A NCM 103 Lecture 2013

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Intermediate Content Teaching-Learning Activities No. of Hours Evaluation

Competency Lec RLE

Given reading materials onStress, the students will beable to:

1. Discuss differentStress Models

2. Identify VariousStressors

Given a client, the student willbe able to provide appropriateBio-behavioral interventionsfor stress

I. INTRODUCTORY CONCEPTS A.STRESS

A. Stress1. Stress and Function:

- Dynamic Balance: The Steady State2. Stress and Adaptation

- Selyes General Adaptation SyndromeModel

- Fight-Flight Model

4. Stress Appraisal Model

B. Stress: Threats to the Steady Sate1. Types of Stress and Stressors2. Stress as a stimulus for disease3. Physiological and Psychological Responses

to Stress4. Maladaptive responses to stress5. Indications of Stress

C. Stress at the Cellular levels

i. Control of steady stateii. Cellular adaptation to stressi ii. Cellular Injury

iv. Cellular response to injury: Inflammationv. Cellular Healing

D. Stress ManagementD1. Promoting healthy lifestyleD2. Enhancing coping strategiesD3. Biobehavioral Interventions for stress

1. Biofeedback2. Progressive Muscle Relaxation3. Meditation4. Guided Imagery

Skills/LabDemonstration and Return

Demonstration

1. Relaxationtechniques

a. biofeedbackb. progressive

musclerelaxation

c. meditat iond. guided

imagery2. Shibashi3. Floor Mat Exercises

a. Pilatesb. Stretching

Parameters forevaluation

1. The following areas evaluation toolsthroughout the enticourse

- Class participatigroup discussions,play, simulationexercises; presentaof a care study

- Progress Test activity will either bannounced or notannounced and thestudent is expectedread and prepare foassigned lesson.

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Intermediate Content Teaching-Learning Activities No. of Hours Evaluat

Competencies Classroom RLE Lec RLE

B. ILLNESSB1. Concept of Illness

1. Cell Injury and Inflammation1.1 Cell adaptation to injury1.2 Body defenses against injury1.3 Monocular phagocyte system1.4 Inflammatory Response

B2. Chronic Illness1. Chronicity of Illness or Disease

1.1 Definition of Chronic Conditions1.2 Prevalence and Causes of Chronic Illness1.3 Characteristics of Chronic Conditions1.4 Phases of Chronic Conditions1.5 Management of Chronic Conditions

C. HEALTHCARE OF THE OLDER ADULT (Geriatric Nursing)

1. Overview of the Aging Processa. Demographics of agingb. Health status of the older adultc. Nursing care of the older adultd. Theories of aging

2. Age-related changesa. Psychosocial aspects of agingb. Physical aspects of agingc. Cognitive aspects of agingd. Pharmacologic considerations for

The older adult.3. Mental health problems in the Older adult

a. Depressionb. Deliriumc. Dementia

4. Common health issues of the older adulta. Impaired mobi lityb. Dizzinessc. Falls and Fallingd. Urinary Incontinencee. Increased susceptibil ity to

Infection

f. A ltered pain and febrileresponses

g. Altered emotional responsesh. Altered Systemic Response

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Given Relevant questions;the student will be able todiscus the pathophysiologicalprocess of

1. Pain

Given a client with simplehealth needs/problems, thestudent will be able to

1. Identify appropriate painassessment tool for a givenage group.

2. States relevant prioritynursing diagnosis with agiven set of cues

C. Pain1. Types of Pain

a. Acuteb. Chronicc. Cancer-related Pain

2. Classifications of Paina. Classification by locationb. Classification by etiology

3. Harmful effects of Pain

a. Effects of Acute Painb. Effects of Chronic Pain

4. Pain Theories5. Pathophysiology

i. Neurophysiological transmission ofPain

ii. Factors Affecting Pain6. Nursing Care of a Client Experiencing Pain

ASSESSMENT1. Pain experience inventory2. Cries Neonatal Post-operative Pain Measurement

Scale3. FLACC Pain assessment tool4. Faces Pain Rating Scale5. Poker Chip tool6. Oucher Pain Rating Scale7. Numerical or Visual analog Scale8. Adolescent Pediatric Pain Tool9. Logs and Diaries

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2. Utilize appropriate non-pharmacologic

interventions to reduceclients pain

PLAN / IMPLEMENTATIONPain Management Strategies

1. Establish therapeutic relationship2. Teach patient about pain relief3. Reduce anxiety and fears4. Provide comfort measure5. Non-Pharmacologic

5.1.1 Guided Imagery5.1.2 Thought Stopping

5.1.3 Hypnosis5.1.4 Aromatherapy, Essential Oils5.1.5 Magnet Therapy5.1.6 Music Therapy5.1.7 Yoga and Meditation5.1.8 Acupuncture5.1.9 Crystal or Gem stone Therapy5.1.10 Herbal Therapies5.1.11 Biofeedback5.1.12 Therapeutic touch and massage5.1.13 TENS5.1.14 Heat and Cold Application

o Pharmacologic Interventions for Pain

o Medications for Pain Management

o Routes of Administration

7. Neurologic and Neurosurgical Approaches to PainManagement

7.1.Surgical destruction of painful stimuli

Rhizotomy

Nerve Block

Continuous Extravascular Infusion

Neurectomy

Sympathectomy

EVALUATION

Bring students to thefloor and observenurses preparingnarcotics to familiarizethem with S2prescription and thenarcotic sheet.

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Given an actual client forsurgery, the studentwill be able to utilizethe nursing process inthe peri-operativecare.

State priority nursingdiagnosis for a clientrequiring surgeryduring the pre-operative phase.

D. PERIOPERATIVE NURSING

1. PREOPERATIVE NURSING CARE

Perioperative and Perianesthesia Nursing

Surgical Classifications

General Considerations- Conditions Requiring Surgery- Categories for surgical procedure as to;

Purpose Degree of Risk to patient

Urgency

Effects of surgery on the person

Factors in the estimation of surgical risks-Preparation for Surgery-Preoperative Nursing Considerations

ASSESSMENT1. Nursing History2. Health History

- development consideration- medical history- medications

- occupation3. Life-style

- nutrition- use of alcohol- elicit drugs or nicotine- ADL- occupation

4. Coping patterns and support system5. Pre-operative physical assessment6. Pre-surgical screening tests

- chest x-ray- ECG- CBC- Electrolyte levels and urinalysis

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Utilizes appropriateinterventions for asurgical client duringthe pre-operativephase

Demonstrates pre-operative teaching

Accomplishes pre-operative teaching

Evaluates patientbased on expectedoutcomes

ANALYSIS- Potential Nursing Diagnosis- Anticipatory Grieving related to perceived loss of normal body

image- Anxiety related to the effects of surgical procedure- Fear related to surgery- Risk for infection

- Ineffective Airway Clearance- Ineffective Individual Coping

PLAN / IMPLEMENTATION1. Physiological / spiritual preparation for surgery2. Legal aspects of the informed consent3. Instructional and Preventive aspects

3.1 Deep breathing exercises3.2 Coughing exercises3.3 Turning exercises3.4 Extremity exercises

4. Physical Preparations4.1 On the night of the surgery

a. Hygiene and skin careb. Eliminationc. Nutrition and fluidd. Rest and sleep

4.2 On the day of the surgerya. Pre-operative checklistb. Pre-operative medications

EVALUATION

* Assign studentsto complete a pre-operative; intra-operative; andpost-operativecare at least (1)surgical client:

A. Pre-operativeperiod

1. Psychologicalpreparation

2. Physiologicalpreparation

3. Physicalpreparation

- shaving- enema

4. Spiritualpreparation

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Given an actual client forsurgery, the student:

Utilize assessmenttechnique during theintra-operative phase

States priority nursingdiagnosis during theintra-operative phase

Discuss the roles andresponsibilities of anurse during intra-operative phase

Demonstrates skills inOR nursing

Evaluate outcomesduring intra-operativephase.

2. INTRAOPERATIVE NURSING CARE

ASSESSMENT1. Identify surgical client2. Assess the emotional and physical status3. Verify information in the pre-operative checklist

ANALYSIS1. Impaired Skin Integrity related to Incision2. Risk of Fluid Volume deficit3. Risk for Injury related to position

PLAN / IMPLEMENTATION1. The surgical team

Duties and responsibilities of the circulating nurse; scrubnurse; RN

first assistants2. The surgical environment

A. Principles of surgical asepsisB. Environmental controlsC. Maintaining surgical asepsisD. The surgical Experience

a. Positioningb. drapingc. types of anesthesia and sedationd. stages of anesthesia

E. Potential Intra-operative complication- Bleeding- Nausea and vomiting- Anaphylaxis- Hypoxia and other respiratory complications- Hyperthermia- DIC

3. Documentation4. Transferring to the PCU

EVALUATION

Filmstrip:Surgical Asepsis

2. Principles andpractice

3. Sterile glovetechnique

4. Sterile Dressing

5. Sterile GownTechnique6. Draping7. Open wound

drainage8. Drains

- penrose- t-tube- J-pratt- Hemovac- Gomco suction

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Given a poet-operative client,student ;

1. Provides appropriatenursing intervention duringthe immediate post-operativeperiod.

Assess a client during theimmediate post-operative period.

Given set of cues, statespriority nursingdiagnosis duringimmediate postoperative period.

