MEDICAL SURGICAL NURSING 1 – R.

CHUA
CARDIOVASCULAR SYSTEM DISORDERS working, your heart still beats and impulse goes to AV
DISTURBANCES IN OXYGENATION with a heart rate of 40-60
 Functions  Would it be enough to sustain perfusion? – can be but
o Transports O2 and nutrients to cells slow
o Removes metabolic waste products  20-40 beats – Purkinje fibers
o Carries hormones from one part of the body
to another BLOOD COAGULATION TESTS
 Prothrombin Time
DIAGNOSTIC TESTS o Coumadin treatment
 Cardiac enzymes and biomarkers o Therapeutic range: 1.5-2 times normal
o Only dead tissues releases cardiac enzymes o Normal range: 11-16 seconds
 ischemia is lack of blood supply (no  Partial Thromboplastin Time
damage therefore cardiac enzymes are o Best single screening test for coagulation
normal) disorder
o Creatinine Kynase o Heparin treatment
 Cardiac Enzyme o Therapeutic Range: 2-2.5 times normal
 Released by dead or damaged o Normal range: 60-70 seconds
muscle tissues  Activated Partial Thromboplastin Time
 Elevation indicates myocardial o Most specific for heparin treatment
damage o Therapeutic Range: 2-2.5 times normal
 Elevates within 4-6 hours o Normal Range: 35-45 seconds
 Peaks in 18-24 hours
 Electrical burn – CK goes up (not QUESTION
accurate)  released generally by A client is at risk for pulmonary embolism and is on anticoagulant
muscle therapy with Warfarin (Coumadin). The client’s prothrombin time
 Stroke; Brain - CK-BB is 20 seconds, with a control of 11 seconds. The nurse assess
 Heart – CK-MB that this result is
o Cardiac enzymes are elevated  Infarction A. Higher than the therapeutic range
o LDH B. Within the therapeutic range
 Occurs in 24 hours C. The same as the client’s own baseline level
 Peaks In 48-72 hours D. Lower than the needed therapeutic level
o Troponin
 0-0.4 ngg/mL ANSWER: (B) (11x1.5-2)
 Most accurate cardiac marker (I
and T) CARDIAC CATHETERIZATION/ANGIOGRAPHY
 FOR HEART
 Tells you whether there is obstruction in your blood
 Elevates in 2-4 hours and last for 3
vessels
weeks
 INVASIVE – insert a dye
 Goes up very fast
 Coronary Artery Visualization – to check for any
 Complete Blood Count – WBC, RBC, H&H, HDL, LDL,
occlusion or narrowing
Triglyceride levels
 Assess for allergies to iodine/dye
 The most important in DIAGNOSTIC TEST WITH
CARDIAC PROBLEMS IS TRIGLYCERIDES  May experience flushing sensation as dye is introduced
 Fluttering sensation as catheter enters chambers of the
 BUN and Creatinine, CXR
o Because of perfusion heart
o If you have an MI, I distribute the problems to  ANGIOGRAM – tells you how much is obstructed
different organs  renal failure  ANGIOPLASTY – removes
 ECG common non-invasive procedure that records the  STENTING – opens it up
electrical activity of the heart  ARTERY – high pressured vessel  prone to bleeding
QUESTION:  Assess for bleeding
 Pressure dressing and sandbag
Which of the following should be avoided in the treatment of a  Monitor distal pulses (pedal pulses)
patient with suspected MI? o Catheter inserted in the femoral artery 
A. IM injection causes hematoma  Clot can obstruct the
B. SQ injection blood going to the legs
C. IV injection o Posterior Tibialis – medial aspect
D. ID injection
QUESTION
When interpreting an ECG, the nurse would keep in mind which of
the following about the P wave? Select all that apply 1. A client has returned to the unit after cardiac catheterization.
A. Reflects atrial muscle depoloarization Her left femoral dressing has a large amount of bloody drainage,
B. Identifies ventricular muscle depolarization and the client is complaining of severe pain in that area. What is
C. Reflects electrical impulse beginning at the SA node the priority nursing intervention?
D. Has duration of normally 0.11 seconds or less A. Assess the airway
E. Indicated electrical impulse beginning at the AV node B. Apply pressure to the site
C. Administer the oxygen
ANSWER: D. Assess the pulse in the left extremity
(1) A – 3x elevation of CK-MB follows an IM injection
(2) C 2. Which of the following diagnostic tools is most commonly used
to determine the location of myocardial damage?
 Intrinsic pacemaker – SA node A. Cardiac catheterization
 If my SA node – gives a heart rate of 60-100; if not B. Cardiac enzymes

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
C. Echocardiogram  “olol”/Very Nice Drugs
D. Electrocardiogram  Nitrates – NTG
 Give SL, dark container,
ANSWERS: (1) B (2) D cool storage, wash
hands
CORONARY ARTERY DISEASE  Warfarin – monitor for PT; Heparin
QUESTION PTT/APTT
 Foods contraindicated because it
A client with angina complains that the angina pain is prolonged contains Vit K – Green leafy
and severe and occurs at the same time each day. On further vegetables
assessment, a nurse notes that the pain occurs in the absence of  Give Warfarin (2-3 days) and
precipitating factors. This type of angina pain is best described as Heparin at the same time
A. Stable Angina – chest pain relieved by rest and NTG
(decreased HR and O2 demand) (NTG is a vasodilator)  MANAGEMENT
B. Unstable Angina o Maintain bed rest with bathroom privileges
C. Prinzmetal’s Angina o Semi-Fowler’s position to reduce cardiac
D. Non-Anginal Angina workload
o Obtain 12-lead ECG for you to know where
ANSWER: C your angina is
o Encourage exercise – build up collateral
ANGINA circulation (alternative circulation; creates
 Chest pain that results from myocardial ischemia – new pathways-blood vessels
most common symptom of CAD – demands exceed  MEDICATIONS
supply o NTG: 3 months; Take 5 minutes maximum of
 TYPES three then go to ER or call 911
o Stable – pain relieved by rest and NTG o Anticoagulants: Heparin (APTT, Protamine
o Unstable Sulfate); Coumadine (PT, Vitamin K)
 Increased severity, duration and o Calcium Channel Blockers (VND)
frequency o Beta Blockers (Propanolol)
 Increased activity severity, duration  TREATMENT
and frequency o Percutaneous Transluminal Coronary
o Variant – vasospastic Angioplasty (PTCA)
o Prinzmetal’s Angina o Intravascular Stenting
 Caused by cold environment  Done to prevent restenosis after
 May occur at rest PTCA
 CAUSES o Directional Atherectomy
o Activity that increases metabolic demands  A catheter equipped with a bladed
o 3E’s (Exertion, Emotion, Eating) tip is guided to the blockage. A
o Atherosclerosis, Thromboembolism balloon is inflated to push the blade
 ASSESSMENT toward the plaque to cut it away.
o Pain – substernal, crushing or compressing; Peces of the plaque are stored
may radiate to arms, jaw or back; usually within a chamber and removed
after exertion, excitement or exposure to cold when catheter is withdrawn
o Anxiety, diaphoresis, dyspnea, tachycardia, o STENT
palpitations, epigastric distress  Platelet tends to aggregate
o Morbidity – MALE; Mortality – FEMALE  Anti-platelet (preventive or
o Pain starts at substernal  keeps on saying prophylactic aspirin)
epigastric  MALE: chest pain (elephant
sitting on the chest) (clutch the chest – MYOCARDIAL INFARCTION
Levin’s Sign)  FEMALE: Sometimes I feel  Total occlusion of on of the coronary arteries >
indigested or heartburn  thinks of this as ischemia, injury, and necrosis
GURG  Infarction most often occurs in the left ventricle
o FEMALES: UNDERDIAGNOSED –  Can cause ventricular arrhythmias
EPIGASTRIC DISTRESS  Risk factors
o MALES: CRUSHING PAIN o Same risk factors as in angina
o I feel like my left arm is heavy – SIGN OF MI  Levine’s Sign
 DIAGNOSTIC EVALUATION o Pressure in the center of the chest
o Increased cholesterol, LDL and Triglycerides  ASSESSMENT
o Cardiac enzymes usually WNL o Crushing substernal pain (radiate to jaw,
o Coronary arteriography shows narrowing of back and arms; unrelieved by rest and NTG
coronary arteries o Dyspnea, diaphoresis
o ECG – ST segment depression, T-wave o Hypoxia causes arrhythmia
inversion (INDICATIVE OF ISCHEMIA)  V. Fibrillation – most common
 NURSING MANAGEMENT cause of death
o Low fat, low cholesterol diet o Tachycardia, anxiety, pallor, hypotension,
o O2 N/V, elevated temperature
o Administer medications as ordered  DIAGNOSTIC EVALUATION
 Anticoagulants (Heparin) and ASA o Increased cardiac enzymes
 Monitor PT/PTT o ECG shows deep, wide Q wave, elevated or
(antidotes) depressed ST segment, T wave inversion
 Beta-blockers and Calcium- o Pathologic Q wave – All layers of the heart
Channel Blockers are affected
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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Epicardium o NTG
 Myocardium o ASA: anti-platelet
 Endocardium o Beta blockers and Ca channel
 TREATMENT o Trombolytics: Given 3-4 hours after s/sx
o Bedrest with bedside commode o Anticoagulants
o Cannot use bedpan  requires more effort,
cannot walk in the hallway QUESTION
o Bleeding precautions (if thrombolytic therapy
used) 1. A client with myocardial infarction has been transferred from a
 Thrombolytics given between 4-6 coronary care unit to a general medical unit with cardiac
hours after the onset of the monitoring via telemetry. A nurse plans to allow which of the
symptoms following client activities
o CABG; Angioplasty A. Ad lib activities because the client is monitored
 Incision on the legs because that is B. Bathroom priviliges and self-care activities
where you have obtained the graft C. Unsupervised hallway ambulation with distances under
 Saphenous vein used for bypass 200 feet
 Varicose veins – cannot be used D. Strict bed rest for 24 hours after transfer
 IMA – Internal Mammary Artery
o Low calorie, low cholesterol, low fat diet 2. Which of the following symptoms should the nurse teach the
o Monitor labs (ABG, CK, electrolyte and client with unstable angina to report immediately to her physician
troponin A. A change in the pattern of her pain
o CPR if patient becomes unconscious and B. Pain during sex
defribillate C. Pain during an argument with her husband
o O2 D. Pain during or after an activity such as jogging
 MEDICATIONS
o Morphine – vasodilator, analgesic (reduces 3. A client with no history of CVD comes into the ambulatory clinic
myocardial O2 demand) with flulike symptoms. The client suddenly complains of chest
o Oxygen pain. Which of the following questions would best help a nurse to
o Nitroglycerin IV discriminate pain caused by a non-cardiac problem
o Aspirin – anti-platelet A. “Have you ever had this pain before?”
o Beta- blockers and Ca channel blockers B. “Can you rate the pain on a scale of 1-10, with 10 being
o Thrombolytics – given 3-4 hours after onset the worst?”
of symptoms C. “Can you describe the pain to me?”
o Anti-coagulants (Heparin/Coumadin) D. “Does the pain get worse when you breathe in”

