Post on 07-May-2015
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
PERIOPERATIVE NURSING A. Major Types of Pathologic Process Requiring Surgical Intervention (OPET) Obstruction – impairment to the flow of vital fluids
(blood,urine,CSF,bile) Perforation – rupture of an organ. Erosion – wearing off of a surface or membrane. Tumors – abnormal new growths.
B. Classification of Surgical Procedure According to PURPOSE: Diagnostic – to establish the presence of a disease condition. (
e.g biopsy ) Exploratory – to determine the extent of disease condition ( e.g
Ex-Lap ) Curative – to treat the disease condition.
* Ablative – removal of an organ * Constructive – repair of congenitally defective organ. * Reconstructive – repair of damage organ Palliative – to relieve distressing sign and symptoms, not
necessarily to cure the disease. According to URGENCY
Classification Indication for Surgery
Examples
Emergent – patient requires immediate attention, life threatening condition.
Without delay
- severe bleeding - gunshot/ stab wounds - Fractured skull
Urgent / Imperative – patient requires prompt attention.
Within 24 to 30 hours
- kidney / ureteral stones
Required – patient needs to have surgery.
Plan within a few weeks or
months
- cataract - thyroid d/o
Elective – patient should have surgery.
Failure to have surgery not catastrophic
- repair of scar - vaginal repair
Optional – patient’s decision.
Personal preference
- cosmetic surgery
C. Inform Consent
Purposes: To ensure that the client understand the nature of the
treatment including the potential complications and disfigurement.
To indicate that the client’s decision was made without pressure.
To protect the client against unauthorized procedure. To protect the surgeon and hospital against legal action by a
client who claims that an authorized procedure was performed.
Essential Elements of Informed Consent the diagnosis and explanation of the condition. a fair explanation of the procedure to be done and used and
the consequences. a description of alternative treatment or procedure. a description of the benefits to be expected. material rights if any. the prognosis, if the recommended care, procedure is refused. Requisites for Validity of Informed Consent Written permission is best and legally accepted.
Signature is obtained with the client’s complete understanding of what to occur. - adult sign their own operative permit - obtained before sedation
For minors, parents or someone standing in their behalf, gives the consent. Note: for a married emancipated minor parental consent is not needed anymore, spouse is accepted
For mentally ill and unconscious patient, consent must be taken from the parents or legal guardian
If the patient is unable to write, an “X” is accepted if there is a witness to his mark
Secured without pressure and threat A witness is desirable – nurse, physician or authorized
persons. When an emergency situation exists, no consent is necessary
because inaction at such time may cause greater injury. (permission via telephone/cellphone is accepted but must be signed within 24hrs.)
D. Preoperative Meds. 5A’s Anxiolitics (Tranquilizers & Sedatives) * Diazepam ( Valium ) * Lorazepam ( Ativan ) * Diphenhydramine Analgesics * Nalbuphine ( Nubain ) Anticholinergics * Atropine Sulfate Anti-Ulcer (Proton Pump Inhibitors) * Omeprazole ( Losec ) * Famotidine Antibiotics E. Preoperative Teachings
Incentive Spirometry
Diaphragmatic Breathing
Coughing Turning
Foot and Leg exercise
Teaching should be done morning/afternoon before the day of surgery
Best Method: Return Demonstration
F. The Surgical Team Surgeon • Performance of the operative procedure according to the
needs of the patients. • The primary decision maker regarding surgical technique to
use during the procedure. Assistant Surgeon • Assists with retracting, hemostasis, suturing and any other
tasks requested by the surgeon to facilitate speed while maintaining quality during the procedure.
Anesthesiologist • Selects the anesthesia, administers it, intubates the client if
necessary, manages technical problems related to the administration of anesthetic agents, and supervises the client’s condition throughout the surgical procedure.
Scrub Nurse • Assists with the preparation of the room. • Scrubs, gowns and gloves self and other members of the
surgical team. • Prepares the instrument table and organizes sterile equipment
for functional use. • Assists with the drapping procedure. • Passes instruments to the surgeon and assistants by
anticipating their need. • Counts sponges, needles and instruments. • Keeps track of irrigations used for calculations of blood loss
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
Circulating Nurse • Responsible and accountable for all activities occurring during
a surgical procedure including the management of personnel equipment, supplies and the environment during a surgical procedure.
• Ensure all equipment is working properly. • Guarantees sterility of instruments and supplies. • Monitor the room and team members for breaks in the sterile
technique. • Handles specimens. • Coordinates activities with other departments, such as
radiology and pathology.
