ABC's of MEDICAL and SURGICAL NURSING

ABC ‘S OF PASSING LOCAL BOARD EXAM
(ADDITIONAL BULLETS FOR MS)
 Abdominal aortic aneurysm
 Main problem :Local distention / outpouching of the artery wall usually in the
thoracic or abdominal area
 Initial manifestation :Initially asymptomatic; pulsating abdominal mass is a
common sign, backache and auscultation of bruit are common manifestations ;
abdominal or back pain
 Laboratory Data : Elevated BUN and creatinine levels MRI, CT scan and X-ray.
UTZ is the best test to confirm AAA
 Nursing Diagnosis : Altered tissue perfusion
 Nursing Interventions : Avoid abdominal palpation, prepare patient for surgery
Monitor for possible rupture preoperatively(signs of shock)
Monitor MIO and laboratory studies
Administer medications to decrease hypertension and control pain
Monitor peripheral pulses postoperatively
 Acne Vulgaris
 Inflammatory disease of sebaceous follicles due to blockage of sebaceous glands
 Initial manifestation : Closed comedones( “ whiteheads “ ), open comedones
( “blackheads”)
 Nursing Diagnosis : Body image disturbance
 Nursing Interventions : Instruct patient to wash face gently with mild soap 1-2
times daily. Instruct patient to use benzoyl peroxide and never squeeze pimples
Use of Isotretinoin ( Accutane ) for treatment can cause birth defects. Instruct
patient to use contraceptives during the entire duration of the therapy unitl a
month thereafter. Avoid exposure to sunlight and use sunblock when using these
medications.
 Acromegaly
 oversecretion of growth hormone(anterior pituitary), long lasting stimulation
affecting skeletal growth in adult by enlarging certain bones and tissues
 Initial manifestation : coarse facial features, increased shoe size, increased
intracranial pressure due to tumor headache and blindness
 Laboratory Data : elevated serum human growth hormone and blood sugar levels
 Priority Nursing Diagnosis : body image disturbance
 Nursing Interventions :
provide emotional support
prepare client for surgery and deligently monitor VS and
Neurologic Status post-op
Monitor for signs and symptoms of diabetes
octreotide ( Sandostatin) to decrease GH
 Acute gastroenteritis ( AGE ) / Diarrhea

 Increase in fluid , frequency and volume of stool usually associated with
rotavirus, clostridium deficile, salmonella
 Initial manifestation : Frequent watery stool
 Laboratory Data : Decrease in Na and K, (+) blood cultures usually for
salmonella, rotavirus and clostridium defficile
 Nursing Diagnosis : Fluid and electrolyte imbalance
Priority ; fluid replacement
Remember : fluid loss is more critical in younger patients
because they have higher body fluid percentage.
Monitor the patient’s fluid status, weight is a critical
indicator of fluid loss, 1 gram of weight equals 1 ml of
body fluid.
Initially offer oral rehydration solution such as pedialyte
then progress to non-carbonated drinks ( Gatorade) limit
apple juice since it can cause diarrhea. BRAT diet
 Acquired Immune Deficiency Syndrome ( AIDS)
 Slow degeneration of the immune system( defect in T- cell mediated immunity
caused by the HIV) with the development of opportunistic infections,
malignancies and frequent impairment of the central nervous system
 Initial Manifestation : Flu- like symptoms occur 2-4 weeks after infection
 Laboratory Data :
Diagnosis of AIDS is based on laboratory evidence of HIV infection coexisting
with one or more indicator diseases such as Pneumocyctis carinii Pneumonia ,
Kaposis Sarcoma( most common malignancy), Cytomegalovirus , Candidal
infection ,Herpes Simplex Virus or AIDS dementia
HIV (+) on ELISA, confirmed by Western Blot
HIV antibodies are detectable by routine tests, 3-6 months after infection so
instruct the patient to have an initial test 3-6 months after exposure. Patients who
are initially negative should have a retest 12 weeks or less since a possible
exposure
CD4 lymphocytes , 200 / cu .mm
 Priority Nursing Diagnosis : Risk for infection
Instruct patient to practice safe sex, avoid needle sharing.Maintain
Satndard Precautions Monitor for opportunistic infections.Monitor
respiratory status and laboratory values.Maintain diet/nutrition
Use 10 % household bleaching solution to cleanse areas with blood stains
from an HIV (+) patient
Assess the patient for signs and symptoms of dementia like
incoordination.
 Addison’s Disease