Evaluates patient based onoutcome criteria

3. POSTOPERATIVE NURSING CAREA. Immediate Post-operative Care in the PACUB. Nursing responsibilities in the PACU

a. assessing the post-operative clientb. maintenance of pulmonary ventilationc. maintenance of circulationd. protection from injury

e. promotion of comfortC. Aldrete post-anesthesia recovery scoring systemD. Ongoing post-operative CareE. Immediate post-operative care in the PACU

ASSESSMENTa. Vital signsb. Color and temperature of the skinc. Level of Consciousnessd. Comforte. Time of Arrival

ANALYSISPostoperative nursing diagnosis

b. risk for surgical site diagnosisc. paind. altered family processes related to loss of

economic stabilitye. impaired physical mobilityf. potential complication: Hemorrhage

PLAN / IMPLEMENTATION1. Preventing Post-operative Complications

1.1 Respiratory Complications1.2 Circulatory Complications1.3 Fluid and Electrolytes Imbalance1.4 Gastrointestinal Complications1.5 Urinary Complications1.6 Wound Complications

2. Post-operative Discomforts

EVALUATION

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Intermediate Teaching-Learning Activities No. of Hours


Given an adult client(young,middle, old, old-old adult)withalteration in fluid, electrolyteand balance, the students willbe able to;

1. Apply knowledgeof normal fluid adelectrolyte balance

and assessmenttechniques.

2. Assess the healthstatus of the client.

a. Conduct ahealth historyand functionalhealth status ofclients having orat-risk for alteredfluid, electrolyteand acid basebalance.

b. Systematic andcomprehensivephysicalassessment tovalidateassessed dat.

c. Interpretdeviations fromnormal findingsin the physicalassessment,diagnostic andlaboratoryexaminations.

E.Fluid and Electrolyte: Balance and Disturbances

1. Fundamental concepts of fluid and electrolyte balanceFluid:

The main constituent of the body and is comprised of water

and dissolved substances in the form of electrolytes, gases and

nonelectrolytes. Therefore, the bodys fluid balance is

extremely important.

Homeostasis of water accounts for approximately 50% to60% of a persons body weight.

Water:

The most important nutrient of life. Humans can survive only

few days without water.

Functions of water:

o Provide a medium for transporting nutrients to cells

and wastes from cells, and for transporting

substances such as hormones, enzymes, blood

platelets, and red and white blood cel ls.o Facilitate cellular metabolism and proper cellular

chemical functioning.

o Act as solvent for electrolytes and nonelectrolytes.

o Help maintain normal body temperature.

o Facilitate digestion and promote elimination.

o Act as a tissue lubricant.

Body Fluid Compartments:

Two main compartments or spaces:

1. Intracellular Fluid

Fluid within the cells, constituting about

40% of an adults body weight or 70% of

TBW.

2. Extracellular Fluid

The fluid outside the cells, constituting

about 20% of an adults body weight or

30% of TBW. Includes intravascular and interstitial

fluids.

Intravascular fluid or plasma is the liquid

component of the blood.

Interstitial fluidis the fluid that surrounds

tissue cells and includes lymph. It acts as a

transport vehicle for gases, nutrients,

wastes, and other materials that move

Teaching materialsappropriate tot ehtopic to bediscussed

- LCD- Video

Different types oftubes, gadgetsused for clientswith disorders offluid and electrolyteand acid baseimbalance

1. IV setsandperipheral lines

2. centrallines

3. peritonealdialysisset

4. bloodtransfusion sets

Bedside clinic on the patient receiving thefollowing:

Therapeutics1. IVF therapy

- Isotonic solutions- Hypotonic solutions- Hypertonic solutions

- Blood expanders

2. Oral / Parenteral electrolyte- administration

- Computations- Nursing precautions3. Blood transfusions- Initiating blood therapy

- monitoring adverse effects

4. Dialysis- peritoneal-hemodialysis

5. Maintenance of Peripheral andCentral lines

- routine care- complications

6. Diet and Nutrition Therapy- oral- enteral- parenteral

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between the vascular compartment and

body cells.

A tissue gel which is spongelike

material composed of large

quantities of

mucopolysaccharides, fills the

tissue spaces and aids in even

distribution of interstitial fluid.

Normally most of the fluid in the

interstitium is in gel form. The

tissue gel, which has a firmer

consistency than water, opposes

the outflow of water from the

capillaries and prevents the

accumulation of free water in the

interstitial spaces.

Transcellular Compartment (usually minor)

includes the CSF and fluid contained in the

various body spaces, such as the peritoneal,

pleural, and pericardial cavi ties, and joint

spaces.

o Normally only about 1% of ECF is

in the transcellular space.

o This amount can increase

considerably in conditions such as

ascites, in which large amounts of

fluid are sequestered in the

peritoneal cavity.

o When the transcellular fluid

compartment becomes

considerably enlarged, it is

referred to as a third space,

because this fluid is not readily

available for exchange with the

rest of the ECF.

Electrolytes

Dissociation of Electrolytes:

Body fluids contain water and electrolytes.

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Electrolytes are substances that dissociate in solution to form

charged particles, or ions.

For example Sodium chloride dissociates to form a positively

charged Na and negatively charged Cl ion.

Particles that do not dissociate into ions such as glucose and

urea are called nonelectrolytes.

The distribution of electrolytes between body compartment is

influenced by their electrical charge.

For example, a positively charged H ion may be exchanged

for a positively charged K and a negatively charged

bicarbonate ion may be exchanged for another negatively

charged Cl ion.

Diffusion and Osmosis

Diffusion is the movement of charged or uncharged particles

along a concentration gradient. Because there are more

molecules in constant motion in a concentrated solution,

particles move from an area of higher concent ration to one of

lower concentration.

The concentrations of electrolytes and solutes can be

expressed in several ways, for example mg/dL, mEq/L, or

millimoles/L (mmol/L).

Osmosis is the movement of water across a semipermeable

membrane (one that is permeable to water but impermeable

to most solutes.)

As with solute particles, water diffuses down itsconcentration gradient, moving from the side of the

membrane with the lesser number of particles and greater

concentration of water to the side with the greater number of

particles and lesser concentration of water.

As water moves across the semipermeable membrane, it

generates a pressure called osmotic pressure, which

represents the pressure needed to oppose the movement of

water across the membrane.

Osmolality and Osmolarity

The osmotic activity of a solution may be expressed in

terms of either its osmolarity or osmolality.

Osmolarity refers to the osmolar concentration in 1L of

solution (mOsm/L); usually used when referring to fluids

outside the body.

Osmolality refers to the osmolar concentration in 1 kg of

water (mOsm/kg of H2O); used for describing fluids inside

the body.

Because 1kg is equal to 1L, both are used interchangeably.

Serum osmolality which is largely determined by sodium

and its attendant anions (CL and HCO3) normally ranges

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from 280 to 295 mOsm/L/

Tonicity

Refers to the tension or effect that the effective osmotic

pressure of a solution with impermeable solutes exerts on cell

size because of water movement across the cell membrane.

Solutions to which body cells are exposed can be classified

as isotonic, hypotonic, or hypertonic, depending on whether

they cause cells to swell or shrink.

Isotonic Solutions

Cells placed in isotonic solution (e.g. 0.9% sodium chlorideor 5% Dextrose in water), which has the same effective

osmolality as the ICF(i.e 280 mOsm/L, neither shrink nor

swell.

These solutions are important in the clinical setting because

they can be infused into the blood without danger of

upsetting the osmotic equilibrium between the ICF and ECF.

Hypotonic Solutions

When cells are placed in a hypotonic solution (i.e. distilled

water), which has a lower effective osmolality than the ICF,

they swell as water moves into the cell.

Hypertonic Solutions

When cells are placed in a hypertonic solution (e.g. 3%normal saline or 10% glucose), which has a greater effective

osmolality than ICF, they shrink as water is pulled out of the

cell.

Capillary / Interstitial Fluid Exchange

The transfer of water between the vascular and interstitial

compartment occurs at the capillary level.

Four Forces Control the Movement of Water Between the

Capillary and Insterstitial Spaces:

Capillary Filtration Pressure/Capillary Hydrostatic

pressure, which pushes water out of the capillary into

the interstitial spaces through mechanical rather than

an osmotic pressure.

It is about 30-40 mmHg at the arterial end,10-15 at the venous end and 25 mmHg at

the middle.

A rise in arterial or venous pressure

increases capillary pressure.

The force of gravity increases capillary

pressure in the dependent parts of the body.

Capillary Colloidal Osmotic Pressure/Plasma

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Oncotic Pressure , which pulls water back into the

capillary (about 28 mmHg).

It is the osmotic pressure generated by the

plasma proteins that are too large to pass

through the pores of the capillary wall.

This is different from the osmotic pressure

that develops at the cell membrane from the

presence of electrolytes and nonelectrolytes.

Because plasma proteins do not normally

penetrate the capillary pores and because

their concentration is greater than in the

interstitial fluids, it is capillary osmoticpressure that pulls fluids back

Insterstitial Hydrostatic Pressure, which opposes the

movement of water out of the capillary

Tissue Colloidal Osmotic Pressure, which pulls

water out of the capillary into the interstitial spaces.

Combination of these forces is such that only a small excess

fluid remains in the interstitium. This excess fluid is removed

from the insterstitium by the lymphatic system and returned to

the systemic circulation.

Edema

Defined as palpable swelling produced by expansion of the

interstitial fluid volume.

Edema does not become evident until the interstitial fluidvolume has been increased by 2.5 to 3 L.

Causes of Edema:

o Increased capillary pressure:

Decreased arteriolar resistance: e.g.

