Medical Surgical Nursing (NCM 112) PDF

MEDICAL SURGICAL NURSING (NCM 112) BRANDO M. RAYRAY JR. RN, CCRN, MAN  BRANDO M. RAYRAY JR ✓ Registered Nurse ✓ Certified Critical Registered Nurse ✓ Masters of Arts in Nursing ✓ Head Nurse in ICU-CCU at VMMC ✓ Part time Instructor of College of nursing. OXYGENATION 1ST CONCEPT...

MEDICAL SURGICAL NURSING (NCM 112) BRANDO M. RAYRAY JR. RN, CCRN, MAN  BRANDO M. RAYRAY JR ✓ Registered Nurse ✓ Certified Critical Registered Nurse ✓ Masters of Arts in Nursing ✓ Head Nurse in ICU-CCU at VMMC ✓ Part time Instructor of College of nursing. OXYGENATION 1ST CONCEPT INTRODUCTION The respiratory system is composed of the upper and lower respiratory tracts. Together, the two tracts are responsible for ventilation (movement of air in and out of the airways). RESPIRATORY SYSTEM It is refers to organ system that moves air into and out of the lungs, so that O2 and CO2 maybe exchange between the air and the blood. THE RESPIRATORY SYSTEM LOWER RESPIRATORY TRACT ✓LUNGS ✓PLEURA ✓BRONCHI and BRONCHIOLES ✓Alveoli ✓THORAX and the DIAPHRAGM UPPER RESPIRATORY TRACT/ UPPER AIRWAYS ✓NOSE ✓PARANASAL SINUSES ✓PHARYNX/ THROAT -Nasopharynx -Oropharynx -Laryngopharynx ✓TONSILS and ADENOIDS ✓LARYNX/ VOICE BOX ✓TRACHEA Assessment of Clients with Resp. Disorders A. History 1. Biographic data 2. Chief Complaints 3. Family History 4. Psychosocial History and Lifestyle B. Physical Examination Inspection Palpation Percussion Auscultation  BREATH SOUND Normal Breath Sounds Abnormal Breath Sounds Vesicular Crackles/FINE Tracheal Crackles/ Rales (Coarse) Bronchial Pleural friction rub WHEEZE Broncho vesicular Gurgling/rhonchi “Diagnostic Procedure/ Examination”  Non-Invasive Procedure Skin Test/Mantoux Test PULSE OXIMETRY  Non-Invasive Procedure Sputum exam Pulmonary Function Test  Non-Invasive Procedure Incentive Spirometry CHEST X-RAY  Non-Invasive Procedure ARTERIAL BLOOD GAS (ABG) Arterial blood gas analysis is an evaluation of gas exchange in the lungs by measuring the Pa02, PC02 and the pH an arterial sample. To evaluate the efficiency of pulmonary gas exchange To assess the acid. base status of the body whether alkalosis or acidosis, is respiratory or metabolic in origin and what degree. Compensated or uncompensated. To provide important diagnostic information on adequacy of gas exchange in the lungs, integrity of the ventilatory control system and blood ph and acid base balance.  Systematic ABG Analysis 1. Remember the Normal Values 2. Look at the ph.  Systematic ABG Analysis 3. Look at the PaCo2 4. Look at the HC03 Systematic ABG Analysis 5. Determine the primary ACID- BASE Disturbance R - espiratory O – pposite M - etabolic E – qual Systematic ABG Analysis 5. Determine the primary ACID- BASE Disturbance R - espiratory O – pposite M - etabolic E – qual Systematic ABG Analysis TICTACTOE METHOD A- acidosis B- alkalosis Component Result T.M ROME ph 7.21 A RESPIRATORY Pco2 51 A ACIDOSIS Hc03 54 B Systematic ABG Analysis TICTACTOE METHOD A- acidosis B- alkalosis Component Result T.M ROME ph 7.51 B RESPIRATORY Pco2 20 B ALKALOSIS Hc03 10 A Systematic ABG Analysis TICTOE METHOD A- acidosis B- alkalosis Component Result T.M ROME ph 7.51 B METABOLIC Pco2 60 A ALKALOSIS Hc03 100 B Systematic ABG Analysis TICTOE METHOD A- acidosis B- alkalosis Component Result T.M ROME ph 7.10 A METABOLIC Pco2 20 A ACIDOSIS Hc03 08 A 6. Look at the degree of compensation Compensated Uncompensated Partial Compensation the values that doesn’t Full or Complete match the acid base status of the ph is normal.  Degree of Compensation TICTOE METHOD This is Partial compensated A- acidosis because the ph did not go back on the normal range B- alkalosis Component Result T.M ROME ph 7.10 A METABOLIC Pco2 10 B ACIDOSIS Hc03 10 A There is a compensation happened because the buffer is abnormal  Degree of Compensation TICTOE METHOD A- acidosis The answer is uncompensated. B- alkalosis Component Result T.M ROME ph 7.10 A METABOLIC Pco2 35 N ACIDOSIS Hc03 20 A There is no compensation happened because the buffer is normal THORACENTESIS Invasive Procedures Bronchoscopy LUNG SCAN BIOPSY OF THE LUNG Respiratory Disorders  Local Causes Dryness leading to crust formation Trauma HPN Bleeding Disorders CA, RHD Diagnostic Evaluation ▪ Inspection using nasal speculum ▪ Laboratory exam Collaborative Management 1. Sit up, lean forward head tipped. Epistaxis is defined as acute 2. Apply pressure hemorrhage from the nostril, 3. Apply cold compress nasal cavity, or 4. May insert a nasal pack nasopharynx. 