CPR ANSWER:
 1st action: ASSESS UNRESPONSIVENESS (1) B
o “Hey, hey are you ok?” – ESTABLISHED (2) A
UNRESPONSIVENESS (3) D – pleuritic chest pain; flu might be secondary to pleurisy;
o Call for help (Emergency Medical Services) pleuritic chest pain on inhalation
o Adult: CALL FOR HELP (cardio)
o Child: CPR (respiratory) CARDIAC ARRYTHMIAS
 CPR: CAB  Abnormal electrical conduction or automaticity that
o Circulation – check for carotid pulse (10 changes cardiac rhythm and rate
seconds), check for gasping (not considered  Possible causes
as breathing) o Congenital, drug toxicity, electrolyte
 NO PULSE – start chest imbalances, heart disease, MI
compressions (30:2, 15:2)  Most common complication and
 2 shockable rhythms: VFib and major cause of death in MI
pulseless Vtac  The most common dysrhythmia in
 SYNC – becomes cardiversion MI is PVCs
 NOT PRESSED SYNC – becomes  PVC of >6/min is life threatening
defibrillator
 DETERMINE WHAT TYPE OF CONDUCTION DEFECTS/HEART BLOCKS/AV BLOCKS
DEFIBRILLATOR YOU HAVE  First Degree AV Block
 Monophasic – 360J o Impulse transmission is normal but is delated
 Bi-phasic – 200J longer at the level of AV node
 PADS: APEX and STERNUM o Treatment: None
 PADDLE: Between 10-20 lbs of  Second Degree AV Block
pressure o AV node is selective of impulse to reach
 3 VISUAL AND VERBAL ventricles
CLEAR o Treatment
 Stop Ambubag, CPR  Requires treatment if VR falls too
 I am clear, You are clear, low to maintain adequate CO
Everyone is clear  Third Degree AV Block
o Airway o No impulse from SA node reaches the
o Breathing ventricles
 MEDICATION o Treatment: Ventricular pacemaker
o MONA
o Morphine: Vasodilator and analgesics CARDIAC ARRYTHMIAS
(reduces myocardial O2 demand)  Abnormal electrical conduction or automaticity that
o O2 changes cardiac rhythm rate

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 PROPERTIES ANSWER: C
o AUTOMATICITY (initiating its own heart
beat) PACEMAKERS
o CONDUCTIVITY (traveling from one point to  Electronic device that causes cellular depolarization
another) and cardiac contraction
o CONTRACTILITY (the ability to empty the  It initiate and maintains HR
content of the heart)  PACING MODES
 CAUSES o Demand – Shocks if bellow the setting (will
o Congenital only work if higher or lower)
o Drug toxicity o Fixed rate – 60-100 bpm
o Electrolyte imbalance (HYPOKALEMIA) o Chamber
o Heart disease (MI, CHF)  Atrium – spike in front of P (A
 TREATMENT phase)
o Anti-arrythmics, synchronized cardioversion,  Ventricular - spike in front of QRS
CPR, defribillation, ICD, transcutaneous (V phase)
pacing  CLINICAL INDICATIONS
 NURSING MANAGEMENT o Tachyarrhythmias
o Monitor for signs of hypoperfusion (altered o Symptomatic bradyarrhythmias
cardiac output) to prevent cerebral anoxia o Heart blocks
and renal failure  NURSING INTERVENTION
o Initiate CPR as needed o Monitor ECG following implantation, include
o If trained, perform defibrillation early for VF VS
and VT o Observe for signs of pacemaker failure
o Provide adequate O2 and reduced cardiac  Dizziness and fainting
workload  Lasts for 3-5 years
 Ventricular problem - Lidocaine o Sterile technique is changing dressing
 Atrial problem – Quinidine o Avoid going near electrical devices (EMI)
 CARDIOVERSION: 50-200 J only
 If you have arrhythmias, perfusion is affected CONGESTIVE HEART FAILURE
  Inability of the heart to pump adequate blood into the
systemic circulation to meet metabolic demands 
QUESTION CONGESTION

Which wave in the ECG is targeted during synchronized HEART FAILURE

cardioversion  Left-Sided HF – pulmonary signs  dyspnea, crackles,
A. P wave orthopnea, tachypnea, tachycardia, S3 and S4 sounds,
B. R wave fatigue, anxiety, frothy sputum, arrythmias
C. U wave  Right Sided HF – systemic signs  dependent edema,
D. T wave weight gain, fatigue, jugular vein distention,
hepatomegaly, ascites
 Synchronization avoids the delivery of a LOW energy  POSSIBLE CAUSES
shock during cardiac repolarization (t-wave) o Endocarditis
 If the shock occurs on the t-wave (during o Atherosclerosis
repolarization), there is a high likelihood that the shock o MI
can precipitate VF (Ventricular Fibrillation) o COPD
o HTN
ANSWER: B o Fluid Overload
o Pulmonary HTN
ANTIDYSRHYTHMICS o Valvular insufficiency
 Sympathomimetics: Atropine  TREATMENT
o Bradycardia o Low sodium diet, I&O , weights, restrict fluids
 Beta-blockers, cardiac glycosides, Ca channel blockers o Assess CV status and VS to detect
o Tachycardia decreased cardiac output
 Quinidine o Keep in Semi-Fowler’s position
o Atrial Dysrhythmia o MEDICATIONS
 Lidocaine  Analgesics (Morphine Sulfate for
o Ventricular dysrhythmias – PVC and VTach Pulmonary Edema)
with pulse  Beta-blockers
 Diuretics (Furosemide) – nursing
QUESTION considerations
 Increase potassium
Which of the following functions is provided by a demand intake  lose potassium
pacemaker? if frequently urinates
A. A continuous stimuli to the heart muscle resulting in a  Inotropic agents (Digitalis-Digoxin)
fixed heart rate normal level (0.5-2ng/ml), signs of
B. Stimuli to the heart muscle only when the heart begins toxicity
to beat irregularly  Antidote: Digibind
C. Stimuli to the heart muscle only when the heart falls ENDOCARDITIS
below to a specified level  Inflammation of the endocardium
D. Continuous stimuli to the heart muscle whenever  Endocardium - Continuous to the valves of the heart
ventricular fibrillation is present  Bacterial infection – valve is damaged  blood
regurgitates
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 MEDICAL SURGICAL NURSING 1 – R. CHUA
o Caused by Rheumatic Fever – GABHS o TRICUSPID VALVE – RIGHT SIDED HEART
o Rheumatic Endocarditis FAILURE
o Infectious Endocarditis – caused by other  FORMS
than bacteria o Aortic insufficiency -
 Risk for clots and CHF o Mitral insufficiency
 Murmur, fever o Mitral stenosis
o The valves can be damaged  embolus o Mitral valve prolapsed
 Janeway lesions, Osler nodes, Roth spots o Tricuspid insufficiency
o When the valves are damaged  produces  VALVULAR REPLACEMENT
clots  leaflets aggregates platelets  o PORCEIN VALVES – heart valves from pigs
embolus that are created  goes to different o PROSTHETIC VAVLES
parts of the body  hands, palms  develop  Hancoc – Tricuspid
flat lesions  Janeway Lesions  petechiae o Take anti-coagulants
 Osler Nodes (nodules)  Roth spots  VALVULAR PROBLEM – CHF
(eyes)
MANAGEMENT OF CLIENTS WITH HYPTENSIVE DISORDERS
 Antibiotiics x 2-6 weeks CLASSIFICATION OF BP FOR ADULTS
o Given IV
 ATB prior to dental procedures until 6 months PHILIPPINE SETTING
o Cavities in the teeth can lodge bacterias  OPTIMAL <120 <80
bacterias can be obtained from tooth decay NORMAL <130 <85
 sore throat (strepto) HIGH NORMAL 130-139 85-89
HPN
PERICARDITIS STAGE 1 (MILD) 140-159 90-99
 Decreased blood pressure – cannot pump STAGE 2 (MOD) 160-179 100-109
 Heart rate is increased - tries to pump but not able to STAGE 3 (SEV) >180 >110
pump 2 consecutive readings over a 2-week period
 Bacterial, viral, fungal
 Heart is compressed  fluid buildup in the interstitial AMERICAN SETTING
space BLOOD SYSTOLIC DIASTOLIC
 ATB, steroids, salicylates PRESSURE mmHg mmHg
 Pain on inspiration CATEGORY
NORMAL LESS THAN AND LESS THAN
CARDIAC TAMPONADE 120 80
 Rapid unchecked rise in intrapericardial pressure due to ELEVATED 120-129 AND LESS THAN
blood or fluid accumulating in pericardial sac 80
 ASSESSMENT HIGH BLOOD 130-139 OR 80-89
o Anxiety, dyspnea, tachycardia, reduced PRESSURE
arterial BP, narrowing pulse pressure, neck (HPN) STAGE 1
vein distention, pallor or cyanosis HIGH BLOOD 140 OR OR 90 OR
o Beck’s Triad Related to Cardiac Tamponade PRESSURE HIGHER HIGHER
 Decreased BP (Hypotenion) (HPN) STAGE 2
 Distended jugular vein (CHF) HYPERTENSIVE HIGHER AND/OR HIGHER
 Distant heart sounds (muffled heart CRISIS THAN 180 THAN 120
sounds  compressed  cannot (CONSULT
hear heart sounds) YOUR DOCTOR
 Avoid salicylates if there is bleeding in the pericardium IMMEDIATELY)
o Anti-inflammatory but cannot be used if blood
is present because bleeding would worsen RISK FACTORS FOR HYPERTENSION
 DIAGNOSTIC EVALUATION NON-MODIFIABLE MODIFIABLE
o CXR shows cardiomegaly and widened FAMILY HISTORY STRESS
mediastinum AGE AND GENDER OBESITY AND NUTRIENTS
 TREATMENT ETHNICITY SUBSTANCE ABUSE
o Pericardiocentesis (needle aspiration) of the
pericardial activity HYPERTENSION
 ASSESSMENT
VALVULAR HEART DISEASE
o Asymptomatic
 3 TYPES OF MECHANICAL DISRUPTION FROM o Elevated BP
VHD o Dizziness
o Stenosis or narrowing o Headache
o Insufficiency – incomplete closure of the o L ventricular hypertrophy
valve o Heart failure
o Prolapse of the valve – protrudes into the LA o Cerebral ischemia
during systole  Blood vessels are vasoconstricted
o Can result from endocarditis and o Renal failure
inflammation > HF o Visual disturbances including blindness
o Can result from endocarditis and  Too much pressure in the occipital
inflammation > HF part
o MITRAL VALVE – LEFT SIDED HEART o Aneurysm – maintain normal BP
FAILURE  True Aneurysms
 Saccular – one side