Calcium channel-blocking drug responses.

Venous obstruction: e.g. liver disease with

portal vein obstruction; acute pulmonary

edema; venous thrombosis

(thrombophlebitis)

Increased vascular volume: heart failure,

kidney diseases, premenstrual sodium

retention, pregnancy, environmental heat

stress.

o Decreased capillary colloidal osmotic pressure:

Increased loss of plasma proteins (albumin):

protein-losing kidney diseases, extensive

burns.

Decreased production of plasma proteins:

liver disease, starvation, malnutrition

o Increase capillary permeability

Inflammation

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Allergic reactions

Malignancy: ascites, pleural effusion

Tissue injury and burns

o Obstruction to lymphatic flow

Malignant obstruction of lymphatic

structures

Surgical removal of lymph nodes

Routes of Gains and Losses

1. Kidneys:

The usual daily urine volume in the adult is 1 to 2L. A generalrule is that the output is approximately 1mL of urine per

kilogram of body weight per hour in all age groups.

2. Skin:

Sensible perspiration refers to visible water and electrolyte

loss through the skin (sweating). The chief solutes in sweat

are sodium, chloride, and potassium. Actual sweat losses can

vary from ) to 1,000 mL or more every hour, depending on

the environmental temperature. Continuous water loss by

evaporation (approximately 600 ml/day) occurs through the

skin as insensible perspiration, a nonvisible form of water

loss. Fever greatly increases insensible water loss through the

lungs and the skin, as does loss of the natural skin barrier

(through major burns, for example).

3. Lungs:

Eliminates water vapor (insensible loss) at a rate of

approximately 400 ml every day. The loss is much greater

with increased respiratory rate or depth, or in a dry climate.

4. GI Tract:

Only 100 to 200 ml daily though 8L of fluid circulates in GIT

every 24 hours. Because the bulk of fluid is reabsorbed in the

small intestine, diarrhea and fistulas cause large losses. In

healthy people, the daily average intake and output of water

are approximately equal .

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Average Daily I and O in an Adult.

Intake

Oral Liquids 1, 300 ml

Water in Food 1, 000 ml

Water produced by metabolism 300 ml

Total Gain 2, 600 ml

Output

Urine 1, 500 ml

Stool 200 ml

Insensible

Lungs 300 ml

Skin 600 ml

Total loss 2, 600 ml

Homeostatic Mechanisms

1. Kidneys

Normally filter 170 L of plasma every day in the adult, while

excreting only 1.5 L of urine. They act both autonomously and in response to blood-borne

messengers such as aldosterone and ADH.

Major Functions to Regulate Fluid and Electrolytes:

o Regulation of ECF volume and osmolality by

selective retention and excretion of body fluids.

o Regulation of electrolyte levels in the ECF by

selective retention of needed substances and

excretion of unneeded substances.

o Regulation of pH of the ECF by retention of

hydrogen ions

o Excretion of metabolic wastes and toxic substances.

2. Heart and Blood Vessels

Distribution of blood to the kidneys to allow for urine

formation. Failure of this pump would interfere with renal

perfusion and thus with water and elect rolyte regulation.

3. Lungs

Through exhalation the lungs remove approximately 300 ml

of water daily in the normal adult

Role in acid-base balance through hyper and hypoventilation

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4. Pituitary Gland

ADH stored in PPG as manufactured by hypothalamus

Controlling retention and excretion of water by kidneys

5. Adrenal Gland

Aldosterone which causes sodium retention and water

retention and potassium loss.

Cortisol in large amount would also cause sodium and water

retention.

6. Parathyroid Glands Parathormone regulates calcium and phosphate balance by

influencing bone resorption, calcium absorption from the

intestines, and calcium reabsorption from the renal tubules.

7. Baroreceptors

Detect blood pressure changes and transmit impulse to CNS

Monitoring the circulating blood volume, regulate

sympathetic and parasympathetic neural activity as well as

endocrine activities.

Sympathetic stimulation and depression of parasympathetic if

there is decrease in arterial pressure.

Sympathetic stimulation also constricts renal arterioles; this

increases the release of aldosterone, decreases glomerular

filtration and increases sodium and water retention.

8. RAAS

9. ADH and Thirst

Increased osmolality of body fluids and decrease of blood

volume stimulate the sensory neurons/osmoreceptors of

hypothalamus through intracellular dehydration thirst

occurs fluid intake

ADH controls urination

Thirst is a conscious sensation of the need to obtain and drink

fluids high in water content

It is controlled by the thirst center in the hypothalamus.

Diabetes Insipidus: is caused by a deficiency or a decreased

response to ADH. Persons with DI are unable to concentratetheir urine during periods of water restriction; they excrete

large volume of urine, usually 3 to 20 L/day. Danger arises

when there is inability to secure the needed water. Inadequate

water intake leads to hypertonic dehydration and increased

serum osmolality.

Syndrome of Inappropriate Secretion of ADH: results from

the failure of the negative feedback system that regulates the

release and inhibition of ADH. ADH secretion continues even

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when serum osmolality is decreased, causing marked water

retention and dilutional hyponatremia

10. Osmoreceptors

Increase of osmotic pressure neurons dehydrated impulse

toward pituitary gland increased release of ADH

11. Release of Atrial Natriuretic Peptide

Increased BV and BPIncrease atrial pressure/atrial

stretch increased ANP release from cardiac cells in atria

ANP decreases vascular resistance by causing

vasodilation decrease in BP suppression of reninlevels**decrease in vascular volume, BP and preload and

after load.

ANPdecreased ADH release from PPG **

ANP increase glomerular filtration rate which increasesurinary excretion of sodium and water **

Fluid Regulation see p. 255.

Regulation of Water and Sodium Balance

It is the amount of water and its effect on sodium

concentration in the ECF that serves to regulate the

distribution of fluid between the ICF and the ECFcompartments.

Most of the bodys sodium (135 to 145 mEq/L) is in the ECF

with only small amount (10-14 mEq/L) located in the ICF

compartment.

Sodium functions mainly in regulating extracellular fluid

volume, including that in the vascular compartment.

Sodium normally enters the body through the GIT and is

eliminated by the kidneys or lost through GIT or skin.

Kidney is efficient in sodium regulation and when sodium

intake is limited or conservation of sodium is needed, it is

able to reabsorb almost all the sodium that has been filtered

by the glomerulus, which will produce essentially sodium-

free urine.

The sympathetic nervous system respond to changes in

arterial pressure and blood volume by adjusting the

glomerular filtration rate and the rate at which sodium is

filtered from the blood (see also RAAS).

Regulation of Potassium Balance

Potassium is the second most abundant cation in the body and

major cation in the ICF compartment.

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98% of body K is contained within the body cells (ICF

K:140-150 mEq/L)

ECF K: 3.5 to 5.0 mEq/L

Because potassium is an intracellular ion, total body stores of

potassium are related to body size and muscle mass. Thus,

total body potassium declines with age, mainly as a result of a

decrease in muscle mass.

Potassium intake is normally derived from dietary sources.

Potassium balance can be maintained by a daily intake of 50

to 100 mEq.

The kidneys are the main potassium losses occur in the urine,

with the remainder being lost in stools or sweat.

Two Mechanisms that regulate serum potassium levels:

o Renal mechanisms that conserve or eliminate

potassium

o Transcellular shift of potassium between the ICF and

ECF compartments.

Renal Regulation

Kidney provides the major route for potassium.

Potassium is filtered in the glomerulus, reabsorbed along with

sodium and water in the proximal tubule and with sodium and

chloride in the ascending loop of Henle, and then secreted

into the late distal and cortical collecting tubules for

elimination in the urine. Aldosterone plays an essential role in regulating potassium

elimination by the kidney. In the presence of aldosterone,

sodium is transported back into the blood and potassium is

secreted into the tubular filtrate for elimination in the urine.

There is also a potassium-hydrogen exchange system in the

collecting tubules of the kidney. When serum potassium

levels are increased, potassium is secreted into the urine and

hydrogen is reabsorbed into the blood, producing a decrease

in pH and metabolic acidosis.

When potassium levels are low, potassium is reabsorbed and

hydrogen is secreted into the urine, leading to metabolic

alkalosis.

Extracellular-Intracellular Shifts

Normally, it takes 6-8 hours to eliminate 50% of potassium

intake.

To avoid rise in extracellular potassium levels during this

time, excess potassium is temporarily shifted into RBC and

other cells such as those of muscle, liver and bone. This is

controlled by the Na/K adenosine triphosphatase (ATPase)

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membrane pump and the permeability of the ion channels in

the cell membrane.

Factors that alter Intracellular/Extracelllular distribution of

potassium:

o Acid-Base disorders

The hydrogen and potassium ions, which

are positively charged, can be exchanged

between the ICF and ECF in a cation shift.

In metabolic acidosis, for example,

hydrogen ions move into body cells for

buffering, causing potassium to leave the

cells and move into the ECF.

o Serum osmolality

Acute increases in serum osmolality cause

water to leave the cell. The loss of cell

water produces an increase in intracellular

potassium, causing it to move out of the cell

into the ECF.

o Insulin

Both insulin and catecholamines

(e.g.epinephrine) increase cellular uptake of

potassium by increasing the activity of the

Na/K ATPase membrane pump.

o Beta-adrenergic stimulation

o Exercise: repeated muscle contraction causes

potassium to be released into the ECF.