G. Principles of Surgical Asepsis Sterile object remains sterile only when touched by another
sterile object Only sterile objects may be placed on a sterile field
A sterile object or field out of range of vision or an object held below a person’s waist is contaminated
When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action
Fluid flows in the direction of gravity The edges of a sterile field or container are considered to be
contaminated (1 inch) H. PACU/RR Care Maintaining a Patent Airway Assessing Status of Circulatory System Maintaining Adequate Respiratory Function Assessing Thermoregulatory Status Maintaining Adequate Fluid Volume Minimizing Complications of Skin Impairment Maintaining Safety Promoting Comfort I. Parameter for Discharge from PACU/RR Activity. Able to obey commands Respiratory. Easy, noiseless breathing Circulation. BP within 20mmHg of preop level Consciousness. Responsive Color. Pinkish skin and mucus membrane
J. Post Operative Complications
Problem Nursing Intervention
RESPIRATORY
Pneumonia
Deep breathing exercises Coughing exercise Early ambulation
Atelectasis
Deep breathing exercises Coughing exercise Early ambulation
Pulmonary Embolism
Turning Ambulation Anti embolic stockings Compression devises Prevent massaging the lower
extremities CIRCULATION Hypovolemia Fluid and blood replacement Hemorrhage Fluid and blood replacement
Vit.k and hemostat Ligation of bleeders Pressure dressing
Thrombophlebitis
Early ambulation Anti embolic stocking Encourage leg exercise Hydrate adequately Avoid any restricting devices
that impaired circulation Avoid massage on the calf of
the leg Initiate anticoagulant therapy
URINARY Urinary Retention Monitor I & O
Interventions to facilitate voiding
Urinary Catheterization as needed
Urinary Incontinence
Monitor I & O
Urinary Tract Infection
Adequate fluid intake Early ambulation Aseptic catheterization as
needed Good perineal hygiene
GASTRO-INTESTINAL Nausea and Vomiting
IV fluids until peristalsis returns
Progressive diet ( clear liquid then full fluids, soft then regular diet)
Anti emetics as ordered Hiccups NGT insertion as needed
Hold breath while taking a large swallow of water
Breath in and out on a paper bag
Anti emetics as ordered Intestinal Obstruction ( 3rd-5th day postop)
NGT insertion as needed Administered IVF as ordered Prepare for possible surgery
Constipation Adequate hydration High fiber diet Encourage early ambulation
Paralytic Ileus Encourage early ambulation WOUND Wound Infection Keep wound clean and dry
Surgical aseptic technique when changing dressing
Antibiotic therapy Wound Dehiscence
Apply abdominal binders Encourage high protein diet
and Vit.C intake Keep in bed rest
Wound Evisceration Semi-Fowlers, bend knees to relieve tension on the abdominal muscles
Splinting on coughing Cover exposed organ with
sterile , moist saline dressing Reassure, keep him/her quite
and relaxed Prepare for surgery and repair
of wound
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
ONCOLOGY NURSING A. Benign VS Malignant Neoplasm Characteristic Benign Neoplasm Malignant Neoplasm Speed Growth Grows slowly
Usually continues to grow throughout life unless surgically removed
Usually grows rapidly Tends to grow relentlessly throughout life
Mode of Growth
Grows by enlarging and expanding Always remains localized; never infiltrates surrounding tissues
Grows by infiltrating surrounding tissues May remain localized (in situ) but usually infiltrates other tissues
Capsule Almost always contained within a fibrous capsule Capsule advantageous because encapsulated tumor can be removed surgically
Never contained within a capsule Absence of capsule allows neoplastic cells to invade surrounding tissues Surgical removal of tumor difficult
Cell characteristics
Usually well differentiated
Usually poorly differentiated
Recurrence Unusual when surgically removed
Common following surgery because tumor cells spread into surrounding tissues
Metastasis Never occur Very common Effect of Neoplasm
Not harmful to host unless located in area where it compresses tissue or obstructs vital organs
Always harmful to host Causes disfigurement, disrupted organ function, nutritional imbalances May result in ulcerations, sepsis, perforations,
Prognosis Very good Tumor generally removed surgically
Depends on cell type and speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis
B. Recommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer Beginning at age 20, routinely perform monthly breast self-
examination Women ages 20-39 should have breast examination by a
healthcare provider every 3 years Women age 40 and older should have a yearly mammogram
and breast self-examination by a healthcare provider 2. For detection of colon and rectal cancer All persons age 50 and older should have a yearly fecal occult
blood test Digital rectal examination and flexible sigmoidoscopy should
be done every 5 years Colonoscopy with barium enema should be done every 10
years 3. For detection of uterine cancer
Yearly papanicolao (Pap) smear for sexually active females and
any female over age 18 At menopause, high-risk women should have an endometrial
tissue sample 4. For detection of prostate cancer At age 50, have a yearly digital rectal examination