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 Fusiform – more  ETIOLOGY
common o Unknown
 Dissecting – o Smoking  vasoconstriction
 False aneurysm – blood goes out; o Males
artery did not ruptured  ASSESSMENT
o Epistaxis o Intermittent claudication
 DIAGNOSTIC EVALUATION  Walks – painful
o Increased BUN, creatinine, Na and  Rest – goes away
cholesterol levels o Ischemic pain occurring in the digits while at
o Sustained BP readings of 140/90 mmHg rest
o CXR shows cardiomegaly o Cool, numb, tingling sensation
 MANAGEMENT o Diminished pulse at distal extremity
o TREATMENT o Ulceration
 Regular exercise to reduce weight  MANAGEMENT
 Low sodium diet and limitation of o Instruct to stop smoking
alcohol o Monitor pulses
o NURSING MANAGEMENT o Avoid injury to extremities
 Assess CV status and VS; Take an o Administer vasodilators as prescribed
average of 2 or more readings to
establish HTN VARICOSE VEINS
 Assess neurologic disorders and  Distended protruding veins that appear darkened and
observe for changes that may tortuous; vein walls weaken and dilate, the valves
indicate an alteration in cerebral become incompetent
perfusion (CVA)  ETIOLOGY
 Monitor I&O and weight o Prolonged standing/sitting
 Maintain a quiet environment to o Pregnancy
reduce stress o Obesity
o Congenital absence of valves
ANTI-HYPERTENSIVES o Constrictive clothing
QUESTION o Increased intra-abdominal pressure
 INCIDENCE
1. Which of the following symptoms usually signifies rapid o Female
expansion and impending rupture of an abdominal aortic o 35-40 years old
aneurysm?  CLINICAL MANIFESTATIONS
A. Abdominal pain o Dilated, purplish, tortuous veins
B. Absent pedal pulse o Leg pain
C. Angina o Leg edema
D. Lower back pain o Heaviness in the legs
 MEDICAL MANAGEMENT
2. Which of the following groups causes secondary hypertension? o Elevation of affected limb for 15-30 minutes
A. Obesity, high Na intake, tobacco use, renal artery o Compression with support stockings
stenosis o Sclerotherapy – involves injection of a
B. Renal artery stenosis, Cushing’s syndrome sclerosing agent into the varicose veins
C. Fluid overload, high Na intake, stenosis of the aorta o Surgery is vein ligation and stripping to
D. Stress, High Na intake, increased BP relieve the pain, reduce swelling, or provide
cosmetic results
ANSWER: o Early ambulation – prevent thrombophlebitis
(1) D – a sign of ruptured Triple A is lower back pain (flanks)
(2) B – secondary to diseases; primary – secondary to diet QUESTION

ARTERIAL DISEASES 1. A client with angina pectoris has a 12 lead ECG taken during
an episode of chest pain. Which ECG change is caused by
REYNAUD’S DISEASE – vasospasm of the arterioles and myocardial ischemia?
arteries of extremities A. Prolonged QT interval
 ETIOLOGY B. ST segment depression
o Cold – no blood supply  pale C. Widened QRS complex
o Stress D. Tall, peaked T waves
o Smoking
 ASSESSMENT 2. A patient with MI developed cardiogenic shock. The signs and
o Blanching of extremities followed by cyanosis symptoms of cardiogenic shock are:
o Reddened tissue A. A drop in systolic BP of 10 mmHg, headache and
o Numbness, tingling sensation (paresthesia) shallow respirations
 MANAGEMENT B. Rapid shallow respirations, polyuria, a drop in BP
o Stop smoking C. Cold, clammy skin, bouding pulse, hyperventilation,
o Vasodilators tachycardia
o Avoid precipitating factor D. Poor tissue perfusion, cold pale clammy skin, a drop in
o Warm clothing systolic BP of 30 mmHg below baseline
o Avoid injuries to hands and fingers
 Cardiogenic shock – below 30
BUERGER’S DISEASE
 Occlusive disease of the median and small arteries and
veins accompanied by clot formation

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
3. Because a client with MI can develop left ventricular failure, the LYMPHOMA
nurse should assess the client for  Lymphatic problems
A. Distended neck veins  LYMPHADENPATHY: phagocytosis – inflammation of
B. Paroxysmal nocturnal dyspnea the lymph node
C. Anorexia and weight loss  Lymphatic System: Goes to the heart and turns
D. RUQ tenderness systemic

4. In caring for a diabetic patient with varicose veins, the nurse HODGKIN’S LYMPHOMA
would instruct the patient to  Proliferation of REED-STERNBERG cells in a single
A. Cut toenails with nail cutter straight across and around lymph node then travels to another lymph node
the edges  Affects B-cell
B. Stand as long as possible on unaffected leg  CAUSE
C. Keep lower extremities level with the body o EPSTEIN BARR VIRUS
D. Keep lower extremities elevated and warm  PROGRESSION
o Stage 1: Single Lymph Node/Cervical Lymph
5. A female client is diagnosed with Raynaud’s Disease. in Node
discharge planning, it is important for the nurse to instruct the o Stage 2: 2 or more lymph nodes on the same
client to avoid side of the diaphragm (GOOD PROGNOSIS)
A. Microwaves o Stage 3: Both sides of the diaphragm
B. Aspirin o Stage 4: Disease disseminated, spreads to
C. Cold weather other extralymphatic organs like spleen
D. Warm baths (POOR PROGNOSIS)
 SIGNS AND SYMPTOMS
6. If a client reports all of the following, which one is most o EARLY
indicative that the client is hypertensive?  Bone Pain (EARLIEST)
A. Client says that he has had unexplained nosebleeds  Cyanosis of the face and neck
B. Client says that he has difficulty sleeping at night  Enlarged, painless, non-tender,
C. Client says he has observed blood in his urine firm and movable lymph nodes
D. Client says he experiences abdominal fullness o LATE
 Hepatomegaly
 Splenomegaly
ANSWERS  DOB
(1). B (4). D  Facial edema
(2). D (5). C  Enlargement of the LE
(3). B (6). A
 DIAGNOSIS: Swab Test
HEMATOLOGIC DISORDERS NON-HODGKIN’S LYMPHOMA
 Affects B and T cells
APLASTIC ANEMIA
 Tumors occurs throughout the lymph nodes and
 Decrease in or damage to marrow stem cells
lymphatic organs in an unpredictable manner
 Renal failure
 SIGNS AND SYMPTOMS
 Results in anemia, leucopenia, thrombocytopenia o Prominent, painless, generalized
 Caused by certain medications, chemicals, or radiation lymphadenopathy
damage  DIAGNOSIS: Lymph Node Biopsy
 Management  MANAGEMENT
o Remove cause o Radiation
o Supportive care o Chemotherapy
o Peripheral Blood Stem Cell Transplantation o Transfusion RBS
o Administer O2 and Rest
LEUKEMIA
 MC Lymphoma in AIDS: NON-HODGKIN
 Malignant disorder of hematopoietic system that
 MC Cancer in AIDS: KAPOSI’S SARCOMA
involves the bone marrow and the lymph nodes
 Characterized by uncontrolled proliferation of immature MULTIPLE MYELOMA
WBC
 Abnormal proliferation of plasma cells (precursors to
 TOO MUCH WBC PRODUCTION: Anemia and antibodies)
thrombocytopenia due to decreased RBC and platelets
 Immature and malignant WBC invade the bone marrow,
 TYPES lymph nodes and liver, spleen, and kidneys
o Acute ML: MC in adults; Aplastic Anemia
 Bone marrow is invaded  blood destruction
o Acute LL: MC in children; Dangerous; very
throughout the body
prone to infections; no defense
 Multiple fractures, increased serum Ca and kidney
o Chronic ML
stones (RF)
o Chronic LL
 BENZ JONES PROTEIN in urine, increased BUN,
 DIAGNOSTICS
Creatinine Hypercalcemia
o BONE MARROW BIOPSY: Leukemic Blast
Cells  SIGNS AND SYMPTOMS
o Pancytopenia
 MANAGEMENT
o Pathologic fracture (fracture secondary to
o Chemotherapy
another disease)
o Radiation
o Hepatomegaly
o Bone Marrow Transplantation: GVHD
o Renal calculi
o Severe bone pain