Regulation of Calcium and Magnesium

99% of body calcium is found in bone, where it provides the

strength and stability for the skeletal system and serves as an

exchangeable source to maintain extracellular calcium levels.

Most of the remaining calcium (approx. 0.7%) is located

inside the cells and only 0.1% to 0.3% is present in the ECF.

Extracellular calcium exists in three forms:

o Protein bound: with albumin

o Complexed: with substances such as citrate,phosphate, and sulfate.

o Ionized: free to leave intravascular and participate in

cellular functions; participates in enzyme reactions,

membrane potentials and neuronal excitability ,

contraction in skeletal, cardiac, smooth muscle, etc.

Factors that Regulate Calcium

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1. Vitamin D: influential in the absorption of calcium

from the intestine. It is then stored in the bone then

excreted by the kidneys.

Only 30-50% is absorbed from the

duodenum and upper jejunum, he remainder

is eliminated in the stool.

Calcium is filtered in the glomerulus of the

kidney and then selectively reabsorbed back

into the blood.

60-65% of filtered calcium is passively

reabsorbed in the proximal tubule, driven by

the reabsorption of sodium chloride;

15-20% is reabsorbed in the thick ascending

loop of Henle, driven by the Na/K/2Cl-

cotransport system;

5-10% is reabsorbed in the distal

convoluted tubule.Thiazide diuretics

enhances reabsorption of calcium.

2. PTH: maintain the calcium concentration of the ECF

by promoting the release of calcium from bone,

increasing the activation of vitamin D and

stimulating calcium conservation by the kidney

while increasing phosphate excretion.

3. Calcitonin: acts on kidney and bone to remove

calcium from the circulation.

4. Serum phosphate level: calcium and phosphate are

reciprocally regulated. Calcium levels fall when

phosphate levels are high.

Regulation of Magnesium

It is the second most abundant intracellular cation. 50-60% is

stored in the bone; 39-49% contained in body cells; 2% is

dispersed in the ECF.

20-30% of ECF magnesium is protein bound and only 15-

30% is exchangeable in the ECF.

The normal serum magnesium is 1.8 to 2.7 mg/dL

Cofactor in many intracellular enzyme reactions; all reactions

that require ATP, replication and transcription of DNA;

cellular energy metabolism; nerve conduction, etc.

Ingested in the diet, absorbed from the intestine and excreted

by kidneys.

Contained in all green vegetables, grains, nuts, meats, and

seafood.

30-40% of filtered Magnesium is reabsorbed in the proximal

tubule.

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50-37% is reabsorbed in the ascending loop of Henle.

The distal tubule is the major site of magnesium regulation.

Increased serum levels of Magnesium decreases reabsorption,

PTH increases reabsorption and increased calcium levels

inhibits reabsorption.

The major driving force for magnesium reabsorption is the

Na/K/2Cl-cotransport system in the thick ascending loop of

Henle. Since this is site of loop diuretics action, this diuretic

lowers magnesium reabsorption.

IV Fluid Administration

Purpose:

1. to provide water, electrolytes, and nutrients to meet

daily requirements ;

2. to replace water and correct electrolyte deficits;

3. to administer medications and blood products.

Types of IV Solutions

1. Isotonic solution:

a. Total electrolyte content is approximately 310

mEq/L, which is closer to that of the ECF (i.e. 280-

295 mEq/L).

b. Expands the ECF volume by 1L; however, it expands

the plasma by only 0.25 L because it is a crystalloid

fluid and diffuses quickly into the ECF compartment.

c. For the same reason, 3L of isotonic solution is

needed to replace 1L of blood loss. Because thes

fluids expand the intravascular space, patients with

hypertension and heart failure should be carefully

monitored for signs of overload.

d. D5W (252 m,Eq/L) initially isotonic but disperses as

hypotonic, 1/3 ECF, 2/3 intracellular. Good is the

patient is at risk of increased in intracranial pressure.

D5W is not used in fluid resuscitation because it can

cause hyperglycemia. It is used mainly to supply

water and to correct an increased serum osmolality.

e. NSS (0.9% sodium chloride) has a total osmolality of308. Since composed mainly of electrolytes, it

remains within ECF. Therefore normally to correct

Extracellular volume deficit. Used with

administration of blood transfusions and to replace

large sodium losses, as in burn injuries. It is not used

for heart failure, pulmonary edema, renal

impairment, or sodium retention.

f L t t d Ri h t i d l i i

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f. Lactated Ringers has potassium and calcium in

addition to NaCl.

2. Hypotonic solutions

a. Total electrolyte content is less than 250 mEq/L.

b. Purpose of hypotonic solution is to replace cellular

fluid because its hypotonic compared to plasma.

Another is to provide water for excretion of body

wastes.

c. Half strength saline (0.45 NaCl with an osmolality of

154 mEq/L is frequently used.

d. Excessive infusion could lead to intravascular fluid

depletion, decreased blood pressure, cellular edema,and cell damage.

3. Hypertonic solutions

a. Total electrolyte count is more than 375 mEq/L.

b. When normal saline solution or lactated ringers

contain 5% dextrose, the total osmolality exceeds

that of the ECF.

c. 50% Dextrose,

d. They draw water from the ICF to the ECF and cause

cells to shrink

Choosing an IV Site:

Factors to consider:1. Condition of the vein

2. type of fluid or medication to be infused

3. Duration of therapy

4. Patients age and size

5. Whether the patient is right or left-handed.

6. Patients age and size

7. Patients medical history and current health status

8. Skill of the person performing the venipuncture.

Systemic Complications

1. Fluid Overload:

a. Increased BP and CVP, moist crackles on

auscultation of the lungs, edema, weight gain,

dyspnea, and respirations that are shallow and have

an increased rate.

b. Causes: rapid infusion, hepatic, cardiac or renal

disease. Common in elderly

c. Mgt: decreasing the IV rate, monitoring vital signs,

assessing breath sounds, place patient in high

Fowlers position. Contact physician.

d. Complication: Heart failure and pulmonary edema.

2 Air Embolism:

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2. Air Embolism:

a. Associated with cannulation of central veins.

b. Manifestations: dyspnea and cyanosis; hypotension;

weak, rapid pulse; loss of consciousness; chest,

shoulder, and low back pain.

c. Treatment: Clamping of cannula, place patient on the

left side in the Trendelenburg position, assess vital

signs and breath sounds; administer oxygen.

d. Complications: shock and death

3. Septicemia and Other Infection

a. Pyrogenic substances can induce a febrile reaction

and septicemia.b. Signs and Symptoms: abrupt temperature elevation

shortly after infusion, backache, headache, increased

pulse and respiratory rate, nausea and vomiting,

diarrhea, chills and shaking, and general malaise

Local Complications:

1. Infiltration and Extravasation

a. Infiltration is the unintentional administration of a

nonvesicant solution or medication into surrounding

tissue. It is characterized by edema around insertion

site, leakage of IV fluids from the insertion site,

discomfort and coolness in the area of infiltration,

and a significant decrease in the flow rate

b. Infiltration Scale:

i. 0 no symptoms

ii. 1 skin blanched, edema less than 1 inch in

any direction, cool to touch, with or without

pain.

iii. 2 skin blanched, edema 1 to 6 inches in

any direction, cool to touch, with or without

pain.

iv. 3 skin blanched, translucent, gross edema

greater than 6 inches in any direction, cool

to touch, mild to moderate pain, possible

numbness

v. 4 skin blanched, translucent, skin tight ,

leaking, skin discolored, bruised, swollen,

gross edema greater than 6 inches in any

direction, deep pitting tissue edema,

circulatory impairment, moderate to severe

pain, infiltration of any amount of blood

products, irritant, or vesicant.

c. Extravasation:

i Is similar to infiltration with an inadvertent

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i. Is similar to infiltration with an inadvertent

administration of vesicant or irritant

solution or medication into the surrounding

tissue.

ii. Medications such as dopamine, calcium

preparations and chemotherapeutic agents

can cause pain, burning, and redness at the

site. Blistering, inflammation, and necrosis

of tissues can occur.

iii. Infusion must be stopped and physician

notified.

2. Phlebit isa. Characterized by reddened, warm area around site or

along path of vein, pain or tenderness at the site or

along the vein.

Grade Clinical Criteria

0 no clinical symptoms

1 erythema at access site with

or without pain

2 pain at access site. Erythema,

edema or both

3 pain at access site, erythema,edema or both, s treak

formation, palpable venous

cord )1 inch or shorter)

4 pain at access site with

erythema, streak formation,

palpable venous cord (longer

than 1 inch) , purulent

drainage.

3. hrombophlebitis

a. Presence of clot plus inflammation in the vein.

b. Localized pain, redness, warmth, and swelling

around the insertion site or along the path of the vein,

immobility of the extremity because of discomfort

and swelling, sluggish flow rate, fever, malaise, and

leukocytosis.

c. Discontinue infusion, cold compress, followed by

warm compress, elevate extremity, restarting the line

in opposite extremity. NO Flushing .

4. Hematoma: apply pressure with a dressing, ice for 24 hours,

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4. Hematoma: apply pressure with a dressing, ice for 24 hours,

warm compress

5. Clotting and Obstruction

2. Nursing Processa. Assessment

A1. Subjective Datai. ECF volume deficits loss of body

weight; changes in I and O; changes inVital Signs

ii. Other manifestations drying of themouth and mucous membrane; tenting

of the skin; changes in urine output andurination; muscle weakness, change inconsistency of the stool; cerebralchanges

A2. Objective Data1. Physical Assessment there is no

specific physical examination toassess fluid, electrolyte, and acid-basebalance.

