Ncm 103 Syllabus Neptunites

29

DOA REMEDIOS T. ROMUALDEZ MEDICAL FOUNDATIONCOLLEGE OF NURSING

CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTE BALANCE, NUTRITION AND METABOLISM AND ENDOCRINE

Course Description: This course deals with the principles and techniques of nursing care management of sick clients across lifespan with emphasis on the adult and the older person, population group in any setting with alterations/problems in oxygenation, fluid and electrolyte balance, nutrition and metabolism and endocrine function and clients undergoing surgery.Course Code : NCM 103Course Credit: 8 units lecture, 6 units RLE Contact Hours/sem: 136 hours lecture and 306 hours RLEPrerequisite: NCM 102Placement: 3rd year, 1st semesterCourse Objectives:At the end of the course, students will be able to:1. Use the nursing process in the care of individuals, families in community and hospital settings. Assess with client/s his/her/their condition/health status through interview, physical examination, interpretation of laboratory findings. Identify actual and at-risk nursing diagnosis Plan appropriate evidence-based nursing interventions with client/s and family for identified nursing diagnosis Implement plan of care with client/s and family. Evaluate the progress of his/her/their clients condition and outcomes of care.

2. Perform actual patient care in accordance with existing laws, legal, ethical and moral principles.3. Effectively communicate in speaking, writing, and presenting using culturally-appropriate language with client/s and their family and the health team.4. Document data on client care clearly, concisely, accurately and in a timely manner.

LEARNING OBJECTIVETOPICDATE ANDTIMELECTURER

Differentiate the normal and abnormal anatomy and physiology of the Respiratory systemI. Responses to Altered Oxygenation, Respiratory Gas Exchange, Transport, Perfusion

I.A. Review: Anatomy and Physiology of the Respiratory System

A. UPPER RESPIRATORY TRACT Nose, Paranasal sinuses, Pharynx, tonsils,adenoids, Larynx, Trachea

B. LOWER RESPIRATORY TRACT Lungs, Mediastinum, Lobes Bronchi and Bronchioles, Alveoli

July 168-12Mrs. Magno

LEARNING OBJECTIVETOPICDATETIMELECTURER

Differentiate normal & abnormal signs and symptoms of respiratory system

Gather relevant information about the present & past health, family & social history of the patient with respiratory disorder

I. B Functions of the Respiratory System-Oxygen Transport-Respiration-Ventilation-Air Pressure Variances-Airway Resistance-Compliance-Lung Volumes and Capacities-Pulmonary Diffusion and Perfusion-Ventilation and Perfusion Balance and Imbalance-Gas Exchange

I.C. Nursing Process:A. Assessment:

1. Subjective Data:

A. Nursing Historya. Common Symptoms-Dyspnea-Cough-Sputum Production-Chest Pain-Wheezing-Hemoptysis-Orthopnea-Cyanosis-Restlessness-Tachypnea-Confusion-Stridor-Nasal and sinus complains

B. Past Health, Family, and Social HistoryC. Functional Health Patterns

2. Objective Data:

A. Physical Assessment 1. General Appearance Clubbing of the fingers Cyanosis 2. Assessment of the Upper Respiratory Structures Nose and sinuses Mouth and Pharynx Trachea 3. Assessment of the Lower Respiratory Structures and Breathing Thoracic Inspection Chest Configuration Breathing Patterns and Respiratory Rates Thoracic Palpation Respiratory Excursion Tactile Fremitus Thoracic Percussion Diaphragmatic excursion Thoracic Auscultation Breath Sounds


1. Interprets deviations from normal findings in the physical assessment, diagnostic and laboratory examination

2. Identify the indications/ purposes, contraindications, side effects, complications and nursing responsibilities before, during and after the procedure.

Formulate nursing diagnosis related to respiratory problems using their knowledge of the assessment of the respiratory

Make an effective & comprehensive nursing care plan for clients with respiratory disorders

B. Diagnostic Exams b.1. Non-invasive Pulmonary Function Test Pulse Oximetry Ventilation Perfusion Scan Radiologic Studies: Chest X-rays CT Scan, MRI, PET, Pulmonary Angiography

b.2. Invasive Endoscopic Exams: Laryngoscopy, Bronchoscopy, Mediatinoscopy Lung Biopsy Thoracentesis and Pleural fluid Analysis Fluoroscopic studies Lung scans

b.3. Laboratory Tests Sputum Culture Nose and throat culture ABGs Fagerstrom Test (Standardized degree of nicotine dependence) Smoke analyser

B. Analysis/ Nursing Diagnosis

1. Ineffective airway clearance as evidenced by shortness of breath, dyspnea, orthopnea, retractions, nasal flaring, altered chest excursion2. Ineffective breathing patterns as evidenced by ineffective cough, diminished or abnormal breath sounds, cyanosis, restlessness3. Impaired gas exchange as evidence by cyanosis, abnormal respiratory rate, rhythm, nasal flaring, tachycardia, diaphoresis, confusion4. Impaired spontaneous ventilation as evidenced by dyspnea, use of accessory muscles, tachycardia, apprehension5. Disturbed sleep pattern (sleep-rest)6. Anxiety (Self- Perception- Self- Concept)

C. Planning:

1. Planning for health promotion2. Planning for health restoration and maintenancea. Maintain airway patency: coughing techniques, suctioningb. Relieving apprehension and fearc. Reducing metabolic demandsd. Maintaining rest and activitye. Decreasing the efforts of breathingf. Maintaining nutrition and hydration


Explain the various respiratory problems and recite all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.

Enumerate the pathognomonic manifestations of each disease and explain the reason why they develop.

g. Preventing and controlling infectionh. Planning for oxygen therapyi. Incentive spirometryj. Aerosol therapyk. Postural drainagel. Ventilation therapym. Artificial airwaysn. Chest drainageo. Chest surgery- Lobectomy- Pneumonectomy- Segmental Resection- Wedge Resection- Decortication- Exploratory Thoracotomy- Thoracotomy not involving lungs- Video- assisted thoracic surgery (VATS)- Lung volume Reduction Surgery (LVRS)

I.D. COMMON HEALTH PROBLEMS

A. Nursing Care of Clients with Upper Respiratory Problems

Rhinitis Viral Rhinitis Rhinosinusitis Pharyngitis Tonsillitis and adenoiditis Peritonsillar abscess Laryngitis Laryngitis Epistaxis Nasal Obstruction Fractures of the nose Laryngeal Obstruction Cancer of the larynx

B. Nursing Care of Clients with Chest and Lower Respiratory Tract Disorders Pneumonia Aspiration Severe Acute Respiratory Syndrome Pulmonary Tuberculosis Lung Abscess Pleurisy Pleural Effusion Empyema Pulmonary Edema Acute Respiratory Failure Acute Respiratory Distress Syndrome-Pulmonary Arterial Hypertension-Pulmonary Heart Disease ( CorPulmonale)-Cardiac Tamponade-Subcutaneous Emphysema-Pulmonary Embolism-Pulmonary Hypertension-Pulmonary Edema

July 23

8-12

Mrs. Magno


Explain the various respiratory problems and recite all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.