5. Instruct patient to avoid blowing 6. Notify physician if bleeding persist.  Causes URTI, smoking, Allergic Rhinitis that inflamed the sinuses resulting Hypersecretion of Mucus----infection Manifestation ▪ Pain- stabbing or aching Maxillary- cheek, upper teeth Frontal- above the eyebrows Ethmoid- in and out of the eyes SINUSITIS Sphenoid- behind the eyes, occiput, top of the head Inflammation of mucosal ▪ Stuffy nose membranes one or more ▪ Headache paranasal sinuses. ▪ Fever ▪ Halitosis  Diagnostic evaluation Sinus X rays and CT scan Nasal and sinus endoscopy Collaborative Management ▪ Bed rest. ▪ Increase fluid intake ▪ Irrigation of sinuses with warm water ▪ Apply hot wet packs over the area. SINUSITIS ▪ ▪ Administered Codeine Antibiotics ▪ Nasal decongestants.  Manifestations: ▪ Persistent and recurrent sorethroat, ▪ Snoring ▪ fever., dysphagia ▪ Mouth breathing, ear pain ▪ Frequent head colds, ▪ Foul breath Tonsilitis/ ▪ Voice impairment Adenoiditis Collaborative Management ▪ Bed rest Tonsils and Adenoids ▪ Increase fluid intake inflamed due to ▪ Warm saline gargle infectious agent causing ▪ Analgesic as ordered ▪ Antimicrobial as ordered AIR WAY OBSTRUCTION ▪ Surgery  Surgery Tonsillectomy and Adenoidectomy indicated if tonsillitis recurs 5-6 times a year Pre op care Assess for URTI Avoid coughing and sneezing Check PT Post op care ▪ Lateral/ prone head to the side ▪ Semi fowler once awake ▪ Monitor for haemorrhage -frequent swallowing Tonsilitis/ Adenoiditis -bright red vomitus -tachycardia ▪ To promote comport -Provide ice collar to the neck -Give acetaminophen as ordered. -Avoid administration of ASA  ▪ Food and Fluids -Provide ice- cold fluids -Provide bland foods. -avoid red or dark foods - Avoid citrus juices Health Education ▪ Avoid clearing the throat ▪ Avoid coughing or sneezing, blowing the nose for 1-2 weeks ▪ Avoid hard or scratchy foods until the throat is healed ▪ Report signs and symptoms of bleeding ▪ Throat discomfort between 4th to 8th day is expected. Tonsilitis/ Adenoiditis ▪ Dark or black stool for a few days due to swallowing of blood ▪ Rest for two weeks ▪ Avoid colds, overcrowded and public places  ETIOLOGY Cigarette smoking Alcohol abuse Voice abuse Environmental pollutants Chronic laryngitis Family History Exposure to asbestos Signs and symptoms HOARSENESS of the VOICE/ Change in voice Cancer of the Larynx Mass anterior of the neck Dyspnea Presence of malignant Dysphagia cells in larynx associated Burning sensation in the throat Halitosis with smoking and Pain radiating to the ears alcoholism Hemoptysis Severe anorexia Severe weight loss  Collaborative Management Prepare client for chemotherapy and surgery Surgery: 1. TOTAL Laryngectomy 2. SUBTOTAL Laryngectomy Pre Op Care: Provide psychosocial support Loss of the voice Permanent tracheostomy Cancer of the Larynx Loss of smell Inability to blow the nose, sip soup, sip through straw, whistle, gargle, Valsalva Manuever, unable to lift objects Establish means of communication to be used. Picture board  POST OP Care ▪ Establish patent airway -Suction PRN -Use sterile technique -Semi fowler’s position -Use sterile NSS to lubricate suction catheter -Apply suction withdrawal of the catheter -Apply suction for 5-10 sec (15sec) -Instill 2-5 ml of NSS to liquefy secretions ▪ Prevent infection Cancer of the Larynx -Change stoma and tracheostomy at regular basis -Change dressings and ties as necessary -Establish means of communication -Assist during speech therapy TRACHEOSTOMY  Pulmonary Tuberculosis Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily attacks the lungs. However, it can spread from there to other organs. Pulmonary TB is curable with an early diagnosis and antibiotic treatment.  