Adrenal hypofunction usually due to autoimmune disease
Initial Manifestation :Hypotension; bronze skin pigmentation is a common sign
Laboratory Data : Hyponatremia, hyperkalemia, hypoglycemia
Nursing Diagnosis : Fluid volume deficit
Nursing Interventions :
Monitor fluid and electrolyte balance
Explain the need for lifelong medications of glucocorticoids and
mineralocorticoids
Maintain high sodium, low potassium diet
Advice patient to avoid infection , trauma or stress, it increases the risk for
addisonian crisis( IV hydrocortisone and saline soln for addisonian crisis)

 Anemia , aplastic
 Main Problem : Bone marrow hypoplasia or aplasia resulting in
pancytopenia( decreased WBC, RBC and platelets)
 Initial manifestation – abnormal bleeding( purpura , petechiae,
ecchymosis,epistaxis , melena and dyspnea)
 Laboratory data: decreased WBC , RBC and Platelet Count
 Nursing diagnosis: risk for infection; risk for injury
 Interventions: prepare the patient for bone marrow transplant
Assess for signs and symptoms of bleeding

 Anemia , folic acid deficiency
 Main Problem : Depletion of folate, which results to progressive anemia
 Initial manifestation: fatigue
 Laboratory data: decreased folate levels
 Nursing diagnosis: activity intolerance
 Interventions: teach patient to increase sources of folic acid in the diet like: green
vegetables ( asparagus, broccoli and spinach), yeast , liver , organ meats and fresh
fruits.
Avoid overcooking of vegetables
Teach the patient regarding oral folic acid replacement
 Anemia , iron deficiency
 Main Problem : Decreased oxygen carrying capacity of the blood. The condition
is usually associated with nutritional deficiency of iron

 Initial manifestation: easy fatigability; poor sucking ( infants) chubby but pale
babies ( milk babies)]
 Laboratory data : decreased Hgb and Hct, microcytic, hypocromic RBC’s
 Nursing Diagnosis:Activity intolerance
 Interventions: Instruct patient to have frequent rest periods
Increase iron in the diet( organ meat , egg yolk) milk is a poor source of iron
Administer oral iron supplements as ordered
 Anemia , Pernicious
 Main Problem : Reduced vitamin B 12 Absorption due to the absence of the
intrinsic factor usually related to gastrectomy and atrophy of the gastric mucosa
 Initial manifestation : Fatigue ; beefy red tongue or glossitis a common sign
 Laboratory Data : Schillings test reveals low value urinary excretion of ingested
vitamin B12 < 10% in 24 hours
 Nursing Diagnosis : Activity Intolerance
 Nursing interventions : Teach patient monthly IM Vit B12 injections for life.
Inform patient to report tingling sensation in
the lower extremities indicating
complication – peripheral neuropathy
 ANAPHYLAXIS
 Main Problem : Dramatic widespread acute atopic/allergic reaction which causes
vascular collapse
 Initial manifestation : Sudden onset of rapidly progressive urticaria , respiratory
distress and hypotension which can lead to shock
 Diagnostic data : Skin testing to determine allergen
 Nursing Diagnosis : Risk for altered airway clearance related to bronchial edema
 Nursing Intervention : Observe for respiratory complications (laryngeal edema ),
watch out for signs and symptoms of shock.
Maintain airway patency – prepare suction and intubation set
Early stages – no loss of consciousness – epinephrine IM
with loss of
consciousness – epinephrine IV
CPR for cardiac arrest
After emergency give antihistamines [diphenhydramine(Benadryl) ] and
corticosteroids
Prevent recurrence by avoiding exposure to known allergens
1) A major nursing responsibility prior to initial administration of antibiotics specifically
penicillin and sulfa drugs is :
a) Skin testing
b) Assessing for sensitivity to iodine
c) Assessing for food allergies
d) Suction equipment at bedside

