MEDICAL-SURGICAL NURSING REVIEW Course Outline
Client in Pain Perioperative Nursing Care III. Alterations in Human Functioning a. Disturbances in Oxygenation: Respiratory & Cardiovascular Functions b. Disturbances in etabolic and !ndocrine Functions c. Disturbances in !limination: "astrointestinal Problems d. Disturbances in Fluids and !lectrolytes: Renal & "enitourinary Functions e. Disturbances in Cellular Functioning: Cancer and Hematologic Problems f. Disturbances in Auditory & #isual Functions g. Disturbances in usculos$eletal Functions IV. Client in %iologic Crisis: i'e t(reatening Conditions o' t(e Human %ody ) *(oc$ V. !mergency & Disaster ) First)aid and Cardiopulmonary *upport I.
II.
-------------------------------------------------------------------------------------------------------------------------------------CLIENT IN PAIN I. Pain + t(e 'i't( vital sign an unpleasant sensory and emotional experience associated ,it( actual or potential tissue damage-
%asic Categories o' Pain: 1. Acute Pain + sudden pain ,(ic( is usually relieved in seconds or a'ter a'ter a 'e, ,ee$s2. C(ronic Pain .Non)alignant/ + constant0 intermittent pain ,(ic( usually persists even a'ter (ealing o' t(e in1ured tissue 3. Cancer)Related Pain) ay be acute or c(ronic2 may or may not be relieved by medications Pain 3ransmission: 4- Nociceptors Nociceptors are are called pain pain receptorsreceptors- 3(ese 3(ese are t(e t(e 'ree nerve nerve endings endings in t(e s$in s$in t(at t(at respond to to intense0 potentially damaging stimuli5- Peri Perip( p(er eral al Nerv Nervou ouss *ys *yste tem m 3. Central Nervous *ystem 6- Desc Descen endi ding ng Cont Contro roll *ys *yste tem m Factors 7n'luencing Pain Response 1. Past !xperience + e-g- trauma 5- Anxi Anxiet etyy and and Depr Depres essi sion on 3. Culture ) belie's 4. Age + in'ants are more sensitive 5. "ender 8- Place lacebo bo !''ec ''ectt C(aracteristics o' Pain 1. 7ntensity +mild0 moderate0 excruciating 2. 3iming + morning or evening0 duration may be longer or s(orter 9- ocation 4. uality + burning0 ac(ing0 stabbing 5. Personal eaning to pain + tolerance to pain may be di''erent 'rom one person to t(e ot(er due to some personal reasons suc( as economic reasons0 ,or$ condition0 etc6. Aggravating and Alleviating 'actors + patient;s environment environment 7. Pain %e(aviors ) 'acial expressions ,it( pain Pain Assessment 4- !valua !valuate: te: Cause Cause00 ocatio ocation0 n0 C(aract C(aracter er and 7ntens 7ntensity ity 2. Numeric Pain *cale + <)severe pain ) = + no pain 9- Descri Descripti ptive ve Pain Pain *cales *cales + mild0 mild0 moder moderate ate00 severe severe 4. #isual Analogue *cales <- Face Facess Pai Painn *ca *cale le Nurse;s Role in Pain anagement 4- 7denti 7denti'y 'y goal goalss 'or 'or Pain Pain man manage agemen mentt a- Decrea Decrease se inten intensit sity0 y0 durat duration ion or or 're>ue 're>uency ncy b- Fact Factor orss in iden identiti'y 'yin ingg goal goals: s: i- *eve *everi rity ty o' pain pain
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ii- Harm'u Harm'ull e''ect e''ectss o' pain pain to t(e clie client nt iiiiii- Dura Duratition on o' t(e t(e pai painn 5- !stabl !stablis( is( Nurse) Nurse)Pat Patien ientt Relation Relations(i s(ipp and 3eac(ing 3eac(ing a- Ac$no, Ac$no,led ledge ge t(e verba verbali? li?ati ation on o' pain pain by t(e clien clientt b- Reli Reliev evee pati patien ent;t;ss anxi anxiet etyy c- 3eac 3eac(( meas measur ures es (o, (o, to to reli reliev evee pain pain 3. Provide P(ysical care a- 3eac 3eac(( and and assi assist st in in sel' sel')c )car aree b- !nvi !nviro ronm nmen enta tall con condi ditition onss c- Applic Applicati ation on o' o' ice@ ice@(ea (eatt on pain'u pain'ull area area 6- ana anage ge anx anxie iety ty rel relat ated ed to to Pain Pain a- 3eac( about about t(e t(e nature nature o' pain pain t(at may be 'elt 'elt by t(e t(e client client and reassure reassure (im@(er (im@(er b- 3eac( 3eac( alter alternat native ive meas measure uress to relie relieve ve pain pain c- *tay ,it( t(e client client@@ 're>uent 're>uent communicat communication ion ,it( ,it( t(e t(e client client
5. Pain edications may be administered as: a. %alanced Anest(esia + given to avoid experiencing pain
b- PRN PRN + Pr Proo Re Re Nata NataBB + as as nee neede dedd c. Preventive + ta$en be'ore pain is 'elt d- 7ndi 7ndivi vidu dual ali? i?ed ed Dosa Dosage ge e. Patient)Controlled Analgesia .PCA/ .PCA/ + patient ta$es medication i' pain 'elt is becoming intolerable
8- Non)p( Non)p(arm armaco acolog logic ic 7nterv 7ntervent ention ionss a- Cutane Cutaneous ous *imula *imulatio tionn and assag assagee b- 7ce 7ce and and (ea (eatt t(e t(era rapi pies es c- 3ransc 3ranscuta utaneo neous us !lectr !lectrica icall Nerve Nerve *timul *timulati ation on d- Distraction e- Rela Relaxa xatition on 3ec( 3ec(ni ni>u >ues es '- "uided 7m 7magery g- Hypnosis II.
PERIOPERATIVE PERIOPERATIVE CARE o
P(ases o' Perioperative Nursing a- Pre) Pre)op oper erat ativ ivee Nursi Nursing ng b. 7nraoperative Nursing c- Post Post)o )ope pera ratitive ve Nurs Nursin ingg A- Pre)operative Care Pre)admission and Admission 3est 4Psyc(ological su support 5Client !ducation: a7mport portaance nce and and pract ractic icee o' o' bre breat at(i (ing ng exer exerci cise sess bocation & support o' ,ound c7mportance o' early ambulation d. 7n'orm and practice leg exercises0 positioning0 turning eAnest(esia an and an analgesics '!duc !ducat atee reg regar ardi ding ng drai drains ns and and dre dress ssin ings gs to be rece receiv ived ed post post)o )opp gRecove covery ry room policies and procedures 9-
7n'ormed consent aAt least 4 years o' age b7n soun soundd mind) ind) ,it ,it(out (out psyc psyc(o (olo logi gicc dis disor orde der r cNot un under t( t(e in in'luence o' o' dr drugs or or al alco(ol d7mmediate relative over ver 4 years old
6-
P(ys P(ysic ical al Asse Assess ssme ment nt and and prep prepar arat atio ionn a. P(ysical P(ysica l Preparation Prepara tion + NPO0 remove dentures0 denture s0 1e,elries0 clot(esetcclot(esetc b. Nutritional Nutritio nal & Fluid *tatus + s(ould be ,ell (ydrated c. Drug or alco(ol alco(ol se + may experience experience delirium or intoxication intoxication to anest(etic drugs because ormal doses do not usually ta$e e''ect to t(ese patients and re>uire (eavier dose to ac(ieve anest(etic e''ectd. Respiratory Respira tory *tatus ) teac( breat(ing breat(in g exercises exerc ises e. Cardio Cardiovas vascul cular ar *tatu *tatuss + s(ould s(ould (ave (ave contro controlle lledd and stable stable cardiovascular 'unctioning be'ore operation to prevent intraoperative problems f. Hepati Hepaticc & Renal Renal Functi Functions ons + normal normal 'uncti 'unctioni oning ng is import important ant in absorbing anest(etic drugs
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g. !ndo !ndocr crin inee
Func Functition onss) impo import rtan antt in moni monito tori ring ng to prev preven entt (ypo@(yperglycemia0 t(yrotoxicosis0 acidosis anest(etic drugs h. 7mmune Functions + allergies esp- to anest(etic i. Psyc(osocia Psyc(osociall Factors Factors + emotional emotional and psyc(ologic psyc(ological al preparation preparation to ensure cooperation 'om t(e patient ,it( t(e procedures j. *piritual & Cultural %elie's ) blood trans'usions0 transplants0 ligation0 ligation0 etc are against ot(er culture & religion-
5.
Pre)operative drugs + given 5=)8= mins-pre)operative a$es patient dro,sy0 $eep siderails up o
6.
Proper positioning
*emi)Fo,lers
HO% elevated at 9= degrees
Head in1ury0 pot)op cranial surgery0 post)op cataract removal0 increased 7CP0 dyspneic patients
Fo,lers
HO% elevated at 6< degrees
Head in1ury0 pot)op cranial surgery2 post)op abdominal surgery2 post)op t(yroidectomy0 post)op cataract surgery0 increased 7CP2 dyspnea
Hig()Fo,ler;s
HO% elevated at E= degrees
Pneumot(orax0 (iatus (ernia
*upine@ Dorsal Recumbent
ying on bac$ ,@ small pillo, under (ead
*pinal cord in1ury0 urinary cat(eteri?ation
ying on abdomen ,it( (ead turned to t(e side
Amputation o' legs@'eet0 legs@'eet0 post lumbar puncture0 post myelogram0 post tonsillectomy & adenoidectomy .3&A/
yin yingg on on sid side0 e0 ,eig ,eig(t (t on t(e lateral side0 t(e lo,er scapula and lo,er iliac-
Post)abominal surgery0 post tonsillectomy & adenoidectomy .3&A/0 post)liver biopsy . rig(t side do,n/0 post pyloric stenosis .rig(t/
ying on side0 ,eig(t on t(e clavicle0 (umerus and anterior aspect o' t(e iliac-
nconscious client
ying on bac$ ,it( $nees and legs bent and raised on a stir up
Perineal0 rectal & vaginal procedures
3rendelenburg
Head & body lo lo,ered0 'eet elevated
*(oc$
Reverse 3redelenburg
Head elevated 0 'eet lo,ered
Cervical traction
!levat !levatee extrem extremity ity
*uppor *upportt ,it( ,it( pillo, pillo,ss
Post)o Post)opp surgic surgical al proced procedure ure on extremity0 cast0 edema0 t(rombop(lebitis
ate atera rall @ *ide *ide lyin lyingg
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Prone *upine
Lateral Recumbent
*im;s Position
Reverse 3rendelenburg
ac$)Gni'e
Hig()Fo,ler;s
it(otomy
%- 7ntr 7ntra) a)op oper erat ativ ivee Care Care
1.
!nsure sterility o' all instruments and supplies at t(e operating 'ield Principle: *3!R7! 3O *3!R7!0 C!AN 3O C!AN Sterile objects touches only only sterile surfaces/objects surfaces/objects Clean objects touches touches only clean surfaces/objects surfaces/objects
*terili?ation tec(ni>ues: Autoclave + *team0 !t(yl Oxide ."as/ o "lutaralde(yde *olution) Cidex o
2.
!nsure sa'ety o' client in t(e operating table) prevent 'alls0 drape t(e patient properly0 provide ,armt(
9-
*tay *tay ,it( ,it( t(e client client to reli relieve eve anxiet anxietyy and and suppo support rt duri during ng anes anest(e t(esia sia Anesthesia Administration:
118
abcd-
6<8C-
"enera "enerall Anes Anest(e t(esia sia via 7n(ala 7n(alatio tionn "enera "enerall Anes Anest(e t(eisi isiaa via via 7ntr 7ntrave avenou nouss Region Regional al Anest( Anest(esi esiaa ) local local anest(es anest(esia ia Conduction Conduction %loc$s@ %loc$s@ *pinal *pinal Anest(esia Anest(esia + !pidura !pidurall & *pinal *pinal %loc$ %loc$ ) 'or operat operation ion belo, belo, t(e ,aist ,aist line ) patient patient is a,a$e during operation operation
Per' Per'or orm m spon sponge ge cou count nt00 inst instru rume ment nt cou count nt and and nee needl dlee coun countt Asepti Asepticc tec(n tec(ni>u i>uee in (an (andli dling ng and and prep prepari aring ng all all inst instrum rument entss and and suppl supplies ies Applie Appliess ground grounding ing devi device ce to preve prevent nt elect electric rical al burn burn durin duringg use o' o' elect electros rosurg urgica icall e>uipment Proper documentation Post)operative Car Care 1. 7mmediate assessment o' #*0 and Neuro #*0 drainages0 surgical dressing 5- on onito itorin ringg o' vital vital signs signs > 4
III. ALTERATIONS IN HUMAN UNCTIONING UNCTIONING
!.
DISTUR DISTUR"AN "ANCES CES IN IN O#$GEN O#$GENATI ATION ON Arterial "loo% Gas Nor&al Value 'H
'CO(
'O(
HCO)
easure o' acidity or al$alinity
-9< + -6<
Part Partia iall pres pressu sure re o' carb carbon on diox dioxid idee resp respir irat ator oryy parameter in'luenced by lungs only
9< )6<
Partial pressure o' oxygen2 measure o' amount oxygen delivered to lungs
=)4==
%icarbonate0 metabolic parameter in'luenced only by metabolic 'actors
55)58
Res'irator* A+i%osis
Normal Compensation
a- Administer NaHco9 b- "et rid o' CO5 c- %ronc(odilators d- onitor A%"
Nor&al Value
'H
-9< + -6<
'CO(
9< )6<
HCO)
55)58
Nursin Interention
Res'irator* Al,alosis
Normal Compensation
a- %reat(e into paper bag or cupped (ands b- Oxygen
119
Meta/oli+ A+i%osis
Nor&al Value
'H
-9< + -6<
'CO(
9< )6<
HCO)
55)58
Normal Compensation
a- 3reat underlying cause .*tarvation0 systemic in'ections0 renal 'ailure0 Diabetic acidosis0 Geratogenic diet0 diarr(ea0 excessive exercise/ b- Promote good air exc(ange c- "ive NAHCO9 via 7#
Nursin Interention
Meta/oli+ Al,alosis
Normal Compensation
Restore 'luid loss ,(ic( may be cause by vomiting0 gastric suction0 al$ali ingestion0 excessive diuretic
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
)
A group o' conditions assoc- ,@ c(ronic obstruction o' air'lo, entering or leaving t(e lungs
a1or diseases 4- Pulmonary !mp(ysema + air,ay is obstructed due to destroyed alveolar ,alls 5- C(ronic %ronc(itis) increased mucus production t(at obstructs air,ay 9- Ast(ma Cause: 4596-
Cigarette smo$ing C(ronic respiratory in'ections Family (istory o' COPD Air pollution
Clinical ani'estations: Fe, ,ords bet,een breat(s Pursed)lip breat(ing Cyanosis Distended nec$ veins %arrel c(est + increased diameter o' t(orax Pulsus paradoxus + Clubbing o' 'ingers Nicotine *tains Pitting edema exertional dyspnea or dyspnea at rest !nlarged pulsating liver Coug() ,it( or ,it(out sputum production
edical anagement: 4- %ronc(odilators 5- Anti(istamines 9- *teroids 6- Antibiotics <- !xpectorants 8- Oxygen t(erapy at 5P + use cautiously Nursing anagement: 4- Administer meds and O5 as ordered 5- Promote ade>uate activities to en(ance cardiovascular 'itness 9- Ade>uate rests 6- Avoid allergens or ot(er irritants <- Psyc(ological *upport
CHRONIC BRONCHITIS “Blue Bloater”
) )
An in'lammation o' t(e bronc(i ,(ic( causes increased mucus production and c(ronic coug(C(ronic condition is diagnosed i' symptoms occur 'or 9 mont(s and 'or 5 consecutive years-
Cause: Cigarette *mo$ing0 in'ection0 pollution
Clinical ani'estations:
Productive coug( 3(ic$er0 more tenacious mucus
*lig(t gynecomastia Petec(iae in midsternal area Dyspnea
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Decreased exercise tolerance I(ee?es
edical anagement: see COPD Nursing anagement: 4- Reduce or avoid irritants 5- 7ncrease (umidity 9- Administer medications as ordered 6- C(est p(ysiot(erapy <- Postural drainage 8- Promote %reat(ing tec(ni>ues EMPHYSEMA “Pink Puffer”
) )
A disorder ,(ere t(e alveolar ,alls are destroyed causing permanent distention o' air spaces.J/ dead areas in t(e lungs t(at do not participate in gas or blood exc(ange
Cause: Cigarette smo$ing0 Alp(a)anti)trypsin de'iciency .an en?yme in t(e alveolar ,alls/ Clinical ani'estations: 4- Dyspnea on exertion 5- 3ac(ypnea 9- %arrel)c(est 6- I(ee?es <- Pin$is( s$in color 8- *(allo, rapid respirations - Pursed lip breat(ing
Nursing anagement: Position: *it up and lean 'or,ard Pulmonary toilet: Coug()K%reat(e deeply)KC(est p(ysiot(erapy)K turn & position Fre>uent rest periods Nebuli?ation 7PP% + 7ntermittent Positive Pressure %reat(ing .aerosoli?ed in(alation/ O5 M 5P
Asthma
)A condition ,(ere t(ere is an increase responsiveness and@or spasm o' t(e trac(ea and bronc(i due to various stimuli ,(ic( causes narro,ing o' air,ays Cause and Ris$ Factors: 4Family (istory o' ast(ma 5Allergens: dust0 pollens0 9*econdary smo$e in(alation 6Air pollution <*tress 3ypes:
