UP COLLEGE OF NURSING 2005

MEDICAL-SURGICAL NURSING Cardiology, Respiratory, Gastrointestinal Lecture Day #5: April 5, 2005 Lecturer: Mr. Ferdinand B. Valdez

CONGESTIVE HEART FAILURE Inabilitiy of the heart to pump blood towards systemic circulation

I.

LEFT-SIDED HEART FAILURE

1.

PREDISPOSING FACTORS 1. 90% mitral !al!e stenosis R"# $ anti streptolysis % titer &'(%) $ *00 todd units ,. *. .. 0. -I I"# "+/ 'ortic !al!e stenosis 'ging +enicillin, +'(', steroids

2.

SIGNS AND SYMPTOMS 1. +ulmonary edema1congestion #yspnea, +/#, , * pillow orthopnea +roducti!e cough &blood tinged)

 ,. *. .. 0.

Rales 2ronchial whee3ing

+ulses alternans 'nore4ia and general body malaise +-I displaced laterally (* &!entricular gallop)

3.

DIAGNOSTICS 1. C5R $ cardiomegaly ,. +'+ $ pulmonary arterial pressure *. -easures pressure in right !entricle Re!eals cardiac status

+C6+ $ pulmonary capillary wedge pressure -easures end systolic and end diastolic pressure

.. 0.

7chocardiograph $ re!eals enlarged heart chamber '2G analysis re!eals ele!ated +C%, and decreased +%, &respiratory acidosis)

8racheostomy for se!ere respiratory distress and laryngospasm performed at bedside within 10 10 minutes

C9+ re!eals fluid status: /ormal ; . 10cm ",o '<<7/=( test $ collateral circulation

II.

RIGHT SIDED HEART FAILURE

1.

PREDISPOSING FACTORS 1. 8ricuspid !al!e stenosis ,. *. C%+# +ulmonary embolism &char by chest pain and dyspnea)

.. 0.

+ulmonic stenosis left sided heart failure

2.

SIGNS AND SYMPTOMS (Venous on!es"#on$ 1. >ugular !ein distention ,. *. .. 0. ?. @. A. 9. 10. pitting edema ascites weight gain hepatosplenomegaly >aundice pruritus1 urticaria esophageal !arices anore4ia generali3ed body malaise

3.

DIAGNOSTICS 1. C5R $ cardiomegaly ,. C9+ $ measures pressure in right atrium: / ; . 10cc ",% *. #uring C9+B trendelenburg to pre!ent pulmo embolism and to promote !entricular filling Clat on bed post C9+ H%&o'o(e)#* $ fluid challenge H%&e+'o(e)#* $ diuretics &loop)

7chocardiography $ re!eals enlarged heart chamber -uffled heart sounds cardiomyopathy Cyanotic heart diseases 8%C DtetE spells cyanosis with hypo4emia 8ricuspid !al!e stenosis 8ransposition of aorta

'cyanotic

+#' $ machine liFe murmur #%CB indomethacin (7B corneal cloudiness

..

<i!er en3ymes (G+8 up (G%8 up

,.

NURSING MANAGEMENT

&GoalB increase myocardial contraction increase C%: /ormal C% is * ?<1min: / stroFe !olume is ?0 @0ml1h,o 1. 'dminister medications as ordered Cardiac glycosides #igo4in #igito4in $ gi!en if &G) 'RC: metaboli3ed in li!er and not in Fidneys

<oop diuretics <asi4

2ronchodilators 'minophylline &theophylline) 8achycardia C/( hyperacti!ity

/arcotic analgesics -orphine sulfate $ induces !asodilation

9asodilators /8G and I(#/ 'nti arrhythmic agents <idocain 2retyllium

2. *. .. 0.

H%I #%/=8 GI97 8"I'JI#7 #IIR78IC( 8% 8"7(7 +'8I7/8(

'dminister %, inhalation at * . <1minute !ia /C as ordered high flow "igh fowler=s Restrict /a and fluids -onitor strictly 9( and I% and 2reath (ounds

?. @. A. 9. 10.

6eigh pt daily and assess for pitting edema abdominal girth daily and notify -# pro!ide meticulous sFin care pro!ide a dietary intaFe which is low in saturated fats and caffeine Institute bloodless phlebotomy ROTATING TOURNI-UET Rotated e!ery 10 minutes to promote a decrease in !enous return

11.