Skin poor skin turgor; cold, clammyskin, pitting edema; flushed dry skin

Pulse bounding; rapid, weak, thready,irregular, slow pulse

BP hypotension, hypertension

Respirations deep, rapid breathing;shallow; slow, irregular breathing;shortness of breath, moist crackles,restricted airways

Skeletal Muscles cramping ofexercised muscle; carpal spasms(Trousseaus), flabby muscles, positiveChvosteks sign

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1. Perform systematic andcomprehensive physical

assessment to validateassessed data.

2. Interpret deviations fromnormal findings in thephysical assessment,diagnostic, and laboratoryexaminations

B. ANALYSIS / NURSING DIAGNOSISB1. Common Problems of Fluid and Electrolyte Imbalance

1. Fluid Volume Disturbances:- Hypovolemia- Hypervolemia

2. Electrolyte Imbalancesa. Sodium imbalancesb. Potassium imbalancesc. Calcium imbalancesd. Magnesium imbalancese. Phosphorus imbalancesf. Chloride imbalances

3. Acid-Base Imbalancesa. Acute and Chronic Metabolic Acidosis

(Base Bicarbonate Deficit)b. Acute and Chronic Metabolic

Alkalosis (Base Bicarbonate Excess)c. Acute and Chronic RespiratoryAcidosis (Carbonic Acid Excess)

d. Acute and Chronic RespiratoryAlkalosis (Carbonic Acid Deficit)

4. Mixed Acid-Base Disorders

B2. Potential Nursing Diagnosis

1. Deficient fluid volume, related to insufficient fluidintake, diarrhea, hemorrhage or third-space fluid shiftsuch as ascites or burns

2. Excess fluid volume related to fluid retentionsecondary to heart, renal, or lives failure, or excessconsumption

3. Impaired Oral Mucous membrane4. Risk for Injury5. Risk for Activity Intolerance6. Risk for Decreased Cardiac Output7. Risk for impaired skin integrity8. Imbalanced Nutrition; Less than body requirements

related to insufficient intake of foods rich in potassium

1. Performanc

evaluation c2. Progress Te

Examination

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Implement individualizednursing care;

1. safely andknowledgeablyadministersprescribedmedications andtreatments

2. actively participatesin planning andcoordinatingculturally sensitiveinterdisciplinarycare.

3. provide appropriate

client education andhealth maintenanceand communitybased care ofclients

4. efficiently andeffectively, utilizeavailable resourcesin the care of clientsto achieveoutcomes

5. evaluate theeffectiveness ofnursing care,revising care asneeded to promote,maintain, or restorefunctional healthstatus of the clients

6. maintainconfidentiality andprotect clientsprivacy

C. PLANNING1. Planning for Health Promotion

Preventing fluid and electrolyte loss Planning for client hydration

Reducing risk for injury

2. Planning for Health Restoration and Maintenance- Fluid and electrolyte Management Oral and

Intravenous fluid and electrolyte replacement

D. IMPLEMENTATION1. Pharmacological Therapy

a. IV Additives- KCl- CaCL- MgSO4

- HCO3b. Plasma Expanders

- Colloids- Dextran- Hexastarch

2. Nutrition and Diet Therapya. Food Sources of- Sodium- Potassium- Calcium- Phosphate- Magnesium

3. Client Education

EVALUATION

Demonstrationand return

demonstrationof appropriateand specificnursingprocedurespertinent tothe care offluid,electrolyte andacid basedisturbances

Medication

Administration

1. Diuretics2. Antidotes

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7. accurately recordsand reports findingsin clinical practice



Alterations in the Respiratory System

I. CONCEPT REVIEWA. Anatomy and Physiology of the Respiratory System

II. APPLICATION OF THE NURSING PROCESS

I. Assessment of Respiratory Function

A. History

a. Biographical and Demographic Data

b. Present Health

b.1 Chief Complaint

1. Dyspnea

- Onset: Sudden onset indicates pneumothorax,

acute respiratory obstruction or ARDS.

2. Cough

a. Results as a reaction to the irritants of the mucous

membrane lining the respiratory tract.

b. Chief protection of the client from the

accumulation of secretions in the bronchi and the

bronchioles.

c. May indicate serious lung disease

d. Evaluate thetype, character and time.

1) Dry, irritative cough: URT infection of

viral origin.

2) Irritative, high-pitched cough:

Laryngotracheitis

3) Brassy cough: tracheal lesions.

4) Severe changing cough: Bronchogenic

carcinoma

5) Cough accompanied by pleuritic chest

pain: Pleural or chest wall involvement.

6) Cough that worsens in supine position:

Sinusitis

7) Coughing at night may indicate left-sided

heart failure or bronchial asthma.

8) Coughing after food intake may indicate

ReadingComprehension on

the assignedconcept onalteration inrespiratoryfunction.

Teacher-StudentDiscussion

Round Table

Discussion

Concept Mapping

aspiration.

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3. Sputum Production

a. Discharge formation which serves as the lungs

reaction to recurring irritant or may be associated

with nasal discharge.

b. The presence of an infection or disease entity and

its causative organism can be determined by its

amount, color, and consistency.

c. Great amount of purulent sputum (thick and

yellow, green or rust colored: Bacterial infection.

d. Increase in amount over time: chronic bronchitis

or bronchiectasis.e. Pink- tinged mucoid sputum: Lung tumor

f. Profuse, frothy, pink-tinged discharge: Pulmonary

edema

g. Foul-smelling sputum with halitosis: Lung

abscess, bronchiectasis, or infection.

4. Chest Pain

a. Discomfort associated with pulmonary or cardiac

disease.

b. Pain related to pulmonary conditions may be

sharp, stabbing, intermittent, or it may be dull,

aching and persistent.

c. May occur with pneumonia, pulmonary embolism

with lung infarction, and pleurisy.

d. Late symptom of bronchogenic carcinoma.

5. Wheezing

a. High-pitched, musical sound heard mainly on

expiration.

b. Indicates obstruction or increased resistance of the

air passages.

6. Clubbing of the Fingers

a. Manifested as sponginess of the nailbed and loss

of the nailbed angle.

b. Observed in clients with chronic hypoxic

conditions, infections, and malignancies.

7. Hemoptysisa. Expectoration of blood from the respiratory tract.

b. Signifies lung or cardiac disorder.

8. Cyanosis

a. A very late indicator of hypoxia

b. Central cyanosis is typified by bluish discoloration

of the lips and tongue .

c. Peripheral cyanosis results from decreased blood

fl t di t l t t (i il b d d l b )

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flow to distal structures (i.e. nail beds and ear lobes)

c. Past Health History: clients previous

hospitalization, illnesses, childhood diseases,

medications, and allergies.

d. Family Health History:previous health history and

present health status of every member of the family.

B. Physical Examination

a. Upper and Lower Respiratory Structures

Use penlight for a routine examination and a nasal

speculum for a thorough examination.1. Nose and Sinuses

a. Inspect the external nose for lesions,

asymmetry, or inflammation.

b. Examine the internal structures for any

signs of swelling, exudates, bleeding or

change in color of the nasal mucosa.

c. Check nasal septum for deviation,

perforation, or bleeding.

d. Inspect the inferior and middle turbinates

for presence of polyps.

e. Palpate the frontal and maxillary sinuses for

tenderness.

2. Pharynx and Mouth

a. Inspect the color, symmetry, and evidence

of exudates, ulceration or enlargement.

3. Trachea

a. Palpate the position and mobility.

4. Thorax

a. Observe the skin over the thorax for color

and turgor and evidence of loss of

subcutaneous tissue.

b. Check for asymmetry.

b. Chest configuration

- Assess shape and dimensions of the chest

1. Funnel chest (Pectus excavatum): depressed lower

portion of the sternum with the lower ribs flaring outward.

2. Pigeon chest (Pectus carinatum): sternum protrudes

anteriorly.

3. Barrel chest: increased anteroposterior diameter of the

thorax due to overinflation of the lungs.

4. Kyphoscoliosis: characterized by elevation of the scapula

and S-shaped spine.

c. Breathing Pattern:

Observe the rate regularity depth and location of

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- Observe the rate, regularity, depth and location of

respiration.

d. Palpation

1. Upper Lobe

Place the tips of thumbs at the midsternal line at the

sternal notch.

Extend fingers above the clavicles.

Ask client to fully exhale then inhale deeply.

2. Middle Lobe

Place tips of thumbs at the xiphoid process. Extend fingers laterally around the ribs.

Ask client to breathe in deeply.

3. Lower Lobe

Place the tips of thumbs along the clients back at the

spinous processes of the lower thoracic level.

Extend fingers around the ribs.

Ask the client to breathe in deeply.

4. Depth of excursion

Measure the girth of the chest at three levels (axilla,

xiphoid, and subcostal) during inspiration and

expiration.

5. Fremitus

Vocal (tactile) fremitus: vibration felt over the chest

wall as the client speaks; used to assess the quality of

underlying tissues.

o Place the palms of hands lightly on the

chest wall

o Ask the client to speak a few words or

repeat 99 several times.

6. Chest wall pain

Ask the client to take a deep breath and identify any

painful areas of the chest wall.

7. Position of Trachea Determine whether the trachea is palpable at midline

or has shifted to the right or left.

e. Thoracic Percussion

Used to determine whether underlying tissues are

filled with air, fluid, or solid material.