At age 50, have a yearly prostate-specific antigen (PSA) test C. American Cancer Society’s seven warning signs of cancer (uses acronym CAUTION US): 1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump in breast or elsewhere 5. Indigestions or difficulty in swallowing 6. Obvious change in wart or mole 7. Nagging cough or hoarseness 8. Unexplained Anemia 9. Sudden loss of weight D. Internal Radiation Therapy (Brachytheraphy) Sources of Internal Radiation Implanted into affected tissue or body cavity Ingested as a solution
Injected as a solution into the bloodstream or body cavity
Introduced through a catheter into the tumor
Side Effects
Fatigue Anorexia
Immunosuppression
Other side effects similar to external radiation
Client Education Avoid close contact with others until treatment is completed Maintain daily activities unless contraindicated, allowing for extra
rest periods as needed
Maintain balanced diet Maintain fluid intake ensure adequate hydration (2-3 liters/day)
If implant is temporary, maintain bedrest to avoid dislodging the
implant. Excreted body fluids may be radioactive; double-flush toilets after
use
Radiation therapy may lead to bone marrow suppression
Nursing Management Exposure to small amounts of radiation is possible during close
contact with persons receiving internal radiation: understand the
principles of protection from exposure to radiation: time, distance, and shielding
Time: minimize time spent in close proximity to the
radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift;
Distance: maintain the maximum distance 6 feet possible
from the radiation source Shielding: use lead shields and other precautions to reduce
exposure to radiation
Place client in private room Instruct visitors to maintain at least a distance of 6 feet from the
client and limit visitors to 10-30 minutes
Ensure proper handling and disposal of body fluids, assuring the containers are marked appropriately
Ensure proper handling of bed linens and clothing
In the event of a dislodged implant, use long-handled forceps and
place the implant into a lead container; never directly touch the
implant
Do not allow pregnant woman to come into any contact with radiation
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
If working routinely near radiation sources, wear a monitoring
device to measure exposure
Educate client in all safety measures
E. External Radiation Therapy (Teletheraphy) The radiation oncologist marks specific locations for radiation
treatment using a semipermanent type of ink
Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7 weeks
The client does not pose a risk for radiation exposure to other people
Side Effects
Tissue damage to target area (erythema, sloughing, hemorrhage) Ulcerations of oral mucous membranes GIT effects such as nausea, vomiting, and diarrhea
Immunosuppression
Client Education Wash the marked area of the skin with plain water only and pat
skin dry; do not use soaps, deodorants, lotions, perfumes, powders
or medications on the site during the duration of the treatment; do not wash off the treatment site marks
Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor
Wear soft, loose-fitting over the treatment area
Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15
Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues
Nursing Management Monitor for adverse side effects of radiation
Monitor for significant decreases in white blood cell counts and platelet counts
Client teaching (refer to later sections for management of immunosuppression, thrombocytopenia
CARDIOVASCULAR NURSING A. Heart Circulation
B. Heart Sound Tricuspid valve (lub) - RT 5th intercostal, medial Mitral valve (lub) - LT 5th intercostal, lateral Aortic semilunar valve (dub) - RT 2nd intercostal Pulmonary semilunar valve (dub) - LT 2nd intercostals
S1 - due to closure of the AV(mitral/tricuspid) valves S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves S3 – Ventricular Diastolic Gallop Mechanism: vibration resulting from resistance to rapid ventricular filling secondary to poor compliance S4 - Atrial Diastolic Gallop
Mechanism: vibration resulting from resistance to late ventricular filling during atrial systole
Heart Murmurs Incompetent / Stenotic Valve Pericardial Friction Rub It is an extra heart sound originating from the pericardial sac Mechanism: Originates from the pericardial sac as it moves Timing: with each heartbeat C. ECG
Cardiac Action Potential Depolarization/Contraction/Systole - electrical activation of
a cell caused by the influx of sodium into the cell while potassium exits the cell
Repolarization/Resting/Diastole - return of the cell to the resting state caused by re-entry of potassium into the cell while sodium exits
D. CARDIAC Proteins and enzymes
a. CK- MB ( creatine kinase) Most cardiac specific enzymes Accurate indicator of myocardial dammage Elevates in MI within 4 hours, peaks in 18 hours and
then declines till 3 days Normal value is 0-7 U/L or males 50-325 mu/ml
Female 50-250 mu/ml b. Lactic Dehydrogenase (LDH)
Most sensitive indicator of myocardial damage Elevates in MI in 24 hours, peaks in 48-72 hours
Return to normal in 10-14 days Normally LDH1 is greater than LDH2
c. Troponin I and T Troponin I is usually utilized for MI Elevates within 3-4 hours, peaks in 4-24 hours and
persists for 7 days to 3 weeks! Normal value for Troponin I is less than 0.6 ng/mL REMEMBER to AVOID IM injections before obtaining
blood sample! Early and late diagnosis can be made!