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 MANAGEMENT  Thin, older and
o Bone Marrow Transplant
o HD, Chemotherapy, Radiation CLINICAL PRESENTATION OF CRONIC BRONCHITIS AND
o Encourage fluid intake EMPHYSEMA
o Maintain seizure precaution due to
hypocalcemia

polycythemia due to

reactive
vasoconstriction from

-Cpr pulmonale from

than
-Pneumothorax due

-Weight loss due to

-Weight loss due to

of
-Pulmonary HTN due

pulmonary

to formation of bullae
COMPLICATION

bronchitis patients
RESPIRATORY PROBLEMS

work of breathing

work
COPD - A group of diseases that includes


-Secondary
Bronchiectasis

hypoxemia

hypoxemia

breathing
o Permanent enlargement of parts of the

chronic
airways of the lung

more
HTN
o Damaged air passages allow bacteria and

to
mucus to build up and pool in the lungs
o Results in frequent infections and blockages

breath
edema

-Prolonged expiration

muscle

appearance due to
-Cyanotic (secondary
to hypoxemia and

(cor

anorexia + increased

chest, hyperresonant
-Hyperinflation/barrel
-pursed lip breathing
-Crackles, wheezes
of the airways

-Frequently obese

work of breathing
 CAUSES

SIGN

diaphragmatic
hypercapnea)
o

RVF
Airborne irritants and pollution

if obstructive

-Decreased
pulmonale)

-Accessory
-Peripheral

percussion
-Cachectic
o Allergens, chronic RT infection, smoking

-Pink skin

sounds,

sounds
from
CHRONIC BRONCHITIS

use
 Bronchitis – inflammation of bronchioles
 Persistent cough for at least 3 months/yr for 2

hyper-resonant
-Cachectic appearance due
to anorexia + increased

/barrel

-Decreased breath sounds,

-Increased minute ventilation

successive years


diaphragmatic excursion
Edema of the mucous membrane

-Accessory muscle use

SYMPTOMS


-Dyspnea (+/- exertion)

-Pursed lip breathing
Hypersecretion of mucus
 Blue bloaters (develop congestion) – hypoxics 

work of breathing
-Hyper-inflation
o RA and RV pumps blood to lungs  lungs

-Minimal cough
permanently damage  It cannot enter the

percussion

-Tachypnea
-Pink skin
lungs  goes back to RV  RA  superior
and inferior vena cava  RHF (Cor

chest,
pulmonale)
 Bacterial infection
 Increased Hemoglobin level  tries to give more
oxygen

Blue bloater

Empysema
Secondary polycythemia

Pink puffer
Bronchitis

 Mostly the obese ones – because of edema

 NURSING DIAGNOSIS
o Impaired airway clearance secondary to a lot
of secretions
 MANAGEMENT
o Drink plenty of fluids
o Cough and with plenty of phlegm  give
expectorants; mucolytics ASTHMA
 Hypersensitivity reaction
EMPHYSEMA  Bronchoconstriction, mucosal edema, hypersecretion of
 Over distended (bullae) and nonfunctional alveoli mucus is the triad
leading to rupture  Leukotrines is the one that causes bronchoconstriction
 CO2 turns to Carbonic Acid  air goes in  air does  Muscles around the bronchioles are constricting it
not go out  alveoli problem  respiratory acidosis  The muscles of an asthmatic bronchial tube are
 Ruptured alveoli  pneumothorax constricted. The airway itself is inflamed and clogged by
 Removal of bullae  Bullaectomy mucus
 NURSING DIAGNOSIS  Give bronchodilators – epi, beta agonist, theophylline,
o Impaired gas exchange  underwent amenophylline
bullaectomy  A chronic inflammatory disease of the airways that
 Retention CO2 and hypoxia leading to respiratory causes
acidosis o Airway hyperresponsiveness
 Pink puffers: Hyperventilation o Mucosal edema
o CO2 is problem  able to inhale O2  I got o Mucus production
lots of CO2 and way to remove is  Hypoxia and respiratory acidosis
hyperventilate  prolonged exhalation   Retention of CO2 and air trapping
pursed lip breathing  Management is similar to COPD
 Normal: Stimulus to breathe is increased CO2  Avoidance of triggers (allergens)
 COPD: Stimulus to breathe is a low pO2  Multifactorial in cause
 Never give high O2 to client with COPD (O2 given 2-
3L/min) COPD
 I am used to a low oxygen because my CO2 level is  ASSESSMENT
high  if you try to remove CO2 level  the more I o Barrel chest and clubbing (excessive trapping
cannot breathe  disruption to the hypoxic drive of air and cyanosis)
 Barrel chest  increase in antero-posterior (AP) o Cough, exertional dyspnea  problem in
diameter  tries to accommodate the bigger lung alveoli

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
o Wheezing and crackles  pleural effusion  lungs compressed outside  not
o Weight loss (unable to eat due to SOB) able to breathe
 Emphysema  PLEURAL EFFUSION: COMMON COMPLICATION
o Sputum production (amount, color  CONSOLIDATION
consistency) o Lobar – consolidation of one side
 Yellow – pneumonia o Lobular or bronchopneumonia
o Use of accessory muscle (emphysema)  CAUSES
o Posturing (leaning forward) o Aspiration, chemical irritants, various
 Lessens pressure  heart is organisms
displaced forward  ASSESSMENT
o Pursed lip breathing (remove CO2) o Chills, fever SOB, tachypnea, accessory
o Can cause COR PULMONALE (R sided HF) muscle use
 DIAGNOSTIC EXAMS o Sputum (rusty green or bloody with
o CXR – congestion and hyperinflation pneumococcal pneumonia and yellow green
o ABG – respiratory acidosis and hypoxemia with bronchopneumonia)
 TREATMENT o Crackles, rhonchi, pleural friction rub on
o CPT, Postural drainage, Incentive spirometer auscultation (sounds like a sandpaper)
o Fluid intake to 3L/day if not contraindicated o Restlessness (earliest sign of cerebral
o O2 at 2-3L/min hypoxia)
o Diet high in CHON, Vitamin C, calories,  DIAGNOSTIC EXAM
nitrogen o CXR shows diffuse patches throughout the
 Not too much on CHO lungs or consolidation in a lobe
 NURSING MANAGEMENT o Sputum culture identifies the organism
o Administer low flow O2 (24-48%). Monitor o Broad spectrum (
pulse oximetry o Narrow spectrum (if sputum culture results
o Encourage to drink plenty of fluids if not comes out)
contraindicated o WBC and ESR are elevated
o Instruct in diaphragmatic or abdominal and  TREATMENT
pursed lip breathing o CPT, PD, IS
o Suction o Diet: High CHON, High calorie, Force fluids
o Encourage small, frequent feedings to  NURSING MANAGEMENT
prevent dyspnea o Administer O2 and respiratory treatments
o Stop smoking o Position in Semi-Fowler’s position to facilitate
o Avoid exposure to persons with infections breathing and lung expansion
o Receive immunization: Pneumonia vaccine,
influenza (flu shot) PNEUMOCYSTIS CARINII PNEUMONIA
 MEDICATIONS  Opportunistic infection associated with HIV
o Bronchodilators  Pneumocystis jiroveci (fungal infection)
 Salbutamol does not increases HR  Leading cause of death among HIV patients
 Theophylline o Wasting syndrome – loses more than 10% of
 Instruct on the use of both oral and TBW
inhalant medicines o CMV  causes blindness
o Steroids - To reduce inflammation  ASSESSMENT
o Anti-leukotrienes – (Montelukast-Singulair) o Fatigue, low grade and intermittent fever,
o Mast cell stabilizers (Cromolyn Na) non-productive cough, dyspnea, anorexia,
o Mucolytics – to thin secretions weight loss
o Expectorants – Guaifenesin (Robitussin)
 NURSING MANAGEMENT
o Administer O2 and monitor for hypxemia
STATUS ASTHMATICUS
o Administer anti-pyretics
 Type of asthma not relieved by normal bronchodilators o Monitor I&O
 High fowler’s position o Give antibiotics (Pentamidine, Bactrim)
 Monitor VS
 Monitor respiratory ststus PLEURAL EFFUSION AND PNEUMONIA
 Epinephrine/Aminophylline IV  Fluid – Pleural Effusion
o THE BEST DRUG IS EPINEPHRINE  Pus – Empyema
BECAUSE IT WORKS FASTER (FOR  Blood – Hemothorax
NCLEX)  Pleural effusion – excess of fluid in the pleural space
 Provide emotional support  Empyema – accumulation of pus and necrotic tissue in
the pleural space
PNEUMONIA
 CAUSES
 Refers to bacterial, viral, parasitic or fungal infection o Bacterial or fungal infections, HF, hepatic
that causes inflammation of alveolar spaces and disease with ascites
increase in alveolar fluid. Ventilations decreases as
 ASSESSMENT
secretion thicken
o Pleuritic chest pain that is sharp and
o The hardest to eradicate is fungal
increases with inspiration
 Lung tissues are inflamed, even alveoli o Dyspnea, decreased breath sounds, fever,
 Pleural space and pleural fluid - Sac that covers the malaise
lungs o Dry, non-productive cough caused by
 Topmost layer of the lungs – parietal layer bronchial irritation or mediastinal shift to
 Innermost lining – viscera unaffected side
 Swollen lungs  fluid shifts to the pleural space
(interstitial space)  accumulates in the pleural space
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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Lungs are compressed  auscultate: possible to have  Used to remove abnormal accumulations of air and fluid
but decreased, sometimes absent breath sounds  from pleural space
atelectasis  CHAMBERS
 TREATMENT o Collection chamber – drainage bottle
o Thoracentesis o Water seal chamber – tip of tube is under
o Thoracotomy with CT insertion water (2 cm) allowing fluid and air to drain
 NURSING MANAGEMENT and prevents air from entering the pleural
o Sudden movement may puncture the lung space
o Explain thoracentesis to patient. Tell patient  No extra air can go back to the
to expect stinging sensation from the local patient
anesthetic and a feeling of pressure when o Water oscillates/tidaling (moves up when
needle is inserted patient inhales and moves down as patient
o Instruct patient to report DOB during the exhales)
procedure. May indicate pneumothorax o Suction control chamber – gentle bubbling
o Remind to breathe normally and to avoid normal
sudden movements such as coughing to  Intermittent bubbling in the water seal
prevent improper placement of needle  Continuous bubbling  air leak
 Empyema  there is pus  bacteria  given  Evaporation  water level down  replace
antibiotics  CARE OF CHEST TUBE
o If drainage bottle accidentally breaks,
PNEUMOTHORAX immerse tube in sterile water, remove broken
 Air in the pleural space system and replace with new one
 TYPES o If chest tube accidentally pulled out, apply
o Spontaneous – rupture of a bleb (bullae), MV sterile occlusive dressing and call MD
 MV – pushing air to lungs  o NURSING MANAGEMENT
overinflate  spontaneous  Monitor for drainage
pneumothorax  Keep tubes free of leaks,
o Open – opening thru the chest wall allows air dependent loops or other
to flow between pleural space and outside of obstructions
the body  Do not strip or milk tubes unless
o Tension – buildup of air in the pleural space specified by the doctor  can
that cannot escape cause tension pneumothorax
o IN ALL CASES, THERE IS DECREASED  Replace the tubing
SURFACE AREA FOR GAS EXCHANGE instead
RESULTING TO HYPOXIA AND  Check for bubbling in the water
HYPERCAPNIA seal
 Measure the Tidal Volume when the patient is in MV  Intermittent bubbling
o Tidal volume normal volume: based on normal
weight of patient – 5-10 ml/kilo  Continuous bubbling –
o 70 kilo person – 700 air leak
 Lungs are compressed  decreased surface area for  If water is used in the suction
gas exchange chamber, check for continuous
 Mediastinal shifting  heart is displaced to the bubbling which indicates the
unaffected side  unaffected lung compressed system is working
o Heart is compressed  BP low, HR  2 REASONS WHY THERE IS NO TIDALING
increased, RR increased (DOB) o Obstructed
o Auscultate lungs  decreased to absent  Empyema – tubing is obstructed 
breath sounds causes why there is no tidaling
 Open pneumothorax better than closed  The patient turns  tube is
o Closed  air went in  close it  lungs are compressed
still compressed o Lungs have re-expanded
 Vented dressing  tape on 3 sides but one side is open  CXR showed almost a L of water  chest drainage
(to allow air to go out) system is only 200L  2nd day check  3rd day same
 ASSESSMENT  add 3rd bottle (suction control bottle – pull secretions
o Dyspnea, decreased O2 sat out)
o Diminished or absent breath sound
o Sharp chest pain that increases with exertion
o Tracheal shift to unaffected side (tension)
o Sucking sound with open chest wound
 NURSING MANAGEMENT
o Apply vented dressing over chest wound
o High-Fowler’s position
o Prepare for CT placement until lung has fully
expanded
o Monitor for hypotension, tachycardia and
tachypnea (mediastinal shift)
o Administer O2

