ALALBAYTUNI

VERSI
TY

SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Tr
aini
ngCour
se
Yahy
aAl
Rhoud

2016

JORDAN – AL M AFRAQ
PageIof1
 Acknowl
edgment
Iwouldli
ketoexpressmydeepestappr eci
ati
ont oallt
hosewhopr ov
idedmet he
possi
bil
i
[Link]
tudeIgi
v et
oourfinal
yearstudent
,
i
nAl MafraqHospi
tal,
Whosecont r
ibut
ioninstimulati
ngsuggesti
onsand
encour
agement,hel
pedt ocoor
dinatei
nwr i
ti
ngandcol lect
ingthi
smanual.

Iwouldal
soli
ketoexpandourdeepestgr
ati
tudetoMohammedALKhal i
dy(
4thy
ear
nur
singst
udent)whohasdir
ectl
yandindi
rectl
yhelpedi
nedi
ti
ngt
hisassi
gnment
.

Manypeopl
e,especi
all
yourclassmat
esandteam membersi
tself
,havemadevaluabl
e
commentsuggesti
onsont hi
smanualwhichgav
eusaninspi
rati
ont oi
mproveour
assi
gnment
.Wet hankall
thepeoplef
orthei
rhel
pdir
ect
lyandindir
ectl
ytocomplet
eour
assi
gnment
.

Wehopei
nfut
uret
omakef
urt
herr
evi
siont
othi
swor
kforhi
ghqual
i
tycar
eforheal
th
t
eam member
s.

Fi
nal
YearSt
udent-Al
Maf
raqHospi
tal

‫ﺎﻥ‬
‫ﺮﺣ‬‫ﻟﺴ‬
‫ﺍ‬‫ﺔﻓﻼﺡ‬
‫ﻤ‬‫ﺭﺣ‬ ‫ﺔ‬
‫ﺮﻋ‬‫ﻟﺸ‬
‫ﺍ‬‫ﺎﻥ‬
‫ﺮﺣ‬‫ﻳﻦﻓ‬
‫ﺪ‬‫ﻟ‬‫ﺍ‬
‫ﻴﻒ‬‫ﺳ‬ ‫ﺎﺕ‬
‫ﻓ‬‫ﺮ‬‫ﻟﺸ‬
‫ﺍ‬‫ﺮ‬‫ﺭﻑﻣﻄ‬
‫ﺎ‬‫ﻴﺲﻋ‬
‫ﻣ‬ ‫ﺔ‬
‫ﺮﻋ‬‫ﻟﺸ‬
‫ﺍ‬‫ﻼﻪ‬
‫ﺪﺳ ﻣ‬
‫ﻤ‬‫ﻩﻣﺤ‬
‫ﺩ‬‫ﻮ‬‫ﻋ‬

‫ﺔ‬
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‫ﻟ‬
‫ﻔﻰ ﺎ‬
‫ﺀﻣﺼﻄ‬
‫ﻭﻻ‬ ‫ﺧﺪ‬
‫ﻟ‬
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‫ﻮﻑﺑ‬
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‫ﺒ‬‫ﻟ‬
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‫ﺎ‬‫ﻴﺼﻞﻫ‬
‫ﺪ ﷲﻓ‬
‫ﺒ‬‫ﻋ‬

‫ﺎﺕ‬
‫ﻤ‬‫ﻴ‬‫ﻠ‬
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‫ﺔﺳ ﻣ‬
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‫ﺪ ﷲﺣﺴ‬
‫ﺒ‬‫ﺀﻋ‬
‫ﺍ‬‫ﺮ‬‫ﺍﺳ‬ ‫ﺮﺏ‬
‫ﻘ‬‫ﻮﻣ‬
‫ﺑ‬‫ﺍ‬‫ﻠﻲ‬
‫ﺪﻋ‬‫ﻤ‬
‫ﺭﻣﺤ‬
‫ﻮ‬‫ﻧ‬ ‫ﺧﺪ‬
‫ﻟ‬
‫ﻨﻲ ﺎ‬
‫ﺮﺑ‬‫ﺎﻫ‬
‫ﺪﺣﺴﻦﻇ‬
‫ﻤ‬‫ﻣﺤ‬

‫ﺎﺕ‬
‫ﻤ‬‫ﻴ‬‫ﻠ‬
‫ﻌ‬‫ﻟ‬
‫ﺍ‬‫ﺩ‬‫ﻮ‬
‫ﻤ‬‫ﻣﻲﻣﺤ‬
‫ﺎ‬‫ﺮﺳ‬
‫ﻴ‬‫ﺛ‬‫ﺍ‬ ‫ﺩ‬
‫ﺍ‬‫ﻮ‬‫ﺭﻋ‬
‫ﺯ‬‫ﺎ‬
‫ﺎ ﺽﻋ‬
‫ﻳ‬‫ﺮﺡﺭ‬
‫ﻣ‬ ‫ﺎﺕ‬
‫ﻓ‬‫ﺮ‬‫ﻟﺸ‬
‫ﺍ‬‫ﺎﺏ‬
‫ﺓﻛﺴ‬
‫ﺩ‬‫ﺎ‬‫ﻴ‬
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‫ﺍﺣ‬ ‫ﺪ‬
‫ﻴ‬‫ﺎﻋ‬
‫ﻤﺴ‬‫ﻟ‬
‫ﺍ‬‫ﺮ‬‫ﻴ‬
‫ﺪﺷﺨ‬
‫ﻤ‬‫ﺔﻣﺤ‬
‫ﺒ‬‫ﻫ‬

‫ﺎﺕ‬
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‫ﻳ‬ ‫ﺔ‬
‫ﺒ‬‫ﻗ‬‫ﺎ‬
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‫ﺪﻣﺤ‬
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‫ﻭ‬‫ﺭ‬

‫ﻪ‬
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‫ﻤ‬‫ﺍﺣ‬ ‫ﻳﻦ‬
‫ﺪ‬‫ﻟ‬‫ﺍ‬
‫ﺓ ﺻﻼﺡ‬
‫ﻭ‬‫ﺮ‬‫ﻣ‬ ‫ﻴﺴﻰ‬
‫ﻌ‬‫ﻟ‬
‫ﺍ‬‫ﺒﺢ‬
‫ﺪﻣﺼ‬
‫ﻤ‬‫ﺩﻣﺤ‬
‫ﺎ‬‫ﻳ‬‫ﺍ‬ ‫ﻴﻦ‬
‫ﺎﺻﺠ‬
‫ﻴ‬‫ﻟ‬
‫ﺍ‬‫ﻡ‬‫ﺎ‬
‫ﺔﺑﺴ‬
‫ﻨ‬‫ﻴ‬‫ﻜ‬
‫ﺳ‬

‫ﺪ‬
‫ﻴ‬‫ﺎﻋ‬
‫ﻤﺴ‬‫ﻟ‬
‫ﺍ‬‫ﻴﻢﺣﺴﻦ‬
‫ﺍﻫ‬‫ﺮ‬
‫ﺑ‬‫ﺍ‬‫ﺪ‬
‫ﺍﺷ‬‫ﺭ‬ ‫ﺩﻱ‬
‫ﺮ‬‫ﻟﺴ‬
‫ﺍ‬‫ﻴﻒ ﷲ‬
‫ﺔﺿ‬‫ﻴ‬
‫ﺒ‬‫ﺫﻫ‬ ‫ﺩ‬
‫ﻮ‬‫ﻳ‬‫ﺰ‬
‫ﻟ‬‫ﺍ‬‫ﻤﻲ‬
‫ﻠ‬‫ﺪ ﷲﺣ‬
‫ﺒ‬‫ﻋ‬ ‫ﺔ‬
‫ﻠ‬‫ﺍﻋ‬
‫ﺰ‬‫ﺭﻉﺧ‬
‫ﺎ‬‫ﺪﻓ‬
‫ﻤ‬‫ﻭﻕﻣﺤ‬
‫ﺮ‬‫ﺷ‬

Lect
urer:
Yahy
aHALRshoud

RN,
BSN,
MSN

ALALBAYTUNI
VERSI
TY

25/
4/2016

PageI
Iof2
 Tabl
eofCont
ent
Page Topi
c Page Appendi
ces
number number

4 Pul
monar
yedema 154 ABG PRACTI
CETEST

7 Pul
monar
yEmbol
i
sm 156 Ant
idot
estoCommon
Medi
cat
ions

11 COPD 157 CommonLabVal

ues

15 Pneumoni
a

17 Pl
eur
alef
fusi
on

20 Pneumot
hor
ax

24 Ast
hma

26 Pul
monar
yTuber
cul
osi
s
(TB)

31 Br
onchi
ti
s

34 Lungf
ibr
osi
s

37 Hy
per
tensi
on

40 DeepVei
nThr
ombosi
s

42 Anemi
a

45 My
ocar
dial
Inf
arc
tion(
MI)

48 ANGTNAPETORTS(
CAD)

50 Conges
tiv
ehear
tfai
l
ure

54 RENALFAI
LURE

60 URI
NARYTRACT
I
NFECTI
ON

65 Meni
ngi
ti
s

68 Mul
ti
pleScl
erosi
s

73 Cer
ebr
ovascul
aracci
dent

77 Tr
ansi
entI
schemi
cAt
tack

82 Di
abet
esmel
l
itus(
DM)

PageI
IIof3
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

87 DKA(
Ketoacidosi
s)&
Ketones

95 Di
abet
icFoot

99 Chol
ecy
sti
ti
s

103 Appendi
cit
is

107 Chol
esl
i
thi
asi
s

111 I
ntest
inal
Obst
ruct
ion

114 Gast
roi
ntest
inal
(GI
)
bl
eeding

118 Obst
ruct
iveJaundi
ce

121 HERNI
A

126 Gast
roent
eri
ti
s

130 Per
it
oni
ti
s

135 Pancr
eat
it
is

142 Li
verCi
rr
hosi
s

146 Hepat
it
is

PageI
Vof4
 [Link]
RATORYDI
SORDERS
[Link]
monar
yedema
Definit
ion:
Pulmonar yedemai saconditioncausedbyexcessf lui
di nthel [Link]
uidcol
lect
s
i
nt henumer ousairsacsinthel ungs,
makingi tdi
ff
iculttobr eath.I
nmostcases, hear
t
pr
obl emscausepul monar [Link] l
uidcanaccumul ateforotherreasons,
i
ncludingpneumoni a,ex
posur etocertai
ntoxinsandmedi cations,t
raumat othechest
wall,andexerci
singorli
vingathi ghel
evati
on.
Type
Poi nts Non-Car di
ogeni
c -cardiogenic

Def
ini
ti
on
Theradiographic Pulmonaryedemai s
evi
denceofal veolar ei
therduetoadi r
ect
fl
uidaccumul ati
on damaget othecar di
ac
wit
houthemody namic ti
ssueorar esultof
evi
dencet osuggest i
nadequatef uncti
oning
cardi
ogenicet i
ology oftheheartor
ci
rcul
atorysy st
em

Cause
1-Inhal
ationoftoxic 1-CHF( congest i
v e
gases.2-Aspi r
ati
on heartfai
lure).2-Sev er
e
(gastr
icfl
uidincaseof arr
hy t
hmi a.3-HTN
drowning).3-multi
ple cri
sis.4-flui
dov erl
oad
bloodtransfusi
on.4- duet okidneyf ai
lureor
severeinfecti
on i
ntravenoust herapy

-Cardiogeni cpat hophysiology:

Incr
easedhy drost at
icpressureleadingt opulmonar yedemamayr esul tfr
om many
causes, includingexcessi veintravascularvolumeadmi nistrat
ion,pul monar yvenous
outfl
owobst ruction(eg,mi t
ralstenosisorleftatr
ial[LA]my xoma) ,andLVf ail
ure
secondar yt osy stoli
cordi astoli
cdy sfuncti
onoft heleftv entr
icl
[Link] eadst o
progressi vedet erior
ati
onofal v
eolargasexchangeandr espi r
atoryf ail
ure.
-Noncar diogeni cpat hophsiology:
noncar diogeni cpulmonar yedema( NPE),iscausedbychangesi nper meabili
tyofthe
pulmonar ycapi l
larymembr aneasar esultofeit
heradi rectorani ndi rectpathologi
c
i
nsul t
-Signandsy mptoms:
-Sudden( acut
e)pulmonaryedemasy mptoms:
-Extremeshortnessofbreathordif
fi
cult
ybreat
hing(
dyspnea)t
hatwor
senswhenl
yi
ng
down
-Af eel
ingofsuff
ocati
ngordrowningandWheez i
ngorgaspi
ngforbr
eat
h

PageVof5
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Anxi
ety,r
est l
essnessorasenseofapprehensi
on
-
Acought hatproducesfr
othysputum t
hatmaybetingedwi t
hbl
ood
-
Chestpainifpulmonaryedemaiscausedbyheartdisease
-
Arapid,
irregul
arheart
beat(pal
pit
ati
ons)

PageVIof6
-
Long-
ter
m(chr
oni
c)pul
monar
yedemasy
mpt
oms:

-
Hav i
ngmor eshor t
nessofbr eat hthannormal whenyou'rephy si
callyacti
ve.
-
Diff
icultybr
eathi
ngwi t
hexer ti
on.
-
Diff
icultybr
eathi
ngwheny ou'relyingflat
.
-
Wheezi ng.
-
Awakeni ngatnightwit
habr eathlessfeeli
ngthatmayber el
ievedbysi tt
ingup.
-
Rapidwei ghtgainwhenpul monar yedemadev el
opsasar esultofcongest i
vehear
t
fai
l
ure,aconditi
oni nwhichyourhear tpumpstool i
tt
lebloodt omeety ourbody'
sneeds.
Thewei ghtgai
n-isfrom buil
dupoff l
uidinyourbody,especiall
yiny ourlegs.
-
Swel l
i
ngi nyourlowerextremities.

-
Diagnosticpr ocedure:
1-Cli
nicalf i
ndingsonassessment.2-OxymetryorABGv al
ues.3-ChestX-rays.(for
fl
uidsinandar oundlungspaceorenl
argedheart)4-Echocardi
ogram (
forvalv
es) .5-
Measur ementf orpulmonaryart
erywedgepressurebyswanganzcat heter
.6-Bl ood
cul
turef orsuspectedinf
ecti
on.7-Car
diacmarkersforMI

-Management :
 1-oxygentherapy:highf
loweitherbynon-r
ebreathermaskorETTintubati
onand
mechanicalventi
lati
on2-Highfowlersposi
ti
on( HOB90◦)3-Morphine:decrease
anxiet
yandr esi
stancewhichtheheartmustpump.4-Di ur
eti
cther
apy( l
asix):
reducesfl
uidoverloadandpulmonarycongestion.

 5-vasodilatortherapy(nitr
ogl ycerin)
:reducesamountofbloodreturningtothehear
t
andr educest heresist
ancet hatt heheartmustpump.6-cont r
acti
l
ityenhancement
therapy(digoxin):i
mprov esabilityoftheheartmuscletopumpmor eef f
ecti
vel
y,
all
owi ngforcompl eteempt yingofbl oodf r
om thevent
ri
cleandasubsequent
decreasei nfl
uidbackingupi nt helungs.7*Aminophyl
l
ine:mayprevent
bronchospasm associ atedwi thpul monarycongesti
on,Usewithcaut i
onasitmay
i
ncreasehear trat
einducingt achy dysr
hythmia

 Nur
singdi
agnosi
s

1-ineff
ecti
vebreat
hingpat
ter
nrelat
edto:
[Link]
eanddecreaseddepthofrespi
rat
ionsassoci
atedwi
thf
earandanxi
ety

[Link]
easedl
ungcompli
ance(di
stensi
bil
i
ty)associ
atedwithpl
eur
alef
fusi
onand
accumul
ati
onoff
lui
dinthepulmonaryint
ersti
ti
um andalv
eol
i

[Link]
minishedlung/
chestwall
expansi
onassoci
atedwi t
hweakness,
decreased
mobili
ty,
andpressureonthedi
aphr
agm asar esul
tofper
it
onealf
luid
accumulati
on(ifpr
esent
)

D.r
espi
rat
orydepr
essantand/
orst
imul
antef
fect
sofhy
poxi
a,hy
per
capni
a,and

PageVI
Iof7
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

di
mini
shedcer
ebr
albl
oodf
low;

2.i
mpai
redgasexchanger
elat
edt
o:

A.I
mpaireddi
ff
usionofgasesassociatedwi
thaccumul
ati
onoffl
uidi
nthe
pul
monaryi
nterst
it
ialandalveol
i.
[Link]
easedpulmonarytissueper
fusi
onassoci
atedwi
thdecr
easedcar
diac
out
put.

-
Out
come:

Thecl
i
entwillexperienceadequaterespir
ator
yfunct
ionAEB:
[Link] rate,rhythm,anddepthofrespi
rat
ions
[Link] spnea
[Link] mpr ovedbreat
hsounds
[Link] r
icalchestexcursi
on
[Link] alstatus
[Link] esult
swi t
hinnor
mal range
[Link] t
hinnormalr
ange.

-
Nur
singI
nter
vent
ion:

[Link] hepat ientrel axt opr omot eoxy genat ion.

[Link] hepat ientinhi ghFowl er’
sposi t
iont oenhancel ungexpansi on.
[Link] nisteroxy genasor der ed.
[Link] efullyr ecor dthet i
memor phineisgi venandt heamountadmi nistered.
[Link] hepat ient’scondi t
ionf requent ly
.
[Link] chf orcompl i
cat ionsoft reatmentsuchasel ectr
oly t
edepletion.
[Link] t
orv i
t alsignsev ery15t o30mi nutesormor eoftenasi ndicated.
[Link] hepat ientt ocompl ywi ththepr escr ibedmedi cationregiment oav oi
d
futureepi sodesofpul monar yedema.
[Link] ainal lpr ocedur etot hepat i
entandhi sf ami l
y.
10.
Emphasi zer epor tingear lysi gnsoff l
uidov erl
oad.
11.
Rev iewal lpr escribedmedi cat i
onswi t
ht hepat i
ent.
12.
Discussway stoobser vephy sical energy .
13.
Assessf orsi gnsandsy mpt omsofi mpai redr espi
ratoryfuncti
on, rapid,
shal l
ow, slow, orirregularr espirations,dy spnea, ort
hopnea, useofaccessor y
muscl eswhenbr eat hing, adv enti
tiousbr eat hsounds( [Link][rales],
wheezes) di minishedorabsentbr eathsounds.

PageVI
IIof8
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageI
Xof9
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageXof10
 [Link]
monar
yEmbol
i
sm
-Defi
nit
ion:
-Apulmonaryembol ism i
sabl oodclotthatoccursinthel
ungs.
Apul monaryembol i
sm candamagepar tofthelungduetor est
ri
ctedbl oodflow,
decreaseoxygenlevelsintheblood,anddamageot heror
gans.
Largeormul t
ipl
ebloodcl ot
scanbef at
[Link] i
fe-
threat eni
ng,but
i
mmedi at
eemer gencytreatmentgreatl
yincreasesyourchanceofav oidingpermanent
l
ungdamage.

-Pat
hophysi
ology:
Therear
ebothr espi
rat
oryandhemody
nami
cconsequencesassoci
atedwi
thpul
monar
y
emboli
sm.
-
Respi
rat
oryconsequences:
Acut
erespi
rat
oryconsequencesofpul
monar
yembol
i
sm i
ncl
udet
hef
oll
owi
ng:
 I
ncreasedalveol
ardeadspace
 Hypoxemia
 Hypervent
il
ati
on
-Additi
onalconsequencest hatmayoccuri ncluder egionall
ossofsur factantand
pulmonar yi
nf arcti
on(seet heimagebel ow).Ar t
er i
alhypoxemiaisaf requent,butnot
universal
,fi
ndi nginpatientswithacuteembol [Link] smsofhy poxemi a
i
ncludev enti
lat i
on-per
fusionmismat ch,int
rapulmonar yshunts,reducedcar di
acout put
,
andi ntr
acardiacshuntv iaapatentforamenov [Link]
ioni san
uncommonconsequencebecauseoft hebronchi alart
eri
alcol
lateralcir
culati
on.
-
SignandSy
mpt
oms:
Dependi
ngonhowmuchoft hel
ungisinv
olv
ed,thesi
gnsandsympt
omscanv
arygr
eat
ly,
especi
all
yift
hepat
ienthasanunder
lyi
ngheartorl
ungdi
sease.

Someofthehallmarksignsandsymptomsi nclude:
 Cough–t hepat i
entmayhavebloodyorbl oodstreakedsput
um.
 Short
nessofbr eath–appearssuddenlyandwor senswi t
hexer
ti
on.
 Chestpain–get sworsewit
hexerti
onanddoesnotgoawayev enifr
est
[Link]
havepleuri
sy(painwit
hdeepbreathi
ng).
 Legpain–usual l
yinthecal
[Link] sohav
esomeswelli
ng.
-
Othersignsandsy
mpt oms:
 Cyanosi s
 Dizziness
 Ra pi
dandorir
regularhear
tbeat
 Swe ating
Nursi
ngDiagnosi
s:
1.I
mpairedGasExchanger
elat
edt
odecr
easedpul
monar
yper
fusi
on.
-
Desi
redout
comes:
Theclientwil
lexhi
bitanadequat
egasexchangeandrespi
rat
oryfunct
ionbymaintai
ninga
respi
ratoryr
ateof12-20breat
hspermi
nute,nochangesinLOC,O2sat ur
ati
ons>92%orPao2

PageXIof11
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

80mmhgorhi
gher
,Paco235-
45%,
andapHbet
ween7.
35-
7.45.
-NursingI nt
erventi
on:-
Moni t
orpul seoximet r
yandr eportO2saturat
ion<92%.
Rati
onal :
Thesesi gnsofsympt omsofr espir
ator
ydistr
essnecessi t
atepr ompti nterv
enti
ons.
-NursingI nt
erventi
on:-
Assessr espir
ator
[Link] t
orifther
eisanincreaseinanxi et
y ,
shor tnessofbreat
h,
cyanosi [Link]- t
owardsignsandsy mptomsi mmedi ately.
Rati
onal :
AnO2sat urat
ionoflessthan92%maydet ecthypoxiaandsi gnalstheneedf or
supplement aloxy
gen.
-NursingI nt
erventi
on:-
Encour agedeepbr eathingexerci
sesandadmi nisteroxy
geni findicated
Rati
onal :
Incr
easesoxy gendeliverytothebodybymobi li
zingsecreti
onsandi mpr ovi
ng
venti
lation.

[Link]
orBl
eedi
ng
rel
atedt
oanti
coagul
antt
her
apyt
opr
eventmor
ecl
ots.

-Desiredoutcomes:
Patientwi l
lbef
reeofoccultorfrankbleedi
ngandwillexhi
bithemody
nami
cst
abi
l
ityby
maintainingapulseoflessthan100beat sperminut
e.
Asy stoli
cbloodpressureofatleast
90mmHgandar espir
ator
yrateif12-20breat
hspermi nut
e.

[Link] i
cientKnowledge
rel
at edt opat i
enti
snotfamil
iarwit
hanti
coagul
antther
apy.
Desi redout comes:
Priort odischarge,t
hepati
entwill
beabletover
bali
zeknowledgeofpr
escri
bed
anticoagul antdrugther
apyandpotent
ialsi
deeff
ectswhil
erecei
vi
ngoralant
icoagul
ant
therapy .

NursingInterventi
on:-
Assesst hepat i
ent’sl
ev elofcompr ehensionandlanguage.
Rati
onal:
Thiswillensurethatt heinfor
mat i
ongivenisatalevelofcomprehensi
onthati
stai
l
ored
tothepat i
entandt heirhealtheducat i
on.
NursingInterventi
on:-
Determinet hepatient’sknowl edgeofmedi cat
ionregime
Rati
onal:
Pati
entswhoar emor eknowl edgeableandeducat edontheirmedi
cati
onsaremore
l
ikelytocont i
nuetot aket hei
rmedi cati
onsaspr escri
bed.
-Nur
singInt
erventi
on
Expl
ainindetai
ltheimpor
tanceofkeepi
ngr
egul
arphy
sici
anandr
out
inel
abor
ator
y
appoi
ntments.

PageXI
Iof12
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Rat
ional:
Thepatientwil
lneedt
obemoni t
oredcl
osel
ybyphysici
anwhowi
l
lneedt
oadj
ust
ant
icoagulant
sasneededdependingonl
aborat
oryr
esult
s.

PageXI
IIof13
-Test
s
Anumberoftestsmaybeusedtohel
pdeterminei
fyouhaveapulmonaryembol
i
sm or
torul
eoutot
hercausesofy
oursymptoms.
Forexampl
e,youmayhaveachestX-
rayortestst
ocheckhowwel ly
ourl
ungsar
e
worki
ng.
Youmayalsohavesomeofthemorespecial
izedt
est
sdiscussedbel
ow.
-
Bloodt
est
s
Bloodtestscanbecar ri
edoutt odetectanumberofsi gnsofpul monaryembol ism.
Oneoft hemai ntestsl
ooksforasubst ancecall
ed( D-
dimmer ).
D-dimmeri saproteinf
oundint hebloodaf terabloodclothasbr okendown.
AD- di
mmert estcanbeusedt ohelpdiagnosebl oodclott
ingabnor mali
tiessuch
ast hr
ombosis( whereabloodclotdev elopsinabl oodvessel).
I
fy ourbloodtestresul
tindi
cateshighlev el
sofD- dimmer,itsuggeststhatpiecesof
bl
oodcl otarelooseinyourbloodstream andmayhav ebecomel odgediny our
pulmonar yar
tery.

-Computer
izedtomogr aphypul monaryangiogr aphy:
Computeri
sedtomogr aphypul monar yangiography( CTPA)i saprocedurewhere
you'
rei
njectedwit
haspeci aldyebeforehav i
ngcomput er
ised.
Thedyemakesi teasiertoseet hebloodv esselsi nyourlungsduringthescan.
ACTscani nvol
vestakingaser i
esofX- r
ayst ocr eat
eahi ghlydet
ai l
edimageofthe
i
[Link]'sapul monaryembol ism inoneofy ourlungs,i
tmayshow
uponthescanasagapi ny ourbloodsupply.

-Ventilati
on-per
fusi
onscan:
Av entilati
onandper f
usionscani susedt oexami netheflowofairandbl
oodiny our
l
ungs.
Bef orehav i
ngthescan, you'
llbeaskedt oinhaleatastel
ess,odourl
essandsli
ghtly
radioact i
vegasthroughamout hpiece.
Thegashel pshighli
ghttheai rfl
owi nyourlungsduri
ngt hescan.
You' l
lalsobegi v
enani nject
ionthatcontainsasmal lamountofr adi
oact
ivematerial
to
highli
ghtt hebloodvesselsiny ourlungsduringthescan.
I
ft hescanshowspar tsofy ourlungshav eairinthem butnobloodsupply
,itmaybet he
resultofapul monaryembol ism .

-
Medi
cat
ions:
Bloodt hi
nners( ant
icoagul ants)
:
Thesedr ugspr eventnewcl otsfr
om formingwhi l
ey ourbodywor kst obreakupt he
[Link] requent l
yusedanticoagulantthatcanbegiv ent hroughthev einor
i
njectedundert heski n.
Itactsquicklyandi sof tenoverl
appedf orseveraldayswithanor al anti
coagulant,such
aswar fari
n,untili
tbecomesef f
ecti
ve,whichcant akedays.
Anewercl assofant icoagulantshasbeent estedandappr ovedf ortreatmentofv enous
thromboembol ism, includingpulmonaryembol ism.
Thesemedi cat
ionshav etheadv ant
ageofbei nggi v
enbymout h,wit houttheneedf or

PageXI
Vof14
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

ov
erl
apwithhepari
[Link]
so,theyworkquickl
yandhavefeweri
nter
act
ionswi
thot
her
medi
cat
ions.
Al
lbl
oodthinner
shavesideeffect
s,wi
thbleedi
ngbei
ngthemostcommon.

PageXVof15
Clotdissol
vers(t
hrombolyti
cs):
Whileclotsusuall
ydissol
veontheirown,t
herearemedicati
onsgiv
enthrought
hevein
thatcandissolv
ecl ot
squickl
[Link]
heseclot-
bust
ingdrugscancausesuddenand
severebleedi
ng,theyusuall
yarereser
vedforl
if
e-t
hreat
eningsit
uati
ons.

-
Sur
gical
andot
herpr
ocedur
es:
 Cl
otr
emov
al.I
fyouhav
eav
eryl
arge,
li
fe-
thr
eat
eni
ngcl
oti
nyourl
ung,
yourdoct
or
maysuggestr
emov
ingi
tvi
aat
hin,
flexi
blet
ube(
cat
het
er)t
hreadedt
hroughy
our
bl
oodv
essel
s.
 Vei
nfi
l
ter
.Acat
het
ercanal
sobeusedt
oposi
ti
onaf
il
teri
ntot
hebody
'smai
nvei
n—
cal
l
edt
hei
nfer
iorv
enacav
a—t
hatl
eadsf
rom y
ourl
egst
other
ightsi
deofy
our
hear
[Link]
sfi
l
tercanhel
pkeepcl
otsf
rom bei
ngcar
ri
edi
ntoy
ourl
[Link]
s
pr
ocedur
eist
ypi
cal
l
yreser
vedf
orpeopl
ewhocan'
ttakeant
icoagul
antdr
ugsor
whenant
icoagul
antdr
ugsdon'
twor
kwel
lenoughorf
[Link]
het
erwi
th
t
hef
il
teri
nthet
ipi
susual
l
yinser
tedi
nav
eini
nyourneck,
andt
heni
ntot
hev
ena
cav
[Link]
il
ter
scanber
emov
edwhent
heyar
enol
ongerneeded.

PageXVIof16
 [Link]

-Widespr
eadinflammat i
onofai rway swithnarrowi
ngorblockingofai
rways,i
ncr
eased
producti
onofmucoi dsput um,andmar kedcyanosis.
-Emphysema:
Mostsev er
ef or
m ofCOPD, characteri
zedbyr ecur
renti
nfl
ammat i
onthatdamagesand
eventual
lydestr
oysalveolarwallstocr eatel
argeblebsorbul
lae(ai
rspaces)and
coll
apsedbronchiol
esonexpi r
ation(air-
tr
apping).
-
DiagnosticStudies
 Chestx- ray:
 Pul monar yfuncti
ont est
s
 Ar ter
ialbloodgases( ABGs):
 Bl oodchemi stry
 DLCO
 Sput um culturepathogen.
 El ect
rocardiogram (ECG):
 ( Exer
ciseECG) ,str
esst est
:

-
Othersi
gnsandsy
mpt
omsofCOPDi
ncl
ude:
 Shortnessofbr eath,especial
lyduringphysical
acti
vi
ties
 Wheezi ng
 Chestt i
ghtness
 Hav i
ngt oclearyourthroatfir
stthinginthemor ni
ng,duetoexcessmucusi
ny our
l
ungs
 Achr oniccought hatproducessput um thatmaybecl ear
,whi
te,yel
l
oworgreenish
 Bluenessoft heli
psorf ingernailbeds(cyanosi
s)
 Frequentrespirat
or yi
nfecti
ons
 Lackofener gy
 Unintendedwei ghtloss(inlaterstages)

-
Nur
singPr
ior
iti
es
[Link]
nairwaypatency.
[Link]
hmeasurest ofaci
l
itat
egasexchange.
[Link]
ti
onalint
ake.
[Link]
cati
ons,sl
owpr ogressi
onofcondi
ti
on.
-
Dischar
geGoal s
[Link] i
l
ation/oxygenati
onadequatetomeetself-car
eneeds.
[Link] r
it
ional i
ntakemeet i
ngcal
ori
cneeds.
[Link]
ont r
eated/prevent
ed.
[Link] ocess/prognosi
sandtherapeuti
cregimenunder
stood.
[Link] acetomeetneedsaf t
erdischarge.

PageXVI
Iof17
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageXVI
IIof18
-
Nur
singDi
agnosi
s:

1.I
nef
fect
iveAi
rwayCl
ear
ance

-
Mayberelatedto:
 Br onchospasm
 Increasedpr oducti
onofsecreti
ons;
ret
ainedsecr
eti
ons;
thi
ck,
viscous
secr et
ions
 Al l
ergi
cai rways
 Hy perplasiaofbronchi
alwall
s
Decr easedenergy/
fat
igue

Nur singI nterv

entions: -
-Auscul [Link] eadventit
iousbr eat
hsounds( wheezes,crackles,
rhonchi ).
-Assessandmoni torrespirat
ionsandbreathsounds, not
ingrateandsounds
(tachy pnea, st
ridor,cr
ackles,wheezes).Not einspir
atoryandexpi r
atoryratio.
-Not epresenceanddegr eeofdy spneaasf orreportsof“airhunger,”r
estlessness,
anxiet y,respir
atorydistress,useofaccessor ymuscles.Use0–10scal eorAmer i
can
Thor acicSoci ety’
s“ GradeofBr eat
hlessnessScal e”torat
ebr eathi
ngdi f
ficult
y.
-Ascer t
ai nprecipitatingf actor swhenpossi [Link]
er enti
ateacuteepisodefrom
exacer bat i
onofchr oni cdy spnea.
-Assistpat ienttoassumeposi ti
onofcomf ort(elev
at eheadofbed, havepat i
entl
eanon
overbedt ableorsi tonedgeofbed) .
-Keepenv i
ronment al pollutiontoami nimum suchasdust ,smoke,andfeatherpi
llows,
accor dingt oindividual si
tuat i
on.
-Encour ageabdomi nal orpur sed-l
i
pbr eathingexer cises.
-Obser v echar acteristicsofcough( persistent,hacking, moist
).Assi
stwithmeasur esto
i
mpr ov eef fectiv
enessofcoughef fort.
-Increasef l
uidintaket o3000mLperdaywi thincar diactol
[Link]
dewar m or
[Link] ntakeoff l
uidsbet ween, i
nsteadofdur i
ng,meals.

[Link]
edGasExchange
-Mayber elatedt o:
 Alteredoxy gensuppl y(
obstruct
ionofai
rwaysbysecr
eti
ons,
bronchospasm;
air
-
t
rapping)
 Alv eolidestructi
on
 Alv eolar-capil
lar
ymembr anechanges
-Possi
blyev idencedby:
 Dy spnea
 Ab nor mal breathing
 Co nfusi on,restl
essness
 Inabi l
i
tyt omov esecret
ions
 Ab nor mal ABGv alues(
hypoxiaandhyper
capni
a)

PageXI
Xof19
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Changesi
nv i
tal
signs
 Reducedt
oler
ancef oract
ivi
ty

PageXXof20
-
Nur
singI
nter
vent
ions:
-
Assessandr
ecor
drespi
rat
oryr
ate,
dept
[Link]
euseofaccessor
ymuscl
es,
pur
sed-
li
p.

br
eat
hing,
inabi
l
ityt
ospeakorconv
erse.

-El
evat
eheadofbed,assi
stpati
entt
oassumeposi
ti
ont
oeasewor
kofbr
eat
hing.I
ncl
ude
peri
odsoft
imeinproneposit
ionastol
erat
ed.

-
Encour
agedeep-
sloworpur
sed-
li
pbr
eat
hingasi
ndi
vi
dual
l
yneededort
oler
ated.

-
Assessandr
out
inel
ymoni
torski
nandmucousmembr
anecol
or.

-
Encour
ageexpect
orat
ionofsput
um;
suct
ionwheni
ndi
cat
ed.

-
Auscul
tat
ebr
eat
hsounds,
not
ingar
easofdecr
easedai
rf
lowandadv
ent
it
ioussounds.

Pal
pat
eforf
remi
tus.

-
Moni
torl
evel
ofconsci
ousnessandment
alst
atus.I
nvest
igat
echanges.

-Ev
aluatelev
elofacti
vi
tytol
[Link]
ovidecal
m,qui
etenvi
[Link]
mitpat
ient’
sacti
vi
tyor
encouragebedorchairr
estduringacut
[Link]
entresumeacti
vi
tygradual
l
yand
i
ncreaseasindiv
idual
lytol
erat
ed.

-
Eval
uat
esl
eeppat
ter
ns,
not
erepor
tsofdi
ff
icul
ti
esandwhet
herpat
ientf
eel
swel
lrest
ed.

-Provi
dequietenv
ironment
,gr
oupcareormonitor
ingact
ivi
ti
estoal
l
owper
iodsofuni
nter
rupt
ed
sleep;l
imi
tstimul
antssuchascaf
fei
ne;encour
ageposit
ionofcomf
ort
.

-
Moni
torv
ital
signsandcar
diacr
hyt
hm.

3.I
mbal
ancedNut
ri
ti
on:
LessThanBodyRequi
rement
s

-
Mayberel
atedto:
 Dyspnea;sputum producti
on
 Me di
cati
onsideeffects;anor
exi
a,nausea/
vomi
ti
ng
 Fati
gue

-
Possi
blyev
idencedby:
 We ightl
oss;l
ossofmuscl
emass,poormuscl
etone
 Re port
edalt
eredt
ast
esensat
ion;
aversi
ont
oeating,
lackofi
nter
esti
nfood

-
Desi
redOut comes:
 Di splayprogressi
veweightgai
ntowardgoalasappr
opr
iate.
 De monst r
atebehavi
ors/l
i
festy
lechangest
oregai
nand/ormaint
ain
appr opr
iateweight
.

PageXXIof21
-NursingInt erv entions:
-Ascertainunder st andi ngofindivi
dual nutri
ti
onalneeds.
-Assessdi et aryhabi t
s, [Link] edegr eeofdi ff
icul
tywitheat
[Link]
uate
weightandbodysi ze( mass) .
-Auscultationbowel sounds.
-Givefrequentor alcar e,remov eexpect or
atedsecr etionspr omptl
y,provi
despecif
ic
containerf ordi sposal ofsecr et
ionsandt issues.
-Encouragear estper iodof1hrbef or
eandaf termeal [Link]
defrequentsmallf
eedings.
-Avoidgas- pr oduci ngf oodsandcar bonatedbev erages.
-Avoidv eryhotorv erycoldf oods.
-Weighasi ndi cated.
-Administersuppl ement aloxygenduringmeal sasi ndicated.

[Link]
skf
orI
nfect
ion
-
Riskf
act
orsmayi ncl
ude
 Inadequateprimar
ydef ences(decreasedci
l
iar
yacti
on,st
asi
sofsecret
ions)
 Inadequateacquir
edimmuni ty(ti
ssuedestr
uct
ion,
incr
easedenv
ironmental
exposure)
 Ch r
onicdiseaseprocess
 Ma lnut
ri
tion

-
Desi
redOut
comes:
-Demonstr
atei
mpr ovedvent
il
ati
onandadequateoxygenationofti
ssuesbyABGswi
thi
n
pati
ent
’snormalrangeandbefreeofsymptomsofrespirator
ydist
ress.
-Par
ti
cipat
eintr
eatmentregi
menwi t
hinl
evelofabi
li
ty/si
tuati
on.

PageXXI
Iof22
 [Link]
a

-
Def
ini
ti
onofPneumoni
a:
Inf
lammati
onofoneorbot
hlungs,
aff
ect
ingpr
imar
il
ythemi
croscopi
cai
rsacsknown
asa l
veol
i
-pathophy si
ologyofpneumoni a:
Thest reptococcireacht heal veol
i andleadtoinfl
ammat i
onandpour i
ngofanexudat esintothe
airspaces.
WBCsmi gratestoalveoli,thealveolibecomemor ethickduet oitsfi
ll
i
ngconsol i
dati
on,involved
areasbyi nflammat ionarenotadequat el
yventi
lated,duetosecr eti
[Link] swil
llead
topar t
ialocclusi
onofal v eoliandbr onchicausingadecr easeinal v
eolaroxygencontent.
Venousbl oodthatgoest oaf f
ectedar easwithoutbeingoxy genatedandr et
urnstothehear t.
Thiswi ll
leadt oarteri
alhy poxemi aandev endeat hduet ointer
ferencewithventi
lat
ion.

-Cause:
[Link].
[Link] a.
3. Fungal pneumonia.
4. Parasiti
cpneumoni a.
5. I
diopathicinter
sti
ti
alpneumoni
a.

-
signsandsy mpt
omsofpneumoni a:
 F ever
.
 Pr oducti
veCough.
 Ch estpai
nwheny oubreat
heorcough.
 Sh ort
nessofbreat
h.
 F at
igue.
 Na usea,vomi
ti
ngordiarr
hea.

-
Diagnost ict est:
 Hi stor ytaking
 Ph ysical examinat
ion
 Ch estx- ray
 Bl oodt est
 Sp utum cul tur
e

-
Nur
singdi
agnosi
s:
 Hyperther
mia
 I
neffecti
vebreathi
ngpat
ter
n
 Acti
vit
yintol
erance
 Chestpain
 I
mpair
edGasExchange
 I
nef
fect
iveAi
rwayCl
earance

PageXXI
IIof23
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

1-
Nursingdiagnosi s:
Hypert
hermia
Nursi
ngInterventi
onandr ationale:
1-
giveptantipyeti
casdoct ororder
Rati
onal:
todecr easebodyt emper ature.
2-
applycoldcompr essesonf orehead, arms, legs….
..
Rati
onal:
todecr easebodyt emper ature.
3-
bathethebodyi nbathunderr unningwat er.
Rati
onal:
todecr easebodyt emper ature.
4-
monitorbodyt emper atureev ery1/ 2hr.
Rati
onal:
toev aluativ
eef f
ectivenesst ot r
eatment.
5-
educati
teabutdanger ousnessofhi ghf ever.
Rati
onal:
tokeepwor ki
ngondecr easet emper ature.

2-Nursingdi agnosi s:
Ineffecti
v ebr eat hingpat tern
NursingInt ervent ionsandr ational:
1-Admi ni
st erhumi difi
edoxy genv i
af acemaskatpr escribedr at [Link]
albl
ood
gases( ABGs)asor dered.
Rational:Suppl ement al,humi difi
edoxy genai dsi nimpr ov ev ent i
lati
onwi t
houtdr yi
ngthe
[Link] ov i
deobj ect i
veev i
denceoft hepat i
ent’stissueoxy genat i
on.
2-Assessv i
tal si
gnsandr espi r
ator ystatus, i
ncludingl ungsounds.
Rational:Fr equentassessmentofv i
talsignsandr espiratoryst atusprovides
i
nfor mationaboutanyi mpr ovementordet eri
orationint hepat ient’sconditi
on
3-Admi ni
st erant ibioti
ct her apy ,(
ampi cil
li
n)asor dered.
Rational:ant i
biot i
ct herapyi sef f
ect iveagai nstpneumococcus.
4-Placethepat ienti nasemi -Fowl erist ohighFowl er’sposi ti
[Link] t
iont hepati
ent
fr
equent l
y .
Rational:Anupr i
ghtposi tionf acil
itatesbr eathingandpr omot esopt i
mal l
ungexpansi on,
Frequentr eposi t
ioningpr ev ent spool ingandst asisofsecr etions.
5-Encour aget hepat i
entt ocough, deepbr eathe.
Rational:Coughi ng,deepbr eathinghel pt omaxi mizev entilation.
6-Assistt hepat i
entwi thmeasur est or el
ax.
Rational:Anxi et yandst ressi ncr easet hepat i
entoxy gendemands.

3-Nursi
ngdiagnosi s:
Impai r
edGasExchange
-Nursi
ngInterventi
ons:
[Link]
or yrate,depth,
andease.
[Link] n,mucousmembr anes,
andnai
lbeds,
notingpr
esenceof
peri
pheralcyanosis( nailbeds)orcent
ralcy
anosi
s(ci
rcumoral
).
[Link] alstatus.
[Link] t
orheartrateandr hyt
hm.

PageXXI
Vof24
 [Link]
eur
alef
fusi
on
-Pleural ef
fusioni sanaccumul ati
onoff luidinthepl eural space.
Thepl eur aisat hinmembr anet hatli
nest hesur f
aceoft hel ungsandt heinsi deofthe
chestwal loutsidet [Link] f
usions,fl
uidaccumul atesint hespace
bet weent hel ayer sofpl [Link],onlyteaspoonsofwat eryf l
uidarepr esentinthe
pleural space, allowi ngthelungst omov esmoot hlywi thinthechestcav i
tydur ing
breathing.
Pleural fl
uidnor mal lyseepscont i
nuall
yi ntothepleur alspacef rom thecapi llari
es
l
iningt hepar ietal pleuraandi sreabsorbedbyt heviscer alpleural capil
l
ariesand
l
y mphat i
csy [Link] ti
ont hati
nt erf
ereswi t
hei thersecr et i
onordr ainageoft his
fl
uidleadst opl eur al ef
fusi
on.

-
TypesBypat
hophy
siol
ogy
:

-
Transudati
vepl euraleff
usion:
-
Incr
easedsy stemi chydrostaticpressure(e.g.,
heartfail
ure)
-
Reducedcapi ll
aryoncoticpr essure( e.
g.,
li
verorrenal f
ail
ure)
-
Exudativepleuraleff
usion:
-
Incr
easedcapi ll
aryPermeabi l
it
y :
infect
ion([Link]
ialpneumoni
aort
rauma)
-
Impairedlymphat i
cfunction( e.g.,
lymphaticobstructi
oncausedbytumour
,
Mal i
gnancy, I
nfecti
on) .
-si
gnandsy mptom:
-Short
nessofbr eath
-crackles -Useofaccessorymuscles
-Chestpain,especial
lyonbr eathi
ngindeepl
y -Fever -
Cough - Cyanosi
s
-Generali
zedweakness
Becausepl euralef
fusionsar eusual
l
ycausedbyunderlyi
ngmedical
condi
ti
ons,
sympt omsoft hesecondi t
ionsarealsooft
enpresent
.

-Diagnosi sofPl eural Effusions:

Apl eural effusioni susual l
ydi agnosedont hebasisofmedi calhi stor
yandphy sical
exam, andconf irmedbyachestX- ray.
-Onphy si cal exam wecanf ound, decreasedmov ementoft hechestont heaf f
ect ed
side,dullnesst oper cussi onov erthefluid,diminishedbreathsoundsont heaffect ed
side,
-chestX- ray: thef ir
stst epini dent i
fyi
ngapl eur
al eff
usion,appearonchestX- ray sas
whi t
espaceatt hebaseoft hel ung
-Comput edt omogr aphy( CTscan) :ACTscant akesmul t
ipl
eX- raysrapi
dly,
anda
comput erconst ructsi magesoft heinsideoft hechest .Compar edt ochestX-r
ay s, CT
scanspr oducemor edet ail
edi nformat i
onaboutpl euralef
fusionsandot herlung
abnor mal it
ies
-Ultr
asound: .canhel pgui dedr ainageandi dentif
ywhet herpleural eff
usi
onsaref ree-
flowingOnceapl euraleffusioni sidentifiedoni maging,af l
uidsampl eisusuallytaken

PageXXVof25
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

todetermi
net hepleur
al ef
fusion'
schar
acterandser
iousness.I
naprocedure
call
edthor
acentesi
s,adoctorinsert
saneedleandacatheterbet
weentheribs,
int
othe
pleur
[Link] lamountoff l
uidi
swi t
hdrawnf
ortesti
ng;alar
geamountcanbe
removedsimul t
aneouslytoreli
evesymptoms.

PageXXVIof26
-Treat
ment :
Treatmentdependsont heunderlyi
ngcauseoft hepleur
aleffusi
[Link] eifacause
pneumoni awecanadmi nist
erantibi
oti
c,anddiuret
icsforheartfai
l
ure..
Somet i
mesr equi
redr
ainaget oimprovesy mpt
omsandpr eventcomplicat
ions.
proceduresmaybeused: Thoracent
esis,Tubethor
acotomy( chesttube),Pleur
aldrai
n

-
Nur
singdi
agnosi
s:
1-I
neff
ecti
veBreathingPattern:
rel
atedto:DecreasedLungVol umeCapaci t
y
-Possi
blyevi
dencedby :Dyspnoea,changesindept
hofbr
eat
hing,
accessor
ymuscl
euse
impaireddevel
opmentoft hechest,
cyanosi
s.
-Goal:
toimprovebreathingpatt
ern.
-Desiredoutcomes:
Patientwil
ldemonstrat
eappr
opriat
ecopi
ngbehavi
our
sandmet
hodstoimprove
breathingpatter
n.
Patientwouldbeabletoappl
ytechni
quest
hatwoul
dimprov
ebr
eat
hingpat
tern.
Nursingi ntervent i
on:
1.
Moni torandr ecordvitalsigns,t obaseli
nedat a.
2.
Assessbr eathsounds, respir
ator yr
ate,depthandr hythm.
3.
Elev ateheadoft hepat i
enttopr omot elungexpansi on.
4.
Encour agepat i
enttoper form deepbr eathingexercises.
5.
Prov ider elaxingenv i
ronment .
6.
Admi nistersuppl ement aloxy genasor dered.
7.
Admi nisterpr escri
bedmedi cationsasor dered.
8.
Maxi mizer espirator
yef fortwi t
hgoodpost ureandef fecti
veusei
faccessor
ymuscl
es.
[Link] epareptforthoracentesi
sandexpl ai
nprocedure.

2-
Acut
ePai n:
-Maymani f
est:
 Co mpl ainstochestpai
nonthet
hor
acost
omysi
te.
 Faci algr i
macesuponmovement
.
 Repor tsofpain.
 Rest lessness.
 Co nf usion.
 Ir
ri
t abilit
y.
-Desiredout comes:
-Pati
entwi llr
eportpainisdecr easedorcontroll
ed.
-Nursingi nterventi
on:
[Link] ientpainforintensit
yusingapai nrat
ingscale,f
orlocati
onandf or
precipitatingfactors.
[Link] idecomf ortmeasur es.
[Link] ablishaqui etenvir
onmentt oreducestheenergydemandsont hepat i
ent
.
[Link] ateheadofbed, Elevati
oni mproveschestexpansionandoxy genati
on.
[Link] torvit
al si
gns,especiall
ypulseandbloodpr essur
e, ev
ery5mi nutesunti
lpai
n
subsides.

PageXXVI
Iof27
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageXXVI
IIof28
3-Acti
vi
tyInt
oler
ance:
rel
atedtodyspnoeaandfat
igue.
-Goal:
cli
entsobtai
nener
gy.

-
Nur
singI
nter
vent
ion:

 Assesst heact i
vi
typat
ter
ns.
 Li
mi tacti
vity.
 Aidstoov ercomeweaknesses.
 Schedulebr eaks.
 Physiotherapyconsult
ati
on.

#Ot
herPossi
bleNur
singdi
agnosi
s-

-Impair
edGasExchange
-Act
ivi
tyInt
oler
ance-
-I
mpairedSkinInt
egr
it
yRTSurgi
calPr
ocedure[Thoracent
esi
s]
-Di
stur
bedBodyI mageRTI
nsert
ionofChestThoracostomyTube.

PageXXI
Xof29
 [Link]
hor
ax
[Link]:
 Pneumot horax,oracol l
apsedl ung, i
sthecol l
ecti
onofai ri nt hespacesar ound
[Link] rbuil
dupput spr essureont helung(s),soi tcannotexpandas
muchasi tnormally.
 Pneumot horaxistheaccumul ati
onofat mospher i
cairint hepl euralspace,whi
ch
resultsi
nar i
seini nt
rathoracicpr essureandreducedv ital capacity.
 Iti
st helossofnegat i
veintrapleuralpressureresult
sincol lapseoft helung.
 Aspont aneouspneumot horaxoccur swiththeruptureofabl eb.
 Anopenpneumot horaxoccur swhenanopeni ngthrought hechestwal lall
ows
theent r
anceofposi ti
veat mospher icpressureintothepl eur alspace.
 Diagnosisofpneumot horaxismadebychestx- rayfil
m

[Link]
gnsandsympt
oms:
 Absentbr
eathsoundsonaf
fect
edsi
de

 Cy
anosi
s

 Decr
easedchestexpansi
onuni
l
ater
all
y

 Dy
spnea

 Hy
pot
ensi
on

 Shar
pchestpai
n

 Subcut
aneousemphy
semaasev
idencedbycr
epi
tusonpal
pat
ion

 Sucki
ngsoundwi
thopenchestwound

 Tachy
car
dia

 Tachy
pnea

 Tr
acheal
dev
iat
iont
otheunaf
fect
edsi
dewi
tht
ensi
onpneumot
hor
ax

[Link]:
 Thecauseofacl osedorprimaryspont aneouspneumot hor
axistheruptureofa
bleb(vesi
cle)onthesurfaceofthev i
sceralpleura.
 Secondar yspont
aneouspneumot hor
axcanr esul
tfrom chroni
cobstructiv
e
pulmonarydisease(COPD) ,whi
chisr el
atedt ohyperi
nflat
ionorairt
rapping,orfrom
theeff
ectsofcancer ,whi
chcanr esulti
ntheweakeni ngofl ungti
ssueorer osion
intot
hepleur al
spacebyt hetumor.

 Bl
untchestt
raumaandpenetr
atingchestt
raumaar
ethepr
imar
ycausesof
tr
aumati
candtensi
onpneumothorax.

 Otherpossibl
ecausesincl
udet
her
apeut
icpr
ocedur
essuchast
hor
acot
omy
,
thor
acentesi
s,andi
nsert
ionofacent
ral
li
ne.

PageXXXof30
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Compl
i
cat
ion:
anot
hercol
l
apsedl
ungi
nthef
utur
e,shock.

[Link]:
Intr
athoracicpressurechangesi nducedbyi ncreasedpleur
alspacevol
umesand
reducedl ungcapacity,
causingrespiratorydist
ressandgasexchangeprobl
ems
andpr oducingtensiononmedi asti
nal struct
uresthatcanimpedecardi
acand
systemi ccir
cul
ation
Compl icati
onsincludehypoxemia, r
espi r
atoryfai
lur
e,andcardi
acarr
est

PageXXXIof31
[Link]
assi
ficat
ions:
• Primaryspontaneouspneumothor
ax
• Secondaryspontaneouspneumothor
ax
• I
atrogenicpneumothorax
• Traumaticpneumot hor
ax

[Link]
iol
ogy:
Pri
mar yspontaneous:
rupt
ureofpleur
alblebsty
pical
l
yoccursi
nyoungpeopl
e
withoutpar
enchy mall
ungdiseaseoroccursi
ntheabsenceoft
raumat
ici
njur
yto
thechestorlungs

Secondar yspont aneous:occursi nthepr esenceofl ungdisease, pri

mar i
ly
emphy sema, butcanalsooccurwi tht uber culosi
s( TB),sarcoidosis,cysti
cf i
brosi
s,
malignancy ,andpul monaryf i
brosis.
Iat
rogenic: complicati
onofmedi cal orsur gicalprocedures, suchast herapeuti
c
thoracentesis,tr
acheostomy ,pleural biopsy ,centralvenouscat heterinsert
ion,
positi
vepr essuremechani calventilation,inadv er
tentintubat i
onofr i
ghtmai nstem
bronchus
Traumat i
c: mostcommonf orm ofpneumot horaxandhemot horax,causedbyopen
orclosedchestt r
aumar elatedtobl untorpenet r
at i
nginjur
ies.