 Answer : a - antibiotic therapy is done after negative skin test results to
prevent occurrence of hypersensitivity reactions
 Aphasia
 Main problem an acquired disorder of communication resulting from brain
damage.Speech difficulty /change usually caused by right sided hemiplegia(left
brain involvement)
 Initial manifestations :
Expressive Aphasia – difficulty expressing self in understandable speech
Receptive Aphasia – does not comprehend spoken or written word
Global Aphasia – combination of both
 Nursing Diagnosis : Impaired Verbal Communication
 Interventions : Give the patient enough time to speak and respond and speak
clearly and slowly while facing patient
Provide visual cues like pictures and gestures when talking to the patient
( verbal and non-verbal)
Approach on the visually unaffected side

 Arrythmias
 Main Problem : Abnormal electrical conduction or automaticity changes in the
heart rate or rhythm which affects cardiac output and blood pressure
 Initial manifestation : Hypotension and deteriorating level of consciousness
 Diagnostic Data : ECG tracing reveals the following:
 Atrial Fibrillation- irregular atrial rhythm > 400 beats / min. indiscernible PR
interval and no P waves
 Ventricular Tachycardia- ECG shows rate of 140 – 220 bpm, wide and
bizarre QRS complex and no P waves
 Ventricular fibrillation - ECG shows rapid and chaotic ventricular rhythm,
wide and irregular QRS complexes and no visible P waves.
 Premature Ventricular Contractions- irregular intervals between QRS
complexes
 Asystole – no atrial or ventricular rate
 Nursing Diagnosis : Ineffective tissue perfusion: cardiopulmonary

Decreased cardiac output
 Nursing Interventions : Watch out for hypotension and decreased urine output
Assist with measures to treat underlying cause ( electrolyte replacement , oxygen
therapy and pulmonary care)
Hook on cardiac monitor and assess Level of consciousness, RR, PR , BP and
fluid and electrolyte balance
Perform ACLS measures
Early defibrillation for VT and VF
Cardioversion for atrial dysrhythmias
Administer antiarrythmics (Lidocaine,Inderal,Cordarone)
for arrythmias and PVC’s
– hypotension common side effect
Perform CPR and intubation prn
prepare patient for possible pacemaker insertion
1) In a patient on antidysrhythmic drug therapy , the following intervention is necessary
to monitor for the common side effect of the drug:
a) Use of infusion pump for continous administration
b) Ensure IV remains patent and check insertion site
c) Check BP regularly
d) Administer slowly and at a prescribed rate
 Answer : c – major side effect of anti arrthmics is hypotension
 Angina Pectoris
 Main Problem _ Insufficient coronary blood flow results to inadequate oxygen
supply causing intermittent chest pain
 Initial Manifestation : squeezing , burning , pressing , chocking , aching or
bursting left sternal chest pain lasting not more than 20 minutes. The patient often
says , “It feels like gas or heartburn or indigestion “ .
 Laboratory Data : ECG reveals ST segment depression
 Nursing Diagnosis : Pain
 Administer nitroglycerine sublingually to relieve the pain. Teach the patient that a
burning sensation under the tongue after nitroglyvcerine indicates that the drug is
potent. The drug may also cause facial flushing or headache
Prepare patient for PTCA ( percutaneous Transluminal Coronary Angioplasty ) by
informing the patient that a balloon tipped catheter will be introduced through a
guide wire into a coronary vessel .

