Nursing Care Management

(NCM501202)

Course Description

This course deals with the principles and techniques of nursing care management of sick clients
across the lifespan in any setting with alterations/problems in oxygenation, fluid, electrolyte and
acid-base balance, metabolism and endocrine as well as alterations/problems in inflammatory
and immunologic reactions, cellular aberrations and pain.

Terminal Competencies

Given an actual client with problems in oxygenation, fluid and electrolyte balance, metabolic and
endocrine function, inflammatory and immunologic reactions, cellular aberrations and pain, the
student should be able to:
1. Utilize the nursing process in the care of individuals / families in selected settings
a. Assess with client/s his/her/their condition/health status through interview,
physical examination, interpretation of laboratory findings,
b. Identify actual and at-risk nursing diagnosis,
c. Plan appropriate nursing interventions with client/s and family for identified
nursing diagnosis,
d. Implement plan of care with client/s and family
e. Evaluate the progress of his/her/their client’s condition and outcomes of care,
2. Ensure a well organized and accurate documentation system;
3. Relate with client/s and their family and health team appropriately;
4. Observe bioethical concepts/principles, core values and nursing standards in the care of
clients; and
5. Promote personal and professional growth of self and others.

Content

Altered Cognitive-Perceptual Pattern: Response to Pain

I. Definition of Pain

II. Perception of Pain

A. Misconceptions and Myths
B. Types of Pain
1. Acute Pain
2. Chronic Pain
C. Physiology
1. Physiologic Basis of Pain Perception
2. Gate Control Theory of Pain
D. Sources of Pain
1. Classification
2. Referred Pain
3. Inflammation
4. Neuropathy
 5. Phantom Limb Sensation
6. Headache
7. Malignancy
E. Factors Affecting Pain
1. Situational Factors
2. Sociocultural Factors
3. Age
4. Gender
5. Meaning of Pain
6. Anxiety
7. Past Experience with Pain
8. Expectation and the Placebo Effect
F. Medications to Control Pain
1. Anesthetic Agents
2. Analgesics
3. Negative Effects of Pain
G. Nonpharmaceutical Interventions
1. Cutaneous Stimulation
2. Transcutaneous Electrical Nerve Stimulation (TENS)
3. Massage
4. Heat and Cold Applications
5. Acupuncture and Acupressure
6. Music
7. Progressive Relaxation Training
8. Deep Breathing for Relaxation
9. Guided Imagery
10. Rhythmic Breathing
11. Meditation
12. Hypnosis
13. Humor
14. Biofeedback
15. Therapeutic Touch
16. Distraction
17. Magnets