* Occupational Lung Disease- Asbestosis- Silicosis- Coal Workers Pneumoconiosis- Hypersensitivity Pneumonitis- Sarcoidosis-Lung Cancer -Tumors of the Mediastinum-Trauma of the Chest or Lungs - Thoracic Injury: Rib Fracture, flail chest, Pulmonary Contusion, Blunt Trauma, Penetratingtrauma: Gunshot and stab wounds - Inhalational Injury: smoke inhalation - near drowning

C. Nursing Care of Clients with Chronic Pulmonary Diseasea. Chronic Obstructive Pulmonary Diseaseb. Emphysemac. Bronchitisd. Bronchiectasise. Asthmaf. Status Asthmaticusg. Cystic Fibrosis

D. Nursing Care of Pediatric Clients with Respiratory Disorders

a. Upper Respiratory Tract Common Colds Allergic Rhinitis/ Chronic Rhinitis Sinusitis Pharyngitis Tonsilitis Epistaxis Aspiration Laryngitis Croup Choanal atresia

b. Lower Respiratory Tract Asthma, Status Asthmaticus Pneumonia PTB/ Primary Complex Cystic Fibrosis Bronchitis/ Bronchiolitis Atelectasis Pneumothorax

c. Others Otitis Media RDS/ SIDS

July 24

8-12

July 30

8-12

Mrs. Magno

Mrs. De Asis


Implement individualize the nursing care:

1. Safely and knowledgeably administer prescribed medications and treatments/ alternative complementary medicine

3. Provide appropriate client education and health maintenance and community- based care of clients.

4. Evaluate the progress of his/her/their clients condition and outcomes of care

Differentiate the normal and abnormal anatomy and physiology of the Cardiovascular & Hematolymphatic System

Differentiate normal & abnormal signs and symptoms of respiratory system

I.E. IMPLEMENTATION

1. Pharmacological Therapeutics Antitussives Decongestants and Antihistamines Antitubecular Broad Spectrum Antibiotics Adrenergic Stimulants Methylxanthines Anticholinergics Corticosterioids Mast Cells Stabilizers Lekotriene Modifiers Surfactant Adminitration Expectorants

2. Complimetary and Alternative Therapy Echinacea Golden Seal Zinc

3. Nutrition and Diet Therapy Tube Feedings Fluid Therapy per Orem, IV High Protein, High Calorie

4. Client Education

II. RESPONSES TO ALTERED OXYGENATION, CARDIAC AND TISSUE PERIPHERAL PERFUSION/ TRANSPORT

II.a Review: Anatomy and Physiology of the Cardiovascular and Hemato-Lympathic System

1. Anatomy of the Heart Heart Chambers, Heart Valves, Coronary Arteries

2. Functions of the Heart Cardiac Electrophysiology Cardiac Action Potential Cardiac Cycle Cardiac output

II. b. Nursing Processa. Assessment

1. Subjective Data:

A. Nursing History:a. Common symptoms

Chest Pain Shortness of breath Peripheral edema Palpitations Fatigue Dizziness Syncope Changes in levels of consciousness

July 31

8-12

Mrs. Alfonso


Gather relevant information about the present & past health, family & social history of the patient with respiratory disorder

Differentiate normal & abnormal signs and symptoms of cardiovascular systems

Identify the indications/ purposes , contraindications, side effects, complications and nursing responsibilities before, during and after the procedure.

B. Functional Health PatternsC. Past health, family and social history

2. Objective Data

a. Physical Assessment General Appearance Inspection of the skin Blood Pressure Pulse Pressure Postural Blood Pressure Changes Arterial Pulses Jugular Venous Pulses Heart Inspection and Palpation Heart Auscultation Inspection of the extremities Assessment of other systemsa. Lungsb. Abdomen

2.a. Problems of Oxygenation: Perfusion Fatigue, fluid retention, dyspnea Irrregular heartbeat, pain tenderness in the calf or legs syncope, leg pain Altered neurologic function

2. b. Problems in Oxygenation Transport: Skin: flushing, jaundice, cyanosis, excoriations, pruritus, leg ulcers, angiomas, telangiectasis, nevus purpura petechiae, ecchymosis, hematomas, chondroma, plasmacytoma Eyes: Icteresia, Conjunctival pallor, blurred Vision, diplopia, visual fields cut Nose: Epistaxis Mouth: Gingival and mucosal membrane Changes Lymph Nodes: Adenopathies Heart and Chest: tachycardia, palpitations, Altered BP, sternal tenderness, low Oxygen saturation Abdomen: Hepato-splenomegaly Nervous System: Paresthesia, Headache, Nuchal Rigidity Musculoskeletal system: bone pain, joint Swelling and arthralgia

B. Diagnostic Tests and Procedures1. Non-invasive: ECG Ultrasound chest Xray Cardiac Stress Testing Exercise stress Testing Pharmacological Stress Testing Echocardiography CT scan MRI Radio-nuclides studies


Interpret deviations from normal findings in the physical assessment, diagnostic and laboratory examination

Communicate to the patient the result of the diagnostic and lab examination

Formulate nursing diagnosis related to respiratory problems using their knowledge of the assessment of the cardiovascular system4. Invasive Studies:

Cardiac Catheterization Angiography Aortography Coronary Arteriography Right Heart Catheterization Electrophysiologic Testing Arteriogram Venogram Lymphography Bone marrow aspiration Hemodynamic monitoring * CVP * Pulmonary artery pressure * Intraarterial BP monitoring