1. 7mmunologic ast(ma ) 2. Non)immunologic ast(ma )
occurs in c(ild(ood occurs in adult(ood and assoc ,@ recurrent resp in'ections) usually K9< y@o 9- ixed0 combined immunologic and non)immunologic Clinical ani'estations: 7ncreased tig(tness o' c(est0 dyspnea 3ac(ycardia0 tac(ypnea Dry0 (ac$ing0 persistent coug( .J/ ,(ee?es0 crac$les Pallor0 cyanosis0 diap(oresis C(ronic barrel c(est0 elevated s(oulders distended nec$ veins ort(opnea 3enacious0 mucoid sputum 3reatment : 4- *teroids0 5- Antibiotics 9- %ronc(odilators0 expectorants 4. O50 nebuli?ation0 aerosol
Nursing anagement:
1. Promote pulmonary ventilation 2. Facilitate expectoration 9- Healt( teac(ing %reat(ing tec(ni>ues *tress management Avoid allergens
Complication: STATUS ASTHMATICUS - a li'e)t(reatening ast(matic attac$ in ,@c symptoms o' ast(ma continues and do not respond to treatment 77-
PAR!NCHLA D7*ORD!R*:
121
PNEUMONIA - An in'lammatory process o' lung parenc(yma assoc- ,@ mar$ed increase in alveolar and interstitial 'luids
!tiology: 4- %acterial @ #iral + streptococcus pneumoniae0 pseudomonas aeruginosa0 in'luen?a 5- Aspiration 9- 7n(alation o' irritating 'umes Ris$ 'actors: 4- Age: too young and elderly are most prone to develop 5- *mo$ing0 air pollution 9- R37 6- Altered conciousness <- 3rac(eal intubation 6. Prolonged immobility: post)operative0 bed)ridden patients Clinical ani'estations: 459-
C(est pain0 irritability0 appre(ensiveness0 irritability0 restlessness0 nausea0 anorexia0 (x o' exposure Coug() productive 0 rusty@ yello,is(@greenis( sputum0 splinting o' a''ected side0 c(est retration CR0 sputum culture0 %lood culture0 increased I%C0 elevated sedimentation rate
Nursing anagement: Promote ade>uate ventilation) positioning0 C(est p(ysiot(erapy0 7PP% Provide rest and com'ort Prevent potential complications Healt( teac(ing: s$in care0 (ygiene Drug t(erapy: o Antibiotics: penicillin0 cep(alosp(orin0 tetracycline0 eryt(romycin Coug( suppressants o !xpectorants o Rest and ade>uate activity Proper Nutrition
PULMONAR$ EDEMA
) o'ten occurs ,(en t(e le't side o' t(e (eart is distended and 'ails to pump ade>uately o
Clinical ani'estation: Constant irritating coug(0 dyspnea0 crac$les0 cyanosis Pat(op(ysiology:
Fluid accumulation in t(e alveolar sacs due to (ypovolemia0 'luid congestions in t(e lungs0 alveoli are congested
Nursing anagement: 4- Diuretics0 lo, sodium diet0 7&O 5- promote e''ective air,ay clearance0 breat(ing patterns and ventilation 9- onitor #* 6- Psyc(ological support <- Administer medications TUBERCULOSIS
) A c(ronic lung in'ection t(at leads to consumption o' alveolar tissues !tiology:
ycobacterium tuberculosis-
Ris$ Factors: Poor living conditions0 overcro,ded 4- Poor nutritional inta$e 5- Previous in'ection
122
3. Close contact ,it( in'ected person 6- 7nade>uate treatment o' primary in'ection Clinical ani'estations: Diagnostic 3ests: 4596<8E-
Productive coug( Hemoptysis Dypnea Rales alaise Nig(t *,eats Ieig(t loss Anorexia0 vomiting 7ndigestion0 pallor
4- CR 5- *putum acid)'ast 9- antoux 3est ) -4 ml o' PPD .Puri'ied Protein Derivative/ 2 Read a'ter 6)5 (rs7nduration: 4=mm + K positive exposure to 3% bacillus < + E mm )K doubt'ul0 may repeat t(e procedure K 6 mm )K Negative
3reatment: 4- !t(ambutol 5- Ri'ampicin 9- 7sonia?id 6- Pyra?inamide <- *treptomycin Client !ducation: 4- 3% is in'ectious but can be cured 5- 3ransmitted by droplet in'ection and not carried on articles li$e clot(ing or eating utensils 9- 7ndividual is generally considered not in'ectious a'ter 4) 5 ,ee$s o' medication6- edication regimen s(ould be continuous and uninterrupted <- Regimen is usually 8 mont(s8- Regular c(ec$)up to monitor progress s(ould be done- *putum samples are obtained 'irst be'ore drug t(erapy is started- Advise proper (and,as(ing and use o' mas$ 'or people in contact ,it( in'ected persons ,(o are not yet under treatment-------------------------------------------------------------------------------------------------------------------------------------------------------CARDIOVASCULAR S$STEM
3H! H!AR3 AND AOR #!**!* I. Dianosti+ Pro+e%ure
Venous Disor%ers0
aboratory 3est !lectrocardiogram !c(ocardiograp(y Central #enous Pressure Pulmonary Artery Pressure@ *,an)"an? Cardiac Cat(eteri?ation
4- 3(rombop(lebitis 5- #aricose #eins
77- Diseases o1 t2e Vas+ular S*ste&:
Car%ia+ Disor%ers
Arterial Disorders: 4- Hypertension 5- Arteriosclerosis 9- At(erosclerosis 6- Aortic Aneurysm <- %uerger;s Disease .3(romboangitis Obliterans/ 8- Raynaud;s Disease
ab7n'arction cFailure de'-
Angina Pectoris yocardial Congestive (eart #alvular *tenosis A# Heart %loc$ Pacema$ers
A. DIAGNOSTIC PROCEDURES0
Pro+e%ure
4- aboratory 3ests
Values 3 Des+ri'tion
a- !lectrolytes + Na0 G0 Ca0 C(loride 0 g .see 'luids & electrolytes/
Pur'ose
Determines (yper$alemia0 Hypernatremia0 etc) determine t(e ability o' t(e (eart to a''ect circulation and regulatory 'unctions o' 'luids and electrolytes-
b- P33 + 48)6= secc- P3 + E)45 sec-
) determines ability o' t(e blood to 'orm clot or t(rombus
d- Clotting time + 4= minse- C(olesterol + 4<=)5<= mg@dl
123
'- 3riglyceride + <=)5<= mg@dl K D .bad c(olesterol/ + 8=)4= mg@dl K HD .good c(olesterol/ + 9=)= mg@dl g- %N + 8)5= mg@dl
) determines t(e development o' at(erosclerosis ,(ic( causes coronary artery disease
) test o' renal 'unction2 determines ade>uacy o' circulation 'rom t(e (eart to t(e $idneys and its ability to excrete protein and urea
(- !n?ymes: K CPG + men) <<)4= ) ,omen) 9=)49< . rises 9)8 (rs a'ter -7-/
) cardiac en?ymes are present in (ig( concentration in t(e myocardial tissues 2 determines tissue damage in t(e myocardium
K DH + 4<=)6<= u@ml .rises 45 (rs a'ter -7-/ K *"O3 + <)6= u@ml i- !*R) =)9=-+ also rises a'ter 7 5- !lectrocardiogram
Pro+e%ure
P) contraction o' t(e atrium R* complex) contraction o' t(e ventricles 3) Resting state o' t(e ventricles PR interval) contraction o' atrium until t(e beginning o' t(e contraction o' ventricles *3) ventricles moves to a resting state
ltrasound o' t(e (eart
6- Central #enous Pressure .C#P/
easures t(e rig(t atrial pressure or t(e pressure o' t(e greater veins ,it(in t(e t(orax by t(reading a cat(eter into a large central vein) *ubclavian ) ugular ) edian ) %asilic ) Femoral !nd o' cat(eter or 3ip + positioned at t(e rig(t atrium or upper portion superior vena cava .'or 'emoral insertion0 tip is at t(e in'erior vena cava/
<- *,an)"an? Cat(eter @ Pulmonary Artery Pressure .PAP/
Determines t(e electrical impulse o' t(e (eart
Normal impulses ensures ade>uate circulation to all body organs and tissues
Values 3 Des+ri'tion
9- 5)Dimensional !c(ocardiograp(y .5D !c(o/
Normal < + 4= cm Iater
easures t(e level o' pressure in t(e le't atrium 6 Ports: a- 3(ermodilution port b- %alloon Port 'or in'lating balloon used 'or placement o' cat(eter c- Rig(t atrium Port d- Pulmonary atrium port
Pur'ose
Determines valvular de'ormities0 t(ic$ening o' myocardium0 pericardial e''usion0etc
*erves
as guide 'or 'luid replacement
onitor
pressures in t(e rig(t atrium and central veins
Administer
blood products0 3PN0 drug t(erapy-
Obtain
venous access ,(en perip(eral veins are inade>uate
3o
insert a temporary pacema$er Obtain central venous samples onitor pressure in t(e '': c. Rig(t ventricle d- Pulmonary artery e. Distal branc(es o' t(e pulmonary artery 3(ermodilution Obtain blood 'or O5 saturation
124
8- Cardiac Cat(eteri?ation
Cat(eter inserted into t(e rig(t or le't side o' t(e (eart and vessels and a dye is introduced sed to determine details on t(e structure and per'ormance o' t(e valves0 (eart and circulation
a- easure O5 concentration0 saturation0 tension and pressure in t(e c(ambers o' t(e (eart b- Detect s(unts c- 3o get blood samples d- Determine cardiac output & pulmonary 'lo, e- Determine need 'or bypass surgery
T2ree t*'es o1 "loo% Vessels0
4- Arteries ) carries oxygenated blood 5- #eins ) carries unoxygenated blood 9- Capillaries + allo,s t(e delivery o' nutrients0 oxygen and 'luids to t(e tissues %- DISEASES O THE VASCULAR S$STEM :
%- 4-AR3!R7A D7*ORD!R* HYPERTENSION
persistent %P above 46= @E= 3ypes o' Hypertension !tiology:
3ypes o' Hypertension
!ssential (ypertension un$no,n etiology ) most common ) may be caused by an increase in cardiac output or increase in perip(eral resistance !ssential (ypertension
*econdary (ypertension caused by ot(er p(ysiologic problems
*econdary (ypertension
Ris$ Factors
"enetic Obesity *tress oss o' elastic tissues Arteriosclerosis o' aorta
Renal problems + Renal Failure0 Nep(ritis !ndocrine problems + 3(yroid problem0 D Neurologic Disorders + %rain tumors0 3rauma Pregnancy)7nduced HPN any ot(ers
*igns & *ymptoms
%P46=@E= 2 (eadac(e0 'atigue0 ,ea$ness0 di??iness0 palpitations0 'lus(ing0 blurred vision and epistaxis
3reatment
Non)p(armacologic: *odium restriction Ieig(t reduction !xercise Diet modi'ication Ca''eine Restriction Alco(ol & *mo$ing cessation Relaxation 3ec(ni>ues Potassium0 Calcium0 agnesium supplements .to balance sodium and ot(er electrolytes/ P(armacologic: Calcium Agonist: Ni'edipine0 #erapamil #asodilators: Hydrala?ine Diuretics: Aldactone0 (ydroc(lorot(i?ide Adrenergic in(ibitors: Propanolol0 Clonidine0 et(yldopa
Nursing 7nterventions
%P monitoring Correct cause: obesity0 diet0 stress0 etc Regular exercise *alt restrictions Administer medications 3eac( ris$ 'actors
125
ARTERIOSCLEROSIS “ Obstruction”
) I(en t(e arteries become o/stru+te% 4it2 'la5ue an% +2olesterol0 t(ey (arden and constrict0 and t(e circulation o' blood t(roug( t(e vessels becomes di''icult0 'orcing t(e blood t(roug( narro,er passage,ays As a result0 blood pressure becomes elevated) Arteriosclerosis occurs ,(en lipids in t(e blood0 including c(olesterol0 accumulate inside t(e ,alls o' blood vessels and reduce t(e si?e o' t(e veins or arteries t(roug( ,(ic( blood 'lo,s ATHEROSCLEROSIS “Thickening”
) A degenerative condition o' t(e arteries c(aracteri?ed /* t2i+,enin %ue to lo+ali6e% a++u&ulation o1 1ats7 &ainl* +2olesterol- 3(e term at(erosclerosis re'ers to a condition in ,(ic( 'atty deposits build up in and on t(e artery ,alls0 inter'ering ,it( t(e normal 'lo, o' blood and oxygen t(roug(out t(e body- I(en t(is (appens0 t(e (eart (as to ,or$ (arder to pump blood t(roug( t(e narro,ed blood vessels0 and a (eart attac$ or a stro$e may result-
Pre%is'osin 1a+tors0
cigarette smo$ing (ig( 'at levels in t(e blood (ig( c(olesterol (ig( blood pressure obesity Sins an% s*&'to&s0
3(e symptoms o' at(erosclerosis depend on t(e part o' t(e body ,(ere t(e condition is ta$ing place*ometimes t(ere arenQt any noticeable symptoms until t(e condition (as advanced to a very serious stageI(en t(e arteries o' t(e (eart are a''ected0 one o' t(e 'irst symptoms is c(est pain0 o'ten called angina- A person ,it( clogged arteries o' t(e (eart may also (ave occasional di''iculty in breat(ing and may experience unusual 'atigue a'ter s(ort periods o' exertion-
Me%i+al 8 Suri+al Interentions 1or At2ero an% Arterios+lerosis0
abcd-
e. abcde-
i'estyle odi'ication 2 Reduce Ris$ Factors Coronary Artery %ypass "ra't .CA%" Percutaneous 3ransluminal Coronary Angioplasty .P3CA/ Directional Coronary At(erectomy .DCA/ 7ntracoronary *tents Nursin Interention0
Healt( 3eac(ing Reduce Ris$ Factors Restore %lood *upply Pre & Post)op Care 'or *urgical Patients AORTIC ANEURYSM
3ypes o' Aneurysm: 3(oracic or Abdominal Aortic Aneurysm Ris$ Factors: Presence o' At(erosclerosis0 7n'ections or a Congenital abnormality *igns & *ymptoms: 3(oracic Aortic Aneurysm Dyspnea Dysp(agia voice (oarseness 3reatment:
3(oracic@c(est pain coug(
Abdominal Aortic Aneurysm .AAA/ Abdominal Pain o, bac$ pain Pulsating Abdominal ass
*urgical Removal o' Aneurysm
Nursing 7ntervention:
a- Psyc(ological support b- onitor patient 'or signs o' rupture o' aneurysm
126
3riad o' mani'estations 'or ruptured abdominal aneurysm: 4- Abdominal pain 5- %ac$ or Flan$ pain .scrotal pain may also occur/ 9- *(oc$: %p K4== systolic2 Pulse Rate K4==bpm c- Pre)operative preparation d- Post)operative care: monitor perip(eral circulation BUERGER’S DISEASE
a-$-a- 3(romboangitis Obliterans .3AO/ De1inition0
#asculitis o' t(e veins and arteries in t(e upper & lo,er extremities
Ris, a+tors0
Men -5=)9< y@o0 Heavy smo$ers0 (ypersensitivity to intradermal in1ections
Sins 8 S*&'to&s :
a- pain in legs relieved by immobility0 numbness and tingling o' toes sensitivity to cold Iea$ or absent pulsations at t(e dorsalis pedis0 posterior tibial Reddis( or Cyanotic extremity ,(ic( may progress to ulceration or gangrene
bcdeTreat&ent0
Calcium C(annel %loc$ers to promote vasodilation Rest0 Pain Relievers0 Avoid exposure to cold *urgery: Amputation o' extremity is delayed until conservative treatments 'ail to e''ect
Nursin Interention0
Healt( teac(ing on li'estyle modi'ications0 spec- smo$ing !nsure protection o' extremities against cold Administration o' medications as ordered Protect client 'rom in1ury Assessment o' extremities
RAYNAUD’S DISEASE
De'inition:
#asospasm o' arteries in t(e (ands .upper extremities only/
Ris$ Factors:
Wo&en7 (eavy smo$ers0 individuals spec- ,omen ,it( *ystemic upus
Cause: *igns & *ymptoms:
(ypersensitivity o' 'ingers to colds0 congenital vasospasm0 *erotonin release
!ryt(ematosus .*!/ or r(eumatoid art(ritis
Cyanosis@pallor o' t(e 'ingers ,(en exposed to cold environment or emotional stimuli Numbness and occasional pain %ilateral or symmetrical involvement
3reatment: Ni'edipine to decrease vasospasm Avoid exposure to cold and $eep (ands ,arm Avoid smo$ing Nursing 7ntervention
*ame as buerger;s disease
%-5-#!NO* D7*ORD!R*: THROMBOPHLEBITIS
De'inition:
Clot disorder in t(e vein usually at t(e lo,er extremity
Ris$ Factors:
3rauma o' t(e blood vessels0 stasis0 7ncreased coagulability
*igns & *ymptoms:
!dema o' t(e extremity0 redness0 pain0 local induration0 .J/ Homan;s sign ) cal' pain upon dorsi'lexion o' 'oot
Nursing 7ntervention: a- se o' t(romboembolytic .3!D/ stoc$ings
127
b- !levate legs c- Heparin t(erapy0 as ordered d- %ed rest e- Iarm compress VARICOSE VEINS
De'inition:
distention0 lengt(ening and totuosity o' veins
Cause:
loss o' valvular competence and constant elevation o' venous pressure most commonly in t(e veins o' t(e legs-
Ris$ Factors:
Prolonged standing0 obesity0 pregnancy
*igns & *ymptoms:
Ac(ing Heaviness oderate s,elling !nlarged0 tortuous veins in t(e legs
3reatment:
*urgical anagement: *clerot(erapy .in1ection o' sclerosing agent to t(e vein- Not a treatment0 (ence0 'or cosmetic purpose only/
Nursing 7ntervention !levate legs at least 9= mins- A'ter prolonged standing Iear t(romoembolic stoc$ings 3eac( client o avoid prolong sitting or standing Avoid cross)legs ,(ile sitting Post)op Care a'ter *clerot(erapy: a- aintain 'irm elastic pressure over t(e ,(ole limb b- Regular but care'ul exercise o' t(e legs to promote circulation + ambulate 'or s(ort periods 56)6 (rs post)op c- Assess'or complications suc( as bleeding0 in'ection0 nerve damage