d. Serum Lipids Lipid profile measures the serum cholesterol,
triglycerides and lipoprotein levels Cholesterol= 200 mg/dL Triglycerides- 40- 150 mg/dL LDH- 130 mg/dL HDL- 30-70- mg/dL NPO post midnight (usually 12 hours)
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
E. Cardiac Catheterization ( Coronary Angiography / Arteriography ) Insertion of a catheter into the heart and surrounding vessels Is an invasive procedure during which physician injects dye
into coronary arteries and immediately takes a series of x-ray films to assess the structures of the arteries Pretest: Ensure Consent, assess for allergy to seafood and iodine, NPO, document weight and height, baseline VS, blood tests and document the peripheral pulses Intra-test: inform patient of a fluttery feeling as the catheter passes through the heart; inform the patient that a feeling of warmth and metallic taste may occur when dye is administered Post-test: Monitor VS and cardiac rhythm
Monitor peripheral pulses, color and warmth and sensation of the extremity distal to insertion site
Maintain sandbag to the insertion site if required to maintain pressure
Monitor for bleeding and hematoma formation
F. CVP ( Central Venous Pressure ) Reflects the pressure of the blood in the right atrium. Engorgement is estimated by the venous column that can be
observed as it rises from an imagined angle at the point of manubrium ( angle of Louis).
With normal physiologic condition, the jugular venous column rises no higher than 2-3 cm above the clavicle with the client in a sitting position at 45 degree angle.
NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg To Measure:
Patient should be flat with zero point of manometer at the same level of the RA which corresponds to the mid-axillary
line of the patient or approx. 5 cm below the sternum.
Fluctuations follow patients respiratory function and will fall on inspiration and rise on expiration due to changes in
intrapulmonary pressure.
Reading should be obtained at the highest point of fluctuation.
G. Coronary Arterial Diseases ANGINA PECTORIS 4 E’s of Angina Pectoris Excessive
physical
exertion
Exposure to
cold
environment
Extreme emotional
response
Excessive intake of
foods or
heavy meal
Levine’s Sign: initial sign that shows the hand clutching the chest Chest pain: characterized by sharp stabbing pain located at sub sterna usually radiates from neck, back, arms, shoulder and jaw muscles Dyspnea Tachycardia Palpitations Diaphoresis
Coronary artery bypass surgery Greater and lesser
saphenous veins are
commonly used for
bypass graft procedures
Percutaneuos Transluminal Coronary Angioplasty (PTCA) Mechanical dilation of
the coronary vessel wall by compresing the
atheromatous plaque.
Nursing Management: NTG Tablets(sublingual) Give 3 doses interval of 3-5minutes
ECG: may reveals ST segment depression T wave inversion
Keep the drug in a dry place, avoid moisture and exposure to sunlight
Change stock every 6 months
Offer sips of water before giving sublingual nitrates,
NTG Nitrol or Transdermal patch Avoid placing near hairy
areas as it may decrease drug absorption
Avoid rotating transdermal patches.
Myocardial Infarction (MI) Death of myocardial cells from inadequate oxygenation, often caused by sudden complete blockage of a coronary artery Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation & fibrosis
Chest pain Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles (abdominal ischemia): severe crushing Not usually relieved by rest or by nitroglycerine N/V Dyspnea Increase in blood pressure & pulse Hyperthermia: elevated temp Skin: cool, clammy, ashen Mild restlessness & apprehension ECG: ST segment elevation T wave inversion Widening of QRS complexes
Nursing Management Goal: Decrease myocardial oxygen demand Administer narcotic
analgesic as ordered:
Morphine
Administer oxygen low flow 2-3 L / min
Enforce CBR in semi-fowlers position without bathroom privileges
Instruct client to avoid forms of valsalva maneuver
Monitor urinary output & report output of less than 30 ml / hr: indicates decrease cardiac output
Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac rehab, post CABG & instruct to:
Instruct client to assume a non weight bearing position
Client can resume sexual intercourse: if can climb or use the staircase
The Most Critical Period 6-8 hours because majority of death occurs due to arrhythmia leading to premature ventricular contractions (PVC) *Lidocaine: DOC for arrhythmia
F. Congestive Heart Failure Inability of the heart to pump blood towards systemic circulation I. Left sided heart failure
90% - Mitral valve stenosis
Pulmonary Symptoms
II. Right sided heart failure
Tricuspid valve stenosis Venous congestion symptoms
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
NURSING MANAGEMENT Goal: increase myocardial contraction Administer medications as ordered
Cardiac glycosides Digoxin *Antidote: Digibind
Loop diuretics Bronchodilators Narcotic analgesics
Morphine sulfate Vasodilators Anti-arrhythmic agents
Administer O2 inhalation at 3-4 L/minute
Restrict Na and fluids
Monitor strictly VS and IO and Breath SoundsWeigh pt daily and assess for pitting edema and abdominal girth daily and notify MD
Provide meticulous skin care
Provide a dietary intake which is low in saturated fats and caffeine
RESPIRATORY NURSING A. Diagnostic Evaluation 1. Skin Test: Mantoux Test or Tuberculin Skin Test This is used to determine if a person has been infected or
has been exposed to the TB bacillus. This utilizes the PPD (Purified Protein Derivatives). The PPD is injected intradermally usually in the inner
aspect of the lower forearm about 4 inches below the elbow. The test is read 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. But for HIV positive clients, induration of about 5 mm is
considered positive
2. Pulse Oximeter Non-invasive method of continuously monitoring he oxygen
saturation of hemoglobin A probe or sensor is attached to the fingertip, forehead,
earlobe or bridge of the nose Normal SpO2 = 95% - 100% < 85% - tissues are not receiving enough O2
3. Chest X-ray This is a NON-invasive procedure involving the use of x-rays
with minimal radiation. The nurse instructs the patient to practice the on cue to
hold his breath and to do deep breathing Instruct the client to remove metals from the chest. Rule out pregnancy first.