5. Laboratory Testsa. Cardiomarker analysis Enzymes and Isoenzymes Studies: CPK-MB, C-Reactive Protein, Troponin-Ib. Blood Chemistry, Hematology and coagulation studiesc. Brain (B-type) Natriuretic Peptided. C-reactive Proteine. Homocysteinef. ESR, ASO-Titerg. Torniquet Testh. Throat Culture

b. ANALYSIS/ NURSING DIAGNOSIS:

1. Decreased Cardiac Output as evidenced by increasedHeart rate, fatigue, SOB, decreased urine output,2. Impaired mental processing, decreasing LOC3. Activity Intolerance as evidenced by weakness, fatigue, vital signs changes4. Fatigue as evidenced by difficulty completing usual daily activities, frequent desire to rest 5. Risk for peripheral neurovascular dysfunction as evidenced by changes in color, temperature, sensation of extremities6. Impaired tissue integrity (Nutrional Metabolic)7. Ineffective Breathing Patterns8. Fluid Volume Excess9. Nutrition, Altered, less than body requirement10. Growth and development, altered11. Family Process, Altered12. Pain13. Activity Intolerance


Make an effective & comprehensive nursing care plan for clients with respiratory disorders

Explain the various cardiovascular problems and recite all the precipitating factors and risk factors that may lead to the development of these diseases

Enumerate the Pathognomonic Manifestations of each disease and explain the reason why they develop.

Discuss the psychopathophysiologic process of these diseases from causes to manifestations and its complicationsc. PLANNING

1. Planning for health promotiona. Risk Factor and risk managementb. Promotion of circulationc. Prevention of infection: immunizationsd. genetic counsellinge. role of nutrition2. Planning for health Maintenance and restorationa. Planning for basic life support, CPRb. Planning for advanced life supportc. Planning for the client having cardiac surgery

II.C. COMMON HEALTH PROBLEMS

A. Nursing Care of Clients with Dysrhythmias and Conduction Problems

1. Dysrhythmias

a. SINUS NODE DYSRHYTHMIAS Sinus Bradycardia Sinus Tachycardia Sinus Arrhythmias

b. ATRIAL DYSRHYTHMIAS Premature atrial complex Atrial Flutter Atrial Fibrillation

c. JUNCTIONAL DYSRHYTHMIAS Premature Junctional Complex Nonparoxysmal Junctional Tachycardia Atrioventriculr Nodal Reentry Tachycardia

d. VENTRICULAR DYSRHYTHMIAS Premature Ventricular Complex Ventricular Tachycardia Venticular Fibrillation Idioventricularrhythym Ventricular asystole

2. CONDUCTION ABNORMALITIESa. First-degree Atriventricular blockb. Second-degree Atriventricular Block, Type I (Wencke Bach)c. Second-degree Atriventricular Block, Type IId. Third-degree Atriventricular Block

B. Nursing Care of Clients with Coronary Vascular Diseasek. Coronary Atherosclerosisl. Angina Pectorism. Acute Coronary Syndrome and Myocardial Infarction

Aug 6

8-12

Aug 78-12

Mrs. De Asis

Mrs. Magno


C. Nursing Care of Clients with Structural, Infectious and Inflammatory Cardiac Disordersa. Mitral Valve Prolapseb. Mitral Regurgitationc. Mitral Stenosisd. Aortic Regurgitatione. Aortic Stenosisf. Septal Defectsg. Cardiomyopathyh. Rheumatic Endocarditisi. Infective Endocarditisj. Myocarditisk. Pericarditis

D. Nursing Management of Clients with Complications from Heart Diseasea. Chronic Heart Failureb. Pulmonary Edemac. Thromboembolismd. Pericardial effusion and cardiac tamponadee. Cardiac arrest

E. Nursing Care of Clients with Vascular Disorder and Problems of Peripheral Circulationa. Peripheral Occlusive Diseaseb. Upper Extremity Arterial Occlusive Diseasec. ThromboangitisObliteransd. Aortoiliac Diseasee. Aneurysmsf. Dissecting Aortag. Arterial Embolism and arterial thrombosish. Raynauds Phenomenoni. Chronic Venous Insufficiency/ Postthrombotic Syndromej. Leg Ulcersk. Varicose Veinsl. Lymphagitis and Lymphadenitism. Lymphedema and elephantiasis

F. Nursing Care of Clients with Hypertension

a. Hypertensionb. Hypertensive Crises

G. Nursing Care of Clients with Hematologic Disorders

a. Hypoproliferativeanemiasb. Hemolyticanemiasc. Polycythemia Verad. Secondary Polycythemiae. Neutropeniaf. Lymphopeniag. Acute Myeloid Leukemiah. Chronic Myeloid Leukemiai. Hodgkin Lymphomaj. Non-hodgkin Lymphomak. Primary Thrombocythemial. Secondary Thrombocytosism. Thrombocytopenia

Aug 12(in lieu of Aug 17)8-12

Aug 13

8-12

Mrs. Alfonso

Mrs. De Asis

EARNING OBJECTIVETOPICDATETIMELECTURER

n. Idiopathic Thrombocytopenic Purpurao. Platelet Defectsp. Thalassemiasq. Hemophiliasr. Von Willebrands Diseases. Vitamin K Deficiencyt. Disseminated Intravascular Coagulationu. Thrombotic Disordersv. Hyperhomocysteinemiaw. Antithrombin Deficiencyx. Protein C Deficiencyy. Protein S Deficiencyz. Activated Protein C Resistance and Factor V Leiden Mutationaa. Acquired Thrombophilia

H. Pediatric Cardiovascular Disorders

A. Defects with increased pulmonary blood flow VSD, ASD, PDA

B. Defects with Obstruction to blood flow PS, AS, COA

C. Defects with mixed blood flow Transposition of great vessels TruncusArteriosus

D. Defects with decreased pulmonary blood flow Tricuspid atresia TOF

E. Acquired Heart Disease CHF Rheumatic Fever Persistent Pulmonary Hypertension Kawasaki Disease Endocarditis Arrythmias Hypertension Dyslipidemia Cardiomyopathy

F. Pediatric Hematologic Disorders

Hyperbilirubinemia Anemias Polycythemia Leukemia Purpuras- ITP, HenochSchonlein syndrome Hemophilias: Factors 8,9,11 deficiencies, Von Willebrands disease Thalassemias DIC

Aug 14

8-12

August 208-12

Mrs. Alfonso

Mrs. Alfonso


Implement individualized nursing care:

1. Safely and knowledgeably administers prescribed medications and treatments/ alternative complementary medicine

2. Provide appropriate client education and health maintenance and community- based care of clients.

Differentiate the normal and abnormal anatomy and physiology of the Digestive systemD. IMPLEMENTATION:

a. Pharmacologic Therapy

Cholesterol lowering drugs, statins, bile acids Sequestrants, nicotinic acid, fibric acid derivatives Antianginal: Nitroglycerine, beta blockers, calciumChannel blockers Antiplatelet: Oral and IV drugs Antidysrhythmic Drugs Heart Failure: ACE inhibitors, Angiotensin II Receptor blockers, diuretics, positive inotropic Agents, sympathomimetics, digoxin, phophodiEsterase inhibitors Anemia: Iron sources, B12 sources, folic acid Sources Antihypertensive: alpha adrenergic blockers, ACE inhibitors, beta adrenergic blockers, calcium Channel blockers, centrally acting Anticoagulants: Heparin, Warfarin

b. Complementary and Alternative Therapies

Fish Oil- Omega 3 Fatty acids Hawthorn Herbs that may affect clotting Natural Lipid Lowering agents Phototherapy DVET

c. Nutrition and Diet Therapy DASH Diet Pritkin Diet Ornish Diet Low Salt, Low Fat Gavage Feeding

d. Blood Transfusione. Bone Marrow Transplantf. Splenectomy

E. Client Education

III. RESPONSES TO ALTERED NUTRITION- METABOLISM

III.a. Review of Anatomy and Physiology of the GIT and Accessory Organs

1. Alimentary Tracta.Oral Cavity or Mouth Tongue, Teeth, Palate and Tonsils Salivary Glands, Pharynx, Esophagus Stomach, Small Intestines, Large Intestines Rectum and Anal Canal

Aug 263-7

(in lieu of Aug 21)

Mrs. De Asis


Interprets deviations from normal findings in the physical assessment, diagnostic and laboratory examinatio

Identify the indications/ purposes, contraindications, side effects, complications and nursing responsibilities before, during and after the procedure.

2. Accessory Organsa.Salivary Glandsb.Pancreas-as exocrine gland-as endocrine glandc.Liver and Biliary Tract

III. b. Nursing Process: a. Assessment:

1.Screening of Nutritional Status Nutritional Health Malnutrition

2.Subjective Data: a. Nursing History Common Symptoms: Abdominal Pain Intestinal Gas Nausea and Vomiting Changes in Bowel Habits and Stool Characteristics Indigestion Diarrhea Appetite and and weight changes Satietyb. Functional Health Pattern c. Past Health, Family and social History

3.Objective Data:

a.Physical Examinations:1. Anthropometric measurements2. Inspection: color, texture of mucous membrane, Growth patterns, scars, masses3. Auscultation: bowel sounds4. Percussion: liver span masses, ascites5. Palpation: masses, ascites, rebound, tenderness,6. Distention, organ enlargements

b.Diagnostic Examinations:1.Imaging tests Barium beefsteak meal Colorectal transit study Computed tomography scan (CT or CAT scan) Defecography Lower GI (gastrointestinal) series (barium enema) Magnetic resonance imaging (MRI) Magnetic resonance cholangiopancreatography (MRCP) Oropharyngeal motility (swallowing) study Radioisotope gastric-emptying scan Ultrasound Upper GI (gastrointestinal) series (also called barium swallow) Flat plate of the abdomen


Formulate nursing diagnosis related to respiratory problems using their knowledge of the assessment of the digestive system

Make an effective & comprehensive nursing care plan for clients with nutrition metabolism disorders

Explain the various gastrointestinal problems and recite all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.


2. Endoscopic procedures Colonoscopy ERCP EGD Sigmoidoscopy Small bowel enteroscopy Proctoscopy Anoscopy

4. Other procedures AnorectalManometry EsophagealManometry EsophagealPhmanometry Gastric Manometry

5. Laboratory Studies1. Blood Chemistries: serum amylase, lipase, proteins2. Total lymphocyte count3. D-xylose absorption test4. Fecal Analysis: Occult, ova and parasites,5. Quantitative fecal fat studies, fecal leukocytes,6. Stool electrolyte tests7. Exfoliativecytologic analysis8. Gastric analysis

b. Analysis/ Nursing Diagnosis1. Fluid Volume deficit related to blood loss from Injury, other complications related to surgery and Impaired gastric tissue function, vomiting and Interstitial fluid shift, diarrhea, loss of fluid and Electrolytes, impaired fluid intake, vomiting and Diarrhea, from intestinal obstruction2. Altered Nutrition: less than body requirements Related to esophageal injury, dysphagia, disease Process , treatment, nausea, vomiting, diarrhea, malignancy and treatment, GI symptomatology, fluid and electrolyte loss3. Risk for infection related to GI infections 4. Skin integrity, impaired, risk for related to Frequent contact with diarrheal stools

C. PlanningA. Planning for health maintenance, restorationa.enema, fecal impaction removalb.NGT, TPNc.Liver transplant

III. C. COMMON HEALTH PROBLEMS

A. Nursing Care of Clients with Oral and Esophageal Disorders Dental Plaques and Carries Dentoalveolar Abscess or Periapical Abscess Malocclusion Temporomandibular Disorders Jaw disorders Requiring Surgical Management Parotitis Sialadenitis

Aug. 27

8-12

Mrs. Magno


1. Explain the various disorders affecting nutrition-metabolism and explicating all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.