 Appendicitis

 MAIN PROBLEM : Inflammation of the appendix due to obstruction of the
intestinal lumen
 Initial manifestation : right lower quadrant abdominal pain with rebound
tenderness. Lessenignof pain indicates rupture of the appendix
 Laboratory Data : Elevated WBC and urinalysis negative for UTI ( ruled out )
 Nursing Diagnosis : Pain and Potential for injury
 Interventions : Place patient in any position of comfort if appendix has not yet
ruptured , if it is ruptured place patient in high fowler’s position to prevent
upward spread of infection. Administer antibiotics as ordered . Avoid applying
hot compress on the RLQ . No analgesics , antispasmodics and enema during
observation phase.
 Prepare patient for appendectomy and teach post op interventions/responsibilities.
 Arthritis , gouty
 Main Problem : Metabolic disorder of uric acid formation and excretion
 Initial manifestation : Initially asymptomatic . A common sign is dusky red hot
swollen joint(inflamed painful), usually the big toe. Pathognomonic : Formation
of Tophi
 Laboratory Data : Elevated urate crystals in synovial fluids and elevated serum
uric acid
 Interventions :
Teach patient to Maintain purine restricted diet
( avoid organ meats , alcohol , legumes, sardines). Increase oral
fluid intake
Avoid aspirin and diuretics as these interfere with uric acid
excretion. Alkalanize urine – fruit, vegetables and milk.
Use bed cradle to prevent linen from coming in contact with the
inflamed joint which aggravates the pain
Common Complication : Uric Acid Kidney stone formation
Encourage compliance to anti gout medications:
Allopurinol- blocks formation of uric acid, Colchicine – analgesic
and anti-inflammatory, Probenecid – reduces uric acid
Sulfinpyrazone – reduces uric acid in the blood
 Arthritis , osteo
 Degeneration of the articular cartilage in the joints
 Initial Manifestation : Pain and swelling in a weight bearing joint, usually
aggravated by activity
 Laboratory Data : X – ray
 Interventions : Priority : Minimize Discomfort – Implement:
W- eight control
H- ot compress or ice packs

A – spirin use
T – runk assistive devices – cane
 Arthritis , Rheumatoid
 Main Problem : systemic recurrent inflammation of the synovial lining of the
joints, usually upper extremities.More common in women
 Initial manifestation : Morning stiffness relieved by warm bath or soaks
 Laboratory Data : elevated ESR and (+) rheumatoid factor
 Nursing Diagnosis : Pain related to joint inflammation
 Interventions : Teach patient to take aspirin regularly as ordered even in the
absence of symptoms , instruct the patient that tinnitus is a side effect of aspirin.
Apply moist heat for 15 – 30 minutes to reduce muscle spasm. Use ice packs
during acute phase to decrease pain
 Asthma
 Main Problem : Abnormal Bronchial hyperactivity to certain substances and
conditions
 Initial manifestation : dyspnea and wheezing(asymptomatic between attacks)
 Laboratory data : PFT’s during attacks show decreased forced expiratory volumes
, elevated immunoglobulin E , ABG reveals respiratory Acidosis, peak flow levels
below normal
 Nursing diagnosis : Ineffective Breathing Pattern related to bronchospasm
 Interventions :
Assess precipitating factor and eradicate these sources
Instruct patient to avoid 3 E’s ( exercise specially in cold weather,
environmental factors like dust , emotional factors )
Position patient in orthopneic position and encourage patient to do pursed lip
breathing
Administer medications – Bronchodilators and corticosteroids usually via
nebulization

 Autonomic dysreflexia

 Main Problem : Exaggerated autonomic responses to local stimuli below the level
of the spinal cord injury. Occurs in clients with lesions above T6 after spinal
shock has subsided
 Initial manifestation : Pounding headache or severe hypertension
 Nursing Diagnosis : Urinary retention related to effects of spinal cord injury
 Interventions :
Catheterize the patient to prevent bladder distention. Relieve fecal
impaction and pressure on skin which can precipitate attacks .
Place patient in sitting position to help lower blood pressure . Administer
antihypertensives
 Benign prostatic hypertrophy
 Main Problem : enlargement of the prostate gland resulting to narrowing of
urethral opening
 Initial manifestation : decreased force and amount of urine
 Laboratory data :elevated Ph of prostatic fluid
rectal examination shows enlarged prostate
Cystoscopy shows enlarged prostate gland, obstructed urine
flow and urinary stasis
 Nursing Diagnosis: Altered bladder elimination related to enlarged prostate
 Interventions : Force fluids
Pre-op – assess understanding of procedure and anticipated
postoperative course. Explain TURP ( Transurethral
Resection Prostatectomy) will not involve any incision.
Post – op assess for pain , discomfort and complications
( bleeding and infections )
Monitor continous bladder irrigations
 Bleeding Esophageal Varices
 Main Problem : bleeding of dilated veins in the lower esophagus
 Initial manifestation : Hematemesis
 Nursing Diagnosis : Fluid Volume Deficit
 Interventions : Monitor the pateint’s airway
Assist with the insertion of Sengstaken – Blakemore Tube ( keep a
pair of scissors at the bedside, this is used to cut the port of the
tube leading the balloon, to deflate it, in case aspiration occurs)
 Bronchiectasis
 Main Problem : Chronic abnormal dilation of bronchi and destruction of
bronchial walls leading to multiple respiratory complications
 Initial Manifestation : Chronic cough that produces copious, foul smelling,
mucopurulent secretions, possibly totaling several cupfuls daily
 Laboratory Data : Bronchoscopy helps identify source
chest x-ray shows peribronchial thickening,