"ealth teaching and discharge planning +re!ent complications 'rrhythmia (hocF 8hrombophlebitis -I Cor pulmonale $ R9 hypertrophy

Regular adherence to medications #iet modifications Importance of ffup care

PERIPHERAL VASCULAR DISORDERS I. A+"e+#*( u( e+s 1. 8hromboangitis obliterans 2uerger=s disease &feet) ,. II. Reynaud=s +henomenon &hand)

Venous U( e+s 1. ,. 9aricose !eins 8hrombophlebitis1#98

ARTERIAL ULCERS

I.

THROM.OANGITIS O.LITERANS $ acute inflammatory condition affecting the smaller and medium si3ed arteries and !eins of the lower e4tremities

1.

PREDISPOSING FACTORS 1. "igh risF group men *0 years old abo!e ,. Chronic smoFing

2.

SIGNS AND SYMPTOMS Consistent to all arterial diseases 1. ,. Intermittent claudication $ leg pain upon walFing cold sensiti!ity and sFin color changes *. .. 0. ?. white1pallor bluish1cyanosis red1rubor &G) especially post smoFing

decreased peripheral pulses= !olume particularly in dorsalis pedis and posterior tibial 8rophic changes ulceration gangrene formation

3.

DIAGNOSTICS 1. os #((o)e"+% $ re!eals a decrease in peripheral pulse !olume ,. *. Do&&(e+ u"/ $ decrease in blood flow to affected e4tremity *n!#o!+*&0% $ site and e4tent of malocclusion

,.

NURSING MANAGEMENT 1. encourage slow progressi!e physical acti!ity ,. walFing * .41day out of bed * .41day

medications as ordered analgesics !asodilators anticoagulants

*.

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

..

institute foot care management a!oid barefoot walFing straight nails lanolin cream for feet & ) constricting clothes

0.

'ssist in surgeryB 2K'

II.

REYNAULD1S DISEASE $ characteri3ed by acute episodes of arterial spasms in!ol!ing the digits of hands and fingers

1.

PREDISPOSING FACTORS 1. high risF group women .0 years old up ,. *. smoFing collagen diseases .. (<7 R'

direct hand trauma piano playing 75C7((I97 8H+I/G &tsF tsFL <agotL) Carpal tunnel syndrome %perating chainsaw &nyeFL) 6riting &tsF tsF, Faya dapat may module ehL GrrL)

2.

SIGNS AND SYMPTOMS 1. Intermittent claudication $ leg pain upon walFing ,. cold sensiti!ity and sFin color changes *. white1pallor bluish1cyanosis red1rubor &G) especially post smoFing

8rophic changes

.. 0.

ulceration gangrene formation

3.

DIAGNOSTICS 1. oscillometry $ re!eals a decrease in peripheral pulse !olume ,. angiography $ site and e4tent of malocclusion

,.

NURSING MANAGEMENT 1. 'd minister medications as ordered ,. *. 'nalgesics 9asodilators

encourage pt to wear glo!es instructB a!oid smoFing and e4posure to cold en!ironment

VENOUS ULCERS

I.

VARICOSE VEINS $ abnormal dilation of the !eins of the lower e4tremities d1t incompetent !al!es leading to increased !enous pooling and !enostasis decreased !enous return

1.

PREDISPOSING FACTORS 1. "ereditary ,. *. .. 0. ?. 7. congenital weaFness of !eins thrombophlebitis cardiac diseases pregnancy obesity prolonged immobility prolonged standing and sitting

2.

SIGNS AND SYMPTOMS

1. ,. *.

pain after prolonged standing dilated tortous sFin !eins which are warm to touch hea!iness in the legs

3.

DIAGNOSTICS 1. 9enography 2. trendelenburg=s test $ re!eals that !eins distend MuicFly N *0 seconds incompetent !al!es

,.

NURSING MANAGEMENT ( ons#s"en" "o *(( 'enous u( e+s$ 1. ele!ate legs abo!e heart le!el increased !enous return &, * pillow ele!ation) ,. *. 4. 0. measure circumference of leg to determine swelling antiembolic stocFing, full support panty hose medications as ordered analgesics assist in surgery !ein stripping and ligation sclerotherapy for spider web !aricosities cold solution in>ection (7B thrombosis

II.

THROM.OPHLE.ITIS2 DEEP VEIN THROM.OSIS (DVT$

1.