[Link]
agnost
icSt
udi
es:
• Thor acicCT:St udiesshowt hatCTi smor esensi t
ivethanx-
rayindet ecti
ng
thoracicinjuri
es, l
ungcontusi on,hemot horax,andpneumot [Link] l
yCTmay
i
nfluencet herapeut i
cmanagement .
• Chestx- ray:Revealsairand/ orflui
daccumul ati
oni nthepl
euralspace; mayshow
shiftofmedi astinalstr
uctures( heart).
• ABGs: Vari
abledependi ngondegr eeofcompr omi sedlungfunction,al
ter
ed
breathingmechani cs,andabi l
itytocompensat e.Paco2occasionallyel
evated.
Pao2maybenor mal ordecreased; oxygensat urati
onusuall
ydecr eased.
• Thor acentesis:Presenceofbl ood/ serosanguineousfluidi
ndicateshemot horax.
• Hb: Maybedecr eased,i
ndicat i
ngbl oodloss.

[Link]
singPriorit
ies:
• Promot e/maintainlungre-
expansionforadequat
eoxygenat
ion/
vent
il
ati
on.
• Mini
mi ze/preventcompl i
cati
ons.
• Reducedi scomf ort
/pain.
• Provi
dei nformationaboutdiseaseprocess,t
reat
mentregi
men,andprognosi
s.

[Link]
agnosti
cEv al
uati
on:
• Chestx-r
ayrevealslungcoll
apsewithairbet
weenchestwallandvi
scer
alpl
eura.
• Lungsarenotf i
l
ledwi t
hairbutr
atherarecol
lapsed.
• OtherTests:Completebloodcount,
plasmaalcoholl
evel
,ar
teri
albl
oodgases,
rib

PageXXXI
Iof32
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

x-
ray
s,comput
edt
omogr
aphy(
CT)scan.

PageXXXI
IIof33
[Link]:
• Thepr iorityistomai ntainai rway,breat hing, andci [Link] mportant
interv ent ionsf ocusonr einflati
ngt hel ungbyev acuat i
ngt [Link]
ents
wi thapr i
mar yspont aneouspneumot hor axt hatissmal lwithmi nimal symptoms
mayhav espont aneousseal i
ngandl ungr e-expansi on.
• Forpat ientswi thjeopar dizedgasexchange, chestt ubeinser ti
onmaybe
necessar yt oachi evel ungr e-expansi on.
• Mai nt ainacl osedchestdr ainagesy stem; besur et ot apeal lconnections,and
secur et het ubecar efull
yatt hei nsertionsi tewi thadhesi [Link] ate
suct ionaccor dingt othechestt ubesy stem di rections; gener al
ly,suctiondoes
notexceed20t o25cm H2Onegat ivepr essur e.
• Moni torachestt ubeuni tforanyki nksorbubbl i
ng, whi chcoul dindicat eanair
leak, butdonotcl ampachestt ubewi thoutaphy sician’sorderbecausecl ampi ng
mayl eadt otensionpneumot horax.
• St abilizet hechestt ubesot hati tdoesnotdr agorpul lagainstthepat ientor
agai nstt hedr ainagesy [Link] ntainasept ictechni que, changingt hechest
tubei nser tionsi t
edr essingandmoni toringt hesi tef orsignsandsy mpt omsof
infect ionsuchasr edness, swel l
ing, war mt h,anddr ainage.

• Oxygenther apyandmechani calventil

ati
onareprescri
[Link] gi
cal
i
ntervent
ionsi ncl
uder emovingt hepenetrat
ingobject,
expl
orator
yt horacotomyif
necessary,thoracentesi
s,andt horacotomyforpatient
swit
ht woormor e
epi
sodesofspont aneouspneumot hor
axorpati
entswi t
hpneumot horaxthat
doesnotr esolvewithin1week.

[Link]
thHi
stor
y:
Under
lyi
ngpul
monar
ydi
seases
*objeci
vedata:Physicalf
indings:Br
eathsounds,vi
tal
signs,l
evel
ofconsciousness,
uri
naryoutput
,skintemperature,amountandcol
orofchesttubedrai
nage,dyspnea,
cyanosi
s,nasalf
lari
ng,al
teredchestexpansi
on,tr
achealdevi
ati
on,absenceofbreath
sounds.

[Link]
s:
1.I
neffecti
veBreathi
ngPat
ter
n:
-Mayber el
atedto:
•Decr
easedl ungexpansi
on(ai
r/
flui
daccumul
ati
on)
•Musculoskelet
ali
mpairment
•Pai
n/anxiety
•I
nfl
ammat or
yprocess

-
Possi
blyev
idencedby:
•Dyspnea,tachy
pnea
•Changesindepth/equal
ityofr
espi
rati
ons;
alt
eredchestexcur
sion
•Useofaccessorymuscl es,
nasalf
lar
ing
•Cyanosis,
abnormal ABGs

-
Desi
redOutcomes:
•Establ
i
shanormal/
eff
ect
iver
espi
rat
orypat
ter
nwi
thABGswi
thi
npat
ient
’snor
mal

PageXXXI
Vof34
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

range.
•Bef reeofcy anosi sandot hersi gns/ sy mpt omsofhy poxia.
•Nur singI nt erv ent ions: Determi neet iologyandpr ecipi t
atingf actors(spontaneous
col l
apse, t
r auma,mal ignancy ,infection, compl icat i
onofmechani calventi
lati
on)
•Rat i
onal e: Under standi ngthecauseofl ungcol lapsei snecessar yforproperchest
tubepl acementandchoi ceofot hert herapeut i
cmeasur es
• Nur si
ngI nt erv ent ions: Checkoutr espi ratoryfunct i
on, notingr apidorshal l
ow
respi r
at i
ons, dy spnea, reportsof“ airhunger ,
”dev elopmentofcy anosis,changesi n
vitalsigns
•Rat i
onal e: Respi rat orydistressandchangesi nv italsignsmayoccurasar esultof
phy siologi cal st ressandpai normayi ndicatedev elopmentofshockduet ohy poxi
a
orhemor rhage
•Nur singI nt erv ent ions: Obser vef orsy nchr onousr espi r
atorypat t
ernwhenusi ng
mechani cal v ent i
lat [Link] echangesi nai rwaypr essures
•Rat i
onal e: Dif ficultybr eathing“ with”v ent i
latorandi ncreasi ngairwaypr essures
suggest swor seni ngofcondi ti
onordev elopmentofcompl icati
ons( spontaneous
ruptur eofabl ebcr eat i
nganewpneumo- thorax)
•Nur singI nt erv ent ions: Maintainposi tionofcomf ort,usual l
ywi thheadofbed
elevat [Link] nt oaf [Link] agepat ientt osi tupasmuchaspossi ble
•Rat i
onal e: Pr omot esmaxi mal inspirat i
on; enhancesl ungexpansi onandv enti
lat
ion
inunaf fectedsi de.

2.
Riskf
orTr
auma/
Suf
focat
ion:

-
Riskf
act
orsmayi
ncl
ude:

-
Concurr
entdisease/injur
ypr ocess
-
Dependenceonext ernaldev i
ce( chestdr ainagesyst
em)
-
Lackofsafet
yeducat i
on/precaut i
ons
-
Desi
redOutcomes
-
Recogni
zeneedf or/seekassi stancet opr eventcompli
cat
ions.
-
Corr
ect/av
oidenv i
ronment al andphy sical hazar
ds

•Nursi
ngInterventi
ons: Advisepat ienttoavoidlyi
ngandpulli
ngont ubi ng
•Rati
onale:Reducesr iskofobst r
uct i
ngdrai
nageandi nadvertent
lydisconnecti
ng
tubi
ng
•Nursi
ngInterventi
ons: Obser v
ef orsignsofr espi
rat
orydist
ressifthoraciccathet
er
i
sdisconnectedordi slodged
•Rati
onale:Pneumot hor axmayr ecurorwor sen,compromisingrespirator
yfuncti
on
andrequir
ingemer gencyi ntervention
•Nursi
ngInterventi
ons: Padbandi ngsiteswithgauzeortape
•Rati
onale:Protectsskinf r
om irritati
onandpr essur
e.

PageXXXVof35
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageXXXVIof36
 [Link]
hma
-Defi
nit
ion:
Asthmai sacondit
ioninwhichyourai
rwaysnarrowandswel
landpr
oduceextr
amucus.
Thiscanmakebr eathi
ngdif
ficul
tandtr
iggercoughi
ng,
wheezi
ngandshor
tnessof
breat
h
-PATHOPHYSI OLOGY:
Ast hmai sadi seasechar acteri
zedbychr onicinflammat i
on–i nfi
l
trati
onofl ymphocy tes
,eosinophi l
sandneut r
ophil
[Link] t
heli
al desquamat i
on( t
hickeningand
disorganizat i
onoft het i
ssuesoft heairwaywal l
s) ,
smoothmuscl ehy pertr
ophy, and
fi
broblastpr oli
f [Link] ructi
oncausedbyt hesechangesi susually
reversi
blespont aneously.
Theacut eorear lyresponseofast hmat ypi
callyoccurwi t
hin10- 20miofexposur eto
anal l
ergen. airbor neant i
genbindt omastcel l
scoat edwith(IgE)antibodiesli
ningthe
[Link] cal mediator
sar ereleasedandcausebr onchoconsr i
cti
on, mucosal
edemar elatedt oi ncreasedpermeabi li
tyofmucosalbl oodv essels, andincreased
mucussecr eti
ons, l
eadt odecreasei nthediamet eroft
heai r
way.
Ast hmai nvolvesacompl exinteracti
onofgenet i
candenv i
ronment [Link]
ized
type1hy per sensi ti
vityreacti
onappeart ohav eagenet i
ccomponentandpat i
entwith
asthmaof tenhav eot herall
ergi
ccondi ti
on, suchashayf ever, hi
vesandeczema.

-
Signsandsy mpt oms:
-
Suddendy spnea, wheezi
ng, t
ight
nessi
nthechest
Dimini
shedbr eathsound, coughi
ng
-
Thick,
clearory ell
owsputum
-
Rapidpulse,t
achy pnea,useofaccessor
ymuscle
-
CAUSE:
-
Airborneal l
ergens,suchaspol l
en,ani
mal dander,mol
d
-
Respiratoryinfecti
ons,suchast hecommoncol d
-
Airpollutantsandi r
ri
tants,suchassmoke
-
Cer t
ainmedi cations,i
ncludingbet
ablockers,aspi
ri
n,
-
Strongemot i
onsandst r
ess
-
PharmacologicTherapy:
Therear
et woclassesofmedicati
ons—long-act
ingcont
rol
andqui
ck-
rel
i
ef
medicat
ions—aswel lascombinat
ionproducts.
 Sh or
t-
acti
ngbet a2-
adr
energicagoni
sts

 Ant
ichol
i
ner
gics

 Cor
ti
cost
eroi
ds:
met
ered-
dosei
nhal
er(
MDI
)

 V/
N,DEXAMETAZONE

 Leukot
ri
enemodi
fier
sinhi
bit
ors/
ant
ileukot
ri
enes

-
NURSI
NGDI
AGNOSI
S:
1.I
nef
fect
iveAi
rwayCl
ear
ance:

PageXXXVI
Iof37
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

rel
atedto:
-
bronchoconstri
cti
on,
increasedmucusproducti
onandrespirator
yinf
ecti
on,
possibl
eevidenceby
-
diff
icul
tybreati
ng,dyspneacoughi
ng,tachypnea,
per
sistentinef
fect
ivecoughi
ng

-
Desir
edOutcome:
Thecl
ientwil
lmaintainclear
,openair
way sasev
idencedby
:
[Link] malbreathsounds
[Link] malrateanddept hofrespi
rat
ions
c.
absenceofdy spnea.
-
Int
erventi
ons:
Assessf orsignsandsy mptomsofinef fect
iveairwaycl ear
ance(e.
[Link]
breathsounds; r
apid,shal
lowrespi
rati
ons; dyspnea; cough).
Implementmeasur estopromoteeffectiveai
rwaycl earance:
perf
orm acti
onst odecreasepaini
fpr esent([Link]
/prot
ectpai
nfular
eaduri
ng
mov ement,administerpr
escr
ibedanal cs)i
gesi nor dertoincr
easethecli
ent'
s
wi
l
li
ngnesst
omove,
cough,
anddeepbr
eat
he
 Admi
nist
ermedi
cat
ionsandmobi
l
izat
ionasor
der
ed.

 Assi
stt
hepat
ienti
nexpel
l
ingmucus(
post
ural
drai
nage)
.

 Encouragethepat
ientt
ousedi
aphr
agmat
icbr
eat
hingandpr
act
icecoughi
ng
exer
cises.

 Ensur
eadequat
ehy
drat
ion.

 Teachpat
ientt
orecogni
zeear
lysi
gnsofi
nfect
iont
ober
epor
tedt
othei
rheal
th
car
eprovi
der.

 Teacht
hepati
entt
oavoi
drespi
ratoryi
rr
it
ant
sli
keaer
osol
s,ci
gar
ett
esmoke,
fumes,
andext
remesoft
emperature.

2.I
neffecti
v eBreat hingPat tern:
rel
atedto:
[Link] at eanddecr easeddept hofr espi
rati
onsassoci at
edwithfearand
anxiety;
[Link] easedr ateanddept hofr espi
rationsassoci atedwiththedepressantef
fect
ofsomemedi cations([Link]
c[ opioid]analgesics,someanti
emet i
cs);
[Link] nishedl ung/ chestwal lexpansionassoci atedwi th:
1.r eluct ancet obreathedeepl ybecauseofpai n
[Link] easedact i
vit
y
Possi
bleevi
denceby
Dyspnea,
coughi
ng,t
achy
pnea, t
achycardi
a, superast
ernalr
eact
ion
Desi
redoutcome
Pati
ntwil
ldemonstrat
epur
sed-
li
pbreat
inganddiaphragmaticbreathi
ng

PageXXXVI
IIof38
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Pat
ientwi
l
lmani
festsi
gnsofdecr
asedr
espi
rat
oryef
for
tAEBabsencedy
spnea
I
nterv
enti
ons
 Assesst hepat i
ent'
sr espirati
onwi t
hr egardstodept h, r
ate,andrhythm.
 Auscultatethepatient'sbr eat
hsoundsandassesshi sbr eat
hingpatter
n.
 El
ev atetheheadoft hebedandchanget hepatient
'sposi ti
oneverytwohour s.
 Encour agethepatienttol imitphysi
cal acti
v i
ti
esandt or est.
 Ensureadequat ehy dration.
 Encour agethepatienttododeepbr eathingandpr acticecoughingexercises.
 Mo nit
ort hepati
ent'sv i
talsigns.
 Reinforceadietthati slowi nsaltandl owi nfat.
 Teacht hepatienttododi aphragmat i
cbr eathi
ngandpur sed-l
ipbreathi
ng.
 Usepul seoximet r
y.

PageXXXI
Xof39
 [Link]
monar
yTuber
cul
osi
s(TB)
-
Tuberculosi
s:i
sanacut eorchronici
nfecti
oncausedbyMy cobacteri
um t
ubercul
osis.
TBischaracter
izedbypul monaryinfi
l
trat
es,for
mationofgranul
omaswi thcaseat
ion,
fi
brosi
s,andcav i
tat
[Link]
ivingincrowdedandpoorl
yv enti
lat
edcondit
ionsand
whoareimmunocompr omisedaremostl i
kelyt
obecomei nfect
ed.

-Sympt omsandCauses
-Sympt oms:
LatentTB: Inthi
scondi t
ion,youhav eaTBi nf
ecti
on,butthebacteri
aremaininyour
bodyi nani nacti
v estateandcausenosy mptoms.
ActiveTB: Thiscondi t
ionmakesy ousickandcanspr eadtoothers.I
tcanoccurint
he
fir
stfewweeksaf terinfect
ionwi t
ht heTBbacteri
a,oritmightoccuryear
slater
.
Signsandsy mpt omsofact iveTBinclude:
•Coughi ngthatlastst hreeormor eweeks.
•Coughi ngupbl ood.
•Chestpai n,orpainwi thbreathing.•wei
ghtloss.
•Fati
gue.
•FeverNight.•sweat sChill
s.
•Lossofappet i
te.

-Causes:
Tuber culosi
siscausedbybacteri
athatspr
eadfrom persontopersonthrough
mi croscopicdropl
etsrel
easedint
otheair
.Thi
scanhappenwhensomeonewi t
hthe
unt r
eated,acti
veform oft
ubercul
osi
scoughs,speaks,sneezes,
spits,
laughsor
sings.

-
Riskfactor
s:
-
Weakenedi mmunesy st
em.
-
Travel
ingorli
vingincertai
nar
eas.
-
Povertyandsubstanceabuse.
-
Lackofmedi calcare.
-
Substanceabuse.
-
Tobaccouse.

-Whereyouworkorliv
e:
1-Heal
thcar
ewor k.
2-Li
vi
ngorworkinginaresi
dent
ial
caref
aci
l
ity
.
3-Li
vi
nginaref
ugeecamporshel t
er.

-Complicati
ons:
1-Spi
nal pain.
2-Joi
ntdamage.
3-Swell
ingoft hemembranest
hatcov
ery
ourbr
ain(
meni
ngi
ti
s).
4-Li
verorkidneyprobl
ems.
5-Heartdisorder
s.

PageXLof40
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageXLIof41
-Diagnost icSt udies:
1-Sput um cul ture: Posi tivef orMy cobact erium t uber culosi si nt heact ivest ageoft he
disease.
2-Zi ehl -
Neel sen( aci d- fastst ainappl iedt oasmearofbodyf l
ui d):Posi ti
vef oraci d-
fast
baci lli(AFB) .
3-Ski nt est s( pur i
fiedpr oteinder i
v at i
v e[PPD]orOl dt uber cul in[ OT]admi ni ster edby
i
nt rader mal inject ion[ Mant oux ]):Aposi ti
v er eact i
on( areaofi ndur ati
on10mm or
great er,occur ring48–72hraf teri nt erder mal inject i
onoft heant i
gen)i ndi cat espast
i
nf ect ionandt hepr esenceofant ibodi esbuti snotnecessar ilyindicat i
veofact ive
[Link] orsassoci atedwi t
hadecr easedr esponset ot uber culinincludeunder lyi
ng
viral orbact erial infect ion, mal nutrition, lymphadenopat hy, ov erwhel mingTBi nfection,
i
nsuf ficientant igeni nject i
on, andconsci ousorunconsci ousbi [Link] gnificantr eaction
i
napat ientwhoi scl inicallyi llmeanst hatact iveTBcannotbedi smi ssedasa
diagnost icpossi bili
ty .Asi gni f
icantr eact ioni nheal t
hyper sonsusual l
ysi gni fies
dor mantTBorani nf ect ioncausedbyadi f
f erentmy cobact er ium.
4-Enzy me- l
inkedi mmunosor bentassay( ELI SA) /West ernbl ot :Mayr eveal pr esenceof
HIV.
5-Chestx- ray : Mayshowsmal l,pat chyi nfil
tr ationsofear lyl esi onsi nt heupper -l
ung
fi
el d, calcium deposi tsofheal edpr imar ylesi ons, orf luidofanef [Link]
i
ndi cat i
ngmor eadv ancedTBmayi ncludecav i
t ation, scart issue/ fibroti
car eas.
6-CTorMRIscan: Det ermi nesdegr eeofl ungdamageandmayconf i
r m adi fficult
diagnosi s.
7-Br onchoscopy :Showsi nflammat ionandal t
er edl ungt i
[Link] sobeper formed
toobt ainsput um i fpat ienti sunabl et opr oduceanadequat especi men.
8-Hi st ologicort issuecul tur es( i
ncl udi nggast ricwashi ngs; ur ineandcer ebr ospi nalflui
d
[CSF] ;ski nbi opsy ):Posi tivef orMy co¬bact er i
um t uber culosi sandmayi ndi cat e
ext rapul monar yinv olv ement .
9-Needl ebi opsyofl ungt issue: Posi tiv
ef orgr anul omasofTB; presenceofgi antcel l
s
i
ndi cat i
ngnecr osis.
10- Elect roly tes: Maybeabnor mal dependi ngont hel ocationandsev er i
tyofi nf ecti
on;
e.g., hy ponat remi acausedbyabnor mal wat err et entionmaybef oundi next ensi ve
chr oni cpul monar yTB.
11- ABGs: Maybeabnor mal dependi ngonl ocat ion, sev erity, andr esidual damaget ot he
l
ungs.
12- Pul monar yf unct i
onst udi es:Decr easedv it
al capaci ty,incr easeddeadspace,
i
ncr easedr atioofr esi dual ai rtot ot al l
ungcapaci ty,anddecr easedoxy gensat ur at
ion
aresecondar yt opar enchy mal i
nfiltration/ fibrosi s, l
ossofl ungt issue, andpl eur al
disease( ext ensi vechr oni cpul monar yTB) .
*Nur singDi agnosi s*
1-RiskforI
nfecti
on:
I
nf ect
ion,r
iskfor[
spread/
react
ivat
ion]
-Ri
skf act
orsmayi ncl
ude:

PageXLI
Iof42
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

I
nadequat epri
mar ydef
enses,decr
easedcil
iaryaction/stasi
sofsecr et
ionsTi
ssue
destruct
ion/
extensionofinf
ecti
onLoweredresist
ance/ suppressedinfl
ammat ory
processMalnutr
it
ionEnvi
ronmentalexposur
eInsuff
icientknowl edgetoavoidexposur
eto
pathogens.

PageXLI
IIof43
-Possibl
yevidencedby:
[Link]
skdi
agnosi
sisnotevi
dencedbysignsandsymptoms,asthe
problem hasnotoccurr
edandnursi
ngint
ervent
ionsaredi
rect
edatprev
enti
on.
-
Desir
edOut comes:
•
Ident
if
yinterventi
onstoprev
ent/r
educeri
skofspreadofinf
ect
ion.
•
Demonstratet echni
ques/
ini
ti
atel
if
esty
lechangestopromotesafeenv
ironment
.
-Nur singI nterventions:
1-Rev iewpat hologyofdi sease( act i
v eandi nact i
vephases; dissemi nati
onofi nfect ion
throughbr onchi t
oadj acentt i
ssuesorv i
abl oodst r
eam and/ orlymphat icsy stem)and
potent ialspr eadofi nf ect i
onv i
aairbor nedr opletdur i
ngcoughi ng, sneezi ng, spitti
ng,
tal
ki ng, l
aughi ng,si ngi ng.
-Rational e:Helpspat ientr eali
z eoracceptnecessi tyofadher ingtomedi cat i
onr egi men
topr ev entr eacti
v ationorcompl i
[Link] st andingofhowt hedi seasei spassed
andawar enessoft ransmi ssionpossi bili
tieshel ppat i
entandSOt akest epst opr event
i
nfect i
onofot hers.
2-Ident i
fyot hersatr iskl ikehousehol dmember s,cl
oseassoci atesandf ri
ends.
•Rational e:Thoseexposedmayr equir eacour seofdr ugtherapyt opr ev
entspr eador
dev elopmentofi nf ect i
on.
3-Inst ructpat ientt ocoughorsneezeandexpect orateintoti
ssueandt or efrainf rom
[Link] i
ewpr operdi sposal oft i
ssueandgoodhandwashi ngt echni ques.
Encour ager eturndemonst r
ation.
•Rational e:Behav ior snecessar ytopr ev entspr eadofi nfecti
on.
4-Rev iewnecessi t yofi nfect i
oncont rol measur [Link] empor aryrespi ratoryi solati
on
i
findi cated.
•Rational e: Mayhel ppat ientunder standneedf orprotecti
ngot herswhi leacknowl edging
patient ’
ssenseofi solat ionandsoci al stigmaassoci atedwi t
hcommuni cabledi seases.
AFBcanpasst hroughst andar dmasks; t
her ef
or e,parti
culat
er espiratorsar er equi red.
5-Moni tort emper atur easi ndicated.
•Rational e:Febr i
l
er eact ionsar eindicat orsofcont inuingpresenceofi nfect i
on.

2.I
neff
ect
iveAirwayCl
earance:
-Ai
rwayCl
earance,i
nef
fect
ive.
-Mayber el
atedto:
Thick,
viscous,orbl
oodysecr
eti
onsFat
igue,
poorcoughef
for
tTr
acheal
/phar
yngeal
edema
-Possibl
yev idencedby :
-Abnormal r
espiratoryr
ate,
rhyt
hm, dept
hAbnormalbreathsounds(
rhonchi
,wheezes)
,
stri
dorDy spnea.
-Desir
edOut comes:
-Maintainpat entairway.
-Expectoratesecr eti
onswit
houtassist
ance.
-Demonst r
atebehav ior
stoimprov
e/ maint
ainai
rwayclearance.

PageXLI
Vof44
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Parti
cipat
ei nt
reatmentregi
men,wit
hinthel
evelofabil
i
ty/
sit
uat
ion.
-
Ident
if
ypot ent
ialcompli
cati
onsandini
ti
ateappr
opriat
eacti
ons.
-NursingI nter vent i
on:
1-Assesr espirat oryfunct i
onnot ingbr eathsounds, rate,rhythm, anddept h,anduseof
accessor ymuscl es.
-Rationale:Dimi nishedbr eathsoundsmayr [Link] ,wheezesi ndicate
accumul ationofsecr etionsandi nabi li
tyt ocl earairway st hatmayl eadt ouseof
accessor ymuscl esandi ncreasedwor kofbr eathi
ng.
2-Not eabi l
it
yt oexpect oratemucusandcoughef f
ect i
vely ;
documentchar acter,
amountofsput um, presenceofhemopt ysis.
-Rationale:Expect orationmaybedi fficultwhensecr etionsar ev eryt hickasar esul tof
i
nf ecti
onand/ ori nadequat ehydr [Link] ood- t
ingedorf rankl ybloodysput um resul t
s
from tissuebr eakdown( cavit
ation)i nt hel ungsorf rom br onchial ulcerati
onandmay
requiref urtherev al
uat ionori ntervent ion.
3-Pl acepat i
enti nsemi orhigh-Fowl er ’
sposi ti
[Link] stpat ientwithcoughi nganddeep
-breathingex ercises.
-Rationale:Posi tioninghel psmaxi mi zel ungexpansi onanddecr easesr espir
atoryef for
t.
Maxi mal ventil
at ionmayopenat electat i
car easandpr omot emov ementofsecr etions
i
nt olargerai rway sforexpect orat i
on.
4-Cl earsecr etionsf r
om mout handt rachea; sucti
onasnecessar y.
-Rationale:Prev ent sobst ruct
ionandaspi [Link] i
oningmaybenecessar yifpat i
ent
i
sunabl et oexpect orat esecr eti
ons.
5-Mai ntainf luidi ntakeofatl east2500mL/ dayunlesscont r
aindicat ed.
-Rationale:Highf lui
di ntakehel pst hi nsecr etions,maki ngt hem easi ert oexpect orate.

3.
Impai
redGasExchange:
ri
skf
orimpai
redGasExchange.

-
Riskfactorsmayinclude:
•
Decreaseineffect
ivelungsurface,
atel
ectasi
s.
•
Destructi
onofalveol
ar -
capil
l
arymembr ane.
•
Thick,vi
scoussecretions.
•
Bronchialedema.
-Possibl
yevidencedby:
[Link]
skdi
agnosi
sisnotevi
dencedbysignsandsymptoms,asthe
problem hasnotoccurr
edandnursi
ngint
ervent
ionsaredi
rect
edatprev
enti
on.
-Desi
redOut comes:
•Reportabsenceof/decr
easeddy spnea.
•Demonst r
ateimprovedventi
lati
onand
adequateoxy genat
ionofti
ssuesbyABGswi t
hinaccept
abl
eranges.
•Befreeofsy mptomsofrespirat
orydist
ress.

PageXLVof45
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-Nur singI ntervent ions:

1-Assessf ordy spnea( usi ng0–10scal e),t
achy pnea, abnor mal ordi mi nishedbr eath
sounds, increasedr espirator yeffort,l
imitedchestwal lexpansi on, andf ati
gue.
•Rat i
onal e:Pul monar yTBcancauseawi der angeofef f
ect sinthel ungs, rangingfrom a
smal lpat chofbr onchopneumoni at odiffusei ntensei nflammat ion, caseousnecr osi
s,
pleur al effusi on,andext ensi v
ef i
[Link] r
at oryeffect scanr angef rom mi ld
dy spneat opr ofoundr espi [Link] et oev aluatedy spneahel ps
clarifydegr eeofdi ffi
cultyandchangesi ncondi ti
on.
2-Ev al uat echangei nlev el ofment ati
[Link] ecy anosi sand/ orchangei nski ncolor,
i
ncl udingmucousmembr anesandnai lbeds.
•Rat i
onal e:Accumul ati
onofsecr eti
onsand/ orai rwaycompr omi secani mpai r
oxy genat ionofv ital or
gansandt issues.
3-Demonst rateandencour agepur sed-li
pbr eat hingdur i
ngexhal ation, especiall
yf or
pat i
ent swi thf i
br osisorpar enchymal destruction.
•Rat i
onal e:Creat esr esistanceagai nstout fl
owi ngai rt
opr eventcol l
apseornar rowingof
theai rway s, therebyhel pingdi stri
but eairthr oughoutt hel ungsandr el
i
ev eorr educe
shor tnessofbr eat h.
4-Moni torser i
al ABGsandpul seoxi met ry.
•Rat i
onal e:Decr easedox ygencont ent( PaO2)and/ orsat urati
onori ncreasedPaCO2
i
ndi cat eneedf ori ntervent ionorchangei nther apeut i
cr egimen.

-
Themedi
cat
ionsusedt
otr
eatl
atentTBi
nfect
ioni
ncl
ude:

•i
soniazi
d( I
NH) .
•ri
fampin(RIF).
•ri
fapenti
ne(RPT) .
•Mucolyti
cagent s:acetyl
cysteine(Mucomy st
);
Reducesthethi
cknessandst i
cki
nessof
pulmonarysecr eti
onst ofacil
it
ateclearance.
•Bronchodil
ators:oxtr
iphyll
ine(Choledyl)
,theophyl
li
ne(Theo-
Dur);
Incr
easeslumensize
ofthetracheobronchialtr
ee, t
husdecr easingresi
stancetoai
rf
lowandi mprovi
ng
oxygendelivery
.

PageXLVIof46
 [Link]
onchi
ti
s
-Defi
nit
ion:
Bronchiti
sisani nf
lammat i
onorswelli
ngoft hebronchi
alt
ubes( br
onchi)
,theai
r
passagesbet weent henoseandt hel
ungs.
Morespeci f
icall
ybronchialt
ubesbecomesi nfl
amedori nf
[Link]
ewi thbr
onchit
is
havear educedabilit
ytobreatheinai
randoxy genintot
heirl
ungs;theyal
sohav eheavy
mucusorphl egm f
or mi
ngintheirai
rways.

-
Fastf act
saboutbr onchit
is:
 Bronchitiscanbecausedbyv i
ruses,bacter
iaandotherpar
ticl
est hatir
ri
tatet
he
bronchial t
ubes.
 Ac utebronchiti
sisashor t-
termill
nessthatoftenfol
lowsacoldorv i
rali
nfect
ion.
 Ch roni
cbr onchiti
sisalong-ter
mi ll
nessandcanbet heresultofenv i
ronmental
factorsorextendedi l
lness.
 Cigarett
esmoki ngisthemostcommoncauseofchr oni
cbronchitis.
 Oc cupationalexposuretopestici
desi sassoci
atedwithanincreasedr i
skofchroni
c
bronchiti
s.
-
Typeofbr onchiti
s:
 1 .acute
 2 .Chroni c

-
Acutebr onchi ti
s:
 Ac utebr onchi t
isisashorterill
nesst hatcommonl yf ol
lowsacol dorvir
alinfecti
on,
suchast [Link]
sofacoughwi thmucus, chestdiscomf or
tor
soreness, feverandsomet i
messhor t nessofbr eat
[Link] ebronchiti
susuallylast
sa
fewday sorweeks.
-
Chronicbr onchi t
is:
 Ch ronicbr onchiti
si saserious,ongoingi llnesschar acter
izedbyaper si
stent,mucus-
produci ngcought hatlastslongerthant hreemont [Link] ewithchroni
cbr onchit
is
hav ev aryingdegr eesofbreathingdifficultiesandsy mptomsmaygetbet terand
wor sedur i
ngdi ff
erentpartsofthey ear .Ifchronicbr onchit
isoccurs
withemphy sema, itmaybecomeobst r
uct ivepulmonar ydisease(COPD).chronic

-
Causesofbr
onchi
ti
s:

 Bronchi
ti
siscausedbyt hei
nfl
ammat
ionoft
hebr
onchi
alt
ubes,
byv
iruses,
bact
eri
a
andotheri
rri
tantpar
ti
cles.

-
Causesofacut
ebr
onchi
ti
s:

#Br
onchi
ti
sisusual
l
ycausedbyvi
rali
nfect
ion.

PageXLVI
Iof47
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Acut
ebronchi
ti
sisnor
mal
l
ycausedbyv
iruses,
typi
cal
l
ythoset
hatal
socausecol
ds
andfl
u.

 I
tcanalsobecausedbybact
eri
ali
nfect
ionandexposur
etosubst
ancesthati
rr
it
ate
t
helungs,suchast
obaccosmoke,dust
,fumes,
vaporsandai
rpol
lut
ion.

PageXLVI
IIof48
 -Causesofchronicbronchit
is:
 Chronicbronchit
isi
scausedbyr epeat
edi r
ri
tationanddamageofthelungand
air
wayt i
ssue.
 Smo ki
ngist hemostcommoncausesofchr onicbronchi
ti
s,wi
thot
hercauses
i
ncludinglong-t
erm exposur
etoairpol
luti
on, dustandfumesfr
om theenvi
ronment
,
andrepeatedepisodesofacutebronchit
is.

-
Diagnost
ictest:
 ChestX-
ray,l
ungf
unct
iont
est
ingandbl
oodt
est
ingar
eusedt
odi
agnosebr
onchi
ti
s.

S&S:
Signsandsy mptomsf orbot
hacut eandchr oni
cbr onchi
ti
sincl
ude:
 Co ughi
ng, mucusproducti
onandbl ockedorr unnynose.
 Wh eezi
ng, Lowfeverandchil
ls,Chesttightening,Sorethr
oat,Bodyaches,
Br
eathl
essness,Headaches,Blockednoseandsi nuses

-
Nur
singDi
agnosi
s:
[Link] fect i
v eai rwaycl ear ance
rel
at edt o:increasedpr oduct ionofsecr etions.
[Link] epai n
rel
at edt o:thei nf l
ammat ionoft hepleur a.
[Link] redgasexchange
rel
at edt o:airwayobst ruct ionbysecr etions, spasm oft hebr onchus.
-I
nter vent i
on:
-Assessr espi rator yrate, dept [Link] euseofaccessor ymuscl espur sedlipbr eathi
ng
Jnabi li
tyt ospeak.
-Elev ateheadoft hebed, assi stpat ientassumeposi ti
ont oeasewor kofbr eathing.
-Encour agedeepsl oworpur sedl i
pbr eathi ngasi ndivi
dual lytol eratedori ndicated.
-Rout inel ymoni t
orski nandmucousmembr anecol or.
-Encour ageexpect orationofsput um; suct i
onwheni ndi cated.
-Eval uat el evel ofact ivi
tyt oler ance. Pr ovidecal m andqui etenv ironment .
-Eval uat esl eeppat terns, not er epor tofdi f fi
cul t
iesandwhet herpat ientfeelswel lrest
ed.
-Moni torv italsignsandcar diacr hythm.
-Admi ni stersuppl ement al oxy genasi ndi cat edbyABGr esultsandpat i
ent stolerance.
-Usef ul inev aluatingt hedegr eeorr espi r
at or ydistr
essandchr oni cit
yoft hedi sease
process.
-Oxy gendel iverymaybei mpr ov edbyupr ightposi t
ionandbr eat hingexer cisesto
decr easeai r
waycol l
apse, dy spneaandwor kofbr eathing.
-Cy anosi smaybeper i
pher al i
nnai l
bedsorcent r
alinlipsorear lobes.
-Duski nessandcent ralcy anosi sindicat eadv ancedhy poxemi a.
-Thick, tenaci ous, copi oussecr etionsar emaj orsourcei fineff ectiveairway s.
-Deepsuct ioningmayber equi redwhencoughi sineffect i
vef orexpect orationof
secret i
ons.

PageXLI
Xof49
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-Dur i
ngsev ereoracut erespiratorydistr
ess,pati
entmay betotal
l
yunabl etoperform
basicsel fcareacti
vit
iesbecauseofhy poxemiaanddy spnea.
-Mul t
ipleexternalsti
mul iandpr esenceofdy spneamaypr ev
entrel
axationandinhibit
sleep.
-Tachy cardia,dysr
hythmias,andchangesi nbloodpr essurecanref
lecteffectof
systemi chypoxemi aoncar diacf uncti
on.
Patientdisplayimprovedv entilati
onandadequat eoxy genati
onofti
ssuesandAr ter
ial
bloodgases( ABGs)wi thi
nnor mal rangeandf reefr
om sy mptomsofr espir
atory
distr
ess.
.
-Sympt omscanbemanagedathomeby

r
est
ing,
dri
nki
ngf
lui
dsandt
reat
ingpai
nswi
thacet
ami
nophenandi
bupr
ofen
(
alt
houghi
bupr
ofenshoul
dnotbeusedi
fyouar
east
hmat
ic)

**Tokeepbronchi
ti
ssy
mpt
omsundercont
rol
andr
eli
evesy
mpt
oms,
doct
orsmay
prescr
ibe:

#Asci
gar
ett
esmokingi
sthemostcommoncauseofchr
oni
cbr
onchi
ti
s,avoi
ding
smoki
ngi
soneofthebestwayst
opreventi
t.

 Ant
ibi
oti
cs-areeffect
ivef
orbact
eri
ali
nfect
ions,
butnotf
orv
iral
inf
ect
[Link]
mayalsopr
eventsecondar
yinf
ecti
ons

PageLof50
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageLIof51
 [Link]
ibr
osi
s
-pulmonar yfibr
osis:
Pul monar yfi
brosisisthescar ri
ngofyourlungt i
ssuesov erti
me.I tisal
socalled
i
nt erstiti
al l
ungdisease.
Theai rsacsandt i
ssuesi ny ourl
ungsswel l
,scarsform,andt het i
ssuesbecomet hick
andst i
ff .
Thi saf fectshowmuchoxy geny ougetandmakesi thardtobr eathe.
I
nt erstitiall
ungdiseasei ssomet imesalsoknownas" int
ersti
tialpul
monaryf i
brosi
s."
Thet ermsi nterst
it
iall
ungdi sease,pulmonaryfibrosi
sandi ntersti
ti
alpul
monar yfi
brosis
areof t
enusedt odescr i
bet hesamecondi ti
on.
-Pat i
entwhoi sdiagnosiswi thidi
opathicl
ungf i
brosismayonl yl i
veforanotherthr
ee
year s;lungf i
brosisiscurrentlywit
houteffecti
vetreatment.
Pul monar yfi
brosisusuallydev el
opsslowly(over20t o30y ears)andisasympt omat i
c
i
nt heear l
ystages

-
PATHOPHYSI OLOGY:
Whilet
hepr ogressandsymptomsoft hesedi
seasesmayvaryfr
om persontoperson;
ther
eisonecommonl inkbetweent hemanyformsofILD.
Theyallbeginwithaninf
lammation.
Theinf
lammat ionmayaf f
ectdif
ferentpart
softhelung(
bronchi
oli
ti
s,alveol
i
tis
vascul
i
tis).
,
Inflammat i
onoft hesepartsofthel ungmayheal ormayleadt opermanentscar ringof
thel ungt i
[Link] ri
ngoft hel ungt issuetakesplace,theconditi
oni scalled
pulmonar yfi
brosi
s.
Fibrosi s,
orscarri
ngoft helungtissue, resultsinpermanentlossoft hatt i
ssue'sabili
ty
tot r
anspor toxygen.
Thel ev elofdi
sabili
tythatapersonexper iencesdependsont heamountofscar r
ingof
thet issue.
Thisi sbecauset heairsacs,aswel last hel ungt i
ssuebetweenandsur roundingt heair
sacs, andthelungcapill
ari
es,aredest royedbyt heformati
onofscart issue.
Ifthishappens, yourdoctormaypr escribeoxy gent ohel
py oubr eat
heeasi er

-
ri
skfactor:
Thecauseofpul monaryfi
brosismaynotbeknown.
-
Familyhistoryofpulmonaryfibrosisorotherlungdiseas
-
Chemi cals,suchasasbestos,sili
ca,orpestici
des
-
Tobaccosmoke
-
Medical conditi
ons,suchasacidr efl
ux,art
hr i
ti
s,ordi
abetes
-
Medicines,suchasant ibi
oti
csandant i
depressants
-
Treat
mentf ormedicalcondit
ions,suchasr adiati
on

PageLI
Iof52
-
signsandsymptoms:
Symptomsofpulmonar yf
ibr
osi
sar
emai
nly
:
 Sh ort
nessofbr
eath,
 Ch roni
cdrycoughing

 Fat
igueandweakness

 Chestdi
scomf
orti
ncl
udi
ngchestpai
n

 Lossofappet
it
eandr
api
dwei
ghtl
oss

-
Others/
s:
 Troubl
ebreathi
ngt hatget
sworseovert
ime
 Fasthear
tbeatPleuralef
fusi
oni
nint
erst
it
ial
lungdi
sease -cr
ackl
es

-
Diagnost
ict
est:
Diagnosti
cTestsThatMayBeUsedt oIdent
if
yPulmonar
yFi
brosi
s
[Link] [Link]
monaryFuncti
onTests
[Link]-ray [Link]
[Link] 6LungBiopsy
[Link]
diogr
am

-
Complicati
ons:
[Link]
atoryfai
lur
e.
2.I
nfecti
onsandsepsi s.
[Link]
acdy sfuncti
on,hypot
ensi
on.
[Link]
lur
e. [Link] rhage.

-
Famil
yhist
ory:
Respi
rat
orydi
sease
-
Subj
ectiveData:
Pati
entsaid:
 “ I’
mf eel
ingpaini
nbothl ungwhichi
ncreasewi thcoughoranymovement ”
.
 ” thi
spaininbothlung,conti
nuesandradiatedtomyhear tandmyl ef
tarm”
 “ Iam complainfr
om shor t
nessofbr
eathing;feeli
ng,i
nabil
i
tytogetenoughai
r,or
diff
icul
tyint
akingadeepenoughbr eath;whichincreasewhenImakeany
mov ementorwhenIt alkwhichmakemef ati
gueandt hisl
eadtoincr
easepai
n
-
Obj
ect
iveDat
a:
ABGS,I/
O,V/S,P/
E,Bl
oodsampl
e,cx-r
ay,
ECG
-HowcanImanagemysy mpt oms?
 Useoxygenathomeasdi [Link]
susuall
ygiventhroughanasalcannul
a.
 Dobreathi
ngexer
cisesathomet ohelpyoubreathemor eeasi
ly
 Gotopulmonaryrehabi
li
tation(PR).PRisaprogram runbyspecial
i
stswhowil
lhel
p
yousafel
ystr
engt
heny ourlungsandpr eventmoretissuedamage
 Donotsmoke.
 Getthefl
uvacci
neev er
yy earassoonasi tbecomesav ail
abl
[Link]

PageLI
IIof53
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

t
hepneumococcal
vacci
net
opr
eventpneumoni
a.

PageLI
Vof54
-
Medi cat
ion:
1-Morphine 2-
Zantac(Ranit
idi
ne)
3-Hydrocort
isone 4-
Atr
ovent-
Ipr
atr
opium (Ant
ichol
i
ner
gic(
5-Anti
bioti
c 6-
Ventol
in-Al
buter
o
7-
(O2t her
apy )

-
Nur
singDi
agnoses:
A-I
neffect
iveBreat
hingPat
ter
n:
rel
atedtofibr
oticl
ungti
ssueasmani
fest
edbySOB
B-I
mpai r
edGasExchange:
rel
atedtof
ibr
oti
clungt
issueandAl
ter
edoxy
gensuppl
yasmani
fest
edbycy
anosi
sand
pal
[Link].
-Planning:
A-Goal:Impr ovementi nbr eat
hingpat tern
-
Obj ecti
ves:
Ptwi l
lbeabl etobr eathnor mal (
RR) attheendmyshi ft:
-Ptrespiratoryratestay swithi
n+5br eaths/minutesofbasel
ineatendofmycl i
nical
day .
-ABGl evelsr emindnor mal atthesecondl abtest
.
B-Goal :I
mpr ov ementingasexchange
-
Obj ecti
ves:
-
pat i
entwillbeabl eto:
-
Demonst r
at eimpr ovedv enti
l
at i
onandadequat eoxygenati
onoft i
ssuesbyABGs
withinpati
ent ’snormal rangeandbewi thoutsymptomsofr espir
ator
ydist
[Link]
theendmyshi f
t.
-
Repor tsdecr easeindy spneawi thinonehour .
-
Ver bali
zesneedf orbronchodi l
ationandoxy genther
apyduringmyshi f
t.
-
Nur
singInt
erv
enti
ons:
-
Assessandrecor
drespi
rat
oryst
atusatl
eastev
eryt st
wohour odet
ectear
lysi
gns
ofcompr
omi
se.
-AssessABGl evel t
omoni t
oroxygenat i
onandvent il
ati
onstatus.
-Assistpat i
enttocomf ortablepositionthatal l
owf ormaxi malchestexpansi onto
facil
i
tat [Link] eassi stptt of owl erpositi
on.
-Perf
or m chestphy si
otherapyt oaidmobi li
zat ionandsecr et
ionr emov al.
-Provideoxy gent herapy,asor der,tohel preliver espirator
ydistress.
-Admi nisterbronchodi l
ati
onsaspr escr i
bed: -
-Eval
uat eef f
ectivenessofnebul i
zer
-Assessf ordecr easeshor tnessofbr eathing.
-Ensuret hattreatmenti sgivenbef oremeal toav oi dnausea,vomi t
ingandt oreduce
fati
gue.
-Encour agemobi l
izati
onofsecr etionst hroughhy drati
onandbr eathingand
coughi ngexer ci
ses.
-I
niti
atepul seoxi met yt
r omoni t
oroxygensat ur ation.
-Eval
uat eef f
ectiveness;obser vesignsofhy poxemi aandnot if
yphy sicianif
restl
essness, anxi ety,
cyanosi sispresent .

PageLVof55
 [Link]
OVASCULARDI
SORDERS
[Link]
per
tensi
on
-Defi
nit
ion
-Hypertensionisthet ermt odescri
behighbl
oodpr [Link] per
tensi
oni sdefi
nedas
systol
icbloodpr essur egreatert
han140mm Hganddi astoli
cpressuregreatert
han90
mm Hgov ersustainedper i
od.
-Pri
mar yhy per
tension: meaningthereasonfortheelev
ationinbloodpr essur
ecannot
beident i
fi
ed.90%- 95%f r
om causes.
-Secondaryhy pertension:i
st het
erm usedtosignif
yhighbl oodpressurefrom an
i
dent i
fi
ed
-Cause:
suchasnarrowi
ngofrenalar
ter
ies,r
enal
par
enchy
madi
sease,
cer
tai
nmedi
cat
ions,
pregnancy
,andcoar
c-t
ati
onofaor t
a.
-
Pat
hophy
siol
ogy
:
Bl
oodpr
essur
e=car
diacout
put*
per
ipher
alr
esi
stance
-
Hy pert
ensi
on=incr
easecar
diacoutput*i
ncr
easeperi
pher
alresi
stance
Increasecar
diacout
put=i
ncreasestr
okevol
ume*incr
easeheartr
ate
-Symptoms:
Sever
eheadache,fat
igueorconf
usi
on,vi
sionproblems,chestpai
n,dif
fi
culty
breat
hing,i
rr
egul
arheart
beat,bl
oodi
ntheurine,poundi
nginyourchest,neck,orear
s.
-Di
agnosi stest
:
[Link]( cr
eat
eni
nekinaseCK, l
acti
cdehydr
ogenaseLDH,t
ropni
nI)
.
[Link]
oodchemi stry
. [Link]
um electr
oly
tes. [Link].
[Link] at
ionstudies. [Link] ay
. [Link](showusuall
yST
depression.
)

-Ri
skfactor
s:
[Link]. 2.D.
M [Link]
ghLDL( l
owdensi
tyl
i
poprot
ein)
[Link]
sicalinact
ivi
ty. [Link]
ty. [Link] above55andFabov
e65.
-Compli
cati
ons:
[Link]
onaryhear tdi
sease.
[Link].
[Link]
dneydi sease.
[Link]
inopathy.
[Link]
ipheralarterydi
seases.

-Management:
[Link]
etmentofunderl
yi
ngcause.
[Link]
festi
lemodifi
cat
ion.
[Link]
uret
ics:t
hiazdediuret
icscal
ledwaterpi
ll
s,aremedicat
ionst
hatactony
ourki
dney
tohelpyourbodyeli
mi nat
esodium ,
reduci
[Link]

PageLVIof56
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

hydrochlorothi
azide( microzide),chlorthalidone.
[Link]–bl ockersagent s:thesemedi cationsr educet heworkl
oadony ourhear tand
openy ourbloodv essl s,casui ngy ourhear ttobeatsl owerandwi t
[Link]
acebutolol(
sectral )
,atenolol(tenormi n).
[Link] oker s:thesemedi cationshel pr el
axt hemusclesofyourbloodv essel
s.
Suchasaml odipine(nor vasc) ,
dil
ti
azem ( cardizem ,t
iazac).
[Link]
ensinI Iblocker s:
thesemedi cationshel prelaxbloodvesselsbyblockingthe
acti
on, notthef ormat ions, ofanat uralchemi cal t
hatnarrowsbloodv essel
[Link]
candesar t
an(atacand) ,l
osar tan(cozaar )
.

-
Nur
singDi
agnosi
s:

1-Acut
epai
n :
-pai
nacut,
heacdache
-
myber elat
edt
o
-
incr
eeasedcer
ebr
alv
ascul
arpr
essur
e
-Possiblyevidencedby:
-verbalreportsofthrobbi
ngpainlaocat
edinsubocci
pit
alregi
on,present
onawahcening
anddi sappear i
ngspontaneousl
yafterbei
ngup
Andabout.
-Reluctancetomov ehead,r
ubbinghead,avoi
dancebri
ghtli
ghtsandnoise,
wri
nkled
brow, clenhedfists
-changesappet i
te.

-
Desir
edout comes:
-
Reportpain/discomforti
sreli
eved/cont r
oll
ed
-
ver
loali
zemet hodsthatprovi
debr el
i
ef
-
fol
l
owpr escribedpharm acol
ogicalregimen
-
Demonst at
euseofr elaxat
iononskillsanddiver
sional
act
ivi
tes,
asi
ndi
cat
ed,
for
i
ndi
vidualsi
tuation.

-Nursingintervention:
[Link] minespeci fi
csofpai n(tocti
on,char actseri
sti
cs,int
ensi t
ytc
(0-10),onsetanddur ation)Rat ionaleFacil
itatesdisagnosisofpr obl
em
andini t
iat
ionofappr opr i
[Link] al
uationeffecti
v aenaaessofther
apy.
[Link] ni
stermedi ctionasi ndicati
onasi ndI cated:-Analgesics,Anttanxi
etyagent
s:-
Lorazepam ( Ativan),alprazolam (xanax),diazepam ( vali
um).RationaleReduceorcontrol
painanddecr easest imul at
ionoft hesy mpat hti
cnev roussyst em mayai di
nthe
reductionoft ensionanddi scomf ortthati
si ntensif
iedby st
ress.
[Link] diacout put.
Cardiacout put,ri
skf ordecr eased.

PageLVI
Iof57
-Ri
skfactor
smayi ncl
ude:
1.I
ncr
easedv ascul
arresi
stance,
vasoconst
ri
cti
on.
[Link]
al i
schemia.
[Link]
icul
arhypertr
ophy/ri
gidi
ty.

-Evi
denecedby:
Notappli
cabl
eexist
enenceofsi
gnsandsy
mpt
omsest
abl
i
shesanact
ual
nur
sing
diagnosi
s.
-
Desi
redoutcomes:
 Part
ici
pateinacti
vi
tiesthatreduceBP/ cardi
acwor kl
oad.
 Mainit
ainBPwithi
ni ndivi
duall
yacceptablerange.
 Demost r
atest
ablecar di
acrhythm andr at
ewi t
hinpati
ent
snor
malrange.
 Part
ici
pateinacti
vi
tiesthatwillpr
eventstress(str
essmanagement,bal
anced
acti
vit
esandrestplan. )

-
Nur
singi
nter
vent
ion:

-
Checklabor
atorydata(car
diacmarkerscomplet
ebloodel
lcount,
elect
rol
yes,
ABGs,
bloodureanit
rogenandcerat
ini
ne,cardi
acenzymes.

 Rat
ional
etoi
dent
if
ycont
ri
but
ingf
act
ors.

-
moni
torandr
ecor
edBP.

 Rati
onalsev
erehyper
tensi
onisclassi
fi
edi
nadultasdi
ast
oli
cpressur
eelev
ati
onti
110mmHgpr ogr
essi
vediast
oli
creadi
ngsabov
e120mmHgar econsi
der
edfir
st
accel
erat
ed,
thanmali
gnant(ever
ysevere)
.

-
Syst
oli
chypert
ensionalsoi
sanest
abl
i
shedr
iskf
act
orf
orcer
ebr
ovascul
ardi
sease
whendi
ast
olicpressur
eisel
evat
ed.

-
Moni
torr
esponset
omedi
cti
onst
ocont
rol
bloodpr
esur
e.

 Rati
onaleResponset
odrugther
apyi
sdependentonbot
hthei
ndi
vi
ual
aswel
last
he
suner
gisti
ceffect
softhebr
ug.

PageLVI
IIof58
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageLI
Xof59
 [Link]
nThr
ombosi
s
-Definiti
on:
Deepv eint hrombosi s,ordeepv enoust hrombosi s,(DVT)isthef ormat i
onofabl ood
clot(thrombus)wi thinadeepv ein,[
a]pr edomi [Link]- speci fi
csi gns
mayi ncludepai n,swelling, r
edness, war mness, andengorgedsuper ficialveins.
Pulmonar yembol i
sm, apot ent i
allyli
fe-threateningcompl i
cation,iscausedbyt he
detachment( embol i
zation)ofacl otthatt [Link] her, DVTand
pulmonar yembol i
sm const i
tut easi ngledi seasepr ocessknownasv enous
thromboembol [Link] -
t hr
ombot i
csy ndrome, anothercompl i
cation, signif
icantly
cont r
ibut est othehealth- [Link] ev enti
onoptionsf orat -
riskindividuals
i
ncl udeear lyandfrequentwal king,calfexer cises,anti
coagulants,aspi rin,gr
aduat ed
compr essi onstockings, andi ntermi t
tentpneumat i
ccompr ession.