2. Enumerate the pathognomonic manifestations of each disease and explain the reason why they develop.

Salivary Calculus Neoplasms Achalasia Diffuse Esophageal Spasm Hiatal Hernia Diverticulum Perforation Foreign Bodies Chemical Burns GERD BarettsEsophagus Benign Tumors of the esophagus Cancer of the Esophagus

B. Nursing Care of Clients with Gastric and Duodenal Ulcer Gastritis PUD Morbid Obesity Gastric Ca Gastric Surgery Duodenal Ulcers

C. Nursing Care of Clients with Intestinal and Rectal Disorders Constipation Diarrhea Fecal Incontinence Food Poisoning Irritable Bowel Syndrome Conditions of Malabsorption Appendicits Diverticular Disease Peritonitis Types of Inflammatory Bowel Disease Small Bowel Obstruction Large Bowel Obstruction Colorectal Ca Polyps of the Colon and Rectum

D. Disorders caused by food, vitamin and mineral deficiencies:

Kwashiorkor Marasmus Iodine Deficiency

E. Malabsorption Syndrome

Celiac Sprue Lactase Deficiency Short Bowel Syndrome

F. Nursing Care of Clients with Hepatic Disorders

Jaundice Portal Hypertension Ascites Esophageal Varices Hepatic Encephalopathy And coma Hep A, B,C,D,E Virus Hep G Virus and GB Virus-C Toxic Hepatitis

Aug 28

8-12

Sept 38-12

Mrs. Magno

Mrs. De Asis


3. Discuss the psychopathophysiologic process of these diseases from causes to manifestations and its complications



Drug- Induced Hepatitis Primary Liver Tumors Liver Metastases Liver Transplantation Liver Abscess

G. Nursing Care of Clients with Biliary Disorders Cholecystitis Cholelithiasis Gallbladder Ca Biliary Atresia Acute Pancreatitis Chronic Pancreatitis Pancreatic Cyst Cancer of the Pancreas Tumors of the Head of the Pancreas Pancreatic Islet Tumors Hyperinsulinism UlcerogenicTumors

H. Pediatric Disorders:

Oral Moniliasis Cleft Lip/ Palate Tracheoesophageal atresia Tracheoesophageal fistula Pediatric Disorders: Enzyme Deficiencies Pyloric Stenosis GERD: Achalasia Hiatal Hernia Necrotizing enterocolitis Meckels diverticulum Megacolon Imperforate anus Inflammatory bowel diseases Intestinal Obstruction Intestinal Parasitic Infections

D. IMPLEMENTATION

1. Pharmacologic Therapeutics Antiemetics Anticoagulants Hematinics Laxatives Antipruritic Vitamin supplement Antacids Antihyperlipidemics Antispasmodics Antidiarrheal Antisecretory agents Vasopressin Octreotide Epinephrine Promotility Cholinergic Antibiotics for H. Pylori A-interferon and ribavirin Pancreatic Enzyme Replacement

Sept 48-12

Mrs. Alfonso


Differentiate the normal and abnormal anatomy and physiology of the endocrine system2. Complementary and Alternative Therapies Ginger Milk Thisle (Silymarin)

3. Surgical and Special Procedures:a. Surgical Procedures: Gastrostomy Gastrectomy Colostomy Hemorrhoidectomy Gastrointestinal bypass Ileostomy Hemicolectomyb. Special Procedures Parenteral Hyperalimentation Feeding per NGT, jejunostomy Gastrostomy tubes Hot sitz bath

4. Nutrition and Diet Therapy Regular Diets Special Diets: High Fiber, gluten free Low Protein, High Calorie

5. Client Education

MIDTERM EXAMINATION

IV. RESPONSES TO ALTERED ENDOCRINE FUNCTION

IV.a. Review on the Anatomy and Physiology of the Endocrine System

A. Hormones 1. Categoriesa. Proteins, Peptides and Amino Acid Derivativesb. Lipid Hormones

B. The Endocrine glands and their hormones

2. The Pituitary and Hypothalamusk. Hormones of the Anterior Pituitary Growth Hormone ( GH) Thyroid Stimulating Hormone (TSH) Adrenocoticotropic Hormone (ACTH)-Hormone (ICHSH)-Prolactin-Melanocyte- Stimulating Hormone-(MSH)l. Hormones of the Posterior Pituitary-Antidiuretic Hormone (ADH)-Oxytocin

3. The Thyroid Glanda.Triidothyronine (T3)b.Thyroxine (T4)c.Calcitonin2.Parathyroid Glanda.Parathyroid Hormone (PTH)

Sept 7-12

Sept 16 3-7

(in lieu of Sept 18 Foundation Days)

Mrs. Alfonso


Differentiate normal & abnormal signs and symptoms of the endocrine function

Gather relevant information about the present & past health, family & social history of the patient with endocrine disorder

1. The Adrenal Glanda. Adrenal Medulla Epinephrine or Adrenalin Norepinephrineb. Adrenal Cortex Glucocorticoids Mineralocorticoids Androgens

2. The Pancreasa. Beta Cells - Insulinb. Alpha Cells Glucagon

3. The Testes and the Ovariesa. Female Estrogen Progesteroneb. Male Testosterone

4. The Thymus Gland- Thymosin

5. The Pineal Gland a. Melatonin

C. Other Hormones 1. Prostaglandins 2. Erythropoietin 3. Human Chorionic Gonadotropin (HCG)

IV.b. Nursing Process a. Assessment

1. Subjective Data a. Nursing History Pain Infection/ Inflammation GI Manifestation Skin Changes Thirst Perfusion Problems: bleeding, bruising, Vital signs changes Sensory and mental changes Visual changes Urinary/ reproductive changes

b. Functional Health Patterns

2. Objective Data a. Physical Assessment Inspection: color, texture and temperature of the skin and mucus membrane, growth pattern, trembling Auscultation: bruit, tachycardia Palpation: organ thyroid enlargement Percussion: fluid, edema Severe weight loss


3. Interprets deviations from normal findings in the physical assessment, diagnostic and laboratory examination

4. Identify the indications/ purposes , contraindications, side effects, complications and nursing responsibilities before, during and after the procedure.

4. Utilize the assessed data in order to:

-Prioritize nursing diagnosis-Discuss the pathophysiological responses to altered nutrition - metabolism

b. Diagnostic/ Laboratory Examinationsa. Non-invasive Test of Thyroid structure and function: size, Shape, position, function by scanning, UTZ, MRI, CT scan, radionuclide imaging, testing forAchilles tendon reflexes, radioiodide uptake Test for adrenal structure and function: Lesions, diseases, CT, MRI, adrenal venogram And angiography Test of Pituitary structure and function: Skull X-ray, CT, MRI Metabolic Function Studies Abdominal UTZ, radiography, CT

b. Invasive Angiography Portal pressure measurement Biopsy Paracentesis Fine needle aspiration biopsy

c. Laboratory Growth Hormone/ human hormone Somatomedin; insulin like growth factor Water deprivation test Thyroid Stimulating Hormone Thyroxine ( T4) Triiodothyronine Thyroid antibodies Parathyroid ormone Calcium Cortisol Aldosterone ACTH ACTH stimulation ACTH suppression 17 ketosteroids Fasting blood sugar Oral Glucose Tolerance test Glycosylated Hemoglobin

b. Analysis/ Nursing Diagnosis:

1. Imbalanced Nutrition less than/ more than body Requirements as evidenced by increased food Intake with weight loss2. Deficient fluid volume as evidenced by dry mucus Membrane, thirst and decreased urine output3. Hyperthermia as evidenced by body temperature Ranging from 39-41 degrees Celsius


Plan the care of clients utilizing evidence-based nursing research Achieve the best clinical outcomes utilizing ethico-moral and legal principles Plan effective care.