Estimates the size and location of certain structures

within the thorax (heart, liver, diaphragm).

Dull and flat sounds: greater than normal amount of

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Dull and flat sounds: greater than normal amount of

solid matter (tumor, consolidation) is present than

air.

Hyperresonance: presence of greater than normal

amount of air in the area (emphysema, asthma)

f. Auscultation

Evaluates the presence of fluid or solid obstruction in

the lung structures by listening to the breath sounds

with the use of stethosocope.

C. Diagnostic Evaluation

a. Tests to Evaluate Respiratory Function

1. Pulmonary Function Test: includes measurements of lung

volumes and capacities, ventilatory functions, mechanics of

breathing, and diffusion and gas exchange .

2. Pulse Oximetry: non-invasive method of monitoring subtle

or sudden changes in oxygen saturation of hemoglobin.

3. Capnography: non-invasive procedure used to measure

carbon dioxide concentration exhaled by the client who are

receiving mechanical ventilation.

4. Arterial Blood Gas Analysis: measures the degree ofoxygenation of the blood and adequacy of alveolar

ventilation.

5. Ventilation-Perfusion Lung Scan: painless procedure used

to measure adequacy of lung ventilation and perfusion.

b. Tests to Evaluate Anatomic Structures

1. Radiography (Chest X-Ray)

2. Magnetic Resonance Imaging

3. Ultrasonography

4. Gallium Scan

5. Bronchoscopy

6. Laryngoscopy

7. Alveolar Lavage

8. Endoscopic Thoracotomy

9. Pulmonary Angiography

c. Specimen Recovery and Analysis

1. Sputum culture: to identify organisms responsible for

infection of the respiratory tract.

2. Nose and Throat Culture: to identify specific pathogenic

organisms present in the nose and throat

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organisms present in the nose and throat

3. Thoracentesis: to remove fluid and air in the pleural cavity.

4. Biopsy: examination of cells through excision of small

amount of tissues obtained from target structures.


Competencies Classroom RLE Lec RLEB. ANALYSIS

1. Common Health Problems of the Respiratory SystemA. Upper Airway Infection

i. Rhinitisii. Acute and Chronic Sinusitisiii. Acute and Chronic Pharyngitisiv. Tonsillitis and Adenoiditisv. Peritonsillar Abscessvi. Laryngitis

B. Obstruction and Trauma of the UpperRespiratory Airway

i. Obstruction during Sleepii. Epistaxis

i ii . Nasal Obstructioniv. Fractures of the Nosev. Laryngeal Obstructionvi. Cancer of the Larynx

C. Chest and Lower Respiratory Tract Disordersi. Atelectasisii. Respiratory Infections

Acute Tracheobronchitis

Pneumonia

Severe Acute RespiratoryDisorders

Pulmonary Tuberculosis

Lung AbscessD. Pleural Conditions

i. Pleurisyii . Pleural Effusioniii. Empyema

E. Pulmonary EdemaF. Severe Acute Respiratory Distress SyndromeG. Pulmonary HypertensionH. Pulmonary Heart Disease (Cor Pulmonale)I. Pulmonary Embolism

J. SarcoidosisK. Occupational Lung Disease

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p gi. Silicosisii. Asbestosisiii. Coal Workers Disease

L. Chest Tumors



K. Chest Traumai. Blunt Traumaii. Penetrating Traumaii i. Pneumothoraxiv. Cardiac Tamponadev. Subcutaneous Emphysemavi. Aspiration

2. Clients with Chronic Obstructive Diseasea. Bronchiectasisb. Asthma

Status Asthmaticusc. Chronic Obstructive Pulmonary Disorders

Emphysema

Chronic Bronchitis

d. Cystic Fibrosis

3. Potential Nursing Diagnosisa. Ineffective Airway Clearance as evidenced by shortness

of breath, dyspnea, orthopnea, retractions, nasal flaring,altered chest excursion

b. Ineffective Breathing Pattern as evidenced by ineffectivecough, diminished or abnormal breath sounds, cyanosis,restlessness

c. Impaired Gas Exchange as evidenced by cyanosis,abnormal respiratory rate, and rhythm, nasal flaring,tachycardia, diaphoresis and confusion

d. Impaired Spontaneous Ventilation as evidenced bydyspnea, use of accessory muscles, tachycardia, and

apprehensione. Disturbed Sleep pattern (Sleep-Rest)f. Anxiety

4. PLANNINGa. Planning for promotionb. Planning for Heath Restoration and Maintenance

i. Maintain Airway Patency

ii. Relieving Apprehension and Feariii. Reducing Metabolic Demand

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iv. Preventing and Controlling Infection


Competencies Classroom RLE Lec RLE5. IMPLEMENTATION

a. Pharmacologic Therapeuticsi. Decongestants and Antihistaminesii. Anti-tubercular Drugsiii. Broad Spectrum Antibioticsiv. Adrenergic Stimulantsv. Methylxanthinesvi. Anticholinergicsvii. Corticosteroidsviii. Mast Cell Stabilizersix. Leukotriene Modifiers

b. Complementary and Alternative Therapiesi. Echinacea

ii. Golden Sealiii. Zincc. Nutritional Diet Therapy

i. Tube feedingsii. Fluid Therapyiii. High Protein, high Calorie supplements

d. Respiratory Care ModalitiesI. Non-invasive Respiratory Therapiesi. Oxygenation Therapyii. Incentive Spirometryiii. Nebulization Therapyiv. Intermittent Positive Pressure Breathingv. Chest PhysiotherapyII. Airway Managementi. Endotracheal Intubationii. Tracheostomyiii. Mechanical Ventilationiv. Chest Drainage

e. Thoracic Surgeryi. Pneumonectomyii. Lobectomyiii. Segmentectomy (Segmental Resection)iv. Wedge Resection

v. Bronchoplastic or Sleeve Resectionvi. Lung Volume Reduction

Cli t H lth T hi

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g. Client Health Teaching

6. EVALUATION


Competencies Classroom RLE Lec RLEGiven an adult client (young,middle, old, old-old) withaltered responses to cardiacand peripheral tissueperfusion/transport, thestudents will be able to;

a. Apply knowledge ofnormal anatomy andphysiology andassessmenttechniques in caringfor clients.

b. Assess the healthstatus of a client1. Conduct a healthhistory and functionalhealth patterninterview of clientswith alterations incardiac and tissueperfusion andtransport.

Altered Oxygenation: Cardiac and Tissue PeripheralPerfusion and Transport

I. Review of Anatomy and Physiology of theCardiovascular and Hemato-lymphatic System

II. The Nursing ProcessA. ASSESSMENT

i. Subjective Data

Nursing Health History

Demographic Information regarding age,gender, and ethnic origin

Presence of signs and symptom related to

cardiovascular and hemato-lymphaticproblems.- Chest pain or discomfort- Shortness of breath or dyspnea- Fluid retention, peripheral edema or weight

gain- Palpitations- Fatigue or changes in level of consciousness- Syncope- Irregular heartbeat- Pain extremities- Tenderness on calf or leg- Altered neurologic function

11 Functional Patternsii. Objective Data

Physical Assessment- Non-invasive tests

ECG

Echocardiogram

Ultrasound

Chest X-ray

Radionuclide studies

Video clips on :Anatomy and

physiology, physicalassessment of thecardiovascular system.

Classroom:a. Paper a

pencil teb. Case stuc. Nursing

Plans

RLE:a. Nursing

Plansb. Perform

Checklis

CT scan

CVP monitoring

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- Invasive tests

Cardiac Catheterization

Arteriogram

Angiocardiogram

Venogram

Lymphography

Bone marrow aspiration

Intermediate Content Teaching-Learning Activities No. of Hours Evaluatio


2. Perform systematic andcomprehensive physicalassessment to validateassessed date

3. Interprets deviationsfrom normal findings inthe physicalassessment, diagnosticsand laboratoryexaminations.

4. Utilize assessed data inorder to;

a. Prioritize nursingdiagnosis

b. Plan the care ofclients utilizingevidenced basednursing research

5. Discuss thepathophysiologicresponses to alteredcardiac and peripheral

tissueperfusion/transport

6. Plan effective care

7. Implement individualizednursing care

III. The Nursing ProcessB. ASSESSMENT

-Diagnostic Tests and Laboratory Procedures

Cardiac Biomarker Analysis

Blood Chemistry

Hematology

Coagulation studies

Lipid Profiles

Cholesterol levels

Triglycerides

C. ANALYSIS1. Common Problems of the Cardiovascular

and Hemato-lymphatic SystemsCardiovascular System

a. Conduction problems of the heart

Dysrhythmiasb. Coronary vascular disorders

1.Coronary Artery Disease

Coronary Atherosclerosis

Angina Pectoris

Myocardial Infarctionc. Structural, Infectious and Inflammatory

cardiac problems1.Valvular Disorders

Mitral Valve Prolapse

Mitral Regurgitation

Mitral Stenosis

Aortic Regurgitation

Aortic Stenosis2.Cardiomyopathy

8. Safely andknowledgeablyadministers prescribed

3.Infectious Disorders of the heart

RheumaticEndocarditis

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administers prescribedmedications andtreatment/alternativecomplementarymedicine.

9. Actively participates inplanning andcoordinating culturallysensitive interdisciplinarycare.

10. Provide appropriate andeffectively utilizeavailable resources inthe care of clients toachieve positiveoutcome.

11. Evaluate the

effectiveness of nursingcare, revising thenursing care plan asneeded to promote,maintain, or restorefunctional health statusof clients with alteredcardiac and peripheraltissueperfusion/transport.