areas of atelectasis and scattered cystic changes
Pulmonary Function tests detect decreased volumes
 Nursing Diagnosis : Ineffective airway clearance related to secretions
Impaired gas exchange related to alveolar exudate
 Nursing Interventions :Assess respiratory status and level of consciousness to
detect early signs of hypoxia and decompensation
Administer antibiotics as necessary
Teach and perform Respiratory Physiotherapy - deep breathing and coughing,
postural drainage and chest percussion(done early morning and before bedtime)
Teach importance of quitting smoking and avoidance of milk products
1) Priority nursing diagnosis for patient with bronchiectasis is:
a) Altered breathing pattern
b) Potential for infection
c) Knowledge deficit
d) Ineffective airway clearance
 Answer: d - copious, foul smelling, mucopurulent secretions, possibly
totaling several cupfuls daily
 Buergers disease ( thromboangitis Obliterans )
 Main Problem : Vasculitis of the small and medium sized veins and arteries
usually in the lower extremities. It is more common in men and in smokers
 Initial manifestation : Pain is an outstanding symptom, intermittent claudication is
a common problem
 Laboratory Data : leg arteriography reveals inflammatory lesions
 Nursing Diagnosis : Altered peripheral Tissue Perfussion
 Interventions : Instruct patient to stop smoking and administer calcium channel
blockers and peripheral vasodilators as ordered.
 Burns
 Main Problem : Traumatic injury caused by thermal , electrical , chemical or
radioactive agents
 Initial Manifestations : 1st Degree – pinkish skin with pain
2nd degree – reddish with painful blisters
3rd degree – eschar , charred , painless
 Laboratory Data : Hyperglycemia , anemia
 Nursing Diagnosis : Decrerased cardiac output related to fluid shifts
 Interventions :
On strict MIO .
Administer fluids as ordered during acute phase by fluid replacement calculations
using body weight multiplied by BSA burned based on rule of nines. ½ of the

total volume to be infused on the first 8 hours then the remaining ½ infused in the
next 16 hours.
Maintain a high calorie , high protein diet
Treat pain with IV narcotics, provide tetanus prophylaxis and topical
antimicrobial therapy. Institute reverse isolation in severe cases. Administer pain
medications prior to ROM ,ambulation and whirlpool therapy
 Cancer , Bladder
 Main Problem : Presence of malignant cells in the bladder
 Initial Manifestation : Painless hematuria
 Laboratory data : Elevated Acid Phosphatase
 Nursing Diagnosis: Altered urinary Elimination
 Interventions : Prepare patient for surgery and chemotherapy
Encourage patient to verbalize fears

 Cancer Breast
 Main Problem : Presence of malignant tumors usually in the upper outer quadrant
of the left breast. It is associated with nulliparity or having the first child after age
35
 Initial manifestation : skin dimpling and edema(peau d’ orange .Painless mass
most common sign
 Laboratory Data : Mammography reveals the presence of non – palpable lesion.
Baseline mammography should be made between age 35 – 40 . Q2 years 40 – 50
years old if w/o predisposition ;yearly for high risk women;yearly after age 50.
 Nursing Diagnosis : Knowledge deficit of breast cancer and mastectomy
 Interventions : Prepare patient for chemotherapy , radiation and surgery. Teach
patient how to perform Self Breast examinations. Done monthly , a week after
menstruation since the breast are less tender at this time. The best position is
lying down with pillow under shoulder of breast being examined.
Inform the patient that Mammography will involve placing the breasts between
two X-ray plates. Avoid use of deodorant ,lotions or powder
In post mastectomy patient elevate affected arm to prevent lympedema and to
avoid activities that increase infection like gardening and sewing. No BP taking ,
venipuncture and constrictive clothing on the affected arm
 Cancer , Cervix
 Main Problem : presence of malignant cells in the cervix associated with multiple
sexual partners and history of sexually transmitted disease
 Initial manifestation : initially asymptomatic , postcoital bleeding is common
manifestation
 Laboratory data : pap smear reveals presence of malignant cells
 Nursing Diagnosis : Knowledge deficit of cervical cancer and chemotherapy