PREDISPOSING FACTORS 1. smoFing ,. *. .. 0. ?. obesity prolonged use of %C+s chronic anemia diet high in saturated fats #-

@. A. 9. 10. 11.

C"C -I post cannulation &insertion of !arious catheters) post surgical operation sedentary lifestyle

2.

SIGNS AND SYMPTOMS 1. pain at the affected e4tremity ,. *. 4. presence of cyanosis dialted tortous !eins (3$ HOMAN4S pain on calf on dorsifle4ion

3.

DIAGNOSTICS 1. !enography ,. *. #oppler ut3 angiography

,.

NURSING MANAGEMENT 1. ele!ate the legs abo!e heart le!el ,. *. .. 0. apply warm moist pacF to relie!e lymphatic congestion measure circumference of leg muscles to determine if it is swollen anti embolic stocFings administer medications as ordered ?. analgesics anticoagulants $ heparin

pre!ent complications pulmonary embolism

RESPIRATORY SYSTEM

I.

U&&e+ Res&#+*"o+% T+* " 1. Fun "#ons 1. ,. *. 2. P*+"s 1. ,. Nose $ made up of frameworF of cartilages: di!ided into R and < by the nasal septum P0*+%n5 $ muscular passageway for both food and air %ropharyn4 /asopharyn4 $ made up of frameworF of B "yoid bone $ u shaped bone in necF Cricoid cartilage 8hyroid cartilage 'rythenoid cartilage speech production and cough refle4 filtering warming and moistening humidification

<aryngopharyn4 Glottis opening of laryn4

II.

Lo6e+ +es&#+*"o+% "+* " 1. CunctionB Gas 74change ,. +arts 1. trachea consists of tracheal rings ,. *. passageway of air site of tracheostomy &.th ?th ring)

2ronchus <ungs Right $ * lobes, 10 segments <eft $ , lobes, A segments Client post pneumonectomy affected side to promote drainage

 +leura

+ost lobectomy unaffected side to promote lung e4pansion

+arietal 9isceral

DIAPHRAGM $ primary muscle for respiration INTERCOSTAL MUSCLES $ secondary muscle for respiration ALVEOLI &'cinar cells) $ site for gas e4change &!ia diffusion) VENTILATION $ mo!ement of air in and out of the lungs RESPIRATION $ lungs to cells Internal 74ternal

A('eo(*+ "%&e II e((s $ secretes surfactants SURFACTANTS $ en3ymes made up of lipoproteins which decrease surface tension thereby pre!enting collapse <ecithin (phingomyelin <1( ratio indicates lung maturity ,B1 normal 1B, immature lungs

RETROLENTAL FI.ROPLASIA $ retinopathy1blindness in immaturity d1t high %, flow in pedia patients

I.

PNEUMONIA $ inflammation of the lung parenchyma leading to pulmonary consolidation because al!eoli is filled with e4udates

1.

ETIOLOGIC AGENTS 1. (treptococcus pneumoniae &pneumococcal pneumonia) ,. *. "emophilus pneumoniae &bronchopneumonia) Klebsiella pneumoniae

.. 0. 2.

#iplococcus pneumoniae 7scherichia coli

HIGH RIS7 GROUPS 1. ,. children less than 0 yo elderly

3.

PREDISPOSING FACTORS 1. (moFing ,. *. air pollution immunocompromised .. 0. &G) 'I#( bronchogenic Ca

prolonged immobility &hypostatic pneumonia) aspiration of food &aspiration pneumonia)

,.

SIGNS AND SYMPTOMS 1. producti!e cough, greenish to rusty ,. *. .. 0. ?. 7. dyspnea with prolong e4piratory grunt fe!er, chills, anore4ia, general body malaise cyanosis pleuritic friction rub rales1cracFles on auscultation abdominal distention paralytic ileus

8.

DIAGNOSTICS 1. (putum gs1cs confirmatory: type and sensiti!ity: &G) to cultured microorganism ,. *. C5R $ &G) pulmonary consolidation C2C ele!ated 7(R &rate of erythropoeisis) / ; 0.0 1.0% ele!ated 62C

..

'2G $ +%, decreased

9.