12. Maintain confidentialityand protect clientsprivacy

13. Accurately reports anddocuments findings inclinical practice.

Rheumatic Endocarditis

Infective Endocarditis

Myocarditis

Pericarditisd. Complications of Heart Disease

1. Cardiac Hemodynamicsa. Heart Failure

A1. Chronic Heart FailureA2. Acute Heart Failure

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2. Other Complicationsa. Cardiogenic shockb. Thromboembolismc. Pericardial Infusion and Cardiac

Tamponaded. Cardiac arrest

e. Hypertension1. Types of hypertension2. Hypertensive Crisis

f. Vascular Disorders: Problems ofPeripheral Circulation

1. Arterial Disorders

Arteriosclerosis and Atherosclerosis

Peripheral Arterial Occlusive Disease

Thromboangiitis Obliterans (Buergers

Disease)

Aortitis

Aortoiliac disorders

Dissecting Aorta

Arterial embolism and Arterial

thrombosis

Raynauds Disease

2. Venous Disorders

Venous thrombosis

- Deep vein thrombosis- Thrombophlebitis- Phlebothrombosis

Chronic Venous Insufficiency

Leg ulcers

Varicose veins

3. Lymphatic Disorders

Lymphangitis and Lymphadenitis

Lymphedema and Elephantiasis

4 Cellulitis

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4. Cellulitis



Hematologic Problemsa. Anemia

Hypoproliferative

Hemolytic

b. Polycythemia

Polycythemia Vera

Secondary Polycythemia

c. Leukopenia

Neutropenia

Lymphopenia

d. Leukemia

Acute Myeloid Leukemia

Chronic Myeloid Leukemia

Acute Lymphocytic Leukemia

Chronic Lymphocytic Leukemia

e. Agnogenic Myeloid Metaplasia(Lymphoma)

Hodgkins Disease

Non-Hodgkins disease

f. Multiple Myelomag. Bleeding Disorders

Primary Thrombocytopenia

Secondary Thrombosis

Thrombocytopenia

Idiopathic Thrombocytopenic Purpura

Platelet Defects

Hemophilia

Von Willebrands Disease

h. Acquired Coagulation Disorders

Vitamin K deficiency

Disseminated Intravascular

Coagulopathy

Thrombotic Disorders

Hyperhomocysteinemia

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Hyperhomocysteinemia

Anti-thrombin Deficiency

Acquired Thrombophilia



2. Gerontologic Considerations

3. Probable Nursing Diagnosis

Decreased Cardiac Output as evidencedby increased heart rate, fatigue, shortnessof breath, decreased urine output,impaired mental processing, decreasedlevel of consciousness

Activity intolerance as evidenced by

weakness, fatigue, vital signs, changeswith activity.

Fatigue as evidenced by difficultycompleting usual daily activities, frequentdesire to rest.

Impaired home maintenance as evidencedby inability to maintain family roles

Risk for peripheral neurovasculardysfunction as evidenced by changes incolor, temperature, sensation ofextremities

Impaired Tissue Integrity

Ineffective Therapeutic RegimenManagement

Ineffective Tissue Perfusion as evidencedby cool, dusky skin, decreased urineoutput and chest pain

Acute pain

D. PLANNING

1. Planning for Health Promotion

a. Risk factor and risk managementb. Promotion of circulationc. Prevention of infection

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d. Genetic Counselinge. Role of Nutrition

2. Planning for Health Maintenance and Restorationa. Planning for basic life support: CPRb. Planning for advanced life support : ACLSc. Planning for Care of clients to have Cardiac

Surgery



E. IMPLEMENTATION

1. Pharmacologic Managementa. Cholesterol lowering medications

- Statins- Bile Sequestrants- Nicotinic Acid- Fibric acid derivatives

b. Antianginal Medication- Nitroglycerin

- Beta-blockers- Calcium Channel Blockers

c. Antidysrhythmics- Class I Sodium Channel Blockers- Class II Beta-Adrenergic Blockers- Class III Prolong Repolarization- Class IV Calcium Channel Blockers

d. Antiplateletse. Diureticsf. Medications for Heart Failure

- ACE Inhibitors- Angiotensin Receptor Blockers- Diuretics- Positive Inotropic Agents

- Sympathomimetic- Phosphodiesterase Inhibitors

g. Medications for Anemia- Iron supplement- Vitamin B12- Folic Acid supplement

h. Antihypertensives- Alpha adrenergic blockers

- ACE Inhibitors- Angiotensin Receptor Blockers- Beta Adrenergic lockers

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- Calcium Channel; Blockers- Centrally acting sympatholytics- Vasodilators

i. Anticoagulants- Heparin- Warfarin


Competencies Classroom RLE Lec RLE2. Surgical Management

a. Invasive Coronary Artery Procedures

- Percutaneous Coronary Interventions

Percutaneous Transluminal Coronary

Angioplasty (PTCA)

Coronary Artery Stents

Atherectomy

Brachytherapy

- Coronary Artery Revascularization

Coronary Artery Bypass Graft (CABG)

b. Heart Transplantationc. Valvular Replacement Procedures

- Valvuloplasty- Valve Replacement Therapy- Septal Repair

3. Complementary and Alternative Therapies

a. Fish oil / Omega 3 fatty acids

b. Hawthorn

c. Herbs that may affect clotting

d. Natural Lipid lowering agents

4. Management for Blood disorders

a. Blood Transfusion

b. Stem Cell Transfusion- Bone marrow transplantation- Peripheral blood stem cell transfusion

5. Adjunctive Modalities for Cardiovascular Problems

a. Cardioversion and Defibrillation

- Electrical Cardioversion

- Pacemaker Insertion

6. Nutrition and Diet Therapy

H EVALUATION

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H. EVALUATION


Competencies Classroom RLE Lec RLENUTRITIONAL-METABOLIC PATTERNS

Responses to Altered Nutrition Functions

I. Anatomy and Physiology of the GastrointestinalSystem

II. The Nursing Process

a) Assessment

i) Nursing History(1) Subjective Data

(a) Demographic Data

(b) Presence of signs and symptomsrelated to Gastrointestinal Problems

Abdominal pain

Dyspepsia

Intestinal gas

Nausea and vomiting

Change in bowel habits or stool

characteristics

(2) Objective Data(a) 11 functional pattern

(b) Physical Assessment(i) Anthropometric Measurement

(ii) Inspection(iii) Auscultation

(iv)Percussion

(v) Palpation

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(c) Diagnostic Assessment

(i) Non-invasive DiagnosticProcedures

1. Radiological Studies2. Upper GI Barium Swallow

3. Lower GI or Barium Enema4. Flat Plate of the Abdomen5. Ultrasound

6. Magnetic Resonance Imaging7. Computed Tomography

(ii) Invasive Diagnostic Procedures

1. Scintigraphy -(Molecular Imaging Scan)

2. Anoscopy3. Proctoscopy

4. Sigmoidoscopy

(ii) Other GI tests1. Bernstein Tests (Esophageal

Acidity, Manometry, AcidPerfusion)

2. Esophageal Manometry3. Ambulatory Esophageal pH

monitoring4. Exfoliative Cytologic Analysis

5. Gastric Analysis

(d) Laboratory Procedures(i) Blood Chemistries

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( )

(ii) Total Lymphocyte Count(iii) Fecal Analysis

1. Occult Blood2. Ova and Parasite

3. Quantitative fat Studies4. Fecal Leukocytes

5. Stool electrolyte tests



b) Analysisi) Common Health Problems of the

Gastrointestinal Systems

(1) Disorders of the Salivary(a) Parotitis

(b) Sialadenitis(c) Salivary Calculus

(2) Cancer of the Oral Cavity

(3) Disorders of the esophagus(a) Achalasia

(b) Diffuse Spasm(c) Hiatal Hernia

(d) Diverticulum(e) Perforation

(f) Foreign Bodies(g) Chemical Burns

(h) Gastroesophageal reflux(i) Barretts esophagus

(j) Benign tumors of the esophagus(k) Cancer of the esophagus

(4) Gastric and Duodenal Disorders

(a) Gastritis(b) Peptic Ulcer Disease

(c) Morbid Obesity

(d) Gastric Acid(e) Duodenal Tumors

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(5) Intestinal and Rectal Disorders

(a) Abnormalities of Fecal Elimination(i) Constipation

(ii) Diarrhea(iii) Fecal Incontinence

(iv)Irritable Bowel Syndrome



(b) Conditions of the Malabsorption,Acute Inflammatory and Intestinal

Disorders(i) Appendicitis

(ii) Diverticular disease(iii) Peritonitis

(c) Inflammatory Bowel Disease

(i) Regional Enteritis (Crohns

Disease)(ii) Ulcerative Colitis(iii) Diverticulosis and

Diverticulitis(iv)Hemorrhoids

(6) Intestinal Obstructions

(a) Small bowel obstruction(b) Colorectal Cancer

(c) Polyps of the Colon and Rectum

(7) Diseases of the Anorectum

(a) Anorectal Abscess(b) Anal Fistula(c) Anal Fissure

(d) Hemorrhoids(e) Sexually Transmitted Anorectal

Disease

(f) Pilonidal Sinus or Cysts

(i) Cholelithiasis

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(ii) Gall Bladder Cancer



(8) Disturbances of the Accessory Organs

(a) Disorders of the liver(i) Hepatitis

(ii) Cirrhosis(iii) Liver Cancer

(b) Disorders of the Pancreas(i) Acute and Chronic pancreatitis

(ii) Pancreatic Cancer

(c) Disorders of the Biliary Tract

ii) Gerontologic Assessment

iii) Potential Nursing Diagnosis

(1) Imbalanced Nutrition less than bodyrequirements as evidenced by decreased food

intake, weight loss 20% or more of idealbody weight, dry or brittle hair, weakness,

impaired tissue healing.(2) Deficient Fluid and Volume as evidenced

by complaints of stomach discomfort,

increased salivation, tachycardia and coldclammy skin.