Given an actual patient withDisorders of the thyroid gland, Disorders of the Parathyroids, Disorders of the adrenal glands, Disorders of the adrenal glands,Disorders of the Pituitary Gland, Disorders of the Pancreas, the student will be able to:

1. Explain the various disorders affecting the endocrine system and explicate all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.


3. Discuss the psychopathophysiologic process of these diseases from causes to manifestations and its complications4. Impaired Skin integrity as evidenced by dry, Rough, reddened and edematous skin5. Ineffective therapeutic regimen management( health perception, health management)6. Disturbed body image ( self-perception, Self-concept)

c. Planning1. Planning for health restoration and maintenance

IV.C. COMMON HEALTH PROBLEMS

1. Disorders of the thyroid glanda. Hyperthyroidism (thyrotoxicosis) Graves Disease Toxic Nodular Goiterb. Hypothyroidism Iodine deficiency Hashimotos thryroiditis Myxedema coma Congenital hypothyroidism

2. Disorders of the Parathyroids Hyperparathyroidism Hypothyroidism Hypocalcemia

3. Disorders of the adrenal glands Hypercortolism Addisons disease Pheochromocytoma Congenital adrenogenital hyperplasia Cushings syndrome

4. Disorders of the Pituitary Gland Anterior Pituitary Disorders Gigantism Acromegaly Posterior Pituitary gland SIADH Diabetes Insipidus

5. Pancreas Diabetes Mellitus Hypoglycemia Diabetic Ketoacidosis Hyperglycemic Hyperosmolar Nonketotic Syndrome MacrovascularComplicstions Microvascular Complications Diabetic nephropathies Foot and leg problems

Sept 178-12

Sept 248-12

Sept 258-12

Mrs. De Asis

Mrs. Alfonso

Mrs. Magno


-Implement individualized nursing care:


2. Actively participates in planning and coordinating culturally sensitive interdisciplinary care

3. Provide appropriate client education and health maintenance and community- based care of clients

4. Efficiently and effectively utilize available resources in the care of clients to achieve outcomes

5. Evaluate effectiveness of nursing care, revising the nursing care plan as needed to promote, maintain or restore functional health status of clients

6. Maintain confidentiality and protect clients privacy

d. Implementation

1.Pharmacologic therapeutics Iodine sources Thyroid preparations Cortisol replacement Insulin Oral Hypoglycemics

2.Complementary and Alternative Therapies Aloe vera Bilberry Bittermelon Fenugreek Fish oils Garlic Ginseng Gymnema Horse chestnut seed extract Marshmallow Milk thistle Nopa Prickly pear cactus Burdock (may increase blood sugar)

3. Surgical procedures: Thryroidectomy Patrathyroidectomy Unilateral or bilateral adrenalectomy (transphenoidal) hypophysectomy Amputation of diabetic patient Pancreas transplant Islet cell transplant

Special Procedures: Adminitration of insulin Adminstration of hormone

4. Nutrition and diet therapy 5. Patient education

V. CARE OF CLIENTS WITH RESPONSES TO ALTERED URINARY ELIMINATION

V.a. Review of Anatomy and Physiology of the Urinary System

A.Structure and Function1.Kidneya. Gross structure of the Kidneyb. Microscopic structure of the kidney nephronc. Blood Supplyd. Functionse. Urine Production Filtration Reabsorption Secretion

Oct 18-12

Mrs. De Asis


Given an adult ( young, middle, old, old-old adult) with responses to altered Urinary elimination, the student will be able to:

A. Apply knowledge and normal anatomy and physiology and assessment techniques in caring for clients

B. Assess the health status of a client

1. Conduct a health history and functional health status of clients having or at risk for alterations in oxygenation; cardiac and peripheral tissue perfusion/ transport

2. Perform systematic and comprehensive physical assessment to validate assessed data.

Interprets deviations from normal findings in the physical assessment, diagnostic and laboratory examination f. Composition of Urineg. Regulation of urine concentration and volumeh. Hormonal Mechanismsi. Effect of Sympathetic innervationj. on Kidney functionk. Urine Movement1. Ureters 2. Urinary Bladder3. Urethra

V.b Nursing Process

a. Assessment I. Nursing History

1. Subjective Dataa. General manifestations: Fatigue Headache Blurred visions elevated BP Anorexia Nausea, vomiting Chills Itching excessive Thirst Unexplained anemia changes in body weight cognitive Changes Edema Pain Change in the pattern of urination, Urine output and urine composition

2. Objective Dataa. Physical assessment

Inspection: Masses, bulges, inflammations,Ulcerations, nodules, lesions, discharges,Indurated areas Auscutation : Bowel sound, cardiac andrespiratory status: lung sounds, cardiacarrhythmias, evidence of congestiveheart failure Palpation: Tenderness or resistance, inflammation, tenderness, masses, hydrocele, varicocele, lymohadepathies Further inspection for vascularity, atrophic vaginitis, bulges for hernias, skin color changes

3.Diagnostics and Laboratory Examinationsa.Non-invasive-Test for renal function-Prostate specific antigen-Urinalysis-CT-MRI, X-ray of KUB-Urine culuture-BUN-Creatinine clearance test-Bladder ultrasonography

EARNING OBJECTIVETOPICDATETIMELECTURER



Prioritize nursing diagnosis Discuss the pathophysiological responses to altered urinary elimination