NURSING MANAGEMENT 1. enforce C2R ,. 'dminister medications as ordered 2road spectrum antibiotics +enicillin $ pneumococcal infections 8etracycline -acrolides '3ithromycin &%# 4 *1days) 1. ,. *. *. .. 0. 'nti pyretics -ucolytics1e4pectorants too costly not much (7 only (7B ototo4icity $ transient hearing loss

'dminister %, inhalation as ordered force fluids to liMuefy secretions institute pulmonary toilet #27 Coughing e4ercises C+8 8urning and repositioning

?. @. A. 9. 10.

nebuli3e and suction +R/ place client of semifowlers to high fowlers pro!ide a comfortable and humid en!ironment pro!ide a dietary intaFe high in C"%, C"%/, Calories and 9it C 'ssist in postural drainage /ursing manatementB -onitor 9( and 2(

2est performed before meals1breaFfast or , * hours p.c. to pre!ent gastroesophageal reflu4 or !omiting 7ncourage #27 'dminister bronchodilators 10 *0 minutes before procedure (top if pt. can=t tolerate the procedure +ro!ide oral care after procedure as it may affect taste sensiti!ity ContraindicationsB Instable 9( "emoptysis Increased IC+ Increased I%+ &glaucoma)

11.

pro!ide pt health teaching and d1c planning a!oidance of precipitating factors pre!ention of complications atelectasis meningitis

regular compliance to medications importance of ffup care

II.

PULMONARY TU.ERCULOSIS (7OCH1S DISEASE$ $ infection of the lung parenchyma caused by in!asion of mycobacterium tuberculosis or tubercle bacilli &gram negati!e, acid fast, motile, aerobic, easily destroyed by heat1sunlight)

1.

PRECIPITATING FACTORS 1. malnutrition ,. *. o!ercrowding alcoholism .. 0. depletes 9it 21 &thiamin) alcoholic beriberi malnutrition

physical and emotional stress ingestion of infected cattle with mycobacterium bo!is

?.

!irulence &degree of pathogenecity)

2.

MODE OF TRANSMISSIONB 'irborne droplet infection

3.

SIGNS AND SYMPTOMS 1. producti!e cough &yellowish) ,. *. .. 0. low grade afternoon fe!er, night sweats anore4ia, malaise, weight loss chest1bacF pain hemoptysis

,.

DIAGNOSTICS 1. (Fin testing M*n"ou5 "es" : PPD Induration width &within .A @, h) 2. *. .. ;-1< )) (DOH$ 1<-1, )) (=HO)

indicates pre!ious e4posure to tubercle bacilli

sputum 'C2 &G) tubercle bacilli C5R $ &G) pulmo infiltrated due to caseous necrosis C2C $ ele!ated 62C

8.

NURSING MANAGEMENT 1. enforce C2R ,. *. .. 0. institute strict respiratory isolation administer %, inhalation forced fluids encourage #27 and coughing NO CLAPPING #n 0+on# PT. >2" 0e)o&"%s#s )*% (e*> "o 0e)o++0*!e

?. @. A.

nebuli3e and suction +R/ pro!ide comfortable and humid en!ironment institute short course chemotheraphy In"ens#'e &0*se I/" (7B peripheral neuritis &increase !it 2? or pyrido4ine

Rifampicin (7B red orange color of bodily secretions

+J' (7B allergic reactions: hepatoto4icity and nephroto4icity

I/" and Rifampicin is gi!en for . months, a.c. to facilitate absorption 8hese * drugs are gi!en simultaneously to pre!ent de!elopment of resistance

S"*n>*+> Re!#)en (treptomycin in>ection &aminoglycoside) /eomycin 'miFacin Gentamycin 1. ,. common (7B Ath C/ damage tinnitus hearing loss ototo4icity nephroto4icity 1. ,. 2I/ &/ ; 10 ,0) CR7' &/ ; A 10)

9.

"ealth teaching and d1c planning '!oidance of precipitating factors +re!ention of complications 'telectasis -ilitary 82

(trict compliance to medications

#iet modifications Importance of ffup care

III.

HISTOPLASMOSIS $ acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum from birds= manure

1.

PREDISPOSING FACTORS Inhalation of contaminated dust

2.

SIGNS AND SYMPTOMS +roducti!e cough Ce!er, chills, anore4ia, generali3ed body malaise Cyanosis Chest and >oint pains #yspnea "emoptysis

3.

DIAGNOSTICS "istoplasmin sFin test is &G) '2G analysis re!eals p%, low

,.