4 . Indirect Bronchography A radiopaque medium is instilled directly into the trachea
and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray.
It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis. Nursing Interventions BEFORE Bronchogram Secure written consent Check for allergies to sea foods or iodine or anesthesia NPO for 6 to 8 hours Pre-op meds: atropine SO4 and valium, topical
anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready.
Nursing Interventions AFTER Bronchogram
Side-lying position NPO until cough and gag reflexes returned Instruct the client to cough and deep breathe client
5. Bronchoscopy This is the direct inspection and observation of the
larynx, trachea and bronchi through a flexible or rigid bronchoscope.
Passage of a lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree. Diagnostic uses: To examine tissues or collect secretions To determine location or pathologic process and
collect specimen for biopsy To evaluate bleeding sites To determine if a tumor can be resected surgically
Therapeutic uses To Remove foreign objects from tracheobronchial tree To Excise lesions To remove tenacious secretions obstructing the
tracheobronchial tree To drain abscess To treat post-operative atelectasis
Nursing Interventions BEFORE Bronchoscopy
Informed consent/ permit needed
Explain procedure to the patient, tell him what to expect, to help him cope with the unkown
Atropine (to diminish secretions) is administered one hour before the procedure
About 30 minutes before bronchoscopy, Valium is given
to sedate patient and allay anxiety.
Topical anesthesia is sprayed followed by local
anesthesia injected into the larynx
Instruct on NPO for 6-8 hours Remove dentures, prostheses and contact lenses
The patient is placed supine with hyperextended neck
during the procedure
Nursing Interventions AFTER Bronchoscopy Put the patient on Side lying position
Tell patient that the throat may feel sore with .
Check for the return of cough and gag reflex.
Check vasovagal response. Watch for cyanosis, hypotension, tachycardia,
arrythmias, hemoptysis, and dyspnea. These signs and
symptoms indicate perforation of bronchial tree. Refer the patient immediately!
6. Sputum Examination
Indicated for microscopic examination of the sputum: Gross appearance, Sputum C&S, AFB staining, and for Cytologic examination/ Papanicolaou examination
Nursing Interventions:
Early morning sputum specimen is to be collected (suctioning or expectoration)
Rinse mouth with plain water Use sterile container.
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
Sputum specimen for C&S is collected before the first dose of anti-microbial therapy.
For AFB staining, collect sputum specimen for three consecutive mornings.
6. Pulmonary Function Test / Studies
Non-invasive test Measurement of lung volume, ventilation, and diffusing
capacity
7. Arterial Blood Gas Assessment of arterial blood for tissue oxygenation,
ventilation, and acid-base status Arterial puncture is performed on areas where good pulses
are palpable (radial, brachial, or femoral). Radial artery is the most common site for withdrawal of blood specimen
Nursing Interventions: Utilize a 10-ml. Pre-heparinized syringe to prevent
clotting of specimen Soak specimen in a container with ice to prevent
hemolysis If ABG monitoring will be done, do Allen’s test to assess
for adequacy of collateral circulation of the hand (the ulnar arteries)
8. Thoracentesis Procedure suing needle aspiration of intrapleural fluid or air
under local anesthesia Specimen examination or removal of pleural fluid
Nursing Intervention BEFORE Thoracentesis Secure consent Take initial vital signs Instruct to remain still, avoid coughing during
insertion of the needle Inform patient that pressure sensation will be felt on
insertion of needle
Nursing Intervention DURING the procedure: Reassess the patient Place the patient in the proper position:
Upright or sitting on the edge of the bed Lying partially on the side, partially on the
back