Altered Activity-Exercise Patterns: Responses to Altered Respiratory Function

I. Concept Review
A. Anatomy, Physiology and Functions of the Respiratory System

II. Application of Nursing Process

A. Assessment
1. Subjective Data
a. Nursing History
• Non-cardiac chest pain
• Dyspnea
• Cough
• Hemoptysis
• Wheezing
 • Stridor
• Nasal and sinus complains
b. Functional Health Patterns
2. Objective Data
a. Physical Assessment of the lungs and thorax
• Inspection
• Palpation
• Percussion
• Auscultation
b. Diagnostic / Laboratory Examinations
1. Non-invasive
• Pulmonary function tests
• Pulse oximetry
• Ventilation-perfusion scan
• Radiologic studies
∗ Chest x-ray
∗ Computed tomography
∗ Magnetic resonance imaging
∗ Pulmonary angiography
∗ Positron emission tomography
• Sputum cultures
2. Invasive
• Endoscopic examinations
∗ Laryngoscopy
∗ Bronchoscopy
∗ Mediastinoscopy
• Lung biopsy
• Thoracentesis and Pleural fluid analysis
3. Laboratory Test
• Sputum culture
• Nose and throat culture
• ABG
• Smoke analyzer
• Fagestrom test –standardized degree of nicotine
dependence
B. Analysis/Nursing Diagnosis
1. Ineffective Airway Clearance as evidenced by shortness of breath,
dyspnea, orthopnea, retractions, nasal flaring, altered chest excursion
2. Ineffective Breathing Pattern as evidenced by ineffective cough,
diminished or abnormal breath sounds, cyanosis, restlessness
3. Impaired Gas Exchange as evidenced by cyanosis, abnormal
respiratory rate and rhythm, nasal flaring, tachycardia, diaphoresis,
confusion
4. Impaired Spontaneous Ventilation as evidenced by dyspnea, use of
accessory respiratory muscles, tachycardia, apprehension
5. Disturbed Sleep Pattern (Sleep–Rest)
6. Anxiety (Self-Perception – Self-Concept)
C. Planning
1. Planning for Health Promotion
 2. Planning for Health Restoration and Maintenance
a. Maintain airway patency
1. Coughing techniques
2. Suctioning
b. Relieving apprehension and fear
c. Reducing metabolic demand
d. Maintaining rest and activity
e. Decreasing the efforts of breathing
f. Maintaining nutrition and hydration
g. Maintaining elimination
h. Preventing and controlling infection
i. Planning for Oxygen therapy
1. Low flow delivery devices
• Nasal cannula
• Simple face mask
• Partial rebreathing mask
• Oxygen-conserving cannula
• Transtracheal catheter
• Face tent
• Tracheostomy collar
• Tracheostomy T-bar
2. High flow delivery devices
• Venturi mask
3. Home Oxygen Delivery System
• Liquid oxygen
• Compressed oxygen cylinder
• Concentrator or extractor
• Oxygen conserving or pulse devices
j. Incentive Spirometry
k. Aerosol Therapy
l. Postural Drainage
m. Ventilation Therapy
n. Artificial Airways
o. Chest Surgery
1. Lobectomy
2. Pneumonectomy
3. Segmental Resection
4. Wedge Resection
5. Decortication
6. Exploratory Thoractomy
7. Thoracotomy not involving lungs
8. Video-assisted thoracic surgery (VATS)
9. Lung Volume Reducation Surgery (LVRS)
p. Chest Drainage

III. Common Health Problems

A. Nursing Care of Clients with Upper Airway Disorders
1. Upper Respiratory Trauma or Obstruction
a. Epistaxis
b. Nasal Trauma or Surgery
 c. Laryngeal Obstruction or Trauma
d. Obstructive Sleep Apnea

B. Nursing Care of Clients with Ventilation Disorders

1. Intrapulmonary Restrictive Pleural Disorders
a. Pleuritis
b. Pleural Effusion
c. Pneumothorax – spontaneous; traumatic; tension
2. Trauma of the Chest or Lung
a. Thoracic injury – rib fracture; flail chest; pulmonary contusion
b. Inhalation injury – smoke inhalation; near-drowning
C. Nursing Care of Clients with Gas Exchange Disorders
1. Reactive Airway Disorders
a. Asthma
b. COPD
1. Bronchitis
2. Emphysema
c. Cystic Fibrosis
d. Atelectasis
2. Interstitial Pulmonary Disorders
a. Occupational Lung Disorders – asbestosis; silicosis; coal worker’s
pneumoconiosis; hypersensitivity pneumonitis
b. Sarcoidosis
3. Pulmonary Vascular Disorders
a. Pulmonary Embolism
b. Pulmonary Hypertension
c. Pulmonary Edema

D. Implementation
1. Pharmacologic Therapeutics
a. Decongestants and Antihistamines
b. Antitubercular – first line; second line
c. Broad-spectrum Antibiotics
d. Adrenergic Stimulants
e. Methylxanthines
f. Anticholinergics
g. Corticosteroids
h. Mast Cell Stabilizers
i. Leukotriene Modifiers
2. Complementary and Alternative Therapies
a. Echinacea
b. Goldenseal
c. Zinc
3. Nutritional and Diet Therapy
a. Tube feedings
b. Fluid therapy – oral; IV
c. High-protein, high calorie supplements
4. Client Education
Response to Altered Oxygenation: Cardiac and Peripheral Tissue Perfusion / Transport