-Pathophy si
ology
Thecoagul ationsy st em, of tendescr ibedasa" cascade" ,consistsofagr oupof
protei nst hatinter actt ofor m abl oodcl [Link] i
ski si ncreasedbyabnor mal itiesinthe
[Link] egul ators,ant i
thr ombi n(ᾳTHR)andact ivatedproteinC( APC)ar eshown
i
ngr eenabov ethebl ood'scl ottingf actor
st heyaf fect .
DVTof tendev el
opsi nt hecal fv einsand" gr ows"i nt hedi r
ecti
onofv enousf low,
towar dst hehear [Link] ow, itcanbecl earednaturall
yanddi ssolved
i
ntot hebl ood( f
ibr i
nol y
sis) .
Vei nsi nthecal fort highar emostcommonl yaf f
ect ed,
i
ncl udi ngt hef emor al vein, thepopl it
eal v
ein, andt hei l
iofemor alvei
n( aswi t
h
May –Thur nersy ndr ome) .Ext ensiv elower-ext remi tyDVTcanr eachi ntothei l
iacv einof
thepel visort hei nferiorv enacav [Link] lythev einsoft hear m areaf fect ed,as
aftercent ralvenouscat het erpl acementandwi tht her ar ePaget –Schröt t
erdi sease.
(duet ot hromphel biti
sofl argerdeeperv ein, 3f act or sincludev enousst asis,endot heli
al
damage&hy percoagul abi l
ityoft hebl [Link] y sedbyendot helialcell
s( good)or
detach&r esulti
nanembol i from v enousci r culationt othehear t
,brainorl ungs. )

-Si
gnsandsy mpt oms
Commonsi gnsandsy mptomsofDVTi ncl
udepai
nortenderness,
swel
li
ng,warmth,
rednessordiscolor
ati
on,
anddi
stent
ionofsurf
acevei
ns,al
thoughabouthal
fofthose
withtheconditi
onhavenosympt
oms
[Link]

[Link]
l
ater
aledema

[Link]
m ski
n

[Link]
fTender
ness

5.+Homan'
ssi
gn

PageLXof60
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

[Link]:
upperext
remi
tyedema

7.I
VC:
lowerext
remi
tyedema

PageLXIof61
-Diagnosis:
DVTdi agnosisrequirestheuseofi magingdevicessuchasul t
[Link]
nical
assessment s,whichpr edi
ctDVTlikel
ihood,canhelpdet ermineifaD-dimert esti
s
usef ul
.Inthosenothi ghl
yli
kel
ytohav eDVT, anor mal D-di
merr esul
t[
g]canr uleouta
diagnosis.
-Treatment:
[Link] i
coagulat
ionAnt i
coagulati
on,whichpr eventsfurt
hercoagulat
ionbutdoes
notactdi
rectl
yonexi st
ingclots,i
sthestandar dtreat
mentf orDVT
[Link] r
eatment ,st
ocki
ngs, walki
ng,andrepeati maging

3.I
VCf
il
ter
s,t
hrombol
ysi
s,andt
hrombect
om

-
Nursi
ngDiagnosisforDVT:
[Link]
ecti
veper i
pher
alt
issueper
fusi
on
2. Alt
eredclott
ing

3. Ri
skf
orPE

4. Def
ici
entknowl
edge

-
Nursi
ngoutcomes/
evaluat
ionsforDVT
[Link]
enthasadequatebloodflowtoextr
emity
[Link]
entmaint
ainstherapeut
icbloodl
evelofant
icoagul
ant
-
Nursi
ngi
nterv
ent
ionsf
orDVT
[Link]

2. el
evat
eli
mb

3. compr
essi
onst
ocki
ng

4. moni
torf
orS/
SofPE

5. Moni
tordi
stal
pul
ses

6. Pai
nrel
i
ef

[Link]/
diagnost
icsf
orDVT

[Link]
erf
low

9. Dupl
exscan(
ult
rasound+doppl
er)

10.D-
Dimer

11.
Medi
cat
ionsf
orDVT

12.
Ant
icoagul
ant
s(hepar
in,
Lov
enox,
War
fri
n)

[Link]
ombol
yti
cagent
s

PageLXI
Iof62
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

[Link]
gat
roban(
alt
ernat
ivet
oHepar
in)

[Link]
ombi
ninhi
bit
ors

PageLXI
IIof63
 [Link]
a

-Anaemia:i
sacondi ti
oninwhichthenumberofr edbl
oodcel l
sorthei
roxy gen-
car
ryi
ng
capaci
tyisinsuff
ici
enttomeetphy si
ologi
cneeds,whi
chv arybyage,sex,alt
it
ude,
smoking,andpregnancystatus.
Thereareseveralty
pesandcl assi
fi
cati
[Link]
ioninwhichthe
bodylackstheamountofr edbloodcellst
okeepupwi ththebody'
sdemandf or

-
Thesesympt omsappearinmostt
ypesofanemi
a:
 p al
eski n
 d i
zziness
 fatigue
 h eadaches
 irri
tabil
it
y
 lowbodyt emper
ature
 n umb/ col
dhandsorfeet
 rapidhear t
beat
 shor tnessofbr
eath
 we akness
 chestpai n

-
TypesofAnemia
Di
ff
erentt
ypesofanemi
ahav
edi
ff
erentcausesandsy
mpt
oms.

-I
ronDefi
ciencyAnemia:Ir
ondeficiencyisoneofthemostcommoncausesofanemi a,
especi
all
yinwomen.I [Link],twentymi
ll
ionwomensufferf
rom i
rondefi
ciency
anemia.I
rondefici
encycausesinsuffi
cienthemoglobi
npr
oduct
ionwhich,
intur
n,
causesanemi aandanemiasympt oms.

-SickleCellAnemia:Si
cklecellanemi a,orsi
cklecel l
disease,i
soneoft heher edi
tary
causesofanemi [Link] npeopl eofAf ri
candescent,si
cklecellanemi ai
s
char acter
izedbytheproducti
onofr igid,si
[Link] mal
sicklecell
sbr eakdownfasterthennor mal r
edbl oodcells,r
esult
inginachr onic
shor tageofredbloodcell
sandanemi asympt oms.
Sicklecellanemiaisaform ofhemol yti
canemi a,whichdescri
best y
pesofanemi a
causedbyt herapi
ddestructi
onofr edbl oodcel l
s.

-Per niciousAnemi a: Certaintypesofanemi aar erefer

redt oasmegal oblast i
c,orv i
tamin
deficiencyanemi [Link] niciousanemi aiscausedbyani nabil
i
t yofthei ntest i
nesto
absor bsuf fi
ci
entamount sofvitaminB12, whichisrequiredint heproduct i
onofr ed
bloodcel ls.
Per niciousanemi asy mpt omsi ncl
udev i
sionpr obl
ems, memor yloss,difficult
ywal king
andnumbhandsandf eet,aswel l
ast hemor ecommonanemi asympt oms.
Riskf act orsforperniciousanemi aincludeaf ami l
yhistoryofper ni
ciousanemi a,
Scandi nav i
anorEur opeanancest ryorahi storyofautoimmuneendocr i
nedi sorders.
Vitami nB12i nj
ectionsar et hestandardper niciousanemi atreatment .Or alvit
aminB12
suppl ement smayal sobeusedasper nici
ousanemi atreatment ,butthey ’renotas
effi
ci entasB12i nj
ect i
ons.

PageLXI
Vof64
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-FolicAci
dDef i
ciencyAnemi a:Fol
i
caciddef i
ciencyanemia,li
kepernici
ousanemia,i
sa
megal oblasticanemi [Link]
cacidi
sessentialf
orhealthybloodandaheal thyner
vous
sy st
[Link] oli
caciddef ici
encydur
ingpregnancycancausebi r
thdefects.
Fol i
cacidsuppl ement sformthebasisoffoli
cacidanemi [Link]
treatmental soincludeseatingadiethi
ghinfolicaci
d, i
ncl
udingsuchf oodsas:

 beansandl egumes
 ci
trusfruit
sandjuices
 darkgreenleafyveget
abl
es
 pork
 poult
ry
 shell
fi
sh
 wheatbr an

-Thal
assemi a:Causesofanemi aof t
enincl udegeneticmut ati
[Link]
aisone
ofthegeneticall
yinheri
tedtypesofanemi [Link] aoccur swhent hebody’
sgenes,
whichareresponsi bl
eforproperhemogl obi nproduction,becomedamagedormut ated.
Likesi
cklecellanemi a,
thal
assemi aisoneoft hehemol y
ticanemi atypes.
Manypossi blegenev ari
ati
onscancauset hal
assemi a,andt hediseasehasbothmi l
d
andseverev ari
eti
[Link]’sanemiaist hemostcommonsev erethalassemi
ainthe
[Link] endstobepr esentatbirthandi tssy mptomsi nclude:

 darkcolor
eduri
ne
 deformedfaci
albones
 fat
igue
 j
aundice
 poorgrowthrat
es
 aswol l
enabdomencausedbyanenl
argedspl
eenandl
i
ver
 weakness

Anumberofet hnicgroupsar eathi gherr i

skofdev elopi
ngt hal
assemi a,i
ncluding
peopl eofAfri
can, Chinese,Fil
ipino,Indian,It
ali
an,GreekandMi ddleEasternethnicit
y.
Treat mentforthalassemi adependsont heseverit
yoft [Link] l
dt y
pesof
thalassemiamaybet reatedwithr [Link] equire
mul tipl
ebloodt r
ansfusions,ir
onchel ati
ont her
apyt oremov eexcessi ronfrom the
bloodandbonemar r
owt [Link] thouttr
eatment ,severethalassemiaoften
prov esfat
al i
near l
ychi l
dhood.

-
Apl
asti
cAnemia:Apl
ast
icanemiai
soneoft
herarerty
pesofanemia,occur
ri
ngwhen
t
hebodymakesinsuf
fi
cientr
edandwhi
tebl
oodcell
[Link]
asti
canemia
i
ncl
ude:

 radi
ati
ontherapy
 chemotherapy
 toxi
cchemi cal
s
 somemedi cati
ons
 bonemar r
owi nfect
ions

PageLXVof65
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-Di
agnosi
sNur
singI
nter
vent
ionsf
orAnemi
a

[Link]
ect i
veTi
ssuePer
fusi
on:
-Object
ives:
 Ad equat
eti
ssueper
fusi
on
-
Nur
singI
nt ervent
ionforAnemia:
 Mo nitorvit
alsi
gns,capi
l
lar
yref
il
l,
ski
ncol
or,
mucousmembr
anes.
 Exaltthepositi
onofheadofinbed

 Examineanddocumentt hepr esenceofpai n.

 Observat
ionofadelayinverbal response,conf
usi
on,
orrest
lessness
 Observeanddocumentt hepr esenceoft hecol
d.
 Maintai
ntheambienttemper aturetokeepwar mthebodyneeds.
 Provi
deoxygenasneeded.

[Link]
vi
tyIntol
erance:
-Obj
ecti
ves:
 To l
erantofactiv
ity
-
Nursi
ngInterventi
on:
 Assessthecapabi l
it
yofdoi
ngtheacti
vi
ty
 Mo ni
torvit
al si
gnsduri
ngandaft
eracti
vi
ty,andnotedaphysi
ologi
calresponset
o
act
ivi
ty(increasedhear
trat
eincr
easedbloodpressur
e,orr
api
dbr eat
hing).

 Pr
ovi
deinfor
mat i
ontothepatientorfamilyt
ost opdoingacti
vit
iesi
ftel
adi
sy
mptomsofi ncreasedheartrate,i
ncreasedbloodpressure,
rapidbr
eathi
ng,
di
zzi
nessorfatigue)
.
 Pr
ovi
desuppor ttoperf
ormthei rdai
lyacti
vit
iesaccor
dingt ot
heabili
tyoft
hechi
l
d.
 Cr
eati
ngaschedul eofacti
vi
tiesinvolvi
ngotherhealt
ht eam.

ManagementofAnemiai
sshownt ofindt
hecauseandreplacel
ostblood:
 Anti
biot
icsgi
ventopr
eventi
nfect
ion.
 Foli
cacidsuppl
ement
scanstimulatet
hefor
mationofredbloodcell
s.

 Avoidsit
uati
onsofoxygendef
iciencyoracti
vit
ythatr
equi
resoxy
gen.
 Treatthecauseofabnor
malbleedingifany.
 I
ron-ri
chdietcont
aini
ngmeatandgr eenvegetabl
es.

Tr
eat
ment(fortreatmentdependsont hecause)
:
[Link]
ondef i
ciencyanemi a
[Link]
cacidAnemi a: Fol
icacid5mg/day/or al
ly
[Link] obleeding: bl
eedi
ngandshockovercomebygiv
ingfl
uidsandbl
ood
tr
ansfusions.
[Link]
ciousAnemi a:vit
ami nB12
[Link]-cont
ai ni
ngf oods,t
ryt
hefoodprov
ided,suchasf
ish,
meat ,
eggsand

PageLXVIof66
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

vegetables.
[Link]
ngpr eparat
ionsFE
7.Perrosulfat3x200mg/day/peror
alaf
termeals
8.Peroglukonat3x200mg/day/peroral
aftermeal
s.

PageLXVI
Iof67
 [Link]
ocar
dial
Inf
arct
ion(
MI)
-Defi
niti
on:
My ocardi
al i
nfarcti
onknownasheartat
tackhappenswhentherei
smar kedr educt
ion
ofbl oodflowt hroughoneormoreoft
hecoronaryar
ter
ies,
resul
ti
ngincardiacmuscle
i
schemi aandnecr osi
[Link]
swhenbl
oodflowstopstoapartoftheheartcausing
damaget othehear tmuscle.
-Sympt oms:
Themostcommonsy mptom ischestpai
nordi
scomf
ortwhi
chmaytrav
elintot
he
shoul der
,arm,back,neck,orjawandt hemostcommonsymptomsofaheartat
tack
i
nclude:
-pressureorti
ght nessinthechest
-paininthechest,back,jaw
-shortnessofbreath-sweati
ng
-nausea, v
omiti
ng
-anxiety
-acough
-diz
ziness

-Di
agnosi stest:
Testswi l
lhelpchecki fyoursignsandsy mpt oms,suchaschestpain,indicat
eahear t
att
ackoranot hercondi ti
[Link] estsinclude:
 E lectr
ocardiogr am (ECG).Thi sfi
rsttestdonet odiagnoseaheartattackrecordsthe
electr
icalactiv
ityofy ourhear tvi
aelectrodesattachedtoyourskin.(pathological
Q
wav es,STel evationordepr essi
on)
 Bl oodt est
[Link] t
ainheartenzy messl owlyleakoutintoyourbl
oodi fyourhearthas
beendamagedbyahear tattack.
(CK/MB2h- 10h—Mgb2hpeak4h—TnT3- 4hremains6-20day—TnTi 3hpeak14h)

-Compli
cations:
Heartat
tackcompli
cat
ionsar
eof t
enrelat
edtot
hedamagedonetoy
ourhear
tdur
inga
heartat
[Link]
sdamagecanleadtothefol
l
owingcondi
ti
ons:

 Abnormal hear
trhythms(ar
rhyt
hmi as).I
fyourheartmusclei
sdamagedf
rom a
heartat
tack,el
ectr
ical"
shortci
rcui
ts"candevelop,resul
ti
ngi
nabnor
malhear
t
rhyt
hms, someofwhi chcanbeserious,evenfatal
.
 Hear
tfai
l
[Link]
nyourhear
tmaybesogreatthatt
he
r
emaini
ngheartmuscl
ecan'tdoanadequatej
obofpumpingbl
oodoutofyourhear
t.
 Hear
trupt
[Link]
easofhear
tmuscl
eweakenedbyahear
tat
tackcanr
upt
ure,
leav
ing
ahol
einpartoft
heheart
.Thi
srupt
urei
soft
enfat
al.
 Val
[Link]
vesdamageddur
ingahear
tat
tackmaydev
elopsev
ere,
l
if
e-t
hreat
eningleakagepr
oblems.

PageLXVI
IIof68
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-Management :
Fir
st,MONAi samnemoni ct hatstandsfor:Mor phine, Oxygen,Nit
rat es, andAspi r
in.
Thesear et he4pr i
maryintervent
ionsthatar eperf
or medwhent reatingapat ientwith
My ocardialInfarcti
on(MI,t heOxy genisal waysgivenf ir
sttostartincr easingt he
amountofav ail
ableoxygeni [Link] tratesar egiventov asodi lateblood
vessels,whi challowsmor er oom forbloodt opasst [Link] heaspi r
inisgivento
help“thin”thebl oodbybr eakingdownpl atelett
ogetr i
dofanycl otsi nt hecor onary
art
eriest hatmi ghtbecont r
ibuti
ngt otheMI .Final
ly, morphinecanbegi vent oreduce
painandanxi ety,whichi
nt urnhelpsdecr easeoxygendemand.

-
Medi
cat
ionsgi
vent
otr
eatahear
tat
tacki
ncl
ude:

 Aspi
ri
nreducesbl
oodcl
ott
ing,
thushel
pingmai
ntai
nbl
oodf
lowt
hroughanar
rowed
ar
ter
y.

 Thrombolyt
[Link]
pdissolv
eabl oodclotthat
'sbl
ocki
ngbl
oodflowt
oyourhear
t.
Theearl
ieryoureceiv
eat hrombolyt
icdrugaft
erahear
tatt
ack,
thegr
eat
erthe
chanceyou'
llsurvi
veandwi thl
essheartdamage.

 Ant
ipl at
[Link] doctorsmaygi veyouot herdr
ugstohel
p
pr
ev entnewcl otsandkeepexisti
ngclotsfrom get
tinglarger
.Theseincl
ude
medi cat
ions,suchasclopidogr
el(Pl
avix)andothers,call
edplatel
etaggr
egati
on
i
nhibitors.

 Otherbl
ood-t
hinni
ngmedicat
[Link]'
lll
ikel
ybegivenot
hermedicati
ons,suchas
hepari
n,t
omakey ourbl
oodless"sti
cky"andlessl
ikel
ytofor
m cl
[Link]
s
gi
venintr
avenousl
yorbyaninject
ionunderyourskin.

 Pai
nrel
i
[Link]
ecei
veapai
nrel
i
ever
,suchasmor
phi
ne,
toeasey
our
di
scomfor
t.

 Ni
tr
ogl
ycer
[Link]
smedicat
ion,usedtot r
eatchestpai
n,canhel
pimpr
ovebl
oodf
low
t
othehear
tbywideni
ngthebloodv essel
s.

 Betabl
[Link]
ionshel
prel
axyourhear
tmuscle,slowy ourhear
tbeat
anddecreasebloodpr
essure,
makingyourhear
t'
sjobeasi
[Link]
mit
theamountofheartmuscledamageandpreventf
utur
eheartattacks.

 ACEi
nhi
bit
[Link]
ugsl
owerbl
oodpr
essur
eandr
educest
ressont
hehear
t.

-
Nursi
ngProcess
-
Thegoal
soft r
eatmentf
orMIar
etor
eli
evechestpai
n,st
abi
l
izehear
trhy
thm,
reduce

PageLXI
Xof69
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

car
diacworkl
oad,
andpr
eser
vemy
ocar
dial
tissue.
-Di
agnosi
s:
A:AcutePain:
rel
atedtoTissueischemi
a( cor
onaryarteryoccl
usion)ev
idencedby
1-Report
sofchestpainwith/wit
houtradiati
on
2-Restl
essness,
changesinlevelofconsciousness
3-Changesinpulse,BP
Out
comes:
Ver
bal
i
zer
eli
ef/
cont
rol
ofchestpai
nwi
thi
nappr
opr
iat
eti
mef
ramef
or
administ
eredmedicat
ions.
-Nur
singInter
vent
ion:
-Monitoranddocumentchar acteri
sti
cofpai n,noti
ngverbalreports,nonv er
balcuesandBP
orhear tratechanges.
Rationale: Vari
ati
onofappear anceandbehav i
orofpati
entsinpai nmaypr esentachall
engein
assessment .Mostpatient
swi thanacut eMIappearill
,dist
racted,andf ocusedonpai n.
-Obtainfulldescri
pti
onofpainf rom pati
entincludi
nglocati
on, i
ntensity(usingscal
eof0–10) ,
duration,andradiati
on.
Rationale: Pai
nisasubj ect
iveexperienceandmustbedescr ibedbypat [Link]
desbasel
ine
forcompar i
sont o aidindetermini
ngef fecti
venessoftherapy,resoluti
onandpr ogressi
onof
problem.

B:Inef f
ectiveTissuePer fusion:
relat edtoReduct ion/ i
nterrupti
onofbloodf low,e.g.
,vasoconstri
ction,
hypov ol
emi a/shunting,andt hromboembol icfor
mat ionevidencedbyAr i
skdi agnosi
s
isnotevi dencedbysi gnsandsympt oms,ast hepr oblem hasnotoccur redand
nur singi nterventionsar edi r
ectedatpr evention.
-Out comes:
-Demonst rateadequat eper fusionasindivi
duall
yappr opri
ate,e.
g.,skinwarm anddry,
per i
pher alpulsespr esent/strong,vi
talsi
gnswi t
hinpat i
ent’
snor mal r
ange,pati
ent
alert/ori
ent ed,bal
ancedI &O, absenceofedema, freeofpai n/
discomf or
t.

-Nur singI nterventi

on:
Invest igatesuddenchangesorcont i
nuedal ter
ationsinment ati
on(changesinLOC,
ment ation,st upor).
Rational eCe rebralperfusionisdirectl
yr elat
edt ocardiacout putandisalsoinfl
uenced
byel ect roly
t eand/ oracid-basevariations,hypoxia,andsy stemicembol i
.
-Nur singI nterventi
on: I
nspectf orpallor,cyanosis,mottl
ing, coolandclammyski [Link]
e
str
engt hofper ipheralpulses.
Rational eSy stemicv asoconst r
ict
ionr esulti
ngfrom diminishedcar di
acout putmaybe
evi
dencedbydecr easedski nperfusionanddi minishedpul ses.

PageLXXof70
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageLXXIof71
 [Link](
CAD)
-Def
ini
ti
on:I
t’
sacl
i
nical
syndr
omech.
chbyepi
sodesofpai
norpr
essur
eint
heant
eri
or
chest

-Stabl
eangi
na:
nor
mal
cor
onar
y:Exer
cise,
heav
ymeal
,st
ressandcol
dmayt
ri
ggert
he
chest.

-
Unstabl
eangina(alsocal
ledprei
nfar
cti
onangi
naorcr
escendoangina)
;symptoms
occurwhenthepati
entisatrest:
symptomsoccurmor
efrequent
lyandlastl
onger.
The
thr
eshol
dforpai
ni sloweraswell.

-I
ntractabl eorr efractor
yangi na:sever
eincapacitatingchestpain.
-Variantangi na(alsocalledprinzmetal
sangi na):painatrestwithrever
sibl
eST-segment
Elevation: thoughtt obeduet ocoronaryarteryvasospasm.
-Sil
entI schemi a:object
iveev i
denceofischemi a(suchasECGwi t
hast r
esstest)
,but
patientr epor tsnosy mpt oms.
-Pathophy siology
-Causedbyat her
oscl er
oticassociat
edwi thsigni
ficantobstruct
ionofCAandanycause
thatincr easedemandordecr easesupply.
-Sympt oms:
1-Chestpai nordi scomf ort. 2- Nausea 3-Fatigue
4-Sweat i
ng 5-Di
zziness 6-shortnessofbreath
7-Paini ny ourar ms, neck,jaw,shoul
derorbackaccompany i
ngchestpain.
Compl i
cat ion
-Management :
1-Nitr
ates:rel
axandwi deny ourbloodv essels,al
lowingmor ebl
oodt oflowy ourhurt
muscl e.
2-Aspi r
in:r
educest heabili
tyofy ourbloodt [Link]
erforbloodt oflow
throughnarrowedhear tarteries.
3-Clot–preventi
ngdr ugs:Cer tai
nmedi cati
ons, scuhasclopidogr
el(Plavix
),prasugrel
(Effi
ent)andticagrel
or( Br
il
inta),canhelppr eventbloodplat
elet
slesslikel
ytost i
ck
together
4-Betablockers:Betablocker swor kbyblockingt heeff
ectsofthehormoneepi nephri
ne,
alsoKnownasadr enaline.

-Diagnosistest
:
1-chestX- RAY:Thist esti
stot akesimagesofy ourheartandlungs.
2-Bloodt est
s:Certainheartenzy messl owlyleakoutintoyourbloodi
fy ourhear
thas
beendamagedbyahear t
.
3-Cr onar
yangiography :Coronaryangiogr aphyusesx-rayimagingtoexaminetheinsi
de
ofy ourheartsbloodi fyourbloodv essels.
4-Car di
accomput erizedtomogr aphy( CT)scan: I
nacar di
acCTscany oulieonatable
i
nsi deadoughnut -shapedmachi ne.

PageLXXI
Iof72
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

[Link]
ocardiogr
am (ECG)
.showSTsegmentdepr essi
on.
[Link]:
someti
mesangi naiseasi
ertodiagnosewheny
ourhearti
sworki
ng
harder.
7-El
ectrocardi
ogram:Anechocardi
ogram usessoundwavest
oproduceimagesoft
he
heart.

Nursi
ngDiagnosi
s:
1-
Acutepain
Mayber
elat
edt
o

 Decr
easedmy
ocar
dial
bloodf
low

 I
ncr
easecar
diacwor
kload/
Oxy
genconsumpt
ion

Possi
blyev
idencedby

 Repor
tsofpai
nv ar
yingi
nfr
equency,
dur
ati
on,
andi
ntensi
ty(
especi
all
yas
condi
ti
onworsens)

 Nar
rowedf
ocus

 Di
str
act
ionbehav
ior
s(moani
ng,
cry
ing,
paci
ng,
rest
lessness)

 Aut onomi cresponses, e.

g,di
aphoresis,bloodpressureandpulser at
echanges,
papi l
larydil
ati
on<, i
ncrease/decreasedrespir
atoryrate.
Desi
redout comes
 reportanginaepisodesdecreasedinf r
equency,duration,andseveri
ty.
 demonst raterel
i
efofpai nasevidencedbyst abl
ev i
tal si
gns,
absenceofmuscle
tensi
onandr estl
essness

-
Nur
singi
nter
vent
ion:

1-Assessanddocumentpat
ientr
esponset
omedi
cat
ion.

Rati
onal
e:aboutdi
seaseprogressi
[Link]
dsi
nev al
uat
ingef
fect
ivenessofi
nter
vent
ions
,andmayindi
cateneedforchangeint
her
apeut
icregi
men.

2-
Ident
if
ypr
eci
pit
ati
ngev
ent
,ifanyf
requency,
dur
ati
onandl
ocat
ionofpai
n.

Rati
onal
e:hel
psdif
ferenti
atethi
schestpai
n,andai
dsi
nev
aluat
ionpossi
ble
progr
essi
ontounstableangina.

2-
Inef
fect
iveTi
ssueper
fusi
onr
elat
edt
oreduct
ion/
int
err
upt
ionofbl
ood

PageLXXI
IIof73
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

f
low.
-
Out
come:

Demonst
rat
eadequat
eper
fusi
onasi
ndi
vi
dual
l
yappr
opr
iat
e.

-
Nur
singi
nter
vent
ions:

 I
nspectforpall
or,
cyanosi
s,andmot
tl
ing,
cool
andcl
ammyski
[Link]
est
rengt
hof
per
ipher
alpulses.

Rat
ional
e:sy
stemicvasoconst
ri
cti
onresul
ti
ngfr
om di
mi ni
shedcar
diacout
putmaybe
evi
dencedbydecr
easedskinperf
usionandanddimi
nishedpul
ses.

 Monit
orrespi
rat
ion,
notworkofbr
eat
hing.
Rat
ional
e:cardi
acpumpfai
lur
eand/ori
schemicpai
nmaypr
eci
pit
ater
espi
rat
ory
di
str
ess.

PageLXXI
Vof74
 [Link]
ivehear
tfai
l
ure(
Hear
tfai
l
ure)
Def i
niti
on:-
HFi
stheinabi
li
tyofthehear
ttopumpsuff
ici
entbl
oodtomeett heneedsoft hetissues
f
oroxygenandnutri
entsdemand.
Ty pes:
Therear
et wotypesofHF,whi
char
eidenti
fi
edbyassessmentofleftv entr
icular
functioning:
1)Syst
oli
cHF: weakhear tmuscl e

2)Di
ast
oli
cHF:
dif
fi
cul
toft
hev
ent
ri
clet
ofi
l
l

Pat
hophy
siol
ogy
:

1-Car
diacmuscl
efi
berar
edamaget hencontr
acti
l
ityint
hel ef
tvent
ri
clewil
l
decr
easeDecreasebl
oodeject
edfrom vent
ri
clesleadt
o:( SO)
1)Bar
orecept
orssenset
hedecr
easei
npr
essur
eand
2)t
heSNSstimul
ated l
eadtor
eleaseofadr
enal
i
net
hatcause
A)incr
easei
nHR, B)i
ncr
easeinBP.

(Thecompensatorymechani
sms):2-
Adr
enal
i
necausevasoconst
ri
cti
oninSki
n,ki
dney
,GI
Thecompensator
ymechani
smsareunabletomaintainadequatecardiac
output
Decr
ease(C.
O) leadtodecr
easerenalper
fusi
on leadt orel
easeof
r
ennintoform angi
otensi
[Link]

Angi
otensi
n1 conv
ert
edt
oangi
otesi
on2 (ByACE) t hatl
eadto
vasoconst
ri
cti
on(
after
load)
.

Angi
otensi
n2st
imul
atest
her
eleaseofal
dost
eri
ont
hatcauseNa+and
waterret
ent
ion.

3-
Sev
erl
eftv
ent
ri
cledi
l
atat
ionoccurasvenousreturnandsyst
emic
vesi
cularr
esistancei
ncr
ease

Ev
ent
ual
l
y,Al
lchamper
smaydilat
ecausi
nggeneral
i
zedcardi
omegal
y
wi
thassociat
edr
iskofar
rhyt
hmiaandembol
i

Leftsi
dehear
tfai
l
ure.*
Rightsi
dehear
tfai
lur
e.*
-
Maj
orsi
gnandsy
mpt
omsofHF:
Lef
tsi
deHFr
elat
edt
opul
monar
ycongest
ionandi
ncl
udes:
-

PageLXXVof75
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Dyspnea,pul
monarycrackl
es,l
owsaturat
ionl
evel
.Thi
rdhear
tsound(
S3),
reduce
ur
ineoutput,
dizzi
ness,f
ati
gueandweakness.
Rightsi
deHFi
nclude:
-
Lowerextr
emi
ti
esedema(
bit
ingedema(
per
ipher
aledema)
,asci
ti
es,
weakness.

PageLXXVIof76
-Causes:
1-coronaryart
erydisease
2-Hy pert
hyroi
dism
3-valvul
arheartdisease(st
enosi
s,r
egur
git
ati
on)
4-Kidneydisease
5-MI
Di
agnosti
cprocedure-
1)ECG MI
2)ECO
3)CBC
4)BUN
5)El
ectr
olyt
es
Pharmacologictherapy:-
1-angiot
ensinconv er
tingenzy mei nhi
bit
ors''
decreasehear
twor kload'
'
2-angiotensi
nI Ir
ecept orblocker'
'ARBS''(
loweredBpandv ascularresi
stance)
3-Hydral
azineandI sosor bi
deDi ni
trat
e
4-Di
ureti
csanddi gi
tali
s
5-BetablockersandCachannel bl
ockers
Nur
singpr
ocess:
-

[Link] diacOut put

-Nursi
ngDi agnosi s: DecreasedCar diacout put
Mayber elat edt o
Alteredmy ocar di
al cont ract il
it
y /
inotr
opi cchanges
Alterat ionsi nr ate,rhy thm, electri
calconduct i
on
Struct ur alchanges( e.g., valvulardefects, v
ent r
icularaneurysm)
Possiblyev idencedby
 I ncr easedhear trat e( tachy cardia)
,dy srhythmi as, ECGchanges
 Ch angesi nBP( hy pot ensi on/hypertension)
 E xtrahear tsounds( S3, S4)
 De cr easedur i
neout put
 Di mi nishedper ipher al pulses
 Co ol ,ashenski n;di aphor esis
 Or thopnea, crackles, JVD, liv
erengor gement ,edema
 Ch estpai n
-Desir
edOut comes
Displ ayv i
tal signswi t
hi naccept ableli
mi ts,dysrhy thmiasabsent/
controll
ed,and
nosy mpt omsoff ailur e(e. g.
,hemody nami cpar amet er
swi t
hinacceptable
l
imi t s,urinar youtputadequat e).
Re por tdecr easedepi sodesofdy spnea, angina.
Pa rti
ci patei nact ivi
tiest hatr educecar diacwor kl oad.

PageLXXVI
Iof77
-Nur singi nterv ention: -
1-Auscul t ateapi cal pul se, assesshear trate, rhy t hm.
Documentdy srhy t
hmi ai ftelemet r
yi sav ailabl et oTachy cardi
ai susual l
ypr esent(even
atrest )t ocompensat ef ordecr easedv ent ricul arcont r actil
i
ty.
Premat ureat ri
al cont ract i
ons( PACs) ,par oxy smal atrial t
achycar dia( PAT) ,PVCs,
mul tifocal atrialtachy car dia( MAT) , andat rial fibr il
lati
on( AF)ar ecommondy sr
hythmi as
associ atedwi t hHF, althoughot hersmayal sooccur .
Not e: Intract abl ev entriculardy srhy thmi asunr esponsi vet omedi cat ionsuggest
vent ri
cul araneur ysm
2-Not ehear tsounds.S1andS2maybeweakbecauseofdi minishedpumpi ngaction.
Gallopr hy thmsar ecommon( S3andS4) ,producedasbl oodf l
owsi ntononcompl iant
chamber [Link] mur smayr ef l
ectv alv ularincompet ence
3-Pal pat eper ipher alpul sest oDecr easedcar diacout putmayber eflectedi ndiminished
radial, popl iteal,dor salispedi s,andpostt ibial pul ses.
Pulsesmaybef leetingori rregulart opal pat ion, andpul susalternans( strongbeat
alt
er nat ingwi thweakbeat )maybepr esent .
4-Moni torBPt oPal l
ori si ndi cati
v eofdi mi nishedper i
pher alper f
usi onsecondar yto
i
nadequat ecar diacout put ,vasoconst ri
ction, andanemi a.
Cyanosi smaydev elopi nr efractoryHF.
Dependentar easar eof t
enbl ueormot tl
edasv enouscongest ioni ncreases.
5-Moni torur i
neout put ,not ingdecr easi ngout putandconcent ratedur i
ne.
toKi dney sr espondt or educedcar diacout putbyr etainingwat erandsodi um.
Urineout puti susual lydecr easeddur ingt hedaybecauseoff luidshi ftsintot i
ssuesbut
maybei ncr easedatni ghtbecausef luidr etur nst oci r
cul ati
onwhenpat i
enti s
recumbent

2-ExcessFl ui dVolume:
-Nursi
ngDi agnosi s
 F l
uidVol umeexcess
Mayber elat edt o
Reducedgl omer ularfi
lt
rati
onrat e(
decreasedcardiacout put)/increased
ant idiureti
chormone( ADH)pr oducti
on,andsodium/ waterret ention
-Possibl
yev idencedby:
Orthopnea, S3heartsound
Oli
gur ia,edema, JVD, posit
ivehepatojugul
arrefl
ex
We ightgai n
Hyper tension
Respi ratorydist
ress,abnormal breathsounds
-Desir
edOut comes
Demonst r
atestabili
zedflui
dv olumewi thbal
ancedi ntakeandout put,breath
soundscl ear/
cleari
ng,vit
alsignswi t
hinacceptablerange, stablewei ght ,
and
absenceofedema.
Verbali
zeunder st
andingofindividualdietary /
fluidrestr
ict
ions

PageLXXVI
IIof78
Nur
singi
nter
vent
ion:
--
1-Moni
torur
ineout
put
,not
ingamountandcol
or,
aswel
last
imeofdaywhendi
uresi
s
occur
s.t
oUr
ineout
putmaybescant
yandconcent
rat
ed(
especi
all
ydur
ingt
heday
)
becauseofr
educedr
enal
per
fusi
[Link]
avor
sdi
uresi
s;t
her
efor
e,ur
ine
out
putmaybei
ncr
easedatni
ghtand/
ordur
ingbedr
est
2-Moni
torandcal
cul
ate24-
houri
ntakeandout
put(
I&O)bal
ance,
Diur
eti
cther
apymay
r
esul
tinsuddeni
ncr
easei
nfl
uidl
oss(
cir
cul
ati
nghy
pov
olemi
a),
event
houghedemaor
asci
tesr
emai
ns
3-Mai
ntai
nchai
rorbedr
esti
nsemi
-Fowl
er’
sposi
ti
ondur
ingacut
ephase,
Recumbency
i
ncr
easesgl
omer
ularf
il
tr
ati
onanddecr
easespr
oduct
ionofADH,
ther
ebyenhanci
ng
di
eresi
s
4-Est
abl
i
shf
lui
dint
akeschedul
eiff
lui
dsar
emedi
cal
l
yrest
ri
cted,
incor
por
ati
ng
bev
eragepr
efer
enceswhenpossi
[Link]
vef
requentmout
hcar
e.I
cechi
pscanbepar
tof
f
lui
dal
l
otment
.,I
nvol
vi
ngpat
ienti
nther
apyr
egi
menmayenhancesenseofcont
rol
and
cooper
ati
onwi
thr
est
ri
cti
ons

PageLXXI
Xof79
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageLXXXof80
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

[Link]
SORDERS

[Link]
LURE
-
Def i
nition:
--Renal failurei sacondi t i
oni nwhi cht hekidney sf ailt
or emov emet abolicend-
product sf rom t hebl oodandr egul atethef luid,elect r
olyte,andpHbal anceoft he
extracel lularf luids.
--Theunder l
y i
ngcausemayber enal di
sease, systemi cdi sease, orurologicdef ects
ofnonr enal origi n.
-
Acut er enal fail
ur e:
-Acut erenal failur er epresent sar api ddeclinei nr enal f
unct ionsuf f
ici
entt o
i
ncr easebl oodl ev elsofni trogenouswast esandi mpai rfluidandel ectroly
te
balance.
-Itisacommont hreatt oser iousl yillpersonsi nint ensi
v ecar eunits,wi t
ha
mor tali
tyr ater angi ngf rom 42%t o88%
-Themostcommoni ndi
cat orofacut erenal fail
ur ei sazot emia,anaccumul ationof
nitr
ogenouswast es( ur
eani trogen, uricacid, andcr eati
nine)i ntheblood.
-Inacut er enal failuret hegl omer ularf i
lt
rati
onr ate( GFR)i sdecr eased.
-Asar esul t,excr et i
onofni t rogenouswast esi sr educedandf luidandel ectr
olyt e
balancecannotbemai ntained.
-Per sonswi thacut er enal failureof tenareasy mpt omat i
c, andt hecondi ti
oni s
diagnosedbyobser vati
onofel ev at i
onsi nbl oodur eanitrogen( BUN)and
creat ini
ne.
-Acut erenal failur eismani festedbyashar pdecr easei nur i
neout putanda
dispr opor tionat eel ev at
ion15: 1t o20: 1(nor mal ratio10:1) .
-
TypesofAcut eRenal Failure:
Thecausesofacut er enal failurecommonl yar ecat egor i
zedas
-Prer enal (55%t o60%)
-Intri
nsi c( 35%t o40%)
-Post r
enal (5%)
1-Pr erenal Failur e:
-Prer enal fai l
ure, t hemostcommonf orm ofacut er enalfai l
ure,ischaracteri
zedby
amar keddecr easei nrenal bloodf low.
-Itisr ever siblei ft hecauseoft hedecr easedr enal bloodf lowcanbei dentif
iedand
corr ectedbef oreki dneydamageoccur s.
-
Causesofpr er
enal f
ail
ureinclude:
-Pr ofounddeplet
ionofv ascularv
olume(e.
g.,hemorr
hage,
lossofext
racel
l
ular
f
luidvolume)
-Impai redper
fusi
oncausedbyhear tfai
l
ureandcardi
ogeni
cshock.
-Decr easedvascularf
il
li
ngbecauseofi ncr
easedvascul
arcapaci
ty(
e.g.
,

PageLXXXIof81
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

anaphyl
axisorsepsi
s).
-Somev asoacti
vemediator
s,dr
ugs,anddiagnosti
cagent
sstimulat
eint
ense
i
ntrar
enalvasoconst
ri
cti
onandinduceglomerularhy
poperf
usionandprer
enal
fai
lur
e.

PageLXXXI
Iof82
-
Examples:
[Link]
nConv erti
ngEnzyme(ACE)i
nhibi
tor
swhencombi
nedwi
th
di
uret
ics
[Link] Dsthr
oughi nhi
biti
onofprost
agl
andi
nsynthesi
s.
[Link] essantdrugs.
[Link] ne.
[Link]
ne.

2-
PostrenalFail
ure:
- Postrenalf
ail
ureresul
tsfrom obst
ructionofuri
neoutfl
owfrom thekidney
s.
- Theobst r
ucti
oncanoccuri ntheureter(i
.e.
,cal
cul
iandstr
ictur
es),bl
adder(i
.e.
,
tumor sorneurogeni
cbladder
),orurethra(i
.e.
,pr
ostat
ichy
per t
rophy)
.

3-I
ntri
nsi cRenalFailure:
-I ntrinsi
corintrarenal renalfail
ureresul
tsfrom condi tionsthatcause
damaget ostruct ureswi thi
nt heki
dney —glomer ular,
t ubul
ar,orinterst
iti
al.
-I nj
ur ytothetubul esi smostcommonandof tenisischemi cortoxici n
origin.
-Themaj orcausesofi nt r
arenalfai
l
ur eareischemi aassoci at
edwi t
h
prer enalf
ail
ure, t
oxi cinsulttothetubularstructur
esoft henephr on,and
intratubul
arobst ruction.
-Acut egl
omerul onephr iti
sandacut epyelonephr i
ti
sal soareintrarenal
causesofacut er enal fai
lure.
-PhasesofRenal Failure:

-Cl
ini
cal Mani f
est at
ions:
Lethargi
c, nausea, vomiti
ng,di
arrhea,dryski
n,uremicf
etorbr
eat
h,
drowsiness, headache, muscletwitchi
ng,sei
zures.
-Di
agnost i
cFi ndings:
-Changei nurine
-Changei nkidneycont our
-IncreasedBUN, creat
ini
n
-Hy perkalemia
-Met abolicacidosis
-Hy pocalcaemi a

PageLXXXI
IIof83
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-I
ncreasedphosphor
us
-Anemia.

PageLXXXI
Vof84
-
Management :
-Pharmacol ogyt herapy.
-Nutri
tionaltherapy .
-Monit ori
ngfluid&el ect
rol
ytebal
ance.
-Reduci ngmet abolicrat
e.
-Promot i
ngpulmonar yfunct
ion.
-Prevent i
nginfecti
on.
-Providingskincar e.
-Providingsuppor t.

Chroni
cr enalfai
lur
e
-Chronicrenal f
ail
urerepresentst
heendresultofcondi
ti
onsthatgr
eat
ly
reducerenalfunctionbydest r
oyi
ngrenalnephronsandproduci
nga
mar keddecreaseint heglomerul
arf
ilt
rat
ionrate(GFR)
.

-
Compl i
cations:
- Hyperkal emi aduet odecreasedexcr et i
on, met abolicacidosis,cataboli
sm,
andexcessi vei nt
ake(diet,medi cati
ons, fluids)
- Pericardi ti
s,per i
cardi
aleffusion,andper icardialtamponadeduet o
ret
entionofur emicwastepr oduct sandi nadequat edi al
ysis
- Hypertensi onduet osodium andwat err et enti
onandmal funct
ionoft he
- Renin–angi otensin–aldost eronesy stem.
- Anemi aduet odecreaseder ythropoietinpr oduct i
on, decreasedRBCl i
fe
span,bleedi ngi ntheGItractf rom ir
ritati
ngt oxins,andbloodl ossdur i
ng
hemodi aly si
s
- Bonedi seaseandmet astati
ccal cif
icationsduet oretentionof
phosphor us,lowser um calci
um l evels,abnor mal vi
taminDmet aboli
sm,

PageLXXXVof85
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

andel ev at edal umi num levels.

-
Medi cal management
-Ant i aci ds
-Ant ihy per tensi ve
-Ant i sei zur eagent s
-Er ythropoi etin
-Cal cium suppl ement s
-Di alysi s
-Ki dneyt ranspl ant
-
Nur singDi agnose( Problems)i nAcut eRenalFai
lure
-I nef fect ivet issueper f
usion( r
enal)
-Excessf luidv olume
-Ri skf ori nf ection
-Ri skf ordef i
cientf l
uidv olume.
-
Treat mentofAcut eRenal Fail
ure
-Cont inuousar t
eriovenoushemof ilt
rat
ion
-Lowpr otei n,increasedcar bohydrate,
moder at
ef at
,andmoderatecalor
ie
diet wi thpot assium, sodium andphosphor usintakeregul
atedaccor
dingto
ser um l ev els
-Per itoneal dialysisorhemodi aly
sis
-Fl ui di ntaker est r
ict
edt ot heamountneededt oreplacefl
uidl
oss.
-Tr ansf usi ont herapywi thpackedRBCsadmi ni
steredover1to3hoursas
toler ated.
-
Plani ngandGoal ofNur singCar ePlane

[Link]
i
entwi
l
lhav
enor
mal
flui
dandel
ect
rol
ytel
evel
s

[Link]
i
entwi
l
lexper
iencenopr
event
abl
ecompl
i
cat
ion

[Link]
ientwi
ll
understandthemeansbywhichHi
s/Herf
ami
l
ymember
swi
l
l
i
mplementhealt
hteachingaft
erdi
schar
ge.

-Nursi
ngI
nterventi
onforAcut eRenal Fail
ure
Tothenursingint
erventi
on,thenursesshoul dbehavegoodknowledgetodecidewhich
phaseofhis/herpati
entrel
atedt otheacuterenalf
ail
[Link]
nfor
mat i
on,
bell
owaresomenur si
nginterventi
ont heycandotothepatientwi
thacut
erenalfai
l
ure:

-Ol
iguric-
anuri
cphase; I
nt hi
sphase,thecli
ent'
sur i
neoutputf
all
sbelow400ml /
day.
Wit
hr esult
antelectrol
ytei
mbal ance,
met aboli
cacidosi
s,andret
enti
onofnitr
ogenouse
wastesf r
om nonf uncti
oningnephrons.
Thi
spahsemayl astupto14day [Link] sesshouldbefoll
owthesesteps:

PageLXXXVIof86
[Link]
nthecl
ientoncompletebedr
est
,or
ganizecaret
oprov
idel
ongrest
per
[Link]
ivi
tyincr
easetherat
eofmet
abol
ism,whichi
ncr
easepr
oducti
onof
ni
tr
ogenousewast eproduct
.

[Link]
erventi
ontoprev
entinf
ecti
onandt hecompli
cati
onsofi
mmobi l
it
y.
BecauseShe/Hei sonbedrest,
thecl
ientbecomessuscepti
bletot
hehazardsof
i
mmobi l
i
ty.I
nfecti
onisaser
iousri
skandt heleadi
ngcauseofdeat
hincl
ientwit
h
acuterenalf
ail
ure.

[Link]
vet
hecl
ientformetabol
icaci
dosi
stoident
if
ycompl
i
cat
ionofr
enal
fai
l
ure.
Obser
vet
hefl
uidandelectr
oly
tebal
ancehourl
y.

4.I
nsertanindwell
i
ngur i
narycathet
erandmeasur eoutputandspeci f
icgravi
ty
hourl
[Link]
onallowthenursetomonitorthekidneys,
whi chhavet he
majorrol
einregulat
ingfl
uidandelect
rol
[Link] l
evelscan
occur.

[Link]
deonl
yenoughfl
uidint
akest
orepl
aceur
ineout
putt
oav
oidanedema
causedbyexcessi
vef
lui
dint
ake.

[Link]
heclient'
sdiettoprov
idehighcarbohydrates,adequatef
ats,andlow
prot
ein.I
fcl
ientreceiveshi
ghcalori
esfrom fatandcarbohy dr
atemetaboli
sm,
thebodydoesn'tbreakdownpr ot
[Link]
nisthusavail
ablefor
growthandrepair.

[Link]
'spotassi
um i
ntaket
ohel ppr
eventel
evatedpot
assium l
evel
s.
Prot
eincataboli
sm causespotassi
um r
eleasefr
om cel
lsintot
heserum.

[Link]
vefort
hear
rhy
tmi
asandcar
diacar
restt
oident
if
ycompl
i
cat
ionsofhi
gh
ser
um pot
assi
um.

[Link]
defrequentor
alhygienet
oav oi
dti
ssuei
rr
it
ati
onandsometi
meul cer
formati
oncausedbyureaandot heraci
dwast
eproduct
sexcr
etedthr
ought he
skinandmucousmembr anes.

10.
Prov
idet
heclientwi
thhar
dcandyandchewi
nggum t
ost
imul
atesal
i
vaf
lowand
decr
easethi
rst.

11.
Maint
ainski
ncarewit
hcoolwatert
or el
iv
epruri
tusandr
emov
eur
emi
cfr
ost
(whi
tecry
stalf
ormedonski
nfrom excret
ionofurea)
.

12.
Admi ni
sterstool
sof
tener
stopr
eventcol
oni
rr
it
ati
onf
rom hi
ghl
evel
sur
eaand
organicacids.

PageLXXXVI
Iof87
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

13.
Provideemoti
onalr
eassur
ancetot
hecli
entandfami
lymemberst
ohelp
decreaseanxi
etyl
evel
scausedbyt
hefactthatt
hecl
i
enthasanacut
eil
lness
withunknownprognosi
s.

14.
Expl
aint
reat
ment
sandpr
ogr
esst
othecl
i
entt
ohel
preduceanxi
ety
.

15.
Prov
idehemodi
aly
sisorper
it
oneal
dial
ysi
sasor
der
ed.

PageLXXXVI
IIof88
-Earlydiureti
cphase; Duringear l
ydi ureti
cphase, whi chlastabout10day s,thecli
ent
excretesal argev olume( ov er3, 0000ml /day )ofv erydil
uteurine.
Thegl omer ul
i arebegi nningt of unctionef fectivel
y ,
butt ubul
esar en'
t,andthecli
entsti
ll
experiencesel ectrolyt
ei mbal ance, retentionofni trogenouswast epr oductand
metabol i
sm aci [Link] seshoul dbedoi nterventi
onsuchas;
[Link] l
ui dandel ect r
olytebal ancet oi dent i
fycont i
nuedf l
uidandelectrol
yte
imbal ancewhent her enal tubulesar en'tfunct i
oning.
[Link] heemot ional statusoft heclientandf ami l
ymember stoprovidesupport
becauset hepr ognosi sisst i
lluncer t
ain.
[Link] inueint er
v enti
onsuseddur i
ngt heol iguricphase.

-LateDi ureticphase; I
nt helatedi ureticphase, t
hecl ientisst il
lexcret
ingmor eflui
d
thannor [Link] i
nespeci ficgrav i
tyi sincreasingbecauset hetubulesarebeginningto
functionef fectiv
ely.
Flui
d, electrolyt
eandaci d-basebal ancesar er eturningt onor mal .
I
nt hiscondi ti
on,Thenur seshoul ddot hef ol
lowi ngst eps;
[Link] inuingimpl ement ati
onsoft heear l
ydi ureti
cphase.
[Link] lowt hecl i
entt oengagei nnonst renuousact i
v i
tyf orbriefperi
odsandi ncreaset
he
act i
vitylevelgradually.
[Link]' tlethim/ herbecomef ati
guedwhi chmayi ncr easet herateofmet aboli
sm and
ov erworkt hekidney s.
[Link] heclienttopr eventi nf
ect ionandt oav oidt hef actorsthatcausedrenal
failuretohel ppreventar ecurrence.

-
Eval
uat
ionofNur
singI
nter
vent
ion

- Thecl
i
entr
egai
nsf
lui
dandel
ect
rol
ytebal
ance.

- Thecl
i
entunder
standst
her
ati
onal
ebehi
ndact
ivi
tyr
est
ri
cti
on.

PageLXXXI
Xof89
 [Link]
NARYTRACTI
NFECTI
ON (
UTI
)
-Definiti
on:
Aur inarytractinf
ection( UTI)i
saninf ect
ioninanypar tofy ourur i
narysystem —y our
kidney s,uret
ers,bladderandur ethr
[Link] nfecti
onsinv ol
vet helowerur i
narytract—
thebl adderandt heur [Link] eatgreaterri
skofdev elopi
ngaUTIt hanmenar e.
Infectionlimit
edt oy ourbladdercanbepai nfulandannoy i
[Link] er
,serious
consequencescanoccuri faUTIspr eadstoy ourki
dney s.
Doct orst y
pical
lytreatur i
narytr
actinfect
ionswi t
hant i
bioti
[Link] oucant akestepsto
reducey ourchancesofget ti
ngaUTIi nthefirstpl
ace.

-
Sympt oms:
Ur
inarytractinf ecti
onsdon' tal
way scausesignsandsy
mpt
oms,butwhentheydothey
mayinclude:
 As t r
ong, per si
stenturgetour i
nate
 Ab urni
ngsensat ionwhenur inati
ng
 Pa ssingfr equent ,
smal lamountsofurine
 Urinet hatappear scloudy
 Urinet hatappear sred,bri
ghtpinkorcola-
color
ed—asi
gnofbl
oodintheuri
ne
 Strong- smel li
ngur i
ne

-
Par
tofur
inar
ytr
actaf
fect
ed:
-
Kidney
s(acut
epy
elonephr
it
is)
.
-
Signsandsy mpt oms:
-
Upperbackandsi de( f
lank)pain
-
Highf ever
-
Shakingandchi ll
s
-
Nausea
-
Vomi ti
ng
-
Partofur inarytr actaff
ect ed:
-
Bladder( cysti
tis)
-
Signsandsy mpt oms:
-
Pelvi
cpr essur e.
-
Lowerabdomendi scomf ortFr
equent,
pai
nful
uri
nat
ion.
-
Bloodi nur i
ne.
-
Pelvi
cpai n, i
nwomen—especi al
lyi
nthecent
eroft
hepelv
isandar
oundt
hear
eaoft
he
pubicbone.
-
Partofur inarytr actaff
ect ed:
-
Urethra(ur et
hritis).
-
Signsandsy mpt oms:
-
Burningwi thur inationDischarge.

PageXCof90
-
Causes:
Urinar
ytr
actinfect
ionstypical
lyoccurwhenbact eri
aentertheuri
narytractthr
ought he
urethr
aandbegi nt
omul tiplyi
nt hebl
[Link]
thoughtheur i
narysystem isdesignedto
keepoutsuchmi croscopicinvaders,
thesedefensessomet i
mesf ail
.Whent hat
happens,bacter
iamayt akehol dandgrowintoaf ul
l-
blowninfect
ionintheur i
narytract
.
-ThemostcommonUTI soccurmai nlyi
nwomenandaf f
ectthebladderandur ethr
a.

-Ty
pesofur i
naryt
ractinf
ect i
on:
EachtypeofUTImayr esultinmor e-
speci
fi
csi
gnsandsy
mpt
oms,
dependi
ngonwhi
ch
partofyourur
inar
ytracti
si nfect
ed.
 Infecti
onoft hebladder(cysti
ti
s).ThistypeofUTIisusuallycausedbyEscher ichi
a
coli([Link]
),atypeofbacteriacommonl yf oundinthegastrointesti
nal(GI
)tract.
Howev er,
somet i
mesot herbacteriaareresponsibl
[Link] i
ntercoursemayl eadto
cystit
is,butyoudon'thavet obesexual l
yactivetodevel
opi [Link] eatr i
sk
ofcy sti
ti
sbecauseoft heiranatomy—speci fi
cal
ly,t
heshor tdistancefrom t
he
urethratot heanusandt heurethralopeningtothebladder.