Nursing Interventions after Thoracentesis Assess the patient’s respiratory status Monitor vital signs frequently Position the patient on the affected side, as ordered,
for at least 1 hour to seal the puncture site Turn on the unaffected side to prevent leakage of
fluid in the thoracic cavity Check the puncture site for fluid leakage
Auscultate lungs to assess for pneumothorax Monitor oxygen saturation (SaO2) levels Bed rest Check for expectoration of blood
C. Chronic Obstructive Pulmonary Diseases Chronic Bronchitis (Blue Bloaters) Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways
Smoking Air pollution
Consistent productive
cough
Dyspnea on exertion with prolonged
expiratory grunt
Anorexia and
generalized body
malaise
Cyanosis Scattered rales/rhonchi
Bronchial Asthma Reversible inflammatory lung condition caused by hypersensitivity to allergens leading to narrowing of smaller airways
Allergens Cough that is productive
Dyspnea
Wheezing on expiration Tachycardia,
palpitations and
diaphoresis Mild apprehension,
restlessness
Cyanosis
Bronchiectasis Permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the alveolar walls
Recurrent LRTI Congenital disease Presence of tumor Chest trauma
Consistent productive
cough
Dyspnea Presence of cyanosis
Rales and crackles Hemoptysis
Anorexia and
generalized body malaise
Pulmonary Emphysema Terminal and irreversible stage of COPD characterized by : Inelasticity of alveoli
Air trapping
Maldistribution of gasses
Overdistention of thoracic cavity
(Barrel chest)
Smoking Pollution Hereditary Allergy
Productive cough Dyspnea at rest Prolonged expiratory
grunt Resonance to
hyperresonance Decreased tactile
fremitus Decreased breath
sounds Barrel chest Anorexia and
generalized body malaise
Rales or crackles Pursed-lip breathing
Nursing Management: Enforce CBR
Low inflow O2 admin; high inflow will cause respiratory arrest * most accurate: venturi mask
Administer medications as ordered
Bronchodilators Antimicrobials Corticosteroids (5-10 minutes after bronchodilators) Mucolytics/expectorants
Force fluids
Nebulize and suction client as needed
Provide comfortable and humid environment Avoidance of smoking and allergens
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
C. PNEUMONIA Inflammation of the lung parenchyma leading to pulmonary
consolidation because alveoli is filled with exudates
I. Etioilogic Agent
1. Streptococcus pneumoniae (pneumococcal pneumonia)
2. Hemophilus influenzae (bronchopneumonia) 3. Klebsiella pneumoniae 4. Diplococcus pneumoniae 5. Escherichia coli 6. Pseudomonas aeruginosa
II. Predisposing Factor
1. Smoking 2. Air pollution 3. Immunocompromised
(+) AIDS Kaposi’s Sarcoma Pneumocystis Carinii Pneumonia
DOC: Zidovudine (Retrovir) Bronchogenic Ca
4. Prolonged immobility (hypostatic pneumonia) 5. Aspiration of food (aspiration pneumonia) 6. Over fatigue
III. Signs / Symptoms
1. Productive cough, greenish to rusty 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia, general body malaise 4. Cyanosis 5. Pleuritic friction rub 6. Rales/crackles on auscultation 7. Abdominal distention paralytic ileus
IV. NURSING MANAGEMENT 1. Enforce CBR (consistent to all respi disorders) 2. Strict respiratory isolation 3. Administer medications as ordered
Broad spectrum antibiotics Penicillin – pneumococcal infections Tetracycline Macrolides
Anti-pyretics Mucolytics/expectorants
4. Administer O2 inhalation as ordered 5. Force fluids to liquefy secretions 6. Institute pulmonary toilet – measures to promote
expectoration of secretions DBE, Coughing exercises, CPT
(clapping/vibration), Turning and repositioning
7. Nebulize and suction PRN 8. Place client of semi-fowlers to high fowlers 9. Provide a comfortable and humid environment 10. Provide a dietary intake high in CHO, CHON, Calories
and Vit C 11. Assist in postural drainage
Patient is placed in various position to drain secretions via force of gravity
Usually, it is the upper lung areas which are drained
Nursing management: Monitor VS and BS Best performed before meals/breakfast
or 2-3 hours p.c. to prevent gastroesophageal reflux or vomiting (pagkagising maraming secretions diba? Nakukuha?)