I. Review of Anatomy and Physiology and Functions of the Cardiovascular and Hemo-
Lymphatic System

II. Nursing Process

A. Assessment
1. Subjective Data
a. Nursing History
1. Problems in Oxygenation: Perfusion
• Fatigue
• Fluid retention
• Irregular heartbeat
• Dyspnea
• Pain
• Tenderness in calf of leg
• Syncope, near syncope
• Altered neurologic function
• Leg pain
2. Problems in Oxygenation: Transport
• Skin: pallor, flushing, jaundice, cyanosis,
excoriation, pruritus, leg ulcers, angioma,
telangiectasis, spider nevus, purpura, petechiae,
ecchymosis, hematoma, chloroma, plasmacytoma
• Eyes: jaundiced sclera, conjunctival pallor, blurred
vision, diplopia, visual fields cuts
• Nose: epistaxis
• Mouth: gingival and mucous membrane changes,
smooth tongue
• Lymph Nodes: lymphadenopathy
• Heart and Chest: tachycardia, palpitations, altered
BP, sterna tenderness, low oxygen saturation
• Abdomen: hepatomegaly, splenomegaly, distended
abdomen
• Nervous System: paresthesia of hands and feet,
ataxia, weakness, headache, nuchal rigidity
• Musculoskeletal system: bone pain, joint swelling
and arthralgia
b. Functional Health Patterns

2. Objective Data
a. Physical Assessment
b. Diagnostic Test and Procedures
1. Non-Invasive
• ECG
• Echocardiogram
• Ultrasound
• Chest X-ray
• Radionuclide studies
 2. Invasive
• Cardiac Catheterization
• Arteriogram
• Angiocardiogram
• Venogram
• Lymphography
• Bone Marrow Aspiration
3. Laboratory Test
B. Analysis/Nursing Diagnosis
(For Alteration in Oxygenation: Cardiac and Peripheral Tissue Perfusion)
1. Decreased Cardiac Output as evidenced by increase heart rate, fatigue,
shortness of breath, decreased urine output, impaired mental processing,
decreased level of consciousness
2. Activity Intolerance as evidenced by prolonged heart rate increases
following activity, shortness of breath with exercise, activity-related chest
pain, fatigue
3. Fatigue as evidenced by inability to consume a full meal without resting,
frequent napping or dozing, expression of tiredness, weakness
4. Ineffective Tissue perfusion as evidenced by cool, dusky skin,
decreased urine output, chest pain
5. Acute Pain (Cognitive-Perceptual)
6. Anxiety (Coping – Stress-Tolerance)
(For Alteration in Oxygenation: Peripheral Tissue Perfusion / Transport)
1. Ineffective Peripheral Tissue Perfusion as evidenced by change in skin
color and temperature, lack of hair growth, skin irritations or ulcers
2. Activity Intolerance as evidenced by weakness, fatigue, vital sign
changes with activity
3. Fatigue as evidenced by difficulty completing usual daily activities,
frequent desire to rest
4. Impaired Home Maintenance as evidenced by inability to maintain
family roles
5. Risk for Peripheral Neurovascular Dysfunction as evidenced by
changes in color temperature, sensation of extremities
6. Impaired Tissue Integrity (Nutritional-Metabolic)
7. Effective Therapeutic Regimen Management (Health-Perception –
Health Management)
C. Planning
1. Planning for Health Promotion
a. Risk factor and risk management
b. Promotion of circulation
c. Prevention of Infection
d. Genetic Counseling
e. Role of Nutrition
2. Planning for Health Maintenance and Restoration
a. Planning for basic life support: CPR
b. Planning for advanced life support
c. Planning for the client having cardiac surgery
D. Implementation
1. Disorders of Myocardial Perfusion
a. Coronary Artery Disease
b. Angina Pectoris
c. Acute Coronary Syndrome
d. Acute Myocardial Infarction
2. Cardiac Rhythm Disorders
a. Cardiac Dysrythmia
b. Sudden Cardiac Death
3. Cardiac Disorders
a. Heart Failure
b. Pulmonary Edema
c. Disorders of Cardiac Structure
1. Valvular heart disease
2. Cardiomyopathy
4. Hematologic Disorders
a. Red blood cell disorders
1. Anemia
2. Myelodysplastic syndrome
3. Polycythemia
b. White blood cell disorders
1. Neutropenia
2. Leukemia
c. Platelet and Coagulation Disorders
1. Thrombocytopenia
2. Hemophilia
3. DIC
5. Peripheral Vascular Disorders
a. Disorders of Peripheral Vascular Regulation
1. Primary Hypertension
2. Secondary Hypertension
3. Hypertensive Crisis
b. Disorders of the Aorta and its Branches
1. Aneurysm
c. Disorders of the Peripheral Arteries
1. Peripheral Vascular Disease
2. Thromboangitis Obliterans
3. Raynaud’s Disease
4. Acute Arterial Occlusion
d. Disorders of Venous Circulation
1. Venous Thrombosis
2. Varicose Veins
e. Disorders of the Lymphatic System
1. Lymphadenopathy
2. Lymphedema
E. Interventions
1. Pharmacological Therapy
a. Cholesterol-lowering drugs – statins, bile acid sequestrants,
nicotinic acid, fibric acid derivatives
b. Antianginal – nitroglycerin, beta-blockers, calcium channel
blockers
 c. Antiplatelet – oral and IV drugs
d. Antidysrhythmic – class I-IV and other drugs
e. Heart Failure – ACE inhibitors, Angiotensin II Receptor Blockers
(ARBs), diuretics, positive inotropic agents, sympathomimetic,
phosphodiesterase inhibitors
f. Anemia – iron sources, B12 sources, Folic Acid sources
g. Antihypertensive – alpha-adrenergic blockers, ACE inhibitors,
ARBs, beta-adrenergic blockers, calcium channel blockers,
centrally acting sympatholytics, vasodilators
h. Anticoagulant – heparin and warfarin
2. Complementary and Alternative Therapies
a. Fish oil / Omega-3 Fatty acids
b. Hawthorn
c. Herbs that may affect clotting
d. Natural Lipid-lowering agents
3. Nutrition and Diet Therapy
a. DASH diet
b. Pritikin diet
c. Ornish diet
d. Low-sodium diet