 Inf
ectionoftheurethr
a(uret
hri
tis)
.ThistypeofUTIcanoccurwhenGIbacteri
a
spreadf r
om [Link]
so,becausethefemal
euret
hraiscl
osetothe
vagina,sexual
lyt
ransmit
tedinfect
ions,suchasherpes,
gonorr
hea,chl
amydiaand
my coplasma,cancauseuret
hriti
s.

-
Riskfactor
s:
Uri
narytracti
nfecti
onsarecommoni nwomen,andmanywomenexperi
encemoret
han
oneinfecti
onduringthei
rli
fet
[Link]
skf
act
orsspeci
fi
ctowomenforUTIsi
ncl
ude:

 [Link]
hrathanamandoes,
whi
chshor
tens
thedi
stancethatbact
eri
amustt
rav
elt
or eachthebladder
.

 Sexualacti
vi
[Link]
lyacti
vewomentendtohavemoreUTIsthandowomenwho
aren'
tsexual
lyacti
[Link]
tneral
soi
ncr
easesy ourr
isk.

 Cert
aint
ypesofbi
rt
hcontr
[Link]
aphr
agmsforbi
rt
hcont
rol
maybe
athi
gherri
sk,
aswellaswomenwhousesper
mici
dal
agent
s.

 [Link],adecl
i
neincir
cul
ati
ngestrogencauseschangesi
n
t
heurinar
ytractthatmakeyoumor evul
ner
ablet
oinfect
ion.
Otherri
skfactorsforUTI
sincl
ude:

 Uri
narytractabnor
malit
[Link]
esbornwi
thuri
naryt
ractabnor
mal
it
iest
hatdon'
t
al
lowurinetoleavethebodynormall
yorcauseuri
netobackupint
heuret
hrahav
e
anincr
easedr i
skofUTIs.

PageXCIof91
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Bl
ockagesintheur
inarytr
[Link]
dneyst
onesoranenl
argedpr
ost
atecant
rapur
ine
i
nthebladderandi
ncreasetheri
skofUTIs.

 Asuppr
essedi
[Link]
abetesandotherdiseasest
hati
mpairt
hei
mmune
sy
stem t
hebody'
sdef
enseagai
nstgerms canincreasether
iskofUTI
s.

 [Link]'turi
nat eonthei
rownanduseat ube(cat
heter)t
o
uri
natehav eanincreasedri
skofUTI [Link]
smayincl
udepeoplewhoar ehospit
ali
zed,
peoplewithneurological
probl
emst hatmakeitdi
ffi
cul
ttocontr
olthei
rabi
lit
yto
uri
nateandpeopl ewhoar eparal
yzed.

 Arecentur
inaryprocedur
[Link]
nar
ysurgeryoranexam ofy
oururi
nar
ytr
actt
hat
i
nvolvesmedicali
nstrument
scanbothincreasey
ourri
skofdevel
opi
ngauri
nar
y
t
racti
nfect
ion.
-
Compl
i
cat
ions:

Whent reat
edpromptlyandproper
ly,
loweruri
nar
ytractinf
ect
ionsrarel
yleadt
o
complicati
[Link]
eftunt
reat
ed,aurinar
ytr
acti
nfecti
oncanhav eseri
ous
consequences.

Compl
icat
ionsofaUTImayi nclude:
 Recurr
entinf
ections,
especi
all
yinwomenwhoexper
iencethreeormoreUTIs.
 Permanentkidneydamagefrom anacut
eorchr
oni
ckidneyinfect
ion(
pyel
onephr
it
is)
duetoanuntreatedUTI.

 I
ncr
easedr
iski
npr
egnantwomenofdel
i
ver
ingl
owbi
rt
hwei
ghtorpr
emat
urei
nfant
s.

 Uret
hralnar
rowing(str
ict
ure)i
nmenf
rom r
ecur
rentur
ethr
it
is,
prev
iousl
yseenwi
th
gonococcalur
ethri
ti
s.

 Sepsi
s,apot
ent
iall
yli
fe-
thr
eateni
ngcompli
cati
onofaninf
ect
ion,
especi
all
yift
he
i
nfect
ionwor
ksitswayupy ourur
inar
ytr
acttoyourki
dney
s.

-
Test
sanddi
agnosi
s:
-
Test
sandpr
ocedur
esusedt
odi
agnoseur
inar
ytr
acti
nfect
ionsi
ncl
ude:
 Analyzingaurinesampl e.
Yourdoct ormayaskf oraur i
nesamplef orl
abanal
ysi
sto
l
ookf orwhitebloodcells,redbl oodcellsorbacteri
[Link] oi
dpotenti
al
contami nat
ionofthesampl e,youmaybei nst
ructedtofir
stwipeyourgeni
tal
area
withanant i
septi
cpadandt ocol l
ecttheuri
nemi dstr
eam.
 Growingur i
narytractbacteriainal [Link]
sisoftheur i
neissometi
mes
fol
lowedbyaur i
necul t
[Link] esttell
syourdoctorwhatbacteri
aarecausi
ngyour
i
nfectionandwhi chmedi cationswi llbemosteffecti
ve.

PageXCI
Iof92
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Creatingi magesofy ourur i

narytract.I
fyouar ehavingf r
equenti nf
ectionsthatyour
doctort hinksmaybecausedbyanabnor malit
yinyourur i
naryt r
act,youmayhav e
anul t
rasound, acomput erizedtomogr aphy(CT)scanormagnet icresonance
i
magi ng( MRI ).Yourdoct ormayal souseacont rastdy etohighli
ghtst r
ucturesi
n
yourur i
nar ytr
act.
 Usingascopet oseei nsidey [Link] ecurr
entUTI s,yourdoctormay
perform acy stoscopy ,usingal ong,thintubewithal ens(cystoscope)t oseeinsi
de
yourur ethraandbl [Link] stoscopeisinsert
edi nyourur et
hraandpassed
thr
ought oy ourbladder.

-Nursi
ngDi
agnosi
sandI
nter
vent
ions:
[Link]
ePai
n:
rel
atedtoinf
lammat i
onandi nfect
ionoft
heuret
hra,bladderandot
herur
inar
ytr
act
structur
es.
Goal:Pai
nisreduced/lost,t
hespasmscanbecont r
oll
ed.
Expectedoutcomes: cl
ientreport
ednopainonurinati
on,nopaini
nthesupr
apubi
cregion.

-
Int
erv
ent
ion:
[Link]
oruri
necol orchanges, monitorthevoidi
ngpatt
ern,
inputandoutputev
ery8hour
sand
monit
ortheresult
sofur i
nalysisrepeated.
Rati
onale:Toidentif
ytheindicati
onsofpr ogressordevi
ati
onsfrom expect
edresul
ts
[Link]
ethelocat
ion,
timeint
ensi
tyscale(
1-10)pai
n.
Rati
onal
e:Tohelpevaluat
etheplaceofobstr
ucti
onandcausepai
n.
[Link]
ovi
deconv
enientmeasures,suchasmassage.
Rati
onal
e:I
ncr
easerelaxat
ion,r
educemuscl
etensi
on.
[Link]
veper
ineal
care.
Rati
onal
e:Toprev
entcont
ami
nat
ionoft
heur
ethr
a.
5.I
fusi
ngacathet
er,cathetert
reat
ment2ti
mesperday.
Rati
onal
e:Thecatheterprovi
desawayforbact
eri
atoent
ert
hebl
adderandur
inar
ytr
act
upt
o.
[Link]
ver
tat
tent
iont
ot hefun.
Rati
onal
e:Rel
axat
ion,av
oidtoof
eel
thepai
n.
[Link]
labor
ati
onofanalgesi
cs.
Rati
onale:t
ocontr
olthepain.

2.I mpairedUri
naryElimination:
-relatedtofr
equentur i
nation, ur
gency,andhesit
ancy
.
-Goal :i
mproveur
inar
yeliminationpatt
ern.
Expect edoutcomes: cl
ientsr eport
edar educt
ioninf
requency(
frequentur
inat
ion)
,
ur gency,andhesist
ensi.

I
ntervent
ion:
[Link]
ient
'
spat
ter
nofel
i
minat
ion.

PageXCI
IIof93
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Rat
ional
e:asabasi
sfordet
ermi
ningi
nter
vent
ions.
[Link] hepat
ienttodri
nkasmuchaspossi
bleandreducedri
nkinginthe
aft
ernoon.
Rati
onale:Tosupporttherenalbl
oodfl
owandtofl
ushbacteri
afrom theur
inarytract
.
Theliqui
dt hatcanir
ri
tatethebl
adder(
eg,
cof
fee,t
ea,al
cohol)i
savoided.I
nor dernotto
wakeupf requentl
yatnighttouri
nat
e.
[Link]
ienttour i
nateever
y2- 3hour
sandwhenitsuddenl
yfel
t.
Rati
onale:Becausei
tsignif
icantlyl
owersthenumberofbact
eri
aintheuri
ne,r
educed
uri
nestatusandpreventrecurrenceofi
nfecti
on.
[Link]/encour
agementdoper
ineal
careeveryday.
Rati
onale:Reducet
heri
skofcont
aminati
on/infect
ioni
ncr
eased.

PageXCI
Vof94
[Link]
tern
relat
edt opai
nandnoct ur
ia.
-Goal:toimprovesl
eeppatter
ns.
-Expectedoutcomes:cl
ientsr
epor
tedbei
ngabl
etosl
eep,
cli
ent
sseem f
resh.
-I
ntervention:
[Link] erminet heusual sleepinghabi tsandchanges.
Rationale:Assessandi dent if
yappr opri
ateinter
venti
ons.
[Link] ovi
deacomf or tablebed.
Rationale:Impr ovesl eepingcomf ortandsuppor tofphysi
ological
/psychological
.
[Link] or tbedt imer egi
men, f
orexampl e,
awar m bathandamassage, agl
ass
ofwar m mi lk.
Rationale:Incr easest heef fectofrelaxati
[Link]:Themilkhassopofikqualit
y,boost
thesy nthesisofser ot onin,aneur otransmitt
erthathel
pspat i
entsandsleeplonger.
[Link] seandl ight.
Rationale:Pr ov i
deasi tuationconduci vetosleep.
[Link] ionmeasur es.
Rationale:Hel psi nducesl eep.

[Link] per
ther
miarelatedtothereacti
ontoinf
lammati
on.
Goal:bodytemperaturebacktonor mal
.
Expectedoutcomes: cl
ientr
eportednofev
er,nopal
pabl
eheat
,vi
tal
signswi
thi
nnor
mal
l
imits.

-I
nterventi
on:
[Link] aint
sorsi gnsofincreasedbodyt emperat
urechanges.
Rationale:Incr easedbodyt emper aturewillshowsav ari
etyofsymptomssuchasr
ed
eyesandt hebodyf eel swar m.
[Link] vationofv i
tal si
gns, especiall
ytemper at
ure,
asi ndi
cat
ed.
Rationale:Todet ermi neinterventions.
[Link] m wat ercompr essont heforeheadandbot haxill
a.
Rationale:Tost imulatethehy pothalamust othetemperatur
econtrolcent
er.
[Link] ionofant i
pyreti
cdr ugs.
Rationale:Cont r
oll
ingf ever.

-Pharmacologi
ctherapi
es:
-fourtypesofpharmacologi
cther
apyar
eusedt
otr
eatOAB:
 Estrogen.

 Ant
imuscar
ini
cdr
ug.

 Non-
sel
ect
ive.

 Sel
ect
ive.

PageXCVof95
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Tr
icy
cli
cant
idepr
essant
s.

 Bot
uli
num t
oxi
n(BOTOX)I
ngect
ions.

PageXCVIof96
 [Link]
CALDI
SORDERS
[Link]
ngi
ti
s
-Def i
nition:
Meni ngi t
isisani nfl
ammat i
onoft hel
iningaroundthebrainandspinalcordcausedby
bact eriaorv iruses.
-CausesofMeni ngiti
s:
1-Bact er i
a:e.g.,meni ngococcus,pneumococcus, inf
luenzabacil
lus,
tubercl
ebaccil
us.
2-Viral:Awi dev ari
etyofvir
uses.
Meni ngi t
isiscl assifi
edas(sept i
corasept i
c).
*Theasept i
cf orm maybev i
ralorsecondarytolymphoma, leukemia,orhuman
i
mmunodef i
ciencyv i
rus(HIV).
*Thesept i
cf ormi scausedbybact eri
asuchasSt reptococcuspneumoni aeand
Neisser i
ameni ngiti
des.
-Riskf actor:
1-Thepr imar yri
skf act
orisasuppr essedimmunesy st
em causedby:
a-alcoholism.
b-immunosuppr essivedrug.
c-remov al ofspl een.
d-smoki ng.

2-ageunder(5)yearandolderthan(60)
.
3-li
vi
ngandwor kingwithlar
gegr oupofpeopl
e(chi
l
dcar
efaci
l
iti
es)
.
4-headinjur
iesandbrainsurgery
.
5-skippi
ngvaccinat
ions.

-
pathophysiologyofMeni ngiti
s:
-
Meni ngi
tisoccur sasar esultoftheext ensionofabodyi nf
ecti
onordirect
lyfrom
woundi ntoskin,skullfr
actureort hroughsur gicalpr
ocedures,l
umberpunct ure.
-
Oncet heor ganism implanted, i
tspreadsintot heCSFt hentosubarachnoidspace
-
Asanybact eri
al i
nfecti
on,thei nf
ectionprocessi sinf
lammat i
on,exudati
on,
accumul ati
onoft hewhi t
ebl oodcel l
sandv aryi
ngdegr eeofti
ssuedamage.
-
Thebr ai
nbecomesedemet ousandt hebrainent ir
esurfaceiscover
edwi t
h
purulentexudat es.
-Ifi
nfecti
onext endst obrainv entr
icl
es,thickpusandadhesi onwi l
lobstr
uctthe
CSFf low.

-
Manif
estat
ionsofMeni ngi t
is:
-
Earl
ymeni ngi
ti
ssympt omsmaymi micthef
lu
-
symptomsmaydev elopov ersev
eral
hoursorfewday
s.
 suddenhi ghfev er.
 stiffneck.
 sev ereheadache.
 headachewi thnauseaorv omiti
ng.
 coughi ngdif
fi
cul ty
.
 seizures.

PageXCVI
Iof97
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 sl
eepiness.
 sensi
tiv
itytol
ight
.
 noappetiteorthi
rst
.
 ski
nrashes.

-
Diagnost
ict
estsofMeningit
is:
►Lumberpunct ur
eisthediagnost
ict
estt
oident
if
ybact
eri
ainbl
ood.
►completebloodcount(usual
lyWBCcountisel
evat
ed)
.
►CTscanoft hehead.
►Bloodcult
ure
-
Compli
cations:
1-seizure
2-braindamge
3-ki
dneyf ai
lur
e.
4-shock.
Ther
apeuticmanagementofMeni ngit
is
Theini
ti
altherapeuticmanagementi ncludes:
►Isolati
onpr ecauti
ons.
►Ini
ti
ationofant imicr
obialt
herapy,usuall
ythr
oughIVi
nfusi
onandi
nlar
gedoses.
►Mai ntenanceofopt imum hydrati
ont hr
oughIVinf
usi
on.
►Reduct ionofincreasedICPControlofseizur
es.
►Mai ntenanceofv enti
lati
on.
►Controlofhy pothermiaorfever
.
►Treatmentofcompl i
cati
ons.

-Nursingdiagnosi sI:
-Alt
eredt i
ssuesper fusion( cerebral)r
elatedt ocerebraledema, i
ncreasedI
CP,
sei
zur
es.
-NurseGoal (
1):
-Thepat i
entreturnedt ot henor mal neurologicstatusbeforetheill
ness.
-increasedpat i
entawar enessandsensor yfuncti
on.
-Expectedout come:
-increaseawar eness, headpai nr educed, normal vi
talsi
gn.
-I
nterventi
on:
1-pat i
enttotalbedr estwi t
hsupi nesl eepingposit i
onwi t
houtpil
low,
Rationale:changei nintracranialpressurei stheriskforbrai
nher ni
ati
on.
2-moni torsignf orneurologicalst
atus.
Rationale:toreducef urtherbraindamage.
3-moni torvit
al si
gn.
Rationale:i
ncreaset emper aturecandescr ibethecour seofinfecti
on.
4-moni t
orintakeandout put,
Rationale:nauseacandecr easeor ali
ntaket hatriskfordehydrati
on.

PageXCVI
IIof98
5-hel
ppat ienttoli
mitvomi ti
ng,coughi
ng, i
nstr
uctthepat
ientt
oexhal
ewhenmov
ing
andturningbed.
Rati
onale:activi
tycanincreaseICPandi ntr
a-abdomen.
6-provideappr opr
iat
eadv icedoctororder.
Rati
onale:therapydecreasecerebraledema.

-Nur si
ngdi agnosi sII:
-Al ter
ednut riti
on: lesst hanbodyr equir
ement s.
relatedt or est r
ictedi ntake;nausea, andv omi t
ing.
-Goal :
-Thepat ientwei ghtwi llbestableandappr opriat
ef orage,moi stmucousmembr ane
andadequat eur ineout put.
-Nauseaandv omi tingcont rol
led.
-Nur si
ngI nt ervent i
on.
►Wei ghtt hepat i
entdailyont hesamescal e.,
R:todet r
mi nedanychangeinweight.
►Moni torski nt urgor ,
mucousmembr aneandur ineout put.
►Pr ovideaf lexiblef eedingschedulewi t
hsmal lfeedingsoffavouri
tefood.R:t
o
increasedpat ientappi ti
te.
►Mi nimi sehandl i
ngar oundf eedingti
mes.
►Assi stt hepat i
entwi thchewi ngwitht hechinandj aw, ifswal
lowingisi
mpairedso
f
eedbyNGTube.
►Assessl evel ofconsci ousnessbef or egivi
ngliquids.
-Expect edout come:
Thepat ientshowshasnauseaandv omi ti
ngundercont r
ol,hasadequatedai
lycalor
ic
i
nt ake.

-Nur si ngdi agnosi sIII

:
-Impai redPhy si
cal Mobi l
ity
relatedt o:general weakness, neurol
ogi cdef i
cit
.
-Char act eri
zedby :
-Pat ient ssai dweakl y.
-Par aly sis,pares, hemi pl
egic,tremor.
-Lessmuscl est rength.
-Expect edout comes:
Pat ient scanmai ntainanopt imal mobilization
-Inter vent i
on:
[Link] heabi lit
ytomobi li
ze.
Rat ional e:Hemi paresemayoccur .
[Link] eadofposi ti
oningthepat i
entever y2hour s.
Rat ional e:Avoidski ndamage.
[Link] f orm massagedepr essedpar tsoft hebody .
Rat ional e:Smoot hfl
owofbl oodandpr ev entpressur
esor
es.
[Link] f orm passi veROM.
Rat ional e:Avoidingcont racturesandat rophy .
[Link] torthromboembol i
sm, consti
pat ion.
Rat ional e:Compl icati
onsofi mmobi l
it
y.

PageXCI
Xof99
 [Link]
ti
pleScl
erosi
s
-
Defini
ti
on
Mult
iplescl
erosis(MS)i
nvolvesani mmune- mediat
edpr ocessinwhi chanabnor mal
r
esponseoft hebody’
simmunesy stem isdirect
edagainstthecentralner
voussy st
em
(
CNS) ,whi
chismadeupoft hebrai
n,[Link]
genor
t
argetthattheimmunecell
sar esensit
izedtoat t
ack remainsunknown,whi chiswhy
(
MS) i s consider
ed by many exper t
s t o be "immune- mediated" r
ather than
"
autoimmune."
 Withint he CNS,t he i
mmune sy stem at tacks my eli
nt he fatt
y subst ance t hat
surroundsandi nsul at
est hener v
ef i
bersaswel lasthenervefibersthemsel ves.
 Thedamagedmy elinformsscart issue(scler osi
s),whichgivesthediseasei tsname.
 Wh enanypar toft hemy el
insheathorner v efi
beri sdamagedordest r
oy ed,ner ve
i
mpul sest ravelingt oandf r
om thebr ainandspi nalcor daredistort
edori nterrupted,
producingawi dev ari
etyofsy mptoms.
 Thedi seasei st houghtt obet ri
ggeredinagenet ical
lysuscepti
bleindivi
dual by
acombi nationofoneormor eenv i
ronment alf act
ors.
 Peoplewi th( MS)t ypi
call
yexper i
enceoneoff ourdiseasecourses,whichcanbemi l
d,
moder ateorsev ere.
1-Typesof( MS) :
 Relapsing-Remi t t
ingMS( RRMS) .Thisisthemostcommonf or
m ofmul ti
plescl erosis.
About( 85%)ofpeopl ewi thMSar einit
iallydiagnosedwi [Link] ewi th
RRMShav et empor aryper iodscalledr el
apses,f l
are-
upsorexacer bati
ons,when
2
newsy mpt omsappear

 Secondar y-Progressiv
eMS( SPMS) .InSPMS,sy mpt omswor senmor esteadi
lyover
ti
me,wi thorwi thouttheoccurrenceofrelapsesandr emi [Link]
arediagnosedwi t
hRRMSwi ll
transi
ti
ontoSPMSatsomepoi nt.
 Primary-ProgressiveMS( PPMS) .Thi
st y
peofMSi snotv erycommon,occur ri
ngin
about( 10%)ofpeopl e wit
h [Link] i s char
act er
ized bysl owl
ywor seni
ng
sympt omsf rom thebeginni
ng,withnorelapsesorremi ssions.
 Progressive-RelapsingMS( PRMS) .Arareform ofMS( 5%),PRMSi scharacter
izedby
asteadi lywor seningdiseasestatefrom thebeginning,wi thacut erel
apsesbutno
remissions, withorwi t
houtrecovery
.
2-SymptomsofMS:
Thesympt omsofMSv arywidel
yfr
om per
sont
oper
sonandcanaf
fectanypar
toft
he
body.
Themainsy mpt
omsinclude:
 fat
igue

 di
ffi
cult
ywalki
ng
 vi
sionprobl
ems,suchasblur
redvi
sion
 probl
emscontrol
li
ngthebl
adder
 numbnessorti
ngli
ngindif
fer
entpartsoft
hebody

PageCof100
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 musclest
if
fnessandspasms
 pr
oblemswithbal
anceandco-or
dinat
ion
 pr
oblemswiththi
nki
ng,l
earni
ngandplanni
ng.

3-Whydopeopl egetMS?
-yourgenesMSi sn'
tdirect
lyi
nherit
ed,butpeoplewhoarer elat
edtosomeonewiththe
condi
ti
onaremoreli
kelytodevelopit
;thechanceofasibli
ngorchi l
dofsomeonewith
MSalsodev el
opi
ngitisestimatedtobearound(
2-3%)
lackofsunli
ghtand(v
itaminD)MSi smor ecommonincountr
iesfarf
rom t
he
equator
,whichcoul
dmeanthatalackofsunl
i
ghtandl
ow(vi
tami
nD)level
smayplayar
olei
n
thecondit
ion,
alt
houghi
t'
snotcl
earwhethervi
tami
nDsuppl
ementscanhel
ppr
eventMS
 smoki ng–peoplewhosmokear eabouttwiceasli
kelytodev el
opMScompar ed
tothosewhodon' tsmoke
 vi
ralinfecti
ons–ithasbeensuggestedthatinf
ecti
ons,parti
cular
lythosecaused
byEpst ein-
Barrv
irus(
responsi
bleforgl
andularfev
er)
,mi ghttri
ggertheimmune
system, l
eadingt
oMSi nsomepeopl e

4-Diagnosingtest
:
-TestsforMS
-Neurol
ogicalexaminati
on
-Magneticresonanceimagi
ng(
MRI
)scan
-Evokedpot ent
ialt
est
-Lumbarpunct ure
-bloodtest

5-Treatment:
Therear evariousMSt reat
mentopti
onsavai
lablet
odaythathavebeenshownt o
decreasethef requencyofrel
apsesandt
odel aydi
seaseprogr
essi
[Link]
al
way sthattheset r
eatmentopti
onscanbetaken.
-Betainter
ferons.
-Glati
rameracet at
.
Fi
ngoli
med.-
-Teri
fl
unomide.

6-
Nur
singdi
agnosi
s:

a-Fat
igue:
-Mayber elatedt o:
 De creasedener gyproducti
on,
incr
easedener
gyr
equi
rement
stoper
for
m
acti
viti
es
 Ps ychol ogical
/emot i
onaldemands
 Pa in/discomf ort
 Me dicationsideeffects

PageCIof101
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Possi
blyevi
dencedby
 Ve r
bali
zati
onofov
erwhel
mingl
ackofener
gy

 I
nabil
it
ytomaint
ainusual
rout i
nes;decreasedperf
ormance
 I
mpai r
edabi
l
ityt
oconcentrate;di
sint
erestinsur
roundi
ngs
 I
ncreasei
nphysi
calcomplaint.

PageCI
Iof102
-
Desi
redOutcomes
 Ident
ifyr
iskf
act
orsandi
ndi
vi
dual
act
ionsaf
fect
ingf
ati
gue.

 I
dentif
yalternati
vest
ohelpmai nt
aindesi
redact
ivi
tyl
evel
.
 Part
ici
pateinr ecommendedtr
eatmentprogram.
 Reporti
mpr ovedsenseofenergy.

-
NursingI nter
ventions: -
Not eandacceptpr esenceoff atigue.
-Rat i
onale:
Fat i
guei sthemostper sistentandcommonsy mpt om [Link] udiesindi
catethatt
he
fatigueencount eredbypat ient swi thMSoccur swi thexpendi t
ureofmi nimalenergy
,is
mor efrequentandsev eret han“ nor mal ”fatigue,hasadi spropor t
ionateimpacton
ADLs, hasasl owerr ecov eryt ime, andmayshownodi rectrelat
ionshipbetween
fatiguesev eri
tyandpat ient’scl inical neurological status.
-
NursingI nter
ventions: -
Ident i
fyandr eviewf actor saf fectingabi lit
yt obeact iv
e: temperatureextremes,
i
nadequat efoodi nt ake, insomni a, useofmedi cations, t
imeofday .
-Rat i
onale:
Prov idesoppor tunityt opr obl em- solv etomai ntainori mpr ovemobi l
i
ty.
-
NursingI nter
ventions: -
Acceptwhenpat i
enti sunabl et odoact ivi
ti
es.
-Rat i
onale:
Abi l
itycanv aryf r
om momentt omoment .Nonj udgment alacceptanceofpat i
ent’
s
eval uati
onofday -to-dayv ariationsi ncapabi l
iti
espr ovi
desoppor t
unitytopromote
i
ndependencewhi lesuppor ti
ngf l
uct uationsi nlevel ofrequiredcar e.
#Admi
nist
ermedi
cat
ionsasi
ndi
cat
ed:
-
Nursi
ngInterventions:-
Amant adine(Sy mmet rel);
pemol ine(Cy ler
t).
-Rat
ionale:
Usefulintreatmentoff ati
[Link] t
iveant iv
iraldrugef f
ectin30%–50%ofpat ients.
Usemaybel i
mi t
edbysi deeffectsofi ncreasedspast ici
ty,i
nsomnia, paresthesiasof
handsandf eet.
-
Nursi
ngInterventions:-
Methylphenidate( Ritali
n) ,
modaf inil
(Pr ovigi
l).
-Rat
ionale:
CNSst imulantst hatmayr educef at
iguebutmayal socausesi deeffectsof
nerv
ousness, r
est l
essness, andinsomni a.
-
Nursi
ngInterventions:-
Sert
rali
ne( Zoloft),
fluoxet ine(Prozac) .
-Rat
ionale:
Anti
depr essantsusef ulinlif
ti
ngmood, and“ energizi
ng”patient(
especi al
lywhen
depressionisaf actor )andwhenpat ientisfreeofant ichol
inergi
csideef fects.

PageCI
IIof103
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCI
Vof104
B-Sel
f -car eDef i
ci t:
-
Mayber el at edt o:
 Ne ur omuscul ar /per cept ual i mpairment;i ntoler
ance t o act i
vit
y; decr eased
st rengt handendur ance; mot orimpairment ,
tremor s
 Pa i
n, discomf ort,fat i
gue
 Me mor yloss
 De pr essi on
-
Possi bl yev idencedby
 F rust rat i
on; i
nabi li
tyt oper formt asksofsel f
-care,poorpersonal hygiene
-
DesiredOut comes
 I dent ifyindi vidual ar easofweakness/ needs.
 De monst rat et echni ques/ l
if
est y
lechangest omeetsel f
-careneeds.
 Pe rfor m sel f-car eact ivitieswi t
hinlevelofownabi lit
y.
 I dent ifyper sonal /communi tyresourcesthatpr ovi
deassi stance.
-Nursi ngI nt ervent ions:
Deter mi necur rentact i
vityl ev elandphy sicalconditi
[Link] eeoffunct i
onal
i
mpai rmentusi ng( 0–4)scal e.
-Rational e:
Prov i
desi nf ormat iont odev eloppl anofcar eforrehabil
itati
[Link] e:Motorsy mpt oms
arelessl ikel ytoi mpr ovet hansensor yones.
-Nur singI nterv ent i
ons:
Encour agepat ientt oper form sel f-caretothemaxi mum ofabi l
it
yasdef i
nedbypat i
ent
.
Donotr ushpat ient .
-Rational e:
Promot esi ndependenceandsenseofcont r
ol;maydecr easef eeli
ngsofhel plessness.
-Nursi ngI nt ervent ions:
Assistaccor dingt odegr eeofdi sabi l
i
ty;all
owasmuchaut onomyaspossi ble.
-Rational e:
Participat ioni nowncar ecaneaset hef r
ustrat
ionov erl
ossofi ndependence.
-Nursi ngI nt ervent ions:
Encour agepat ienti nputi npl anningschedul e.
-Rational e:
Patient ’squal i
tyofl ifeisenhancedwhendesi r
esandl i
kesar econsideredi ndail
y
acti
v ities.
-Nursi ngI nt ervent ions:
Notepr esenceoff at i
gue.
-Rational e:
Fati
gueexper i
encedbypat i
ent swi thMScanbev erydebi l
i
tati
ngandgr eatlyimpact
abil
ityt opar t
icipat ei [Link] ecti
venat ur
eofr eportsoff ati
guecanbe
misint er pr etedbyheal thcar epr ovidersandf amily,l
eadingtoconf li
ctandt hebel i
ef
thatt hepat ienti s“ mani pul ative”when, i
nfact,thi
smaynotbet hecase.

PageCVof105
#Admi
nist
ermedi
cat
ionsasi
ndi
cat
ed:
-NursingI nterventions:
Tizanidine( Zanaf l
ex) ,bacl ofen( Lioresal )
, car bamazepi ne(Tegret ol)
.
-Rati
onal e:
Newerdr ugsusedf orr educi ngspast icit
y, pr omot i
ngmuscl erel
axat ion,andinhibi
ting
refl
exesatt hespi nal ner ver ootl [Link] li
tyandmai nt enanceofact ivi
ty.
Tizanidine( Zanaf l
ex)mayhav eanaddi t
iveef fectwithbaclofen( Lioresal)
,butusewi th
cautionbecausebot hdr ugshav esimi l
arsi deef f
[Link] i
onofact ionrequires
careful i
ndividualizingofdosaget omaxi mi zet herapeuticeffect
.
-NursingI nterventions:
Diazepam ( Val i
um) ,clonazepam ( Klonopi n), cy cl
obenzapr i
ne(Flexeril)
,gabapent i
n
(Neur ontin,dantrolene( Dant rium) .
-Rati
onal e:
Av arietyofmedi cat i
onsar eusedt or educespast ici
[Link] smsar enotwel l
under stood, andr esponsesv aryineachper [Link] efore,i
tmayt akeaper iodof
medi cationt ri
alstodi scov erwhatpr ovidest hemostef fecti
vereliefofmuscl e
spast i
cityandassoci atedpai [Link] e: Adv erseef f
ectsmaybei ncr easedmuscl e
weakness, lossofmuscl et one, andl ivertoxi city.
-NursingI nterventions:
Mecl i
zine( Antivert),scopol ami nepat ches( Tr ansderm- Scop).
-Rati
onal e:
Reducesdi zziness, allowi ngpat i
entt obemor emobi l
e.

#ot
herdi
agnosi
s:

C-LowSel
f-
Est
eem.

D-
Power
lessness/
Hopel
essness.

PageCVIof106
 [Link]
ebr
ovascul
aracci
dent(
str
oke)
-alsoknownas:
-(
brainatt
ack)
:isasuddenl
ossofbr
ainf
uncti
onresul
ti
ngf
rom ast
opoft
hebl
ood
supplytoapartoft
hebrai
nleadi
ngi
ncel
ldeath.
-
Pathophysi
ology:
i
sinj
uryordeathtopar t
softhebrai
ncausedbyanint
err
upt
ioninthebl
oodsuppl
yto
t
hatareacausingdisabi
li
ty,
suchasparal
ysi
sorspeechi
mpairment.
-Therearet womai ntypesofstr
oke:-
1)Ischemi c:i
smostcommont y
pewi th88%ofcases;causedbycerebrov
ascular
obstruct
ionbyat hrombusorembol i
.
2)hemor rhagic:
isassociatedwit
hgr eat
ermorbi
dit
yandmor tal
i
ty;causedbythe
ruptureofbloodv esselsandbl
eedingintot
hebrai
ntissue.

-
Signsandsy
mpt
oms:
St
rokesympt
omsty
pical
l
yst
artsuddenl
y,ov
ersecondst
omi
nut
es.

-Gener alsignsandsy mptomsinclude:

1-numbnessorweaknessoff ace,arm, orleg(especial
lyononesideofbody)
.
2-confusi onorchangei nmentalstat
us.
3-troublespeaki ngorunderst
andingspeech.
4-visualdi st
urbances;l
ossofbalance,dizziness,di
fficult
ywalki
ng;
5-suddensev ereheadache.
6-Lossofconsci ousness.
7-v omi t
ingusual l
yoccurmoreof t
eninhemor rhagicstr
okethanint
hrombosi
s
becauseoft heincreasedi
ntracr
anialpressuref r
om theleaki
ngbl
oodcompressi
ng
thebr ain.

-speci
alsignsandsy mpt oms:
1-decreasedr efl
exes:gag,swal
l
ow,pupilr
eact
ivi
tytoli
ght.
2-decreasedsensat i
onandmuscl eweaknessoftheface
3-ptosis(droopingofeyeli
d).
4-memor ydef ici
ts.

-
Causes:
1-Thr
ombot
icst
roke.
2-Embol
i
cst
roke.
3-Cerebr
alhypoper
fusi
on:
ist
her
educt
ionofbl
oodf
lowt
othebr
aincel
l
sbecause
reducedcar
diacout
put.
4-Venoust
hrombosi
s

PageCVI
Iof107
-
RiskFact ors:
-
Nonmodi fi
able:
 Ad vancedage( oldert
han55y
ear
s)
 Ge nder( Male)
-
Modi fi
able:
 Hy pertension
 b l
eedingdi sorders
 c erebral aneurysm
 At rialfibril
lati
on
 I ncreasechol esteroll
evel
.
 Ob esity
 Smo ki
ng
 Di abetes
 Al cohol i
cabuse.

-
Diagnost ictest:
CTscan: Demonst ratesst ructuralabnor malit
ies,edema, hemat omas,ischemi a,and
i
nfar cti
ons,whi chv eryimpor tantint heear l
yst agest odisti
ngui shhaemor rhagic
str
okeandi schaemi cst roke.
PETscan( Posi t
ronEmi ssionTomogr aphyscan) :Providesdat aoncer ebral
met abolism andbl oodf l
owchanges, especiallyi
ni schemi cstroke.
MRI :Showsar easofi nf arcti
on, hemor rhage,ar t
eriovenousmal for
mat i
ons; andareas
ofischemi a.
Cerebr alangiography :Hel psdet ermi nespeci fi
ccauseofst r
oke.
Lumbarpunct ure(LP) :CSFt otalproteinl ev
elmaybeel evatedincasesoft hrombosis
becauseofi nflammat orypr ocess.
EEG: I
denti
fiespr oblemsbasedonr educedel ectricalacti
v i
tyinspecifi
car easof
i
nfar cti
on;andcandi f
fer enti
at eseizur eactivi
tyfrom CVAdamage.

-Medicalmanagement :
-Recombi nantti
ssueplasminogenactiv
ator(t
PA)al
teplase,unl
esscontr
aindi
cat
ed;
monitorforbleedi
ng
-Ant
icoagulati
ontherapy(warf
ari
n,hepari
n),Fi
bri
nol
yti
ct her
apy(amicar
).
-
Ant
ihy
per
tensi
ves.
-Peri
pheralvasodi
lat
ors,e.g.
,cy cl
andelate(Cycl
ospasmol),
-Managementofi ncreasedintracrani
alpressure(I
CP):osmoticdi
uret
ics,
maintai
n
PaCO2at( 30to35mm)Hg, posit
iontoav oidhypoxi
a(elev
atetheheadofbedt o
promotev enousdrai
nageandt oloweri ncr
easedICP)
-i
ntubat
ionwi t
hanendot racheal t
ubetoest abli
shapatentair
way,i
fnecessar
y.
-Neur
ologi
cassessmenttodeter
minei
fthest
rokei
sev ol
v i
ngandifotheracut
e
compli
cati
onsaredevel
oping,
suchas:
paral
ysi
s,di
ff
icult
iesinspeechandswallowi
ng
andmemor yl
oss.

PageCVI
IIof108
-
familyhist
ory
:
Assessthepresenceofri
skfact
orsinthefamil
y.
-
subjecti
vedata:
Pati
entsaid"Ihaveasevereheadache"
Pati
entsaid"Ifeel
ingdi
zzi
nessandinabil
i
tytovisi
on"
-
obj
ect
ivedat
a:ABG'
s,V/
S,bl
oodsampl
e(PT,
PTT)
,CTscan,
Glasgowcomascal
e.
-Nursingdiagnosi s:
1-Ineffecti
veCer ebralTissuePer f
usion
-Mayber el
atedto:
Int
erruptionofbloodf low: occl
usivedisorder,hemor rhage;cerebr
alvasospasm,
cerebraledema.
-Possiblyevidencedby :
 Al teredlevelofconsci ousness;memor yloss
 Changesi nmot or/sensoryresponses;restlessness
 Sensor y,l
anguage, intel
lect
ual,andemot ional defi
cit
s
 Changesi nv it
al si
gns
-Desir
edOut comes
-Maintainimpr ovedlevelofconsciousness, cognition,andmot or/
sensoryfunct
ion.
-Demonst ratestablevitalsignsandabsenceofsi gnsofi ncreasedICP.
-NursingI nterv ent i
ons:
1-Moni t
oranddocumentneur ologi calst atusf requent lyandcompar ewi thbaseline.
Rational e: Assessest rendsi nLOCandpot enti
al forincreasedI CPandi susef ulin
deter miningl ocat ion, extent ,andpr ogr essi onorr esoluti
onofCNSdamage.
2-Moni torv i
tal signsnot i
ng: Hy per tensionorhy pot ension.
Rational e: Fl
uct uat i
onsi npr essur emayoccurbecauseofcer ebr alpressur
eori njuryin
vasomot orar eaoft hebr [Link] per t
ensi onorhy potensionmayhav ebeena
precipitati
ngf act or.
3-gr adual elev ationoft heheadi nneut ral posi t
ion.
Rational e:Reducesar ter ialpr essur ebypr omot i
ngv enousdr ainageandmayi mpr ove
cerebr alcirculation/ perf usi on.
4-Mai ntai
nbedr est, prov ideaqui etenv i
ronment .
Rational e: activitycani ncr easeI [Link] uterestandqui etmaybeneededt opr event
rebleedingi nt hecaseofhemor rhage.
5-Admi nistersuppl ement al ox ygenasi ndi cated.
Rational e:Reduceshy poxemi a,whi chcancausecer ebralvasodi lati
onandi ncrease
pressur e/edemaf ormat ion.
6-Moni torlabor at or
yst udi esasi ndicat ed, e.g.,prothrombi ntime( PT)/acti
vatedpar ti
al
thrombopl astint ime( aPTT)t ime.
Rational e: Prov idesi nfor mat ionaboutdr ugef fect i
veness/ therapeut i
clevel.
Evaluat i
on:
After( 2-3)weeksofnur si ngi nter vent i
ont hecl i
entwi l
lbeabl et odemonst r
ate
i
ncr easedPer fusi on( e.g. ,vital signswi thinnor mal range, ori
ent ed,fr
eeof

PageCI
Xof109
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

pai
n/di
scomf
ort
.
2-
Impai redPhy sical Mobilit
y:
-
Mayber elatedt o:
-
Neur omuscul arinvolvement :weakness,paresthesia;f
lacci
d/hypot
onicparal
ysi
s
(
initiall
y )
; spast i
cpar alysis
-
Per cept ual /cogni t
iveimpai r
ment .
-
Possi bl yev idencedby :
-
Inabilitytopur posel ymov ewithint
hephy sicalenvir
onment ;i
mpairedcoordi
nati
on;
l
imitedr angeofmot i
on; decreasedmuscl estrength/control
.
-
Desi redOut comes:
-
increasest rengt handf unctionofaffectedorcompensat orybodypart
.
-
Mai ntai nopt i
mal posit
ionoff uncti
onasev idencedbyabsenceofcont r
actur
es.
Mai nt ainski nint egri
ty.

-
Nur singInter
ventions:
1-Changeposi t
ionsatl eastev ery2hr( supi ne,sidely
ing)andpossiblymoreofteni f
placedonaf fectedsi de.
Rationale:Reducesr iskoft i
ssuei schemi a/i
[Link]
ectedsidehaspoorcir
culation
andr educedsensat ionandi smor epr edisposedt oskinbreakdown.
2-Placekneeandhopi next endedposi tion.
Rationale:Mai ntai
nsf unctional posit
ion.
3-Obser veaffectedsi deforcol or,edema, orothersignsofcompr omisedci
rculation.
Rationale:Oedemat oust i
ssuei smor eeasi l
yt r
aumat i
zedandheal smoreslowly.
4-encour agepat i
entt oassistwi thmov ementandexer cisesusingunaff
ect
ed
extremi t
ytosuppor t/mov eweakersi de.
Rationale:Mayr espondasi faffectedsi dei snol ongerpartofbodyandneeds
encour agementandact ivetr ai
ningto“ r
ei ncorporate”i
tasapar tofownbody .

-
OTHERNURSI
NGDI
AGNOSI
S:
 I
mpai
redVer
bal
Communi
cat
ion
 Di
stur
bedSensor
yPer
cept
ion
 I
nef
fect
iveCopi
ng
 Sel
f-
Car
eDef
ici
t
 Ri
skf
orI
mpai
redSwal
l
owi
ng
 Knowl
edgeDef
ici
t

PageCXof110
 [Link]
ansi
entI
schemi
cAt
tack(
TIA)
-Defi
nit
ion:
(TIA)i
sat ransi
entepisodeofneur ol
ogi
cdy sfuncti
oncausedbyischemi
a(l
ossofblood
fl
ow)wi t
houtacuteinfar
ction(ti
ssuedeath).TIAshavethesameunderl
yi
ngcause
asstrokesandar eoftenrefer
redtoasmi ni-
strokesormega-st
rokesSympt
omscaused
byaTI Aresolvein24hour sorless
-
Causes
Transi
entischaemi
catt
acks(
TIAs)occurwhenoneoft
hebl
oodvessel
sthatsuppl
y
yourbrai
nwi t
hoxygen-
ri
chbl
oodbecomesblocked.
Thisinterruptioninthef lowofbl oodtothebr ai
nmeanst hatthebr aincannotcar ry
outsomeofi tsnormal f
unct i
onspr operly
,leadingtosympt omssuchassl urredspeech
andweakness.
InTIAs, thebl ockagequi cklyresolvesandy ourbrain'
sbloodsuppl yr etur
nst onor mal
beforet here'sanysigni f
icantdamage.
Inaf ul
l stroke,thebloodf lowt oy ourbrai
ni sdisr
uptedformuchl onger ,
leadingto
mor esev er edamaget ot hebr ainandl onger-t
erm probl
ems.
Thebl ockagei nthebloodv esselsresponsibleformostTI Asisusual lycausedby
abloodcl otthathasf ormedel sewher ei
ny ourbodyandt ravell
edt ot hebloodv essel
s
supplyingt hebr ai
n,althoughi tcanal sobecausedbypi ecesoff attymat eri
alorair
bubbles.
Inveryr arecases, TI
Ascanbecausedbyasmal lamountofbl eedingi nthebr ai
nknown
asahaemor r
hage.
Sy
- mpt
oms:
Symptomsbegi nsuddenl y,l
astashor ttime( from af ewmi nutesto1t o2hours),
and
goaway .Theymayoccuragai natal atertime.
Thesympt omsofTI Aar et hesameast hesy mpt omsofast roke,andincl
ude:
 Ch angei nal ertness( i
ncl udingsl eepinessorunconsci ousness)
 Ch angesi nt hesenses( suchashear ing, vi
sion,taste,andt ouch)
 Me ntal changes( suchasconf usion,memor yloss,diff
icult
ywr i
ti
ngorreadi
ng,
troubl espeaki ngorunder standingot hers)
 Mu sclepr obl ems( suchasweakness, tr
oubl eswal l
owi ng,tr
oublewalki
ng)
 Di zzinessorl ossofbal anceandcoor dination
 L ackofcont rolov erthebl adderorbowel s
 Ne rvepr obl ems( suchasnumbnessort ingli
ngononesi deofthebody)
-Ri
skfact orsforTI A: aret hesameast hosef orischemi cstroke.
Modifiabler i
skf act orsincludet hef oll
owi ng:
 Al cohol ism
 Hy pertensi on
 s moki ng
 Dy sl i
pidemi a
 Di abetes
 Ob esit
y
 L ackofphy sicalact i
vit
y
 Ps ychosoci al str
ess( e.g., depression)

PageCXIof111
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Heartdi
sorder
s(part
icul
arlydi
sorder
sthatpredi
sposet
oembol
i
,suchasacut
e
MI,i
nfect
iveendocar
diti
s,andatr
ialf
ibr
il
lat
ion)

PageCXI
Iof112
-
diagnosi stests:
-CTscan
-MRIoft hebrai n
-
Treat ment :
-
Prev ent i
onofstr okes
Treat mentisai medatpreventi
ngstrokes;
antipl
ateletdr
ugsandstat
insar
eused.
Car otidendarterect
omyorar t
eri
alangiopl
astyplusstenti
ngcanbeuseful
forsome
pat ients,part
icular
lyt
hosewhohav enoneurologicdefi
cit
sbutwhoareathighr
isk
ofst r
oke.
Ant icoagulat
ioni si
ndi
catedifcar
diacsourcesofembol iarepr
esent
.

-
Nur singDi agnosi s:
1-Inef f
ect i
v eCer ebr al TissuePer fusi on
-
Mayber el at edt o:
 I nt err upt i
onofbl oodf low: occl usi vedi sor der ,hemor r
hage; cerebral
vaso¬spasm, cer ebr al edema
-
Possi blyev idencedby :
 Al ter edl ev el ofconsci ousness; memor yloss
 Ch angesi nmot or/sensor yr esponses; rest lessness
 Se nsor y,language, intellectual ,andemot i
onal deficits
 Ch angesi nv ital signs
-
Nur singI nt er vent ions:
Assessf act orsr elatedt oi ndiv i
dual situat ionf ordecr easedcer ebral perfusionand
pot ential fori ncr easedI CP.
-Rat i
onal e:
Assessmentwi lldet er mi neandi nfluencet hechoi ceofi nterventions.
Det eri
or at ioni nneur ologi cal signsorf ailuret oi mpr ov eafteri ni
ti
al insultmayr efl
ect
decr easedi nt racr ani al adapt i
v ecapaci tyr equi r
ingpat i
entt obet ransf erredt ocri
ti
cal
areaf ormoni toringofI CP, othert her api es.
Ifthest rokei sev olving, pat ientcandet erior atequi cklyandr equirer epeat ed
assessmentandpr ogr essi v et r
eatment .
Ifthest rokei s“ compl et ed,”t heneur ol ogi cal def icitisnonpr ogressi ve,andt reatment
i
sgear edt owar dr ehabi l
itationandpr event i
ngr ecur rence.
-Nur si
ngI nter vent i
ons:
Closel yassessandmoni torneur ologi cal st atusf requent lyandcompar ewi th
basel i
ne.
-Rat i
onal e:
Assessest rendsi nl ev el ofconsci ousness( LOC)andpot entialfori ncreasedI CPand
i
susef ul indet er mi ningl ocat ion,ext ent ,andpr ogr essi onofdamage.
Mayal sor ev eal pr esenceofTI A,whi chmaywar nofi mpendi ngthr ombot i
cCVA.
-Nur si
ngI nter vent i
ons:
changesi nbl oodpr essur e,compar eBPr eadi ngsi nbot har ms.

PageCXI
IIof113
-Rationale:
Fluctuat i
onsi npr essuremayoccurbecauseofcer ebral
injur
yinv asomot orar
eaof
thebr ain.
Hy pertensi onorpost ur
alhypotensionmayhav ebeenapr eci
pit
atingf actor.
Hy potensi onmayoccurbecauseofshock( ci
rcul
atorycoll
apse).IncreasedI CPmay
occurbecauseoft issueedemaorcl otformati
[Link] i
anarterybl ockagemay
ber evealedbydi fferenceinpressurer eadi
ngsbetweenar ms.
-NursingI nt erventions:
Hear trateandr hy t
hm, assessformur mur s.
-Rationale:
Changesi nr ate,especiall
ybr adycardia,canoccurbecauseoft hebr aindamage.
Dy srhythmi asandmur mursmayr efl
ectcardi
acdisease,whichmayhav e
precipitatedCVA( str
okeafterMIorf rom valvedysfunct
ion).
#Moni
torv
ital
signs:
-
Nur singInt
erventions:
Respirati
ons,notingpatter
nsandrhyt
hm (peri
odsofapneaaf t
erhyper
vent
il
ati
on),
Chey ne-
Stokesrespi r
ati
on.
-
Rat i
onale:
I
rregulari
ti
escansuggestl ocat
ionofcerebr
alinsul
torincreasi
ngICPandneedf or
furt
herinter
vention,incl
udi
ngpossibl
erespi
ratorysupport
#Admi
nist
ermedi
cat
ionsasi
ndi
cat
ed:
-Nur singI ntervent ions:
Altepl ase( Act i
v ase), t-
PA;
-Rat ional e:
Thr ombol yti
cagent sar eusef ul i
ndi ssol vingcl otwhenst artedwi thin3hrofi nit
ial
sympt [Link] rtyper centar elikelytor ecov erwi t
hl i
ttl
eornodi sabi li
[Link]
basedont ryi
ngt ol i
mi tthesizeoft hei nfarct,anduser equirescl osemoni tori
ngf or
signsofi ntr
acr anial hemor r
[Link] e: Theseagent sar econt raindi catedincr anial
hemor rhageasdi agnosedbyCTscan.
-Nur singI ntervent ions:
(Ant i
coagul ants) :war fari
nsodi um ( Coumadi n),l
ow- molecul ar-wei ghthepar in
(Lov enox) ;
-Rational e:
Maybeusedt oi mpr ovecer ebr albloodf lowandpr eventfur thercl otti
ngwhen
embol ism and/ ort hrombosi sist hepr obl em.
-Nur singI ntervent ions:
(Ant i
pl at eletagent s):aspi ri
n( ASA) ,di py r
idamol e( Persantine), ticlopidine( Ticl
id);
-Rational e:
Cont rai ndi catedi nhy pertensivepat ient sbecauseofi ncreasedr iskofhemor rhage.
-Nur singI ntervent ions:
Ant i
fibr inol y
tics: ami nocapr oicaci d( Ami car);
-Rational e:Usedwi thcaut ioninhemor rhagi cdi sordertopr ev ently sisoff ormedcl ots

PageCXI
Vof114
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

andsubsequentr
ebl
eedi
ng.

PageCXVof115
 -
Nur si
ngInter
venti
ons:
(Anti
hypert
ensive)
-
Rational
e:
Chronichyper
tensionr
equi
rescaut
ioust
reat
mentbecauseaggr
essi
vemanagement
i
ncreasestheriskofext
ensi
onofti
ssuedamage.
2-I
mpai redPhy sical Mobi l
ity:
-Mayber el atedt o:
 Ne ur omuscul ari nvol vement : weakness, paresthesi a; f
lacci d/hypotonic
par alysis( init
iall
y );spast icpar alysis
 Pe rcept ual /cogni t
ivei mpai rment
-Possiblyev idencedby :
 I nabi l
ityt opur posef ullymov ewi thint hephy sical env ir
onment ;i
mpai r
ed
coor dinat ion; l
imi t
edr angeofmot ion; decreasedmuscl est rength/control
-DesiredOut comes
 Ma int ain/increasest rengthandf unctionofaf fectedorcompensat orybody
par t.
 Ma int ainopt i
mal posi ti
onoff unct ionasev i
dencedbyabsenceof
cont ract ures, footdr op.
 De monst r
at etechni ques/ behav i
orst hatenabl eresumpt ionofact ivi
ti
es.
 Ma int ainski nint egr i
ty .
-NursingI nt er vent i
ons:
Assessext entofi mpai rmenti niti
all
yandonar egularbasi s.
Classi fyaccor dingt o0–4scal e.
-Rat i
onal e:
Ident ifiesst rengt hsanddef i
cienciest hatmaypr ovi
dei nfor mat ionr egarding
recov ery .Assi stsi nchoi ceofi nt
ervent ions, becausedi fferentt echni quesar eused
forf l
acci dandspast icpar alysis.
-Nur singI nterv ent i
ons:
Changeposi tionsatl eastev ery2hr( supi ne, sidelying)andpossi blymor eof t
enif
placedonaf fectedsi de.
-Rat i
onal e:
Reducesr iskoft issuei njur [Link] f
ectedsi dehaspoor erci rculationandr educed
sensat ionandi smor epr edi sposedt oski nbr eakdown.
-Nur singI nterv ent i
ons:
Posi tioni npr oneposi t
iononceort wi ceadayi fpatientcant oler ate.
-Rat i
onal e:
Hel psmai nt ainf unctional hipext ension; howev er,
mayi ncr easeanxi ety,
especi al
l
y
aboutabi litytobr eathe.