7#-CARD7AC D7*ORD!R* ANGINA PECTORIS Chest ain
insu''icient coronary blood 'lo, inade>uate oxygen exc(ange in t(e (eart causing intermittent c(est pain can be relieved ,it( rest 7t lasts only 'or 4)< minutes and ta$ing up o' nitroglycerine ,ill be bene'icial 'or t(e client
Sins an% s*&'to&s0
Patient experiences retrosternal c(est discom'ort Pressing0 (eaviness0 s>uee?ing0 burning and c(o$ing sensation Pain in t(e epigastrium0 bac$ nec$ 1a, or in t(e s(oulders Radiation o' pain in t(e arms0 s(oulders and t(e nec$
Pre+i'itatin 1a+tor0
over exertion eating exposure to cold emotional stress
Classi'ication o' *ymptoms: Class I + no limitations o' p(ysical activity .ordinary p(ysical activity does not cause symptoms/Class II + slig(t limitation o' p(ysical activity .ordinary p(ysical activity does cause symptoms/Class III + moderate limitation o' activity .patient is com'ortable at rest0 but less t(an ordinary
activity can cause symptoms/-
Class IV + unable to per'orm any p(ysical activity ,it(out discom'ort0 t(ere'ore severe limitations
.patient may be symptomatic even at rest/-
128
Nursin Interentions0
a. Assess pain + location0 c(aracter0 !C" .*3 elevation/0 precipitating 'actors b-
Help client to ad1ust li'estyle to prevemt angina attac$ + avoid excessive activity in cold ,eat(er0 avoid overeating0 avoid constipation0 rest a'ter meals0 exercise
c-
3eac( patient (o, to cope ,it( angina attac$ + nitroglycerin every < mins upto 9x0 i' still not relieved go to t(e (ospital
Dianosti+ Assess&ent0
abcd-
!C" *tress 3est Radioisotope 7maging Coronary Angiograp(y
Me%i+al Manae&ent0
a- Opiate Analgesic + o*o6 b- #asidilators + Nitroglygcerin0 7sosorbide ononitrate@Dinitrate c- Calcium C(annel %loc$ers + Dlitia?em0 Ni'edipine d. %eta %loc$ing Agents +Propanolol MYOCARDIAL INFARCTION
Destruction o' myocardial tissue due to reduced coronary blood 'lo, 3(e rapid development o' myocardial necrosis caused by imbalance bet,een t(e oxygen supply
and demand o' t(e myocardium-
Results 'rom pla>ue rupture ,it( t(rombus 'ormation in a coronaryvessel0 resulting in an acute
reduction o' blood supply to a portion o' t(e myocardium-
Causes0
4- At(erosclerotic (eart 5- Coronary Artery !mbolism Sins an% s*&'to&s0
4- c(est pain + (eavy .viseli$e0 crus(ing0 s>uee?ing/ usually across t(e anterior pericardium typically is described as tig(tness0 pressure0 or s>uee?ing Pain may radiate to t(e 1a,0 nec$0 arms0 bac$0 and epigastrium- 3(e le't arm is a''ected more 're>uently2 (o,ever0 a patient may experience pain in bot( arms-
2. Dyspnea0 Ort(opnea + sense o' su''ocation 3. Nausea and@or abdominal pain) gas pains around t(e (eart 4. Anxiety0 Appre(ension <- ig(t (eadedness ,it( or ,it(out syncope
6. Coug( 0 I(ee?ing - Nausea ,it( or ,it(out vomiting
8. Cold diap(oresis0 gray 'acial color0 E-
Iea$ness and altered mental status + common in elderly patients-
10. Rales + may be present in congestive (eart 'ailure11. Nec$ vein distention + represents rig(t pump 'ailure45- Dysryt(mias ) an irregular (eart beat or pulse0 usually tac(ycardic49- Oliguria + urine less t(an 9= ml@(r Ris, 1a+tors0
129
Age 0 ale gender0 *mo$ing0 D0 Family (istory0 *edentary li'estyle0 obesity0 diet0 stress0 (ypertension0 3ype A personality
DIAGNOSTICS0 La/ stu%ies0
Creatine $inase+% .CG)%/ yoglobin C%C 0 3rponin Potassium and magnesium level Creatinine level C + Reactive protein .CRP/ !ryt(rocyte sedimentation rate .!*R/ *erum lactate de(ydrogenase .DH/
I&ain stu%ies0
C(est radiograp(y or c(est x)ray + reveals pulmonary edema secondary to (eart 'ailureC3 scan Radionuclide 7maging Positron !mission 7maging 3ransesop(ageal !c(ocardiograp(y agnetic resonance imaging .R7/ ) can identi'y ,all t(inning0 scar0 delayed en(ancement .in'arction/0 and ,all motion abnormalities .isc(emia/!lectrocardiogram .!C"/ ) *3)segment elevation greater t(an 4 mm- t(e presence o' ne, ,aves-
-
intermediate probability o' 7 are *3)segment depression0 3),ave inversion0 and ot(er nonspeci'ic *3)3 ,ave abnormalitiesI&&e%iate e&eren+* interention0
7# access + t(rombolytic agents e-g- (eparin supplemental oxygen pulse oximetry + maintain oxygen saturation at KE= 7mmediate administration o' aspirin en route Nitroglycerin 'or active c(est pain0 given sublingually or by spray !C"
Treat&ent is ai&e% at0
Restoration o' balance bet,een oxygen supply and demand to prevent 'urt(er isc(emiaC(est Pain relie' Prevention and treatment o' complicationsDru o1 +2oi+e 1or 'atient 4it2 MI0
Antit(rombotic agents ) prevent t(e 'ormation o' t(rombus and in(ibit platelet 'unction.asirin! "hearin# #asodilators ) Opposes coronary artery spasm0 ,(ic( augments coronary blood 'lo, and reduces cardiac ,or$ by decreasing preload and a'terload ) can be administered sublingually by tablet or spray0 topically0 or 7#
$nitroglycerine#
%eta)adrenergic bloc$ers ) reduce blood pressure0 ,(ic( decreases myocardial oxygen demand- .metorolol# Platelet aggregation in(ibitors + in(ibits platelet aggregation cloidogrel $la%i Analgesics + reduce pain ,(ic( decreases sympat(etic stress .morhine sulfate#
130
Angiotensin converting en?yme .AC!/ in(ibitors + prevents conversion o' angiotensin 7 to angiotensin 770 a potent vasoconstrictor- )catoril$caoten# Co&'li+ations o1 MI0
Dysr(ytmias Cardiogenic *(oc$ Heart Failure Pulmonary !dema Pulmonary !mbolism Recurrent 7 Complications due to Necrosis + #*D0 rupture o' t(e (eart0 ruptured papillary muscles Pericarditis
Re+o&&en%ations0
-
All 7 patients s(ould be admitted in t(e 7CPatient s(ould remain on complete bed rest during (is stay in t(e (ospital and avoid straining activities-
Nursin interentions 1or MI
4abcde'-
!arly
g. (5abcde-
3reat arryt(mias promptly + lidocaine "ive analgesic) morp(ine Provide p(ysical rest Administer O5 via cannula Fre>uent #* Ni'edipine Propanolol HC !motional *upport
ater
"ive stool so'tener Provide lo, 'at0 lo, c(olesterol0 lo, sodium diet0 so't 'ood Commode *el')care Plan 'or re(abilitation !xercise program *tress management 3eac( ris$ 'actors 'Psyc(ological support gong)term drug t(erapy Antiarry(tmics) >uinidine0 lidocaine Anticoagualnt + (eparin0 aspirin Anti(ypertensives + propanolol0 c(lorat(ia?ide
TRANSIENT ISCHEMIC ATTACK (TIA)
temporary episode o' neurological dys'unction lasting only a 'e, minutes or seconds .in a day@ 56(rs/ due to decreased blood 'lo, to t(e brain A ,arning sign o' stro$e especially in 'irst 6 ,ee$s a'ter 37A
Causes: 4- At(erosclerosis 5- icroemboli 'rom at(erosclerotic pla>ue
ani'estations: 4- *udden loss o' visual 'unction 5- *udden loss o' sensory 'unction 9- *udden loss o' motor 'unction anagement: ) *urgical Carotid !ndarterectomy .bypass/ 4-
Post)op 'ocus + assess neurologic de'icits2 avoid 'lexing nec$ 7nability to s,allo,0 move tongue0 raise arm0 smile may indicate problem in t(e speci'ic cranial nerve-
5- Anticoagulant t(erapy: aspirin0 etcCONGESTIVE HEART FAILURE (CHF)
De'inition:
inability o' t(e (eart to meet oxygen and metabolic needs o' t(e body
131
Causes: 4- Abnormal loading conditions ) Congenital de'ects0 ventricular @ atrial septal de'ect0 Patent Ductus Arteriosus0 #alvular stenosis0 HPN0 Hig( Perip(eral #ascular Resistance
2. Abnormal muscle 'unction ) yocardial 7n'arction0 myocarditis0 cardiomyopat(y0 ventricular aneurysm
3. Diseases t(at exacerbate or precipitate (eart 'ailure + *tress0 dysr(yt(mia0
in'ection0 anemia0 t(yroid disorders0 pregnancy0 nutritional de'iciency0 pulmonary disease0 (ypervolemia
e't #entricular Failure *igns & *ymptoms
Rig(t #entricular
Causes Pulmonary Congestion: apnea byne;s *tro$e
Dys
c.
Cou
C(e
g(0 Rales0 ,(ee?ing dOrt( opnea ePar oxysmal Nocturnal Dyspnea 'Pul monary !dema gCer ebral (ypoxia (Fati gue &muscular ,ea$ness i- Renal C(anges0 Nocturia
Perip(eral edema #enous congestion o' organs Hepatomegaly Cyanosis o' t(e nail beds assive s,elling o' t(e legs0 genitals and trun$ .Anasarca/ '- Anxiety0 'ear and depression
'-
anagement: Positioning + Hig( 'o,ler;s position to reduce pulmonary congestion O5 Administration P(armacology: Digitalis0 Dopamine & Dobutamine0 AC! in(ibitors Digitalis: increases ventricular contractility 7ncreases ventricular emptying 7ncrease Cardiac output Iatc( out 'or Digitalis toxicity • • • •
Sins o1 Diitalis To9i+it*0
abcd-
!yes: "astrointestinal 3ract: Cardiovascular: Central Nervous *ystem:
Halo around lig(ts Diarr(ea0 anorexia0 vomiting0 abdominal cramps %radycardia0 're>uent P#C;s Headac(e 0 Fatigue0 et(argy
Nursing 7ntervention: 4- *odium restriction 5- Reduce pain and anxiety 3. 7mprove oxygenation: proper positioning0 O5 4. Reduce congestion and edema: meds0 positioning
132
VALVULAR STENOSIS
De'inition:
Narro,ing o' valve ,(ic( prevents blood 'lo, or impaired closure o' t(e valves causing regurgitation
*igns & *ymptoms:
urmurs0 decreased cardiac output0 (eart 'ailure
3reatment:
Heart valve replacement0 mitral commisurotomy P(armacology: Anti)coagulant) Coumadin anagement: lo, sodium0 lo, c(olesterol diet
Nursing 7ntervention: same as CHF
*tenosed
AV HEART BLOCK
De'inition:
Altered transmission o' impulse 'rom *A node t(roug( A# node
D!" #$ B%#&'
Ds&"t#*
T"atm*t
First)degree A# %loc$
delayed transmission o' impulse to A# node
None
*econd)degree A# %loc$
not all impulses pass t(roug( A# node
Atrop(ine 7soproterenol
3(ird)degree A# %loc$
No impulse pass t(roug( A# node
#entricular Pacema$er
PACEMAKERS
De'inition: 3ypes:
!lectronic device .battery) operated/ t(at produce electrical stimuli to t(e (eart and controls (eart rate a- 3emporary Pacema$ers ) +t"*al0 device can be (eld in a belt) used 'or emergency purposes0 temporary pacing ) inserted trans t(oracic0 transvenous0 transesop(ageal0 transcutaneous0 transesop(ageal b- Permanent Pacema$ers , *t"*a% 0 device0 sutured ,it(in t(e subcutaneous tissue-
Nursing 7ntervention: a-
C(ec$ 'or signs o' in'ection on t(e site: 'ever0 (eat0 pain0 s$in brea$do,n
b-
Avoid (ig()energy radar0 television0 micro,ave: i' di??iness or tac(ycardia occur0 as$ patient to move 6)8 'eet a,ay 'rom source-
c-
Remind to ,ear 7D)in'ormation bracelet at all times esp- ,(en traveling
d- Care o' *ite: K ,ear loose)'itting around pace)ma$er K !ncourage bat( tubs rat(er t(an s(o,er to protect incision site 'or t(e 'irst 4= days K !xplain t(at (ealing ta$es place ,it(in 9 mont(s
133
))) !xternal Pacema$er
7nternal Pacema$er .sutured subcutaneously/
Appearance o' a person ,@ internal pacema$er
-------------------------------------------------------------------------------------------------------------------------------------------------------------Co&'arison o1 C2est Pain Anina Pe+toris
M*o+ar%ial In1ar+tion
3ype
s>uee?ing0 pressing0 burning
*udden0 severe0 crus(ing0 (eavy0 tig(tness
ocation
Retrosternal0 substernal0 le't o' sternum0 radiates to t(e le't arm
*ubsternal0 radiates to one or bot( arms0 1a,0 nec$
K9= mins-
Oxygen0 narcotics0 not relieved by rest & nitroglycerin
Duration Relie'
sually 9)< mins duration S9= mins rest0 nitroglycerin
Co&'arison o1 ot2er sins 8 s*&'to&s
Anina Pe+toris
M*o+ar%ial In1ar+tion
Transient Is+2e&i+ Atta+,
134
*ub1ective Data: Dyspnea Palpitation Di??iness Faintness
*ub1ective Data: *(ortness o' breat( Appre(ens ion0 'ear o' impending deat( Nausea •
•
*udden loss o': #isual 'xn *ensory 'xn otor 'xn • • •
•
Ob1ective Data: 3ac(ycardia Pallor Diap(oresis
Ob1ective Data: *ymptoms o' s(oc$ Cyanosis0 diap(oresis • Restless
•
Ob1ective Data: oss o' 'unctioning 'or about and returns to normal
•
•
•
•
Nursin Care Manae&ent
A"t"#s&%"#ss
!.
A*!*a P&t#"s
Li1est*le Mo%i1i+ation
1.
Diet0 stress mgt0 (abits
(. Restore /loo% su''l* Anti)embolic stoc$ings0
anti)coagulants
).
Pre 8 'ost-o' +are
:.
Healt2 tea+2in
CA%"0P3CA0 *tents odi'ications0 diet0etc-
Proi%e relie1 1ro& 'ain0
Rest Nitroglycerin i'estyle modi'ication #ital signs Assist ,@ ambulation
(.
Proi%e e&otional su''ort
).
Healt2 tea+2in
T"a*s*t Is&hm& Atta&'
4- Assess neurologic status 5- Administer meds
Pain di''erentiation edication Dx test Diet0 exercise0 CA%"
Nursin Care Manae&ent M*o+ar%ial In1ar+tion
1.
Re%u+e 'ain 8 %is+o&1ort:
Narcotics0 O50 *emi)'o,ler;s position to improve ventilation battery) operated 2. Maintain a%e5uate +ir+ulation onitor #*0 rine Output & !C" eds: Anti)arryt(mics & anticoagulants C(ec$ 'or edema0 cyanosis0 dyspnea0 coug(0 crac$les C#P: normal <)4
).
(. Glan%
De+rease o9*en %e&an%3 Pro&ote o9*enation
O50 %edrest .56)6 (rs/0 rest periods *emi)'o,ler;s position Anticipate needs o' client: call lig(t0 ,ater eds: vasodilators0 vasopressors0 Cal-C-%loc$ers
:.
Maintain 1lui% 8 ele+trol*te /alan+e 3 Nutrition
Geep 7# open2 C#P0 #*0 O ab data: NaJ49<)46<2 G 9-<)<-= m!>@ !C" Diet: lo, calorie0 lo, sodium0 lo, c(olesterol0 lo, 'at
5.
a+ilitate 1e+al eli&ination
stool so'tener0 avoid #alsalva0 mout( breat(ing0 bedside commode
;.
Proi%e e&otional su''ort
<.
Pro&ote se9ual 1un+tionin
discuss concerns include partner resume <) ,$s a'ter uncomplicated 7
=. Healt2 tea+2in
DISTUR"ANCES IN META"OLIC 8 ENDOCRINE UNCTIONING Hor&one
un+tions
135
Pituitary "land Anterior obe
Posterior lobe
3(yroid "land
"ro,t( Hormone
*timulates gro,t( o' body tissues and bones
Prolactin
*timulates mammary tissue gro,t( & lactation
3(yrotropic (ormone .3*H/
*timulates t(yroid gland
"onadotropic (ormones .H & F*H/
A''ect gro,t(0 maturity and 'unctioning o' primary and secondary sex organs
Adrenocorticotropic (ormone .AC3H/
*timulates steroid production by adrenal cortex
elanocyte)stimulating Hormone .*H/
ay stimulate adrenal cortex2 may a''ect pigmentation
Anti)diuretic (ormones .ADH0 vasopressin/
Promotes reabsorption o' ,ater by t(e distal tubules and collecting ducts o' t(e $idney0 t(us decreasing urine output
Oxytocin
*timulates e1ection o' mil$ 'rom mammary alveoli into t(e ducts: stimulates uterine contractions may possibly be involved in t(e transport o' sperm in t(e reproductive tract o' t(e 'emale
3(yroxine .36/
7ncreases metabolic activity o' almost all cells2 stimulates most aspects o' 'at0 protein and carbo(ydrate metabolism
3riiodot(yronine .39/ 3(ryrocalcitonin
o,ers serum calcium levels and elevates p(osp(ate level2 opposite e''ect 'rom t(at o' P3H
Parat(yroid
Parat(ormone .P3H/
7ncreases calcium levels and decreases p(osp(ate levels2 increases resorption o' bones
Adrenal Cortex
"lucocorticoids .primarily cortisol/ )) *ugar
Promotes carbo(ydrate0 protein and 'at catabolism0 increases tissue responsiveness to ot(er (ormones
ineralcorticoids .Aldosterone/ )) *alt
3ends to increase sodium retention and potassium excretion
Androgens .male (ormones/ )) *ex
"overns certain secondary sex c(aracteristics2 all corticoids are important 'or de'ense against stress or in1ury
!pinep(rine .Adrenalin/)=
!levates blood pressure0 converts glycogen to glucose ,(en needed by muscles 'or energy2 increases (eart rate2 increases cardiac contractility2 dilates bronc(ioles
Controls SSS: *"AR0 *A30 *!