 Interventions : Instruct patient to avoid douching and sexual intercourse 24 hours
before Paps’ Smear
Stress the importance of lifelong follow up visits to detect response
to treatment.
Prepare patient for chemotherapy , radiation and surgery

 Cancer , Esophagus
 Main Problem : Malignant tumor in the esophagus related to alcoholism and
smoking
 Initial manifestation : Dysphagia – presenting symptom
 Laboratory Data : Barium Swallow with fluoroscopy reveals large masses.
CT scans may be employed to evaluate extent of tumor
 Nursing Diagnosis : Altered Nutrition
 Interventions : Prepare patient for surgery , radiation therapy and chemotherapy.
Administer antacids and analgesics as ordered
Prepare patient for tube or gastroctomy feedings and short
course hyperalimentation
Post operatively instruct patient to avoid overeating
raw fruits and vegetables
 Cancer ,Larynx
 Main Problem : presence of malignant cells in the larynx associated with smoking
and alcoholism
 Initial Manifestations : Hoarseness or voice change, tickling sensation in the
throat
 Laboratory data : Laryngoscopy and Biopsy reveals malignant cells
 Nursing Diagnosis : Knowledge deficit of laryngeal cancer
 Interventions : Prepare patient for radiation , chemotherapy and surgery . teach
patient to avoid cold air
Instruct patient that swimming is not recommended post –
laryngectomy.
Institute alternative modes of communication

 Cancer , Ovary
 Main Problem : Gynecologic cancer associated with high fat diet and nulliparity
 Initial Manifestation : Initial asymptomatic , vague abdominal discomfort like
indigestion is a common symptom
 Laboratory data : laparoscopy and Ultrasound reveals the presence of mass

Assist the patient to cope with change in body image
Institute effective pharmacologic and non pharmacologic
pain management
 Cancer , Prostate
 Main Problem : Malignant tumor in the prostate gland
 Initial Manifestation : Decreased size and force of urinary stream
 Laboratory data : Elevated Prostate Specific Antigen ( PSA ) , elevated acid
phosphatase
 Nursing Diagnosis : Pain related to tumor metastases to bone
 Interventions : Support patient undergoing radiation therapy
Inform the patient that radical prostatectomy, which involves the
removal of the entire prostate gland, may cause impotence

 Cancer , colon( colorectal Ca)
 Primary or metastatic malignant tumor of the colon or rectum which infiltrate
causing obstruction, ulceration and hemorrhage.
 Change in bowel habits, character of stools, diarrhea and constipation- fecal
oozing ( melena or hematochezia)
 Barium enema locates mass, sigmoidoscopy / colonoscopy identifies and locates
mass, positive for fecal occult blood and positive biopsy for Ca cells
 Altered bowel elimination
 Assess GI status, fluid and electrolyte studies, monitor for bleeding , infection and
electrolyte imbalance
Provide post-chemotherapeutic and post radiation therapy nursing care
Provide adequate nutrition and administer antiemetics and anti - diarrheals
Prepare for surgery and Teach ostomy self care
Administer TPN as ordered
1) Among the following diagnostic results ,which is more suggestive of colorectal
cancer?
a) Painless hematuria
b) Presence of occult blood in stool
c) Increased level of acid phosphatase

d) Indigestion
 Answer: b – lab test suggestive of colorectal cancer includes fecal occult
blood and positive biopsy for Ca cells