Symptoms of Cough with phlegm pulmonary TB: Coughing out of blood Have a consistent fever, including low-grade fevers Have night sweats Have chest pains Have unexplained weight loss RISK FACTORS OF older adults HAVING PTB small children people who smoke people with an autoimmune disorder, such as lupus or rheumatoid arthritis people with lifelong conditions, such as diabetes or kidney disease people who inject drugs people who are immunocompromised, such as those living with HIV, undergoing chemotherapy, or taking chronic steroids  DIAGNOSTIC PROCEDURE FOR PTB Lung CT scan Bronchoscopy Thoracentesis Lung biopsy CHEST XRAY  Classification System for TB (DSSM) In addition to this test, a doctor can also “culture” a sputum sample. This means they take a portion of the sputum sample and put it in a special material that makes TB bacteria grow. If TB bacteria grow, this is a positive culture. Doctors can also order a polymerase chain reaction (PCR) assay to be per for med. This tests the sputum for the presence of certain genes from the germs that cause TB.  The most common TB medicines are: MEDICATION FOR PTB Isoniazid Pyrazinamide Ethambutol (Myambutol) Rifampin (Rifadin) Note: Evaluate effectiveness of anti –TB drugs by sputum culture for acid fast bacilli. Drugs should be taken on empty stomach for maximum absorption. Advise the client to avoid alcohol. Anti tb meds are hepatotoxic. TB is no longer contagious 2-3 weeks after starting starting chemotherapy or after 2 negative sputum culture. PREVENTION FOR PTB Provide education on preventing TB like cough with etiquette. Avoid extended close contact with someone who has TB. Air out rooms regularly. Cover your face with a mask that is approved for protection against TB. PNUEMONIA Pneumonia is an infection in one or both lungs. Bacteria, viruses, and fungi cause it. The infection causes inflammation in the air sacs in your lungs, which are called alveoli. The alveoli fill with fluid or pus, making it difficult to breathe.  coughing that may produce phlegm (mucus) Symptoms of Pneumonia fever sweating or chills shortness of breath that happens while doing normal activities or even while resting chest pain that’s worse when you breathe or cough feelings of tiredness or fatigue loss of appetite nausea or vomiting headaches Risk Factors Anyone can get pneumonia, but certain groups do have a higher risk. These groups include: infants from birth to 2 years old people ages 65 years and older people with weakened immune systems because of disease or use of medications, such as steroids or certain cancer drugs people with certain chronic medical conditions, such as asthma, cystic fibrosis, diabetes, or heart failure people who’ve recently had a respiratory infection, such as a cold or the flu people who’ve been recently or are currently hospitalized, particularly if they were or are on a ventilator people who’ve had a stroke, have problems swallowing, or have a condition that causes immobility people who smoke, use certain types of drugs, or drink excessive amounts of alcohol people who’ve been exposed to lung irritants, such as pollution, fumes, and certain chemicals  Causes of Pneumonia ❖Bacterial pneumonia ❖Viral pneumonia ❖Fungal pneumonia  Types of Pneumonia Hospital-acquired pneumonia Community-acquired pneumonia (HAP) (CAP) Ventilator-associated pneumonia (VAP) Aspiration pneumonia  DIAGNOSTIC PROCEDURE CHEST XRAY BACTERIA VIRAL FUNGAL  Collaborative Promote rest Management for Pneumonia Provide adequate fluids Incentive spirometry. Semi-Fowlers position Oral hygiene Maintain a healthy lifestyle Oral antibiotics If you smoke, try to quit  Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. It's typically caused by long-term exposure to irritating gases or particulate m a t t e r, m o s t o f t e n f r o m cigarette smoke. Risk factors for COPD ❑ Exposure to tobacco smoke ❑ People with asthma. ❑ Occupational exposure to dusts and chemicals. ❑ Exposure to fumes from burning fuel. ❑ Genetics.  ❖ Cough Signs and symptoms ❖ Dyspnea ❖ Chest pain ❖ Sputum production ❖ Adventitious breath ❖ Alteration in LOC ❖ Alteration in skin temperature ❖ Alteration in skin color ❖ Voice changes ❖ Decreased metabolism ❖ Alteration in thoracic anatomy barrel chest ❖ Clubbing of finger ❖ Polycythemia Collaborative ▪ Promote Rest Management ▪ Increase fluid intake ▪ Good oral care ▪ Diet. High Calorie, High Protein, Low Carbohydrates. ▪ O2 therapy 1-3 LPM ▪ Avoid cigarette smoking, alcohol, environmental pollutants. ▪ Pharmacotherapy. ✓ Expectorants ✓ Antitussives ✓ Bronchodilators ✓ Antihistamine ✓ Steroids ✓ Antimicrobials