edulla
Norepinep(rine) 5= Ovaries
!strogens and progesterone
*timulate development o' secondary sex c(aracteristics0 e''ect repair o' t(e endometrium a'ter menstruation
3estes
3estosterone
!ssential 'or normal 'unctioning o' male reproductive organs2 stimulates development o' secondary sex c(aracteristics
Pancreas 7slets o' anger(ans
7nsulin
Promotes metabolism o' carbo(ydrates0 protein and 'at t(us decreasing blood glucose obili?es glycogen stores0 t(us raising blood glucose levels Decreases secretion o' insulin0 glucagons0 gro,t( (ormone and several gastrointestinal (ormones. gastrin0 secretin/
"lucagon *omatostatin
PITUITARY GLAND PROBLEMS
136
Clini+al Mani1estations A+ro&eal*
"ro,t( Hormone 7N AD3*
Giantis&
4- !nlarged extremities 5- Protrusion o' 1a, and orbit 9- No increase in (eig(t and ,eig(t but (ands and 'eet become bigger 6- 7ncreased perspiration <- #isual problems 8- Hyperglycemia@calcemia
Manae&ent
4- 7rradiation o' pituitary ,it( "ro&o+ri'tine to decrease secretion o' gro,t( (ormone 5- *urgery: Hypop(ysectomy)removal o' t(e pituitary gland 9- Post)op Care: a- Assess 7CP b- !levate (ead o' bed .HO%/ 9= degrees c- Avoid coug(ing0 snee?ing0 blo,ing nose
Overgro,t( o' all body tissues and bones
"ro,t( Hormone
7n CH7DR!N
D4ar1is&
4- Retarded p(ysical gro,t( 5- Premature body aging 9- *lo, intellectual development
4- Removal o' cause : tumor 5- Human "ro,t( Hormone 7n1ection 9- *ame as acromegaly & gigantism
4- Polyuria 5- Polydipsia 9- De(yration
4- P(armacology: a- Desmopressin Acetate nasal spray b- #asopressin 3annate + 7 in1ections c- Hypressin Nasal *pray
"ro,t( Hormone 7n CH7DR!N
Dia/etes Insi'i%us
Anti) diuretic Hormone
5- Nursing 7nterventions2 a- aintain ade>uate 'luids b- *odium Restriction c- 7nta$e & Output monitoring d- 3eac( sel')in1ection tec(ni>ues e- Daily ,eig(ts '- *peci'ic gravity SIADH > S*n%ro&e o1 Ina''ro'riate se+retion o1 ADH
4- Hyponatremia 5- ental con'usion 9- Personality c(anges 6- et(argy0 ,ea$ness0 (eadac(e <- Ieig(t gain 8- Abdominal cramping - Anorexia0 nausea0 vomiting
4- Fluid restriction 5- 3reat underlying causes 9- P(arma: a- Demeclocycline administration as ordered b- it(ium Carbonate c- %utorp(anol 3atrate
ADRENAL GLAND PROBLEMS
137
Clini+al Mani1estations A%%ison?s Disease
"lucocorticoids ineralcorticoids *ex Hormones
4- alaise and general ,ea$ness 5- Hypotension0 (ypovolemia 9- 7ncreased pigmentation o' s$in 6- Anorexia0 nausea0 vomiting <- !lectrolyte 7mbalance 8- Ieig(t loss - oss o' libido - Hypoglycemia .8=)=/ E- Personality C(anges
Manae&ent
4- P(armacology: *teroids .Prednisone0 dexamet(asone/ 5- Diet: (ig( CHO0 CHON diet 9- Observe side e''ects o' (ormone replacement + Cus(ingoid Appearance 6- onitor 'luid & electrolyte <- 3eac( importance o' li'elong medications 6- IOF *igns o' Addisonian Crisis: Addisonian Crisis'
*udden pro'ound ,ea$ness *evere abdominal0 bac$ and leg pain Hyperpyrexia 'ollo,ed by (ypot(ermia Perip(eral vascular collapse *(oc$ Renal *(utdo,n )K Deat(
Cus2in?s S*n%ro&e
"lucocorticoids
4596<8E4=-
3(in scalp oon Face Acne 7ncreased body (air %u''alo (ump Obesity Hyperpigmentation 3(in extremities !asy %ruising ood s,ings0 male c(aracteristics appear in ,omen 44- Hypo$alemia0 Hyperglycemia0 HPN 45- Amenorr(ea 49- Osteoporosis
4- *urgical gt: Adrenalectomy 5- C(emot(erapy: "ro&o+ri'tine 9- Diet: (ig( CHON0 lo, CHO0 lo, Na diet 0 potassium supplement 6- Nursing gt: K protect 'rom in'ection K protect 'rom accidents K (ealt( teac(ing on sel')medication
*3!RO7D*: Purpose: Anti)in'lammatory and anti)allergy2 *tress 3olerance edication: a. 3a$e at t(e same time everyday b- Follo, regime and do not stop abruptly c- Causes gastric upset *ide e''ects: Cus(ingoid Appearance Conn?s S*n%ro&e 3 Al%osteronis&
4- HPN 5- Hypo$alemia
4- *urgery: Removal o' tumor 5- Potassium replacement 9- 3reatment o' (ypertension 6- Nursing gt: onitor %P0 administer meds0 provide >uiet environment
4- HPN 5- 7ncrease Perspiration 9-Appre(ension 6-Palpitations <- Nausea0 #omiting0 Headac(e 8- 3ac(ycardia - Hyperglycema
4- *urgical gt: Removal o tumor 5- edical anagement: *ymptomatic .3reat symptoms as it occurs/ 9- Nursing gt: K Hig( caloric diet K Ade>uate Rest
ineralcorticoids .Aldosterone/
P2eo+2ro&o+*to&a
!pinep(rine@ Norepinep(rine
THYROID GLAND PROBLEMS
138
Clini+al Mani1estations Grae?s Disease 3 H*'ert2*roi%is&3 T2*roto9i+osis
390 360 3(yrocalcitonin
4- !xopt(almos) protrusion o' eyes 5- !nlargement o' t(e t(yroid gland 9- 7ncrease metabolism: ,eig(t loss0 diarr(ea0 diap(oresis 6- Personality c(anges <- Cardiac Arryt(mias 8- !asy 'atigability - uscle ,ea$ness - HPN E- Anxiety0 7nsomnia
TH$ROID STORM0
abcd-
Cretinis&
390 360 3(yrocalcitonin INANTS
Fever 3ac(ycardia Delirium 7rritability
Manae&ent
4- *urgery: 3(yroidectomy 5- Drug 3(erapy: a- et(ima?ole b- Propyl) 3(yracil c- 7odides: ugol;s solution + strains teet(0 drin$ ,@ stra, *aturated *olution o' Potassium 7odide .**G7/ d- Propanolol 9- Radioiodine t(erapy 6- Nursing gt: a- Ade>uate Rest b- Hig( caloric0 (ig( protein0 carbo(ydrate0 vitamins ,it(out stimulants c- easure daily ,eig(ts d- !ye protection 'or xopt(almos e- IOF: 3(yroid *torm
4- P(ysical & mental retardation 5- *ensitive to cold 9- Dry s$in 6- Poor appetite and constipated 3reatment: Hormone Replacement
M*9e%e&a
390 360 3(yrocalcitonin ADULT
4- anorexia and constipation 5- intolerance to cold 9- *lo, metabolism: decreased s,eating0 edema 6- Dry s$in <- !nlarged t(yroid
4- Drug 3(erapy: a- evot(yroxine b- 3(yroid Replacement .Desiccated t(yroid/ TT ta$en in empty stomac( TT (eart rate less t(an 4== bpm )o$
PARATHYROID GLAND PROBLEMS
Clini+al Mani1estations H*'o'arat2*roi%
Parat(ormone
%radycardia 0 Fluid retention0 Dry0 coarse s$in0 Decreased libido0 irregular menses
!asy bruising Constipation Fatigue0 let(argy enorr(agia0
Manae&ent
4- Drug t(erapy: evot(yroxine0 iot(yronine *odium 5- Avoid stimulus
139
3ac(ycardia Palpitations 7ncreased persitalsis ,eig(t loss Heat intolerance Decreased libido Amenorr(ea
H*'ert2*roi%
Parat(ormone
4- Drug t(erapy: Prop(ylt(iuracil et(ima?ole0 *aturated solution o' Potassium 7odide0 Radioactive 7odine 5- Diet: lo, calcium0 (ig( 'iber 9- Force 'luid
PANCREATIC PROBLEMS
DIABETES MELLITUS
T*'e I Insulin De'en%ent DM @IDDM
Ot(er Name
T*'e II Non-Insulin De'en%ent DM @NIDDM
uvenile D
Adult D
%e'ore 9= years old but may occur at any age
K9< y@o but can occur in c(ildren
Abrupt
7nsidious
4=
<)E=
ittle or none
%elo, normal Normal or Above normal
Re>uired
Necessary 'or only 5=)9= o' clients
ay occur
nli$ely to occur
7deal body ,eig(t or t(in
sually Obese
Diet0 exercise and insulin
Diet0 exercise0 (ypoglycemic agent or insulin
Age o' Onset Onset 7ncidence 7nsulin production
7nsulin 7n1ections Getosis %ody ,eig(t at onset anagement
Car%inal Sins 8 S*&'to&s:
1. 2. 3.
Polydipsia
) excessive t(irst ) 're>uent urination Polyuria Polyp(agia ) excessive (unger 6- Ieig(t oss ) 'or 7DD Treat&ent0 !. Oral 2*'ol*+e&i+s0
abcde'-
"lipi?ide "lyburide 3olbutamide 3ola?amide Aceto(examide C(lorpropamide
*ide e''ects: a- Hypoglycemia b- *$in ras(es c- "7 disturbances d- Flus(ing e- Nausea0 vomiting Administration: K usually administered 9= mins- be'ore meals to promote 'aster absorption o' t(e meds
140
(. Insulin InBe+tions0
Action
Appearance) Preparation Onset o1 E11e+t
*(ort)Acting
7ntermediate Acting ong)Acting
Pre)ixed
Clear
) Regular 7nsulin
Pea,
Duration o1 E11e+t
9= mins- + 4 (r-
5 + 6 (rs-
8 + (rs-
Cloudy ) *emilente
9= mins- + 4 (r-
5 + (rs-
+ 48 (rs
Cloudy ) NPH
4 + 5 (rs-
8 + 45 (rs-
4 )58 (rs-
Cloudy ) ente
4 + 9 (rs-
8 + 45 (rs-
4 )58 (rs-
Cloudy
) Protamine ?inc
6 + 8 (rs-
4 + 56 (rs-
5 + 98 (rs-
Cloudy
) ltralente
6 + 8 (rs-
46 + 56 (rs-
98 (rs-
9= mins-
5 )45 (rs-
4) 56 (rs-
Cloudy ) = NPH ) 9= regular
Complications o' D: a.
/.
H*'ol*+e&ia
Cause:
Hunger0 less dietary inta$e0 excessive insulin
*igns & *ymptoms:
Diap(oresis0 3ac(ycardia0 tremors0 ,ea$ness0 irritability0 con'usion
Nursing 7nterventions:
"ive candy0 1uice or so'tdrin$s0 let t(e patient eat C(ec$ sugar level
Dia/eti+ etoa+i%osis
Cause:
ac$ o' insulin 0 7n'ection0 *tress
*igns & *ymptoms:
Polyuria0 t(irst0 Nausea0 vomiting0 dry mucous membranes0 Gussmaul resp0 Coma0 sun$en eyesballs0 acetone odor o' breat(0 (ypotension0 abdominal rigidity
Nursing 7nterventions: +.
%.
"ive regular insulin
Li'o%*stro'2*
Cause:
7ndurated areas on s$in due to in1ections
*igns & *ymptoms:
*$in indurations
Nursing 7nterventions:
3eac( client to rotate sites o' in1ection
H*'erl*+e&i+ H*'eros&olar Non,etoti+ Co&a @HHN
Cause:
!xtremely (ig( glucose0 no $etosis
*igns & *ymptoms:
Polyp(agia0 polydipsia0 polyuria0 glucosuria0 de(ydration0 abdominal discom'ort0 (yperpyrexia0 (yperventilation0 c(anges in sensorium0 coma0 (ypotension0 s(oc$
Nursing 7nterventions:
Fluid & electroluyte replacement0 7nsulin
141
:.
DISTUR"ANCES IN ELIMINATION -./. I*$%ammat#"0 a*1 N#%ast& Ds#"1"s
abcde-
Acute "astritis C(ronic "astritis Duodenal lcer "astric lcer "astric Cancer
A+ute Gastritis In+i%en+e0
o
o
o
Cause0
C2roni+ Gastritis
*ame in Acute "astritis
Common in age <=)8= years old Fre>uent in male t(an 'emale "reater incidents in (eavy drin$ers and smo$ers
o
Helicobacter Pylori o
edicines: Aspirin0 N*A7D*0 c(emo drugs0 steroids
o o
Food: Alco(ol0 co''ee0 spicy 'oods Duration0
Treat&ent
History o' or presence o' peptic ulcer disease Previous gastric surgery *ame as acute gastritis
Prolonged
*(ort
edical anagement: a- Antacids b- *mall 're>uent meals c- %land diet d- ay prescribe antic(olinergics in c(ronic gastritis Nursing 7nterventions@ Healt( 3eac(ing: )Avoid spicy 'oods )Avoid alco(ol inta$e )Fre>uent small meals
ay be asymptomatic Ot(er symptoms include: o Dyspepsia0 belc(ing0 vague epigastric pain0 N@#0 intolerance to spicy or 'atty 'oods o
Clini+al Mani1estations0
A+i% 'ro%u+tion:
o
!pigastric discom'ort0 Abdominal pain0 cramping0 severe nausea0 vomiting and sometimes (ematemesis 7ncreased (ydroc(loric acid-
No increase in (ydroc(loric acid Duo%enal Ul+er
O++urren+e0
o
5<)<= yrs- old
Gastri+ Ul+er
K <= yrs- old
Nursin Interention:
a- Relaxation tec(ni>ues o
o
3ype A personality .leaders0 executives/2 sually in a ,ell) nouris(ed individual
ost common in persons li$e 'armers0 construction ,or$ers o
sually a''ects malnouris(ed individuals o
Cause0
*tress0 Poor 'ood (abit
A+i% 'ro%u+tion0
Hypersecretion
!xcessive smo$ing0 salicylates inta$e
Pylorus
Normal to (yposecretion
Lo+ation o1 Ul+er
!xperienced 5)9 (rs a'ter meal o 7ngestion o' FOOD R!7!#!* PA7N o
Pain0
esser curvature !xperienced U to 4 (our a'ter meal 7ngestion o' o FOOD DO!* NO3 R!7!#! PA7N o
b- !liminate ca''eine0 cigarette smo$ing0 alco(ol inta$e and spicy 'oods c- Hig( 'at0 (ig( carbo(ydrate Me%i+al Treat&ent0
Antacids ) avoid administration ,it(in 4)5 (r o' ot(er oral meds ) 're>uent administration + ac0 pc0 (s H5 Antagonists ) ,it( meals@pc Antic(olinergics Prostaglandin Analogs ) TTmisoprostolTT & AC7D PP 7NH7%73OR* ) TTin(ibits t(e en?yme t(at produces gastric acid H Pylori + etronida?ole Omepra?ole 3etraycline@Clarit(romycin Cytoprotective + binds ,it(
142
elena is more common t(an (ematemesis
"lee%in
Malinan+*0
Hematemesis is more common t(an melena
Not possible Possible
diseased tissue and provides a protective barrier to acid Suri+al Treat&ent
4- #agotomy 5- "astric Resection) "astroduodenostomy2 "astro1e1unostomy
GASTRIC CANCER
7ncidence:
'g(i 1-
Common in men t(an ,omen History or presence o' Pernicious Anemia O'ten develops ,it( t(e occurrence o' atrop(ic gastritis o,)socio economic status2 live in urban area !xposure to radiation or trace metals in soil
Cause: Helicobacter Pylori Clinical ani'estations: a- Palpable mass b- Ascites c. Ieig(t loss d- Dysp(agia e. 7ndigestion and anorexia '- .J/ (ig( lactate de(ydrogenase level in gastric 1uice Diagnosis: "73 x)ray0 gastroscopy 3reatment: C(emot(erapy0 radiation t(erapy0 gastric resection Nursing 7ntervention: *ame as ,it( patient;s ,it( ulcer0 emotional support0 pre and post)operative (ealt( teac(ing -.2. Ds#"1"s #$ th La"! a*1 Sma%% B#3% VIRAL AND "ACTERIAL GASTROENTERITIS3 D$SENTER$
"astroenteritis ) 7n'lammation o' stomac( and intestine usually t(e small bo,elS3S0 abdominal cramps0 diarr(ea0 vomiting0 'ever0 severe 'luid and electrolyte loss0 mild to severe temperature Cause: #iral Dysentery ) 7n'lammation in t(e colon S3S0 severe bloody diarr(ea and abdominal cramping0 severe 'luid and electrolyte loss0 mild to severe temperature Cause0 %acterial . !-coli nd@or s(igella0 salmonella0 Clostriduum di''icile 'rom antibiotics/ o o o o
Ris$ Factors: Poor 'ood (andling Poor sanitary conditions Overcro,ding Food remaining on (ig( temperature ma$ing organisms incubate and coloni?e easily-
anagement: o Replace 'luid loss o Anti)in'ective Agent .e-g- etronida?ole spec 'or amoebiasis0 %actrim/ Nursing 7ntervention: o easure inta$e and output o Administer medications o Replace 'luids APPENDICITIS o
7n'lammation o' t(e vermi'orm appendix 7ncidence: Common bet,een 5=)9= yrs- old
143
Cause:
Fecalit( .stone or calculus in t(e appendix/ Fibrous condition in t(e bo,el ,all
-)K Gin$ing o' t(e appendix )K %o,el ad(esion
*@*: Pain starts in t(e epigastriium t(e s(i'ts to t(e t(e rig(t lo,er >uadrant "uarding o' pain'ul area Geeps legs bent to relieve tension ay (ave vomiting0 loss o' apetite0 lo, grade 'ever0 coated tongue and (alitosis Diagnosis: 7ncreased I%C0 .J/ pain at c %urney;s point .R/ 3reatment: Appendectomy Nursing intervention: Assess t(e #* and pain scale care'ully Observe 'or symptoms o' peritonitis 0 Pre & post)operative care PERITONITIS
7n'lammation o' t(e peritoneal membrane Cause: "angrenous c(olecystitis Ruptured gallbladder Per'orated gastric cancer Per'orated Peptic ulcer Ruptured spleen Acute pancreatitis Penetrating ,ound lcerative colitis "angrenous obstruction o' t(e bo,el Per'orated diverticulum
o o
o
o
o
o
7leitis Appendicitis ,it( per'oration Ruptured retroperitoneal abscess *trangulated (ernia *alpingitis *eptic Abortion Ruptured bladder Puerperal in'ection 7atrogenic Cause
*igns and *ymptoms: ocali?ed pain Abdominal rigidity 7ncreased pain upon movement Nausea0 vomiting .N@#/ Absence o' bo,el sounds *(allo, respirations 7ncreased I%C 0 dilation and edema o' intestines revealed in "73 x)ray edical anagement: N"3: avage to relieve pressure in t(e abdomen Fluid & electrolyte replacement *urgical 3reatment: Appendectomy or !xploration o' t(e abdomen ,it( drainage Nursing intervention: Care'ul assessment o' (istory0 #@*0 'luid & electrolytes Pre & Post)operative Care
+. In1la&&ator* "o4el Disease0
ULCERATIVE COLITIS 8 CHRON?S DISEASE
CHRON?S DISEASE
ULCERATIVE COLITIS
Pat2olo* 8 Anato&*
7nvolves primarily t(e ileum & rig(t colon Distribution o' d;se is segmental alignancy is rare
ucosal ulceration o' lo,er colon and rectum Distribution o' d;se is continuous alignancy may occur a'ter 4= years
Etiolo*
ay be genetic
ay be caused by in'ection or alteration in immunity
Onset
sually in t(e 9=;s
Course o1 Disease
*lo,ly progressive
Loung adults .5=)6=/ Remissions and relapses Common
144
Re+tal /lee%in
Occasional
Anore+tal 1istula
Common
Rare
Ot2er S3S0
Abdominal pain Ieig(t loss Diarr(ea + so't or semi)li>uid Pain in R0 cramping0 tenderness0 'latulence0 nausea .mimics Appendicitis/
Me%i+al Treat&ent
Replacement o' 'luid loss Anti)diarr(eal: Dip(enoxylate HC .omotil/ 2 operamide HC .7modium/
Rectal bleeding0 diarr(ea .5= stools@day or more/2 *tools may occur ,it( blood or pus0 ,eig(t loss rgency0 cramping0 Pain 0 abdominal distention0 emotional stress*ame as C(ron;s D;se
3otal Parenteral Nutrition %o,el Resection0 7leostomy
%o,el Resection0 7leostomy
Suri+al Treat&ent
Assess 7nta$e and output0 ,eig(t !motionla support Client teac(ing regarding surgery
Nursin interentions0
*ame as C(ron;s D;se
Post)op intervention: Observation o' t(e stoma 3eac( client re: sel')care
HERNIA
)An abnormal protrusion o' an organ or tissue t(roug( t(e structure t(at contains it) Fre>uently a congenital occurrence or ac>uired ,ea$ness o' t(e abdominal muscles 3ypes:
1. 7ndirect 7nguinal Hernia 5- Direct 7nguinal Hernia 9- Femoral Hernia 6- mbilical Hernia <- 7ncisional Hernia edical 3reatment: se o' 3R** i' (ernia is not strangulated or incarcerated*urgical 3reatment:
Herniorr(ap(y
Nursing 7ntervention:
Pre & Post)operative Care
Post"o Care:
a-
a$e sure t(e client voids a'ter surgery0 urinary retention is common a'ter (erniorr(ap(y b- Resume diet as tolerated by t(e patient c- 7ce pac$ over t(e incisional site to control pain and s,elling d- 7nstruct patient to avoid (eavy li'ting 'rom 6)8 ,ee$s post surgery
DIVERTICULUM
Diverticulum + an outpouc(ing o' intestinal mucosa t(roug( t(e muscular coat o' t(e large intestine .most commonly t(e sigmoid colon/ Diverticulosis + re'ers to t(e presence o' non)in'lamed out pouc(ing o' t(e intestine Diverticulitis + in'lammation o' a diverticulum 7ncidence:
K 6< yrs- old 2 ale & Female
!tiology:
o,er 'iber diet ,(ic( causes bul$ in stools ,(ic( may cause intraluminal pressure in t(e bo,el causing diverticula
Ris$ 'actors:
C(ronic Constipation
*@*:
e't uadrant Pain 7ncreased 'latus
Anorexia o, grade 'ever
145
.J/ rectal mass on digital rectal examination edical 7ntervention:
Hig()'iber diet and laxatives N"3 insertion to relieve pressure Control in'lammation t(roug( antibiotics and advise patient to: aAvoid activities t(at may increase abdominal pressure .bending0 li'ting0 etc/ b7nta$e o' 8) glasses o' ,ater a day cReduce ,eig(t i' obese
*urgical 7ntervention:
7ndicated 'or t(ose ,(o developed complications as mani'ested by (emorr(age0 abscess0 per'oration and obstructionColon resection ,it( colostomy
o
7ndications Colosto&* o
o
7nvolves t(e large bo,el .colon/ stool is semi)'ormed
7n'lammatory @ obstructive process o' t(e lo,er intestinal tract 3rauma Rectal or sigmoid cancer Diverticulum o
Ileosto&* o
o
7nvolves t(e small bo,el .ileum/ stool is in li>uid 'orm
d.