Nutritional-Metabolic Patterns: Responses to Altered Endocrine Function

I. Anatomy, Physiology and Functions of the Endocrine System

II. Nursing Process
A. Assessment
1. Subjective Data
a. Nursing History
1. Pain
2. Infection / Inflammation
3. GI manifestations
4. Skin changes
5. Perfusion problems – bleeding, bruising or vital sign
changes
6. Visual changes
7. Urinary / reproductive changes
b. Functional Health Pattern
2. Objective Data
a. Physical Assessment
1. Inspection – color, texture of skin, mucous membrane,
growth patterns
2. Auscultation – bruit
3. Palpation – organ: thyroid enlargement
4. Percussion – fluid, edema
b. Diagnostic / Laboratory examination
1. Non-invasive
• Test of Thyroid structure and Function – size,
shape, position, and function by scanning,
ultrasound, MRI, CT, radionuclide imaging, fine
 needle aspiration, testing of the Achilles tendon
reflexes; Radioiodine Uptake
• Test of Adrenal structure and function – lesions or
disease, CT, MRI, adrenal venogram and
angiography
• Test of Pituitary structure and function – skull x-ray
studies, CT or MRI
• Metabolic Function studies – abdominal ultrasound,
radiography, CT
2. Invasive
• Angiography
• Portal Pressure Measurement
• Biopsy
• Paracentesis
3. Laboratory
• Growth hormone / Human Growth Hormone
• Somatomedin (insulin-like Growth Factor or IGF-1)
• Water Deprivation Test
• Thyroid-Stimulating Hormone
• Thyroxine (T4) and Triiodothyronine (T3)
• Triiodothyronine Resin Uptake (T3RU)
• Thyroid Antibodies
• Parathyroid Hormone (PTH)
• Calcium
• Cortisol
• Aldosterone
• Adrenocorticotrophic Hormone (ACTH)
• ACTH Stimulation and ACTH Suppression
• 17-Ketosteroids
• Fasting Blood Sugar (FBS)
• Oral Glucose Tolerance Test (OGTT)
• Glycosylated Hemoglobin (HbAC)
B. Analysis/Nursing Diagnosis:
1. Imbalanced nutrition: Less/More than body requirements as evidenced
by increased food intake with weight loss
2. Deficient Fluid Volume as evidenced by dry mucous membranes, thirst
and decreased urine output
3. Hyperthermia as evidenced by body temperatures ranging from 102°F
(39°C) to 106°F (41°C)
4. Impaired Skin Integrity as evidenced by dry, rough, reddened and
edematous skin
5. Disturbed Body Image (Self-Perception – Self-Concept)
6. Ineffective Therapeutic Regimen Management (Health-Perception –
Health-Management)
C. Planning for Health Restoration and Maintenance
1. Disorders of the Thyroid Gland
a. Hyperthyroidism (thyrotoxicosis)
1. Grave’s disease
2. Toxic Nodular Goiter
 b. Hypothyroidism
1. Iodine deficiency
2. Hashimoto’s thyroiditis
3. Myxedema coma
2. Disorders of the Parathyroid Gland
a. Hyperparathyroidism
b. Hypoparathyroidism
3. Disorders of the Adrenal Glands
a. Hypercortisolism
b. Addison’s Disease
c. Pheochromocytoma
4. Disorders of the Pituitary Gland
a. Anterior Pituitary Disorders
1. Gigantism
2. Acromegaly
b. Posterior Pituitary Gland
1. SIADH
2. Diabetes Insipidus
5. Disorder of the Pancreas
a. Diabetes Mellitus
D. Implementation
1. Pharmacologic therapeutics
a. Iodine sources
b. Antithyroid
c. Thyroid preparations
d. Cortisol replacements
e. Insulin
f. Oral hypoglycemics
2. Complementary and Alternative Therapies
a. Herbs that may lower blood glucose – aloe vera, bilberry, bitter
melon, fenugreek, fish oils, garlic, ginseng, gymnema, horse
chestnut seed extract, marshmallow, milk thistle, nopal
b. Prickly pear (cactus)
c. Herbs that may raise blood glucose – burdock
3. Surgical and Special procedures
a. Surgical procedures
1. Thyroidectomy
2. Parathyroidectomy
3. Unilateral or bilateral adrenalectomy
4. Transphenoidal hypophysectomy
5. Amputation of Diabetic client
6. Pancreas transplant
7. Islet cell transplant
b. Special procedures
1. Administration of Insulin
2. Administration of Hormones
4. Nutrition and Diet Therapy
5. Patient Education
Nutritional-Metabolic Patterns: Responses to Altered Nutrition