CHEST TUBES IMAGE SOURCE:

 Lungs is negative pressure [Link]
bottle+system&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiX7-
 Too much  drain or remove it out uzqPHbAhUCWysKHZRhCvoQ_AUICigB&biw=1366&bih=664#imgrc=43a2fc5JFWmPK
 Returns negative pressure to intrapleural space M:

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
LUNG CANCER A. Chronic, productive cough
 Malignant tumor of the lungs (primary/metastatic) B. Dyspnea on rest
o Highly vascular  receives a lot of blood C. Slow deep respirations
from the heart D. Wheezing
 TYPES
o Non-small cell lung cancer (NSCLC) – 5. A COPD patient presents with edema of legs and feet,
adenocarcinoma, squamous cell, large cell distended neck veins and a large palpable liver. He is most likely
o Small cell LC suffering from
 CAUSES A. Atelectasis
o Smoking (pack/yr/history, exposure to B. Pulmonary embolism
environmental and occupational pollutants) C. Cor pulmonale
 Smoking 5 cigarretes for 10 years – D. Pleurisy
2.5 pack yrs history (0.25x10)
 Half a pack a day – 5 pack year 6. Which of the following is the most normal in water-seal
history (0.5x10) chamber within the first 24 hours post operatively with a two-bottle
 One cigarette box – 20 sticks water seal drainage?
 ASSESSMENT A. No fluctuations in the water-seal tube
o Productive cough, dyspnea, hoarseness, B. Intermittent slight bubbling
chest pain, anorexia and weight loss, C. Bright red bloody drainage
weakness D. Orders to maintain suction at 30cm H2O
o Hemoptysis (late sign) – cancer has eroded
the tissues in the lung 7. A patient has a chest tube to underwater drainage that is
 NURSING MANAGEMENT connected to suction. A nurse observes that there is continuous
o Monitor VS, breathing patterns, breath bubbling in the suction control chamber. This finding most likely
sounds, and respiratory impairment indicates that
o Place in Fowler’s position A. There is a leak in the tubing
o Administer O2 and humidification to moisten B. The system is functioning properly
and loosen secretions C. The tube needs to be repositioned
o Administer corticosteroids and D. Additional suction should be applied to the system
bronchodilators
o Rest 8. A nursing measure that should be instituted after a
 MEDICAL MANAGEMENT pneumonectomy is
o Radiation therapy A. Monitoring chest tube drainage and functioning
o Chemotherapy B. Positioning the client on the unaffected side or back
o Surgery C. ROM exercises on the affected upper extremity
 Segmentectomy/Wedge Resection/ D. Auscultation for lung sounds on the affected side
Lobectomy
 Chest tubes ANSWER:
 Unaffected side (1) C
 Pneumonectomy (2) D
(3) A
 No chest tube
(4) C
 Affected side
(5) B; if A, first 24 hours, you do not expect lungs to expand
 Surgery in lungs  there is blood
(6) B
 give chest tubes
(7) C
 Surgery in R lung  place to
unaffected side  for the lung that
TRAUMA
underwent surgery to expand
 Lungs in R  Strain (overstretch; muscle) vs. sprain (overtwisting;
joints)
QUESTION
 Dislocation (goes out of the joint)
1. Which of the following findings in a client with lung resection  Subluxation – partial dislocation
would require immediate intervention?  FRACTURE
A. Decreased cough o Signs (injury  inflammation)
B. Pain on inspiration  Pain aggravated by motion,
C. Assent breath sounds tenderness
D. Drainage from chest tubes  Loss of function, obvious deformity
 Edema, loss of sensation
2. While assisting a client in changing positions, the tube is  Crepitus (rubbing against another
accidentally pulled out. What would the nurse do first? bone)
A. Check breath sounds  Shortening of extremity – compare
B. Place the end in a cup of water it to the other side
C. Place the client in Trendelenburg position o MANAGEMENT
D. Cover the opening in the chest with a dressing  Immobilize (splint) – the more you
move it, the more it will break
3. The nurse explains to the client about the result of positive PPD  Neck (cervical) – immobilize neck
A. You have been exposed to TB ASAP
B. You have been infected with TB  Cervical collar – prevent injury to
C. You are immune to TB phrenic nerve (innervates the
D. You have an increased risk of developing TB diaphragm)
 Compressed –
4. In assessing a client admitted with respiratory distress, the respiratory depression
nurse correlates which finding to the client with emphysema?

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Phrenic – between C2-  Pelvic Traction
C3 o Lumbosacral
 RICE  Crutchfield Tong
 Reduction o Skeletal traction – drills pinned into the bones
 Open – surgery to re- o Drilled in the parietal area
align the bone  SKIN TRACTIONS: temporary, minor injuries
 Close (casting/traction)  SKELETAL TRACTIONS: severe injuries
 STAGES OF BONE HEALING
o Fracture hematoma CARE OF PIN SITE
 Immobilize  Clean with antiseptic
 Inflamed (first 3 days)  Apply antibiotic
 Do not place a cast  compress  No betadine  rust pins
the site  No peroxide  aerobic infection
 PLACE A POSTERIOR MOLD
o Granulation tissue QUESTION
 Osteoblasts go to the site
 Bones are made of protein at this A client was placed in traction to align a fractured bone in a lower
stage protein will be laid down extremity. The nurse observes the traction weights touching the
 WHOLE CAST are now placed floor. The nurse should
here since inflammation has A. Raise the foot of the bed
decreased B. Notify the MD
o Callus formation C. Lengthen the traction rope
 Start of Calcium deposition D. Move the client up toward the head of the bed
 Partial weight bearing can now be
done ANSWER: D
o Ossification
o Remodeling CRUTCHES
 CAST CARE  2” below axilla – damages the brachial plexus 
o TYPES  2-3 into the side, 6-12 in to the front elbow flexion (20-
PLASTER OF PARIS FIBERGLASS 30 degrees)
-Chalky consistency -Plastic/synthetic  Exercises to prepare for CW
-Place in water then squeeze -Wet the gauze and little bit of o Hand muscle ex
then mold it in place water o Arm muscle ex
-Dries in 24-48 hours -Dries in 20 minutes  Stair climbing
-Do not touch when wet -Plastic  light o UP: Good leg  crutches with bad leg
-USE PALM when molding or o DOWN: bad leg with crutches  good leg
moving it around o Up with the good, down with the bad
-Cement  HEAVY
 All the weight of the crutches should fall in the palm of
the hands
o The cast must not be too tight 
 If the patient is non weight bearing: 3 point gait, may
Compartment syndrome
also use Swing to (crutch forward and swing to the
o Expose to air to dry
point of the crutch) and Swing Trough (crutch forward
o Monitor the extremity for circulatory
and pass the crutches)
impairment (5P’s – Compartment Syndrome)
 If patient is partial weight bearing: 4-point gait
o Monitor for any drainage of the cast
o Instruct not too insert anything in the cast  2-point gait: as if walking; faster version of 4-point gait
o Instruct to keep the cast clean and dry
o Inspect cast edges and skin for irritation CANES
o Monitor the smell of the cast  Cane held on non-affected side
o Windowing – creating a small window and  Cane walks together with weak leg
cover with gauze to allow to clean the wound
inside COMPLICATIONS OF FRACTURES
o Petalling – cut edges so that it would not  Fat embolism
cause irritation o Systemic fat globules released into the
o Bivalving – cut into half circulation
o Instruct to do isometric exercises – prevent o Long bones (ribs, tibia, pelvis)
muscle atrophy o Chest pain, tachypnea, tachycardia, change
 Alternate contraction and relaxation in LOC, petechiae neck and anterior chest
of muscles (intravascular thrombosis)
o DOB within 48 hours – considered FAT
TRACTION – Skin/Skeletal EMBOLISM
 Ensure that the weights are hanging freely o O2, coughing and deep breathing, intubation
 Maintain continuous traction  Infection/Osteomyelitis
 There should be a countertraction (patient’s body o Debridement, ATB (IV, oral)
weight)  Compartment Syndrome
 Traction is only 10% of patient’s body weight o Neurovascular compromise, 5P’s, monitor for
 MALUNION – “dumikit, tabingi” ATN (myoglobin)
o Myoglobin – goes out in an hour after muscle
 NON-UNION – caused by infection
injury; miniscule; obstruct renal tubules 
 Bryant’s Traction
acute tubular necrosis
o Buttocks should be off the mattress
o ATN – electrical burns; full thickness burns
 If it is, no pulling force  traction is
(damages the muscles)
useless
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 MEDICAL SURGICAL NURSING 1 – R. CHUA
o Fasciotomy – cutting up to the level of fascia D. Unnecessary movement of the extremity can cause
and release pressure wound dehiscence