o o
Nursing 7ntervention 4- !motional support 5- Psyc(ological *upport 9- Heat( !ducation regarding: a-surgery .ileostomy@colostomy/ b- *el')care
C(ron;s Disease lcerative Colitis
Hirs+2'run?s Disease an% Mea+olon
Congenital absence o' parasympat(etic ganglion Clinical ani'estations: N% 'ail to pass meconium 56 (rs o a'ter birt( Older c(ild + recurrent abdominal o distention0 c(ronic constipation0 ribbon)li$e stool0 diarr(ea0 emesis ,@ bile stain 3reatment: a- Colostomy b- %o,el Resection c- Cleansing !nema Post)op Nursing 7ntervention2 a- 3eac( colostomy care) c(ec$ color o' stoma .s(ould be brig(t leg/ b- C(ec$ dressing c- onitor inta$e & output d- Avoid incision by $eeping diapers lo, e- 4=)44 yr- old c(ild can already ta$e care o' e. He&orr2oi%s o
Peri)anal varicosities ,(ic( is eit(er internal or external
3ypes: a- 7nternal + varicosities above t(e mucocutaneous border covered by t(e mucous membraneo
146
b- !xternal Hemorr(oids) + varicosities belo, t(e mucocutaneous border covered by t(e anal s$in7ncidence:
%ot( male and 'emale aged 5=)<= y@oPregnancy0 CHF0 Prolonged sitting or standing0 portal (ypertension
Ris$ 'actors:
7ncreased abdominal pressure0 constipation0 straining during bo,el ovement
*@*:
7nternal + bleeding and renal prolapse0 bleeding and rectal itc(ing !xternal + enlarged mass at t(e anus
Present symptoms in bot( internal & external: %rig(t red .blood/ stain in stool or tissue0 Pain edical 7ntervention: a- 3reat constipation b- Relieve pain t(roug( (eat application @ *it(;s bat( *urgical 7ntervention:
Hemorr(oidectomy0 *clerot(erap(y0 Rubber band ligation0 aser *urgery0 cryosurgery
1. istula-in-ano
3iny0 tubular 'ibrous tract t(at extends into t(e anal canal ay develop 'rom trauma0 'issures or regional enteritis Fistulectomy is recommended--.-. A41#m*a% T"a5ma :
a. %lunt 3rauma + in1ury li$e ve(icular accident b. Penetrating Abdominal 3rauma + stab ,ound .
DISTUR"ANCES IN LUIDS AND ELECTROL$TES
Fluid Content in t(e Human %ody : a- Iomen ) b- en ) c- 7n'ant ) d- !lderly ) !lectrolytes in t(e Human %ody: a- *odium .Na/ b- Potassium .G/ c- C(loride .Cl/ d- %icarbonate .HCO9 /
<=)<< o' body ,eig(t is ,ater 8=)= o' body ,eig(t is ,ater <) = o' body ,eig(t is ,ater 6 o' body ,eig(t is ,ater ) ) ) )
49<)46< m!>@ 9-< + <-< m!>@ <)44< m!>@ 55)5E m!>@
Functions o' t(e Fluid & !lectrolytes in t(e Human %ody: a- Regulates acid)base balance in t(e body b- aintains 'luid volume c- Regulates exc(ange o' ,ater bet,een 'luid compartments abc-
Actions o' t(e Fluids & !lectrolytes Di''usion + 'luids move 'rom area o' (ig(er concentration to an area o' lo,er concentration Osmosis ) 'luids move 'rom an area o' lesser concentration to a (ig(er concentration Filtration + 'luids and substances moves 'rom (ig(er (ydrostatic pressure to lesser (ydrostatic pressure7ntravenous *olutions sed to correct imbalance: e. 7sotonic + =-E N**0 D
Cause
'luids exceeds t(e normal volume t(e body needs ) p(ysiologic or over (ydration as
lui% Volu&e De1i+it
'luids and@or electrolytes are loss p(ysiologic or de(ydration
147
in 7# t(erapy 7llness:
Clinical ani'estations
Nursing 7nterventions
Renal Disease Neurologic Diseases Congestive Heart Failure Addison;s Disease
Renal Disease Diarr(ea Post)operative conditions %urns 3rauma "73 *uction@Drainage
Ieig(t gain !dema Flus(ed s$in 3ac(ycardia 7ncreased %P0 RR Rales Nec$ #ein distention 7ncreased Central #enous Pressure Decreased Hct rine output: K 40<== ml@day
Ieig(t loss Dry s$in and mucous embrane 3ac(ycardia .same ,@ excess/ Poor s$in turgor Decreased urine output Decreased Central #enous Pressure 7ncreased (ematocrit rine output: S 9= cc@(r
onitor vital signs onitor 7 & O Fluid restriction o, sodium diet Ieig(t daily Prevent s$in brea$do,n) s$in is 'ragile Geep client in *emi)'o,ler;s position to establis( good gas ex(ange Administer Diuretics as ordered) asix .Furosemide/
onitor vital signs onitor 7 & O Replace 'luids0 Re(ydration Ieig(t daily Administer medications as ordered . depending on electrolytes loss/ !ncourage proper nutrition an 'luid inta$e
. Normal rine Output 9= cc@(r/
*ources o' !lectrolytes: Ele+trol*te
Potassium *odium agnesium Calcium
4.1
oo% sour+e
%ananas0 peac(es0 melon0 prunes0 raisins0 apricots0 tomato0 nuts & vegetables0 red meat0 tur$ey 7odi?ed or table *alt Peas0 beans0 nuts0 'ruits il$0 c(eese0 sardines0 'is(
Genitourinar* 8 Renal Pro/le&s
abcde-
Renal Function 3ests Normal #alues: %lood rea Nitrogen .%N/ + 4=)5= mg@dl *erum Creatinine) =)4 mg@d Creatinine Clearance + 4==)45= ml@ minute .56 (r- urine collection/ *erum ric Acid )9-< )- mg@d rine ric Acid + 5<=)<= mg@ 56 (rs- .56 (r- urine collection/
6-4-5- Cystitis @ ret(ritis@ rinary 3ract 7n'ection +usually caused by !-Coli *igns & *ymptoms a- Fre>uency & rgency o' urination b- Dysuria c- *uprapubic pain d- Hematuria e- Fever0 c(ills '- Cloudy urine Nursing Considerations: a- Collect urine 'or testing b- Antibiotic treatment0 as ordered c- Force 'luids d- "ood (ygiene
4.1.3. "lomerulonep(ritis + in'lammatory damage o' t(e glomeruli + usually *treptococcus • • •
*igns & *ymptoms: Hematuria0 proteinuria0 'ever0 c(ills0 ,ea$ness0 nausea0 vomiting !dema Oliguria
148
• • • • •
HPN Headac(e 7ncreased rea Nitrogen Flan$ Pain Anemia Nursing Considerations: a- Penicillin0 as ordered b- Proper dietary inta$e c- *odium & 'luid restriction d- %ed rest 6-4-6- Nep(rotic *ydrome + glomeruli disorder due to ot(er diseases li$e D0 *!0 etc*igns & *ypmtoms: a- Proteinuria b- Hypoalbunimemia c- Hyperbilirubinemia d- !dema Nursing Considerations: a- bed rest b- (ig( calorie0 (ig( protein0 lo, sodium c- onitor 7 & O d- Protect 'rom in'ection e- Administer meds as ordered: Diuretics0 *teroids0 7mmunosuppresiove agents0 anticoagulants 6-4-<- rolit(iasis ) stones in t(e urinary system *igns & *ymptoms: a- Dull ac(ing pain b- Nausea0 vomiting0 diarr(ea c- Hematuria d- 37 symptoms Nursing Considerations: a- Force 'luids: at least 9 o' ,ater in a day b- *train rine 'or stones c- Administer meds as ordered 6-4-8- Acute Renal Failure +sudden and reversible mal'unction o' t(e $idney due to trauma0 allergies0 stones or benign Prostatic (yperplasia *igns & *ymptoms: 9 P(ases a- Oliguric P(ase + sudden 0 .J/ edema ) urine is less t(an 6== cc in 56 (rsb- Period o' Diuresis + urine is 4=== ml in 56 (rs and is diluted c- Recovery Period Nursing 7ntervention: a- 3reat cause o' sudden occurrence b- aintain Fluid & electrolyte balance c- Prevent (ypo$alemia d- Administer insulin or 7# glucose as ordered to promote potassium absorption e- Proper diet : Oliguric + lo, CHON0 Hig( CHO0 (ig( 'at0 less potassium Diuresis + (ig( CHON0 (ig( calorie0 less 'luid '- Ieig( daily g- onitor 7 & O (- Dialysis i' indicated i- Psyc(ological & emotional support 6-4-- C(ronic Renal Failure + progressive 'ailure o' $idney 'unction ,(ic( may result to deat(0 caused by c(ronic gomerulonep(ritis .C"N/0 pyelopnep(ritis0 D0 uncontrolled HPN *igns & *ymptoms: a- 'atigue b- Headac(e c- "astrointestinal symptoms d- HPN e- 7rritability '- Convulsions
149
g- Anemia (- !levated %N0 crea0 sodium0 potassium 3reatment: Dialysis Renal 3ransplant abcd-
e.
Nursing Considerations: aintain 'luid & electrolyte balance %edrest Diet: lo, protein0 lo, sodium0 (ig( CHO and vitamins Control HPN IOF cerebral irritation
4.1.8. %enign Prostatic Hyperplasia + enlargement o' t(e prostate ,it( un$no,n etiology usually in older males *igns & *ymptoms: Di''iculty in urinating Nocturia0 (ematuria0 dribbling sensation
*urgical 3reatment: Prostatectomy Post)operative Nursing Consideration: a- Observe 'or s(oc$ and (emorr(age b- %ladder Drainage2 monitor bladder irrigation c- Avoid li'ting (eavy ob1ects x 8 ,ee$s and avoid strenuous activities d- 7ncrease 'luid inta$e e- Decrease pain0 administer meds as odered 3R!A3!N3 FOR "!N73OR7NARL PRO%!*: 4- Dialysis a- Hemodialysis Process o' cleansing t(e blood o' ,aste products ,(ic( t(e "3 is unable to eliminate Cat(et(er inserted via a small incision on t(e nec$ .intra1ugular/0 arms or at t(e 'emoral areab- Peritoneal Dialysis se o' peritoneum via a cat(eter 'or proper exc(ange o' 'luids and electrolytes and drainage o' 'luids Cat(eter inserted 1ust belo, t(e umbilicus ,it( small incision cabcde-
Continuous Ambulatory Peritoneal Dialysis
Nursing 7nterventions: Ieig( daily onitor vital signs aintain asepsis at all times Record inta$e and output onitor 'or complications: %leeding0 peritonitis0 abdominal pain0 dyspnea0 bo,el per'oration 5- rinary 3ract *urgery a- 3ransuret(ral Removal o' t(e Prostate b- Prostatectomy Nursing 7nterventions: Ieig( daily 0 monitor 7&O onitor vital signs aintain asepsis at all times onitor 'or complications: %leeding0 peritonitis0 abdominal pain0 dyspnea0 bo,el Replace 'luids Proper irrigation 9- Gidney 3ransplant IDNE$ DISEASE IN THE PHILIPPINE HEALTH SITUATION
80=== ne, cases o' renal disease per year A''ects all ages Adult: !nd)*tage Renal Disease .!*RD/
150
C(ildren and young: C(ronic "lomrulonep(ritis Causes: 4- C(ronic "lomerulonep(ritis + 6 5- C(ronic Pyelopnep(ritis + 4 9- Diabetes ellitus) 49 6- Hypertensive Nep(rosclerosis) < Gidney Disease Prevention: "ood Nutrition Clean !nvironment !arly detection o' o' t(e disease 3(oroug( urinary screening o' asymptomatic c(ildren 7ncrease case'inding and treatment 'or c(ronic glomerulonep(ritis "ood glycemic control .,@ D/ Optimum %lood Pressure Control Nursing Healt( !ducation: 4- 7ncrease a,areness and prevent renal disease: Ade>uate ,ater inta$e %alanced diet "ood personal (ygiene Regular exercise Regular %P c(ec$)up Complete immuni?ation 'or in'ants and c(ildren Proper management o' t(roat and s$in in'ections Learly urinalysis • • • • • • • •
5- 7ncrease a,areness o' signs & symptoms o' $idney disease as edema and HPN 9- Routine screening 'or 370 diabetes and $idney disease ;. ;.!.
DISTUR"ANCES IN CELLULAR UNCTIONING
CANCER o
o o
Abnormal gro,t( o' tissues a- Carcinoma ) epit(elial cells lining t(e internal and external sur'aces o' t(e bodyb- eu$emia ) cancer 'rom blood)'orming organs c- ymp(oma + cancer 'rom reticulo)endot(elial lymp( node organs d- *acrcoma) cancer 'rom connective tissues
Cancer in t(e P(ilippines: Ran$s t(ird in leading cause o' morbidity and mortality < o' cancers occur at age <= y@o *taging o' 3umors a- !xtent o' tumor 3 primary tumor N regional nodes metastasis b- !xtent o' alignancy 3= no evidence o' primary tumor 37* Carcinoma in *itu 340 350 390 36 progressive tumor in si?e and involvement 3 tumor cannot be assessed c-
7nvolvement o' Regional Nodes NO regional lymp( nodes not abnormal N40 N50N90 N6 increasing degree o' abnormal regional lymp( nodes
d- etastatic Development O no evidence o' distant metastasis 40 50 9 increasing degree o' distant metastasis Clinical ani'estations o' 3umor Presence $based on Community (ealth )ursing Ser%ices in the Philiines by the *O(# C A U T I
C(ange in bo,el or bladder (abits A sore t(at does not (eal nusual bleeding or disc(arge 3(ic$ening or lump in breast or else,(ere 7ndigestion or di''iculty in
!x- "astric Ca0 Colon Ca0 Rectal Ca 0 Renal Ca0 Prostate Ca !x- aryngeal Ca !x- terine Ca !x- %reast Ca0 Hodg$in;s ymp(oma !x- !sop(ageal Ca
151
O N
s,allo,ing Obvious c(ange in ,art or mole Nagging coug( or (oarseness
!x- elanoma0 *>uamous cell Ca !x- ung Ca
U S
nexplained Anemia *udden uexplained ,eig(t loss
ost Ca conditions
Ris$ Factors Age Healt( Habits *ex Family History Race *ocio)!conomic *tatus Occupation i'estyle Cancer 3(erapy a- *urgery b. C(emot(erapy + c(emical@ medication c. Radiation 3(erapy + electromagnetic rays destroys cancer cells d- Palliative@ *upportive Care) 'or end)stage or terminal stage ) given i' c(emo0 surgery or radiation t(erapy cannot assure treatment o' t(e patient 2 it is a (olistic care 'or t(e patient and 'amily ) management o ' care is geared to,ards a symptom)'ree individual ,it( psyc(ologic and spiritual support Cancer Prevention & !arly Detection T*'e o1 Can+er
Earl* Preention
Earl* Dete+tion
Oral Cancer
Avoid *mo$ing tobacco0 %etel >uid NgangaB c(e,ing0 Proper cavity and dental c(e,ing
3(oroug( dental c(ec$)up eac( year
%reast
No conclusive evidence 'or early prevention
ont(ly sel')exam and annual exam ,it( p(ysician2 ammograp(y: 7nitially at age 6= and t(en 4)5 yrs o t(erea'ter Hig( ris$ ,omen) s(ould consult a o doctor be'ore age 6=
ung
Avoid smo$ing
Annual c(ec$)up
terine @ Cervix
Clean0 sa'e sex *ingle partner reduces ris$
Regular pap smear: Once sexually active t(en every 9 years i' 'indings are normal
iver
Hepa- vaccine0 inimal alco(ol inta$e0 Avoid moldy 'oods
None
Colon and Rectum
aintenance o' a (ig( 'iber and lo, 'at diet
Regular medical c(ec$)up a'ter 6= years0 yearly occult blood tests in stools0 rectal exams and sigmoidoscopy
*$in
Avoid excessive sun exposure
*el' s$in assessment
Prostate
No conclusive evidence 'or early prevention
Rectal !xam
Nursing 7ntervention abcde-
Assist t(e patient in maintaining sel')dignity and integrity by continued and sustained communication and contact Allo, patient to ventilate 'eelings suc( as 'ear0 anger0 indi''erence a$e arrangements 'or spiritual consolation Assist in re(abilitation even be'ore treatment and until s(e recovers and ad1ust to t(e society Collaborate ,it( ot(er (ealt( ,or$ers 'or t(e patient;s (olistic needs
152
'-
Home visits and education about t(e client;s condition0 course o' treatment and alternatives
Priorities 'or Healt( *upervision: a- Ne,ly diagnosed cases b- Post)operative Cases c- 7ndigent Cases d- 3erminal Cases ;.(. HEMATOLOGIC PRO"LEMS
Normal #alues to Remember: "loo% Co&'onent
;.(.!.
ab-
Nor&al Values
R%C + red blood cells
Female: ale:
6-5 + <-6 x 4= 8 6- + 8-4 x 4= 8
Hgb ) (emoglobin
Female: ale:
44-< + 4<-< g@d 49-< + 4-< g@d
Hct ) (ematocrit
Female: ale:
98 + 6 6= )<5
I%C + ,(ite blood cells
60<== + 440===@ mm 9
PC)
4<=0 === + 6==0=== @ mm 9
Platelet count
ANEMIA
Causes: *udden or C(ronic blood loss Abnormal bone marro, 'unction c- R%C 'ails to mature ade>uately *igns & *ymptoms: Fatigue0 Iea$ness0 Di??iness0 Pallor0 Decreased R%C0 (emoglobin & (ematocrit T0s #$ A*ma6
a.