PageCXVIof116
 -Nursi
ngI nterventions:
Propextr emiti
esinf unct i
onal positi
on;
usef ootboardduringtheper i
odoff lacci
d
paraly
[Link] ntai
nneut r alpositi
onofhead.
-Rati
onale:
Preventscont racturesandf ootdropandfacili
tat
esusewhenf uncti
onreturns.
Flacci
dpar alysismayi nt erf
erewi thabi
li
tytosuppor thead,wher easspasti
c
paraly
sismayl eadt odev i
ati
onofheadt oonesi de.
-Nursi
ngI nterventions:
Usear m sli
ngwhenpat ientisinupr i
ghtpositi
on, asindi
cated.
-Rati
onale:
Duringflaccidparal ysi
s,useofsl ingmayr educer iskofshouldersubluxati
onand
shoulder-handsy ndr ome.
-NursingInt
er ventions:-
Evaluateneedf orposi ti
onal aidsand/ orspl
int
sdur ingspasticparal
ysis:
-Rational
e:Flexioncont r
actur esoccurbecausef lexormuscl esarestrongerthan
extensors.
-NursingInt
er ventions:
Placepi l
l
owunderaxi ll
at oabductar m.
-Rational
e:Prev entsadduct ionofshoul derandflexionofelbow.
-NursingInt
er ventions:
Elevatearm andhand.
-Rational
e:Promot esv enousr etur
nandhel psprev entedemaf or
mati
on.
-NursingInt
er ventions:
Placehar dhand- roll
si nthepal m withfi
ngersandt humbopposed.
-Rational
e:Har dconesdecr easet hest i
mulati
onoff ingerf
lexion,mai
nt ai
ningfi
nger
andt humbi naf unctionalposi ti
on.
-NursingInt
er ventions:
Placekneeandhopi next endedposi ti
on.
-Rational
e:Mai ntainsf uncti
onal posit
ion.
-NursingInt
er ventions:
Mai ntai
nleginneut ralpositionwi that r
ochanterroll
;
-Rational
e:Prev entsext ernal hiprotati
on.

#Otherdiagnosis:
3.I
mbal ancedNut rit
ion,LessThanBodyRequi
rement
s.
4.I
mpai redSki
nI ntegrit
y.
5.I
mpai redVerbal Communi cati
on
[Link]
urbedSensor yPercepti
on
[Link]
-CareDefici
t
[Link] icit
9-I
neffecti
veCopi ng

PageCXVI
Iof117
 [Link]
NTESTI
NALDI
SORDERS
[Link]
abet
esmel
l
itus(
DM)
i
sachr onicdiseaseschar acteri
zedbyi
nsuffi
cientproducti
onofi nsul
ininthepancr
eas
orwhent hebodycannotef fecti
vel
yusetheinsuli
[Link]
i
ncreasedconcent r
ationofgl ucoseint
hebloodstream (hypergl
ycemia).Iti
s
charact
erizedbydisturbancesi ncar
bohydr
ate,protei
n,andf atmetaboli
sm

- T y p e s o f D i a b e t e s :
Althoughtherearethr
eemai nty
pesofdi abetes,t
hereisalsoastagebeforedi
abetes
calledpre-
diabet
[Link]-di
abetes,alsoknownasI mpairedglucosetol
erancei
sa
conditi
onwher eyourBloodsugarl evelel
evatestoalevelhighert
hanthenormalrange
formostpeopl e,
butisst i
l
llowenoughnott obeconsi
dereddiabet
es.
-
Peopl
ewhohavepre-di
abet
esareatr
iskofdev
elopi
ngTy
pe2di
abet
esl
ateri
nli
fei
f
t
heydonotmoni
torthei
rcondi
ti
oncar
eful
ly
.

-
Ty pe1diabetes:t
hepancr easisunabletoproduceanyinsul
in,t
hehormonet hat
control
sbloodsugarlevels.
Insul
inproducti
onbecomesi nadequateforthecontr
olofbloodglucoselevel
sduet o
thegradualdestr
ucti
onofbet acell
[Link]
ucti
onprogresses
withoutnoti
ceov ert
imeunt i
lthemassoft hesecel
lsdecreasestotheextentthatt
he
amountofi nsul
inproducedisinsuff
ici
ent.
(Type1diabet
es)typi
cal
l
yappear
sinchi
l
dhoodoradol
escence,
buti
tsonseti
sal
so
possibl
einadul
thood.
-
Ty pe2di abetes:melli
tusmostcommonl ydev el
opsi nadult
hoodandismoreli
kelyto
occurinpeopl ewhoar eoverweightandphy sical
lyinacti
ve.
-
gest at
ional di
abetes:whichisacondi ti
ont hatwomencangetwhent heyarei
nt he
(secondt r
imest erofpregnancy).
About4per centofallpregnantwomenwi l
l developgestati
onaldi
abet
[Link]
ke( Ty
pe
1andTy pe2di abetes),gestat
ionaldiabeteswi l
ldisappearaf
tert
hebabyisborn.

-Di
abetesi
nsipidus:
occurswhentheki dneysareunabl
etoconserv
ewater
.di
abet
esi
nsipi
dusi
sei
thera
probl
em withthepr oduct
ionofant
idi
uret
ichor
moneorki
dney
'sr
esponset
o
anti
diur
eti
chor mone

-Pat
hophy si
ology:
I
nsulinisthepr i
nci
palhormonethatregulat
est heuptakeofglucosefr
om t hebloodint
o
mostcel l
soft hebody
, especi
all
yli
ver,muscle,andadiposeti
[Link],
defi
ciencyofinsuli
nort hei
nsensit
ivi
tyofit
sr ecept
orsplaysacentral
roleinallfor
ms
ofdiabetesmel l
it
us

PageCXVI
IIof118
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCXI
Xof119
-Causes:
Type1
l
ossoft hei nsuli
n-produci ngbet acellsofthei sl
et sofLanger hansi nthepancr eas,
l
eadingt oi nsulindeficiency .Thistypecanbef urtherclassifi
edasi mmune- mediat
edor
i
diopathi [Link] ori
tyoft ype1di abetesisoft hei mmune- medi atednat ure,
inwhicha
T-cel
l medi atedaut oimmuneat tackleadst othel ossofbet acellsandt husinsul
in
Type2
Type2DM i sduepr i
mar il
yt olifest
ylefactorsandgenet i
cs.
Anumberofl ifestyl
ef actor sareknownt obei mpor tanttothedev el
opmentoft ype2
DM, i
ncl udingobesi ty( definedbyabodymassi ndexofgr eaterthan30) ,
lackof
physical activi
ty,poordi et, str
ess
Gestational diabetes
combi nat i
onofr elati
vel yinadequat einsuli
nsecr etionandr esponsi [Link]
n
about2–( 10%)ofal l
pr egnanci esandmayi mpr ov eordisappearaf t
erdel i
ver

-Signsandsy mpt oms:

Thecl assi
csy mpt omsofunt r
eateddiabet
esareweightl
oss,polyur
ia(i
ncreased
urinati
on),poly
dipsia(
increasedthir
st),
andpol
yphagia(i
ncreasedhunger
).
blurryvi
sion,headache,fati
gue,slowheali
ngofcut
s,anditchyski
n

-Compli
cations:
Theprimarycompl icati
onsofdi abetesduet odamagei nsmal lbl
oodv esselsinclude
damaget otheeyes, kidneys,andner [Link] otheeyes,
knownasdi abeti
cr eti
nopat hy,
iscausedbydamaget othebloodvesselsint hereti
naof
theeye,andcanr esultingradualvisi
onl [Link] ot hekidneys,
knownasdi abeti
cnephr opathy,
canl eadtotissuescarr
ing,uri
neprot
ei nloss,and
event
uallychroni
cki dneydies

-
Diagnost icStudi es:-
1-Ser um gl ucose: Incr eased(200–1000mg/ Dl)ormor e.
2-Ser um acet one( ketones) :Str
onglyposi t
ive.
3-Fat tyaci ds: Lipids,tr i
glycer i
des,andchol ester ollev el el
ev ated.
4-Ser um osmol ality:Elev atedbutusual lylesst han( 330mOsm/ L).
5-Gl ucagon: Elev atedl ev elisassociatedwi thcondi tionst hatproduce( 1)act ual
hypogl ycemi a, (2)rel ativelackofglucose( e.g.,trauma, inf
ect i
on),or(3)l
ackof
[Link] efor e,glucagonmaybeel evatedwi t
hsev ereDKAdespi te
hyper glycemi a.
6-Gl ycosy latedhemogl obin( HbA1C):Evaluatesgl ucosecont rolduringpast( 8–12
weekwi t
ht hepr evious( 2week)mostheav il
ywei ght ed.
-Usef ulindifferent i
at inginadequat econt rolv ersusi nci dent-relat
edDKA( e.g.,
currentupperr espirat oryinfecti
on[ URI])
.Ar esul tgr eat erthan8%r epresent san
aver agebl oodgl ucoseof( 200mg/ dL)andsi gnal saneedf orchangesi nt reatment
.
7-Ser um i nsulin: Maybedecr eased/absent( type1)ornor mal tohigh( t
ype2) ,
indicatinginsul ininsuf fi
ciency/i
mpr operut il
i
zat i
on( endogenous/ exogenous) .

PageCXXof120
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

I
nsul
i
nresi
stancemaydev
elopsecondar
ytof
ormat
ionofant
ibodi
es.

PageCXXIof121
8-Electrol
y tes:
-Sodium: Maybenor mal ,elev ated, ordecr eased.
-Potassium: Nor mal orf alsel yel evated( cellularshift
s),t
henmar kedlydecreased.
-Phosphor us: Fr equent lydecr eased.
9-Arteri
al bloodgases( ABGs) :
10-
Usuallyr eflect sl owpHanddecr easedHCO3( met aboli
cacidosi
s)wi t
h
compensat or yr espir
at oryal kal osis.
11-
CBC: Hctmaybeel ev ated( dehy dr
at i
on); leukocy tosi
ssuggesthemoconcent r
ati
on,
responset ost ressori nfect i
on.
12-
BUN: Maybenor mal orel ev ated( dehy drat i
on/ decreasedrenalperf
usion).
13-
Serum amy lase: Maybeel ev ated,indicat i
ngacut epancreatit
isascauseofDKA.
14-
Thy r
oidf unct iont ests: I
ncr easedt hyroidact i
vitycanincreasebloodglucoseand
insuli
nneeds.
15-
Urine:Posi tivef orgl ucoseandket ones; speci fi
cgr avi
tyandosmol ali
tymaybe
elevated.
16-
Culturesandsensi t
iviti
es: Possi bl
eUTI ,
r espiratoryorwoundi nfect
ions

-Pr
eventi
on:
normalbodywei
ghtphysi
cal
exer
cise,heal
thf
uldi
edi
etr
i nwhol
chi egr
ainsandf
iber
,

-Management
:
Lif
esty
le:
goodnut
ri
ti
ont
oachi
eveanor
mal
bodywei
ghtandexer
cise
-
Medi
cat
ions:met
for
min,
fort
ype2di
abet
es,Ty
pe1di
abet
escanonl
ybet
reat
edwi
thi
nsul
i
n,

-Nursi
ngCarePl
ans:
1-Fl
uidVol
umeDeficit
rel
atedtoosmot
icdiuresi
s
-
Goal:
Demonstr
ateadequatehydr
ati
onevi
dencedbyst
abl
evi
talsigns,pal
pabl
eperi
pheralpul
se,ski
n
t
urgorandcapi
ll
aryref
il
lwel
l,i
ndi
vi
dual
lyappr
opr
iat
eur
inaryoutputande
, l
ect
roly
t elev
els
wit
hinnor
mal l
i
mits

-NursingIntervent i
on:
1.)Monitorvitalsigns.
Rational:hypov olemi acanbemani festedbyhy potensionandt achycardia.
2.)Assessper i
pher al pulses,capil
laryrefi
l
l,ski
nt urgor,andmucousmembr anes.
Rational:Thisisani ndicatoroft helevelofdehy drati
on, oranadequateci rculat
ing
volume.
3.)Moni t
orinputandout put,r
ecordt hespecifi
cgr avityofurine.
Rational:Topr ov i
deest i
mat esoft heneedf orflui
dr eplacement,renal
f unction,and
effecti
venessoft het herapygi ven.
4.)Measur ewei ghtev eryday .
Rational:Topr ov i
det hebestassessmentoff l
uidstatusofongoi ngandf urt
hert o
providear eplacementf l
uid.

PageCXXI
Iof122
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCXXI
IIof123
5.)Providef l
uidt herapyasi ndi
cated.
Rational:Thet ypeandamountofl iquiddependsont hedegr
eeofl
ackoff
lui
dsandt
he
responseofi ndi vidualpati
ents
2-I
mbal ancedNut r i
ti
onLesst hanBodyRequi r
ments
rel
atedt oinsufficiencyofinsulin,
decr easedoral
input
-Goal:
Digesttheamountofcal or
ies/nut ri
entsright
.
Showst heener gyl eveli
susually.
Stableori ncr
easi ngwei ght.

-NursingI nter vent i

on:
1.)Det ermi net hepat i
ent '
sdi etandeat ingpat ternsandcompar edwi t
hfoodt hatcanbe
spentbyt hepat ient .
Rationale: Ident i
f ydef icienciesanddev iationsf rom thet herapeut i
cneeds.
2.)Wei ghwei ghtperdayorasi ndicated.
Rational: Assessi nganadequat ef oodi ntake(includingabsor ptionandut i
li
zati
on).
3.)Ident i
ficationofpr efer r
edf ood/desi redincludet heneedsofet hnic/cultural
.
Rational: I
ft hepat ient '
sf oodpr eferencescanbei ncludedi nmeal planning,t
his
cooper ationcanbepur suedaf terdischar ge.
4.)Involvepat ient si nplanni ngt hef ami lymeal asindicated.
Rationale: Incr easet hesenseofi nv olvement ;
pr ovideinformat ionont hefami l
yto
under standt hepat ient'snut ri
tion.
5.)Giv eregul ari nsul intreatmentasi ndi cated.
Rational: regul arinsul inhasar apidonsetandqui cklyandt her efor
ecanhel pmov e
glucosei nt ocel ls.
3 - R i s k f o r I n f e c t i o n :
r e l a t e d t o h y p e r g l y c e m i a
Goal :
Identi
f yinterv entionst opr event/r educet heriskofi nfecti
on.
Demonst rat et echni ques, l
if
est ylechangest opr eventinfection.

NursingI ntervention:
1).Obser vedsi gnsofi nfectionandi nfl
ammat i
on.
Rationale:Pat i
ent smaybeent eredwithaninfecti
onthatusuall
yhassparkedast at
eof
ketoacidosi sormayhav enosocomi ali
nfect
ions.
2).Improv eef fortstopr eventionbygoodhandwashi ngforall
peopleincontactwit
h
patient
si ncludingt hepat i
ent sthemselves.
Rationale:Pr eventscr ossinfection.
3).Maint ainasept ictechniquei ninvasi
veprocedures.
Rational:highgl ucosel evelsinbl oodwouldbet hebestmedium fort
hegrowt hof
germs.
4).Givey ourski nwi t
hr egularcar eandearnest.
Rational:theper ipheralcirculati
onmaybedi st
urbedthatputspati
entsatincr
easedrisk

PageCXXI
Vof124
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

ofdamagetotheskin/skinirri
tati
onandi nfect
ion.
5)Makechangestotheposi t
ion,effect
ivecoughingandencour
agedeepbreat
hing.
Rati
onal
:memv ent
il
asiAssistinallareasandmobi li
zepul
monarysecr
eti
ons

A1CNor
mal
lesst
han(
5.7%)Pr
edi
abet
es(
5.7%)t
o(6.
4%)Di
abet
es(
6.5%)orhi
gher
Fast
ingPl
asmaGl
ucose(
FPG)
:
Resul
t:
Fast
ingPl
asmaGl
ucose(
FPG)Nor
mal
lesst
han100mg/
dlPr
edi
abet
es100mg/
dlt
o
125mg/
dlDi
abet
es126mg/
dlorhi
gher
Or
alGl
ucoseTol
eranceTest(
alsocal
l
edt
heOGTT)
:Nor
mall
esst
han140
mg/
dlPr
edi
abet
es140mg/
dlt
o199mg/
dlDi
abet
es200mg/
dlorhi
gher
.

PageCXXVof125
 [Link](
Ket
oaci
dosi
s)&Ket
ones
-Def i
nit
ion:
Di abeticket oacidosi s( DKA)i saser i
ouscondi t
iont hatcanl eadt o
diabet i
ccoma( passi ngoutf oral ongt ime)orev endeat h.
Wheny ourcel lsdon' tgett hegl ucoset heyneedf orener gy ,yourbodybegi nst oburnfat
forener gy ,whi chpr oducesket ones.
Ket onesar echemi calst hatt hebodycr eat eswheni tbreaksdownf attousef orenergy.
Thebodydoest hi swheni tdoesn’ thav eenoughi nsul i
ntousegl ucose, t
hebody ’
s
nor mal sour ceofener gy .Whenket onesbui ldupi nthebl ood, theymakei tmor eacidic.
Theyar eawar ningsi gnt haty ourdi abet esisoutofcont rol orthaty ouar eget tingsi
ck.
Highl evel sofket onescanpoi sont hebody .
Whenl ev elsgett oohi gh, youcandev elopDKA.
DKAmayhappent oany onewi thdi abet es,thoughi tisrarei npeopl ewi tht ype2.
Treat mentf orDKAusual lyt akespl acei nt hehospi tal
.
Buty oucanhel ppr ev enti tbyl ear ningt hewar ni
ngsi gnsandchecki ngy ourur ineand
bloodr egul ar l
y.
Pat hophy siologyDi abet icket oacidosi s( DKA)i sReducedi nsul i
nconcent rationoraction,
alongwi thincr easedi nsul incount er -regulatoryhor mones, leadst othehy perglycaemia,
volumedepl etion, andel ect rolyteimbal ancet hatunder l
iet hepat hophy siologyofDKA.
Hor monal alterationsl eadt oincr easedgl uconeogenesi s, hepat i
candr enal glucose
product ion, andi mpai r edgl ucoseut il
isat i
oninper ipheraltissues, whichr esul tsin
hyper gl
y caemi aandhy per osmol ar [Link] i
ndef iciencyleadst or el
easeoff reef at
ty
acidsf rom adi poset issue( l
ipol y
si s) ,
hepat i
cf attyaci doxidat i
on, andfor mat ionof
ketonebodi es( beta- hy dr oxy but yr
at eandacet oacet ate)
,whi chresultinket onaemi aand

PageCXXVIof126
-
compl
i
cat
ionsi
ncl
ude:

-Lowbl oodsugar( hypoglycemia) :

Insul
inallowssugart oent eryourcells,causingyourbl [Link]
bloodsugarl eveldropstooqui ckly,y
oucandev elopl owbloodsugar .
-Lowpot assium (hypokalemia):
Thef l
uidsandi nsuli
nusedt ot reatdiabeti
cketoaci dosiscancausey ourpotassium
l
ev elt
odr opt [Link] owpot assium levelcanimpai rtheacti
vit
iesofy ourheart,
musclesandner ves.
-Swell
inginthebr ain(cerebraledema) :
Adjusti
ngy ourbloodsugarl evel tooquicklycanpr oduceswelli
ngi [Link]
compl i
cationappear stobemor ecommoni nchil
dr en,especi
all
ythosewi thnewly
diagnoseddi abetes.

-
Cl i
nical DKAcl assification( adaptedwi t
hmodi f
icat
ion)
Diagnost iccr iteriaandcl assi f
icati
on:
-
Mi ldDKA:
Plasmagl ucose: >250mg/ dL(>13.9mmol /L)
Ar t
er i
al pH: 7. 25t o7. 30
Ser um bi car bonat e: 15t o18mEq/ L(15to18mmol /L)
Ur i
neket one: positive
Ser um ket one: posi ti
ve
Ef f
ect iveser um osmol al i
ty:vari
able
Ani ongap: >10
Ment al stat us: alert.
-
Moder ateDKA:
Plasmagl ucose: >250mg/ dL(>13.9mmol /L)
Arterial pH: 7.00t o<7. 24
Serum bi car bonat e:10t o<15mEq/ L(10to<15mmol /L)
Urineket one: posi tiv
e
Serum ket one: posi t
ive
Effect i
veser um osmol ali
ty:vari
able
Aniongap: >12
Ment alst at us:aler tand/ ordrowsy .
-
Sev er eDKA:
Plasmagl ucose: >250mg/ dL(>13.9mmol /L)
Arterial pH: <7.00
Serum bi car bonat e:<10mEq/ L(<10mmol /L)
Urineket one: posi tiv
e
Serum ket one: posi t
ive
Effect i
veser um osmol ali
ty:vari
able
Aniongap: >12
Ment alst at us:stuporand/ orcoma.

PageCXXVI
Iof127
PageCXXVI
IIof128
-
Whatar etheWar ningSignsofDKA:
 DKAu suallydev [Link] omi t
ingoccurs,thisli
fe-t
hreatening
condi t
ioncandev elopinaf ewhour [Link] l
ysympt omsi ncludethefollowing:
 Thirstorav er
ydr ymout h
 Frequentur inati
on
 Highbl oodgl ucose( bloodsugar )lev els
 Highl evelsofket onesi ntheurine
 Then, othersy mpt omsappear :
 Co nstantlyfeel
ingt ir
ed
 Dryorf lushedski n
 Na usea, vomiti
ng, orabdomi nal pain
(Vomi ti
ngcanbecausedbymanyi llnesses,[Link]
continuesf ormor ethan2hour s, cont actyourhealt
hcar epr ov
ider.
)
 Diffi
cultybreathing
 Fruityodoronbr eath
 Ah ardt i
mepay ingat t
ention,orconf usion

-WhatCausesDKA?
Herearethreebasi
creasonsformoderat
eorlar
geamountsofket
ones:
1-Notenoughinsul
in
May beyoudidnotinj
ectenoughi
nsul
[Link]
ourbodycoul
dneedmoreinsul
i
nthan
usualbecauseofil
l
ness.
2-
Notenoughfood
Whenyou'r
esick,youoft
endon'
tfeel
li
keeati
ng,somet
imesresul
ti
ngin
hi
ghketonelevel
[Link]
evel
smayalsooccurwhenyoumissameal .
3-Insulinreaction(lowbl oodgl ucose)
-Iftesti
ngshowshi ghket onelevelsinthemor ning,youmayhav ehadaninsul
in
reactionwhi leasleep.
-alsooccuri nsomeonewhohasal readybeendi agnosedwi t
hty pe1diabet
[Link]
ion,
i
nj ury,aser i
ousi l
l
ness, mi ssi
ngdosesofi nsuli
nshot s,
orsurgerycanleadtoDKAi n
peopl ewi thtype1di abetes.
-Peopl ewi t
ht ype2di abetescanal sodev elopDKA, butitisl
esscommon.I tisusuall
y
triggeredbyuncont roll
edbl oodsugar ,
mi ssingdosesofmedi cines,orasever
ei l
l
ness.
-Commonphy siol
ogicst r
essest hatcant ri
ggerDKAi nclude
 Acut einfecti
on( parti
cularl
ypneumoni aandUTI )
 MI
 St roke
 Pancr eati
tis
 Tr auma
4-
Drugsimpli
catedincausi
ngDKAi
ncl
ude
 Cort
icost
eroi
ds
 Thi
azidediur
eti
cs
 Sympathomimetics

PageCXXI
Xof129
-Diagnost icSt udies
1-Ser um gl ucose: Incr eased200–1000mg/ dLormor e.
2-Ser um acet one( ket ones) :Strongl yposi tive.
3-Fat tyacids: Lipids, trigly cer i
des, andchol est er ol l
ev elelevat ed.
4-Ser um osmol ality:El ev at edbutusual lylesst han330mOsm/ L.
5-Glucagon: Elev atedl evel isassoci at edwi thcondi tionst hatpr oduce( 1)act ual
hypogl y
cemi a, (2)r elativel ackofgl ucose( e.g. ,trauma, i
nfect ion),or( 3)l ackofi nsuli
n.
Ther efore, glucagonmaybeel ev atedwi t
hsev ereDKAdespi tehy pergly cemi a.
6-Glycosy lat edhemogl obi n( HbA1C) : Evaluat esgl ucosecont r ol duringpast8–12wk
witht hepr ev i
ous2wkmostheav i
lywei ght [Link] ulindiffer ent i
atingi nadequat e
cont rolversusi ncident -rel atedDKA( e.g.,cur r
entupperr espirat oryinf ection[ URI]).A
resultgr eat ert han8%r epr esent sanav eragebl oodgl ucoseof200mg/ dLandsi gnalsa
needf orchangesi nt reat ment .
7-Ser um insul i
n: Maybedecr eased/ absent( type1)ornor mal tohigh( type2) ,i
ndi cat
ing
i
nsul ininsuf fi
ciency /i
mpr operut il
i
zat ion( endogenous/ exogenous) .Insul i
nr esi
st ance
maydev elopsecondar yt of ormat ionofant ibodi es.
8-Elect r
olytes:
Sodi um: Maybenor mal ,elev at ed, ordecr eased.
Pot assium: Nor mal orf alsel yel evated( cellul arshi f
ts) ,t
henmar kedlydecr eased.
Phosphor us: Frequent lydecr eased.
8-Ar t
er i
albl oodgases( ABGs) : Usual lyr eflect sl owpHanddecr easedHCO3( metabolic
acidosi s)wi t hcompensat or yr espi rat oryal kal osi s.
9-CBC: Hctmaybeel ev at ed( dehy dr at i
on) ;leukocy tosissuggesthemoconcent ration,
responset ost ressori nfect i
on.
10-BUN: Maybenor mal orel ev ated( dehy dr at i
on/ decr easedr enal per fusion).
11-Ser um amy lase: Maybeel ev ated, indicat ingacut epancr eat i
tisascauseofDKA.
12-Thy r
oidf unct i
ont est s: Incr easedt hy r
oidact ivitycani ncr easebl oodgl ucoseand
i
nsul inneeds.
13-Ur ine:Posi ti
v eforgl ucoseandket ones; speci fi
cgr avi
tyandosmol al i
tymaybe
elevat ed.
14-Cul turesandsensi tivities: Possi bleUTI ,respi rator yorwoundi nfect ions.

-
Phar macot herapy:
 Regul arandanal oghumani nsulin'sareusedf orcorr
ecti
onofhy pergl
ycemi
a,unl
ess
bov i
neorpor kinsul
inist heonl yav ail
ableinsuli
n.
 Medi cat i
onsusedi nthemanagementofDKAi ncludethefol
lowing:
 Rapid- acti
nginsuli
n's(e.g. ,
insuli
naspar t
,insul
inglul
isi
ne,i
nsuli
nlispr
o)
 Short-actinginsuli
n'
s( e.g.,regularinsuli
n)
 El
ect rolytesupplement s( e.
g.,pot assi
um chl or
ide)
 Alkali
ni zi
ngagent s(e.
g., sodium bi carbonate)

PageCXXXof130
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCXXXIof131
-
Managementt oDKA:
 Correct
ionoffl
uidlosswi thint
ravenousflui
ds
 Correct
ionofhypergl
y cemiawi t
hinsuli
n
 Correct
ionofel
ectrolytedistur
bances,parti
cul
arl
ypot
assi
um l
oss
 Correct
ionofacid-
basebal ance
 Treatmentofconcurrentinfect
ion,i
fpresent

-
Nursingdi
agnosi
s
Nur
singDiagnosi
sforDi
abet
icKet
oaci
dosi
s

1-Fl
uidVolumeDef i
cit
:
rel
atedto:
-
osmot i
cdiuresisduetohypergl
ycemia,
-
excessivedischar
ge:diar
rhea,v
omiti
ng;rest
ri
cti
oni
ntakeduet
onausea,
ment
almess.
2-ImbalancedNut ri
ti
on:LessThanBodyRequi
rement
s
relat
edt o:
i
nsuf f
ici
encyofi nsul
in,
decreasedor ali
nput,
hipermet abol
ismestatus.
3-Ri
skf orInf ecti
on(sepsis)
rel
atedt o:
i
ncreasedl ev elsofglucose,
decreasedl eukocy t
ef uncti
on,
changesi nt hecircul
ation.
4-Fati
gue
rel
atedto:
decreasedmetabolicener
gyproduct
ion,
i
nsuffici
encyofinsul
in,
i
ncreasingenergydemand: st
atushy
permet
abol
i
c/i
nfect
ion.

[Link] i
cientFluidVolume:
Glucoseappear sintheurine(gl
ycosuri
a)becauset hekidneyexcretestheexcess
glucoset omaket [Link]
edi ntheurineactsas
osmot icdiureti
candcausesexcr eti
onofi ncreasedamountofwat er,
result
inginfl
uid
volumedef i
citorpolyuri
a.
-Nursingdiagnosis:
Defici
entFl ui
dVol umer el
atedtointr
acell
ulardehydrati
onsecondar ytodiabetes
mel l
it
us
-Possiblyev i
dencedby :
- Elev at
edt emper at
ure
-I ncreasedur ineoutput
- Sweat i
ng
- Thi r
st
- Exhaust ion
- Wei ghtloss
- Dr yskinand/ ormucousmembr ane

PageCXXXI
Iof132
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCXXXI
IIof133
-
Desiredoutcomes
Pati
entwil
lverbal
izeunder
standi
ngofcausati
vef
actor
sandpur poseofindi
vi
dual
ther
apeuti
cinter
venti
onsandmedi cat
ions.
Pati
entwil
limproveormaintai
nflui
dvolumeatafunct
ional
levelasevi
dencedby
i
ndivi
dualgoodskinturgor
,moistmucousmembrane,andstablevi
tal
signs.
1-Nur
singInter
vent
ions:Establ
ishrapport.
-
Rati
onale:Fri
endl
yandt rusti
ngrelat
ionshipwi
thpat
ientandt
obeabl
etounder
stand
eachother’
sconcern.
2-
Nursi
ngInter
vent
ions:Takeandrecor
dvi
tal
signs.
-
Rat
ional
e:Toobtainbaseli
nedat
a.
3-
Nursi
ngInter
vent
ions:Monit
ort
hetemperature.
-
Rat
ional
e:Tomoni t
orchangesi
ntemperature.
4-Nursi
ngI nt
ervent
ions:Assessskint
urgorandmucousmembr anesf
orsi
gnsof
dehydrat
ion.
-
Rationale:Drymucousmembr anesaresi
gnsofdehydr
ati
on.
5-
Nursi
ngInter
vent
ions:Moni
tori
ntakeandoutput
.
-
Rat
ional
e:Toassessforsi
gnsofdehydrat
ion.
6-
Nursi
ngInter
vent
ions:Encouragepat
ienttoincr
easefl
uidi
ntakeast
oler
ated.
-
Rat
ional
e:Torepl
acef l
uidlossandpreventdehydr
ati
on.
7-
Nursi
ngInter
vent
ions:Admi
nist
erIVFasor
dered.
-
Rat
ional
e:Torepl
acelostel
ectr
oly
tesandf
lui
ds.

2.I
mbalancedNutri
ti
on:LessThanBodyRequi
rement:
Nursi
ngDiagnosi
s
I
mbalancedNutri
ti
on:LessThanBodyRequi
rements
-Mayber elatedto:-
Insulindefici
ency( decreasedupt akeandutil
i
zati
onofglucosebyt hetissues,r
esul
ti
ng
i
ni ncreasedpr otein/f
atmet aboli
sm)
Decr easedor ali
ntake: anorexi
a,nausea,gastr
icf
ull
ness,abdominalpain;alt
ered
consci ousness
Hy permet aboli
cstate:releaseofst r
esshormones(e.g.
,epinephr
ine,corti
sol,
and
growt hhor mone) ,
infecti
ouspr ocess
-
Possiblyevi
dencedby :-
I
ncreasedurinaryoutput,
dil
uteuri
ne
Reportedi
nadequatef oodint
ake,lackofinteresti
nfood
Recentweightloss;weakness,fat
igue,poormuscl et
one
Diar
rhea
I
ncreasedketones( endproductoffatmet aboli
sm)
-
DesiredOutcomes:-
I
ngestappropri
ateamountsofcalori
es/
nutr
ient
s.
Di
splayusualenergylev
el.
Demonstrat
est abi
li
zedweightorgai
ntowardusual
/desi
redr
angewi
thnor
mal
l
aborator
yvalues.

PageCXXXI
Vof134
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

1-Nursi ngI ntervent i

ons:Wei ghdai lyorasor der ed.
Rat i
onal e:Wei ghi ngser vesasanassessmentt ool todet er mi net headequacyof
nutrit
ional i
ntake.
2-Nursi ngI ntervent i
ons:Ascer t
ai npat i
ent ’sdi etarypr ogr am andusual pat ternt hen
compar ewi t
hr ecenti ntake.
Rat i
onal e:I dent i
f i
esdef icitsanddev i
at ionsf rom t her apeut i
cneeds.
3-Nursi ngI ntervent i
ons:Auscul tatebowel [Link] er epor tsofabdomi nal pain,
bloating, nausea, vomi ti
ngofundi gest edf ood.
Mai ntainNPOst atusasi ndi cated
Rat i
onal e:Hy per glycemi aandf luidandel ect rol ytedi stur bancescandecr easegast r
ic
mot il
ityand/ orfunct ion( duet odi st ent ionori l
eus)af fect i
ngchoi ceofi nt er ventions.
Not e:Chr onicdi f f
icultieswi thdecr easedgast ricempt yingt i
meandpoori ntest i
nal
mot il
itymaysuggestaut onomi cneur opat hi esaf f
ect ingt heGIt r
actandr equi ri
ng
sympt omat ictreat ment .
4-Nursi ngI ntervent i
ons:Pr ov idel iqui dscont aini ngnut ri
ent sandel ectroly tesassoonas
patientcant oler ateor al fluidst henpr ogr esst oamor esol idf oodast oler at ed.
Rat i
onal e:Or alrout eispr ef erredwhenpat ienti sal ertandbowel f unctioni sr est or ed.
5-Nursi ngI ntervent i
ons:I dent i
fyf oodpr efer ences, includi nget hnicandcul tural needs.
Rat i
onal e:I fpat ient’sf oodpr efer encescanbei ncor por atedi ntot hemeal plan,
cooper at i
onwi thdi etar yr equi rement smaybef acilitatedaf terdi schar ge.
6-Nursi ngI ntervent i
ons:I ncl udeSOi nmeal planni ngasi ndi cated.
Rat i
onal e:Topr omot esenseofi nv olv ementandpr ov i
dei nf ormat iontot heSOt o
under st andt henut r
iti
onal needsoft hepat i
ent .
Not e:Var iousmet hodsav ai l
abl eordi et arypl anni ngi ncludeexchangel ist , pointsy stem,
glycemi ci ndex, orpr esel ect edmenus.
7-Nursi ngI ntervent i
ons:Obser vef orsi gnsofhy pogl ycemi a: changesi nLOC, col dand
clammyski n, r
api dpul se, hunger ,irritabi l
ity,anxi ety ,headache, l
ight headedness,
shakiness.
Rat i
onal e:Hy pogl ycemi acanoccuroncebl oodgl ucosel ev el i
sreducedand
carbohy dr atemet abol ism r esumesandi nsul ini sbei nggi ven.I fthepat ienti scomat ose,
hypogl y cemi amayoccurwi t
houtnot abl echangei nLOC.
Thispot ent iall
yl if
e-threat eningemer gencyshoul dbeassessedandt reat edqui cklyper
protocol .Not e: Type1di abet icsofl ongst andi ngmaynotdi splayusual signsof
hypogl y cemi abecausenor mal responset ol owbl oodsugarmaybedi mi nished.
8-Nursi ngI ntervent i
ons:Per formf ingerst ickgl ucoset est ing.
Rat i
onal e:Besi deanal y sisofser um gl ucosei smor eaccur at ethanmoni tor i
ngur ine
sugar .Ur i
negl ucosei snotsensi tiv eenought odet ectf luct uat i
onsi nser um l ev elsand
canbeaf fectedbypat ient ’si ndiv idual renal thr eshol dort hepr esenceofur inary
retention.

PageCXXXVof135
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Note:Normallev
elsforf
ingerst
ickgl
ucoset
esti
ngmayv arydependingonhowmuch
thepati
entateduri
nghislastmeal.I
ngener
al:
(80–120)mg/dL( 4.4–6.
6mmol /
L)
befor
emeal sorwhenwaki ngup;100–140mg/dL(5.
5–7.7mmol /L)atbedt
ime.

9-Nur singI nterv ent i

ons:Admi nist erregul arinsuli
nbyi ntermi ttentorcont inuousI V
met hod: I
Vbol usf oll
owedbyacont inuousdr i
pv i
apumpofappr oximat ely5–10U/ hrso
thatgl ucosei sr educedby50mg/ dL/hr.
Rational e:Regul ari nsulinhasar api donsetandt husqui cklyhel psmov egl ucosei nto
cells.
TheI Vr out ei sthei nit
ialrout eofchoi cebecauseabsor ptionf rom subcut aneous
ti
ssuesmaybeer rati
c.
Manybel i
ev et hecont inuousmet hodi st heopt imal wayt of acili
tatetransi ti
ont o
carbohy dratemet abolism andr educei nci denceofhy pogly cemi a.
10-Nur singI nter vent i
ons:Admi nisterglucosesol uti
ons: dext roseandhal f-normal sali
ne.
Rational e:Gl ucosesol ut i
onsmaybeaddedaf terinsulinandf l
uidshav ebr oughtt he
bloodgl ucoset oappr oximat ely400mg/ [Link] bohy drat emet aboli
sm appr oaches
normal ,caremustbet akent oav oidhy pogl ycemia.
11-Nur singI nter vent i
ons:Pr ov i
dedi etofappr oximat ely60%car bohy drates, 20%
prot eins, 20%f at si ndesi gnat ednumberofmeal sandsnacks.
Rational e:Compl excar bohy drat es( appl es,broccoli,peas, dr i
edbeads, car rots,peas,
oats)decr easegl ucosel evels/ insul i
nneeds, r
educeser um chol esterollev el
s, and
promot esat [Link] ntakei sschedul edaccordingt ospeci f
icinsulinchar acter i
sti
cs
andi ndi vi
dual patientr esponse.
Not e: Asnackatbedt i
meofcompl excar bohydratesi sespeci all
yi mpor t
ant( i
finsulinis
giveni ndi videddoses)t opr ev enthy pogl ycemiadur ingsl eepandpot ent i
al Somogy i
response.
12-Nur singI nter vent i
ons:Admi nisterot hermedi cationsasi ndicated: met ocloprami de
tetracy cline.
Rational e:Maybeusef ul i
nt reat ingsy mpt omsr elatedt oaut onomi cneur opat hies
affect ingGIt ract ,thusenhanci ngor al i
nt akeandabsor pti
onofnut ri
ents.

PageCXXXVIof136
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCXXXVI
Iof137
 [Link]
abet
icFoot
:
Footul cersar eacommoncompl icati
onofpoorl
ycont r
oll
eddiabetes,f
ormingasa
resultofski nt i
ssuebr eakingdownandexposi ngthelayer
sunder neat
h.
They ’
remostcommonundery ourbigtoesandtheballsofyourfeet,andtheycan
af f
ecty ourfeetdownt ot hebones.
-I
dent i
fyingSy mpt omsandDi agnosis:
-dr ai
nage
-Unusual swel l
ing,ir
ri
tati
on
-redness, andodor sfr
om oneorbot hfeet
-themostv isibl
esi gn:
-Par ti
alorcompl etegangr
ene, odorousdischar
ge,pain,
and
numbnesscanoccurandbl ackt i
ssue( cal
l
edeschar)
CausesofDi abeticFootPai nandUl cer
s
-
Diabet i
cul cersar emostcommonl ycausedby :
 p oorci rculat i
on
 h ighbl oodsugar( hy perglycemi a)
 n er vedamage
 irritatedorwoundedf eet
-
Poorbl oodci rculati
oni saf orm ofv ascul ardiseaseinwhi chbl ooddoesn’tfl
owt oy our
feetef fi
ciently.
-
Poorci rculationcanal somakei tmor edi ff
icul
tforulcerstoheal .
-
Hi ghgl ucosel ev el
scansl owdownt heheal ingprocessofani nfectedfootul
cer,so
bloodsugarmanagementi scr it
ical
.
-
Peopl ewi tht ype2di abet esof tenhav eahar derti
mef ightingof fi
nfect
ionsfr
om ul cers.
-
Ner v edamagei salong- t
er m effectandcanev enleadt oal ossoff eel
i
ngi nyourfeet.
-
Damagedner vescanf eel ti
nglyandpai nfulatfir
st.
-
Ner v edamager educesy oursensi t
ivit
yt ofootpainandr esultsinpainl
esswoundst hat
cancauseul cer s.
-
Ulcer scanbei denti
fiedbydr ai
nagef rom theaf f
ectedar eaandsomet i
mesa
not iceablel umpt hati sn’talway spai nful
.
-
Dr yski niscommoni ndi abet es.
Yourf eetmaybemor epr onet ocracki ng.
Calluses, cor ns, andbl eedi ngwoundsmayoccur .
-
RiskFact orsf orDiabeticFootUlcers:
All
peopl ewi thdiabetesar eatri
skf orfootul
cers,whichcanhav
emul
ti
plecauses.
Somef actor scani ncreasetheriskoffootulcers,
incl
uding:
-poorlyfittedorpoorqual i
tyshoes
-poorhy giene( notwashi ngregularl
yorthoroughly)
-impropert r
immi ngoft oenai
ls
-alcohol consumpt ion
-eyediseasef rom diabetes
-heartdisease
-kidneydi sease

PageCXXXVI
IIof138
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-obesi t
y
-t obaccouse( inhibi
tsbl oodci rcul
ation)
-Di abet i
cf ootul cersareal somostcommoni noldermen.
-
Tr eat i
ngDi abet i
cFootUl cer s:
St ayof fyourf eett oprev entpai nandul cers.
Thi siscal l
edof f-l
oading, andi t’
shelpful f
orallformsofdiabeti
cfootulcers.
Pr essur efrom wal ki
ngcanmakeani nfecti
onwor seandanul cerexpand.
Forpeopl ewhoar eov erwei ght,extr
apr essuremaybet hecauseofongoi ngfootpai
n.
Ani nfecti
oni saser i
ouscompl icat
ionofaf ootulcerandrequir
esimmedi ate
treat ment.
Notal li
nfectionsar etreat edthesameway .
Tissuesur roundi ngt heul cermaybesentt oal abtodeterminewhichantibiot
icwil
l
hel p.
Ify ourdoct orsuspect saser iousinfection,heorshemayor deranX-raytolookfor
signsofbonei nfecti
on.
-
Inf
ecti
onofaf ootulcercanbepr eventedwith:
-footbaths.
-disi
nfecti
ngt heski nar
oundanul cer.
-keepingtheul cerdrywithfr
equentdr essi
ngchanges.
-enzymet reatment s.
-dressingscont ai
ningcalci
um alginatestoinhi
bitbact
eri
algr
owt
h.
-Medications:
Yourdoct ormaypr escribeanti
biot
ics,anti
platel
ets,
orant i-
clot
ti
ngmedi cat
ionstotreat
yourulceriftheinfect
ionprogressesev enafterpreventiv
eorant i
-pr
essuretreat
ment s.
Manyoft heseantibi
oticsatackSt
t aphylococcusaur eus,bact
eri
aknownt ocause
staphinfecti orß-
ons, haemol yticStreptococcus, whi chisnormall
yfoundiny our
i
nt est
ines.
-
Over-
the- CounterTr eatment
s:
- Manyt opi
caltreatmentsareavail
abl
eforfootulcers,i
ncludi
ng:
- dressingscontai ningsi
lv
erorsil
versul
phadiazi
necr eam
- polyhexamet hylenebiguani
de(PHMB)gel orsoluti
ons
-iodine( eit
herpov i
doneorcadexomer)
- medi calgradehoneyi noint
mentorgel f
orm
-
Sur
gical
Procedur
es.

PageCXXXI
Xof139
-Nur
singDi
agnosis:
-
1-Ri
skforI
nfect
ion:

-
Riskf
act
orsmayinclude
 Highglucoselevels,decreasedleukocy
tef
unct
ion,
alt
erat
ionsi
nci
rcul
ati
on
 Preexi
sti
ngr espi
ratoryinfect
ion,orUTI
-
Possi
blyevidencedby
 [ Notappl icableforri
[Link]
signsandsympt oms,ast heproblem hasnotoccur r
edandnur si
ng
interventi
onsar edirect
edatpr eventi
on.]
-
Desi
redOut comes:
 I dentif
yinter
venti
onstoprevent
/reduceri
skofinf
ecti
on.
 De monstratetechni
ques,l
if
esty
lechangestopreventdevel
opmentof
infecti
on.

1-Nur singInter vention:-Obser vef orthesi gnsofi nfect i

onandi nflammat i
on: fever,
fl
ushedappear ance, wounddr ainage, pur ulentsput um, cloudyur ine.
Rat i
onal e:Patient swithDM maybeadmi ttedwi thinf ection, whi chcoul dhav e
precipitatedt heket oaci dot i
cst at [Link] sodev elopnosocomi al i
nfection.
2-Nur singInter vention:-Teachandpr omot egoodhandhy giene.
Rat i
onal e:Reducesr i
skofcr oss- cont ami nat i
on.
3-Nur singInter vention:-Mai ntainasepsi sdur ingI Vinser tion, admi ni
strati
onof
medi cati
ons, andpr ovidingwoundorsi t ecar [Link] ateI Vsi tesasi ndi
cated.
Rat i
onal e:I
ncr easedgl ucosei nt hebl oodcr eatesanexcel l
entmedi um forbact eriato
thri
v e.
4-Nur singInter vention:-Pr ovidecat heterorper ineal [Link] emal epatientst o
cleanf rom frontt obackaf terel imi nat ion.
Rat i
onal e:Minimi zesr iskofUTI .Comat osepat ientmaybeatpar ticularri
ski furinary
retent i
onoccur redbef or ehospi t [Link] e:Elder l
yf emal edi abeticpat i
ent sare
especi allypronet ourinar ytractand/ orv agi naly easti nfections.
5-Nur singInter vention:-Pr ovidemet i
cul ousski ncar e: gent l
ymassagebonyar eas, keep
skindr [Link] inensdr yandwr inkl e-free.
Rat i
onal e:Peripher alcirculationmaybei nef fectiveori mpai red, placingthepat i
entat
i
ncr easedr i
skf orski nbr eakdownandi nf ect i
on.
6-Nur singInter vention:-Admi nist erant ibioticsasappr opr i
ate.
Rat i
onal e:Earlyt r
eat mentmayhel ppr ev entsepsi s.

[Link]
bedSensoryPercepti
on:
-Ri
skfactorsmayi ncl
ude:
 E ndogenouschemi cal
alter
ation:
glucose/i
nsul
inand/
orelect
rol
ytei
mbalance
-Possi
blyevidencedby
 [ Notappl i
cableforri
skdi [Link]
sisnotevidencedby
signsandsympt oms,ast hepr obl
em hasnotoccur r
edandnur sing

PageCXLof140
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

i
nter
vent
ionsar
edi
rect
edatpr
event
ion.
]

PageCXLIof141
-
Desi
redOut
comes:
 Ma i
ntai
nusuall
evelofmutat
ion.
 Recognizeandcompensat
eforexist
ingsensor
yimpai
rment
s.

1-Nur singI ntervention:-Moni torv i

tal si
gnsandment al status.
Rational e:Topr ov i
debasel inef r om whi chtocompar eabnor mal f
indings.
2-Nur singI ntervention:-Call thepat i
entbyname, reorientasneededt oplace,person,
andt ime.
Giveshor texpl anat i
ons, speaksl owl yandenunci atecl early
.
Rational e:Decr easesconf usi onandhel psmai ntaincont actwithreali
t y.
3-Nur singI ntervention:-Schedul eandcl usternursingt imeandi nterventions.
Rational e:Topr ov i
deuni nterrupt edr estperiodsandpr omot erestfulsleep,mi ni
mi ze
fati
gueandi mpr ovecogni tion.
4-Nur singI ntervention:-Keeppat i
ent ’
sr outi
neasconsi stentaspossi [Link] age
parti
ci pationi nact i
v i
ti
esofdai l
yl iv i
ng( ADLs)asabl e.
Rational e:Hel pskeeppat i
enti nt ouchwi threali
tyandmai ntainorientati
ont othe
environment .
5-Nur singI ntervention:-Prot ectpat i
entf r
om injurybyav oidingorl i
mit i
ngtheuseof
restraintsasnecessar ywhenLOCi simpai r
[Link] acebedi nlowposi t
ionandpadbed
rai
lsi fpat i
enti spr onet osei zur es.
Rational e:Di sori
ent edpat i
ent sar epr onet oinjury,especi all
yatni ght,andpr ecauti
ons
needt obet akenasi [Link] zurepr ecauti
onsneedt obet akenasappr opri
ateto
preventphy sicalinj
ury,aspi ration, andfal l
s.

#Anot
hernur
singdi
agnosi
s:

-
Impai
redski
nint
egr
it
y.

-
acut
epai
n.

-
impai
redphy
sical
mobi
l
ity
.

-
imbal
ancednut
ri
ti
on:
l
esst
hanbodyr
equi
rement
.

PageCXLI
Iof142
 [Link]
ecy
sti
ti
s

-Chol ecyst i
ti
si sinflammat ionoft hegal l
bladder.
Althoughmostpeopl ewi thgal l
st onesdonothav esy mptomsandwi llnotgoont o
dev elopchol ecystit
is, chol ecy stiti
soccur smostcommonl yduet obl ockageoft he
cy sti
cductwi thgallstones( chol elit
hiasis).
Thi sblockagecausesabui ldupofbi l
eint hegall
bladderandi ncreasedpr essurewi t
hin
thegal l
bladder, leadi ngt or ightupperabdomi nalpain.
Concent ratedbi l
e, pressur e, andsomet imesbact eri
alinfectionirri
tateanddamaget he
gal l
bladderwal l,causi ngi nf l
ammat ionandswel l
ingoft hegal lbl
adder .
Inflammat ionandswel l
ingoft hegal l
bladdercanr educenor mal bloodf l
owt oareasof
thegal l
bladder ,whi chcanl eadt ocel ldeathduet oinadequat eoxy gen
Acut echol ecysti
t i
sr eferst oacut einflammat ionoft hegallbladderwal l.
Thei nci
denceofchol ecy stitisisi ncreasedi ncli
ent swhoar eov erweight ,especi
ally
thosewi thasedent arylifest y l
e.
Chr onicchol ecystit
issomet imesar isesasasequel t
oacut echolecy stit
is.
Ty picall
y ,howev er,itdev elopsi ndependent l
yofacut echol ecystit
is.
Inaddi tion, i
tisal mostal way sassoci atedwi thgall
stones.
Chr onicchol ecystit
ispr inci pallyaf fectsmi ddle-
ageandol [Link] emale
-to-mal erat i
oi s3:1.
-
Signsandsy mptomsi ncl
ude:
•severeabdomi nalpainsthatmayf eelsharpordull
•abdomi nalcr
ampi ngandbl oat
ing
•painthatspreadst oyourbackorbel owy ourr
ightshoul
derblade
•fever
•nausea
•vomi t
ing
•loose,li
ght-
color
edst ool
s
•jaundice,whi
chiswheny ourskinandt hewhit
esofy oureyestur
nyel
l
ow
-di
agnost i
ct est:
Laboratorytestsar enotal way sr eli
able,butthef ol
lowi ngf i
ndingsmaybedi agnost i
call
y
useful
:
 L eukocy tosiswi thal eftshiftmaybeobser ved
 Al anineami notransferase( ALT)andaspar tat eami notr
ansf er
ase( AST)levels
maybeel evatedinchol ecy sti
ti
sorwi thcommonbi leduct( CBD)obstructi
on
 Bi l
irubinandal kal
inephosphat aseassay smayr evealev i
denceofCBD
obst r
uction.
 Amy l
ase/ l
ipaseassay sar eusedt oassessf orpancr eatiti
s;amy l
asemayal so
bemi ldlyelevat edinchol ecysti
t i
s
 Al kali
nephosphat aselev elmaybeel evated( 25%ofpat ientswithcholecystit
is)
 Ur inalysi
si susedt oruleoutpy el
onephr i
tisandr enalcalculi
 Al lfemal esofchi ldbear i
ngageshoul dunder gopr egnancyt est
ing

PageCXLI
IIof143
-
Diagnost
icimagingmodal i
ti
esthatmaybeconsi
der
edi
ncl
udet
hef
oll
owi
ng:
 Radiogr
aphy
 Ult
rasonography
 Comput edtomography(CT)
 Ma gnet
icresonanceimaging(
MRI)
-Tr
eat
ment :
i
nit
ial
treat
mentincludes:bowel
rest
,IVhy dr
ati
on,cor
rect
ionofel
ect
rol
yte
abnor
mal i
ti
es,
analgesia,
andIVanti
biot
[Link]
ons.

Sur
gicalandinter
venti
onalpr
oceduresusedtotreatchol
ecy
sti
ti
sincl
udethef
oll
owi
ng:
 L aparoscopicchol
ecyst
ectomy(standar
dofcar ef
orsur
gicalt
reat
mentof
cholecysti
ti
s)
 Pe r
cutaneousdrai
nage.

 Endoscopi
cul
tr
asound-guidedtransmur
alchol
ecy
stost
omy
.
 Endoscopi
cgal
lbl
adderdrainage.

-Nursi ngDi agnosi s:

1-Acut ePai n
-Mayber el atedt o:
 Bi ologi cal injuringagent s:obst ruct ion/ ductal spasm, i
nfl
ammat orypr ocess,
t
issuei schemi a/necr osis
-Possi blyev idencedby :
 Re por tsofpai n, bil
iarycol i
c( wav esofpai n).
 F aci al maskofpai n;guar dingbehav iour.
 Au tonomi cr esponses( changesi nBP, pul
se) .
 Se lf-focusi ng; narrowedf ocus.
-DesiredOut comes:
 Re por tpai ni sr eli
eved/ control l
ed.
 De monst rat euseofr elaxationski ll
sanddi v ersionalact
ivi
ti
esasi ndicatedf or
i
ndi vidual situat i
on.
-Nursi ngI nt erv ent ions:
1)Obser v eanddocumentl ocat i
on, sev erity( 0–10scal e),
andchar acterofpai n( steady
,
intermi ttent ,col icky ).
Rat ional e: Assi st sindi ff
er entiat
ingcauseofpai n, andpr ovi
desinformat i
onabout
diseasepr ogr essi onandr esol uti
on, dev elopmentofcompl i
cati
ons, andef fectiv
eness
ofi nterv ent ions.
2)Not er esponset omedi cation,andr epor ttophy si ci
anifpainisnotbei ngr eli
ev ed.
Rat ional e: Sev er epai nnotr eli
evedbyr out inemeasur esmayi ndi
catedev eloping
compl icat ionsorneedf orf urt
heri nterv ent i
on.
3)Pr omot ebedr est, al
lowi ngpat ientt oassumeposi t
ionofcomf ort
.
Rat ional e: Bedr esti nl ow- Fowl er’
sposi tionr educesi ntra-
abdominal pressur e;howev er
,
pat i
entwi llnat ur al l
yassumel eastpai nful posi t
ion.

PageCXLI
Vof144
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

4)Usesoftorcott
onli
nens;cal
ami
nelot
ion,
oilbat
h;cool
ormoistcompressesas
i
ndicat
ed.
Rati
onal
e:Reducesir
ri
tat
ionanddr
ynessoftheski
nanditchi
ngsensat
ion.