Plan the care of clients utilizing evidence-based nursing research Achieve the best clinical outcomes utilizing ethico-moral and legal principles Plan effective care.b. Invasive IVP Retrograde Pyelography Cystourethrogram Renal Scans Cystoscopy Renal biopsy Radioisotope scanning Nuclear Scans Intraveous urography Renal angiography Voiding cystourethrography

b. Analysis/ Nursing Diagnosis1. Impaired urinary elimination as evidenced by , urgency, frequency, hesitancy, dysuria, nocturia2. Urge urinary incontinence as evidenced by frequency, urgency, loss of urine before reaching toilet and voiding in small and large amount3. Urinary retention as evidenced by dribbling urine with increased intraabdominal pressure, urinary urgency, urinary frequency4. Acute Pain5. Ineffective health maintenance

c. Planning1. Planning for health promotion Promoting urinary elimination Preventing urinary infection Managing risk as renal calculi and hypertension2. Planning for health maintenance and Restoration

Catheters: Urethral, Nephrostomy, Ureteral, Suprapubic System intermittent and intermittent self- catheterization, indwelling-exdwelling drainage system Urulogic Surgery:a. Nephrotomyb. Nephrectomyc. Pyelotomyd. Ureterotomye. Cystotomy, cystectomyf. Lithotripsyg. Extracorporeal renal surgeryh. Percutaneous nephrostomyi. Urinary diversionj. Renal transplantk. Dialysis types


Given an actual patient with urinary tract and renal disorders, the student will be able to:

1. Explain the various disorders affecting the urinary system and explicate all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.


3. Discuss the psychopathophysiologic process of these diseases from causes to manifestations and its complications



V.C. COMMON HEALTH PROBLEMS

I. Nursing Care of Clients with Urinary Tract Disorders Lower Urinary Tract Infections Upper Urinary Tract Infections Urinary Incontinence Urinary Retention Urinary calculi Neurogenic Bladder Cancer of the Bladder

II.Nursing Care of Clients with Renal Disorder Nephrosclerosis Primary Glomerular disease Polycystic disease Acute Renal Failure Chronic Renal Failure Kidney Trauma

III.Disorders affecting Pediatric Clients Vesicoureteral reflux Wilmstumor Acute poststreptococcal glomerulonephritis Polycystic kidney Systemic Lupus Erythomatosus

d. Implementation

a.Pharmacologic therapeutics Diuretics Medications for Gout Antispasmodics Cholinergics Analgesics Alpha-Blockers

2. Complementary and Alternative Therapies Biofeedback for urinary incontinence HalamangGamot

3. Nutrition and diet therapya. Protein-mineral-and Fluid Modified Diets

4. Patient education

Oct 28-12

Oct 88-12Mrs. Alfonso

Mrs. Magno


Given an adult ( young, middle, old, old-old adult) with responses to altered fluids, electrolytes and acid-base balance, the student will be able to:

A. Apply knowledge and normal anatomy and physiology and assessment techniques in caring for clientsB. Assess the health status of a client1. Conduct a health history and functional health status of clients having or at risk for alterations in fluids, electrolytes and acid-base balance

2. Perform systematic and comprehensive physical assessment to validate assessed data.

3. Interprets deviations from normal findings in the physical assessment, diagnostic and laboratory examination.


VI. CARE OF CLIENTS WITH ALTERED FLUIDS, ELECTROLYTES AND ACID-BASE BALANCE

VI. a. Overview of Normal fluid and electrolytes Balance

VI. b. Nursing Processa. Assessment

1. Nursing Historya. Subjective Data

1. ECF Volume Deficits Loss of body weight Changes in I & O Changes in Vital signs Other manifestations: - Dryness of the mouth And mucous membrane- Tenting of the skin- Changes in Urine output and mentation- muscle weakness- change in consistency of the stool; cerebral changes

b. Objective Data1. Physical Assessmenta. Skin : poor skin turgor, cold, clammy skin, pitting edema, flushed, dry skinb. Pulse: bounding, rapid, weak; thread, irregular, rapid weak pulse, slow pulsec. BP: hypo/hypertensiond. Respirations: deep, rapid breathing, shallow, slow, irregular breathing, shortness of breath, moist crackles, restricted airwayse. Skeletal muscles: cramping of exercised muscle; carpal spasm; flabby muscles, chvosteks sign

d. Laboratory tests

B. ANALYSIS/ NURSING DIAGNOSIS

1. Deficient Fluid Volume related to insufficient fluid intake, diarrhea, haemorrhage or third-space fluid loss such as ascites or burns2. Excess Fluid Volume related to fluid retention secondary to3. Heart, renal, or liver failure or excess consumption4. Impaired Oral Mucous Membrane5. Risk for injury6. Risk for activity intolerance7. Risk for decreased cardiac output8. Risk for impaired skin integrity9. Imbalance nutrition: Less than body requirements related to insufficient intake of foods rich in potassium

Oct 98-12

Mrs. Alfonso



Prioritize nursing diagnosis Discuss the pathophysiological responses to altered fluid, electrolytes and acid-base balance

Plan the care of clients utilizing evidence-based nursing research Achieve the best clinical outcomes utilizing ethico-moral and legal principles Plan effective care.

Given an actual patient with alterations influids, electrolytes and acid-base balance , the student will be able to:

1. Explain the various disorders affecting fluids, electrolytes and acid-base balance and explicating all the precipitating factors and risk factors that may lead to the development of these diseases /disorders.


3. Discuss the psychopathophysiologic process of these diseases from causes to manifestations and its complications4. Implement individualized nursing careC. Planning1.Planning for health promotion-Preventing fluid and electrolyte loss-Planning for client hydration-Reducing risk for injury2.Planning for health maintenance and Restoration -Fluid and electrolyte management-oral and intravenous fluid and electrolyte replacement

VI. C. COMMMON HEALTH PROBLEMS AND CARE OF CLIENTS WITH FLUID AND ELECTROLYTE IMBALANCE

1. Fluid Imbalance Fluid Volume Deficit Fluid Volume Excess

2. Electrolyte Imbalancea. Sodium Imbalance Hypernatremia Hyponatremia

b. Potassium-Hypokalemia-Hyperkalemia

c. Calcium-HYpocalcemia-Hypercalcemia

d. Phosphate-Hypophosphatemia-Hyperphosphatemia

e. Magnesium-Hypomagnesemia-Hypermagnesemia

2. Acid-Base Imbalancea. Respiratory Acid-base Imbalance-Acidosis-Alkalosisb.Metabolic Acid-base Imbalance-Acidosis-Alkalosis

d. Implementation1. Pharmacologic therapeuticsa. IV Additives KCL CaCl MgSO4 HCO3-b. Plasma Expanders Colloids Dextran Hexastarch