H0#"#%$"at#* A*ma + bone marro, 'ails to produce ade>uate blood cells a. 7ron De'iciency Anemia + nutritional de'iciency0 blood loss b. Aplastic Anemia ) due to radiation0 drugs0 toxin c- Anemia due to Renal Disease
Clinical ani'estations: Hypoxia Prone to in'ection Fatigue !asy bruising Nursing 7ntervention: Proper nutrition Psyc(ological support Protect against in'ection and in1ury
b.
or atrop(y o' t(e
M!a%#4%ast& A*ma + due to previous gastric surgery0 malabsorption
gastric mucosa
Pernicious Anemia + #it- %45 and Folic acid de'iciency in gastric 1uice Clinical ani'estations: Parest(esia 3ingling or numbness o' extremities "ait disturbances %e(avioral Disturbances Nursing 7ntervention: 7nta$e o' #it- %45 'ollo,ing t(is regimen: 9x a ,ee$ 'or 5 ,ee$s0 t(en o
153
5 x a ,ee$ 'or 5 ,ee$s0 t(en Once a mont( Protect lo,er extremities Rest in non)stimulating environment o o
&.
Hm#%0t& A*ma •
• •
*ic$le Cell Anemia) de'ective (emoglobin0 turns to sic$le cell ,(en oxygen in venous blood is lo, 3(alassemia "lucose)8 P(osp(ate De(ydrogenase De'iciency
Clinical ani'estations: 3(alassemia & "8PD + usually asymptomatic *ic$le Cell Anemia: *evere Pain o *,elling o Fever o aundice o Prone to in'ection o Nursing 7ntervention:
6.2.2.
Proper oxygenation Hydration Analgesics Ade>uate Rest Re'er to genetic counseling Avoid cold places to prevent sic$le cell proli'eration
LEUOC$TOSIS 8 LEUEMIA
eu$ocytosis
+ increase level o' I%C0 persistent increased can be malignant
eu$emia
) proli'eration o' neoplastic ,(ite blood cells in t(e bone marro, a''ecting t(e di''erent tissues and organs in t(e body • • •
Acute & C(ronic yeloid eu$emia .A @ C/ Acute & C(ronic ymp(ocytic eu$emia .A @ C/ Angiogenic yeloid etaplasia .A/
Clinical ani'estations: Fever Prone to 7n'ection Pain Ieig(t oss Fatigue Nursing 7nterventions: !nergy conservation Reverse 7solation %lood 3rans'usion
6.2.3.
POL$C$THEMIA > neoplasm o' myeloid cells
Clinical ani'estations: Di??iness0 (eadac(e0 tinnitus0 'atige0 parest(esia0 blurred vision0 at(erosclerosis
6.2.4.
THROM"OC$TOPHENIA ) 7ncreased %leeding 3endencies
6.2.5.
L$MPHOMAS > neoplasm o' lymp(atic cells • •
• •
Hodg$in;s ymp(oma Non)Hodg$in;s ymp(oma ultiple yeloma 3(rombocytop(enia + lo, platelet 0 bleeding
anagement: C(emot(erapy0 %lood 3rans'usions0 Reverse 7solation0 Radiation t(erapy0 *teroids Nursing 7nterventions: !motional *upport Reverse isolation Ade>uate Rest and Nutrition *trict edication Regimen
154
.(.;. "LOOD TRANSUSION
3ypes o' %lood Components 3rans'used I(ole %lood Pac$ed Red %lood Cells Fres( Fro?en Plasma@ Plasma Concentrate
459-
3rans'usion Complications Non)(emolytic reaction) Fever Hemolytic Reaction) li'e t(reatening: 'ear0 c(ills0 bac$pain0 nausea0 c(est tig(tness0 dyspnea and anxiety Allergic reaction +urticaria0 'lus(ing0 itc(ing Hypervolemia + nec$ vein distention0 dyspnea0 ort(opnea0 tac(ycardia0 sudden anxiety Diseases 3ransmitted t(roug( %lood 3rans'usion Hepatitis % or C 0 A7D* @ H7#0 Cytomegalovirus Nursing 7nterventions: 4596-
5.
C(ec$ name0 7D0 blood type0 expiration0 serial V 3a$e baseline vitals signs %lood pac$ s(ould be at room temperature onitor 'or trans'usion reaction Allergic .pruritus0 respiratory distress0 urticaria/ Hemolytic .lo, bac$ pain0 'ever0 c(ills/ 3reat trans'usion reaction0 i' present + symptomatic treatment
155
7.
NEUROLOGIC DISTUR"ANCES
7- Central Nervous *ystem: %rain *pinal Cord 77- Perip(eral Nervous *ystem ab-
Cranial Nerves + 45 pairs *pinal Nerves + 94 pairs Cervical + 3(oracic + 45 umbar + < *acral + < Coccygeal ) 4 c- Autonomic Nervous *ystem *ympat(etic Nervous *ystem Parasympat(etic Nervous *ystem 3(e Cranial Nerves:
O(0 O(0 O(0 To Touc( And eel A Girls Veil So Heaven I II III IV V VI VII VIII
Ol'actory Optic Oculomotor Troc(lear Trigeminal Abducens acial
#I
Auditory Glossop(aryngeal Vagus Spinal Accessory
#II
Hypoglossal
I# #
*mell #isual Acuity Pupil constriction and dilation !ye movement: 7n'erior and medial a, muscles !ye movement: ateral directions *ymmetrical 'acial movement0 Client identi'ies taste0 !yelid reaction to stimulus Hearing Acuity "ag Response Ability to spea$ clearly *(oulder;s ability to resist against pressure 3ongue at midline
Neurologic *tatus: a b. c. d.
Conscious) alert0 attentive0 and 'ollo,s command et(argic) dro,sy but a,a$ens2 'ollo,s command0 but slo,ly and inattentively *tuporous ) arouses to vigorous and continuous stimulation )response may be an attempt to remove t(e pain'ul stimulusComa- + no sounds0 no movement THE GLASGOW COMA SCALE
)
An assessment tool measuring t(e individual;s neurologic status speci'ically t(e spontaneity o' t(e client;s eye movement 0 spea$ing ability and motor abilities in response to a stimuliPer'ect score is 4< points ) *pontaneous@ Normal eye0 motor and verbal response o,est score is 9 points ) No response E*e O'enin Res'onse
Moto r Res'onse
Points
a- *pontaneous b- 3o speec( c- 3o pain d- No response
6 9 5 4
a- Obeys verbal commands b- ocali?es pain c- Flexion: no ,it(dra,al d- Flexion: abnormal .decorticate/ e- !xtension: abnormal .decerebrate/ '- No response to pain on any limb
8 < 6 9 5 4 156
a- Oriented b- Able to Converse c- 7nappropriate speec( d- a$es incompre(ensible sound e- No response
"est er/al res'onse
< 6 9 5 4
!xample: Patient s conscious0 co(erentCan tell ,(ere (e is0 can loo$ at surroundings0 can raise (ands ,(en as$ed to0 and can express sel' t(roug( ,ords0 ans,er >uestions appropriately-
!ye slig(tly opens ,(en name is called 2 No movement@response ,(en s$in is Pinc(ed 2 I(en calling t(e nurse: can only say neW-eWe-B sound
"C* *coring:
"C* *coring:
!ye opening otor Response #erbal Response
6 8 <
!ye opening otor Response #erbal Response
9 4 5
GCS S+ore
!
GCS S+ore
;
CERE"ROVASCULAR ACCIDENT @CVA “StrokeF
o
A sudden disruption o' blood supply to t(e brain ,(ic( may lead to temporary or permanent dys'unction-
Ris$s Factors:
*igns & *yptoms: a- *peec( problem @ Ap(asia ) a loss or impairment o' t(e ability to produce and@or compre(end language b- Hemiparesis) ,ea$ness o' one side o' t(e body c. Hemiplegia ) total paralysis o' t(e arm0 leg and trun$ on t(e same side ' t(e bodyd- Decreased a,areness o' body space
3ypes o' stro$e0
) )
HPN0 Obesity0 perip(eral vascular disease0 obesity0 aneurysm
4- Transient +schaemic Attack $T+A ) s(ort)term stro$e t(at lasts 'or less t(an 56 (ours . seconds or minutes in a day/ oxygen supply to t(e brain is restored >uic$ly transient stro$e needs prompt medical attention as it is a ,arning o' serious ris$ o' a ma1or stro$e(. Cerebral t(rombosis
) a blood clot .t(rombus/ 'orms in an artery .blood vessel/ supplying blood to t(e brain) brain cells are starved o' oxygen-
9- Cerebral embolism ) blood clot t(at 'orms and t(en travel to t(e brain6- Cerebral (emorr(age ) occurs ,(en a blood vessel bursts inside t(e brain and bleeds .(aemorr(ages/- Iit( a (emorr(age0 extra damage is done to t(e brain tissue by t(e blood t(at seeps into itNursing 7nterventions: 4- aintain ade>uate air,ay 5- onitor neuro vital signs: #ital signs and "lasgo, coma scale including inta$e and output 9- aintain 'luid & electrolyte balance
157
SPINAL CORD INUR$
A damage in t(e nerve structure causing dys'unction resulting to paralysis0 sensory loss and altered activityDe1inition0
Cause0
#e(icular accidents0 #iolence0 Falls0 *ports0 7n'ection0 3umor T2e S'inal Neres:
4596-
Cervical Nerve 3(oracic Nerve umbar Nerve *acral Nerve
Etiolo*0
4- *pinal *(oc$ .Are'lexia/ 5- Autonomic Hyperre'lexia 7n1ury in 38 and above i'e)t(reatening Nursin Interentions :
4- 7mmobili?ation specially a'ter in1ury or trauma 5- aintain respiratory 'unction0 A%C 9- %ladder & bo,el management 6- Re(abilitation
Neres
Leel
"o%* 'art a11e+te%
C4 C5 C9 C6 C< C8 C C
Head & Nec$
C"7&a% N"7
7n1ury causes uadriplegia@ 3etraplegia
34 35 39 36 3< 38 3 3 3E 34= 344 345
Th#"a&& N"7
7n1ury causes Paraplegia
Lu&/ar Nere
Paralysis o' legs2 loss o' bladder and bo,el control Sa&"a% N"7
*exual0 %ladder & %o,el conrol
Diap(ragm Deltoid0 biceps Irist !xtenders 3riceps Hand
*4 *5 *9 *6 *<
Paralysis belo, nec$2 impaired breat(ing0 bo,el & bladder incontinence0 sexual dys'unction *(oulder elevation possible0 ventilation support !lbo,0 upper arm0 ,rist movement
oss o' (and control0 Paralysis belo, ,aist
C(est uscles Abdominal uscles
4 5 9 6 <
S'inal Cor% InBur* E11e+t
3run$ and Abdominal control
Hip adduction impaired eg muscles
%ladder & %o,el control *exual Control
Gnee and an$le movement impaired
%ladder@%o,el 7ncontinence0etc Decrease sensation in t(e peineum
158
PARINSON?S DISEASE
De1inition0
)
A disorder a''ecting control and regulation o' movement nilateral 'lexion o' arms0 s(u''ling gait0 di''iculty in ,al$ing0 ,ea$ness0 disability
Clini+al Mani1estations0
Rigidity 7nvoluntary body tremors Hips and $nees 'lexion as$li$e 'acial expression *lurred speec( Drooling Constipation Depression Retropulsion0 propulsion Me%i+al Manae&ent0
Suri+al Manae&ent0
Anti)par$insonian Agent: evodopa Anti)c(olinergic: Cogentin *tereotaxic 3(alamotomy + surgery o' t(e t(alamus to treat disorder
Nursin Interentions0
abcde-
Re(abiltation + exercise *peec( t(erapy Diet: o, CH7N in am0 (ig( CHON in P Hig( 'iber 'oods to promote bo,el elimination Prevent 7n1ury + 'all0 etc
M$ASTHENIA GRAVIS De1inition0 *evere ,ea$ness o' one or ore groups o' s$eletal muscles2
*evere ,ea$ness o' t(e neuro 'unctions most commonly a''ecting t(e *event( cranial nerve) Facial Nerve
Clini+al Mani1estation0
4596-
as$)li$e 'acial expression Diplopia) double)vision Ptosis) di''iculty opening o' t(e eye Dyp(agia
Manae&ent0
a- Pyridostigmine %romine .mestinon/ b- Ambenomium C(loride c- *teroids +Prednisone d- Atrop(ine *ul'ate
Nursin Interentions0
Avoid 'atigue Administer meds as ordered Avoi neomycin and morp(ine CATARACT De1inition0 ) t(e eye lenses becomes t(ic$ and unclear or yello,is(Clini+al Mani1estations0
S5"!&a% T"atm*t6 Dru0
5- "radual visual loss9- Ha?y vision @ Lello,is( (a?e 4. I(itis( to yello,is( eyelenseCataract extraction
4- M*%riatri+s ) causes dilation o' pupils2 increases intraocular pressure .7OP/ a- Atrop(ine *ul'ate b. P(enylep(rine Hydroc(loride
#ision #ision ,@ ,@ Cataract Cataract
159
5- Cyclopegics + decreases ciliary muscle accomodation *ide e''ects: blurred vision0 increase %P Nursin Interention:
2. onitor %P2 avoid use to patients ,it( HPN
9- 3eac( client t(at blurring o' vision may be experienced6- Post)op intervention: $eep eye covered (ead o' bed elevated at 9=)6< degreed0 supine position Avoid bending or li'ting (eavy ob1ects0 coug(ing and snee?ing as it may 'urt(er increase 7OP
GLAUCOMA
)A
non)curable condition o' t(e eye due to increase in intraocular pressure causing deterioration o' t(e optic nerve( t*'es o1 Glau+o&a0
4- Acute or Closed" Angle ,laucoma a- Rain/o4 aroun% li2ts b- Pain around t(e eye c- Cloudy and blurred vision d- Nausea & vomiting e- Dilation o' pupils 5- Chronic or Oen"Angle ,laucoma a- Halo aroun% li2ts b- Progressive loss o' vision c- 3ired 'eeling in t(e eye d- *lo,ly diminis(ing perip(eral vision
#ision ,@ "laucoma
Suri+al Manae&ent:
4- 3rabeculectomy 5- 3(ermosclerectomy 9- 7ridenclesis Drus0
1. 596-
Mioti+s + causes constriction o' pupils
Pilocarpine (ydroc(loride ) Drains a>ueous (umor Aceta?olamide + decreases production o' a>ueous (umor annitol + reduces 7OP 7sosorbid + also decreases production o' a>ueous (umor
Nursin Interention0
4- Administer drugs as ordered 2. 3eac( client t(at glaucoma can be controlled but not curable .even surgery can;t cure t(e disease/ 9- !ncourage moderate exercise 6- Avoid straining o' bo,el <- !ncourage lo, residue0 (ig( 'iber diet =.