QUESTION ANSWER: A

An indication of a neuromuscular problem noted during GASTROINTESTINAL AND HEPATOBILIARY DISORDERS

assessment of the patient with a fracture is GERD
A. Exaggeration of extremity movement  Gastric contents flow upwards to esophagus
B. Petechiae on the head and upper thorax  If contents cannot go down to stomach, goes back to
C. Decreased sensation distal to the site esophagus  esophagitis
D. Purulent drainage at the site of open fracture  Common in obese and pregnant women
 Any activity that increase intra-abdominal pressure
ANSWER: C (overeating, bending, tight clothing), foods that relax
B is for fat embolism cardiac sphincter (alcohol, peppermint, caffeine, high
fat diet[ takes a long time to digest]) lying down after
HIP FRACTURES meals  pushes esophageal sphincter  stands up
 Fracture of the proximal 3rd of the femur 30mins to 1 hour
 Common among elderly women  Can be caused by any increased intra-abdominal
 Partial Hip Replacement pressure
o Hip Herniarthroplasty  ASSESSMENT
o Surgical procedure where only the femoral o Dyspepsia, dysphagia
head (the ball) of the damage hip joint is o Odynophagia (painful swallowing)
replaced o Esophagitis
o The acetabulum (the socket) is not replaced  MANAGEMENT
 Total Hip Replacement o Avoid alcohol, peppermint, caffeine, high fat
o The acetabulum is replaced with a prosthetic diet
 Post-op care o Lose weight
o Maintain legs in abduction (place pillow o Avoid over-eating and tight fitting clothes
between legs) – adduction will displace o Elevate HOB during and after meals
prosthesis (8 weeks) o Antacids, PPIs
o Avoid bending/cross legs
o Use trochanter roll to prevent external HERNIA
rotation  SLIDING
 You have your esophagus, lower part is
QUESTION esophageal sphincter then stomach. Eat, goes
down. A part of your stomach went up your throat
The nurse teaches a patient scheduled for THR that it is important  YOU HAVE GERD
after surgery to avoid  No DOB, but difficulty swallow
A. Sleeping on the abdomen  Give antacids, PPIs
B. Sittings with legs crossed  Standing up  content goes down
C. Abduction exercises of the affected leg
 Repair of the sphincter – herniorraphy
D. Bearing weight on the affected leg for 4-6 weeks
 ROLLING
ANSWER: B  Diaphragm separates the two cavities  tear 
stomach went out of diaphragm and went to
thoracic cavity (heart and lungs)
AMPUTATION
 Stomach is in heart and lungs  dyspnea, chest
 Surgical removal of a part of a limb
pain (heart)
 Limbs are vascular  bleeding
 Once you cut it  stump
QUESTION
 Post-op care
o Monitor VS How can gastric regurgitation best be reduced?
o Evaluate for phantom limb sensation and A. Eat small frequent feedings and avoid overeating
pain; explain to the patient B. Small evening meals with bedtime snacks
o During the 1st 24 hours, elevate stump; put C. Belch frequently
pillows; after that flat on bed to prevent D. Swallow air
flexion hip contractures
 Contractures – stiffness of joint The nurse is preparing a client with hiatal hernia for discharge.
o After 48 hours, instruct also to be on prone Which of the following statements by the client would indicate the
position several times a day teaching has been effective?
o Maintain application of ace wrap to promote A. “I will join the gym and get in shape by lifting weight”
stump shrinkage B. “I know I need to eat a high fat diet to slow down my
digestion”
QUESTION C. “I will join a support group”
D. “I will take a walk after dinner each night”
During the post-op period, the patient with AKA should be
instructed that the residual limb should not be routinely elevated
because ANSWER:
A. The flexed position can promote hip flexion contracture (1) A
B. This position reduces the development of phantom limb (2) D (lift, increase intra-abdominal pressure)
sensation PEPTIC ULCER DISEASE
C. This position promotes clot formation at the incision site
 Impaired GI mucosa leading to erosion and ulceration
and thigh
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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 May be gastric or duodenal (most common) monitored, can also cause bacterial
 Predisposing factors: contamination
o Stress  Wala pa bag na next pero ubos na
o Food (MILK included) – milk contains proteins  hypoglycemia  D50 only for
and fat  stimulates release of pepsin _-> unconscious, D10W for conscious
triggers parietal cells  pepsin stimulates
release of HCl DUMPING SYNDROME
o Cigarette smoking and alcohol  Prevent dumping syndrome – rapid emptying of gastric
o Caffeine contents into the small intestine which has been
o Drugs anastomosed to the gastric stump
o H. pylori (90%)
 CAUSE
 MANIFESTATIONS: o Ingestion of food high in CHO and
Gastric Duodenal electrolytes, which must be diluted in the
- Caused by decreased - Hyperacidity jejunum; ingestion of fluid at mealtimes
mucus with normal acidity - Midline or to the right  Onset is 15-30 minutes after meals
- Pain midline - Same  SIGNS AND SYMPTOMS
- Gnawing, aching, burning - 2-4 hours after meals o Diarrhea
- 1-2 hours after meals and at night o Dizziness
- Relieved or worsened by - Relieved by food and o Diaphoresis
food or antacid antacid o Nausea and vomiting
o Palpitations
 NURSING MANAGEMENT
o Small frequent meals
 Food acts as a buffer – empty stomach – gastric o Moderate protein, moderate fat, low carbs
mucosa irritated o Chew food thoroughly
 MANAGEMENT o Drink meals in between
o Relieve the pain o Avoid high carbohydrate diet
o Lifestyle modification o Avoid liquid within meals
o Dietary modification o Lying down after meals – flat for 5-30 min p.c.
o Quit smoking
o Stress therapy QUESTION
o Use of cool (not ice) lavage with saline 
causes more ischemia Following a subtotal gastrectomy, a client develops dumping
 COMPLICATIONS syndrome. The nurse understand that dumping syndrome refers
o Hemorrhage to
o Perforations A. Nausea due to full stomach
o Adhesions – causing obstruction B. Rapid passage of osmotic fluid into the jejunum
 MEDICATIONS C. Reflux of intestinal contents into the esophagus
o Neutralize gastric acid D. Buildup of feces and gas within the large intestine
 Antacids (magnesium(diarrhea),
aluminum (constipation), calcium) ANSWER: B
o Decrease acid production C is for GERD
 Proton pump inhibitors D is for Large bowel obstruction
(esomeprazole)
 H2 blockers (cimetidine, ranitidine)
o Provide protective coating over ulcerated site APPENDICITIS
 Sucralfate (Carafate)  Obstruction of vermiform appendix
o Increases mucus production  FECALITH – hard stony mass of feces
 Misoprostol (Cytotec)  BLUMBERG’S SIGN: Rebound Tenderness; Peritonitis
o Antibiotics  ROVSING’S SIGN: Palpate on the Left, hurts more on
 Amoxicillin the right
 Metronidazole (Flagyl)  SIGNS
 SURGERY o Acute abdominal pain (RLQ) McBurney’s
o Vagotomy – sever the vagus nerve point
(stimulates release of HCl) – inhibits release o Anorexia, nausea and vomiting
of HCI o Rigid abdomen with guarding
o Billroth I (duodenum) and II (jejunum) – o Rebound tenderness
gastric resections o Elevated WBC count, fever
o Bilroth II results to dumping syndrome  eat o Sudden cessation of pain means rupture
palang  jejunum straight  NURSING MANAGEMENT:
o Gastrectomy (Pernicious anemia) o Bed rest
 POST-OP CARE AFTER GASTRIC RESECTION o NPO
o Maintain on fowler’s position for comfort and o Do not give NARCOTICS initially – will mask
to promote drainage the pain
o NGT for drainage o No enema/laxatives – can cause perforation
o Monitor dressings for drainage (bleeding) o Antibiotic therapy
o Assess bowel sounds; maintain on NPO o Surgery: appendectomy
o Nutritional support (TPN)
 (TPN – hyperglycemia, do not d/c CROHN’S DISEASE AND ULCERATIVE COLITIS
abruptly, only good for 24hrs); CBG  INFLAMMATORY BOWEL DISEASES
 Chime – partially digested food