I. Anatomy, Physiology, and Functions of the Gastrointestinal System

II. Nursing Process

A. Assessment
1. Screening of Nutritional Health
a. Nutritional Health
b. Malnutrition
c. Nutrition Screen
2. Subjective Data
a. Nursing History
1. Abdominal Pain
2. Nausea and vomiting
3. Indigestion
4. Diarrhea
5. Appetite and weight change
b. Functional Health Pattern Interview
3. Objective Data
a. Physical Examination
1. Anthropometric measurement
2. Inspection – color, texture of skin and mucous membrane,
growth patterns, scars, masses
3. Auscultation – bowel sounds, bruits
4. Percussion – liver span, masses, ascites
5. Palpation – masses, ascites, rebound tenderness,
distention
b. Diagnostic Procedures
1. Non-invasive
• Radiologic studies
∗ Upper GI series or Barium Swallow
∗ Lower GI series or Barium Enema
∗ Flat plate of the abdomen
∗ Magnetic Resonance Imaging
∗ Computed Tomography
∗ Scintigraphy (Nuclear Imaging Scans)
2. Invasive
• Endoscopy
∗ Esophagogastroduodenoscopy (EGD)
∗ Colonoscopy
∗ Capsule Endoscopy
∗ Sigmoidoscopy
∗ Double Balloon Enteroscopy
∗ Endoscopic Retrograde
Cholangiopancreatography (ERCP)
∗ Endoscopic Ultrasound
∗ Laparascopy (Peritoneoscopy)
• Liver Biopsy and other GI tests
• Bernstein Test (Esophageal Acidity, Manometry
Acid Perfusion)
 • Esophageal Manometry
• Ambulatory Esophageal pH monitoring
• Exfoliative Cytologic Analysis
• Gastric Analysis
3. Laboratory Tests
• Blood Chemistries – serum protein, serum
amylase, serum lipase
• Total Lymphocyte count
• D-Xylose absorption test
• Nitrogen balance
• Fecal Analysis (occult blood, ova and parasite,
quantitative fecal fat studies, fecal leucocytes, stool
electrolyte tests)
B. Analysis/Nursing Diagnosis
1. Imbalanced Nutrition: Less than Body Requirements as evidenced by
decreased food intake, weight loss 20% or more of ideal body weight, dry
and brittle hair, weakness, impaired tissue healing
2. Deficient Fluid Volume as evidenced by dry mucous membranes, poor
skin turgor, thirst, increased body temperature
3. Nausea as evidenced by complaints of stomach discomfort, increased
salivation, tachycardia and cold clammy skin
4. Impaired Skin Integrity as evidenced by disruption of skin surface, pain,
itching
5. Acute Pain (Cognitive-Perceptual)
6. Diarrhea (Elimination)

