rales or cracFles

10. alar flaring

11. pursedlip breathing &to eliminate e4cess C)

3. DIAGNOSTICS

1. '2G analysis re!eal

+anlobular, centrilobular + ele!ation and +C depressionrespiratoryacidosis &blue bloaters)

+anacinarcentriacinar +C deptression and + ele!ation &pinF puffers $

hypera4emia)

. pulmo function test $ decreased !ital lung capacity

+77+ $ positi!e end e4piratory pressure

allows for ma4imum al!eolar diffusion

pre!ent lung collapse


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1. enforce C2R


bronchodilators

antimicrobials

corticosteroids



. force fluids






C narcosis coma

Cor pulmonale

+leural effusion

+neumothora4



. PNEUMOTHORA?$ partial or complete collapse of the lungs due to accumulation of air in pleural space

1. TYPES

1. S&on"*neous$ air enters pleural space without an ob!ious cause

Ruptured blebs &al!eolar $ filled sacs) inflammatory lung conditions

. O&en$ air enters pleural space through an opening in pleural wall

Gun shot wounds

-ultiple stab wounds


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3. Tens#on$ air enters pleural space during inspiration and cannot escape leading to

o!erdistention of the thoracic ca!ity mediastinal shift to the affected side &ie. lail

chest)parado4ical breathing


1. Chest trauma

. Inflammatory lung condition

*. tumors


1. chest pain, dyspnea, cyanosis

. diminished breath sounds

*. cool, moist sFin

. mild restlessness and apprehension

. resonance to hyperresonance

,. DIAGNOSTICS

1. '2G analysisB + decreased

. C5R $ confirms collapse of lungs

8. NURSING MANAGEMENT

1. 'ssist in endotracheal intubation

. 'ssist in thoracentesis

*. 'dminister meds as ordered

/arcotic analgesics $ -orphine sulfate

'ntibiotics

. 'ssist in C88 to "0 sealed drainage

=ATER SEALED DRAINAGE

I. O@ECTIVES


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1. 8o restore &) pressure in lungs

. +romote ree4pansion of lungs

*. 8o drain blood, fluid, and air

. +re!ent reflu4 of blood, fluid and air

II. NURSING MANAGEMENT

1. -aintain strict asepsis

. -onitor (, I, 2(

*. 7ncourage #27

. 'dminister medications as ordered

1. /arcotic analgesics $ -orphine sulfate

. antimicrobials

. +repareB clamp, e4tra bottle, petroleum gau3e

?. -onitorassess oscillation, bubbles or fluctuations

1. If &) intermittent bubbling normalintact

" goes up with each inspiration

" goes down with each e4piration

. If &) continuous, remittent, bubbling

ChecF for leaFage

Clamp towards the chest tube

/otify physician

*. If &) fluctuations

ChecF for loopsFinFsclots

-ilF if &) clots

ull ree4pansion of lungs

&) fluctuations

&) breath sounds

C5R $ full ree4pansion


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III. NURSING MANAGEMENT UPON CTT REMOVAL

1. 7ncourage #27

. Instruct pt to a!oid performance of !alsal!a maneu!er to pre!ent entry of air in pleural space and

to facilitate easy remo!al of C88

*. 'pply !aselinated air occlusi!e dressing

. -aintain dressing clean and intact

OVERVIE= OF THE STRUCTURE AND FUNCTION OF THE GASTROINTESTINAL TRACT

I. UPPER ALIMENTARY CANAL (D#!es"#on$

1. -outh

. +haryn4

*. 7sophagus

. (tomach

5. irst half of duodenum digestion

II. MIDDLE ALIMENTARY CANAL (Aso+&"#on$

1. ndhalf of duodenum

. >e>unum

*. ileum

. 1st

half of ascending colon

III. LO=ER ALIMENTARY CANAL (E#)#n*"#on$

1. ndhalf of ascending colon

. trans!erse colon

*. descending colon

. sigmoid colon

. rectum

IV. ACCESSORY ORGANS

1. (ali!ary glands $ produces 1.1. < of sali!a per day

1. +arotid $ below and behind the ear

. (ublingual

*. (ubmandibular

. ermiform appendi4


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*.


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-eningitis

rchitissterility

II. APPENDECITIS$ Inflammation of the !ermiform appendi4 &located at the R. iliac region, produces62C during fetal life)


1. -icrobial in!ation

. FECALITHS$ undigested food particles &tomato, gua!a seeds)

*. intestinal obstruction


1. &) rebound tenderness

. low grade fe!er, anore4ia, nausea and !omiting

*. pain at R iliac region

. diarrheaconstipation

. tachycardia dt pain

3. DIAGNOSTICS

1. C2C $ mild leuFocytosis

. +7 $ &) rebound tenderness

*. rinalysis $ &) acetone)

,. NURSING MANAGEMENT PRE-OP

1. secure informed consent

. routinary nursing care

/+

(Fin preparation

'!oid enemamay lead to rupture

*. administer medications as ordered


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antipyretics

antibiotics

/ '/'+*#n&indicates rupture) $ place patient on affected site

. IB (-$based on pt. comfort

*. 'dminister )e>#*"#onsas ordered

Analgesics

Antibitics

Antipyretics !"

. maintain patent I line

. monitor ( I and bowel sounds (No+o+%!)#$

MC URNEYS POINT$ incision site for appendectomy

up college of nursing 2005.doc

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