 Cancer , lung ( Bronchogenic Ca )
 Development of a neoplasm in the respiratory tract(squamous cell-slow growing;
large and small oat cell – fast growing).Presence of malignant tumor in the
epithelium of the respiratory tract usually related to smoking or exposure to
asbestosis
 Chronic,nagging cough ( smokers cough)
 Sputum cytology positive for cancer cells
CXR shows a lesion or mass
Bronchoscopy confirms a positive biopsy
 Impaired gas exchange
Impaired breathing pattern
 Monitor respiratory status and pulse oximetry
Check for cyanosis suggesting respiratory failure and increase in sputum
production indicates infection
Provide adequate pain control
Increase oral fluid intake and IVF as ordered
Provide increased CHON, high caloric diet( TPN or enteral,prn)
Perform and teach Respiratory Physiotherapy
Provide rest periods and mouth care
Prepare patient for surgery and chemotherapy
Elevate head of bed to prevent fluid collection in the upper body
1) All the following except one are diagnostic procedures done to confirm bronchogenic
cancer:
a) Sputum cytology
b) Chest X- ray
c) Bronchoscopy
d) Pulmonary angiography
 Answer : d - pulmonary angiography is the rapid injection of radiopaque
dye into the pulmonary circulation useful in determining the site of
pulmonary embolism, sputum cytology, CXRay and bronchoscopy are tests
done to confirm lung cancer.
 Cancer, Skin
 Malignant primary tumor of the skin mainly caused by prolonged exposure to the
sun or other carcinogenic agents
 Squamous cell carcinoma- small red nodular lesion that begins as an
erythematous macule or plaque

 Skin biopsy shows positive cytology
 Impaired skin integrity
 Assess lesion and monitor skin punch test site for bleeding
Pre and post chemotherapy or radiation therapy nursing care
Teach patient to avoid contact with chemical irritants.
Use sunblock and layered clothing when outdoors

1) Nursing interventions for patients undergoing radiation therapy include all of the
following except:
a) Monitoring the punch test site for bleeding
b) Teach patient to avoid contact with chemical irritants
c) Using sunblock when outdoors
d) Using layered clothing when sun exposure is possible
Answer : a - skin punch test / skin biopsy is a diagnostic procedure to confirm the
presence of skin cancer

 Cancer , Testicular
 Main Problem : Malignancy in the testes usually associated with cryptorchidism
 Initial manifestations Painless swelling and enlargement of the testes ,
accompanied by sensation of heaviness in the scrotum
 Laboratory data : Elevated HCG and alpha feto protein
 Nursing Diagnosis : Knowledge deficit
Teach patient about testicular self examination .It should be done once a
month while having warm bath or standing in front of mirror. Suspect cancer
when spongy upon palpation

 Cardiogenic shock
 Main Problem : Extensive damage of the left ventricle due to Myocardial
Infarction

 Initial manifestation : decreased systolic pressure
 Laboratory Data : Elevated BUN , creatinine and liver enzymes
 Nursing diagnosis : Altered cardiac Output ( decreased related to impaired
contractility of the heart
 Interventions : Monitor BP , MIO and weight . Evaluate serum electrolytes for
hyponatremia and hypokalemia
 Cataract
 Main Problem : Opacity of the lens usually associated with aging , prolonged
intake of steroids and chromosomal aberrations
 Initial manifestation : painless blurring of vision
 Laboratory data : Slit lamp test reveals milky white color of the pupils
 Nursing diagnosis : potential for injury related to visual loss
 Interventions : Prepare patient for surgery
Postoperatively instruct patient to avoid activities that requires
bending, report sudden eye pain, this indicates hemorrhage and
increased IOP.
Avoid lifting and rapid head movements
Position in fowlers position or instruct patient to lie down on the
unaffected side
 Cerebrovascular Accident (CVA)
 Sudden loss of brain function resulting from a disruption of blood supply to a part
of the brain causing temporary or permanent dysfunction.(TIA warning sign of
CVA – no neurovascular deficits / complete resolution of manifestation within 24
hours)
 Initial Manifestation : depends on the site of brain involvement
Middle cerebral artery : hemiparesis
Internal Carotid artery : hemiplegia
Right hemispheric lesion : spatial disorientation
Left Hemispheric lesion : language disturbances
Common manifestations:
Hemiplegia and homonymous hemianopsia
Emotional and personality disturbances
Aphasia
Dysphagia
 Laboratory : Elevated Cholesterol Levels
 Nursing Diagnosis : Ineffective Breathing Pattern
Unilateral Neglect
 Interventions :
Maintain adequate airway
Institute regular bowel and bladder training
Establish means of communication