MUSCULOSELETAL DISTUR"ANCES
OINT DISORDERS
De'inition
RHEUMATOID ARTHRITIS
A systemic in'lammatory disorder o' +onne+tie tissues an%3 or Boints
OSTEOARTHRITIS
Degeneration o' t(e arti+ular +artilae Iear & 3ear o' 1oints
c(aracteri?ed by exacerbation & remissionGinds o' oints
Cervical0 'inger 1oints0 ulnar0 can also be involved:(eart and lung .as in r(eumatic (eart disease/
Ieig(t)bearing 1oints: $nees0 (ips0 spine
7ncidence
C(ronic disease2 early to mid)adult(ood0 common in ,omen
Older ,omen
Clinical ani'estations
• •
*ynovitis Pain relieved ,it( rest
Pain 'elt a'ter activity
160
•
•
•
anagement
7ntermittent bone pain0 s,elling0 redness0 ,arm 'eeling due to vasodialtion and increased blood 'lo, Pannus 'ormation) granulation o' tissue causing destruction o' ad1acent cartilage0 1oints and bones 'atigue0 anorexia0 malaise0 ,eig(t loss
Rest0 exercise0 A*A0 N*A7Ds0 *teroids0 (eat
%alanced rest and activity0 (eat pac$s0 steroids in 1oist only Drug: *teroid0 A*A0 7ndomet(acin0 P(enylbuta?one
Nursing 7ntervention
aintain body alignment0 %alance rest and exercise0 proper diet
Gout 3 Gout* Art2ritis De1intion0
pain'ul metabolic disorder due to in'lammation o' t(e Boints due to (ig( uri+ a+i%
Ris, a+tors0
Hereditary0 most common in men
Clini+al Mani1estations A salt o' uric acid .rate/ crystalli?es in so't and bony tissues causing local in'lammation and
irritation-
*evere pain0 usually in great toe Red0 pain'ul and s,ollen 1oints 3op(i .crystal 'ormation in 1oints/ are palapated around great toes0 'ingers0 earlobes Allopurinol N*A7D;s + 7bubro'en 0 7ndomet(acin Probenecid Colc(icine *ul'inpyra?one
Drus0
Nursin Manae&ent0
abcd-
%edrest during attac$s Heat or cold compress 7ncrease 'luid inta$e to 'lus( out uric acid Avoid eating organ meats0 s(ell'is(0 sardines ) ) ) 'ood ,it( (ig( purine @ uric acid content S*ste&i+ Lu'ous Er*t2e&atosus @SLE
De1inition0
Di''use connective tissue disease a''ecting s$in0 1oints0 $idney0 serous membranes o' t(e (eart and lungs0 lymp( nodes and "7 tract-
Ris, 1a+tors0
C(ildren0 middle)aged and elderly2 (ereditary
Clini+al Mani1estations0 "utter1l* ras2F in t(e 'ace . across bot( c(ee$s and nose/
ani'ests symptoms same as t(at o' art(ritis and Raynaud;s
Manae&ent0
N*A7D;s *teroids Cytotoxic drugs ) A?at(ioprine0 Cyclop(osp(amide
Nursin Interenions0
a-
Avoid exposure to sunlig(t because symptoms aggravate symptoms or ,ear (ats0 umbrella or sunscreen b- Ade>uate nutrition0 rest and exercise c- *tress management0 i' possible avoid stress
ra+tures
De1inition0
A brea$ in t(e continuity o' t(e bones
Clini+al Mani1estations0
161
Pain oss o' 'unction De'ormity False motion
!dema *pasm Crepitus Hematoma around s$in %rea$s 'or penetrating bone 'ragments
Manae&ent0
First Aid
4- aintain air,ay and circulation 5- 7mmobili?e 1oints t(at may be a''ected2 *plint limb 9- %ring to nearest (ospital@medical institution
3raction
)balanced pulling o' t(e musculos$eletal structure to align bones2 re>uires countertraction
Closed Reduction
) external manipulation suc( as manually aligning bones by pulling- For patients ,(o (ave lo,er pain tolerance .elderly0 c(ildren/ reduction may be done under sedation anest(esia-
Open Reduction
) internal manipulation o' bones re>uiring surgical operation
7nternal Fixation
) surgically applying scre,s0 plates0 pins0 nails to align bones .opening o' t(e s$in and exposing bones a''ected/2 s$in is closed a'ter t(e procedure-
!xternal Fixation
) applying nails and metal scre,s to bones t(roug( t(e s$in sur'ace
)
Casts
Nursin Manae&ent0
4596-
)a rigid mold used to immobili?e an in1ured structure to promote (ealing
ainatin positioning For traction maintaing ,eig(ts and countertraction Clean ,ounds to prevent in'ection Assess 'or #A*CAR OCC*7ON
P?s0 < signs o' #ascular Occlusion due to extremely tig(t casts @ traction a- Pain b- Pallor c- Pulselessness d- P Arest(esia e- Paralysis
.
INTEGUMENTAR$ DISTUR"ANCES "urn
De't2 o1 InBur*
Mani1estation
Leel o1 S,in A11e+te%
First)degree
Pain'ul0 pin$ to reddis(0 subsides >uic$ly
!pidermis and part o' dermis
*uper'icial
*econd)degree
Pain0 pin$ to red0 ,it( blisters .'luid 'ormation/
!pidermis and dermis (air 'ollicle intact
*uper'icial partial t(ic$ness2 Deep partial t(ic$ness
3(ird) degree
Reddis(0 bro,nis( or ,(itis(0 painless0 esc(ar 'ormation .eat(er)li$e s$in/
!pidermis0 dermis0 subcutaneous tissue
Full t(ic$ness
!pidermis0 dermis0 subcutaneous tissue2 'at0 'ascia0 muscle and bone
Full t(ic$ness
Fourt()degree Rule o1 Nines0
a- Head and Nec$ b- Anterior 3ruc$
) )
E 4
162
c- Posterior 3run$ d- Arms e- egs '- Perineum
) ) ) )
4 E eac( 4 4 eac( 98 4 4==
Rule o1 Nine?s
Manae&ent0 irst-Ai%0
4-
%urning person: As$ person to stop0 drop and roll . lie do,n and roll/ 2. %urning person: *top burning process suc( as ,rapping t(e burning part ,it( ,et to,el or blan$et 3. C(ec$ air,ay 6- First)degree burn: Run cool ,ater to a''ected area 'or 4= minutes
Hos'ital Interentions0
4596-
C(ec$ A%C0 give oxygen and 7# 'luids Assess client;s data0 (istory o' in1ury .time0 cause0etc/ aintain asepsis) burn patients are very prone to in'ections edical + *urgical anagement: a- 3etanus toxoid b- 3opical Anti)microbial agent: *ilver Nitrate0 *ilver *ul'adia?ine0 "entamicin *ul'ate0 a'enide acetate c- Debridement SHOC
Failure o' t(e circulatory system to maintain ade>uate per'usion o' vital organsCritically severe de'iciency in nutrients0 oxygen and electrolytes delivered to body tissues0 plus de'iciency in removal o' cellular ,astes0 resulting to cardiac 'ailure I. Staes o1 S2o+, )on" rogressi%e Stage
Progressi%e Stage
-.
+rre%ersible Stage
) Cardiac output is slig(tly decreased ) %ody compensates ) Compensatory mec(anism is not ade>uate ) blood 'lo, to t(e (eart is not ade>uate t(us (eart begins to deteriorate ) 7nade>uate tissue per'usion ) Cellular isc(emia & necrosis lead to organ 'ailure
II. T0s #$ Sh#&'
Hypovolemic *(oc$
Cause
!tiology
due to inade>uate circulating blood volume
%lood loss: assive 3rauma0 "7 %leeding0 Ruptured Aortic Aneurysm0 *urgery0 !rosion o' #essesl due to lesion0 tubes or ot(er devices0 Disseminated 7ntravascular Coaguation Plasma loss: %urns0 Accumulation o' intra) abdominal 'luid0 malnutrition0 severe dermatitis0 D7C Crystalloid loss: De(ydration0 Protracted #omiting0 Diarr(ea0 nasogastric suction
Cardiogenic *(oc$
due to *a185at 5m*! a&t#* yocardial disease: Acute 70 yocardial Contusion #$ th ha"t because o' primary cardiac muscle dys'unction or mec(anical obstruction o' blood 'lo, Cardiomypat(ies #alvular Disease or in1ury: caused by 7 or valvular Ruptured Aortic Cusp0 Ruptured Papillary insu''iciency muscle0 %all t(rombus
163
!xternal Pressure on t(e Heart inter'eres ,it( (eart 'illing or emptying: Pericardial 3amponade due to 3rauma0 aneurysm0 cardiac surgery0 pericarditis0 massive pulmonary embolus0 tension pneumot(orax Cardiac Dysr(tymias: 3ac(yarr(yt(mias0 %radyarryt(mias0 !lectromec(anical dissociation 9- Distributive *(oc$ a-
Neurogenic *(oc$
- inter'erence ,it( *"7#5s
s0stm control o' t(e blood
vessels
b- Anap(ylactic *(oc$
)severe h0"s*st7t0 reaction resulting in massive systemic vasodilation
c-
) systemic reaction vasodilation due to *$&t#*
*eptic *(oc$
*pinal: *pinal anest(esia0 spinal cord in1ury #aso)vagal reaction: *evere pain0 severe emotional stress Allergy to 'ood0 medicines0 dye0 insect bites or stings
"ram)negative septicemia but also caused by ot(er organisms
III. Sins o1 S2o+,
Anxiety Restlessness Di??iness 3(irst Fainting Pale s$in0 urticaria in anap(ylactic s(oc$ Oliguria0 *lo, capillary re'ill
%P) (ypotension Pulse + tac(ycardia0 t(ready0 irregular .Cardio-*(oc$/ Respiration: increased dept(0 tac(ypnea0 ,(ee?ing .anap(ylactic s(oc$/ 3emperature: cold clammy s$in0 elevated in anap(ylactic OC ) could be alert0 oriented0 unresponsive C#P + belo, < cm H5= .(ypovolemic/ ) above 4< cms .cardio & septic/
IV. Nursin Care Manae&ent GOAL0 Pro&ote enous return7 +ir+ulator* 'er1usion
Position: Feet elevated ,it( (ead slig(tly elevated also #entilation: loosen restrictive clot(ing0 O50 monitor respiration Fluids: 7#0 administer blood@plasma as ordered . stop blood immediately in anap(ylactic s-/ #ital signs: C#P0 !C"0 -O-0*,an "an? edications .depends on type/ Anti(ypotensive .epinep(rine0 norepinep(rine0 dopamine/ Anti)arryt(mics0 Cardiac "lycosides0 Antibiotics0 Adrenocorticoids #asodilators .nitroprusside/0 %eta)adrenergic .dobutamine/ ec(anical support : ilitary Anti)s(oc$ 3rousers.A*3/
E11e+ts o1 S2o+, in Di11erent Orans
Respiratory *ystem
Hypoxia actic acid accumulates tissue necrosis
Cardiovascular *ystem
yocardial deterioration Disseminated 7ntravascular Coagulation
Neuroendocrine *ystem
*tage o' resistance ADH is released causing $idneys to o retain sodium and ,ater 7ncrease in adrenocorticoid o mineralcorticoid (ormones
164
7mmune *ystem
IV.
acrop(ages in bloodstream and tissues are depressed 7ncreased susceptibility to s(oc$
"7 *ystem
"73 vagal stimulation stops@slo, do,n no peristalsis iver + ability to detoxi'y is lost2 blood is pooled in t(e liver or portal bed
Renal *ystem
Altered capillary blood pressure and glomerular 'iltration Renal isc(emia
IRST AID *** FIRST AID: Details from www.redcross.org
Dislo+ation0 irst ai%JJJ
4- "et medical (elp immediately2. Dont &oe t2e Boint. *plint t(e a''ected 1oint into its 'ixed position- DonQt try to move a dislocated 1oint or 'orce it bac$ into place- 3(is can damage t(e 1oint and its surrounding muscles0 ligaments0 nerves or blood vessels3. Put i+e on t2e inBure% Boint. 3(is can (elp reduce s,elling by controlling internal bleeding and t(e buildup o' 'luids in and around t(e in1ured 1ointCuts an% s+ra'es0 irst ai%JJJ
inor cuts and scrapes usually donQt re>uire a trip to t(e emergency room- Let proper care is essential to avoid in'ection or ot(er complications- 3(ese guidelines can (elp you care 'or simple ,ounds: 1. Sto' t2e /lee%in. inor cuts and scrapes usually stop bleeding on t(eir o,n- 7' t(ey donQt0 apply gentle pressure ,it( a clean clot( or bandage- Hold t(e pressure continuously 'or 5= to 9= minutesDonQt $eep c(ec$ing to see i' t(e bleeding (as stopped because t(is may damage or dislodge t(e 'res( clot t(atQs 'orming and cause bleeding to resume- 7' t(e blood spurts or continues to 'lo, a'ter continuous pressure0 see$ medical assistance2. Clean t2e 4oun%. Rinse out t(e ,ound ,it( clear ,ater- *oap can irritate t(e ,ound0 so try to $eep it out o' t(e actual ,ound- 7' dirt or debris remains in t(e ,ound a'ter ,as(ing0 use t,ee?ers cleaned ,it( alco(ol to remove t(e particles- 7' debris remains embedded in t(e ,ound a'ter cleaning0 see your doctor- 3(oroug( ,ound cleaning reduces t(e ris$ o' tetanus- 3o clean t(e area around t(e ,ound0 use soap and a ,as(clot(- 3(ereQs no need to use (ydrogen peroxide0 iodine or an iodine)containing cleanser- 3(ese substances irritate living cells- 7' you c(oose to use t(em0 donQt apply t(em directly on t(e ,ound3. A''l* an anti/ioti+. A'ter you clean t(e ,ound0 apply a t(in layer o' an antibiotic cream or ointment suc( as Neosporin or Polysporin to (elp $eep t(e sur'ace moist- 3(e products donQt ma$e t(e ,ound (eal 'aster0 but t(ey can discourage in'ection and allo, your bodyQs (ealing process to close t(e ,ound more e''iciently- Certain ingredients in some ointments can cause a mild ras( in some people- 7' a ras( appears0 stop using t(e ointment4. Coer t2e 4oun%. %andages can (elp $eep t(e ,ound clean and $eep (arm'ul bacteria out- A'ter t(e ,ound (as (ealed enoug( to ma$e in'ection unli$ely0 exposure to t(e air ,ill speed ,ound (ealing5. C2ane t2e %ressin. C(ange t(e dressing at least daily or ,(enever it becomes ,et or dirty- 7' youQre allergic to t(e ad(esive used in most bandages0 s,itc( to ad(esive)'ree dressings or sterile gau?e (eld in place ,it( paper tape0 gau?e roll or a loosely applied elastic bandage- 3(ese supplies generally are available at p(armacies-
165
6. Get stit+2es 1or %ee' 4oun%s. A ,ound t(at cuts deeply t(roug( t(e s$in or is gaping or 1agged) edged and (as 'at or muscle protruding usually re>uires stitc(es- A strip or t,o o' surgical tape may (old a minor cut toget(er0 but i' you canQt easily close t(e mout( o' t(e ,ound0 see your doctor as soon as possible- Proper closure ,it(in a 'e, (ours minimi?es t(e ris$ o' in'ection7. Wat+2 1or sins o1 in1e+tion. *ee your doctor i' t(e ,ound isnQt (ealing or you notice any redness0 drainage0 ,armt( or s,elling8. Get a tetanus s2ot. Doctors recommend you get a tetanus s(ot every 4= years- 7' your ,ound is deep or dirty and your last s(ot ,as more t(an 'ive years ago0 your doctor may recommend a tetanus s(ot booster- "et t(e booster ,it(in 6 (ours o' t(e in1ury "urns0 irst ai%JJJ or &inor /urns 0 including second)degree burns limited to an area no larger t(an 5 to 9 inc(es in
diameter0 ta$e t(e 'ollo,ing action:
Cool t2e /urn. Hold t(e burned area under cold running ,ater 'or at least < minutes0 or until t(e
Coer t2e /urn 4it2 a sterile au6e /an%ae. DonQt use 'lu''y cotton0 ,(ic( may irritate t(e s$in-
pain subsides- 7' t(is is impractical0 immerse t(e burn in cold ,ater or cool it ,it( cold compressesCooling t(e burn reduces s,elling by conducting (eat a,ay 'rom t(e s$in- DonQt put ice on t(e burnIrap t(e gau?e loosely to avoid putting pressure on burned s$in- %andaging $eeps air o'' t(e burned s$in0 reduces pain and protects blistered s$inTa,e an oer-t2e-+ounter 'ain relieer. 3(ese include aspirin0 ibupro'en .Advil0 otrin0 ot(ers/0 naproxen .Aleve/ or acetaminop(en .3ylenol0 ot(ers/- Never give aspirin to c(ildren or teenagers
inor burns usually (eal ,it(out 'urt(er treatment- 3(ey may (eal ,it( pigment c(anges0 meaning t(e (ealed area may be a di''erent color 'rom t(e surrounding s$in- Iatc( 'or signs o' in'ection0 suc( as increased pain0 redness0 'ever0 s,elling or oo?ing- 7' in'ection develops0 see$ medical (elp- Avoid re)in1uring or tanning i' t(e burns are less t(an a year old X doing so may cause more extensive pigmentation c(anges- se sunscreen on t(e area 'or at least a yearCaution
Dont use i+e. Putting ice directly on a burn can cause 'rostbite0 'urt(er damaging your s$in-
Dont /rea, /listers. %ro$en blisters are vulnerable to in'ection-
T2ir%-%eree /urn
3(e most serious burns are painless and involve all layers o' t(e s$in- Fat0 muscle and even bone may be a''ected- Areas may be c(arred blac$ or appear dry and ,(ite- Di''iculty in(aling and ex(aling0 carbon monoxide poisoning or ot(er toxic e''ects may occur i' smo$e in(alation accompanies t(e burnor &aBor /urns 0 dial E44 or call 'or emergency medical assistance- ntil an emergency unit arrives0 'ollo,
t(ese steps:
1. Dont re&oe /urnt +lot2in. Ho,ever0 do ma$e sure t(e victim is no longer in contact ,it( smoldering materials or exposed to smo$e or (eat2. Dont i&&erse seere lare /urns in +ol% 4ater. Doing so could cause s(oc$3. C2e+, 1or sins o1 +ir+ulation @/reat2in7 +ou2in or &oe&ent. 7' t(ere is no breat(ing or ot(er sign o' circulation0 begin cardiopulmonary resuscitation .CPR/4. Coer t2e area o1 t2e /urn. se a cool0 moist0 sterile bandage2 clean0 moist clot(2 or moist to,els-
7' a C2e&i+al /urns0 irst ai%JJJ
c(emical burns t(e s$in0 'ollo, t(ese steps: 1. Re&oe t2e +ause o1 t2e /urn by 'lus(ing t(e c(emicals o'' t(e s$in sur'ace ,it( cool0 running ,ater 'or 4< minutes or more- 7' t(e burning c(emical is a po,der)li$e substance suc( as lime0 brus( it o'' t(e s$in be'ore 'lus(ing-
166
2. Re&oe +lot2in or Be4elr* t(at (as been contaminated by t(e c(emical3. Wra' t2e /urne% area loosel* ,it( a dry0 sterile dressing or a clean clot(-
inor c(emical burns usually (eal ,it(out 'urt(er treatment-
See, e&eren+* &e%i+al assistan+e i10
3(e victim (as signs o' s(oc$0 suc( as 'ainting0 pale complexion or breat(ing in a notably s(allo, manner
3(e c(emical burn penetrated t(roug( t(e 'irst layer o' s$in0 and t(e resulting second)degree burn covers an area more t(an 5 to 9 inc(es in diameter
3(e c(emical burn occurred on t(e eye0 (ands0 'eet0 'ace0 groin or buttoc$s0 or over a ma1or 1oint-
7' youQre unsure ,(et(er a substance is toxic0 call t(e poison centerEle+tri+al /urns0 irst ai%JJJ
An electrical burn may appear minor or not s(o, on t(e s$in at all0 but t(e damage can extend deep into t(e tissues beneat( your s$in- 7' a strong electrical current passes t(roug( your body0 internal damage0 suc( as a (eart r(yt(m disturbance or cardiac arrest0 can occur- *ometimes t(e 1olt associated ,it( t(e electrical burn can cause you to be t(ro,n or to 'all0 resulting in 'ractures or ot(er associated in1uriesDial E44 or call 'or emergency medical assistance i' t(e person ,(o (as been burned is in pain0 is con'used0 or is experiencing c(anges in (is or (er breat(ing0 (eartbeat or consciousnessW2ile 2el'in so&eone 4it2 an ele+tri+al /urn an% 4aitin 1or &e%i+al 2el'7 1ollo4 t2ese ste's0
1. Loo, 1irst. Dont tou+2. 3(e person may still be in contact ,it( t(e electrical source- 3ouc(ing t(e person may pass t(e current t(roug( you2. Turn o11 t2e sour+e o1 ele+tri+it* i1 'ossi/le. 7' not0 move t(e source a,ay 'rom bot( you and t(e in1ured person using a nonconducting ob1ect made o' cardboard0 plastic or ,ood3. C2e+, 1or sins o1 +ir+ulation @/reat2in7 +ou2in or &oe&ent. 7' absent0 begin cardiopulmonary resuscitation .CPR/ immediately4. Preent s2o+,. ay t(e person do,n ,it( t(e (ead slig(tly lo,er t(an t(e trun$ and t(e legs elevated5. Coer t2e a11e+te% areas. 7' t(e person is breat(ing0 cover any burned areas ,it( a sterile gau?e bandage0 i' available0 or a clean clot(- DonQt use a blan$et or to,el- oose 'ibers can stic$ to t(e burnsAni&al /ites0 irst ai%JJJ
Domestic pets cause most animal bites- Dogs are more li$ely to bite t(an cats- Cat bites0 (o,ever0 are more li$ely to cause in'ection- %ites 'rom nonimmuni?ed domestic animals and ,ild animals carry t(e ris$ o' rabies- Rabies is more common in raccoons0 s$un$s0 bats and 'oxes t(an in cats and dogs- Rabbits0 s>uirrels and ot(er rodents rarely carry rabies- 7' an animal bites you or your c(ild0 'ollo, t(ese guidelines:
or &inor 4oun%s. 7' t(e bite barely brea$s t(e s$in and t(ere is no danger o' rabies0 treat it as a
minor ,ound- Ias( t(e ,ound t(oroug(ly ,it( soap and ,ater- Apply an antibiotic cream to prevent in'ection and cover t(e bite ,it( a clean bandageor %ee' 4oun%s. 7' t(e animal bite creates a deep puncture o' t(e s$in or t(e s$in is badly torn and bleeding0 apply pressure ,it( a clean0 dry clot( to stop t(e bleeding and see your doctor
or in1e+tion. 7' you notice signs o' in'ection suc( as s,elling0 redness0 increased pain or oo?ing0
see your doctor immediately167
or sus'e+te% ra/ies. 7' you suspect t(e bite ,as caused by an animal t(at mig(t carry rabies X
any bite 'rom a ,ild or domestic animal o' un$no,n immuni?ation status X see your doctor immediately-
Doctors recommend getting a tetanus s(ot every 4= years- 7' your last one ,as more t(an 'ive years ago and your ,ound is deep or dirty0 your doctor may recommend a booster- Lou s(ould (ave t(e booster ,it(in 6 (ours o' t(e in1uryall 'reention0 ; 4a*s to re%u+e *our 1allin ris,JJJ
alls 'ut *ou at ris, o1 serious inBur*. Preent 1alls 4it2 t2ese 1all-'reention &easures.