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Digestion of food happens in the duodenum losed. The terminal ileum is
 Pancreatic enzyme brought out of the abdominal wall
o Amylase - carbs o Continent Ileostomy or Koch pouch – a
o Protyases – proteins reservoir or pouch is constructed from a loop
o Lipase-fats of ileum
 Jejunum – passageway; absorption  With a flat stoma on the r side of
 Ileum – fats are absorbed abdomen (drained every 2-4 hours
 Small intestine absorbed nutrients  large intestine with catheter)
(water absorption and excretion of fecal material)  Advantages
(production of vitamin K) need normal flora bacteria to  No need to wear an
produce vitamin K  external pouch
 Know the part that is affected  you know the symptom  Minimal skin problems
 Ulcer – wound that bleeds and could perforate  No flatus or leakage of
 Colitis – inflammation of the colon – colon is wounded stool (if there is, minimal)
 rectosigmoid o ILEAL CONDUIT – there is diversion; urine
o Experience bleeding goes out
Crohn’s Disease Ulcerative Colitis o PROCTOCOLECTOMY:
 Pre-op bowel prep:
 Autoimmune  Chronic
 Reduce bacteria in the
 Ileum and ascending  Rectosigmoid
intestinal tract to prevent
colon  Lower left quadrant
post-operative
 Right lower quadrant pain
complications or
pain  Diarrhea infections
 Diarrhea 3-5 watery  15-20 watery stools  Antibiotics – neomycin
stools mucoid stools  Bloody mucoid stools (aminoglycoside)
with pus with pus  Reduce colon content –
 Transmural involvement  Shallow ulcerations low residue diet,
 Ileostomy  Colostomy laxatives, enema
 Steroids and Flagyl  Steroids and Flagyl  Decompress
gastrointestinal tract
 Crohn’s disease is lifetime, on and off condition COLOSTOMY CARE:
 IN CROHN’S YOU MIGHT THINK YOU ARE HAVING  Skin care – cleanse with mild soap and water
AN ATTACK OF CROHN’S WELL IN FACT IT MIGHT  Odor control
BE APPPENDICITS  COMPREHENSIVE  Control of gas
ASSESSMENT!  Colostomy irrigation – to stimulate peristalsis; to
 Rectosigmoid – elimination problems establish a regular pattern of evacuation
 Ileum and ascending colon – nutrition and elimination o Do not force catheter into the stoma
o Cannot tolerate a high fat diet o Insert no more than 4 inches
o Cannot absorb fat soluble vitamins (ADEK) o Irrigate only with 500-1000mL of warm tap
o K – clotting that is why you are prone to water – prevent abdominal cramps
bleeding in Crohn’s o Do not irrigate more than once a day –
 Inflammatory response of GI is diarrhea prevent diarrhea
o Crohn’s is 3-5 o Elevate solution 12-18 inches – more than
o Ulcerative colitis – 15-20 would result to fast drip
 In Ulcerative colitis there is wound  there is blood 
that is why you have bloody mucoid stools  prone to STOMA CARE:
bleeding  Color: pinkish, reddish in color with slight edema for 5-7
 Shallow ulcerations – shallow wound days
 Crohn’s transumral – all layers are affected  it could
perforate LIVER CIRRHOSIS
 Ileostomy – Crohn’s  watery  Scarring of the liver; irreversible damage to the liver
 Ulcerative – Rectosigmoidectomy  formed if there is a  Liver regenerates
colostomy  Liver damage whatever reason (hepatitis –
 Ulcerative colitis – inflammation of the rectosigmoid  inflammation of the liver ; can be caused by alcohol) 
continuous pattern  entire pattern is inflamed liver keeps on getting injured  cirrhosis
 Crohn’s  skipped pattern of inflammation  formed if  CAUSES
may colostomy bag o Laennec (alcohol)
 INTERVENTIONS o Post hepatitis- fibrosis
o Rest the bowel o Billiary obstruction
o Control the inflammation o Cardiac
 Steroids  Cystic duct  gallbladder; bile is stored
o Treat infx  Fat content (cholecystokinin)  bile goes out to cystic
o Correct malnutrition  TPN duct  common bile duct  sphincter of Oddi 
o Alleviate stress  triggering factor duodenum
o Provide symptomatic relief  Gallstone is not in the gallbladder  common bile duct
o Meds: aminosalicylates (sulfasalazine), ATB,  the bile that is produced goes back up to liver  liver
steroids,immunosuppresants damage  chronic gall stone  cirrhosis  biliary
 SURGERY obstruction
o Ulcerative colitis  Ivc continuous to heart  blood congests the liver 
 TOTAL PROCTOCOLECTOMY liver cirrhosis
with permanent ileostomy – colon
and rectum removed and anus ic
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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Liver receives blood from hepatic artery around 30%,  If without encephalopathy – high
70% is unoxygenated coming from the portal vein protein
 Liver filters blood coming from the GI  removes  If with encephalopathy - low protein
microorganisms from GI tract  Portal Hypertension  goes back to blood vessels 
 Symptoms: produces new blood vessels  esophageal varices
 N/V  Any veins that is full of blood is known as varicose
 anorexia  Liver cirrhosis  hemorrhoids
 decreased energy – because the liver is  Patient might end up having hematochezia (fresh)
responsible for metabolizing nutrients  Vomiting blood  hematemesis (fresh blood)
o cannot metabolize carb  no glucose   NURSING MANAGEMENT
energy level down o Iv fluids
 liver cannot metabolize fats  fat wraps up on the o Anti-emetics
liver  hepatomegaly (fatty liver) o Seng-staken Blakemore tube (balloon
 Protein  abundant in blood: albumin tamponade) – insert the tube to stop the
 Decreased albumin production – edema and ascites; bleeding
decreased production of clotting factors – bleeding;  Keep a pair of scissors at beside in
anemia the event of acute respiratory
 Ascites - Compresses diaphragm leading to DOB distress cut across tubing to deflate
o Paracentesis to aspirate the fluid balloon
 X protein, x antibodies  prone to infection  Cut near the nostril
 Bile produced by liver  fat tissue accumulates   Deflate esophageal balloon for 5
Obstruction of bile flow- decreased absorption of fats  munites at 8-10 hours interval to
no Vitamin ADEK prevent necrosis
o Danger of liver cirrhosis: BLEEDING
 Decreased conjugation of bilirubin – acholic stools, tea- PANCREATITIS
colored urine  Inflammation
o Unconjugated bilirubin  non-water soluble o Autodigestion by the trapped pancreatic
 for the body to excrete  mix and change enzymes
to conjugated bilirubin  process in liver  o Obstruction and edema
go and mix with stools  stool turns into o Interstitial hemorrhage and tissue necrosis
stercobilin (brownish color of stool which  CAUSES
came from biluirubin) o Chronic alcoholism
o Liver is damage  gets conjugated  cannot o Gallstone
go out  no color  acholic (clay-colored o Infection
stools; grayish)  sit in the blood  bilirubin o Drugs: clorothiazide, glucocorticoid 
in blood  hyperbilirubinemia  jaundice provoke pancreatitis
 All blood goes to kidneys for filter  high bilirubin 
urine color normal is amber or yellowish  too much GALL BLADDER
bilirubin  tea colored urine (hyperbilirubinemia)   Cholelithiasis – stone formation in the gall bladder
acholic stool  Cholecystitis – inflammation of gall bladder usually
 Increased destruction of RBC  bilirubin goes up  precipitated by gallstones
thalassemia  unconjugated bilirubin  Choledocholithiasis – stone formation at the common
 Protein is also responsible for Decreased deamination bile duct
of CHON  ammonia not water soluble  convert  Incidence: (5 F’s)
through mixing with a chemical  urea o Female
o Can’t be converted to urea  removed o Forty (age – 40 years and above)
through kidneys  kidney damage  blood o Fair complexion
urea nitrogen increase  hepatic o Fertile
encephalopathy o Fat
o Renal failure  protein is not allowed   SIGNS AND SYMPTOMS
cannot excrete urea o Epigastric distress
o Can’t be converted to urea  toxic to o Abdominal distention
nervous system (central and peripheral)  o Ruq pain after fatty meal
hepatic encephalopathy manifested by o Referred pain to shoulders
confusion and forgetfulness  coma o Murphy’s sign – pain in site when palpated by
 Ammonia toxic to nervous system  asterixis  examiner during deep breathing
excitability of nerves  MANAGEMENT
 MANAGEMENT o Pain control – Demerol (drug of choice); do
o Correct electrolyte imbalance not give MORPHINE – causes spasm of the
o Reduction of ammonia formation Sphincter of Oddi
o *Neomycin (given for h encephalopathy) , o ESWL Extracorporeal Shock Wave
liver damaged  cannot be excreted Lithotripsy – shock waves used to
because it is not converted to urea  laxative disintegrate gallstones
 Lactulose (reduce ammonia) , CHON  Takes 6 months to remove 1 stone
restriction, tap water enema o Cholecystectomy
o NGT to suction  OPEN – monitor for respiratory
o Potassium sparing diuretics distress
o Paracentesis  Big incision
o Bedrest – to reduce metabolic demands to  Postop – cannot deep
the liver breathe because of pain
o High CHO, high calorie diet,  LAPAROSCOPIC