C. Planning for Health Restoration and Maintenance

1. Disturbance in Ingestion
a. Disorders of the Esophagus
1. GERD
2. Hiatal Hernia
3. Impaired Esophageal Motility
4. Esophageal Diverticula
2. Disturbances in Digestion
a. Nausea and Vomiting
b. Gastrointestinal Bleeding
c. Gastritis
d. Peptic Ulcer Disease
e. Food Poisoning
3. Disturbances in Absorption and Elimination
a. Disorders of Intestinal Motility
1. Diarrhea
2. Constipation
3. Irritable Bowel Syndrome
4. Fecal Incontinence
b. Malabsorption Syndromes
1. Sprue
2. Lactase Deficiency
3. Short Bowel Syndrome
c. Structural and Obstructive Bowel Disorders
 1. Hernia
2. Intestinal Obstruction
3. Diverticular Disease
d. Anorectal Disorders
1. Hemorrhoids
2. Lesions – anal fissure; anorectal fistula; pilonidal disease
4. Disturbances in Accessory Organs
a. Disorders of the Liver
1. Hepatitis
2. Cirrhosis
3. Liver Cancer
b. Disorders of the Pancreas
1. Acute and Chronis Pancreatitis
2. Pancreatic Cancer
c. Disorders of the Biliary Tract
1. Cholelithiasis and Cholecystitis
2. Gallbladder Cancer

D. Implementation
1. Pharmacologic therapeutics
a. Antiemetics
b. Anticoagulant
c. Hematinic Agents
d. Laxatives – bulk-forming; stool softeners and lubricants; saline
and osmotic solutions; stimulants; selective chloride channel
activator; serotonin type 4 (5-HT4) receptor partial agonist
e. Antipruritus
f. Vitamin supplement
g. Antacids
h. Antihyperlipidemics
i. Antispasmodics
j. Antidiarrheal
k. Antisecretory agents – H2 receptor blockers; Proton Pump
Inhibitors
l. Vasopressin
m. Octreotide
n. Epinephrine
o. Promotility – prokinetic
p. Cholinergic – bethanechol
q. Antibiotics for H. pylori and Antiinfectives
r. A-interferon and Ribavirin
s. Pancreatic Enzyme Replacement
2. Complementary and Alternative Therapies
a. Ginger
b. Milk Thistle (Silymarin)
3. Surgical and special procedures
a. Surgical procedures
1. Gastrostomy
2. Gastrectomy
3. Colostomy
4. Hemorrhoidectomy
 5. Gastrointestinal bypass
6. Ileostomy
b. Special procedures
1. Parenteral hyperalimentation
2. Feeding per nasogastric jejunostomy, gastrostomy tubes
3. Colostomy care and irrigation
4. Hot sitz bath
4. Nutritional and Diet Therapy
a. Regular diets
b. Special diets
1. High fiber
2. Gluten free
3. Low protein
4. High calorie, high protein
5. Client Education