NURSING MANAGEMENT 7nforce C2G 'dminister meds as ordered 'ntifungal agents 'mphotericin 2 &Cungi3one) (7B nephroto4icity and hypoFalemia

Corticosteroids 'nti pyretics -ucolytics1e4pectorants

'dminister o4ygen inhalation as ordered Corced fluids +re!ent complications 2ronchiectasis

+re!ention of spread (praying of breeding places Kill bird and ownerL "eheL

COPD 1. ,. *. .. Chronic 2ronchitis 2ronchial 'sthma 2ronchiectasis +ulmonary 7mphysema

I.

CHRONIC .RONCHITIS &2lue 2loaters) $ Inflammation of the bronchi due to hypertrophy or hyperplasia of goblet mucous producing cells leading to narrowing of smaller airways

1.

PREDISPOSING FACTORS 1. (moFing ,. air pollution

2.

SIGNS AND SYMPTOMS 1. producti!e cough ,. *. .. dyspnea on e4ertion prolonged e4piratory grunt anore4ia and generali3ed body malaise

0. ?. @.

cyanosis scattered rales1rhonchi pulmonary hypertension peripheral edema cor pulmonale

3.

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

,.

NURSING MANAGEMENT 1. enforce C2R ,. administer medications as ordered *. .. 0. ?. @. bronchodilators antimicrobials corticosteroids mucolytics1e4pectorants

low inflow %, admin: high inflow will cause respiratory arrest force fluids nebuli3e and suction client as needed pro!ide comfortable and humid en!ironment health teaching and d1c planning a!oidance of smoFing pre!ent complications C%, narcosis coma Cor pulmonale +leural effusion +neumothora4

Regular adherence to meds Importance of ffup care

II.

.RONCHIAL ASTHMA $ re!ersible inflammatory lung condition caused by hypersensiti!ity to allergens leading to narrowing of smaller airways

1.

PREDISPOSING FACTORS 1. E5"+#ns# &'topic1'llergic 'sthma) ,. +ollens, dust, fumes, smoFe, fur, dander, lints

In"+#ns# &/on 'topic1/on 'llergic) #rugs &aspirin, penicillin, 2 blocFers) Coods &seafoods, eggs, chicFen, chocolate) Cood additi!es &nitrates, nitrites) (udden change in temperature, humidity and air pressure Genetics +hysical and emotional stress

3.

M#5e> "%&e combination of both

2.

SIGNS AND SYMPTOMS 1. cough that is producti!e ,. *. .. 0. ?. dyspnea whee3ing on e4piration tachycardia, palpitations and diaphoresis mild apprehension, restlessness cyanosis

3.

DIAGNOSTICS 1. +C8 decreased !ital lung capacity 2. '2G analysis +%, decreased

,.

NURSING MANAGEMENT 1. enforce C2R

,.

administer medications as ordered bronchodilators administer first to facilitate absorption of corticosteroids inhalation -#I

Corticosteroids -ucolytics1e4pectorants -ucomyst 'ntihistamine

*. .. 0. ?.

administer o4ygen inhalation as ordered forced fluids nebuli3e and suction patient as necessary health teaching and d1c planning a!oidance of precipitating factors pre!ention of complications status asthmaticus epinephrine aminophylline drip

emphysema

regular adherence to medications importance of ffup care

III.

.RONCHIECTASIS $ permanent dilation of the bronchus due to destruction of muscular and elastic tissue of the al!eolar walls

1.

PREDISPOSING FACTORS 1. recurrent lower respiratory tract infection ,. *. histoplasmosis

congenital disease presence of tumor

..

chest trauma

2.

SIGNS AND SYMPTOMS 1. consistent producti!e cough ,. *. .. 0. dyspnea presence of cyanosis rales and cracFles hemoptysis

3.

DIAGNOSTICS 1. '2G analysis re!eals low +%, ,. 2ronchoscopy $ direct !isuali3ation of bronchi lining using a fibroscope +re op (ecure consent 74plain procedure /+% -onitor 9( and breath sounds

+ost operati!e Ceeding initiated upon return of gag refle4 Instruct client to a!oid talFing, coughing and smoFing as it may irritate respiratory tract -onitor for s1s4 of franF or gross bleeding -onitor for signs of laryngeal spasm #%2 and (%2

*. ..