(3) Impaired skin integrity as evidenced by

disruption of skin integrity as evidenced bydisruption of skin surface, pain and itching

(4) Acute pain

(5) Diarrhea

c) Planning

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d) Implementation

i) Pharmacologic Management(1) Antiemetics

(2) Anticoagulants(3) Histamine agents

(4) Laxatives(a) Bulk forming

(b) Stool softeners

(c) Saline and osmotic solutions(d) Stimulants(e) Selective chloride channel activator

(f) Serotonin type 4 receptor partialagonists

(5) Antipruritis(6) Vitamin Supplement

(7) Antacids(8) Antihyperlipidemics

(9) Antispasmodics(10) Antidiarrheal

(11) Antisecretory agents H2 Receptor

Blockers(12) Vasopressin(13) Epinephrine

(14) Cholinergics(15) Antibiotics for H. Pylori and Anti-

infectives

(16) Alpha-interferon and ribavirin

(17) Pancreatic Enzyme Replacement

ii) Complimentary Therapy

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ii) Complimentary Therapy(1) Ginger

(2) Milk thistle (Silymarin)



iii) Surgical Management(1) Neck Dissection

(2) Esophagectomy(3) Vagotomy

(4) Pyloroplasty(5) Gastrostomy

(6) Gastrectomy

(7) Colostomy(8) Hemorrhoidectomy(9) Gastrointestinal Bypass

(10) Ileostomy(11) Vagotomy

(12) Pyloroplasty(13) Antrectomy

(a) Billroth I (Gastroduodenostomy)(b) Billroth II (Gastrojejunostomy)

(14) Bariatric Surgery(15) Fistulectomy

iv) Modalities of Care of the GastrointestinalSystem(1) Parenteral Hyperalimentation

Feeding via Nasogastric, Jejunostomy andGastrostomy Tubes

(2) Colostomy

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v) Special Procedures(1) Colostomy care and Irrigation

(2) Hot Sitz Bath

vi) Nutrition and Diet Therapy(1) Regular Diets

(2) Special; Diets high fiber, gluten free,low-protein, high calorie, high protein diets

vii)Client Education

e) Evaluation

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Responses to Altered Metabolic and Endocrine

Function

I. Anatomy and Physiology of the Endocrine

System

II. The Nursing ProcessI. Assessment

a. Subjective Datai. Demographic Data

ii. Presence of Signs and Symptomsb. Objective Data

i. 11 functional patternii. Physical assessment

iii. Diagnostic Assessment1. Invasive Procedures

2. Non-invasive Procedures3. Laboratory

II. Analysisa. Common Health Problems

b. Gerontologic Considerationsc. Potential Nursing diagnosis

III. PlanningIV. Implementation

a. Pharmacologic Managementb. Complimentary Therapy

c. Surgical Management

d. Modalities of Caree. Special Procedures

f. Nutrition and Diet

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f. Nutrition and Dietg. Client Education

V. Evaluation



Intermediate

CompetenciesGiven an adult client

(young, middle, old,old-old adult) with

response4s to alteredendocrine function; the

student should be to;

Apply knowledge ofnormal anatomy and

physiology, andassessment techniques

in caring for clients.

1. Conduct a healthhistory and

functional healthstatus of clients

having at risk for

alterations forendocrine function

2. Perform systemic

andcomprehensive

physical

Endocrine and Metabolic Problems

I. Anatomy and Physiology of the Metabolic, Hepatic

and Endocrine Systems

II. The Nursing Process

b. Assessment

i. Subjective Data1. Demographic Data2. Presence of Signs and Symptoms related

to the Endocrine and Metabolic Systems

Jaundice

Malaise

Weakness

Fatigue

Pruritus

Abdominal Pain

Increasing abdominal girth (ascites)

MelenaHematochezia

ii. Objective Data1. 11 functional pattern

2. Physical assessment

assessment tovalidate assessed

data.

Abdominal Girth Measurement

Inspection

Percussion

Palpation

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Palpation

Auscultation



3. Interpret deviationsfrom normal

findings in thephysical

assessment,diagnostic and

laboratoryexaminations

4. Utilize the assesseddata in order to;

Prioritize nursing

diagnosis

Discuss thephysiological

processes

Plan the care of

clients utilizingevidence-based

nursing research

Achieve the best

clinical outcomesutilizing ethico-

moral and legalprinciples.

Plan effective care.

5. Diagnostic Assessment

Invasive Procedures

a. Angiographyb. Adrenal Venogram

c. Portal PressureMeasurement

d. Biopsy

e. Paracentesis

f. Endoscopic RetrogradeCholangiopancreatography

Non-invasive Procedures

a. Test of anatomic systemstructure and function

b. MRIc. Electroencephalogram

d. Ultrasonographye. CT scan

f. Radionuclide Imagingg. Fine needle aspiration

h. Achilles tendon reflextests

i. Radioiodine re-uptaketests

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6. Implement

individualized nursingcare;

Safely and

knowledgeably

administersprescribedmedications and

treatments

Activelyparticipates in

planning,coordinating,

culturallysensitive

interdisciplinarycare

Provideappropriate clienteduction, health

maintenanceinstructions and

community

Laboratorya. Pigment Studies

b. Protein Studiesc. Serum

Aminotransferase

Studiesd. Prothrombin Timee. Serum

AminotransferaseStudies

f. Ammoniag. Cholesterol

c. Analysis

i. Common Health Problems1. Common Problems of the

Endocrine System

Disorders of the Thyroid Glanda. Hyperthyroidism

i. Graves diseaseii. Toxic Nodular Goiter

iii . Thyroiditisiv. Thyroid Tumors

b. Hypothyroidism

i. Iodine Insufficiencyii. Hashimotos Disease

iii. Myxedema

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based-care Disorders of the Parathyroid Glanda. Hyperparathyroidism

b. Hypoparathyroidism

Disorders of the Adrenal Glanda. Addisons Disease

b. Pheochromocytomac. Cushings Syndrome

Disorders of the Pituitary Glanda. Anterior Pituitary

Gland Disorders

i. Gigantismb. Posterior Pituitary

Gland Disordersi. SIADH

ii. Diabetes Insipidus



2. Common Problems of the BiliarySystem

Cholecystitis

Cholelithiasis

Pancreatitisa. Acute

b. Chronic

Pancreatic Cysts

Hyperinsulinism

Diabetes Mellitus

a. Types of Diabetes

Mellitusb. Acute complications ofDiabetes Mellitus

i. Hypoglycemia (InsulinReactions)

ii. Diabetic Ketoacidosis

(DKA)

iii. Hyperglycemichyperosmolar nonketotic

syndrome (HHNS)li i

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c. Long Term complications

of Diabetes Mellitusi. Macrovascular

complicationsii. Microvascular

complicationsiii. Foot and leg problems

d. Special Issues in DiabeticCare

3. Common Problems of the Hepatic

System

Viral Hepatitisa. Hepatitis A, B, C, D,E

and G

Non-viral Hepatitisa. Toxic Hepatitis

b. Drug Induced Hepatitis

Fulminant Hepatic Failure

Hepatic Cirrhosis

Cancer of the Liver



ii. Gerontologic Considerations

iii. Potential Nursing diagnosis

1. Activity Intolerance related to fatigueand depressed cognitive process

2. Risk for imbalance body temperature3. Constipation related to depressed

gastrointestinal function4. Ineffective Breathing Pattern related

to depressed ventilation5. Disturbed thought process related to

depressed metabolism

6. Imbalanced Nutrition: Less / More

than Body requirements7. Deficient fluid volume as evidenced

by dry mucus membranes, thirst andd d i t t

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decreased urine output

8. Impaired skin integrity asevidenced by dry, rough, reddened,

and edematous skin.9. Disturbed body image

10. Ineffective therapeutic management

d. Planningi. Planning for Health Restoration and

Health Maintenance

e. Implementationi. Pharmacologic Management

1. Iodine Resources2. Antithyroid

3. Thyroid Replacement4. Cortisol Replacement

5. Insulin6. Oral Hypoglycemics

7. Hormone therapy



ii. Complimentary Therapy1. Aloe vera

2. Bilberry3. Biter Melon

4. Fish Oil

5. Fenugreek 6. Garlic7. Ginseng

8. Gymema9. Horse Chestnut Seed Extract

10. Prickly pear

iii. Surgical Management1. Thyroidectomy

2. Parathyroidectomy3 Unilateral and Bilateral

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3. Unilateral and Bilateral

Adrenalectomy4. Transsphenoidal-

Hypophysectomy5. AK//BK Amputation

6. Pacreatic Transplantation7. Liver Transplantation

8. Surgical Bypass Procedures9. Revascularization and Transition

10. Lobectomy11. Cryosurgery



iv. Modalities of Care/Special Procedures

1. Balloon Tamponade2. Endosc

Documents

A NCM 103 Lecture 2013