Elimination Patterns: Response to Altered Urinary Elimination

I. Anatomy, Physiology, and Functions of the Gastrointestinal System

II. Nursing Process

A. Assessment
1. Subjective Data
a. Nursing History
1. General manifestations: fatigue, headaches, blurred vision,
elevated BP, anorexia, nausea and vomiting, chills, itching,
excessive thirst, change in body weight, cognitive changes
2. Edema
3. Pain
4. Change in the patterns of urination, urine output and urine
composition
b. Functional Health Patterns
2. Objective Data
a. Physical Assessment
1. Percussion of the Kidneys
2. Palpation of the Kidneys
b. Urinary Assessment
1. Skin Assessment
2. Abdominal Assessment
3. Urinary Meatus Assessment
4. Kidney Assessment
5. Bladder Assessment
c. Diagnostic and Laboratory Tests
1. Non-invasive Tests
• KUB
• IVP
• Renal Ultrasound
• Computerized Tomography
• Magnetic Resonance Imaging
 2. Invasive Tests
• Transurethral Biopsy
• Transrectal Biopsy
• Endoscopy
3. Laboratory Tests
• Urine studies
• Blood studies
• Serum Creatinine
• Creatinine Clearance
B. Analysis/Nursing Diagnosis
1. Impaired Urinary Elimination as evidenced by frequency, urgency,
hesitancy, dysuria and nocturia
2. UrgeUrinary Incontinence as evidenced by frequency, urgency, loss of
urine before reaching toilet, and voiding in small or large amounts
3. Urinary Retention as evidenced by sensation of bladder fullness,
dribbling urine, dysuria and bladder retention
4. Stress Urinary Incontinence as evidenced by dribbling urine with
increased abdominal pressure, urinary urgency, and urinary frequency
5. Acute Pain (Cognitive-Perceptual)
6. Ineffective Health Maintenance (Health-Perception – Health-
Management)
C. Planning
1. Planning for Health Promotion
a. Promoting urinary elimination
b. Preventing urinary tract infections
c. Managing risks such as renal calculi and hypertension
2. Planning for Health Maintenance and Restoration
a. Catheters
1. Types – urethral, nephrostomy, ureteral, suprapubic
2. System – intermittent and intermittent self-catheterization,
exdwelling drainage systems
b. Urologic Surgery
1. Nephrotomy
2. Nephrectomy
3. Pyelotomy
4. Ureterotomy
5. Cystotomy
6. Cystectomy
7. Lithoytipsy
8. Extracorporeal renal surgery
9. Percutaneous nephrostomy
10. Urinary diversion
11. Renal transplantation
12. Dialysis

* Nursing Care of Clients with Urinary Elimination Disorders

A. Urinary Tract Disorders
1. Urinary Tract Infection
2. Urinary Calculi
3. Urinary Tract Tumor
 4. Urinary Retention
5. Neurogenic Bladder
6. Urinary Incontinence
B. Kidney Disorders
1. Glomerular Disorders
a. Glomerulonephritis
b. Nephrotic Syndrome
2. Vascular Kidney Disorder
3. Kidney Trauma
4. Renal Failure

D. Implementation
1. Pharmacological Therapies
a. Diuretics
b. Medications for Gout
c. Antispasmodics
d. Cholinergics
e. Analgesics
f. Aplha-Blockers
2. Complementary Alternative Medications
a. Biofeedback for Urinary incontinence
b. Halamang Gamot
3. Nutrition and Diet Therapy
a. Protein-, Mineral-, and Fluid-Modified Diets

Pathophysiology and Patterns of Health; Nursing Care of Clients with Altered Fluid,
Electrolyte, and Acid-Base Balance