(egmental lobectomy +neumonectomy

,.

NURSING MANAGEMENT 1. enforce C2R ,. administer medications as ordered

 *. .. 0. ?. @.

bronchodilators antimicrobials corticosteroids mucolytics1e4pectorants

low inflow %, admin: high inflow will cause respiratory arrest force fluids nebuli3e and suction client as needed pro!ide comfortable and humid en!ironment health teaching and d1c planning a!oidance of smoFing pre!ent complications C%, narcosis coma Cor pulmonale +leural effusion +neumothora4

Regular adherence to meds Importance of ffup care

I9.

PULMONARY EMPHYSEMA $ terminal and irre!ersible stage of C%+# characteri3ed by B Inelasticity of al!eoli 'ir trapping -aldistribution of gasses %!erdistention of thoracic ca!ity &2arrel chest)

1.

PREDISPOSING FACTORS 1. smoFing ,. 3. air pollution hereditaryB in!ol!es alpha 1 antitrypsin for elastase production for recoil of the al!eoli

.. 5.

allergy high risF group elderly degenerati!e decreased !ital lung capacity and thinning of al!eolar lobes

2.

SIGNS AND SYMPTOMS 1. producti!e cough ,. *. .. 0. 6. @. A. 9. 10. 11. dyspnea at rest prolonged e4piratory grunt resonance to hyperresonance decreased tactile fremitus decreased breath sounds & if & ) 2( lung collapse) 2arrel chest anore4ia and generali3ed body malaise rales or cracFles alar flaring pursed lip breathing &to eliminate e4cess C%,)

3.

DIAGNOSTICS 1. '2G analysis re!eal ,. +anlobular, centrilobular +%, ele!ation and +C%, depression respiratory acidosis &blue bloaters) +anacinar1centriacinar +C%, deptression and +%, ele!ation &pinF puffers $ hypera4emia)

pulmo function test $ decreased !ital lung capacity

+77+ $ positi!e end e4piratory pressure allows for ma4imum al!eolar diffusion pre!ent lung collapse

,.

NURSING MANAGEMENT 1. enforce C2R ,. administer medications as ordered *. .. 0. ?. @. bronchodilators antimicrobials corticosteroids mucolytics1e4pectorants

low inflow %, admin: high inflow will cause respiratory arrest force fluids nebuli3e and suction client as needed pro!ide comfortable and humid en!ironment health teaching and d1c planning a!oidance of smoFing pre!ent complications C%, narcosis coma Cor pulmonale +leural effusion +neumothora4

Regular adherence to meds Importance of ffup care

9.

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

1.

TYPES 1. S&on"*neous $ air enters pleural space without an ob!ious cause ,. Ruptured blebs &al!eolar $ filled sacs) inflammatory lung conditions

O&en $ air enters pleural space through an opening in pleural wall Gun shot wounds -ultiple stab wounds

3.

Tens#on $ air enters pleural space during inspiration and cannot escape leading to o!erdistention of the thoracic ca!ity mediastinal shift to the affected side &ie. Clail chest) parado4ical breathing

2.

PREDISPOSING FACTORS 1. Chest trauma ,. *. Inflammatory lung condition tumors

3.

SIGNS AND SYMPTOMS 1. ,. *. .. 0. chest pain, dyspnea, cyanosis diminished breath sounds cool, moist sFin mild restlessness and apprehension resonance to hyperresonance

,.

DIAGNOSTICS 1. '2G analysisB +%, decreased ,. C5R $ confirms collapse of lungs

8.

NURSING MANAGEMENT 1. 'ssist in endotracheal intubation ,. *. 'ssist in thoracentesis 'dminister meds as ordered .. /arcotic analgesics $ -orphine sulfate 'ntibiotics

'ssist in C88 to ",0 sealed drainage

=ATER SEALED DRAINAGE

I.

O.@ECTIVES

1. ,. *. ..

8o restore & ) pressure in lungs +romote re e4pansion of lungs 8o drain blood, fluid, and air +re!ent reflu4 of blood, fluid and air

II.

NURSING MANAGEMENT 1. -aintain strict asepsis ,. *. .. -onitor 9(, I%, 2( 7ncourage #27 'dminister medications as ordered 1. ,. 0. ?. /arcotic analgesics $ -orphine sulfate antimicrobials

+repareB clamp, e4tra bottle, petroleum gau3e -onitor1assess oscillation, bubbles or fluctuations 1. If &G) intermittent bubbling normal1intact ,. ",% goes up with each inspiration ",% goes down with each e4piration

If &G) continuous, remittent, bubbling ChecF for leaFage Clamp towards the chest tube /otify physician

*.