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Small incision, less C. Notify the physician immediately
infection D. Decreased fluid intake
 POST-OPERATIVE NURSING CARE
o Maintain patency of NGT ANSWER: B
o Assess T tube insertion if common bile duct is
manipulated (500ml/day for 1st few days) RENAL FAILURE
o Position: Low to SF  TYPES
o Monitor dressing o Acute – sudden loss of renal function;
o Clamp tube as ordered: Open ready to eat reversible
o DBE o Chronic – gradual progressive and
o Early ambulation irreversible loss of renal function
o Fat-free diet for 6 weeks  CAUSES
o Pre-renal – decreased blood supply;
GENITOURINARY DISORDERS perfusion
 Functions of the Kidney:  MI
o Urine formation  Diabetes
o Excretion of waste products  Stabbed (bleeding)
 Urea (major) o Renal – damage to the kidney itself
 Creatinine, phosphates  Kidney stones
 Sulfates, uric acid  Diabetes
o Regulation of electrolytes  Streptomycin
 Sodium o Post-renal – the urine is already made. Went
 Potassium out of the kidney but there is an obstruction
 80% of all K goes out of kidneys  goes back  renal failure
 20% of all K goes out of GI  BPH
o Regulation of acid base balance
 Kidneys damage  Metabolic ACUTE RENAL FAILURE
acidosis  Oliguria/anuric phase
o Control of water balance o 8-15 days
 ADH (vasopressin) o Output <400 ml/day
 Aldosterone (sodium and water) o Toxins accumulate  metabolic acidosis 
o Control of blood pressure Increased BUN, Crea, K; REVERSIBLE;
 Renin-angiotensin system o IF ALL OF MY KIDNEYS HAD SHUT DOWN
o Regulation of RBC production  ANURIA, OLIGURIA, TOXINS
 Erythropoeitin ACCUMULATE
 Damaged kidneys  no production of erythropoietin  o Decreased ph, bicarb, Na and Ca
anemic  BP goes up hypertensive o Azotemia (elevated serum levels of urea,
 Glucose and protein not thrown out (proteinuria and creatinine and uric acid)
glycosuria) o REMOVE BPH – KIDNEY CAN GO BACK
 Nitrogenous waste products  uric acid TO NORMAL
 Minimum urine output – 720/day  Diuretic phase
 <720 – oliguria o Extends from the time daily output > 400
 No urine – anuria ml/day
 LABORATORY TESTS o BUN stops increasing
o Routine urinalysis o UO > 3-5 L/day
o Creatinine clearance o hyponatremia, hypokalemia, change in LOC,
 Tagatanggal ng crea si kidneys; I hypotension
am measuring how much my  Recovery phase
kidneys are removing crea o Extends from 1st day BUN falls to the day it
 Damaged kidneys  down returns to normal
(inversely proportional)  INTERVENTIONS:
 How to collect o Dialysis, monitor F&E, acids and bases
 24-hour urine collection observe for fluid overload
1st void is thrown out o Moderate protein restriction, high in calories,
 Put it on ice CHO, low K
 Urinate at 8, throw it out. o Monitor cardiac status, I&O, weigh daily
But last monitoring is at o Monitor creatinine and BUN
8pm o Fluid restriction
o Blood studies: BUN (8-25 mg/dL), Serum o Diuretic therapy to treat oliguric phase
Creatinine (0.6-1.3 mg/dL), creatinine o Sodium polystyrene sulfonate (Kayexalate) –
clearance (85-135 ml/min), serum electrolytes hyperkalemia – to exchange Na for K ions in
o Cystoscopy GIT
o Abdominal X-ray (KUB)
CHRONIC RENAL FAILURE
 STAGES
o Diminished renal reserve
QUESTION  Normal serum BUN and creatinine
 No symptoms
After a cystoscopy, a patient is alarmed with the presence of pink-  Other kidney compensates
tinged urine. The nurse would o Renal insufficiency
A. Administer atropine suppository as ordered  GFR is only 25% normal
B. Tell the patient this is common and continue to observe  Azotemia; mild anemia

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
 Decreasing creatinine clearance o Hypogastric pain
o End Stage Renal Disease o Malaise
 GFR < 10% o Fever, chills
 Severe azotemia o Nausea and vomiting
 MANIFESTATIONS o Low back pain
o Azotemia, metabolic acidosis o Urinalysis findings
o Altered LOC due to accumulation of wastes  MANAGEMENT
o Irregular heart rate o C and S before antibiotic therapy
o Yellow bronze skin due to altered metabolic o Increase fluid intake
process o Acidify the urine
o Dry, scaly skin and severe itching due to o Perineal hygiene
uremic frost o Regular bladder emptying
o Proteinuria, glycosuria o Hot sitz bath
o Diminished erythropoietin secretion – anemia
o Renal phosphate excretion and Vit. D UROLITHIASIS/NEPHROLITHIASIS
synthesis are diminished; K secretion  Formation of stones in the urinary tract
increases  RISK FACTORS
o Heart failure, pulmonary edema o Diet high in calcium and protein
o Kussmaul’s respirations o Urinary stasis
 INTERVENTIONS o Dehydration
o Dialysis, monitor I&O, F&E o Uric acid accumulation
o Kidney transplant o Prolonged immobility
o Low CHON diet – limit accumulation of end  TYPES OF STONES:
products of CHON metabolism o Calcium oxalates, phosphates
o Fluid restrictions o Uric acid
o Antihypertensives, diuretics  SIGNS
o Epogen – stimulate bone marrow to produce o Colicky pain
RBCs o Nausea and vomiting
o Antipruritics; good skin care o Dysuria and hematuria
 MANAGEMENT
TYPES OF DIALYSIS: o Fluids
 Hemodialysis – removes wastes and fluids rapidly than PD o Strain urine
 Semi-permeable membrane used has pores large enough o Encourage ambulation
for wastes to go through but too small for blood cells and o Pain control
CHON to pass through o Acid ash diet for Ca/phosphate stones
 Removes toxic wastes and impurities from the blood o Alkaline ash – cystine and uric acid stones
 Blood removed from surgically created access site o Low purine diet for uric acid stones
 AV fistula, AV graft, Central venous catheter (temporary) o Surgery
 Osmosis, diffusion and filtration  Urolithotomy/nephrolithotomy
 NURSING RESPONSIBILITIES (nephrostomy tube)
o Monitor venous access site for bleeding  ESWL
o Don’t use arm for BP, IVT or venipuncture
o Auscultate for bruits and palpate for thrills Benign Prostatic Hypertrophy (BPH)
o Weigh before and after the procedure  Slow enlargement of the prostate gland – 40 years and
o Monitor for shock and hypovolemia above
o Monitor for disequilibrium syndrome – too fast  Interference in urination
removal of wastes – confusion, weakness  CAUSES: hormonal factors, age related changes
 Urethral compression occurs with signs of urinary
PERITONEAL DIALYSIS: obstruction > urinary stasis > UTI
 Peritoneal Dialysis – introduction of specially prepared  MANIFESTATIONS: Urinary frequency, nocturia,
dialysate solution into the abdominal cavity where the bladder distention, hematuria, bladder calculi
peritoneum acts as a semi-permeable membrane  INTERVENTIONS
 CHON may leak out o Administer Finasteride(Proscar) – reduces
 Nursing Interventions size
o Weigh, VS every 15 minutes then every hour o Terazosin – Hytrin – promote urination
o Patient voids prior to procedure o ATB (UTI)
o Warm dialysate solution to body temperature
– prevent cramps SURGICAL REMOVAL OF PROSTATE
o Inflow time, Dwell time and Drain time  TURP – resectoscope or laser inserted through urethra
 Suprapubic – incision in abdomen and bladder
URINARY TRACT INFECTION  Retropubic – abdominal incision
 Stasis of urine in the bladder and reflux of urine back  Perineal – perineal incision – highest risk for
into the bladder are primary causes of UTI (E. Coli) incontinence, impotence and wound contamination
 Upper UTI: Pyelonephritis  CBI (continuous bladder irrigation) after surgeryto
 Lower UTI: Cystitis, Urethritis promote hemostasis and limit clots that block the
 Most common is ascending type catheter
 Females > males (shorter urethra)  NURSING CARE:
 Instrumentation and obstruction also common causes. o Set rate of infusion per MD order; usually to
Also, sexual intercourse promotes development of UTI keep drainage reddish pink
 SIGNS o Maintain infusion continuously, observing
o Frequency, urgency, dysuria color, clarity and amount of drainage

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 MEDICAL SURGICAL NURSING 1 – R. CHUA
o Bladder spasms typical after TURP, notify ANSWERS
patient (1) B (4) A
(2) C (5) C
PROSTATE CANCER (3) B (6) A – oxalate is made up of green leafy vegetables
 Slow malignant change in the prostate gland that
spreads by direct invasion of surrounding tissue and
can metastasize to bony pelvis and spine
 Elevated serum acid phosphatase and serum PSA
(prostate specific antigen) and carcinoembryonic
antigen (CEA)
 Biopsy – reveals malignancy, MRI, CT
 INTERVENTIONS:
o Radical prostatectomy
o Radiation
o Diethylstilbestrol (Estrogen)
o Orchiectomy – limit production of
testosterone slowing the spread of the
disease

QUESTION

1. When teaching a client who has just started peritoneal dialysis

about the procedure, the nurse should tell the client that if the
drainage of dialysate from the peritoneal cavity ceases before the
required amount has been drained out, the client should
A. Drink 8 oz of water
B. Turn from side to side
C. Deep breathe and cough
D. Periodically rotate the catheter

2. During the oliguric stage of ARF, serum potassium is usually

A. Normal
B. Decreased
C. Elevated
D. Absent

3. A client with ARF moves into the diuretic phase after 1 week of
therapy. During the phase the client must be assessed for signs
of developing
A. Renal failure
B. Hypovolemia
C. Hyperkalemia
D. Metabolic acidosis

4. In caring for a client with hypovolemic shock related to trauma,

the nurse recognizes that he is at risk for pre-renal failure related
to
A. Decreased perfusion to kidneys
B. Direct trauma to kidneys
C. Obstruction to urine flow
D. Vasodilation of renal arterioles

5. To help prevent recurring UTI, the nurse should plan to instruct

a female client to
A. Increase the daily intake of citrus fruits
B. Douche frequently with alkaline agents
C. Urinate ASAP after intercourse
D. Cleanse from the vaginal orifice to the urethra

6. A patient passes a urinary stone and laboratory analysis of the

stone indicates that it is composed of calcium oxalate. On the
basis of this analysis, which of the following would the nurse
include in the dietary instructions?
A. Increase intake of meat, fish, plums and cranberries
B. Increase citrus fruits and juices
C. Eat more green leafy vegetables such as spinach and
bran
D. Increase intake of dietary products

J.E.A.D. 19 UST CON BATCH 2018