2. Nutrition and diet therapya. Food sources Sodium, Potassium, Calcium Phosphate, Magnesium3. Patient education

Oct 158-12

Oct 168-12

Mrs. Magno

Mrs. De Asis


Given an actual patient undergoing surgery, the students will be able to:1. Define the 3 phases of perioperative care2. Describe a comprehensive preoperative assessment to identify surgical risk factors3. Identify health factors that affect patients preoperatively4. Identify legal and ethical considerations related to obtaining informed consent5. Describe the preoperative nursing measures that decrease the risk for infection and other postoperative complications6. Give examples of pertinent nursing diagnoses for surgical clients7. Enumerate the principles of asepsis and sterile technique.8. Identify the different surgical instruments and equipment and their respective uses9. Identify nursing responsibilities in planning perioperative nursing care.10. Enumerate the roles and responsibilities of a scrub and circulating nurse. 11. Describe essential preoperative teaching, including pain control, moving, leg exercises, and coughing and deep-breathing exercises

VII. NURSING CARE OF CLIENTS UNDERGOING SURGERY

I. Introductory Information: Perioperative Nursing

A. Fundamentals of Theory and Practicea. Perioperative Educationb. Foundations of Perioperative Care Standardsc. Legal and Ethical IssuesB. The Perioperative Patient Care Teama. The Perioperative Patient Care Teamb. The Surgical First Assistantc. Administration of Perioperative Patient Care ServiceC. The Patient as a Unique Individuala. The Patient: The Reason for your existenceb. Perioperative Pediatricsc. Perioperative Geriatrics

D. The Perioperative Environmenta. Physical Facilitiesb. Ambulatory Surgery Centersc. Care of The Perioperative Environmentd. Potential Sources of Injury to the Caregiver and the Patient

E. Preoperative Patient Carea. Preoperative Preparation of the Patientb. Diagnostic Procedures

F. Pharmacology and Anesthesiaa. Surgical Anesthesiab. Anesthesia: Techniques and Agents

G. Surgical Asepsis and Sterile Techniquea. Microbiologic Considerationsb. Principles of Asepsis and Sterile Techniquec. Attire, Surgical Scrub, Gowning and Glovingd. Decontamination and Disinfectione. Sterilization

H. Surgical Instrumentation and Equipmenta. Surgical Instrumentationb. Specialized Surgical Equipment

I. Intraoperative Patient Carea. Coordinated Roles of the Scrub Person and the Circulatorb. Positioning, Prepping and draping the Patientc. Physiologic Maintenance and Monitoring of the Perioperative Patient

Oct 228-12

Oct 238-12

Oct 298-10

Oct 2310-12

Oct 308-12

Nov 58-12

Mrs. De Asis

Mrs. Magno

Mrs. Magno

Mrs. Alfonso

Mrs. Alfonso

Mrs. Alfonso


12. Describe essential aspects of preparing a client for surgery, including skin preparation.13. Compare various types of anesthesia.14. Describe the immediate preoperative preparation of the patient15. Discuss various types of surgery according to degree of urgency, degree of risk, and purpose.16. Develop a preoperative teaching plan designed to promote the patients recovery from anesthesia and surgery, thus preventing postoperative complications17. postoperative client.18. Identify potential postoperative complications and describe nursing interventions to prevent them.19. Identify essential nursing assessments and interventions during the immediate postanesthetic phase.20. Demonstrate ongoing nursing assessments and interventions for the21. Identify essential aspects of managing gastrointestinal suction.22. Describe appropriate wound care for a postoperative client.J. Surgical Specialties Endoscopic Surgery General Surgery Gynecologic and Obstetric Surgery Urologic Surgery Orthopedic Surgery Neurosurgery Opthalmic Surgery Plastic and Reconstructive Surgery Otorhinolaryngologic and Head and Neck Surgery Thoracic Surgery Cardiac Surgery Vascular Surgery Organ Procurement and Transplantation

K. Surgical Site Managementa. Hemostasis and Wound Closureb. Wound Healing Wound dressing Fluids and nutrition Medications Post operative Discharge instructions Rest and activity Eating Sleeping Wound healing Bowel and urinary elimination Bathing, showering Clothing Driving Bending and lifting Medications Follow up care

L. Perianesthesia and Postprocedural Patient Care

a. Postoperative Patient Careb. Potential Perioperative Complications Shock Hemorrhage Pulmonary embolism Deep vein thrombosis Urinary retention Intestinal obstruction Hiccups Wound infection Dehiscence Evisceration Psychological disturbances

FINAL EXAMINATION

Nov 6, 128-12

Nov. 128-12

Nov 19-20

Mrs. De Asis

Mrs. Magno

SCHEDULE: THURSDAYS: 8:00 AM 12:00 NN FRIDAYS: 8:00 AM - 12: 00 NN

References:1. Brunner and Suddarth. Textbook of Medical-Surgical Nursing 13th edition. 20132. Joyce M. Black and Jane Hokanson Hawks. Medical-Surgical Nursing- 8th Ed. 20093. Lippincott Williams & Wilkins. The Lippincott Manual of Nursing Practice 10th edition. 4. Nettina, Sandra: Lippincott Manual of Nursing Practice, 8TH Ed. Williams and Wilkins5. Nancymarie Phillips. Berry & Kohn's Operating Room Technique, 12th Edition. 20136. Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family, 6TH Ed. 20107. Barbara L. Bullock, Reet L. Henze. Focus on Pathophysiology. 20008. Sue E. Huether, RN, PhD and Kathryn L. McCance, RN, PhD. Understanding Pathophysiology. 5th Edition. 20139. Donna D. Ignatavicius, MS, RN, ANEF and M. Linda Workman, PhD, RN, FAAN. Medical-Surgical Nursing. 7th Ed. 201310. Shirley M. Tighe, RN, BA. Instrumentation for the Operating Room, 8th Edition. 2012

Level III Clinical Instructors: Alfonso, Louradel U., MAN, RN Magno, Jesusa M., MAN, RN

De Asis, Rebecca, MAN, RN

PREPARED BY: APPROVED BY:

LOURADEL U. ALFONSO, MAN, RN DR. SOCORRO S. GASCO, RN, DMHRMACADEMIC COORDINATOR DEAN, COLLEGE OF NURSING

Documents

Ncm 103 Syllabus Neptunites