If & ) fluctuations ChecF for loops1FinFs1clots -ilF if &G) clots Cull re e4pansion of lungs & ) fluctuations &G) breath sounds C5R $ full re e4pansion

III.

NURSING MANAGEMENT UPON CTT REMOVAL 1. 7ncourage #27 ,. *. .. Instruct pt to a!oid performance of !alsal!a maneu!er to pre!ent entry of air in pleural space and to facilitate easy remo!al of C88 'pply !aselinated air occlusi!e dressing -aintain dressing clean and intact

OVERVIE= OF THE STRUCTURE AND FUNCTION OF THE GASTROINTESTINAL TRACT

I.

UPPER ALIMENTARY CANAL (D#!es"#on$ 1. -outh ,. *. .. 5. +haryn4 7sophagus (tomach Cirst half of duodenum digestion

II.

MIDDLE ALIMENTARY CANAL (AAso+&"#on$ 1. ,. *. .. ,nd half of duodenum >e>unum ileum 1st half of ascending colon

III.

LO=ER ALIMENTARY CANAL (E(#)#n*"#on$ 1. ,. *. .. 0. ,nd half of ascending colon trans!erse colon descending colon sigmoid colon rectum

IV.

ACCESSORY ORGANS 1. (ali!ary glands $ produces 1., 1.0 < of sali!a per day 1. ,. *. ,. +arotid $ below and behind the ear (ublingual (ubmandibular

9ermiform appendi4

*. .. 0.

<i!er Gall bladder +ancreas

8earsB lacrimal gland lacrimal duct lacrimal sac punctae nasolacrimal gland

I.

PAROTITIS &7ndemic mumps) $ inflammation of the parotid gland

1.

ETIOLOGIC AGENT 1. paramy4o!irus !irus

2.

SIGNS AND SYMPTOMS 1. swollen parotid gland ,. *. .. earache 1 otalgia dysphagia fe!er, chills, anore4ia, generali3ed body malaise

3.

NURSING MANAGEMENT 1. (trict isolation ,. -eds as ordered 'ntipyretics 'ntibiotics to pre!ent secondary infection *. .. 0. G7/8I'/ 9I%<78 "'( /% C%%<I/G 7CC7C8L Cooling effect may be caused by !inegarL 2etter to ha!e mumps at an early stage, preferably before puberty may lead to sterility

+ro!ide a general liMuid to soft diet apply cold compress or ice pacF at affected site +re!ent complications Cer!icitis, oophoritis, !aginitis

-eningitis %rchitis sterility

II.

APPENDECITIS $ Inflammation of the !ermiform appendi4 &located at the R. iliac region, produces 62C during fetal life)

1.

PREDISPOSING FACTORS 1. -icrobial in!ation ,. *. FECALITHS $ undigested food particles &tomato, gua!a seeds) intestinal obstruction

2.

SIGNS AND SYMPTOMS 1. &G) rebound tenderness ,. *. .. 0. low grade fe!er, anore4ia, nausea and !omiting pain at R iliac region diarrhea1constipation tachycardia d1t pain

3.

DIAGNOSTICS 1. C2C $ mild leuFocytosis ,. *. +7 $ &G) rebound tenderness Irinalysis $ &G) acetone)

,.

NURSING MANAGEMENT PRE-OP 1. secure informed consent ,. routinary nursing care *. /+% (Fin preparation '!oid enema may lead to rupture

administer medications as ordered

 .. 5.

antipyretics antibiotics /% '/'<G7(IC(L -ay masF pain which indicates impending rupture

monitor I% 9( and 2owel sounds a!oid heat application rupture

8.

NURSING MANAGEMENT POST-OP 1. IB (3$ &en+ose >+*#n &indicates rupture) $ place patient on affected site ,. *. IB (-$C based on pt. comfort 'dminister )e># *"#ons as ordered

.. 0.

Analgesics Antibi tics Antipyretics !"#

maintain patent I9 line monitor 9( I% and bowel sounds (NDAo+Ao+%!)#$

MC .URNEY1S POINT $ incision site for appendectomy