PageCXLVof145
 5)Contr
olenvironmentaltemperature.
Rati
onal
e:Cool surr
oundingsaidinmi ni
mizi
ngdermaldiscomfort
.
#Administ
ermedi cati
onsasindicated:
6)Anti
choli
nergics:at
ropi
ne,propanthel
ine(
Pro-
Banthı
-ne);
Rati
onal
e:Reli
ev esrefl
exspasm andsmoot hmusclecont r
acti
onandassi
stswi
thpai
n
management .
7)Sedati
ves:Phenobarbit
al.
Rati
onal
e:Promot esrestandrelaxessmoothmuscle,r
elievi
ngpain.
8)Anti
biot
ics.
Rati
onal
e:Tot r
eatinfecti
ous

2-Ri
skf orDef icientFl uidVolume:
-Ri
skf actorsmayi nclude
E xcessi v
el ossest hroughgastr
icsuction;vomit
ing,dist
ensi
on,andgast r
ic
hy per¬mot il
it
y
 Me dicall
yr est r
ictedintake
 Alteredcl ottingpr ocess
-Desi
redOut comes:
 De monst rateadequat eflui
dbalanceev i
dencedbyst ablevi
talsi
gns,moist
mucousmembr anes,goodskinturgor,capi
ll
aryrefi
l
l,i
ndiv
iduall
yappropri
ate
ur i
naryout put,absenceofv omiti
ng.
-NursingI nter v
ent ions:
1)Mai nt ainaccur ater ecordofI &O, noti
ngout putl essthani ntake, increasedur i
ne
specificgr av i
[Link] nandmucousmembr anes, per i
pher al pul ses,andcapi l
lar
y
refi
ll.
Rat i
onal e:Topr ov i
dei nformat i
onaboutf l
uidst atusandci rcul ati
ngv ol
umeneedi ng
replacement .
2)Moni torf orsignsandsy mpt omsofi ncr easedorcont inuednauseaorv omi ting,
abdomi nal cramps, weakness, twitchi ng, sei
zur es,irr
egul arhear trat e,parest hesi a,
hypoact iveorabsentbowel sounds, depressedr espirations.
Rat i
onal e:Pr ol
ongedv omi ting, gast ri
caspi ration,andr est rictedor al i
ntakecanl eadt o
deficit
si nsodi um, pot assium, andchl oride.
3)El i
mi natenoxi oussi ghtsorsmel lsf r
om env ironment .
Rat i
onal e:Reducesst imul ationofv omi tingcent er.
4)Per for mf requentor al hygienewi t halcohol -
f r
eemout hwash; appl ylubricant s.
Rat i
onal e:Decr easesdr ynessofor al mucousmembr anes; r educesr i
skofor al bleeding.
5)Usesmal l-
gaugeneedl esf ori nject i
onsandappl yf i
rm pr essur ef orlongert hanusual
afterveni punct ure.
Rat i
onal e:Reducest rauma, riskofbl eedingorhemat omaf or mat ion.
6)Assessf orunusual bleedi ng: oozi ngfrom i njectionsi tes, epistaxi s,bleedinggums,
ecchy mosi s, petechi ae, hemat emesi sormel ena.
Rat i
onal e:Pr ot
hr ombi ni sr educedandcoagul ationt i
mepr olongedwhenbi l
ef lowi s

PageCXLVIof146
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

obst
ruct
ed,
incr
easi
ngr
iskofbl
eedi
ngorhemor
rhage.

PageCXLVI
Iof147
7)Keeppati
entNPOasnecessar y.
Rati
onal
e:DecreasesGIsecret
ionsandmoti
li
ty.
8)I
nsertNGtube,connecttosucti
on,andmai
ntainpat
encyasi
ndi
cat
ed.
Rati
onal
e:ToresttheGITract.

Ot
herdi
agnosi
s:

Ri
skf
orI
mbal
ancedNut
ri
ti
on:
LessThanBodyRequi
rement
s.

PageCXLVI
IIof148
 [Link]
cit
is
-Defi
nit
ion:
Appendiciti
sisi nfl
ammat ionoft heappendix.
Appendiciti
scommonl ypresentswithri
ghtili
acfossaabdomi nal
pain,nausea,v
omiting,
anddecr easedappet i
te.
Howev er,onet hir
dt oahalfofper sonsdonothav ethesety
picalsignsandsy mptoms.
Severecompl icationsofar upturedappendixincl
udewidespread,painf
uli
nflammation
oftheinnerliningoft heabdomi nalwallandsepsis.
-Pathophy siol
ogy :
appendi cit
isiscausedbyobst ructi
onoft heappendi
ceallumenf r
om avar
ietyofcauses
I
ndependentoft heet i
ology
,obst r
uct i
onisbeli
evedt
ocauseani ncreasei
npr essur
e
withinthel [Link] ncreasei srel
atedtocont
inuoussecreti
onoffl
uidsand
mucusf rom themucosaandt hest agnati
onofthismateri
al.
Atthesamet i
me, intesti
nalbacteri
awi thi
ntheappendixmulti
ply,
leadi
ngtot he
recruit
mentofwhi tebl oodcell
sandt heformati
onofpusandsubsequenthi gher
i
ntralumi nalpressure.
-CausesAppendi cit
is?
Obst ructionisof tencausedbyanaccumul ati
onoff ecalmatt
[Link]
sobecaused
by :
 e nlargedl ymphoi df ol
li
cles.
 wo rms.
 t rauma.
 t umor s.
-Sympt omsofAppendi citi
s?
 lowerr i
ghtsi deabdomi nal pain.
 lossofappet it
e.
 n ausea.
 v omi ti
ng.
 d iarrhea.
 c onst i
pation.
 inabi li
tytopassgas.
 a bdomi nalswel l
ing.
 lowgr adef ever.
 as ensey oumi ghtfeel bet t
erafterpassingstool.
-Appendi citi
sDi agnosed?
-Uri
nal ysiscanr uleoutaur i
nar yt r
actinfect
ionorkidneystone.
-Pelvicexamscanmakecer tainthatwomendon’ thavereproducti
veprobl
[Link]
canal sor ul
eoutot herpelvici nfecti
ons.
-Pregnancyt estscanr ul
eoutasuspect edect opi
cpregnancy.
-Abdomi nalimagi ngcandet ermi neifyouhav eanabscessorot hercompli
cat
ions.
Thismaybedonewi thanX- ray,ult
rasound, orCTscan.
-Chestx- raycanr uleoutr i
ghtl ower-l
obepneumoni [Link]
ssomet imeshassymptoms
l
ikeappendi cit
is.

PageCXLI
Xof149
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCLof150
-
Treat
ment
sanddr
ugs:
-
Ant
ibiot
ics:
 Ant
ibiot
icpr
ophy
laxi
sshoul
dbeadmi
nist
eredbef
oreev
eryappendect
omy
 Pr
eoper
ati
veant
ibi
oti
csshoul
dbeadmi
nist
eredi
nconj
unct
ionwi
tht
hesur
gical
consul
tant
 Br
oad-
spect
rum gr
am-
negat
iveandanaer
obi
ccov
eragei
sindi
cat
ed
 Cef
otet
anandcef
oxi
ti
nseem t
obet
hebestchoi
cesofant
ibi
oti
cs
I
npeni
cil
l
in-
all
ergi
cpat
ient
s,car
bapenemsar
eagoodopt
ion
 Pr
egnantpat
ient
sshoul
drecei
vepr
egnancycat
egor
yAorBant
ibi
oti
cs
 Ant
ibi
oti
ctr
eat
mentmaybest
oppedwhent
hepat
ientbecomesaf
ebr
il
eandt
he
WBCcountnor
mal
i
zes.
-Surgeryt oremov etheappendi x( appendect omy ):
-Appendect omycanbeper formedasopensur geryusingoneabdomi nalincisi
onabout
2t o4i nches( 5t o10cent i
met er s)long(laparotomy ).
Ort hesur gerycanbedonet hroughaf ewsmal labdomi nal inci
sions(l
aparoscopi c
surger y)
.Dur i
ngal apar
oscopi cappendect omy ,thesurgeoni nsert
sspecialsurgical
toolsandav i
deocamer aint oyourabdoment or emovey ourappendix.
-I
ngener al,
laparoscopicsur ger yallowsy outor ecoverf asterandheal wi
thlesspai n
andscar ri
[Link] terf orpeopl ewhoar eelderl
yorobese.
Butl aparoscopi csurgeryisn'tappr opriat
ef oreveryone.
Ifyourappendi xhasr upturedandi nfecti
onhasspr eadbey ondt heappendixory ouhav e
anabscess, youmayneedanopenappendect omy ,whi chal l
owsy oursurgeont oclean
theabdomi nal cavity
.
-Expectt ospendoneort woday si nthehospi t
al aft
ery ourappendect omy .
-Nursingdiagnosis:
1-Pain:
rel
atedt oeffect
sofappendicit
is.
-PlanningGoal :
todecreasepain
-Outcomes: thePati
entwill
statepai
niswi
thi
ntol
erabl
eli
mit
sunt
ilsur
ger
y.
-
Inter
v enti
ons:
[Link] hepat i
ent'
spai nusi
nganappr opri
atepai n-assessmenttool.
Rati
onal:prov i
desbaselineinf
ormat i
onf [Link] n-
assessmenttool
providesanobj ectivemeansf ordeterminingtheext entandintensi
tyofthepain.
[Link] nist
eranyanal gesi
[Link] h(NPO).
Rational:Analgesicscanmaskt hesi gnsofpossi bleruptureandsubsequent
peri
toniti
[Link] ni
mizestheriskforfurthervomi ti
ngandpr eventabdominal
[Link]
ndingaposi t
ionofcomf [Link]
owsasappr opri
ate.

Rat
ional
Findi
ngaposi
ti
onofcomf
orthel
psmi
nimi
zespai
[Link]
l
lowsof
feraddi
ti
onal

PageCLIof151
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

suppor
ttomai
ntai
ntheposi
ti
onofcomf
ort
.

PageCLI
Iof152
 [Link]
stthepati
entwit
husingnonphar
macol
ogi
cmet
hodsofpai
ncont
rol
,suchas
i
magery,dist
ract
ion,
andthoughtst
oppi
ng.

Rati
onal:
Imager
y,di
str
act
ion,
andt
houghtst
oppi
ngar
egat
econt
rol
theor
ytechni
ques
usef
ulinrel
i
evi
ngpain.

[Link]
aget
hepat
ientt
ouset
heset
echni
quesatt
heonsetofpai
n.

Rat
ional
:Usi
ngt
het
echni
quesear
lyonenhancest
hei
ref
fect
ivenessi
ncont
rol
l
ingpai
n.

NursingDiagnosis:
2-Riskforinfecti
on
rel
atedtopossi bl
eruptur
eofappendi
x
Goal:Toprev enti
nfect
ion
Outcomes: Chil
dwillr
emainf
reeofanysi
gnsandsy
mpt
omsofr
upt
ureunt
ilsur
ger
y
[Link] entofpai nf r
equent [Link] oidpalpatingthe
abdomenunl essabsol ut elynecessar y.
Rational:Ani ncr easeinpai nandbr oad1ikeabdomeni ssignsofper i
toni
ti
sf rom a
ruptureappendi x.
[Link] torv i
tal signsev ery15t o30mi ntsr eportanyel ev ati
oni ntemper ateor
respirat
[Link] ional:elev atedt emper aturei ndicat
esacut einfection.
[Link] ainl abor atories’test s,includingwhi tebl oodcel lcount,asor [Link] i
onalA
whitebl oodcel lcount. ov ere2O, 000/mm3i ndicaterupture.
[Link] t
iont hepat i
entcomf ortablywi thheadofbedel ev atedinsemi -Fowlerpositi
on.
Rational Semi -Fowl er’
sposi ti
onkeepsi nfect eddrainagel ocali
zedt ot helower
abdomi nal cav it
yshoul dt heappendi xr uptur e.
[Link] ni steri ntravenousf luidt herapyasor der
[Link] ici
patet heneedf orintrav
enous
anti
biotict her apy .
Rational I
nt rav enousf luidt her apypr ovidesadequat ehy drati
on.I ntravenousant i
biot
ics
helptocombati nfecti
onshoul dr uptureoccur .
[Link] oidappl yingheatt ot heabdomen.
Rat i
onal :Thi smeasur ecoul dl eadtor uptur e.

-Nursi
ngDi agnosis:
-Ri
skf orfluidvolumedef i
cit
rel
atedt ov omiti
ngl ackofor alintake,andNPOst atus.
-Goal:Tomai ntenanceFl ui
dv olumebal ance
-Outcomes: patientwi l
lbemai ntainingsignsandsy mptomsofadequat ehydrat
ion
pri
ortosur gery
Int
ervention:
[Link] eral1hy drat
ionstatusonadmi ssi
onincludi
ngskintur
gor,
mucous
membr anesandwei ght .
Rati
onal :Admi ssionassessmentpr ovi
desabasel ineforpl
anninganevaluat
ing
changeswei ghtisreliabl
eindicatoroff l
uidbalance.

PageCLI
IIof153
[Link] ntai
nNPOst [Link]
it
utei ntrav enousf l
uidtherapywit
hel ectroly
tesasor der
ed.
Rational:NPOst at
usi snecessar yt omi ni
mizet herisksofsurgeryIntravenousflui
d
therapywi t
hel ectr
ol yteshel
pstor eplaceanyl ossthroughvomi t
ingandl ackoforal
i
ntakeandal somai ntainadequatehy dr at
ioninl i
ghtofpati
entbeingNPO.
[Link] tori
nt akeandout putasor der ed, i
ncludingintr
avenousfluid,uri
ne, st
ool,
and
emesi [Link]
onal :I
nt akeandout putpr ov i
desanobj ecti
veesti
mat eofov eral
1fl
uid
balance.

PageCLI
Vof154
 [Link]
esl
i
thi
asi
s
-Def i
nition:
st
onesorcal culii
nt hegal l
bladder ,resultsfr
om changesinbi l
ecomponent s.
Gallstonesar emadeofchol est erol,calcium bil
i
rubi
nate,orami xofchol est
eroland
bil
ir
ubi nThecomposi ti
onofgal lstonesi saf f
ectedbyage,dietandet hnicit
y
Theyar i
sedur i
ngper iodsofsl uggi shnessi nthegal
lbl
adderduet opregnancy ,
hormonal
cont r
acept i
v es,diabetesmel l
itus, celiacdisease,ci
rr
hosi
soft hel i
ver,andpancr eat
it
is.
Gallstonesar eformedi nt hegal l
bladderbutmaypassdi stall
yintootherpar t
sof
thebiliarytractsuchast hecy sticduct ,
commonbi l
educt,pancr eat
icductor
theampul laofVat er
.
Gallstonescanv aryi
nsi zeandshapef rom assmallasagr ainofsandt oasl argeasa
golfbal l
.
Thegal l
bladdermaycont ainasi nglel argestoneormanysmal lerones.

-
Typeofst one:
-
Chol esterol stones:
Chol esterol stonesv ar yfrom lighty ellowt odarkgr eenorbr ownorchalkwhi t
eandar e
oval,usual lysol i
tary ,between2and3cm l ong
-
Bil
irubinst ones:
Bili
rubin( "Pi gment ","BlackPi gment " )stonesar esmal l
,dar
k( oft
enappear i
ngblack)
,
and usual l
ynumer ous.
-
Mixedst ones:
Mixed( "Br ownPi gment "
)
-
Signsandsy mpt oms:
p aini nt heupper -
rightsideoft heabdomen( betweentheshoul derbladesorbelow
ther i
ghtshoul der (
n ausea
v omi ting
" gal l
st one-at t
acksoccuraf terapar ti
cular
lyfattymeal andalmostalwayshappen
atni ght , andaf terdr i
nk.
 Ap osi tiveMur phy 'ssigni sacommonf i
ndingonphy sicalexaminati
on.
-
Diagnost i
cSt udi es:
 Ult
r asound
 Oral chol ecy stogr aphy( OCG
E ndoscopi cr etr
ogr adechol angi opancr eatography(ERCP
 Percut aneoust ranshepat icchol angi ography(PTC
 CTs can
 MRI
 Abdomi nal x-rayf i
lms
 Chestx- ray :Rul eoutr espir
at orycausesofr eferr
edpai
 CBC: Moder at eleukocy t
osis( acut e).
 Serum bi lirubi nandamy lase: Elevated.
 Serum l i
v erenzy mes—AST; ALT; ALP;LDH: Sli
ghtelevat i
on;al
kal
inephosphatase

PageCLVof155
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

and5-nucleoti
dasearemarkedl
yel
evat
edinbi
l
iar
yobstr
uct
ion.
 Prot
hrombinl ev
els:
Reducedwhenobstr
uct
iont
othefl
owofbilei
ntot
hei
ntest
ine
decreasesabsorpti
onofvi
taminK.
-
Treatment:
-
Cholester
olgal
l
st onescansometimesbedissol
vedbyoralur
sodeoxy
chol
icaci
d,buti
t
maybenecessaryf orthepat
ientt
otakethi
smedicati
onforuptotwoyear
s.
Gal
- l
stonesmayr ecur,howev
er,oncethedr
ugisstopped.
-
li
thot
r i
psy
: ,
whichi
samet hodofconcentr
ati
ngul
tr
asoni
cshockwav
es
ontothestonestobreakthem i
ntoti
nypieces
-
Cholecyst
ectomy(gallbl
adderremoval)

-Therear et wosur gicaloptionsf orchol ecyst

ectomy :
-Openchol ecy stectomy :isper f
or medv iaanabdomi nal incision(laparot
omy )belowt he
l
owerr i
ghtr ibs.
Recov eryt ypicallyrequires(3–5)day sofhospi tal
ization, wi t
har eturntonormal dieta
weekaf terreleaseandt onor mal acti
vityseveralweeksaf terrel
ease
Lapar
- oscopi cchol ecystectomy : i
sper formedv i
at hreet of oursmal lpunct
urehol esfor
acamer aandi nstrument sPost -operati
v ecaretypicall
yi ncludesasame- dayreleaseor
aoneni ghthospi talstay,foll
owedbyaf ewdaysofhomer estandpai nmedication.
-Laparoscopi cchol ecystectomy : pati
ent scan,i
ngener al,resumenor maldietandl i
ght
acti
vityaweekaf terrelease, wi
thsomedecr easedener gyl evelandmi norresi
dual pain
continuingf oramont hort wo.
Studieshav eshownt hatthispr ocedur eisasef f
ect i
veast hemor einvasi
veopen
cholecy stectomy ,providedt hest onesar eaccuratelylocat edbychol angiogram priorto
thepr ocedur esot hattheycanal lberemov ed

*Nursingdi agnosi s
1-AcutePai n:
-Mayber elatedt o:
 Bi ologi cal i
njuri
ngagent s:obstr
uct
ion/duct
alspasm,inf
lammator
yprocess,t
issue
i
schemi a/necrosis
-Possiblyev idencedby
 Re por tsofpai n,bil
iarycoli
c(wavesofpain)
 F aci almaskofpai n;guardi
ngbehav i
or
 Au tonomi cresponses( changesinBP, pul
se)
 Se lf-focusi ng;narrowedf ocus
-DesiredOut comes
 Re por tpaini sreli
eved/control
l
ed.
 De monst rateuseofr el
axati
onskil
l
sanddi ver
sional
acti
v i
ti
esasi
ndi
catedfor
i
ndi vidual sit
uat i
on.

PageCLVIof156
-Nursi
ngI
ntervent
ions:
1)Takevi
talsi
gntobaseli
nedat
a.
2)
Obser
veanddocumentl
ocat
ion,
sev
eri
ty(
0–10scal
e),
andchar
act
erofpai
n(st
eady
,
i
nter
mit
tent
,col
i
cky
)
3)
Promot
ebedr
est
,comf
ort
abl
eposi
ti
on(
low-
Fowl
er’
sposi
ti
on)
Rat
ional
e:t
oreducesi
ntr
a-abdomi
nal
pressur
e.

#Admi
nist
ermedi
cat
ionsasor
der
:
4)
Ant
ichol
i
ner
gics:
atr
opi
ne,
propant
hel
i
ne(
Pro-
Bant
hı-
ne)
Rat
ional
e:t
oRel
i
evesr
efl
exspasm andsmoot
hmuscl
econt
ract
ionandassi
stswi
th
pai
nmanagement
.
5)
Sedat
ives:
phenobar
bit
al:
Rat
ional
e:t
oPr
omot
esr
estandr
elaxessmoot
hmuscl
e,r
eli
evi
ngpai
n
6)
Smoot
hmuscl
erel
axant
s:papav
eri
ne(
Pav
abi
d),
nit
rogl
ycer
in,
amy
lni
tr
it
e
Rat
ional
e:t
oRel
i
evesduct
alspasm.
7)
Chenodeoxy
chol
i
caci
d(Cheni
x),
ursodeoxy
chol
i
caci
d(Ur
so,
Act
igal
l
)
Rat
ional
e:t
oThesenat
ural
bil
eaci
dsdecr
easechol
est
erol
synt
hesi
s,di
ssol
vi
ng
gal
l
[Link]
hist
reat
mentdependsont
henumberandsi
zeofgal
l
stones
(
pref
erabl
ythr
eeorf
ewerst
onessmal
l
ert
han20mi
nindi
amet
er)f
loat
ingi
na
f
unct
ioni
nggal
l
bladder
.

2-
Riskf
orDef
ici
entFl
uidVol
ume:
-
Riskf
act
orsmayi
ncl
ude
 Excessi
vel
ossest
hroughgast
ri
csuct
ion;
vomi
ti
ng,
dist
ensi
on,
andgast
ri
c
hy
per
¬mot
il
it
y
 Medi
cal
l
yrest
ri
ctedi
ntake
 Al
ter
edcl
ott
ingpr
ocess
-
Possi
blyev
idencedby
:
 Notappl
i
cabl
[Link]
iskdi
agnosi
sisnotev
idencedbysi
gnsandsy
mpt
oms,
ast
he
pr
obl
em hasnotoccur
redandnur
singi
nter
vent
ionsar
edi
rect
edatpr
event
ion.
-
Desi
redOut
comes
 Demonst
rat
eadequat
efl
uidbal
anceev
idencedbyst
abl
evi
tal
signs,
moi
stmucous
membr
anes,
goodski
ntur
gor
,capi
l
lar
yref
il
l,
indi
vi
dual
l
yappr
opr
iat
eur
inar
yout
put
,
absenceofv
omi
ti
ng.

PageCLVI
Iof157
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCLVI
IIof158
-
Nur
singI
nter
vent
ions:
1)
Mai
ntai
naccur
ater
ecor
dofI
&O,
not
ingout
putl
esst
hani
ntake,
incr
easedur
ine
speci
fi
cgr
avi
[Link]
nandmucousmembr
anes,
per
ipher
alpul
ses,
andcapi
l
lar
y
r
efi
l
l.
Rat
ional
e:t
opr
ovi
dei
nfor
mat
ionaboutf
lui
dst
atusandci
rcul
ati
ngv
olumeneedi
ng
r
epl
acement
.
2)
moni
torf
orsi
gnsandsy
mpt
omsofi
ncr
easedorcont
inuednauseaorv
omi
ti
ng,
abdomi
nal
cramps,
weakness,
twi
tchi
ng,
sei
zur
es,
irr
egul
arhear
trat
e,par
est
hesi
a,
hy
poact
iveorabsentbowel
sounds,
depr
essedr
espi
rat
ions.
Rat
ional
e:t
oPr
olongedv
omi
ti
ng,
gast
ri
caspi
rat
ion,
andr
est
ri
ctedor
ali
ntakecanl
ead
t
odef
ici
tsi
nsodi
um,
pot
assi
um,
andchl
ori
de.
3)
Keeppat
ientNPOasnecessar
y.
Rat
ional
e:ToDecr
easesGIsecr
eti
onsandmot
il
it
y.
4)
Inser
tNGt
ube,
connectt
osuct
ion,
andmai
ntai
npat
encyasi
ndi
cat
ed
Rat
ional
e:Tor
estt
heGITr
act
.

#Ot
herdi
agnosi
s:

-
Def
ici
entKnowl
edge.

-
Riskf
orI
mbal
ancedNut
ri
ti
on:
LessThanBodyRequi
rement
s.

PageCLI
Xof159
 7.I
ntest
inal
Obst
ruct
ion
-Defi
niti
on:
-I
ntesti
nalObstruct
ioniscompl eteorpart
ialbl
ockagei nthei [Link]
sbl ockage
preventsthesoli
ds,fl
uidsandt hegasesfrom mov ingfrom thei ntesti
nesnor [Link]
obstructi
onmayoccurei therinthesmallint
estineorlargeintest i
[Link]
mayt roubleyoualotifnottakencareproperly
.Acompl et
ei ntestinalobstruct
ionmay
causecompl eteabsenceofgasorst [Link]
alblockagemaycausedi ar
rhea.

-
Causes:

Adhesions:Adhesi
onisapar ti
cularareaoffibrousconnecti
[Link]
scan
[Link] el
opbecauseofi nj
ury
i
nsideoroutsideoftheint
estineorev enthepelvi
[Link]
yany t
hingthat
dist
urbstheti
ssueintheintesti
naltractoral
mostany whereinthebodycan
causeadhesions.
-
Therear emanydi ff
erentcausesofbowel obstruct
ions:
 Paralyticileus.
 Useofcer t
ainmedi cations( narcotics)
.
 ForeignBody .
 Hernia.
 Colorect alcancer.
 Volvulus: twisti
ngoft hei nt esti
ne.
 Diverti
cul ardiseaseorcr ohn’ sdisease.
 Dif
ficultiesinpassi ngst ool sori mpactedst oolsthesearesevereconsti
pat
ions.
I nt
ussuscept ion:tel
escopi ngofpar tofi
ntestine.
 Congeni tal malformationoft hebowel .
 Swel l
ing/i nfl
ammat i
on.
 Tumor s:Acancer oust umorcandev el
opintoabowel obst
ructi
on,usual
lyt
het umor
wil
l causeasmal l
erobst ructionint [Link],tumorscangr ow
andev entuallycauselar gerobst ructi
ons.

-
Signsandsy
mpt
omsofbowel
obst
ruct
ion:
 Vomi
ti
ngandnausea.
 Acr
ampi
ngabdomi
nal
pai
nthatcomesl
i
keawav
efr
equent
lyf
orf
ivet
oten
mi
nut
es.
 Hav
ingt
roubl
epassi
nggas.
 Anabdomi
nal
tender
ness
 Rapi
dpul
seandi
ncr
easedr
espi
rat
ion’
s(br
eat
hing)att
het
imeofabdomi
nal
cr
ampi
ng.
 Di
arr
hea:
li
qui
dst
ool
leaki
ngf
rom t
hear
eaofpar
ti
alobst
ruct
ion.

PageCLXof160
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Acol
ont
umori
sanot
hercauseofhav
ingal
argebowel
obst
ruct
ion.
 Lowerabdomi
nal
pai
n;whi
chcanbemi
l
dorsev
[Link]
nwi
l
ldependoncauses
ofbowelobstructi
on.
 Ab dominalful
lness.
 Ba dbreat
h.
 Co nst
ipati
on.

-
DiagnosticEval
uati
on:
- Labs:duetopossibl
eel
ect
rol
ytei
mbal
[Link]
fi
cal
l
yChl
ori
de,
Pot
assi
um,
and
Sodium.
- CToft heabdomen.
- X-r
ayoft heabdomen.
- Bari
um enema.
-Tr
eatments:-
1)Nonsurgicalt
reat
ment
:
- Tr
eat
menti
sfocusedonr
eli
evi
ngt
heobst
ruct
ionandt
hecauseoft
heobst
ruct
ion.
- NPO.
-I
VFl
uids.
- NGt
ubet
olowi
nter
mit
tentsuct
[Link]
sisf
ori
ntest
inal
descompr
essi
on.
- Pai
nmedi
cat
ionsasor
der
edbyMD(
Not
esomepai
nmedi
cat
ioncancause
const
ipat
ion)
.

2)
Sur
gical
Treat
ment
s
- At
reat
mentcal
l
ed:

PageCLXIof161
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

- si
gmoi
doscopyorcol
onoscopy
.
- Lapar
oscopy
.
- Endoscopi
cst
ent
ing.
- Ent
erot
omyf
orr
emov
aloff
orei
gnbodi
es.

PageCLXI
Iof162
-
Compl i
cati
ons:
 Dehydrati
onduetolossofwat
er,
sodi
um,
andchl
ori
de
 Peri
tonit
is
Infecti
on
 Jaundice
 El
ectroly
teimbal
ances

 Shockduet
olossofel
ect
rol
ytesanddehy
drat
ion
 Deathduet
oshock

-
Nur
singDi
agnosi
s:-
Nonsur
gical(pre)
:
[Link] ui
dVol umeDef i
cient
.
2. AcutePai n.
[Link] y.
4. I
neffectiveBreathingPatt
ern.
[Link] orInfect
ion.
[Link] edgedef ici
t.
[Link] ri
ti
on,LessThanBodyRequi
rement
s.
sur
gical(post ):
[Link] n.
2.I mpai redSki nI nt egrity.
[Link] edgedef icit.
[Link] teredNut ri
tion, LessThanBodyRequi rement s.
[Link] skf orI nfect i
on.
[Link] skFl uidVol umeDef i
cient.
Nur
- singI nterv entions:
[Link] lowt hepat i
entnot hingbymout h,asor der ed.
2.I nsertanasogast r i
ctubet odecompr esst hebowel asordered.
[Link] nandmai nt ainI .
V.t her apyasor dered.
[Link] ni steranal gesi cs, broadspect rum ant i
bioti
cs,andot hermedi cation,as
ordered.
[Link] hepat ienti nsemi -
Fowl er’
sorFowl er’
sposi ti
onasmuchaspossi bl
eto
promot epul monar yv entil
at i
on.
[Link] orsi gnsofdehy dration.
[Link] tornasogast ri
ct ubedr ainagef orcol or,consistency,andamount .
[Link] tori ntakeandout put.
[Link] torv i
tal signsf requent l
y.
10. Whenadmi nister ingmedi cat ion,moni tort hepat i
entforthedesi r
edef fectsand
foradv erser eact ions.
11. Cont i
nual l
yassesst hepat ient ’
spain.
12. Moni torur i
neout putcar efullytoassessr enal f
unction,ci
rculat
ingbl oodv ol
ume,
andpossi bleur iner etentionduet obl addercompr essionbyt hedistended
i
nt esti
ne.
13. Teacht hepat i
entabouthi sdi sorder,focusi ngonhi st ypeofintesti
nal
obst r
uct ion, itscause, andsi gnsandsy mpt oms.
14. Emphasi zet hei mpor tanceoff oll
owi ngast ructuredbowel regi
men, parti
cul
arl
yif
thepat i
enthadamechani cal obstructi
onf rom fecal i
mpaction.

PageCLXI
IIof163
 [Link]
roi
ntest
inal(
GI)bl
eedi
ng
-
Def i
ni t
ion:
Gast r
ointestinal(GI)bl
eedingi sasy mptom ofadi sorderi
ny ourdi gesti
vetract
.
Thebl oodof t
enappear sinst oolorvomitbutisn'talwaysv i
sibl
e,thoughi tmaycause
thest ool tol
ookbl ackortarry.
Thel evel ofbleedingcanrangef rom mildtosev ereandlife-
threatening.
Bleedingi nthest omachorcol oncanusuall
ybeeasi l
yidentif
ied,butf i
ndingthecause
ofbleedi ngthatoccur sinthesmal lint
esti
necanbedi ffi
cult
.
Butsophi sti
catedimagingt echnologycanusuallylocatethepr oblem, andmi ni
mall
y
i
nv asivepr oceduresoftencanf i
xit.

-
Dif
fer
ent
ial
diagnosi
s:

Gast
roi
ntest
inal
bleedi
ngcanber
oughl
ydi
vi
dedi
ntot
wocl
i
nical
syndr
omes:

uppergast
roi
ntest
inalbl
eedi
ngandl
owergast
roi
ntest
inalbl
eedi
ng.

About(
2/3)ofal
lGIbl
eedsar
efr
om uppersour
cesand(
1/3)f
rom l
owersour
ces.

Commoncausesofgastr
oint
esti
nalbl
eedi
ngincludeinf
ecti
ons,
cancers,
vascul
ardi
sor
der
s,adv
erseeff
ectsofmedicat
ions,andbloodcl
ott
ingdisor
der
s.

-Uppergastr ointesti
nal:
Uppergast rointesti
nal bleedingi sfr
om asour cebetweent hephar ynxandt heli
gament
ofTreitz.
Anuppersour cei schar acterisedbyhemat emesis(v
omi ti
ngupbl ood)andmel ena(t
arr
y
stoolcontainingal t
eredbl ood) .
Abouthal fofcasesar eduet opept i
cul cerdisease.
Esophageal inf l
ammat i
onander osi
vedi seasear et
henextmostcommoncauses.
Inthosewi thlivercirr
hosi s,(50–60%)ofbl eedingisduet oesophageal vari
ces.
Appr oximatelyhal fofthosewi thpepticul cershavean( [Link]
nfecti
on).
Othercausesi ncludegast ri
corduodenal ulcers,Mal
lory
-Wei sstears,cancer,
andangi odyspl asia
Anumberofmedi cationsar ef oundtocauseupperGIbl eeds.
(NSAI Ds)or( COX- 2)inhibitorsincreaset her i
skaboutfourfold.
SSRIs,corti
cost eroids,andant i
coagulant smayal soincreaset heri
sk.
Ther i
skwi t
hdabi gatrani s(30%)gr eaterthant hatwit
hwar farin.

-Lowergast
rointestinal:
Lowergastr
ointestinal bl
eedi
ngisty pi
call
yfrom thecolon, r
ectum oranus.
Commoncausesofl owergastr
ointest
inalbl
eedingincludehemor rhoids,
cancer,
angi
ody splasi a,ul
cerat
ivecoli
ti
s,Crohn'
sdi sease,andaor t
oenter
icfi
stul
a.
Itmaybeindicatedbyt hepassageoff r
eshredbl oodrectall
y,especial
lyi
ntheabsence

PageCLXI
Vof164
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

ofbloodyv
omi t
ing.
Isol
atedmelenamayor
igi
nat
efr
om any
wher
ebet
weent
hest
omachandt
hepr
oxi
mal
colon.

PageCLXVof165
 -
Causes:
 Thecausesofgastr
oint
esti
nal
(GI
)bl
eedi
ngar
ecl
assi
fi
edi
ntoupperorl
ower
,
dependi
ngontheirl
ocati
onint
heGIt
ract
.

 CausesofupperGIbleedi
ngincl
ude:
- pepti
culcers.
- gastr
it
is.
- esophagealvari
ces.
- Cancers.
-inflammationoftheGIli
ningf
rom i
ngest
edmat
eri
als.

 Themostcommoncausesofl owerGIbl
eedi
ngi
ncl
ude:
- Di
verticulardisease(di
v er
ti
culi
ti
s).
- Gastrointesti
nalcancers.
- I
nfl
ammat oryboweldisease(IBD).
- I
nfectiousdi arr
hea.
- Angiody splasi
a.
- Poly
ps.
- Hemor rhoids.
- Analfissures.

-
Sympt
omsandSi
gns:
- Bloodinthestool
- Pain
- Vomi t
ingbloodorwhatl
ooksli
kecof
feegr
ounds
- Dark,tar
rystool
s
- Abdomi nalcr
ampsordiar
rhea
- Fati
gue
- Palenessinappear
ance
- Anemi a

-
Compl
i
cat
ions:
 Anemi
a
 Hy
pov
olemi
a
 Shock
 Dehy
drat
ion
 ChestPai
n

PageCLXVIof166
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Treat
ment
:
May
oCl
i
nicspeci
ali
stshav
eav
ari
etyoft
reat
mentopt
ionst
hatmaybeusedi
n
combi
nat
ion,
dependi
ngont
hesour
ceofy
ourGIbl
eedi
ng:
 Endoscopi
cther
mal
[Link]
str
eat
mentcanst
opbl
eedi
ngf
rom ul
cer
sandot
her
abnor
mal
i
tiesbybur
ning(
coagul
ati
ng)t
hebl
oodv
essel
orabnor
mal
tissue.
 Endoscopi
cinj
ect
ion.
Wit
hendoscopi
cinj
ect
ion,
yourdoct
orcanst
opt
hebl
eedi
ngby
i
nject
ingal
i
qui
d,suchasdi
l
utedepi
nephr
ine,
att
hesour
ceoft
hebl
eedi
ng.
 Ar
gonpl
asmacoagul
ati
onandr
adi
ofr
equencyabl
ati
onar
eot
hert
ypesoft
her
mal
t
echni
quesusedt
otr
eatabnor
mal
bloodv
essel
sint
hest
omach,
smal
li
ntest
ineand
col
on.
 Endoscopi
ccl
i
pscanbeusedt
ocl
oseabl
eedi
ngv
essel
orot
herdef
ect
ivet
issue.
 Endoscopi
cbandl
i
gat
ionusesspeci
albandst
otr
eatbl
eedi
nghemor
rhoi
dsand
bl
eedi
ngbl
oodv
essel
s(v
ari
ces)i
ntheesophagus.
 Endoscopi
cint
rav
ari
ceal
cyanoacr
ylat
einj
ect
ionusesaspeci
algl
uet
otr
eatdi
ff
icul
t
bl
eedi
ngf
rom v
ari
cesi
nthest
omach.
 Angi
ogr
aphi
cembol
i
zat
ioni
nject
spar
ti
clesdi
rect
lyi
ntoabl
oodv
essel
tost
op
bl
eedi
ng.
I
fbleedi
ngrecursaft
ert
reat
ment,
youmayneedar
epeatev
aluat
ionandt
reat
ment
.
Al
thoughit
'srar
e,youmayneedsurger
y.

-NURSINGDI GNOSI S:
1-Flui
dVolumeDef i
cit(Isotonic)PossibleEti
ologi
es:
(Rel
atedto)Acti
vev olumel oss( hemor rhage)
:
Goal:fl
uidandelectrolytedeficiti
sr esolved :
-out
come:
-
signsofdehy dr
ation: none,
-
mucosaoft hemout handl ipsmoi st,f
lui
dbalance.

-
Int
erv
ention:
 Observati
onofvit
al si
gns.
 Observati
onforsi
gnsofdehy drati
on.
 Measuretheinputandout putoff l
uid(f
luidbalance).
 Pr
ov i
deandencour agethef amilytodri
nkal otmor ethan2000-2500ccperday
.
 Col
laborati
onwithphy si
ciansinfluidt
herapy,laborat
orytest
select
rol
yte.
 Col
laborati
onwithat eam ofnut r
it
ioni
nl ow-sodium fl
uidadmini
str
ati
on.

PageCLXVI
Iof167
2.I
mbalancedNutri
ti
onLessThanBodyRequi
rement
s
rel
atedt
otheinputI
nadequat
enutr
ient
.
-
Object
ives:
Pat
ient
scani ncr
easet
hei
nputofnut
ri
ent
sisadequat
eandt
oav
oidi
rr
it
ati
ngf
oods.

Nursi
nginterventi
ons:
 Provi
dephy sicalandemot i
onal
support
 Avoidfoodsandl iquidsbymouthunt
ilacut
esy
mpt
omsofdecr
eases
GiveIVtherapyasneeded
 Avoidcaffeinedrinks
 Avoidalcohol andnicoti
ne.

#Ot
hernur
singdi
agnosi
s:

 Pai
n

 Anxi
ety

 Def
ici
entknowl
edge

PageCLXVI
IIof168
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCLXI
Xof169
 [Link]
ruct
iveJaundi
ce
-Definiti
on:
Obst ructivejaundiceisacondi tioni
nwhi chthereisblockageofthefl
owofbi l
e
outoft heliver.
Thisr esul t
si nredir
ectionofexcessbi l
eandi tsby-
productsint
ot hebl
ood,and
bileexcr eti
onf rom thebodyi sincompl et
e.
Bilecont ai
nsmanyby -pr
oduct s,oneofwhi chi sbili
rubi
n,api gmentderi
ved
from deadr edbl oodcel l
s.
Bili
rubini sy el
low,and t his gives t
he character
isti
cy ell
ow appear
ance of
j
aundi cei ntheski n,eyes,andmucousmembr anes.
Sy mpt omsofobst r
ucti
v ejaundiceincl
udey el
lowey esandskin,abdomi
nalpain,
andf ev er.
-CLASSIFI
CATI ONOFOBSTRUCTI VEJAUNDI CE:
1-CONGENI TAL: Bil
i
aryatresia,chol
edochalcyst
2-I
NFLAMMATORY: Ascendingcholangit
is,Scl
erosi
ngcholangit
is
3-OBSTRUCTI VE: CBDstone, bi
l
iarystr
ict
ure,par
asit
ici
nfestat
ion
4-NEOPLASTI C:Car ci
nomaheadofpancr eas
Peri
ampul l
arycar ci
noma
cholangi
ocarcinoma
Klat
skintumor
-
Commonsy mptomsofobst ructi
vejaundi
ce:
 Ab domi nalpain(typi
cal l
yoccur sintheri
ghtupperquadr
antoft
hebody
)
 Da rk-
coloredur i
ne
 Diarrhea
 Easybl eedingorbr uising
 Fev erandchi l
ls
 I
tchyski n
 Lossofappet it
e( anorexia)
 Ma laiseorlethargy
 Pa l
est ools
 Un i
ntentionalweightl oss
 Yellowcol orati
onoft heey esandskin(j
aundice)
-
CausesofObst ructiveJaundi ce:
 Bi
li
aryst r
icture( nar r
owingoft hebil
educt).
 Canceroft hegal l
bladderorpancr eas.
 Cholangit
is( i
nfect ionorinflammat i
onofthecommonbi
l
educt
).
 Cholel
it
hiasis( gal l
stones).
 Congenitalstruct uraldefects.
 Cystsofthebi leduct .
 Lymphnodeenl ar gement .
 Pancreati
tis.
 Parasi
ticinfection.
 Tr
auma, i
ncludingsur gicalcompli
cations.

PageCLXXof170
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Whataret heri
skf actor
sforobst
ruct
ivej
aundi
ce?
 Abdomi nali
njury
 Gall
stones
 Pancreati
ccancer
 Tumor sintheareaofthecommonbi l
educt
-
diagnosti
ct est
 Ult
rasoundabdomen.
 Endoscopi cret
rogradecholangi
ogram (ERCP).
 MAGNE TI
CRESONANCEI MAGE( MRI )
.
 CHOL ANGI OPANCREATOGRAPHY( MRCP) .
 PercutaneousTr anshepat
icCholangiogram (
PTC)
.

-
Whatar ethepotentialcompli
cati
onsofobst ructi
vej
aundi
ce?
 Adverseeffectsofobstr
uctivejaundicetreatment
 Ci
rrhosis(scarr
ingoftheli
ver)
 Coagulopathy(abloodclott
ingdisorder)
 Di
gest i
veproblems
 Li
verfail
ure
 Malabsorpti
onsy ndrome(adi sorderthatinter
fer
eswit
htheabsor
pti
onofnut
ri
ent
s
f
rom food)
 Spreadofcancer
 Spreadofinfecti
on

-
Treat
mentopt
ionsf
orobst
ruct
ivej
aundi
ce:
 Antibiotictherapy(ifindicatedforinf
ecti
on) .
 Endoscopi cr etrogradechol angi
opancreatography(ERCP),animagingpr ocedure
thatal l
owst reat
mentofsomebi leductproblems,incl
udi
ngr emoval ofgall
stones
thatar ecausi ngobst ructi
on.
 I
ntrav enousf luidsandpai nmedi cati
ons.
 Nutriti
onal suppor t
.
 Surger yorot herprocedur est or
epairanatomicaldefect
sorcreateal t
ernati
ve
pathway sfort heflowofbi le.
 Transpl antati
onoft heli
ver( i
fal
lothermet hodsareunsuccessfulandal loft
heliver
i
sdamaged) .
 Treatmentf orcancer ,i
fpresent,whichmayi ncludesurger
y,chemot herapy
orr adiati
ont herapy .

PageCLXXIof171
-Nursi
ngDi agnosi
s:
1-Defi
cientFlui
dVolumer
elat
edt
oinadequat
efl
uidi
ntake,
phot
o-t
her
apy
,anddi
arr
hea.

-
Inter
v ention:
 Re cordt henumberandqual it
yofst ools,
 Mo nit
orski ntur gor ,
 Mo nit
orint akeout put ,
 Giv ewat erbet weenbr east -
feedi ngorgi v
ebot t
le.
 Hy perther miar elatedt ot heef fectsofphot otherapy
 -I
nt ervention:
 Giv eaneut ralambi entt emper atur e,
 Ke ept het emper aturebet ween( 35.5°-37°) C,
 Ch eckv italsignsev ery2hour s.
 Impai redski nint egr i
tyrel atedt ohy perbil
irubinemi aanddiar
rhea
-
Inter
v ention:
 As sessski ncol orev ery8hour s,
 Mo nit
ordi rectandi ndirectbi l
irubin,
 Ch angeposi ti
onev er ytwohour s,
 Ma ssaget hear eat hatst andsout ,
 Ke epski ncl eanandmoi sture.
 An xietyrelatedt omedi cal t
her apygi v
ent ot hebaby .
I
ntervent i
on:
 Re viewknowl edgeoft hecl ient'sfami l
y,
 Giv ethecauseofy ellowheal theducat ion,therapyandt r
eatmentpr
ocess.
 Giv eheal theducat i
ononi nfantcar etohome.

2-
Acut
ePai
nrel
atedtoBiol
ogi
cali
njur
ingagent
s:obst
ruct
ion/
duct
alspasm,
i
nfl
ammat
orypr
ocess,t
issuei
schemia/necr
osi
s

3-
Riskf
orI
mbal
ancedNut
ri
ti
on:
LessThanBodyRequi
rement
s.

PageCLXXI
Iof172
 [Link]
A
1-Defi
niti
on:-
Aherniaoccur swhenanor ganpushest hroughanopeninginthemuscleort
issuethat
[Link] e,t
heintesti
nesmaybr eakthroughaweakenedareainthe
abdomi nalwal l
.
Herni
asar emostcommoni ntheabdomen, buttheycanalsoappeari
ntheupperthigh,
bell
ybut t
on, [Link] ni
asarenot
immedi atel
yl i
fethreateni
ng,buttheydon’tgoawayont heirownandcanrequir
e
surger
yt oprev entpotenti
all
ydangerouscompl i
cati
ons.

2-Ty
pes:
-
-Inguinal Hernia:
Inguinal Herniaarethemostcommont y
peofhernia.
Theymakeupabout( 70)per centof allher
ni as,Theseher niasoccurwhent he
i
nt estinespusht hr
oughaweakspotort eari
nt helowerabdomi nalwal
l,oft
eninthe
i
ngui nal canal.
Thei ngui nalcanalisfoundiny ourgroi
n.
Inmen,i tist hear eawher et hespermaticcordpassesf r
om theabdoment othe
scrotum.
Thi scor dhol dsupt hetesti
[Link],theinguinalcanalcontai
nsaligamentt
hat
helpshol dtheuterusinplace.
-HiatalHernia:
Ahi atalherniaoccur
swhenpar tofyourstomachprotr
udesupthroughthedi
aphragm
i
nt oy ourchest .The di
aphragm is a sheetofmusclet hathel
ps you br
eat
he by
contracti
nganddr awingai
rintothel
ungs.
Itseparatestheorgansinyourabdomenf r
om thosei
nyourchest
.

-UmbilicalHernia:
Umbi l
icalherniascanoccuri
nchildrenandbabiesunder6mont hsol
d.
Thishappenswhen t hei
rintest
inesbulge through t
heirabdominalwallnearthei
r
bell
ybut t
[Link] i
ceabulgei norneary ourchi
ld’
sbell
ybut
ton,especi
all
ywhen
they’
recr yi
ng.

-
Inci
sionalHer
nia:
-
Inci
sionalher
niascanoccuraf
terpat
ienthadabdominalsur
ger
y.i
ntest
inesmaypush
t
hrought hei
nci
sionscarort
hesurr
ounding,
weakenedti
ssue.
-Femor
alher
nia:Thef
emor
alcanali
sthepaththr
oughwhi
cht
hef
emor
alar
ter
y,v
ein,
andnerv
eleavet
heabdomi
nalcavi
tyt
oenterthethi
gh.

3-CausesaHer
nia:
-
-Her
niasarecausedbyacombi
nati
onofmuscleweaknessandst
rai
[Link]
ngoni
ts
cause,aherni
acandevel
opqui
ckl
yoroveral
ongperi
odoftime.

PageCLXXI
IIof173
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCLXXI
Vof174
-Commoncausesofmuscl eweaknessi
ncl
ude:
-fai
l
ur eoft heabdominalwallt
ocloseproper
lyi
nthewomb,whi
chi
sacongeni
tal
defect.
-age.
-damagef rom i
njur
yorsurger
y.
-chroniccoughi
ng.
-
Factorsthatst r
ainyourbodyandmaycauseaher nia,especi
all
yifyourmuscl
esar
e
weak,i
nclude:
-
beingpregnant ,
whichputspressureonyourabdomen).
-
beingconst i
pated,whichcausesyoutostr
ainwhenhavi
ngabowel movement.
-
heavywei ghtli
fti
ng.
-
fl
uidintheabdomen, orasci
tes.
-
suddenlygainingweight.
-
persi
stentcoughi ngorsneezi
ng.
4-Symptoms:-
-Themostcommonsy mpt om ofaherniaisabulgeorl umpint heaf
fectedarea.I
nthe
caseofani ngui
nalher nia,youmaynot icealumponei t
hersideofy ourpubicbone
whereyourgroinandt highmeet .You’r
emor elikel
yt ofeelyourher
niat hr
oughtouch
whenyou’r
estandingup.
-I
fbabyhasaher nia,
youmayonl ybeabletofeelthebulgewhenheorshei scryi
ng.A
bulgei
stypi
call
ytheonlysy mptom ofanumbil
icalherni
a.
-Othercommonsy mptomsofani ngui
nalher
niaincl
ude:
-painordiscomf or
tintheaf f
ectedarea(usual
lythelowerabdomen),especi
all
ywhen
bendingov er
,coughing,orli
ft
ing
weakness, pr
essure,orafeeli
ngofheav i
nessintheabdomen
abur ni
ng,gurgl
ing,orachingsensati
onatthesit
eoft hebul
ge
-Othersympt omsofahiat
alher
niai
ncl
ude:
-acidrefl
ux,whichi
swhenstomachaci
dmov esbackwar
dint
otheesophaguscausi
nga
burningsensation.
-chestpain.
-dif
ficul
tyswall
owing.
-I
nsomecases,herni
ashavenosy [Link] youhav eaher
nia
unlessi
tshowsupdur
ingar
out
inephysi
caloramedi
cal
exam f
oranunr
elat
edpr
obl
em.
5-di
agnostictest:-
I
nguinalorinci
sionalherni
asareusuall
ydiagnosedt
hroughaphysi
calexaminati
on.
the doctor mayf eelforabulgeinanabdomenorgr oi
nthatget
sl ar
gerwhent he
pati
entstand,cough, orst
rai
n.
abarium X-r
ayorendoscopy .Thesetest
sallowthedoctort
oseethei
nternall
ocati
onof
astomach:

PageCLXXVof175
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-Abari
um X- r
ay:isaser i
esofX- raypi
cturesofdigest
ivet r
act.
Thepict uresarer ecordedaf t
erapatientfini
sheddri
nki ngal i
qui
dsoluti
oncont
aining
bari
um, whi chshowsupwel lontheX-rayimages.
-Anendoscopy: i
nv ol
vest hr
eadingasmal lcameraattachedt oatubedownyourthroat
andint
oy ouresophagusandst omach.
I
fthechi l
dhasanumbi li
calherni
a,thedoctormayper form anultr
asound.
-Anultrasound: useshi gh-f
requencysoundwav estocr eateanimageofthestr
uctures
i
nsidethebody.
6-Medi
cal
management:
-
-Li
festyleChanges:
Dietarychangescanof tent r
eatthesymptomsofahi at
[Link]
georheav y
meal s,don’tl
i
edownorbendov eraft
erameal ,andkeepyourbodywei ghtinahealthy
range.
Ifthesechangesi ndietdon’ teli
minat
ey ourdiscomfort,youmayneedsur ger
yt o
correcttheher [Link] soimprovesympt omsbyav oidi
ngf oodsthatcauseacid
refl
uxorhear tbur n,suchasspi cyfoodsandt omato-
basedf [Link]
ional
ly,y
oucan
avoidrefluxbyl osingwei ghtandgivi
ngupcigarett
es.
-Medicat
ion:
Ifyouhav eahi at
alhernia,over
-the-
counterandpr
escri
pti
onmedicat
ionst
hatreduce
stomach acid can rel
ievey ourdiscomfortand i
mprove sy
[Link] i
nclude
antaci
ds,H-2receptorblocker
s,andprotonpumpinhi
bit
ors.
-Sur
ger y:
-I
fherni ai sgr owi ngl argerorcausi ngpai n,thedoct ormaydeci det hati t
’sbestto
[Link] ormayr epairherniabysewi ngt hehol eintheabdomi nalwal lcl
osed
duri
ngsur [Link] sismostcommonl ydonebypat chingtheholewi thsurgicalmesh.
-Herni
ascanber epairedwi theitheropenorl aparoscopicsurgery.
Laparoscopi csur geryusesat inycamer aandmi niaturi
zedsurgicalequipmentt orepai
r
theher ni
ausi ngonl yaf ewsmal lincisi
[Link] oscopicsurgeryisl essdamagi ngto
thesurroundi ngt issue.
-Opensur geryr equi resal ongerr ecov er
ypr [Link] etomov earound
normallyf orupt osi [Link] oscopi
csur geryhasamuchshor terrecoveryti
me.
Howev er,t her i
skofy ourher niareoccur r
ingi shi [Link]
on,notal lherni
asare
suit
ablef orlapar oscopi crepair,i
ncludingthosei nwhi chaporti
onofy ourintesti
neshas
mov eddowni ntot hescr otum .

7-Nur
singdiagnosi
s:-
#Postoperati
venursi
ngcar
epl
ans:
(
1)Acut
ePai
n:

PageCLXXVIof176
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Mayberel
atedto
 Di
srupti
onofski
n,t
issue,
andmuscl
eint
egr
it
y; muscul
oskel
etal
/bone
tr
auma
 Pr
esenceoftubesanddrains

PageCLXXVI
Iof177
-
Possi
blyev
idencedby
:
 Repor tsofpai n
 Alterati
oni nmuscl et
one; faci
al maskofpain
 Distracti
on/ guarding/pr
otect i
vebehavi
ors
 Self-f
ocusing; narrowedf ocus
 Au tonomicr esponses
-
Desir
edOut comes:
 Repor tpainr el
ieved/controll
ed.
 Ap pearrelaxed, abletorest/sleepandpart
ici
pat
einact
ivi
ti
esappr
opr
iat
ely
.