Encourage DBE
Administer bronchodilators 15-30 minutes before procedure
Stop if pt. can’t tolerate the procedure Provide oral care after procedure as it
may affect taste sensitivity Contraindications:
Unstable VS
Hemoptysis
Increased ICP
Increased IOP (glaucoma) 12. Provide pt health teaching and d/c planning
Avoidance of precipitating factors Prevention of complications
Atelectasis Meningitis
Regular compliance to medications Importance of ffup care
HEMATOLOGY NURSING A. Blood Cellular Components RBC * Hemoglobin * Hematocrit
4-6 million/mm3 Ave. 12 - 18 g/dL F: 36-42% M: 42-48%
iron-containing protein of RBC, delivers oxygen to tissue red cell percentage in whole blood
WBC *Neutrophils *Eosinophils *Basophils *Monocytes *Lymphocytes
N = 5,000-10,000/mm3 Most common type of leukocyte but a short lifespan of only 10-12 hours Lifespan= hours to 3 days B Cells T Cells NK Cells
First line of defense, Helpful in localizing the
infection and in immobilizing the pathogens until other WBCs arrive
Allergic Reaction and
Parasitic Invasion they are mediators in
inflammatory process. largest WBC
(macrophage) Antibody response Immunity Anti tumor
Platelets
N = 150-450 thousand mm3
Promotes hemostasis → prevention of blood loss → promote clotting mechanisms
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
B. Blood Disorder IRON DEFICIENCY ANEMIA (IDA) – chronic microcytic anemia due to inadequate absorption of iron leading to hypoxemic tissue injury
Monitor for signs of bleeding of all hema test including urine, stool and GIT
Enforce CBR so as not to overtire patient Encourage increased iron diet Avoid tannates in tea and coffee Administer medications as ordered Oral iron preparations (300mg OD) NURSING MANAGEMENT
1. Administer with meals to lessen GIT irritation
2. Use straw for liquid form 3. Administer with orange juice or
vitamin C to facilitate absorption 4. Inform client of SE/monitor for
a. Anorexia b. Nausea and vomiting c. Abdominal pain d. Diarrhea/constipation e. Melena
Parenteral Iron Preparations NURSING MANAGEMENT
1. Administer using z-tract method to prevent discomfort, discoloration and leakage
2. Avoid massaging of injection site instead encourage pt. to ambulate to facilitate absorption
3. Monitor SE a. Pain at injection site b. Localized abscess c. Lymphadenopathy d. Fever and chills
APLASTIC ANEMIA – stem cell disorder leading to bone marrow depression pancytopenia (all blood cells decreased) anemia, leucopenia, thrombocytopenia
Enforce complete BR Administer O2 inhalation Reverse isolation Monitor for signs of infection Avoid IM, SQ or any venipuncture sites instruct: use electric razor when shaving Medications as ordered
Immunosuppressants via central
venous catheter
Anti-lymphocyte globulin (ALG) –
given within 6 days – 3 weeks to
achieve maximum therapeutic effect
PERNICIOUS ANEMIA – chronic anemia resulting from deficiency of intrinsic factor leading to hypochlorhydria (decreased HCl secretion);
Headache, dizziness, dyspnea, palpitation,
cold sensitivity, pallor and generalized body malaise
GIT changes: Mouth sores, Red beefy
tongue, Dyspepsia or indigestion, Weight loss, Jaundice
CNS changes – PA is the most dangerous
form of anemia, Tingling sensation, Paresthesia, Ataxia, Psychosis
DIAGNOSTICS SCHILLING’S TEST – indicates decreased reabsorption of vitamin B12; confirms presence of pernicious anemia
NURSING MANAGEMENT Enforce complete bed rest (consistent to
all types of anemia) Administer Vit B12 injections at
MONTHLY intervals for lifetime as ordered; common site: dorso and ventrogluteal, no drug toxicity because it
is water soluble and is easily excretable; oral forms might develop tolerance.
Increase caloric intake, CHON, CHO, Fe, Vit C
Encourage client to use soft bristled toothbrush and avoid irritating mouthwashes (remember there are mouthsores!)
Avoid heat application (there is numbness remember?) may lead to burns
GUT NURSING A. Causes of Acute Renal Failure
Acute Renal Failure Chronic Renal Failure Sudden inability of the kidneys to excrete nitrogenous waste products, leads to azotemia STAGES
Oliguric phase – passage of urine (1-2 weeks) UO: <400 ml/cc
Hyperkalemia
Hypernatremia Hyperphosphatemia
HYPOCALCEMIA
Hypermagnesemia Metabolic acidosis
Elevated BUN, Crea
Diuretic Phase (2-3 weeks) Increased passage of
urine Hyperkalemia
Hyponatremia
Metabolic acidosis
Convalescent phase (3-12 months) Improvement in
passage of urine Characterized by
complete diuresis
Irreversible loss of kidney function
PREDISPOSING FACTORS DM and HPN (common
causes)
Recurrent pyelonephritis
Exposure to renal toxins
Tumor
STAGES Diminished renal reserve
volume – asymptomatic,
normal BUN and CREA Renal insufficiency
End-stage renal disease
(ESRD) – presence of oliguria, azotemia
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
NURSING MANAGEMENT ARF/CRF Enforce CBR
Admin oxygen inhalation as ordered
High CHO diet low CHON, fats, High vit and minerals Provide meticulous skin care
Wash with warm water
Soap irritates and dries skin Meds as ordered