I. Overview of Normal Fluid and Electrolyte Balance

A. Body Fluid Composition
B. Body Fluid Distribution
C. Body Fluid Movement
D. Body Fluid Regulation

II. Nursing Process

A. Assessment
1. Subjective Data
a. Nursing History
1. ECF volume deficits – loss of body weight; changes in I
and O; changes in vital signs
2. Other manifestations – dryness of the mouth and mucous
membrane; tenting of the skin; changes in urine output and
urination; muscle weakness; changes in consistency of the
stool; cerebral changes
b. Functional Health Patterns
2. Objective Data
a. Physical Assessment – there is no specific physical examination
to assess fluid, electrolyte, and acid-base balance
1. Skin – poor skin turgor; cold clammy skin; pitting edema;
flushed dry skin
 2. Pulse – bounding; rapid, weak, thready; weak, irregular,
slow pulse
3. Blood pressure – hypo/hypertension
4. Respirations – deep, rapid breathing; shallow, slow,
irregular breathing; shortness of breath; moist crackles;
restricted airway
5. Skeletal muscles – cramping of exercised muscle; carpal
spasms (Trousseau’s); flabby muscles; positive Chvostek’s
sign
B. Analysis/Nursing Diagnosis
1. Deficient Fluid Volume related to insufficient fluid intake, diarrhea,
hemorrhage, or third space fluid loss such as ascites or burns
2. Excess Fluid Volume related to fluid retention secondary to heart, renal
or liver failure or excess consumption
3. Impaired Oral Mucous Membrane
4. Risk for Injury
5. Risk for Activity Intolerance
6. Risk for Decreased Cardiac Output
7. Risk for Impaired Skin Integrity
8. Imbalanced Nutrition: Less than Body Requirements related to
insufficient intake of foods rich in potassium
C. Planning
1. Planning for Health Promotion
a. Preventing fluid and electrolyte loss
b. Planning for client hydration
c. Reducing risk of injury
2. Planning for Health Restoration and Maintenance
a. Fluid and electrolyte management – oral and intravenous fluid and
electrolyte replacement
3. Nursing Process of Clients with Fluid and Electrolyte Imbalances
a. Fluid Imbalance
1. Fluid Volume Deficit (FVD)
2. Fluid Volume Excess
b. Electrolyte Imbalance
1. Sodium Imbalances
• Hypernatremia
• Hyponatremia
2. Potassium Imbalances
• Hyperkalemia
• Hypokalemia
3. Calcium Imbalances
• Hypercalcemia
• Hypocalcemia
4. Phosphate Imbalances
• Hyperphosphatemia
• Hypophosphatemia
5. Magnesium Imbalances
• Hypermagnesemia
• Hypomagnesemia
 c. Acid-Base Imbalances
1. Respiratory Acid-Base Imbalances
2. Metabolic Acid-Base Imbalances
D. Implementation
1. Pharmacological Therapy
a. IV additives
1. KCl
2. CaCl
3. MgSO4
-
4. HCO3
b. Plasma Expanders
1. Colloids
2. Dextran
3. Hexastarch
2. Nutrition and Diet Therapy
a. Food Sources
1. Sodium
2. Potassium
3. Calcium
4. Phosphate
5. Magnesium
3. Client Education

Health Perception – Health Management Pattern

I. Care of Clients with Infection

A. Overview of the Immune System
1. Immune System Components
2. Nonspecific Inflammatory Response
3. Specific Immune Response
4. Natural or Acquired Immunity
B. Normal Immune Responses
1. Tissue Inflammation
2. Infection

II. Care of Clients with Altered Immunity

A. Altered Immune Responses
1. Hypersensitivity Reaction
2. Autoimmune Disorder
3. Tissue Transplant
B. Impaired Immune Responses
1. HIV Infection

III. Nursing Process for Clients with Infection / Altered Immune Response
A. Health History
B. Physical Assessment
C. Diagnoses
D. Intervention
E. Client, family, community education
IV. Care of Clients with Cancer
A. Incidence and Mortality
1. Risk Factors
B. Pathophysiology
1. Normal Cell Growth
2. The Cell Cycle
C. Etiology
1. Theories of Carcinogenesis
2. Known carcinogens
3. Types of Neoplasms
4. Characteristics of malignant cells
5. Tumor invasion and metastasis
D. Psychophysiologic Effects of Cancer
1. Disruption of Function
2. Hematologic Alterations
3. Infection
4. Hemorrhage
5. Anorexia-Cachexia Syndrome
6. Paraneoplastic Syndromes
7. Pain
8. Physical Stress
9. Psychologic Stress

V. Nursing Care of Clients with Cellular Aberration

A. Assessment
1. Subjective
a. Risk Factors – heredity, age, gender, poverty, stress, diet,
occupation, infection, tobacco use, alcohol use, recreational drug
use, obesity, sun exposure
b. Health History
2. Physical Assessment
B. Nursing Diagnosis
1. Risk for Infection as evidenced by tissue trauma or impaired immune
response
2. Ineffective Health Maintenance as evidenced by lack of preventive care
or health screening
3. Ineffective Protection as evidenced by impaired immunity related to
cancer therapy or HIV disease
4. Risk for Trauma as evidenced by high-risk personal behaviors
C. Planning
1. Planning for Health Promotion and Maintenance
a. Cancer Prevention and Control
b. Prevention, Screening and Early Detection
c. Approaches to Cancer Prevention
2. Planning for Health Restoration
a. Surgery
b. Radiation therapy
c. Chemotherapy
d. Immunotherapy
D. Implementation
1. Pharmacological Therapy – anti-neoplastic drugs
2. Nutrition and Diet Therapy – ACS Dietary Guidelines to Prevent Cancer
3. Complementary Therapies
a. Botanical agents
b. Nutritional supplements
c. Dietary regimens
d. Mind-Body modalities
e. Energy healing
f. Spiritual approaches
g. Miscellaneous therapies