-1-NursingI nterventi
ons:
Not epat ient’sage, weight,coexisti
ngmedi cal orpsy chologi
cal condi t
ions,
i
diosy ncraticsensi ti
vit
yt oanalgesics,andi ntraoperativecourse.
-Rati
onal e:
Appr oacht opost operati
vepainmanagementi sbasedonmul ti
plev ariablefact
ors.
-2-Nur si
ngI nter v
entions:
Reposi ti
onasi ndicated: semi-Fowl er’
s;lateral Sims’
-Rati
onal e:
Mayr eli
evepai nandenhanceci rculati
[Link] -Fowler’
sposi t
ionr eli
ev esabdomi nal
muscl et ensionandar thri
ticbackmuscl etensi on,wher easlateralSims’ wil
lrel
i
eve
dorsal pressur es.
-3-Nur si
ngI nter v
entions:
Provideaddi ti
onal comf ortmeasur es:backr ub, heatorcol dapplications.
-Rati
onal e:
I
mpr ov esci rculati
on,reducesmuscl etensi
onandanxi etyassoci atedwi thpain.
Enhancessenseofwel l
-being.
-4-Nur si
ngIntervent
ions:
Encour ageuseofr el
axati
ontechniques:deep-
breat
hingexer
cises,
guidedi
mager
y,
visuali
zati
on, li
stentoQuranormusi c.
-Rational
e:
Relievesmuscl eandemot i
onaltension;
enhancessenseofcontrolandmayimpr
ove
copingabi l
i
ties.

(
2)Ri
skf
orI
nfect
ion:

-
Riskf
act
orsmayinclude
 Brokenskin,t
raumati
zedti
ssues,stasi
sofbodyfl
uids.
 Presenceofpathogens/
contaminants,
envi
ronmentalexposur
e,i
nvasi
ve
procedur
es

PageCLXXVI
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SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCLXXI
Xof179
-
Possi
blyev
idencedby
 Notappl i
cabl
[Link]
agnosi
sisnotevi
dencedbysignsandsymptoms,
as
theproblem hasnotoccur
redandnursi
ngint
erv
enti
onsaredir
ectedat
preventi
on.
-
Desi
redOut comes
 Ident i
fyindi
vi
dualri
skfact
orsandi
nterv
enti
onstoreducepot
enti
alfor
i
nfection.
 Ma int
ainsafeasepti
cenvi
ronment.

-1-Nur singI nterventi

ons:
Adher et ofacili
tyinfectioncont r
ol,st
eril
ization, andasept icpoliciesandpr ocedures.
-Rat i
onal e:
Establ ishedmechani smsdesi gnedt oprev enti nfect
ion.
-2-Nur singInterventions:
Rev iewl abor atorystudiesf orpossibi
li
tyofsy stemicinfections.
-Rat i
onal e:
I
ncr easedWBCcountmayi ndicateongoi ngi nfecti
on, whicht heoper ativ
eprocedurewil
l
all
ev iate( appendi ci
tis,abscess,infl
ammat ionf rom trauma); orpr esenceofsy st
emic
oror gani nfecti
on.
-3-Nur singInterventions:
Exami neski nf orbreaksori r
ri
tati
on,signsofi nfecti
on.
-Rat i
onal e:
Disr uptionsofski nintegri
tyatorneart heoper ati
vesitear esour cesofcont aminati
on
tot hewound.
-4-Nur singInterventions:
Appl yst eril
edr essing.
-
Rationale:
Prev
ent senv i
ronmentalcontaminat
ionoffreshwound.
-
5-Nur si
ngI nterv
enti
ons:
Admi ni
sterantibi
oti
csasi ndi
cated.
-
Rationale:
Maybegi v
enpr ophyl
actical
lyf
orsuspectedinfect
ionorcont
ami
nat
ion.

#Ot
hernur
singdi
agnosi
s:
-
Def
ici
entKnowl
edge.
-
Riskf
orFl
uidVol
umeDef
ici
t.
-
Impai
redSki
n/Ti
ssueI
ntegr
it
y.
-
Riskf
orAl
ter
edTi
ssuePer
fusi
on.

PageCLXXXof180
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCLXXXIof181
 [Link]
roent
eri
ti
s
-
Def
ini
ti
on:

AMedi calcondi tionchar acteri

zedbyi rri
tat
ionandi nfl
ammat ionof
thegast rointestinaltr
actt hatinvolvesthest omachandsmal lint
esti
ne.
¬¬
-Causes:
[Link] ral(Rot av i
rusi st
hemostcommoncauseofgast roenteri
tisinchil
dren,duet o
theirlackofi mmuni tyandr el
ativel
ypoorhy giene,Acid-suppressingmedication
appear stoi ncreasether i
skofsi gnif
icantinfecti
onafterexposur etoanumberof
organi sms) .
[Link] erial.
[Link] asiti
c.
[Link] ansmi ssion( Transmi ssionmayoccurv i
aconsumpt ionofcont aminatedwat er,
or
whenpeopl eshar epersonal objects,Bottl
e-feedi
ngofbabi eswi thimproperly
sani t
izedbot tl
es)
[Link]- infectiousSomeoft hemor ecommoni ncludemedi cations(li
keNSAI Ds),
certainf oodssuchasl act ose(i
nt hosewhoar ei
ntol
erant )
,andgl ut
en(i
nt hose
withcel i
acdi sease).
-
Pat
hophysi
ology:
-
Thepat
hologicpr
ocessst
art
swi
thi
ngest
ionoff
ecal
l
ycont
ami
nat
edf
oodandwat
er.
-
Theor
gani
sm af
fect
sthebodyt
hroughdi
recti
nvasi
onandbyendot
oxi
nbei
ngr
eleased
byt
heor
gani
sm.
-
Thr
ought
heset
wopr
ocessest
hebowel
mucosal
li
ningi
sst
imul
atedanddest
roy
edt
he
ev
ent
ual
l
yleadt
oat
tempt
eddef
ecat
ionort
enesmus(
isaf
eel
i
ngofconst
ant
ly
needi
ngt
opassst
ool
s)ast
hebodyt
ri
est
ogetr
idoft
hef
orei
gnor
gani
sm i
nthe
st
omach.
-
Thecl
i
entwi
thacut
egast
roent
eri
ti
smayal
sor
epor
texcessi
vegasf
ormat
iont
hatmay
l
eadst
oabdomi
nal
dist
ent
ionandpassi
ngoff
lat
usduet
odi
gest
iveandabsor
pti
ve
mal
funct
ioni
nthesy
stem.
-
Ast
hebowel
isst
imul
atedbyt
heor
gani
sm andi
tst
oxi
n,t
hei
ntest
inal
tractsecr
etes
wat
erandel
ect
rol
ytesi
nthei
ntest
inal
lumen.
-
Thebodysecr
etesandt
her
efor
elostChl
ori
deandbi
car
bonat
eionsi
nthebowel
ast
he
bodyt
ryt
ogetr
idoft
heor
gani
sm byi
ncr
easi
ngper
ist
alsi
sandnumberofdef
ecat
ion.
-
Mil
ddi
arr
heai
schar
act
eri
zedby(
2-3st
ool
),bor
bor
ygmi
(hy
per
act
ivebowel
sound)
,f
lui
dandel
ect
rol
ytei
mbal
anceandhy
per
nat
remi
a.
-
Whent
hecondi
ti
oncont
inuet
opr
ogr
ess,
prot
eini
nthebodyi
sexcr
etedt
othel
umen

PageCLXXXI
Iof182
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

t
hatf
urt
herdecr
easest
her
eabsor
pti
onandt
hebodybecomeov
erwhel
medt
hatl
eads
t
oint
ensedi
arr
heawi
thmor
ethan10wat
eryst
ool
.
-
Ser
iousf
lui
dvol
umedef
ici
tmayl
eadt
ohy
pov
olemi
cshockandev
ent
ual
l
ydeat
h.

-
Signsandsy mpt oms:
 nauseaandv omi t
ing.
 di
arrhea.
 Abdomi nal cramping.
 fever.
 fati
gue, headache, andmusclepai
n.
 Ifthestool isbloody,t
hecauseislessli
kelyt
obev i
ralandmor
eli
kel
ytobe
bacter
ial.
 Dehydration-weakness, decr
easedurinat
ion,
dryski
n,drymout
h.

-Ri
skf
act
ors:

Ri
skf
act
orsf
orgast
roent
eri
ti
sincl
ude:

 Dr
inki
ngwel
lwat
er.

 Eat
ingunder
cookedf
ood,especi
all
yseaf
ood.

 I
mpr
oper
lyst
oredf
ood.

 Tr
avelt
ohi
ghr
iskar
eas.

Anycondi
ti
ont
hatcausesaweakeni
ngoft
hei
mmunesyst
em suchas:
 Di
abet
es.
 Or
gantranspl
ant.
 Chemot
herapy:Theadmi
nist
rat
ionofmedi
cinest
hatki
l
lcancercel
l
s.
 AI
DS.

Li
vingar
oundpoorsani
tat
ion*Li
vingi
ncl
osequar
ter
s:
 Armybar racks.
 Do r
mi t
ori
es.
 Nu r
singhomes.
-Di
agnost i
ctest:
-Gast
roenterit
isistypicall
ydiagnosedcli
nical
l
y,basedonaper son'
ssi
gnsand
symptoms.
-Physicalexamination.
-stoolcultur
e( Appearance, Volume, Fr
equency,Presenceorabsenceofbl
ood,pH
,Presenceorabsenceofr educi
ngsubstances, Whi
tebloodcell
(WBC)count,Ser
um WBC

PageCLXXXI
IIof183
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

count
)
,
uri
nal
ysi
s.
-
V/S,bloodsampl
e(WBCel
evat
ed)

-
Medical
management:
Goal
sofEmergencyDepar
tmentther
apyi
ncl
udet hef
oll
owi
ng:
[Link]
ateoral
lyori
ntr
avenousl
yasneeded.

[Link]
eatsy
mpt
oms(
eg,
fev
er,
pai
n)asi
ndi
cat
ed.

3.I
dent
if
ycompl
i
cat
ions.

[Link]
eventt
hespr
eadofi
nfect
ions.

Cl i
nicalassessmentandser um electrolyteconcent rati
onsshoul dguidetherapy.
-Admi ni
str
ati
onof( 1-2)Ldext r
ose5% i n( 0.5)isotonicsodium chlori
desol uti
onwith
(50mEq)NaHCO3and( 10-20)mEqKCl over( 30-45)minutesmaybenecessar yin
patientswhoar esev erel
ydehy dr
ated.
-I
ndi cati
onsf orI
Vr ehy drationincludesev erei nt
ractablevomi ti
ng,alt
ered
consciousness, sever edehy drati
on, i
leus, excessi vecholer
al i
kestools,
andt imeor
environmentnotconduci vetoor alrehy drationt herapy(ORT) .
-Anti-emeticsmaybeusef ulinthetreat mentofnauseaandv omiti
nginadul t
s.
-Theyar eusual l
ynotr ecommendedi nchi ldren.
-Ant i-di
arr
heal :
Oct reotide( Sandostat i
n)

-
Fami l
yhist
ory:
Assesswatersourcesandfood,
andassesstheenv
ironment
alsi
tuat
ionandpl
aceof
resi
denceofthefamil
y,hi
stor
yofimmunizat
ion.
-
Subj
ect
ivedat
a:
 Pati
entsai
d"Ihav
easevereAbdomi
nal
crampi
ng"
 Pati
entsai
d"Ihav
eadiar
rhea"
-
Object
ivedat
a:
V/S,bl
oodsample(
WBCel
evat
ed)
,ur
inal
ysi
s,st
ool
cul
tur
e,

-
Phy
sical
exami
nat
ion:

Sy
stemat
icI
nspect
ion:

1.I
nspecti
on:
sunkeneyes,
lar
gefontanel
,mucousmembr
anes,
drymout
handl
i
ps,
decr
easedbodywei
ght,r
ectal
redness.

[Link]
cussi
on:
theexi
stenceofabdomi
nal
dist
ensi
on(t
ympani
c)

PageCLXXXI
Vof184
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

[Link]
pat
ion:
lessel
ast
icski
ntur
gor

[Link]
tat
ion:
bowel
sounds>35

-
Nur
singdi
agnosi
s:

1-f
lui
dvol
umedef
ici
tandel
ect
rol
ytel
esst
hanbodyr
equi
rement
s

r
elatedt oexcessi
vefluidoutput.
-
Outcomes:
-Maintainsurineoutputmor ethan1300ml /
day(oratl
east30ml/hr
)
-Maintainsnor malbl
oodpr essure,pul
se,andbodytemperatur
e
-Maintainselasti
cskint ur
gor;moisttongueandmucousmembr anes;andor
ient
ati
on
toper son,pl
ace,ti
me
-Explainsmeasur esthatcanbet akentotreatorpr
eventfl
uidvol
umeloss.

NursingI ntervent ions:

1)Mai ntainadequat ehy dration, i
ncr easef lui
di ntake.
Rati
onal e: Topr ev entdehy dration&mai ntainhy drationst at
us.
¬¬¬¬
2)Pr ov i
def requentor alcar e, Encour agef luidintake.
Rati
onal e: Topr ev entfrom dr yness
3)Admi nisterIntrav enousf l
uidsaspr escr i
bed
Rational e:Todel iverflui
dsaccur atelyandatdesi redr at
es.
4)Det ermi neef f
ect sofage.
Rational e:Veryy oungandext remel yel derlyindi vi
dual sarequi
cklyaff
ectedbyflui
d
vol
umedef icit
5)Rest ri
ctsol i
df oodi ntake, asi ndicat ed
Rational e:Toal lowf orbowel r
estandt or educedi ntesti
nalworkl
oad.
6)Discussi ndividual ri
skf act ors/pot ent i
al problemsandspeci f
icint
ervent
ions
Rati
onal e: Topr ev entorl imitoccur r enceoff l
uiddef i
cit.

2-Acut ePain:
r
elatedtodi stenti
on
-Goal:pai
ni sr esol
vedorcont r
oll
ed
-Outcomes:
 Pa ti
entwillreportadecreaseofpain.
 Pa ti
entwillbefreef r
om painanddemonstrat
erelaxat
ional
ski
ll
s.
-NursingInterventi
ons:
1) Rev i
ewf act
orthataggr avat
eorallev
iatepai
n.
Rat i
onale: Tolessen/all
eviatepai
ncausedbyv ari
ousfactor
s(admini
stermedsv
iaI
V
push).

PageCLXXXVof185
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

2) Mai ntainbedr estinacomf ortabl eposi tion, donotsupporttheknee.

Rationale:Tor educepai nandpr omot er el
ief /comf ort
.
3) Encour agepai nr eductiont echni ques.
Rationale:Topr omot eheal i
ngandpr ov idenon- pharmacologi
calpai
nr educt
ion
techniques( deepbr eathing,focusonapoi nt) .
4) Pr ovideadequat erest.
Rationale:Tor educepai nandpr omot er el
ief /comf ort
.
5) Pr ovidedi versional acti
viti
eslikesoci alization.
Rationale:Forcl ient’scomf ortandr elieffrom pai n.
6) Admi nisteranal gesicstomai ntai naccept ablelevelofpai
nifnotcontrai
ndi
cat
ed.
Rationale:Forcl ient’scomf ortandr elieffrom pai n.
7) I nst
ructcl i
entt operform deepbr eathingexer ci
ses(DBE).
Rationale:Deepbr eat hi
ngexer cisesmayr educepai nsensati
on/usedinpain
management .
8) Moni toreffectivenessofpai nmedi cations.
Rationale:Topr omot et i
mel yintervent ion/r evisionofplanofcare.
#othernursingdiagnosis:
-ImbalancedNut r
it
ion:Lesst
hanBodyRequi
rement
sduet
oinsuf
fi
cienti
ntakeand
excessiveout put
.
-Hy pert
hermiaRTi nflammatorypr
ocess.
-Act i
vi
tyIntol
erance.

PageCLXXXVIof186
 [Link]
it
oni
ti
s
-defi
nit
ion:
i
st heacuteorchr
onici
nfl
ammati
onoftheperi
toneum,
themembr
anet
hatl
i
nest
he
abdomi nal
cavi
tyandcover
sthev
iscer
alor
gans.

-Pathophysiol
ogy :
Peritoni
ti
si smostof t
encausedbyi nt
roductionofani nf ecti
oni ntotheot herwisester
il
e
perit
oneal envir
onmentthroughorganperforation,butitmayal sor esultfrom other
i
rrit
ants,suchasf orei
gnbodies,bi
lefr
om aper for
atedgal lbladderoral aceratedli
ver
,
orgast r
icacidfrom aperfor
atedulcer
.
Womenal soexper i
encelocal
izedperi
toni
tisfrom aninf ectedfal l
opiant ubeora
rupturedov ar
iancyst.
Patientsmaypr esentwit
hanacut eorinsidi
ousonsetofsy mpt oms, l
imitedandmi ld
disease,orsystemicandsev eredi
seasewi thsepticshock
-
Sympt
omsofPer
it
oni
ti
s
Thefir
stsymptomsofper i
tonit
isar
etypi
cal
lypoorappeti
teandnauseaandadul
l
abdominalachet
hatquickl
yt ur
nsint
opersi
stent
,sever
eabdominalpai
n,whi
chis
worsenedbyanymov ement .
Ot
hersignsandsy mptomsr el
atedt operit
oniti
smayi ncl
ude:
 Ab domi naltender
nessordist ensi
on
 Ch i
lls
 Fev er
 Fluidint heabdomen
 Extremet hi
rst
 No tpassi nganyurine,
orpassi ngsigni
ficant
lylessur
inet
hanusual
 Difficul
typassinggasorhav ingabowel mov ement
 Vo mi ti
ng

CausesofPer
- it
oni
ti
s
Thetwomai nt y
pesofper i
toniti
sarepri
mar yspont aneousperit
onit
is,
aninfect
ionthat
developsintheperit
oneum; andsecondaryperitoniti
s,whichusuall
ydevelopswhenan
i
njuryorinfecti
onintheabdomi nal
cavit
yallowsi nfecti
ousorganismsintothe
peri
[Link] htypesofper it
onit
isareli
fe-t
hreatening.
Thedeat hratefrom per
itoniti
sdependsonmanyf actors,
butcanbeashi ghas( 40%)i
n
thosewhoal sohav ecir
rhosis.
Asmanyas( 10%)maydi efrom secondaryperit
oni t
is.

-
Riskf
act
or:
Themostcommonr
iskf
act
orsf
orpr
imar
yspont
aneousper
it
oni
ti
sincl
ude:
Liverdiseasewit
hcir
rhosi
[Link]
tencausesabui
l
dupofabdomi
nal
flui
d
(ascit
es)thatcanbecomeinf
ected.

PageCLXXXVI
Iof187
Ki
- dneyf
ail
ureget
ti
ngper
it
oneal
dial
ysi
[Link]
stechni
que,
whi
chi
nvol
vest
he
i
mplantati
onof
acathet
erintotheperi
toneum,i
susedtoremov ewasteproductsi
nthebl
oodofpeopl
e
wit
hkidneyf ai
l
ure.I
t'
sli
nkedtoahigherr
iskofperi
toni
ti
sduet oacci
dent
al
cont
ami nat
ionoftheperit
oneum bywayofthecat
heter.
Commoncausesofsecondar yperi
toni
tisincl
ude:
 Ar upturedappendi x,diver
ti
cul
um, orst omachulcer
 Digestivedi seasessuchasCr ohn'sdiseaseanddi v
ert
icul
it
is
 Pancr eatiti
s
 Pelvicinflammat orydisease
 Perforationsoft hestomach, i
ntest
ine,gall
bladder
,orappendix
 Surger y

-
Test
s
Youmayneedbl oodtestsanduri
net eststocheckfori
nfect
ion.
 a nX-rayforevi
denceofairleakagefrom t
hebowel
 a nult
rasoundscan–wher esoundwav esareusedtobuil
dapi
ctur
eoft
hei
nsi
de
ofyourperi
toneum
 ac omput eri
sedtomography( CT)scan

-Tr
eati
ngperi
toni
ti
s
Thisi
sbecausether
eisar
iskofser
iouscompl
i
cat
ionsofper
it
oni
ti
s,suchasbl
ood
poi
soning.

-
Medi cati
on:
Theiniti
altreat
mentforper
it
oni
ti
sinv
olv
esi
nject
ionsofant
ibi
oti
csorant
if
ungal
medicine.
Nutr
iti
onal suppor
t.
Sur
ger y.
-NursingCarePlans
Earlytreat
mentofGIi nf
lammationcondi
ti
onsandpr
eoperat
iveandpost
operat
ive
therapyhelppreventperi
toni
ti
s.
Patientcareincl
udesmoni t
ori
ngandmeasurestopr
eventcompli
cat
ionsandthe
spreadofi nf
ecti
on.

-Nursi
ngDi agnosis:
[Link]
cientFluidVol ume
Mayber elatedto:
 F l
uidshiftsfrom extr
acell
ular
,int
ravascul
ar,
andi nt
erst
it
ialcompart
ment
s
intointesti
nesand/ orperi
tonealspace
 Vo miti
ng; medicall
yrestr
ictedint
ake;NG/int
esti
nalaspir
ati
on
 F ever
/hy permetaboli
cstate
-Possi
blyev i
dencedby
 Dr ymucousmembr anes,poorskinturgor
,delay
edcapill
aryref
il
l,
weak
per i
pheralpulses

PageCLXXXVI
IIof188
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Di
mini
sheduri
naryout
put,dar
k/concent
rat
edur
ine
 Hypot
ensi
on,
tachycar
dia

-
Desir
edOut comes:
 De monst rat eimpr ov edf luidbal anceasev idencedbyadequat eur inar yout put
wi t
hnor mal speci f
icgr av ity, stabl ev it
al signs, moi stmucousmembr anes,
goodski nt urgor ,pr omptcapi ll
ar yref i
ll,andwei ghtwi thi naccept abl er ange.
-
Nursi
ngI nter vent ions:
1)Moni t
orv it
al si gns, not ingpr esenceofhy pot ensi on( i
ncl udi ngpost ur al changes) ,
tachy car dia, tachy pnea, fev er.
2)Measur ecent ral venouspr essur e( CVP)i fav ai l
abl e.
Rational e: Ai dsi nev aluat ingdegr eeoff luiddef i
ci toref fect ivenessoff l
ui d
replacementt herapyandr esponset omedi cat ions.
3)Mai ntainaccur ateI &Oandcor relat ewi thdai lywei ght s.
Includemeasur edl osses.I ncl udemeasur ement sf rom gast r icsuct ion, dr ains,
dressi ngs, Hemov acs, diaphor esi s,andabdomi nal girthf ort hi r
dspaci ngoff lui
d.
Rational e: Ref l
ect sov erall hy dr ationst atus.
Urineout putmaybedi mi nishedbecauseofhy pov olemi aanddecr easedr enal
perfusi on, butwei ghtmayst illincr ease, reflect ingt issueedemaorasci tes
accumul [Link] ricsuct ionl ossesmaybel ar ge, andagr eatdeal off l
ui dcan
besequest eredi nt hebowel andper itoneal space( asci tes) .
4)Measur eur inespeci fi
cgr av ity.
Rational e: Ref l
ect shy dr at i
onst at usandchangesi nrenal funct ion, whi chmay
war nofdev elopi ngacut er enal fai l
urei nr esponset ohy pov olemi aandef fectof
toxins.
Manyant i
biot icsal sohav enephr ot oxicef fect st hatmayf urt heraf fectki dney
funct i
onandur ineout put .
5)Obser v eski normucousmembr anedr yness, tur gor .
Not eper i
pher al andsacr al edema.
Rational e: Hy pov olemi a,flui dshi fts,andnut ritional deficitscont r i
but et opoor
skint urgor , tautedemat oust issues.
6)El i
mi nat enoxi oussi ght sandsmel lsf rom env ironment .
Limi tintakeofi cechi ps.
Rational e: Reducesgast ricst imul ationandv omi tingr [Link] veuseof
icechi psdur inggast r
icaspi rationcani ncr easegast r
icwashoutofel ect roly t
es.
7)Changeposi ti
onf requent ly, prov i
def requentski ncar e, andmai ntaindr yor
wr i
nkle- freebeddi ng.
Rational e: Edemat oust i
ssuewi t hcompr omi sedci r
cul ati
oni spr onet o
breakdown.
8)Moni t
orl abor at oryst udi es: Hb/Hct ,electrol y tes, pr otein,al bumi n,BUN, Cr .
Rational e: Pr ov idesi nf ormat ionabouthy dr at ion, organf unct ion.

PageCLXXXI
Xof189
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Vari
edalter
ati
onswit
hsi gni
fi
cantconsequencestosyst
emicfuncti
onare
possi
bleasaresul
toffluidshi
ft
s,hypovol
emi a,
hypoxemia,
cir
culat
ingt
oxins,
andnecroti
cti
ssueproducts.

PageCXCof190
 9)Admi nisterplasmaorbl ood,fl
uids,electr
ol y
t es,diuret
icsasindicat
ed.
Rat i
onale:Repleni
shesci r
culati
ngv olumeandel ectrol
y t
[Link]
oids
(plasma, blood)helpmov ewat erbacki ntoint ravascul
arcompar tmentby
increasingosmot icpr
essur [Link] oassisti
n
excretionoft oxi
nsandt oenhancer enalfunct ion.
10)
Mai ntainNPOwi thnasogast ri
cori ntesti
nal aspirati
on.
Rat i
onale:Reduceshy peracti
vit
yofbowel anddi arrhealosses.

2-AcutePai n:
-Mayber elatedt o:
 Chemi cal i
rr i
tationoft hepar iet
alper i
toneum (t
oxins)
 Tr aumat ot issues
 Accumul ationoff lui
di nabdomi nal/perit
onealcavi
ty(abdominaldi
stensi
on)
-Possi
blyev i
dencedby :
 Ver balizationsofpai n
 Muscl eguar ding,reboundt enderness
 Faci almaskofpai n,self-f
ocus
 Distract i
onbehav ior
, autonomi c/emot ional
responses(anxiet
y)
-Desi
redOut comes:
 Repor tpaini sr eli
eved/ controll
ed.
 Demonst rateuseofr elaxati
onski l
ls,othermethodstopr omotecomf or
t.

-
Nursi
ngI nter vent i
ons:
1)I nvest igatepai nrepor ts,notinglocat i
on,durat i
on,intensi t
y(0–10scal e)
, and
char act erist
ics( dull,
shar p,const ant).
Rat i
onal e:Changesi nl ocat i
onori ntensityarenotuncommonbutmayr eflect
dev elopi ngcompl [Link] ntendst obecomeconst ant,mor eintense, and
diffuseov ert heent ir
eabdomenasi nfl
ammat or
ypr ocessaccel erates;painmay
l
ocal izei fanabscessdev elops.
2)Mai ntai nsemi -Fowler’sposi ti
onasi ndicated.
Rat i
onal e:Faci l
it
atesf luidorwounddr ainagebygr avity,reducingdi aphragmat ic
i
r r
itationand/ orabdomi nal tension, andt herebyreduci ngpai n.
3)Mov epat i
entsl owl yanddel iberately,splinti
ngpai nful area.
Rat i
onal e:Reducesmuscl etensionandguar ding,whi chmayhel pmi nimizepain
ofmov ement .
4)Pr ov idecomf ortmeasur es:massage, backr ubs,deepbr [Link]
relaxat ionandv i
sualizat i
onexer ci [Link] ovi
dedi versional acti
viti
es.
Rat i
onal e:Promot esr elaxationandmayenhancepat ient ’
scopi ngabi l
it
iesby
refocusi ngat tenti
on.
5)Pr ov idef r
equentor alcar [Link] enoxi ousenv ir
onment alst
imul i
.
Rat i
onal e:Reducesnauseaandv omi t
ing, whichcani ncr easeint r
a-abdomi nal
pressur eandpai n.
#Admi
nist
ermedi
cat
ionsasi
ndi
cat
ed:
6)Analgesi
cs,narcot
ics;
Rati
onale:Reducemet abol
icrateandintesti
nali
rr
it
ati
onf r
om circulat
ingorlocal
toxi
ns,whichaidsinpainrel
iefandpromot esheali
[Link]
mayr equi
renarcoti
[Link]
gesicsmaybewi thheldduringini
tial

PageCXCIof191
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

di
agnosticprocessbecauset heycanmasksignsandsymptoms.
7)Ant
iemet i
c:hydroxyzine(Vist
aril
);
Rat
ionale:Reducenauseaandv omiti
ng,whi
chcanincr
easeabdomi
nal
pai
n.
8)Ant
ipyreti
cs:acetami nophen(Tylenol
).
Rat
ionale:Reducedi scomf or
tassociatedwi
thf
ever
.

PageCXCI
Iof192
 [Link]
eat
it
is
-
Def i
niti
on:
i
nflammat i
onoft hepancr eas:
maybeacut eorchronic.
Acutepancr eatit
is:canbeamedi calemergencyassoci
atedwit
hahighriskf
or
l
ifethreateningcompl icat
ionsandmor t
ali
ty.
Chronicpancr eatit
is:
of t
enundetectedunt
il80%t o90%oft heexocr
ineandendocr
ine
ti
ssuei sdest r
oyed.
-Signsandsy mpt oms:
Acut epancr eatit
is:
1-sev ereabdomi nal pain.
2-nausea.
3-vomi t
ing.
4-t ender nesswhent ouchi
ngt hesignsandsy
mpt
omsabdomen.
Chr onicpancr eatit
is:
1-upperabdomi nal pain.
2-losi ngwei ghtwi thouttry
ing.
3-oi l
ysmel l
yst ools( steat
orrhea)
.
-Causes:
1-al
coholism.
2-gall
stones.
3-abdomi nalsur
ger y
.
4-ci
garettesmoki ng.
5-cyst
icfibrosi
s.
6-hi
ghcal cium l
evelsint
hebl
ood(hypocal
caemia)whi
chmaybecausedbyan
overacti
vepar at
hy r
oidgl
and(
hyperpar
athy
roi
dism).
7-i
nfecti
on.
8-i
njurytotheabdomen.
9-pancreati
ccancer .

-Pat
hophysiol
ogy:
thepancreati
cductbecomesobst r
ucted---
--
--accompani
edbyhypersecr
eti
onofthe
exocri
neenzymesoft hepancreas.
--
--
--
-theseenzymesentert
hebil
eductwheret
hey
areacti
vatedandtogetherwi
thbil
ebackup( ref
lux)
int
othepancr
eati
cductcausi
ng
pancreat
it
is.
-Diagnosti
ctest:
-BloodTests:Bloodt est
scanevaluat
ethefunct
ionofthegallbl
adder,
liver
,and
[Link] hepancreat
icenzymesamy l
aseandlipasecanbemeasur ed.
Bloodt est
scanal socheckf orsi
gnsofrel
atedcondit
ions,
includi
nginfecti
on,anemia
(lowbloodcount )
, anddehydrati
[Link]
edCA19- 9maybecheckedi f
pancreaticcancerissuspected.
-Secreti
onStimulationTest:
Secreti
oni sahormonemadebyt hesmalli
ntest
ine.

PageCXCI
IIof193
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Secret i
onst i
mulatest hepancr east or el
easeaf l
uidt hatneutral
izesstomachaci dand
ai
dsi ndi gesti
on.
Thesecr et
ionstimulationtestmeasur estheabi l
ityoft hepancreast orespondto
secret i
n.
Thist estmaybeper formedt odet erminetheact i
vit
yoft hepancreasinpeoplewith
diseasest hataffectthepancr eas( f
orexampl e, cysti
cf ibrosi
sorpancr eat
iccancer
Duringt hetest,aheal t
hcar epr ofessionalplacesat ubedownt hethroat,i
ntothe
stomach, t
henintot heupperpar toft hesmal lintesti
ne.
Secret i
onisadmi nisteredbyv einandt hecont entsoft heduodenal secret
ionsar
e
aspirated(remov edwi thsucti
on)andanal yzedov eraper i
odofaboutt wohours.

-FecalElast
aseTest:Thefecalel
astasetestisanothertestofpancr
easfuncti
on.
Thet estmeasuresthelevel
sofelastase,
anenzy mef oundinflui
dsproducedbyt
he
[Link]
asedigests(br
eaksdown)pr otei
ns.
-I
nt hi
stest,apati
ent'
sstoolsampleisanalyzedforthepresenceofelast
ase.
-ComputedTomogr aphy(CT)ScanWi t
hCont r
astDye:
Thisi
magi ngt
estcanhelpassesst heheal
thofthepancreas.
ACTscancani dentif
ycomplicat
ionsofpancreati
cdiseasesuchasf l
uidaroundt
he
pancreas,
anenclosedinf
ecti
on(abscess),oracoll
ecti
onoftissue,
flui
d,andpancreat
ic
enzymes(pancreat
icpseudocyst
).
-AbdominalUl
trasound:Anabdomi
nalul
trasoundcandet
ectgal
l
stonest
hatmight
blocktheoutf
lowoff l
uidf
rom t
hepancr
[Link]
socanshowanabscessora
pancreat
icpseudocyst.
-EndoscopicRet
rogradeCholangi
opancr eatogr
aphy(ERCP)
:
I
nanERCP, ahealt
hcar eprof
essional
pl acesatubedownthethr
oat,
intothestomach,
thenintothesmalli
ntesti
ne.
Dy ei
susedt ohel
pthedoct orseethestructureofthecommonbil
educt,otherbi
l
e
ducts,andthepancreati
cductonanX- ray.
I
fgallstonesar
eblockingthebil
educt,theymayal soberemov
edduringanERCP.

-Endoscopi cUltr
asound: I
nthistest,
apr obeattachedtoalight
edscopeisplaceddown
thet hroatandintothestomach.
Soundwav esshowi magesofor gansint heabdomen.
Endoscopi cultr
asoundmayr evealgall
stonesandcanbehel pf
uli
ndiagnosi
ngsevere
pancr eati
ti
swhenani nvasiv
etestsuchasERCPmi ghtmaket hecondi
ti
onwor se.
Abi opsyorsampl i
ngoft hepancreasmayal sobepossi bl
ewi t
hthi
stypeofultr
asound.
-Magnet
icResonanceCholangiopancr
eatogr
aphy(MRCP)
Thi
skindofmagnet i
cresonanceimaging(MRI)canbeusedt
olookatt
hebi
l
educt
s
andthepancr
eati
cduct.

PageCXCI
Vof194
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-Medicalmanagement :
-Foracutepancreatit
is:Youwi l
lrecei
vetreatmentint
hehospit
al t
oall
owthepancr
eas
[Link] l
lreceiveint
ravenous(IV)flui
dstorepl
acelostf
lui
dsandmaintai
nyour
[Link] ouwi l
lgetmedi ci
nestocontrolpai
nunti
ltheinf
lammat
iongoes
away .
Tohel
presty
ourpancr
eas,
youl
i
kel
ywi
l
lnotbegi
venany
thi
ngt
oeatf
orsev
eral
day
s.
I
fgal l
stonesarecausingpancr eati
ti
s,youmayhaveapr ocedurecal
ledendoscopic
ret
rogradecholangiopancreatogram (ERCP)t
oremov ethestonesfr
om thecommon
bil
educt .
Afterrecover
ingfrom pancreatit
is,
youmayhav esurger
yt oremovethegall
bladder
.
Thissurgeryoftenprevent
sf utureatt
acksofpancr
eatit
is.
-Forchroni
cpancreati
ti
s:Peoplewhohavechr
oni
cpancreati
ti
salsomayhaveepi
sodes
ofacutepancreat
iti
s,whicharetr
eat
edthesameasaninit
ialepi
sodeofacut
e
pancreati
ti
s.
-
Ongoi ngtreatment:
Excessiveuseofalcoholisthemostcommoncauseofchr oni
cpancreat
it
is.
I
tisext r
emel yi
mportantthatyounotdri
nkanyalcohol
.
Drinki
ngev ensmallamount scancausesever
epainandcompli
cat
ions.
Drinki
nglargeamount sofalcoholwhenyouhavechroni
cpancr
eat
iti
scanshort
eny
our
l
ife.
I
fy ouhav echroni
cpancreatit
is,
youmaystruggl
ewi t
hongoi
ngpai
n.

-Treatmentf orpai n:
i
ncl udesav oidingalcohol ,eatingal ow-fatdi et,usingpai nmedi cine,andi nsome
casest akingenzy mepi l
l
st ohel pr estyourpancr eas.
Youmayneedsur ger
yoranot herpr ocedur etowi denanar rowpancreaticductorto
remov etissueorst onesthatar eblockingt hepancr eaticduct .Surgerycanalsodraina
pseudocy storanobst ructedduct .
Yourdoct orwillwantt oseey our egular
lytomakesur et haty ourpainmedi ci
neis
helpingy ouandt hatyoudonothav ecompl i
cationsofchr onicpancreati
tis.
Compl icationsofchr onicpancr eatit
ismayi ncl
uder ecurringf l
are-
upsofsy mptoms,
flui
dbui l
dup, andbl ockageofabl oodv essel ,t
hebi l
educt , orthesmal l
intest
ine.
Chr oni
cpancr eati
tisalsoincreasesy ourriskofpancr eaticcancer

[Link] n
-Mayber elatedto:
 Ob structi
onofpancr eati
c,bil
i
aryducts.
 Ch emi calcontaminati
onofperit
onealsur
facesbypancr
eaticexudat
es/
aut odigesti
onofpancr eas.
 E xtensionofinfl
ammat i
ontotheret
roper
it
onealner
veplexus.
-Possi
blyev i
dencedby :

PageCXCVof195
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Repor
tsofpai
n.

 Sel
f-
focusing,gr
imacing,
dist
ract
ion/
guar
dingbehav
iour
s.
 Aut
onomi cresponses,al
ter
ati
oninmuscl
etone.

PageCXCVIof196
-DesiredOut comes:
 Re por tpai ni sr eliev ed/ cont r olled.
 F ol lowpr escr ibedt her apeut icr egi men.
 De monst rateuseofmet hodst hatpr ov ider el ief.
Nursi ngI nter vent ions:
1)Inv estigat ev er bal repor tsofpai n, notingspeci ficl ocat ionandi ntensi ty(0–10scal e).
Not efact orst hataggr av ateandr elievepai n.
Rat i
onal e: Pai ni sof tendi ffuse, sev ere, andunr elent ingi nacut eorhemor rhagi c
pancr eat iti
[Link] er epai nisof tent hemaj orsy mpt om i npat ientswi thchr onic
pancr eat iti
s.I sol at edpai ni nt heRUQr eflect si nv ol vementoft heheadoft he
pancr [Link] ni nt hel eftupperquadr ant( LUQ)suggest si nv ol
vementoft he
pancr eat ict [Link] izedpai nmayi ndi catedev el opmentofpseudocy st
sor
abscesses.
2)Mai ntainbedr estdur i
ngacut eat [Link] ov idequi et,rest ful environment .
Rat i
onal e: Decr easesmet abol icr at eandGIst imul ationandsecr eti
ons, ther eby
reduci ngpancr eat icact ivi
ty .
3)Pr omot eposi tionofcomf or tononesi dewi thkneesf lexed, sitt
ingupandl eaning
for war d.
Rat i
onal e: Reducesabdomi nal pr essur eandt ensi on, prov idingsomemeasur eof
comf or tandpai nr elief .Not e: Supi neposi tionof teni ncr easespai n.
4)Pr ov i
deal ter nat ivecomf ortmeasur es( backr ub) , encour ager el
axat iont echni ques
(gui dedi mager y, visual ization) ,qui etdi ver sional act iviti
es( TV, radio).
Rat i
onal e: Pr omot esr el axat ionandenabl espat ientt or ef ocusat tention; may
enhancecopi ng.
5)Keepenv i
ronmentf reeoff oododor s.
Rat i
onal e: Sensor yst imul ationcanact ivatepancr eat icenzy mes, i
ncreasi ngpai n.
6)Admi ni steranal gesi csi ntimel ymanner( smal ler ,mor ef requentdoses) .
Rat i
onal e: Sev ereandpr olongedpai ncanaggr av at eshockandi smor edi f
ficultto
relieve, r
equi ri
ngl ar gerdosesofmedi cat ion, whi chcanmaskunder l
y i
ngpr oblems
andcompl icat ionsandmaycont ributet or espi rat or ydepr essi on.
7)Mai ntainmet icul ousski ncar e, especi al l
yi npr esenceofdr ainingabdomi nal wall
fistulas.
Rat i
onal e: Pancr eat icenzy mescandi gestt heski nandt issuesoft heabdomi nal wal
l,
cr eatingachemi cal bur n.
#Admi ni stermedi cat ionasi ndi cat ed:
8)Nar coticanal gesi cs: meper i
di ne( Demer ol ),fent any l(Subl imaze) ,pent azoci ne
(Tal win) ;
Rat i
onal e: Meper idi nei susual lyef fect i
v ei nr eliev ingpai nandmaybepr eferredov er
mor phi ne, whi chcanhav easi deef fectofbi li
ar y-pancr eat icspasms.
Par av ertebr al bl ockhasbeenusedt oachi ev epr ol ongedpai ncont rol.
Not e:Pai ninpat ient swhohav er ecur r entorchr oni cpancr eat i
ti
sepi sodesmaybe
dif fi
cul ttomanagebecauset heymaybecomedependentont henar coticsgi venf or

PageCXCVI
Iof197
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

paincont r
ol.
9)Sedat i
ves: diazepam ( Valium) ;antispasmodi cs:atropi ne;
Rati
onal e: Potent i
atesact i
onofnar cot i
ctopr omot er estandt or educemuscul arand
ductalspasm, therebyr educi ngmet abol icneeds, enzy mesecr eti
ons.
10)Antaci ds: My l
anta, Maal ox, Amphoj el,Riopan;
Rati
onal e: Neut ral
izesgast ri
caci dt or educepr oduct ionofpancr eati
cenzy mesand
toreducei ncidenceofupperGIbl eedi ng.
11)Cimet idine( Tagamet ),ranitidi
ne( Zant ac),famot idine( Pepcid)
Rati
onal e: Decreasi ngsecr etionofHCl reducesst i
mul ati
onoft hepancreasand
associat edpai n.
12)Withhol df oodandf l
uidasi ndicated.
Rati
onal e: Limitsandr educesr eleaseofpancr eati
cenzy mesandr esult
antpai
n.
13)Mai ntaingast ricsuct ionwhenused.
Rati
onal e: Preventsaccumul ati
onofgast ri
csecr etions, whichcanst i
mulate
pancreat icenzy meact ivity.
14)Prepar ef orsur gi
cal intervent i
oni findicated.
Rati
onal e: Surgical explorat i
onmayber equiredi npr esenceofi nt
ractablepai
nand
compl i
cat ionsi nvolvingt hebi li
aryt ract,suchaspancr eaticabscessorpseudocy st
.

[Link]
entFl uidVol ume:
-Ri
skfactorsmayi nclude:
 E xcessivelosses: vomi ti
ng,gastri
csucti
oning
 Increasei nsizeofv ascularbed(vasodil
ati
on,ef
fect
sofki
nins)
 Th ir
d-spacef luidtransudation,asci
tesformat
ion
 Al t
erati
onofcl ott
ingpr ocess,hemor r
hage
-Possi
blyevidencedby :
 Notappl
i
cabl
[Link]
stenceofsi
gnsandsympt
omsest
abl
i
shesanact
ualnur
sing
di
agnosi
s.
-
Desi
redOut comes:
 Ma i
ntainadequat
ehydrati
onasevidencedbystabl
evi
talsi
gns,goodski
nturgor
,
pr
omptcapi ll
aryr
efi
l
l,st
rongper
ipheralpul
ses,
andindi
vi
duall
yappropri
ate
ur
inaryoutput.

-
Nur
singI
nter
vent
ions:
-
1)Moni torBPandmeasur eCVPi favailabl
e.
Rat i
onale:
Fluidsequestrati
on(shif
tsintothir
dspace) ,bleedi
ng,
andrel
easeofvasodi
l
ator
s
(kini
ns)andcar diacdepressantfactortr
iggeredbypancr
eati
cischemi
amay
resultinprof
oundhy potension.

PageCXCVI
IIof198
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Reducedcardiacout putandpoororganperf
usi
onsecondar yt
oahypot
ensi
ve
epi
sodecanpr ecipi
tat
ewidespreadsyst
emiccompl i
cati
ons.
2)MeasureI&Oi ncludingvomit
ing,gast
ri
caspi
rat
e,diarr
hea.
Cal
culat
e24- hrfluidbal
ance.
Rati
onal
e:Indicatorsofrepl
acementneedsandeffectiv
enessoft
her
apy.

3)Not edecr easei nur i

neout put( lesst han400mLper24hr ).
Rat i
onal e:
Oligur i
amayoccur ,signal ingr enal impai r
mentandacut et ubularnecrosis(ATN),
relatedt oi ncr easei nr enal vascul arresistanceorr educedandal t
eredr enal
bloodf low.
4)Recor dcol orandchar acterofgast ri
cdr ainage, measur epH, andnot epr esence
ofoccul tbl ood.
Rat i
onal e: Riskofgast ricbl eedi ngandhemor rhagei shigh.
5)Wei ghasi ndicat ed.
Cor relatewi thcal culatedf l
uidbal ance.
Rat i
onal e: Wei ghtl ossmaysuggesthy pov olemi a;
howev er , edema, fl
uidr etent ion, andasci tesmayber efl
ectedbyi ncreasedor
stabl ewei ght,ev eni nt hepr esenceofmuscl ewast ing.
6)Not epoorski nt urgor ,dr yski nandmucousmembr anes, r
eportsoft hir
st.
Rat i
onal e: Fur therphy si ological indicatorsofdehy drat i
on.
7)Obser veandr ecor dper ipher al anddependentedema.
Measur eabdomi nal girthi fasci tespr esent.
Rat i
onal e:
Edemaandf l
uidshi ftsoccurasar esultofi ncreasedv ascularpermeabi l
it
y,
sodi um r et ention,anddecr easedcol l
oidosmot i
cpr essur eintheintravascular
compar tment .
Not e: Flui dl oss( sequest ration)ofmor ethan( 6)Lper( 48)hrisconsi dereda
poorpr ognost icsi gn.
8)Invest igat echangesi nsensor ium (conf usion, sl
owedr esponses) .
Rat i
onal e:
Changesmayber elatedt ohy povolemi a,hypoxi a,electrolyteimbalance, or
i
mpendi ngdel iri
um t remens( i
npat ientwi thacut epancr eati
ti
ssecondar yto
excessi veal cohol i
ntake) .
Sev erepancr eaticdi seasemaycauset oxicpsy chosis.
9)Auscul tat ionhear tsounds; not er at
eandr hy thm.
Moni t
oranddocumentr hy thm, changes.
Rat i
onal e:
Car diacchangesanddy srhy thmi asmayr ef l
ecthy pov olemi aorelectrolyt
e

PageCXCI
Xof199
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

i
mbalance, commonl yhypokalemiaandhy pocalcemia.
Hyperkalemiamayoccurr elat
edt ot
issuenecrosis,aci
dosis,
andrenal
i
nsuffi
ciencyandmaypr eci
pit
atelet
haldy sr
hythmiasifuncorr
ect
ed.
S3gall
opi nconjunct
ionwi t
hJVDandcr ackl
essuggestHForpul monaryedema.
Note:Car di
ovascul
arcompl i
cati
onsarecommonandi ncl
udeMI ,
peri
cardi
ti
s,and
per
icardialeff
usionwit
horwi thoutt
amponade.

PageCCof200
 10)
Inspectski nf orpet echi ae, hemat omas, andunusual woundorv eni puncture
bleedi [Link] ehemat ur i
a, mucousmembr anebl eeding, andbl oodygast ri
c
cont ent s.
Rat ional e: DICmaybei ni ti
at edbyr eleaseofact ivepancr eat icpr ot easesi ntothe
circul at i
on.
Themostf r
equent lyaf fect edor gansar et hekidney s, skin, andl ungs.
11)
Wat choutf orsi gnsandsy mpt omsofcal cium def i
ciency .
Obser veandr epor tcoar semuscl etremor s,twit
ching, posi ti
v e
Chv ost ek’ s, Tr ousseau’ ssi gn, t etany ,cramps, carpopedal spasm, andsei zures.
Rat ional e: Sy mpt omsofcal cium i mbal ance.
Cal cium bi ndswi thf reef atsi nt hei ntest ineandi sl ostbyexcr etioni nt hestool.
12)
Keepai rwayandsuct ionappar atushandyandpadsi der ai l
s.
Rat ional e: Ify oususpecthy pocal cemi a.
13)
Admi nist erf luidr epl acementasi ndicat ed( sali
nesol utions, albumi n,blood,blood
product s, dext ran) .
Rat ional e: Choi ceofr epl acementsol utionmaybel essi mpor tantt hanr apidi
ty
andadequacyofv olumer est oration.
Sal i
nesol utionsandal bumi nmaybeusedt opr omot emobi lizat i
onoff l
uidback
intov ascul arspace.
Low- mol ecul ar -
wei ghtdext rani ssomet imesusedt or educer iskofr enal
dysf unct ionandpul monar yedemaassoci atedwi t
hpancr eat i
tis.
14)
Moni torl abor ator yst udi es( HbandHct , Protein,albumi n, elect roly tes,BUN,
creat ini ne, ur ineosmol alityandsodi um, potassium, coagul at ionst udies).
Rat ional e: Ident ifiesdef icitsandr eplacementneedsanddev el opi ng
compl icat ions( ATN, DIC) .
15)
Repl aceel ect rolytes( sodi um, pot assi um, chlori
de, calcium asi ndi cated).
Rat ional e:
Decr easedor al int akeandexcessi vel ossesgr eatl
yaf fectel ect roly teandaci d-
basebal ance, whi chi snecessar ytomai ntainopt i
mal cel lularandor ganf unction.
16)
Prepar eandassi stwi thper i
toneal lav age, hemoper it
oneal dial ysis.
Rat ional e:
Remov est oxi cchemi cal sandpancr eat i
cenzy mesandal lowsf ormor erapid
cor rect ionofmet abol icabnor mal it
iesi nsev ereandunr esponsi v ecasesofacut e
pancr eat i
tis.

#Ot
herdi
agnosi
s:

3.I
mbal
ancedNut
ri
ti
on:
LessThanBodyRequi
rement
s

[Link]
ici
entKnowl
edge

5.r
iskf
orI
nfect
ion

[Link]
skf
orI
mbal
ancedFl
uidVol
ume

PageCCIof201
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCCI
Iof202
 [Link]
verCi
rr
hosi
s
-Defi
niti
on:
Cirr
hosisisachr oni
cdi seasechar act
erizedbyr epl
acementofnor mall
ivert
issuewithd
i
ffusefibrosi
sthatdisrupt sthestruct
ureandf unctionoftheli
ver.
Thef i
brosisal
tersli
verst ructur
eandv asculature,i
mpairi
ngbloodandly mphflowandr
esulti
nginhepat i
cinsuffi
ci encyandhyper t
ensionintheportalvei
n.
Afteryearsofli
verinfl
ammat i
on,i
twillgraduall
yloseit
sabili
tytofunct
ionwell,whi
chc
anleadt oaseriousprobl em inotherpartsofthebody .
-
Thethreeclassifi
cationsofCi rr
hosi s:
[Link] coholi
ccirrhosi s-scarti
ssuechact er
isti
callysur roundst hepor talar
[Link]
s
themostpr ev alenttypethatcausedbyl onghi storyofchr onical cohol
ism
[Link] necroti
cci rrhosis-
consistbroadbandsofscart i
ssueandr esultsfrom pr
evi
o
usacutev ir
al hepatiti
sordr ug-i
nducedmassi vehepat i
cnecr osis.
[Link] l
iar
ycirrhosis-consistofscar ri
ngofliveraroundt [Link] stypeofcir
r
hosisusuallyresul t
sf r
om chr oni
cbili
aryobst ructionandi nfection(cholangi
ti
s)i
t
i
smuchl esscommont hant heothertwocl assificati
onsofci rrhosis.
-Causes:
Thev ari
ouscausesofci rrhosisar eacombi nati
onofal cohol,hepatisCorbot h.
Peoplewi thci rr
hosist y picall
ynotcausedbyt r
aumat ot heli
verorot heracut eorshor tt
erm causeofdamage.
Itusual
lyy ear sofpr olongedi njur yr equiredt ocauset hedi sease.
[Link] onical cohol ism- Theamountofal coholintakei sbr okendownactasat oxin,
l
eadi ngt oinflammat ion. Wi thprolongeduse, scart issuedev elopsandt heli
veri s
unabl et of unctionpr oper ly .
[Link] ralorAut oi
mmunehepat iti
s-Thisdi seaseappear stobecausedbyt heimmune
sy stem andi nflammat oryr esponsesbyat t
acki ngt heliverandcausingdamage,
andev entuallyscar ri
ngoft hel iv
ert issues
3.I nheritedorGenet icdi sorder -Cysticf i
brosi
s,alpha- 1ant it
rypsi
ndef i
ciency ,
hemo
chromat osis,Wi lsondi sease, galact osemia,andgl ycogenst oragediseasesar ei
nher i
teddi seasest hatint er f
er ewi t
hhowt hel iv
erpr oduces, processes, andstor e
senzy mes, protei ns, met al s,andot hersubstancest hebodyneedst of unct
ionpr
oper l
[Link] r
rhosiscanr esul tfrom t hesecondi tions
[Link] leduct sobst ruct ion-Theductt hat '
scar r
ythebi l
eoutoft heli
verblocked, bil
eb
acksupanddamagesl ivert issue.
[Link] ugsandt oxin-Pr olongedexposur et odrugsandenv i
ronment altoxinscanl ead
tohepat i
ccel ldamage.

-
Clinical
Manifestati
ons:
Si
gnsandsy mpt omsofci r
rhosi
sincr
easeinsev
eri
tyasdiseasepr
ogresses.
Cl
inicalmanif
estationar
ecategori
esascompensat
edanddecompensat ed.
-
Compensat edcirrhosi
smeanst hatt
heli
veri
sheavi
lyscarr
edbutcanstil
lper
for
m man

PageCCI
IIof203
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

yimport
antbodilyfunctions.
Manypeopl ewit
hcompensat edcir
rhosisexperiencefewornosymptomsandcanl i
vef
ormanyy earswithoutseriouscompli
cations.
¬
-Decompensatedcirrhosismeansthattheliverisextensi
vel
yscar
redandunabl
etofunc
ti
onproperl
y .
Peoplewi t
hdecompensat edcirrhosisevent
ual
lydev
elopmanysymptoms
andcompl i
cati
onst hatcanbel i
fet
hreatening.

Compensat
ed Decompensat
ed
 Ascites

 Jaundi
ce
 I
nter
mit
entmi
l
dfev
er
 Weakness
 Vaguemor
ningi
ndi
gest
ion
 Muscl
ewast
ing
 Vascul
arspi
der
s
 Wei
ghtl
oss
 Fl
atul
entdy
spepsi
a
 Cont
inuousmi
l
dfev
er
 Pal
marer
ythema(
reddenedpal
m
 cl
ubbi
ngoff
inger
s
s)
 Pur
pur
a(duet
odecr
easedpl
atel
etcount
 Abdomi
nal
pai
n
 Spont
aneousbr
uisi
ng
 Unexpl
ainedepi
taxi
s
 Epi
taxi
s
 Fi
rma,
enl
argedl
i
ver
 Hy
pot
ensi
on
 Ankl
eedema
 Spar
sebodyhai
r
 Spl
enomegal
y
 Whi
tenai
l
s

 Gonadal
atr
ophy

-
Diagnost
icTest
 CTscanorUl tr
asound–showshr i
nkageorabnor malappearanceoft hel
iver
.
 Laboratorystudies–bi l
irubi
n,albumin,alaninetransaminase(ALT),aspart
atetr
a
nsaminase( AST) ,prot
hrombintime, andser um ammoni a-tocheckf orel
evat
ed
val
ues,whi chindicatehepati
ccel ldestruct
ion.
 Laparoscopyandl i
verbiopsy-di
rectvisuali
zati
onoft heli
ver
 Paracentesis-
toexami neascet i
cfluidforcell,protei
nandbact er
ialcount
s.
 Esophagoscopy–t odeterminethepr esenceofesophagealv ari
ces.