Lour odds o' 'alling eac( year a'ter age 8< are about one in t(ree- Fortunately0 most o' t(ese 'alls arenQt serious- *till0 'alls are t(e leading cause o' in1ury and in1ury)related deat( among older adults- LouQre more li$ely to 'all as you get older because o' common0 age)related p(ysical c(anges and medical conditions X and t(e medications you ta$e to treat suc( conditionsLou neednQt let t(e 'ear o' 'alling rule your li'e- any 'alls and 'all)related in1uries are preventable ,it( 'all) prevention measures- HereQs a loo$ at six 'all)prevention approac(es t(at can (elp you avoid 'allsall-'reention ste' !0 Ma,e an a''oint&ent 4it2 *our %o+tor
%egin your 'all)prevention plan by ma$ing an appointment ,it( your doctor- Lou and your doctor can ta$e a compre(ensive loo$ at your environment0 your (ealt( and your medications to identi'y situations ,(en youQre vulnerable to 'alling- 7n order to devise a 'all)prevention plan0 your doctor ,ill ,ant to $no,: W2at &e%i+ations are *ou ta,inK 7nclude all t(e prescription and over)t(e)counter medications you ta$e0 along ,it( t(e dosages- Or bring t(em all ,it( you- Lour doctor can revie, your medications 'or side e''ects and interactions t(at may increase your ris$ o' 'alling- 3o (elp ,it( 'all prevention0 (e or s(e may decide to ,ean you o'' certain medications0 especially t(ose used to treat anxiety and insomnia
Hae *ou 1allen /e1oreK Irite do,n t(e details0 including ,(en0 ,(ere and (o, you 'ell- %e prepared to discuss instances ,(en you almost 'ell but managed to grab (old o' somet(ing 1ust in time or ,ere caug(t by someone
Coul% *our 2ealt2 +on%itions +ause a 1allK Lour doctor li$ely ,ants to $no, about eye and ear
disorders t(at may increase your ris$ o' 'alls- %e prepared to discuss t(ese and to tell (im or (er (o, you ,al$ X describe any di??iness0 1oint pain0 numbness or s(ortness o' breat( t(at a''ects your ,al$- Lour doctor may t(en evaluate your muscle strengt(0 balance and individual ,al$ing style .gait/all-'reention ste' (0 ee' &oin
7' you arenQt already getting regular p(ysical activity0 consider starting a general exercise program as part o' your 'all)prevention plan- Consider activities suc( as ,al$ing0 ,ater ,or$outs or tai c(i X a gentle exercise t(at involves slo, and grace'ul dance)li$e movements- *uc( activities reduce your ris$ o' 'alls by improving your strengt(0 balance0 coordination and 'lexibility- %e sure to get your doctorQs OG 'irst0 t(oug(7' you avoid exercise because youQre a'raid it ,ill ma$e a 'all more li$ely0 bring t(is concern to your doctorHe or s(e may recommend care'ully monitored exercise programs or give you a re'erral to a p(ysical t(erapist ,(o can devise a custom exercise program aimed at improving your balance0 muscle strengt( and gait- 3o improve your 'lexibility0 t(e p(ysical t(erapist may use tec(ni>ues suc( as electrical stimulation0 massage or ultrasound- 7' you (ave inner ear problems t(at a''ect your balance0 (e or s(e may also teac( you balance retraining exercises .vestibular re(abilitation/ X ,(ic( involve speci'ic (ead and body movements to correct loss o' balanceall-'reention ste' )0 Wear sensi/le s2oes
Consider c(anging your 'oot,ear as part o' your 'all)prevention plan- Hig( (eels0 'loppy slippers and s(oes ,it( slic$ soles can ma$e you slip0 stumble and 'all- *o can ,al$ing in your stoc$ing 'eet- 7nstead:
Have your 'eet measured eac( time you buy s(oes0 since your si?e can c(ange%uy properly 'itting0 sturdy s(oes ,it( nons$id soles-
168
Avoid s(oes ,it( extra)t(ic$ solesC(oose lace)up s(oes instead o' slip)ons0 and $eep t(e laces tied*elect 'oot,ear ,it( 'abric 'asteners i' you (ave trouble tying laces*(op in t(e menQs department i' youQre a ,oman ,(o canQt 'ind ,ide enoug( s(oes-
7' bending over to put on your s(oes puts you o'' balance0 consider a long s(oe(orn t(at (elps you slip your s(oes on ,it(out bending over-
all-'reention ste' :0 Re&oe 2o&e 2a6ar%s
As part o' your 'all)prevention measures0 ta$e a loo$ around you X your living room0 $itc(en0 bedroom0 bat(room0 (all,ays and stair,ays may be 'illed ,it( booby traps- Clutter can get in your ,ay0 but so can t(e decorative accents you add to your (ome- 3o ma$e your (ome sa'er0 you mig(t try t(ese tips:
Remove boxes0 ne,spapers0 electrical cords and p(one cords 'rom ,al$,ays-
ove co''ee tables0 maga?ine rac$s and plant stands 'rom (ig()tra''ic areas-
*ecure loose rugs ,it( double)'aced tape0 tac$s or a slip)resistant bac$ing-
Repair loose0 ,ooden 'loorboards and carpeting rig(t a,ay-
*tore clot(ing0 dis(es0 'ood and ot(er (ouse(old necessities ,it(in easy reac(-
7mmediately clean spilled li>uids0 grease or 'ood-
se nons$id 'loor ,ax-
se nonslip mats in your bat(tub or s(o,er-
all-'reention ste' 0 Li2t u' *our liin s'a+e
As you get older0 less lig(t reac(es t(e bac$ o' your eyes ,(ere you sense color and motion- *o $eep your (ome brig(tly lit ,it( 4==),att bulbs or (ig(er to avoid tripping on ob1ects t(at are (ard to see- DonQt use bulbs t(at exceed t(e ,attage rating on lamps and lig(ting 'ixtures0 (o,ever0 since t(is can present a 'ire (a?ard- Also:
Place a lamp near your bed and ,it(in reac( so t(at you can use it i' you get up at nig(t-
a$e lig(t s,itc(es more easily accessible in rooms- a$e a clear pat( to t(e s,itc( i' it isnQt rig(t near t(e room entrance- Consider installing glo,)in)t(e)dar$ or illuminated s,itc(es
Place nig(t lig(ts in your bedroom0 bat(room and (all,ays-
3urn on t(e lig(ts be'ore going up or do,n stairs- 3(is mig(t re>uire installing s,itc(es at t(e top and bottom o' stairs
*tore 'las(lig(ts in easy)to)'ind places in case o' po,er outages-
all-'reention ste' ;0 Use assistie %ei+es
Lour doctor mig(t recommend using a cane or ,al$er to $eep you steady- Ot(er assistive devices can (elp0 too- All sorts o' gadgets (ave been invented to ma$e everyday tas$s easier- *ome you mig(t consider: "rab bars mounted inside and 1ust outside your s(o,er or bat(tub A raised toilet seat or one ,it( armrests to stabili?e yoursel' A sturdy plastic seat placed in your s(o,er or tub so t(at you can sit do,n i' you need to- %uy a (and)(eld s(o,er no??le so t(at you can s(o,er sitting do,n Handrails on bot( sides o' stair,ays Nonslip treads on bare),ood steps
As$ your doctor 'or a re'erral to an occupational t(erapist ,(o can (elp you devise ot(er ,ays to prevent 'alls in your (ome- *ome solutions are easily installed and relatively inexpensive- Ot(ers may re>uire
169
pro'essional (elp and more o' an investment- 7' you plan on staying in your (ome 'or many more years0 an investment in sa'ety and 'all prevention no, may ma$e t(at possibleInse+t /ites an% stins0 irst ai%JJJ
*igns and symptoms o' an insect bite result 'rom t(e in1ection o' venom or ot(er substances into your s$in3(e venom triggers an allergic reaction- 3(e severity o' your reaction depends on your sensitivity to t(e insect venom or substanceost reactions to insect bites are mild0 causing little more t(an an annoying itc(ing or stinging sensation and mild s,elling t(at disappear ,it(in a day or so- A delayed reaction may cause 'ever0 (ives0 pain'ul 1oints and s,ollen glands- Lou mig(t experience bot( t(e immediate and t(e delayed reactions 'rom t(e same insect bite or sting- Only a small percentage o' people develop severe reactions .anap(ylaxis/ to insect venom- *igns and symptoms o' a severe reaction include 'acial s,elling0 di''iculty breat(ing and s(oc$%ites 'rom bees0 ,asps0 (ornets0 yello, 1ac$ets and 'ire ants are typically t(e most troublesome- %ites 'rom mos>uitoes0 tic$s0 biting 'lies and some spiders also can cause reactions0 but t(ese are generally milderor &il% rea+tions0
ove to a sa'e area to avoid more stings-
*crape or brus( o'' t(e stinger ,it( a straig(t)edged ob1ect0 suc( as a credit card or t(e bac$ o' a $ni'e- Ias( t(e a''ected area ,it( soap and ,ater- DonQt try to pull out t(e stinger2 doing so may release more venom
3o reduce pain and s,elling0 apply a cold pac$ or clot( 'illed ,it( ice-
Apply =-< percent or 4 percent (ydrocortisone cream0 calamine lotion or a ba$ing soda paste X ,it( a ratio o' 9 teaspoons ba$ing soda to 4 teaspoon ,ater X to t(e bite or sting several times a day until your symptoms subside
3a$e an anti(istamine containing dip(en(ydramine .%enadryl0 3ylenol *evere Allergy/ or c(lorp(eniramine maleate .C(lor)3rimeton0 3eldrin/
Allergic reactions may include mild nausea and intestinal cramps0 diarr(ea or s,elling larger t(an 5 inc(es in diameter at t(e site- *ee your doctor promptly i' you experience any o' t(ese signs and symptomsor seere rea+tions0
*evere reactions may progress rapidly- Dial E44 or call 'or emergency medical assistance i' t(e 'ollo,ing signs or symptoms occur:
Di''iculty breat(ing *,elling o' your lips or t(roat Faintness Di??iness Con'usion Rapid (eartbeat Hives Nausea0 cramps and vomiting
3a$e t(ese actions immediately ,(ile ,aiting ,it( an a''ected person 'or medical (elp: 4- C(ec$ 'or special medications t(at t(e person mig(t be carrying to treat an allergic attac$0 suc( as an auto)in1ector o' epinep(rine .'or example0 !piPen/- Administer t(e drug as directed X usually by pressing t(e auto)in1ector against t(e personQs t(ig( and (olding it in place 'or several secondsassage t(e in1ection site 'or 4= seconds to en(ance absorption5- A'ter administering epinep(rine0 (ave t(e person ta$e an anti(istamine pill i' (e or s(e is able to do so ,it(out c(o$ing9- Have t(e person lie still on (is or (er bac$ ,it( 'eet (ig(er t(an t(e (ead-
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6- oosen tig(t clot(ing and cover t(e person ,it( a blan$et- DonQt give anyt(ing to drin$<- 7' t(ereQs vomiting or bleeding 'rom t(e mout(0 turn t(e person on (is or (er side to prevent c(o$ing8- 7' t(ere are no signs o' circulation .breat(ing0 coug(ing or movement/0 begin CPR-
htt'//.redcross.org
RESPIRATORY ARREST
Respiratory Arrest .)/ RR .J/ PR A condition o' t(e victim ,(erein t(ere is no breat(ing but pulse continues
CA*!*: 4- *trangulation 5- Poisoning)7n1ection0 7ngestion0 7n(alation 7n1ection) *na$ebite0 Rabies0 *corpions0 bees0 1elly'is(0 spiders 9- *evere %leeding 6- Dro,ning <- !lectrocution 8- *u''ocation 7. C(o$ing: niversal *ign o' C(o$ing) palms guarding t(roat - Disease 3HR!! .9/ G7ND* OF A7RIAL O%*3RC37ON in% O Air4a* O/stru+tion
Sins
irst Ai%
Iit( "ood Air !xc(ange
#ictim can still 3AG
Observe t(e victim as (e coug( out obstruction
Iit( Poor Air !xc(ange
#ictim produces ,(ee?ing sound
Abdominal 3(rust @ Heimlic( aneuver
nconscious
4- Abdominal 3(rust 4= %lind Finger s,eep 'or adults
3otal Air,ay Obstruction ,it( No Air !xc(ange
5- Arti'icial Respiration .AR/ 5 9- C(ec$ i' Air is going bac$) oo$0 isten & Feel .F/ 6- Repeat blind 'inger s,eep <- Arti'icial Respiration 5 i' e''ective First Aid: Arti'icial Respiration .AR/ + "iving o' arti'icial air only eit(er t(roug( a blo, or ambubag ) c(est compression not indicated because t(ere is pulse rate !3HOD* 7N "7#7N" AR37F7C7A R!*P7RA37ON
1. 2. 3. 4.
out( to out( ) usual met(od out( to Nose ) i' mout( is obstructed out( to out( & Nose + used in in'ants out( to *toma ) li$e 'or patients ,it( trac(eostomy <- out( to as$ 8- Ambu %ag to out( & Nose Ambu %ag) a device used 'or arti'icial mec(anical breat(ing unit
171
AD3
CH7D
7NFAN3
!3HOD
out( 3O out(
out( 3O out(
out( 3O out( & Nose
anner o' %reat(ing
Full and *lo,
Regulated
Rate o' %lo,s
4 %lo, every < secs 45 blo,s per min
4 %lo, every 6 secs 4< blo,s per min
Pu'' 4 %lo, every 9 seconds 5= blo,s per min
*3AR3 I73H A %OI AND !ND I73H A %OI IH!N 3O *3OP 4- I(en t(e rescuer is ex(austed 5- I(en t(e victim is breat(ing on (is o,n 9- I(en t(e service o' t(e p(ysician is available 4. I(en t(e pulse disappears2 arti'icial respiration is stopped and cardiopulmonary rescucitation begins <- I(en anot(er 'irst aider ta$es over CARDIAC ARREST
Condition o' t(e victim ,(en t(e pulse and breat(ing is absent-
7ntervention 'or Cardiac Arrest: CPR CPR) Cardio Pulmonary Resuscitation ) A combination o' external c(est compression and arti'icial ventilations to revive t(e (eart and t(e lungs CA*!*
All causes o' Respiratory Arrest0 Heart Attac$0 *tro$e ocation O' C(est Compressions
1. AD3) 9 'ingers above mid xip(oid 5- 7NFAN3) along nipple line
Danger o' Failure to revive Patient: 4- C7N7CA D!A3H) may occur i' (eart rate is not revived ,it(in 6)8 minutes 5- %7OO"7CA D!A3H) usually occurs a'ter 6)8 mins o' cardiac arrest
ADULT
CHILD
INANT
et(od
5 Heels o' 5 Hands
4 Heel o' 4 (and
5 Fingers .ring and mid 'inger/
Dept(
4 U;) 5B
4B) 4 UB
UB + 4B
Rate
4< !CC@5 blo,s 6@min
*peed
8=)= !CC@min 45@min
=)4== !CC@min
4==)45= !CC@min
5 R!*C!R*
< !CC@4 blo,
DON;3;* 7N CPR: 4596<8-
Don;t be a double crosser Don;t be a roc$er Don;t be a 1er$er Don;t be a render Don;t be a bouncer Don;t be a massager
CPR) start ,it( 5 blo,s end ,it( 5 blo,s
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