anti-HPN agents Hydralazine (appresoline)
SE: orthostatic hypotension NaHCO3 Kayexelate enema Hematinics Antibiotics Supplementary vitamins and minerals Phosphate binders Calcium gluconate
B. Nursing Management on Hemodialysis
Secure consent and explain procedure to client Maintain strict aseptic technique Obtain baseline data – before and q30 during
procedure VS Wt Blood exams – secure all pre-procedure I/O
Have client void pre-procedure Inform pt about bleeding (blood is heparinized) Monitor for signs of complications (BEDSSH)
Bleeding Embolism DISEQUILIBRIUM SYNDROME – results from rapid
loss of nitrogenous waste products particularly UREA from the brain
HPN
Disorientation – initial sign
Nausea and vomiting
Anorexia
Headache
Paresthesia, peripheral
Numbness Septicemia Shock Hepatitis Avoid BP taking, phlebotomy, IV meds at the site of
fistula, blood extraction to prevent compression Maintain patency of shunt/fistula:
Palpate for thrills, auscultate for bruits Instruct that minimal bleeding is expected since blood
is heparinized Avoid use vasodilators, sedatives, and tranquilizers to
prevent hypotension unless ordered Prepare at bedside bulldog clips to prevent embolism Auscultate for bruits and palpate for thrills (if (+)
patent)
ENDOCRINE NURSING A. Thyroid Gland Disorders
HYPOTHYROIDISM HYPERTHYROIDSM Decreased T3 and T4 Increased T3 and T4 Early Signs 1. Weakness and fatigue 2. Loss of appetite but
(+) weight gain d/t increased lipolysis
3. Dry skin 4. Cold intolerance 5. Constipation 6. Menorrhagia Late Signs 1. Brittleness of hair 2. Non-pitting edema 3. Hoarseness of voice 4. Decreased libido 5. Decreased VS 6. CNS changes
a. Lethargy b. Memory
impairment c. Psychosis
1. Hyperphagia – increased appetite
2. (+) weight loss d/t increased metabolism
3. heat intolerance 4. moist skin 5. diarrhea 6. increased VS 7. CNS changes
a. Irritability b. agitation c. Tremors d. Restlessness e. Insomnia f. Hallucinations
8. Goiter 9. Exophthalmos 10. Amenorrhea
1. Monitor STRICTLY VS, IO to determine presence of MYXEDEMA COMA a complication of severe hypothyroidism characterized by: a. Severe
hypotension b. Bradycardia c. Bradypnea d. Hypoventilation e. Hypoglycemia f. Hyponatremia g. Hypothermia
2. Administer isotonic fluids as ordered
3. Administer medications as ordered – thyroid hormones or agents (may cause insomnia and heat intolerance)
4. Provide dietary intake low in calories to prevent weight gain
5. Institute meticulous skin care
6. Provide comfortable and warm environment
7. Forced fluids
1. Monitor VS and IO strictly to determine presence of THYROID STORM/Crisis
2. Administer medications as ordered
a. Anti-Thyroid Agents: PTU toxic effects is AGRANULOCYTOSIS fever and chills, sore throat (throat CS pls!), LEUKOCYTOSIS (CBC pls!)
b. Methimazole (Tapazole)
3. High calorie diet to correct weight loss
4. Provide comfortable and cool environment
5. Institute meticulous skin care
6. Maintain side rails 7. Bilateral eye patch to
prevent drying of eyes 8. Assist in surgical
procedure: subtotal thyroidectomy
PRE-OP Administer lugol’s solutions/ SSRI to promote decreased vasculature and promote atrophy of the thyroid gland to prevent/minimize bleeding and hemorrhage POST-OP WOF signs of THYROID STORM agitation, hyper-thermia, HPN. If (+) thyroid storm: administer anti-pyretics and beta-blockers; VS, IO and NVS strictly, siderails up, provide hypothermic blanket WOF: inadvertent or accidental removal of
WHAT YOU SHOULD KNOW BEFORE THE PNLE
DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
parathyroid gland hypocalcemia or tetany [(+) trousseu’s signs, (+) chvostek’s Give Ca Gluc slowly to prevent arrhythmia and arrest WOF accidental laryngeal nerve damage hoarness of voice instruct client to talk immediately post-op if (+) notify MD WOF signs of bleeding (+) feeling of fullness at incision site, (+) soiled dressings at back or nape area, notify MD WOF signs of laryngeal spasm DOB and SOB prep trache set 9. Hormonal Replacement
therapy for life 10. importance of FFup care 11. wearing of medic-alert
bracelet B. Insulin Therapy I. Types of Insulin
A. Rapid (SAI) – clear, peak: 2-4 hours , Regular insulin B. Intermediate AI – NPH (Non-Protamine Hagedorn) –
cloudy, peak : 6-12 hours C. Long AI – Ultra lente – cloudy, peak 12-24 hours
II. Nursing Management
A. Administer insulin at room temp to prevent lipodystrophy atrophy/hypertrophy of SQ tissue
B. Insulin only refrigerated once opened C. Avoid shaking insulin, roll between palms only D. Accuracy of administration is important E. Rotate insulin sites to prevent lipodystrophy F. Use short bore needle gauge 25-26 G. No need to aspirate H. Administer insulin 45/90 degrees angle depending on
amount to pt’s SQ tissue I. Most accessible route: abdomen J. Aspirate CLEAR before CLOUDY to prevent
contamination and promote accurate calibration K. Monitor for local complications:
1. Allergic reactions 2. Lipodystrophy 3. SOMOGYI’S PHENOMENON – rebound effect of insulin
characterized by hypoglycemia, hyperglycemia