PageCCI
Vof204
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

-
Medi
cal
Management
:-
-
Phar
macologi cal:
 Potassium spar ingdiuret
icspironol
actone(Aldactone)-
usetodecreasedasci
ted
andpleur al enf
fusion.
 Lactulose( Chol
ac)-usedtoeliminatetheammoni af rom t
hebloodintothebowel
.
Tapwat erenemasmayal sobeor der
edt ohel
pt hebodyel i
minatetheammonia.
 Propranol olhydrochlor
ide(I
nderal)
-anantihypertensiv
emedi cat
ion maybeorde
redtol owerpor talhypert
ension.

PageCCVof205
-
Sur
gical
:
 Paracentesis–mayper formt or emov ethef luidfrom theabdomenandr eliv
epr e
ssureont hediaphragm andl ungs. Apar acent esi
si sdonebymaki ngasmal l i
nci
si
onandi nsert
ingat rocharint otheabdoment odr ai
nt [Link]
nfusedatt hesamet i
met opul lexcessf luidbacki ntov ascularsystem.
 Esophagogast ri
cintubation( balloonpl acedi ntotheesophagusandi nfl
atedt op
utpressureonbl eedingsi t
es)orendoscopi csclerotherapy( placi
ngaf l
exibletub
eintotheesophagusandusi nganagentt hatcausesscl er
osingoft hebleedingar
ea)forbleedingesophageal v ari
ces.I fsclerotherapyisunsuccessf ul
,endoscopic
bandingmaybeper [Link] st echniquei nvolvesbandi ngoft hevari
cescausi
ngstrangulati
onandev ent uallyfibrosisoft hearea

-
(10)Nur
singDi
agnosi
sforLi
verCi
rr
hosi
s:
1.I
mbal ancedNut r
it
ionLessThanBodyRequi rementsr el
atedt oanor exi
a.
[Link]
v i
tyIntolerancer el
atedt omuscl eweakness.
[Link]
uidandel ectrolyteimbal ancesr el atedtoportalhypertension.
4.I
neffecti
v eTi ssuePer fusionr elatedt ohemat emesisandmel ena.
[Link] ohemat emesi sandmel ena.
6.I
neffecti
v eBr eathingPat ternr el
at edt odecreasedlungexpansi on.
7.I
mpai redVer bal Communi cati
onr elatedtoneurologicaldisturbancestalki
ng.
[Link] el
atedt ouncont rolledmov ement s.
9.I
mpai rePhy sical Mobilit
yr elatedt ot heeffectofmuscl est i
ffness.
[Link]-
caredef i
citrelat
edt oast ateofcoma.

-
Cir
rhosi
sNur
singManagement
:

 Moni torvitalsigns, int

akeandout putandel ectroly
televelstodet erminef luidvol
umest atus.
 Mai nt ainsomeper iodsofr estwtihlegsel evatedtomobi li
zeedemaandasci t
es.
Al t
er naterestper i
odswi thambul ation.
 Toassessf l
uidr etention, measur eandr ecordabdomi nalgirt
hev eryshif [Link] ght
t hepat i
entdai l
yanddocumenthi swei ght.
 Admi nisterdiuret i
cs,pot asium andpr oteinorv it
aminsuppl ement sasor der [Link]
strictsodi um andf luidint akeasor dered.
 Obser veanddocumentf orbl eedi
nggums, ecchy moses,epistaxi
s,petechi aeandd
egr eeofscl erae,ski njaundi [Link] nwi t
ht hepatientduringthehemor rhagi ce
pisodes.
 Inspectst oolsf orammount ,
colorandconsi [Link] oolsandv omi tusf oro
ccul tbloodasor dered.
 Wat chf orsignsofanxi ety,epigastri
cf ull
ness, r
estl
essnessandweakness.
 Obser veclosel yforsi gnsofbehav i
oralorper sonali
[Link] tincr easing
st upor ,l
ethargy ,
hallucinat ionsorneur omuscul ardysfuncti
[Link] ouset hepat ient
per i
odi call
yt odet ermi nel ev elofconsci [Link] chforast er
ixis,asignofdev

PageCCVIof206
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

el
opingencephalopat
hy .
 Al
lowt hepati
enttoexpresshi
sfeel
ingsabouthavingci
rr
hosi
[Link]
ferpsy
chol
ogi
c
alsupportandencouragement
,whenappropri
ate.

-
Pat
ientteachi ng:
 Tomi nimizetheriskforbleeding,warnthepatientagai
nsttaki
ngnonsteroi
dal
anti
-inflammat orydrugs,strai
ningtodefecateandblowinghisnoseorsneezingt
ov i
gor ously.
 Suggestusi nganel ectri
crazorandasof ttoot
hbrush.
 Adv iset hepatientthatrestandgoodnut ri
ti
onconserveenergyanddecreaseme
tabolicdemandsont heli
ver.
 Ur gehi mt oeatf r
equent,smal lmeals.
 Teachhi mtoal t
ernateperiodsofrestandact i
vit
ytoreduceoxygendemandand
preventf ati
gue

PageCCVI
Iof207
 [Link]
it
is
-Defi
niti
on:
Hepat i
tisreferstoani nfl
ammat orycondit
ionoftheli
ver.
I
t ’
scommonl ycausedbyav ir
ali
nfecti
on,butthereareotherpossi
blecausesof
hepat i
ti
s.
Thesei ncludeaut oimmunehepat it
isandhepatit
isthatoccursasasecondaryresul
tof
medi cati
ons, drugs,toxi
ns,andalcohol.
Autoimmunehepat it
isisadiseasethatoccurswheny ourbodymakesant i
bodies
againsty ourliv
ertissue.
-Theliverislocatedont herightupperquadrantofyourabdomen.
-
Itperformsmanycr i
ti
calfunctionst hataffectmet abolism t
hroughouty
ourbody
i
ncludi
ng:
1)bil
epr oducti
onthat’sessent i
al todigesti
on.
2)fi
lteri
ngoftoxinsfrom thebody .
3)excretionofbil
ir
ubin,cholesterol,hormones, anddr ugs.
4)met aboli
sm ofcarbohy dr
at es,
f ats,
andpr ot
eins.
5)activati
onofenzy mes,whi char especializedproteinsessenti
altometabol
i
c
functions.
6)storageofglycogen, minerals,andv it
ami ns(A,D, E,andK).
7)synthesisofplasmapr oteins,suchasal bumin.
8)synthesisofclott
ingfactors.

-Vi
ralinf
ect i
onsoft hel
ivert
hatareclassi
fiedashepatiti
sincl
ude(hepati
ti
sA,B,C,D,
andE) .(
Hepat it
isA)isami l
derversi
onoft hedisease,and(hepat
it
isCandD)ar emore
[Link] i
onsvarydependingonwhatf or
m ofhepati
ti
sy ouhaveandwhat
causedt heinfecti
on.
Youcanpr eventsomef ormsofhepatit
isthroughimmuni zati
onsorli
fest
ylepr
ecaut
ions
-The5Ty pesofVi
ralHepati
ti
s:
1)Hepatiti
sA:
Thistypederi
vesf
rom aninfect
ionwit
hthehepati
ti
sAv i
rus(HAV)
.
Thistypeofhepat
it
isismostcommonl ytransmi
tt
edbyconsumingfoodorwat
er
contaminatedbyf
ecesfrom apersoninf
ectedwit
hhepati
ti
sA.
2)Hepati
ti
sB:
Thist
ypeder i
vesfrom ani nfect
ionwit
hthehepati
tisBvir
us(HBV).
Thist
ypeist r
ansmi tt
edthroughpuncturewoundsorcontactwit
hinfecti
ousbodyf
lui
ds,
suchasblood, sal
i
v a,orsemen.
Inj
ect
iondruguse, havingsexwi thani
nfect
edpartner,
orshar
ingrazorswit
han
i
nfect
edper sonincreasey ourri
skofgett
inghepat
iti
sB.
3)Hepati
ti
sC:
Thist
ypecomesf rom thehepat
it
isCvirus(HCV).
Hepati
ti
sCistransmitt
edthroughdi
rectcontactwi
thi
nfect
edbodyf
lui
ds,
typi
cal
l
y
thr
oughinj
ect
iondr uguseandsexualcontact
.

PageCCVI
IIof208
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

HCVi
samongt
hemostcommonbl
ood-
bor
nev
iral
inf
ect
ionsi
ntheUni
tedSt
ates.

PageCCI
Xof209
4)Hepat
it
isD:
Thi
sisalsocall
eddeltahepati
ti
s.
Hepat
iti
sDisaser i
ousliverdi
seasecausedbythehepati
ti
sDv ir
us(HDV).
HDViscontract
edthroughpuncturewoundsorcontactwit
hinfect
edblood.
Hepat
iti
sDisar ar
eform ofhepatit
ist
hatoccur
sinconjuncti
onwithhepati
ti
sB
i
nfect
ion.
5)Hepati
tisE:
Hepat
iti
sEi sawat erbornediseasecausedbythehepati
ti
sEv i
rus(HEV).
Hepat
iti
sEi smainlyfoundi nareaswithpoorsani
tat
ionandistypi
cal
lycausedby
i
ngesti
ngf ecal
mat ter.
However,casesofhepat it
isEhav ebeenrepor
tedi
nt heMiddl
eEast,Asi
a,Centr
al
Ameri
ca,andAf ri
ca, r
eportstheCDC.
-Hepati
ti
sAandE:
arenor
mal l
ycont
ract
edfrom eat
ingcont ami
natedfoodordr
inki
ngcont
ami
nat
edwat
er.
Hepati
ti
sB, C,
andDar econt
ract
edt hroughcontaminat
edbl
ood.
Theseformsofhepati
ti
scanbeei t
heracuteorchronic.
TypesBandCusual l
ybecomechr onic.

-CausesofNonv ir
alHepat i
ti
s:
-Alcohol:
Hepat i
tiscanbecausedbyl iv
erdamagef rom excessi
vealcoholconsumption.
Thisissomet imesr eferr
edtoasal coholi
chepat i
ti
s.
Theal coholcausest heliv
ertoswel landbecomei nfl
amed.
Othert oxi
ccausesi ncludeoveruseofmedi cat
ionorexposuretopoisons.
-AutoimmuneDi sease:
Thei mmunesy stem maymi stakethel i
verasahar mfulobj
ectandbegi nt
oat t
acki
t,
hinderingli
verfuncti
on.
-CommonSy mpt omsofHepat i
ti
s:
Ifyouhav ef or
msofhepat i
ti
st hatar
eusuallychronic(hepat
it
isBandC) ,y
oumaynot
hav esy mptomsi [Link] il
liverdamageoccur
s.
-Signsandsy mptomsofacut ehepati
ti
sappearqui ckly
.Theyinclude:
 F ati
gue.
 f lu-l
ikesy mptoms.
 d arkurine.
 p al
est ool.
 a bdomi nalpain.
 l ossofappet i
te.
 u nexplainedweightloss.
 y ellowski nandey es,whichmaybesi gnsofj aundice.
Sincechr onichepati
tisdevelopsslowly,
thesesignsandsy mpt omsmaybet oosubt
le
tonot i
ce.

PageCCXof210
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

#HowI sHepat i
tisDi agnosed?
-Phy sical Exam:
Dur i
ngaphy si
cal exami nation,yourdoct ormaypr essdowngent l
yony ourabdoment o
seei ft here’spainort ender ness.
Yourdoct ormayal sof eeltoseei fyourliveri
senlar ged.
Ifyourski norey esar eyellow, yourdoct orwil
lnotet hisduri
ngt heexam.
-LiverBi opsy :
Al i
v erbi opsyisani nvasivepr ocedur ethatinvolv
est hedoctort aki
ngasampl eofti
ssue
from y ourl i
v er
.Thi sisacl osedpr ocedur e.
Inot herwor ds,itcanbedonet hrought heskinwi thaneedl eanddoesn’ tr
equiresurgery.
Thist estal lowsy ourdoct ort odeterminei faninfectionorinflammat ionispresentorif
l
iverdamagehasoccur red.
-LiverFunct i
onTest s:
Liverf unct i
ont estsusebl oodsampl est odeterminehowef ficientl
ytheliv
erwor ks.
Theset estscheckhowt hel i
verclearsbl oodwast e,prot
ein,andenzy mes.
Highl iverenzy mel evelsmayi ndicatethatt heli
verisst r
essedordamaged.
-Ultrasound:
Anabdomi nal ultr
asoundusesultrasoundwavestocreateanimageoftheorgans
withint [Link] stestwi
l
l r
evealfl
uidi
ntheabdomen, anenl
argedli
ver,orl
i
ver
damage.
-BloodTest s:
Bloodt estsusedt odetectthepr
esenceofhepatit
isvi
rusanti
bodi
esandant i
geninthe
bloodwi l
lindicateorconf ir
m whichvir
usisthecauseofthehepati
ti
s.
-ViralAntibodyTest i
ng:
Fur t
herv i
ral antibodytesti
ngmaybeneededt odeter
mineifaspecif
ictypeofthe
hepat it
isvirusi spresent.
#HowI sHepati
tisTr
eated?
Tr
eatmentoptionsaredeter
minedbywhi
cht
ypeofhepat
it
isy
ouhav
eandwhet
hert
he
i
nfect
ionisacuteorchroni
c.
-
Hepatit
isA:
Hepat
it
isAi
sn’
tusual
l
ytr
eat
ed.
Bedr
estmayber
ecommendedi
fsy
mpt
omscauseagr
eatdeal
ofdi
scomf
ort
.
I
fyouexper
iencev
omi
ti
ngordi
arr
hea,
youwi
l
lbeputonaspeci
aldi
etcr
eat
edbyy
our
doct
ort
opr
eventmal
nut
ri
ti
onordehy
drat
ion.
Vacci
nat
ioncanal
sopr
eventhepat
it
isAi
nfect
ionsbyhel
pingy
ourbodypr
oducet
he
ant
ibodi
est
hatf
ightt
hist
ypeofi
nfect
ion.

PageCCXIof211
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Mostchi
l
drenr
ecei
vet
hev
acci
nat
ionbet
weenages12and18mont
hs.
Vacci
nat
ioni
sal
soav
ail
abl
eforadul
ts.

-Hepat it
isB:
Acutehepat it
isBdoesn’ tr equi respeci fi
ct reat ment .
Chroni chepat iti
sBi str
eat edwi thant i
v i
ral medi cations.
Thisf orm oft reatmentcanbecost lybecausei tmustbef ollowedf orseveralmonthsor
[Link] eatmentf orchroni chepat it
isBal sor equi resr egularmedicalevaluati
onsand
moni toringtodet erminei fthev i
rusi spr ogr [Link] ecommendshepat it
isB
vaccinat i
onsf oral lnewbor [Link] acci nei sal sor ecommendedf orallhealt
hcareand
medi cal personnel .
-Hepat it
isC:
Antiviralmedi cationsar eusedt ot r
eatbot hacut eandchr oni cf
ormsofhepat i
ti
sC.
Peopl ewhodev elopchr oni chepat i
tisCar et ypicallytreatedwi t
hacombi nati
onof
anti
viral drugt herapies.
Theymayal soneedf ur
thert estingtodet ermi net hebestf orm oftreatment.
Peopl ewhodev elopci r
rhosi s( scar r
ingoft hel i
v er)orl i
verdiseaseasar esul
tofchroni
c
hepat i
tisCmaybecandi dat esf oral ivertranspl ant .
-Hepat it
isD:
Hepat iti
sDi st reatedwi thamedi cati
oncal ledal phai nterferon.
-Hepat it
isE:
Therear ecur rentlynospeci fi
cmedi cal therapi est ot reathepatit
isE.
Becauset heinf ectionisof tenacut e, i
ttypical l
yr esol vesoni tsown.
Peopl ewi ththist ypeofi nfect i
onar eof t
enadv isedt ogetadequat erest,dri
nkplentyof
fl
uids, getenoughnut ri
ent s,andav oidal cohol .

#TypstoPreventHepat
it
is:
1-
Hy gi
ene:
Practi
ci
nggoodhy gi
enei
sonekeywayt
oav
oidcont
ract
inghepat
it
is.
-
Ifyou’
ret
ravel
i
ngt
oadevel
opi
ngcount
ry,
youshoul
davoi
d:
 dri
nkingl
ocal
wat er.
 I
ce.
 Seafood.
 rawfrui
tandvegetabl
es.
-
Hepat
it
iscont
ract
edt
hroughcont
ami
nat
edbl
oodcanbepr
event
edby:
 notshari
ngdrugneedles.
 notshari
ngrazor
s.
 notusingsomeoneelse’st
oot
hbr
ush.
 nottouchi
ngspil
l
edblood.

2-
Vacci
nes:

PageCCXI
Iof212
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Theuti
li
zati
onofvaccinesisasecondkeyt oprev
enti
nghepati
ti
s.
Vacci
nati
onsareavai
labletopreventthedevel
opmentofhepat
iti
[Link]
tsar
e
cur
rent
lydevel
opi
ngv accinesagainsthepat
it
isC,D,
andE.

-Compl icationsofHepat it
is:
Chr oni chepat i
ti
sBorCcanof t enl eadt omor eser i
ousheal [Link] he
viruspr imar ilyaf f
ect st heliver, peopl ewi thchronichepat iti
sBorCar eatri
skfor:
 chr onicl i
verdi sease
 cirrhosi s(scar ri
ngoft hel iver)
 canceroft hel iv
er( i
nr arecases)
Whent heliverst opsf unctioningnor mal l
y,l
iverfail
urecanoccur .
-Compl icationsofl iverf ai
lurei nclude:
 bleedi ngdi sor ders
 abui l
dupoff l
uidi nt heabdomen
 i
ncr easedbl oodpr essur einpor tal vei
nst hatent ertheliver
 kidneyf ail
ur e
 hepat i
cencephal opat hy ,whichcani nv ol
vefat i
gue,memor yloss,anddi mi
nishedment al
abi l
iti
esduet ot hebui ldupoft oxi nsthataf fectthebr ai
n( especiall
yammoni a)
 hepat ocell
ul arcar cinoma, whi chi saf orm oflivercancer
Peopl ewi t
hchr oni chepat i
tisCar eencour agedt oav oidalcohol becauseitcan
accel eratel iverdiseaseandf [Link] t
ainsuppl ement s,prescri
ption,andover-
the-
count ermedi cationscanal soaf fectliverfunction.
Ify ouhav echr oni chepat i
tisC, checkwi thyourdoct orbef oretakinganynew
medi cations.

#NursingCarePl ans:
-
NursingPri
orities:
[Link] i
verwhil
epr omot i
ngphysicalwel
l-
bei
ng.
[Link] eventcompl i
cations.
[Link] f
-concept ,
acceptanceofsi t
uati
on.
[Link] ovideinformat i
onaboutdi seasepr ocess,pr
ognosis,
andtreat
mentneeds.
-
DischargeGoal s:
[Link] i
ngbasi cself-careneeds.
[Link] i
cati
onspr ev ent
ed/minimized.
[Link] i
ngwi threal
ityofcur r
entsit
uation.
[Link] ocess,pr ognosis,
andt herapeuti
cregimenunder
stood.
[Link] npl acetomeetneedsaf t
erdischarge.

1.I
mbalancedNut ri
ti
on:lessthanbodyr
equi
rement
s
-Mayberelat
edt o:
 Insuff
icienti
ntaketomeetmetabol
icdemands:
anor
exi
a,nausea/
vomi
ti
ng

PageCCXI
IIof213
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 Al teredabsor pt i
onandmet abol i
sm ofi ngest edf oods: r
educedper ist al
sis
(viscer al r eflexes) ,bilest asi s
 I ncr easedcal or ieneeds/ hy per met abol i
cst at e
-
Possiblyev idencedby :
 Av ersiont oeat ing/ lackofi nt er esti nf ood; alteredt ast esensat ion
 Ab domi nal pai n/ cr ampi ng
 L ossofwei ght ; poormuscl et one
-
DesiredOut comes:
 I nitiatebehav ior s, lif
est y l
echangest or egai n/ maint ainappr opr i
at ewei ght.
 De monst ratepr ogr essi vewei ghtgai nt owar dgoal withnor mal izationof
labor ator yv al uesandnosi gnsofmal nutrit
ion.
-
NursingI nt ervent ions:
1)Moni tordi etar yi ntakeandcal or iccount .
Suggestsev er al smal lfeedi ngsandof f
er“ lar gest”meal atbr eakfast.
Rat i
onal e: Lar gemeal sar edi ff i
cul tt omanagewhenpat ienti sanor exi c.
Anor exi amayal sowor sendur ingt heday ,maki ngi ntakeoff ooddi fficultl aterinthe
day .
2)Encour agemout hcar ebef or emeal s.
Rat i
onal e: Enhancesappet itebyel i
mi natingunpl easantt ast e.
3)Recommendeat ingi nupr ightposi ti
on.
Rat i
onal e: Reducessensat ionofabdomi nal f
ullnessandmayenhancei nt ake.
4)Encour agei nt akeoff ruitjuices, car bonat edbev erages, andhar dcandyt hr oughout
theday .
Rat i
onal e: Thesesuppl yext r acal oriesandmaybemor eeasi l
ydigest edort oler
ated
thanot herf oods.
5)Consul twi thdi etitian, nut ri
tional suppor tt eam t opr ov i
dedi etaccor di ngt opat i
ent’
s
needs, wi thf atandpr ot eini ntakeast olerat ed.
Rat i
onal e: Usef ul inf ormul at i
ngdi et arypr ogr am t omeeti ndi vi
dual needs.
Fatmet abol ism v ar iesaccor dingt obi lepr oduct i
onandexcr etionandmay
necessi tater est rict i
onoff ati nt akei fdi arrheadev elops.
Iftolerat ed, anor mal ori ncr easedpr ot eini ntakehel pswi thliverregener ation.
Proteinr est rict i
onmaybei ndi cat edi nsev er edisease( fulmi nanthepat i
tis)because
theaccumul at ionoft heendpr oduct sofpr ot ei
nmet abolism canpot entiat ehepatic
encephal opat hy .
6)Moni torser um gl ucoseasi ndi cat ed.
Rat i
onal e: Hy per gly cemi aorhy pogl ycemi amaydev elop,necessi tatingdi etary
changesandi nsul inadmi nist ration.
Fingerst ickmoni tor ingmaybedonebypat i
entonar egularschedul et odet ermine
therapyneeds.
#Admi
nist
ermedi
cat
ionsasi
ndi
cat
ed:
7)Ant
iemeti
cs:
metocl
opr
amide(
Regl
an),
tri
methobenzami
de(Ti
gan).
Rat
ional
e:Gi
ven1/
2hrbef
oremeal
s,mayreducenauseaandi
ncreasef
ood

PageCCXI
Vof214
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

tol
[Link]
azi ne(Compazi ne)i
scontr
aindicat
edinhepat
icdisease.
8)Antacids:
My lanta,Ti
tralac
Rati
onale:Counteractsgast ri
cacidit
y,reduci
nggastri
cirr
it
ati
onandriskofbleedi
ng.
9)Vit
ami ns:Bcompl ex,C, otherdiet
arysupplement
sasi ndi
cated
Rati
onale:Correctsdeficienciesandaidsintheheali
ngprocess.

10)St eroi dtherapy :prednisone( Delt

asone) ,
aloneori ncombinat
ionwi thazathiopr
ine
(Imur an)
Rational e:St
eroi dsmaybecont rai
ndicatedbecauset heycanincreaseriskof
rel
apseanddev elopmentofchr onichepatiti
si npati
entswithv
iralhepati
tis;
howev er ,
anti-inflammat or yef f
ectmaybeusef uli
nchr onicactiv
ehepati
tis(especiall
y
i
diopat hic)toreducenauseaandv omiti
ngandenabl epati
entt
or etai
nfoodand
fl
uids.
Ster oidsmaydecr easeser um ami notransferaseandbi l
ir
ubinl
evels,buttheydonot
affectl ivernecr osisorr egener ati
on.
Combi nati
ont her apyhasf ewerst eroi
d-rel
atedsi deeff
ects.
11)Pr ov i
desuppl ement al
f eedingsandTPNi fneeded.
Rational e:Maybenecessar ytomeetcal ori
cr equir
ementsifmarkeddef i
citsare
presentandsy mpt omsar epr olonged.

[Link]
ici
entFluidVolume
Nursi
ngDiagnosis
 Riskf orDefi
cientFluidVol
ume
Riskf
actor
smayi ncl
ude
 Excessi v
elossest hroughvomi
ti
nganddi
arr
hea,
thi
rd-
spaceshi
ft
 Alteredclott
ingprocess

Possi
blyev
idencedby
 Notapplicabl
[Link]
agnosi
sisnotevi
dencedbysignsandsymptoms,
as
theproblem hasnotoccur
redandnursi
ngint
ervent
ionsar
edir
ectedat
prevent
ion.
Desi
redOutcomes
 Ma intai
nadequat ehydr
ation,asevidencedbystabl
evi
talsigns,
goodski
n
turgor,capi
ll
aryrefi
l
l,st
rongperipheralpul
ses,andi
ndi
viduall
yappr
opri
ate
uri
nar youtput.
 Bef reeofsignsofhemor rhagewithclotti
ngti
mesWNL.

-
Nur
singInter
venti
ons:
1)MonitorI&O,comparewi
thper
iodi
cwei
ght
.Not
eent
eri
closses:
vomi
ti
ngand
diar
rhea.

PageCCXVof215
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Rat i
onal e: Pr ov i
desi nf or mat ionaboutr epl acementneedsandef fectsoft herapy .
Diarrheamaybeduet ot ransi entf l
u-liker esponset ov i
ral i
nfect i
onormayr epresent
amor eser iouspr obl em ofobst ructedpor t
al bloodf lowwi thv ascul arcongest ionin
theGIt ract ,ori tmaybet hei ntendedr esul tofmedi cat ionuse( neomy cin,lactulose)
todecr easeser um ammoni alev el
si nt hepr esenceofhepat i
cencephal opat hy.
2)Assessv i
t al si
gns, per ipher al pulses, capi ll
aryr efi
ll,skint urgor, andmucous
membr anes.
Rat i
onal e: Indicat or sofci rculat i
ngv olumeandper fusi on.
3)Checkf orasci t esoredemaf or mat i
on.
Measur eabdomi nal girthasi ndi cated.
Rat i
onal e: Usef ulinmoni tor i
ngpr ogr essi onandr esol uti
onoff luidshi fts.
4)Usesmal l-gaugeneedl esf ori njections, appl yingpr essur ef orlongert hanusual
afterv enipunct ur e.
Rat i
onal e: Reducespossi bili
tyofbl eedi ngi ntot i
ssues.
5)Hav epat i
entusecot tonorspongeswabsandmout hwashi nst eadoft oot hbrushor
usesof tbr ist l
edt oot hbr ush.
Rat i
onal e: Av oidst raumaandbl eedi ngoft hegums.
6)Obser v ef orsi gnsofbl eedi ng: hemat ur ia,mel ena, ecchy mosi s,oozi ngf rom gums,
punct ur esi tes
Rat i
onal e: Pr othrombi nlev elsar ereducedandcoagul ationt i
mespr ol
ongedwhen
vit
ami nKabsor pt ioni sal teredi nGIt ractandsy nthesi sofpr othr ombi ni s
decreasedi naf fect edl iver.
7)Moni torper iodi cl abor ator yv alues: Hb/ Hct ,Na, al
bumi n, andcl ottingtimes.
Rat i
onal e: Ref lect shy dr ationandi dent ifiessodi um r etent i
on/pr oteindef icits,which
mayl eadt oedemaf ormat ion.
Def i
citsi ncl ott i
ngpot ent i
at er i
skofbl eedi ngandhemor rhage.
8)Admi ni sterant idiar rheal agent s:diphenoxy l
atewi that r
opi ne(Lomot i
l
) .
Rat i
onal e: Reducesf l
ui dandel ectroly tel ossf rom GIt ract .
9)Prov i
deI Vf luids( usual lygl ucose) , elect rolytes.
Proteinhy dr olysat es.
Rat i
onal e: Pr ov i
desf luidandel ectrol yter eplacementi nacut etoxi cstat e.
#Admi
nist
ermedi
cat
ionsasi
ndi
cat
ed:
10)
Vi t
aminK
Rat i
onale:Correctionofal buminandpr otei
ndef i
cit
scanaidinretur
noff lui
dfrom
tissuestot hecirculat
orysy stem.
Becauseabsor ptionisaltered,supplement ati
onmaypr eventcoagulati
onproblems,
whi chmayoccuri fclott
ingf actorsandpr othrombinti
me( PT)isdepressed.
11)
Ant aci
dsorH2- receptorant agonists:cimeti
dine(Tagamet).
Rat i
onale:Neutralizeandr educegast ricsecreti
onstolowerri
skofgast ri
cirr
it
ati
on
andbl eeding.
12)
Infusefreshf r
ozenpl asma, asindicated.

PageCCXVIof216
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

Rat
ional
e:Mayber
equi
redt
orepl
acecl
ott
ingf
act
orsi
nthepr
esenceofcoagul
ati
on
def
ects.

Ot
herdi
agnosi
s:
*Fat
igue.
*I
mpai
redSki
nInt
egr
it
y.
*Ri
skf
orI
nfect
ion
*
Knowl
edgeDef
ici
t.

PageCCXVI
Iof217
 Appendi
x(A)
(
ABG PRACTI
CETEST)

PageCCXVI
IIof218
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCCXI
Xof219
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCCXXof220
 Appendi
x(B)Ant
idot
est
oCommonMedi
cat
ions
•Acet
ami
nophen:
acet
ylcy
stei
neormucomy
st

•Ant
ichol
i
nest
erase:
atr
opi
neorpr
ali
doxi
me

•Ant
ichol
i
ner
gics:
phy
sost
igmi
ne

•Ant
if
reeze:
fomepi
zol
e,et
hanol

•Benzodi
azepi
nes:
Romaz
icon(
fl
umazeni
l
)

•Bet
a-Bl
ocki
ngAgent
s:Gl
ucagon,
epi
nephr
ine

•Ca++Channel
Blocker
s:Ca+chl
ori
de,
glucagon

•Car
bonMonoxi
de(
CO)
:hy
per
bar
ic,
oxy
gen

•Coumadi
n:phy
tonadi
oneorv
itami
nK

•Cy
ani
de:
amy
lni
tr
it
e,sodi
um ni
tr
it
e,orsodi
um t
hiosul
fat
e

•Cy
clophosphami
de:
mesna

•Di
goxi
n:Di
gibi
ndorDi
goxi
nImmuneFab

•Dopami
ne:
Rigi
ti
ne

•EPS:
Benadr
yl(
diphenhy
drami
ne)(
Ext
raPy
rami
dal
Sympt
oms)

•Et
hyl
eneGl
ycol
:fomepi
zol
e

•Fl
uor
our
aci
l
:leucov
ori
ncal
cium

•Her
oin:
Nar
can(
nal
oxone)ornal
mef
ene

•Hepar
in:
prot
ami
nesul
fat
e

•I
nsul
i
nReact
ion:
IVgl
ucose(
D50)

•I
ron(
Fe)
:def
eroxami
ne

•Lead:
edet
atecal
cium di
sodi
um,
dimer
capr
ol,
orsucci
mer

•Mal
i
gnantHy
per
ther
mia(
MH)
:dant
rol
ene

•Met
hanol
:et
hanol

PageCCXXIof221
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

•Met
hot
rexat
e:l
eucov
ori
ncal
cium

•Nar
cot
ics:
Nar
can(
nal
oxone)ornal
mef
ene

•Opi
oidAnal
gesi
cs:
Nar
can(
nal
oxone)ornal
mef
ene

•Or
ganophosphat
e(OPP)
:at
ropi
ne,
pral
i
doxi
me

•Pot
assi
um (
K):
Insul
i
nandgl
ucose,
NaHCO3,
albut
erol
inhal
er,
orKay
exal
ate(
sodi
um
pol
yst
yrenesul
fonat
e)

•Rohy
pnol
:Romazi
con(
fl
umazeny
l)

•TCA(tr
icycl
i
canti
depressant
s):
phy
sost
igmi
neorNaHCO3•Tr
anqui
l
izer
s-EPSsy
mpt
oms:
Benadr
yl(di
phenhy
dramine)

•Ty
lenol
:acet
ylcy
stei
ne

•War
far
in:
phy
tonadi
oneorv
itami
nK.

PageCCXXI
Iof222
 Appendi
x(C)CommonLabVal
ues
 Hemat ologyValues
 El
ect r
olyteValues
 Hepat i
cEnzy mes
 Renal Relat
ed
 Protein
 Li
pids
 Thyroid
 Cardiac

-
Hemat
ologyVal
ues:
 HEMATOCRIT(HCT)
-Nor
malAdultFemaleRange:37-47%
-Opt
imal
AdultFemaleReading:42%
-Nor
malAdultMaleRange40-54%
-Opt
imal
AdultMaleReading:47%
-Nor
malNewbor nRange:50-62%
-Opt
imal
Newbor nReading:56%

 HEMOGLOBIN(
HGB)
-Normal
AdultFemaleRange:12-16g/ dl
-Opti
malAdul
tFemaleReading:14g/dl
-Normal
AdultMaleRange:14-18g/ dl
-Opti
malAdul
tMaleReading:16g/dl
-Normal
Newbor nRange:14-20g/dl
-Opti
malNewbornReading:17g/dl

 MCH(MeanCorpuscularHemoglobi
n)
- NormalAdultRange:27-33pg
- Opti
malAdultReading:30

 MCV(MeanCorpuscularVolume)
-NormalAdultRange:80-100fl
-Opti
malAdultReading:90
-Hi
gherr
angesar efoundinnewbor
nsandi
nfant
s

 MCHC(MeanCor puscul
arHemogl obi
nConcent
rat
ion)
- NormalAdultRange: 32-36%
- OptimalAdultReading:34%
- Higherr
angesar efoundinnewbor
nsandinfant
s

PageCCXXI
IIof223
 R.
B.C.(RedBl oodCel lCount):
-
Normal AdultFemal eRange: 3.9-5.2mi l
l/
mcl
-
Optimal AdultFemal eReading:4.55mill
/mcl
-
Normal AdultMal eRange: 4.2-5.6mi l
l
/mcl
-
Optimal AdultMaleReadi ng:4.9mill
/mcl
-
Lowerr angesar efoundinChi l
dren,newbornsandinf
ant
s
 W.B.
C.(Whi teBloodCel lCount):
-Normal AdultRange: 3.8-10.8thous/mcl
-Optimal AdultReading:7.3thous/mcl
-Higherrangesar efoundi nchil
dren,newbor
nsandinf
ant
s.

 PLATELETCOUNT:
-Nor
malAdultRange:130-400thous/mcl
-Opt
imalAdul
tReading:265t
hous/ mcl
-Hi
gherr
angesarefoundinchi
ldren,newbor
nsandi
nfant
s
 NEUTROPHI
LSandNEUTROPHILCOUNT
 -t
hisi
sthemai
ndef
enderoft
hebodyagai
nsti
nfect
ionandant
[Link]
ghl
evel
s
mayi
ndi
cat
eanact
ivei
nfect
ion.
-
Nor
malAdultRange:48-73%
-
Opt
imal
AdultReading:60.5%
-
Nor
malChi
ldren’
sRange: 30-60%
-
Opt
imal
Chil
dren’sReading:45%

 LYMPHOCYTESandLYMPHOCYTECOUNT-El
evat
edl
evel
smayi
ndi
cat
ean
act
ivevi
rali
nfect
ionssuchasmeasl
es,
rubel
l
a,chi
ckenpox,
ori
nfect
ious
mononucleosi
s.
-
Nor
malAdultRange:18-48%
-
Opt
imal
AdultReading:33%
-
Nor
malChi
ldren’
sRange: 25-50%
-
Opt
imal
Chil
dren’sReading:37.
5%

 MONOCYTESandMONOCYTECOUNT-El
evat
edl
evel
sar
eseeni
nti
ssue
br
eakdownorchr
oni
cinf
ect
ions,
car
cinomas,
leukemi
a(monocyt
ic)or
l
ymphomas.
-
Nor
malAdul
tRange:0-9%
-
Opt
imal
Adul
tReading:
4.5%

 EOSI
NOPHI
LSandEOSI LCOUNT -El
NOPHI evat
edl
evel
smayi
ndi
cat
eanal
l
ergi
c
r
eact
ionsorpar
asi
tes.
-
Nor
malAdul
tRange:0-5%
-
Opt
imal
Adul
tReading:
2.5%

 BASOPHI LCOUNT-Basophi
LSandBASOPHI l
icact
ivi
tyi
snotf
ull
yunder
stood
buti
tisknownt ocar
ryhi
stami
ne,
hepar
inandser
otoni
[Link]
ghl
evel
sar
efoundi
n
al
ler
gicreact
ions.
-
Nor
malAdul
tRange:0-2%
-
Opt
imal
Adul
tReading:
1%

PageCCXXI
Vof224
-
Elect
rol
yteVal
ues:
 UM -Sodi
SODI um i
sthemostabundantcat
ioni
nthebl
oodandi
tschi
efbase.I
t
f
uncti
onsinthebodyt
omai ntai
nosmoti
cpressur
e,aci
d-basebalanceandt
o
t
ransmitner
veimpul
[Link]
ue:sei
zureandNeurologi
cSx.
-
Nor
malAdul
tRange:135-146mEq/L
-
Opt
imal
Adul
tReading:140.5mEq/
L
 UM -Pot
POTASSI assi
um i
sthemaj
ori
ntr
acel
l
ularcat
[Link]
ylowval
ue:Car
diac
ar
ythemi
a.
-
Nor
malRange:3.
5-5.5mEq/
L
-
Opt
imal
AdultReadi
ng:4.
5mEq/
L
 DE-El
CHLORI evat
edl
evel
sar
erel
atedt
oaci
dosi
saswel
last
oomuchwat
er
cr
ossingthecel
lmembr [Link]
easedl
evel
swit
hdecreasedser
um al
bumi
n
mayindicat
ewaterdef
iciencycr
ossi
ngthecel
lmembrane(edema).
-
Nor
malAdul
tRange:95-112mEq/
L
-
Opt
imal
Adul
tReading:103mEq/L
 CO2(
Car
bonDi de)-TheCO2l
oxi eveli
srel
atedt
other
espi
rat
oryexchangeof
car
bondi oxi
deinthel
ungsandispartofthebodi
esbuff
[Link]
all
y
whenusedwi ththeot
herel
ect
rolyt
es,i
tisagoodindi
catorofacidosi
sand
al
kali
nit
y.
-
Nor
malAdultRange:22-32mEq/
L
-
Opt
imal
AdultReading:27mEq/L
-
Nor
malChi
ldrensRange-20-28mEq/L
-
Opt
imal
Chil
drensReading:24mEq/
L

 UM -i
CALCI nvol
vedi
nbonemet
abol
i
sm,
prot
einabsor
pti
on,
fatt
ransf
er
muscul
arcontr
acti
on,t
ransmissi
onofner
vei
mpul
ses,
bloodcl
ott
ingandcar
diac
f
uncti
[Link]
atedbyparat
hyroi
d.
o Nor
malAdul
tRange:8.
5-10.
3mEq/dl
Opt
imal
Adul
tReading:
9.4mEq/L
 PHOSPHORUS-Gener al
l
yinversewit
hCalci
um.
o No r
malAdultRange:2.5-4.5mEq/dl
Opt
imal
AdultReading:3.5mEq/L
Nor
malChi
ldrensRange: 3-6mEq/dl
Opt
imal
Chil
drensRange: 4.
5mEq/ L

 ANI
ONGAP(
Sodi
um +Pot
assi
um -CO2+Chl
orde)-Ani
i ncr
easedmeasur
ement
i
sassociatedwit
hmetaboli
cacidosi
sduetotheoverproduct
ionofacids(
astat
e
ofalkal
i
nit
yisineff
ect
).Decr
easedlevel
smayindicatemetaboli
calkal
osi
sdue
totheover
producti
onofal
kaloi
ds(astat
eofacidosisisi
neffect
).
o Nor
malAdul
tRange:4-14(
cal
cul
ated)
Opt
imal
Adul
tReading:
9

PageCCXXVof225
  CALCI
UM/PHOSPHORUSRat i
o
o No r
malAdultRange:2.
3-3. 3(cal
culated)
Opt
imal
AdultReading:2.8
Nor
malChi
ldren’
srange: 1.
3-3.3(calculat
ed)
Opt
imal
Chil
dren’sReading:2.
3

 SODI
UM/ POTASSIUM
o No rmalAdultRange:26-38(
cal
cul
ated)
Opti
malAdultReading:32

-
Hepat
icEnzy
mes:
 AST(
Ser
um Gl
utami
c-Oxal
ocet
icTr nase-SGOT)-f
ansami oundpr
imar
il
yint
he
l
iver
,hear
t,kidney,
pancr
eas,
andmuscl
[Link]
nti
ssuedamage,
especi
all
y
hear
tandlive:
-
Nor
malAdul
tRange:0-42U/
L
-
Opt
imal
Adul
tReading:
21U/L
 ALT(
Ser
um Gl
utami
c-Py
ruv
icTr nase-SGPT)-Decr
ansami easedSGPTi
n
combi nat
ionwi t
hincreasedcholest
eroll
evel
sisseeni ncasesofacongested
l
[Link] soseeincreasedlevelsi
nmononucleosis,al
coholi
sm,l
iverdamage,
kidneyinf
ection,chemicalpoll
utant
sormyocardialinf
arct
ion
-
Nor
malAdul
tRange:0-48U/
L
-
Opt
imal
Adul
tReading:
24U/L
 NEPHOSPHATASE-Usedext
ALKALI ensi
vel
yasat
umormar
keri
tisal
so
presenti
nbonei
njur
y,pregnancy,orskeletalgrowth(
[Link]
l
evelsaresomet
imesfoundi nhypoadrenia,protei
ndefi
ciency,
mal nutri
ti
onanda
numberofvit
amindefi
cienci
es
-
Nor
malAdultRange:20-125U/ L
-
Opt
imal
AdultReading:72.5U/L
-
Nor
malChi
ldrensRange: 40-400U/L
-
Opt
imal
Chil
drensReading: 220U/
L
 GGT(
Gamma-
Glut
amy
lTr
anspept
idase)-El
evat
edl
evel
smaybef
oundi
nli
ver
disease,
alcoholi
sm, bi
le-
ductobstr
ucti
on,cholangi
ti
s,drugabuse,andinsome
casesexcessivemagnesi um i
ngesti
[Link]
evelscanbef oundin
hypothyr
oidi
sm, hypothal
amicmal f
uncti
onandl owlevel
sofmagnesi um.
-
Nor
malAdul
tFemaleRange:0-45U/ L
-
Opt
imal
FemaleReadi
ng:22.
5U/ L
-
Nor
malAdul
tMaleRange:0-65U/ L
-
Opt
imal
MaleReadi
ng:32.5U/L

PageCCXXVIof226
  LDH(
Lact
icAci
dDehy
drogenase)-I
ncr
easesar
eusual
l
yfoundi
ncel
l
ulardeat
h
and/orleakagefrom t
hecellori
nsomecasesi tcanbeusefulinconfi
rming
myocar di
alorpulmonaryi
nfarct
ion(onl
yinrel
ati
ontoothertest
s).Decreased
l
evelsoft heenzymemaybeseeni ncasesofmalnut
ri
ti
on,hypoglycemia,
adrenalexhausti
onorlowti
ssueoror ganacti
vi
ty.
-
Nor
malAdul
tRange:0-250U/
L
-
Opt
imal
Adul
tReading:
125U/L
 BI
LIRUBI
N,TOTAL-El
evat
edi
nli
verdi
sease,
mononucl
eosi
s,hemol
yti
canemi
a,
l
owl evel
sofexposur
etothesun,andtoxiceffectstosomedrugs,decreased
l
evelsareseeni
npeoplewithaninef
fi
cientl
iver,excessi
vef
atdigest
ion,and
possibl
yadietl
owinnit
rogenbeari
ngfoods
-
Nor
malAdul
tRange0-1.3mg/dl
-
Opt
imal
Adul
tReading:
.65mg/
dl

-
Renal
Rel
ated:
 B.
U.N.(
BloodUr
eaNi
togen)-I
r ncr
easescanbecausedbyexcessi
vepr
otei
n
i
ntake,ki
dneydamage, cer
tai
ndrugs,l
owf l
uidi
ntake,
intest
inalbl
eedi
ng,
exer
ciseorheartfail
[Link]
easedlevel
smaybeduet oapoordiet,
malabsorpt
ion,
liverdamageorlowni t
rogenint
ake.
-
Nor
malAdul
tRange:7-25mg/dl
-
Opt
imal
Adul
tReading:
16mg/dl

 CREATI
NINE-Lowl
evel
sar
esomet
imesseeni
nki
dneydamage,
prot
ein
star
vati
on, li
verdi
[Link]
evat
edlevel
sar
esomet i
messeenin
ki
dneydi seaseduet ot
hekidneysjobofexcr
eti
ngcreat
ini
ne,muscl
e
degeneration,andsomedrugsinvolvedi
nimpai
rmentofkidneyf
uncti
on.
-
Nor
malAdul
tRange:7-1.4mg/
dl
-
Opt
imal
Adul
tReading:
1.05mg/dl

 URI D-Hi
CACI ghl
evel
sar
enot
edi
ngout
,inf
ect
ions,
kidneydi
sease,
alcohol
i
sm,
hi
ghprotei
ndiets,
andwitht
oxemiai
[Link]
smaybeindi
cat
ive
ofki
dneydisease,
malabsor
pti
on,
poordi
et,l
iverdamageoranover
lyaci
dki
dney.
-
Nor
malAdul
tFemaleRange:2.5-7.
5mg/dl
-
Opt
imal
Adul
tFemaleReading:5.
0mg/dl
-
Nor
malAdul
tMaleRange:3.5-7.
5mg/dl
-
Opt
imal
Adul
tMaleReading:
5.5mg/dl

 BUN/
CREATI
NINE-Thi
scal
cul
ati
oni
sagoodmeasur
ementofki
dneyandl
i
ver
f
unct
ion.
-
Nor
malAdul
tRange:6-25(
cal
cul
ated)
-
Opt
imal
Adul
tReading:
15.5

PageCCXXVI
Iof227
-
Prot
ein:
 PROTEI
N,TOTAL-Decr
easedl
evel
smaybeduet
opoornut
ri
ti
on,
li
verdi
sease,
malabsorpt
ion,
diar
rhea,[Link]
easedlevel
sareseeni
nlupus,l
i
ver
di
sease,chroni
cinf
ecti
ons,alcohol
ism, l
eukemia,t
ubercul
osisamongstmany
ot
hers.
-
Nor
malAdul
tRange:6.
0-8.
5g/dl
-
Opt
imal
Adul
tReading:
7.25g/
dl

 N-maj
ALBUMI orconst
it
uentofser
um pr
otei
n(usual
l
yover50%)
.Hi
ghl
evel
sar
e
seeninliverdi
sease(
rarely),shock,dehydr
ati
on,ormul
ti
[Link]
l
evelsareseeni npoordiets,diar
rhea,f
ever,
inf
ecti
on,
li
verdi
sease,i
nadequat
e
i
ronintake,thi
rd-
degreebur nsandedemasorhypocalcemia
-
Nor
malAdul
tRange:3.
2-5.0g/dl
-
Opt
imal
Adul
tReading:
4.1g/dl

 N-Gl
GLOBULI obul
i
nshavemanydi
ver
sef
unct
ionssuchas,
thecar
ri
erofsome
hormones,l
ipi
ds,met al
s,andant i
bodies(I
gA, I
gG, I
gM, andIgE).El
evatedlevel
s
areseenwit
h chronicinfect
ions,l
iverdisease,rheumat oi
darthri
ti
s,myelomas,
andlupusarepresent,.Lowerlevelsi
ni mmunecompr omisedpatient
s,poor
di
etaryhabi
ts,
mal absorpti
onandl i
verorki dneydisease.
-
Nor
malAdul
tRange:2.
2-4.2g/dl
(cal
cul
ated)
-
Opt
imal
Adul
tReading:
3.2g/dl

 A/
GRATIO(Al
bumin/Gl
obuli
nRati
o)
-
NormalAdul
tRange:0.8-2.
0(cal
cul
ated)
-
Opti
malAdultReadi
ng:1.
9

-
Lipi
ds:
 CHOLESTEROL-Hi
ghdensi
tyl
i
popr
otei
ns(
HDL)i
sdesi
redasopposedt
othe
l
owdensityli
poproteins(LDL) ,t
wot ypesofchol est
er [Link]
edcholest
erolhas
beenseeninartherosclerosis,
diabetes,hypothyroi
dism andpr [Link]
l
evelsar
eseeni ndepr ession,malnutri
ti
on, l
i
verinsufficiency,mal
ignanci
es,
anemiaandinfecti
on.
-
Nor
malAdul
tRange:120-240mg/
dl
-
Opt
imal
Adul
tReading:180mg/
dl
 LDL(
LowDensi
tyLi
popr
ot n)-st
ei udi
escor
rel
atet
heassoci
ati
onbet
weenhi
gh
l
evel
sofLDLandar
ter
ialar
ther
oscl
erosi
s
-
Nor
malAdul
tRange:62-130mg/
dl
-
Opt
imal
Adul
tReading:81mg/
dl

 HDL(
HighDensi
tyLi
popr
ot n)-Ahi
ei ghl
evelofHDLi
sani
ndi
cat
ionofaheal
thy
met
abol
i
csyst
em i
fther
eisnosi
gnofl
i
verdi
seaseori
ntoxi
cat
ion.
-
Nor
malAdul
tRange:35-135mg/dl
-
Opt
imal
Adul
tReading:+85mg/
dl

PageCCXXVI
IIof228
  TRI DES-I
GLYCERI ncr
easedl
evel
smaybepr
esenti
nar
ther
oscl
erosi
s,
hypothyroidism,liverdisease,
pancreati
ti
s,myocardi
ali
nfarct
ion,metaboli
c
disorders,toxemia, andnephroti
[Link]
smaybepr esenti
n
chronicobst ruct
ivepulmonar ydisease,
brai
ninfar
cti
on,hyperthyr
oidi
sm,
mal nutr
iti
on, andmal absorpti
on.
-
Nor
malAdul
tRange:0-200mg/dl
-
Opt
imal
Adul
tReading:
100mg/dl
 CHOLESTEROL/LDLRATIO
-
NormalAdultRange:1-6
-
Opti
malAdultReading:
3.5

-
Thy
roi
d:
 THYROXI T4)-I
NE( ncr
easedl
evel
sar
efoundi
nhyper
thyr
oidi
sm,
acut
ethyr
oidi
ti
s,
andhepat
it
[Link]
scanbefoundi
nCr
eti
nism,
hypot
hyr
oidi
sm,
cir
rhosi
s,
malnut
ri
ti
on,andchroni
cthyr
oidi
ti
s.
-
Nor
malAdul
tRange:4-12ug/
dl
-
Opt
imal
Adul
tReading:
8ug/dl

 T3- ncr
UPTAKE-I easedl
evel
sar
efoundi
nhyper
thyr
oidi
sm,
sever
eli
verdi
sease,
met
astati
cmalignancy,andpul
monaryinsuf
fi
[Link]
sar
efound
i
nhypothyr
oidi
sm, nor
malpregnancy,
andhyperestrogeni
sstatus.
-
Nor
malAdul
tRange:27-47%
-
Opt
imal
Adul
tReading:37%
 FREET4INDEX(T7)
-
NormalAdul
tRange:4-12
-
Opti
malAdul
tReading:
8

 THYROI
D-STI
MULATI TSH)-pr
NGHORMONE( oducedbyt
heant
eri
orpi
tui
tar
y
gland,
causesther el
easeanddist
ri
buti
onofstor
edt
hyr
oidhor
mones.WhenT4
andT3ar etoohigh,TSHsecret
iondecr
eases,
whenT4andT3arel
ow,TSH
secret
ionincr
eases.
-
Nor
mal
Adul
tRange:
.5-6mi
l
iI
U/L

-
Car
diac:
 Cr
eat
inephosphoki CK)-Lev
nase( elsr
ise4t
o8hour
saf
teranacut
eMI
,
peaki
ngat16t
o30hour
sandr
etur
ningt
obasel
i
newi
thi
n4days
o 25-
200U/
L
o 32-
150U/
L
 CK-
MBCKi me -I
soenzy tbegi
nst
oincr
ease6t
o10hour
saf
teranacut
eMI
,
peaksi
n24hour
s,andr
emai
nsel
evat
edf
orupt
o72hour
s.
o <12IU/
Lift
otal
CKis<400I
U/L
o <3.
5%oftot
alCKift
otal
CKi
s>400I
U/L

PageCCXXI
Xof229
 SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

 (
LDH)Lact
atedehydrogenase:Tot
alLDHwi
l
lbegi
ntor
ise2t
o5day
saf
teranMI
;
t
heel
evati
oncanlast10day s.
o 140-280U/L

 LDH- 1andLDH- 2 LDHisoenzy mes:CompareLDH1andLDH2l ev

[Link]
l
y,
theLDH- 1valuewill
belesst [Link]
heacut
eMI ,
howev er,
theLDH2r emainsconstant,whil
eLDH1r i
ses.
 Wh entheLDH1i shigherthanLDH2, theLDHissai
dtobef l
ipped,whichis
highlysuggesti
veofanMI .
 Af l
ippedpatter
nappear s12-24hourspostMIandpersi
stsfor48hour s.
o L DH-118%- 33%
o L DH-228%- 40%

 SGOT -wi
llbegi
ntor
isei
n8-
12hour
sandpeaki
n18-
30hour
s
o 1 0-
42U/ L

 Myoglobi
n:earlyandsensit
ivedi
agnosi
sofmy ocar
dial
inf
arct
ioninthe
emergencydepart
mentThissmallhemeprotei
nbecomesabnor malwit
hin1to2
hoursofnecr
osis,peaksi
n4-8hours,
anddropstonormali
nabout12hour s.
o <1

 Tr
oponi
nCompl
ex-Peaksi
n10-
24hour
s,begi
nst
ofal
lof
faf
ter1-
2weeks.
o <0 .
4

Tabl
eofCar
diacmar
ker
s:

Ser
um Mar
ker
sofMy
ocar
dial
Inj
ury

Det
ect
ed Peak Fal
ls

My
ogl
obi
n 1-
3 1-
8 12-
18

CK/
CK-
MB 3-
8 12-
16 24-
48

MBI
sof
orms 1-
6 4-
8 12-
48

Tr
oponi
nCompl
ex 3-
6 10-
24 cTnI
:5-
9day
scTnT:
7-
14days

PageCCXXXof230
SUMMARYFORTHEMOSTCOMMONCLI
NICALCASES

PageCCXXXIof231