 Chest injury (Flail Chest )
 Main Problem : Loss of stability of chest wall with subsequent respiratory
impairment
 Initial manifestation : Dyspnea , Paradoxical Chest Movement may occur
( detached part of the chest will be pulled in on inspiration and blown out on
expiration )
 Laboratory data : X ray reveals rib fractures
 Nursing Diagnosis : Ineffective breathing pattern
 Interventions : Stabilize the flail portion of the chest with hands or cover with
impermeable dressing with three sides taped
Turn patient on affected side to provide space for the unaffected lung to reexpand
Place 10 pound sandbag at the site of flail
 Cholecystitis / Cholelithiasis
 Infection of the biliary tract associated with the presence of gallstones
(Cholelithiasis) . Predisposing factors includes Fat, Female, Age Forty and above,
and Fair skinned.
 Intolerance to fatty foods and severe pain located on the RUQ of abdomen
radiating to R scapula with nausea and vomiting. Indigestion, flatulence,
belching, jaundice and clay colored stools
 Hepatobiliary tract UTZ
 Altered nutrition ; less than body requirements
 Position in semi-fowlers,provide rest and limit activity
Small frequent meals low fat, low calorie, high carbohydrate and fiber , no gas
forming foods.
NPO on acute phase. Administer IV fluids / TPN as ordered
Prepare client for Extracorporeal Shock Wave Lithotripsy or cholecystectomy- T
– tube for biliary drainage placed
Teach post-op procedures and care(incentive spirometry and deep breathing)
Give medications as ordered:
Analgesics-Demerol ( morphine contraindicated)
Antibiotics-Ceftazidine, Clindamycin , Gentamycin
Anticholinergics- Probanthine
Anti-emetic- Compazine
Anti-pruritic- Benadryl
NGT to low suction to decompress stomach
1) Management for patient post cholecystectomy includes:
a) Adequate fat diet
b) Maintain NPO for 3 days
c) Place patient in supine position
d) Instruct and encourage use of incentive spirometry

 Answer : d – management for clients post cholocystectomy includes
maintaining high fowlers position, deep breathing and coughing, pain
management, NPO until peristalsis returns, administer IVF and T – tube
monitoring and care.
 Cardiac Tamponade
 Main Problem : Fluid Accumulation in the pericardial sac
 Initial Manifestation : hypotension muffled heart sounds is a common sign
 Laboratory data : ECG reveals ST and T wave abnormalities
 Nursing Diagnosis : Altered cardiac Output
 Interventions : prepare the patient for pericardiocentesis. Tjis involves aspirating
the fluid or air from the pericardial sac. Assess for complications

 Cor pulmonale
 A chronic heart condition, is the hypertrophy of the heart, right ventricle and
associated structure that results from diseases affecting the function and the
structure of the lungs
 Chronic productive cough , dyspnea on exertion, edema and fatigue
 ABG- decreased Pa O2 < 70 mmHg
CXR and UTZ – suggests R ventricular hypertrophy
ECG- shows arrhythmia during severe hypoxia
 Altered Tissue perfusion related to cardiopulmonary changes
 Measure ABG levels and administer O2 by mask or cannula as ordered. Monitor
serum K if on diuretics
Low salt , fluid restricted , small frequent feedings
Monitor digoxin level and check radial pulse prior to cardiac glycoside
administration to avoid complications
Reposition and provide meticulous respiratory care
1) Then following are diagnostic tests done to assess the presence of cor
pulmonale except:
a. CXR
b. ECG
c. UTZ
d. Venogram
 Answer : d – insertion of a dye into a vein for the purpose
of outlining an obstruction or lesion.

 Chronic Bronchitis ( Blue Bloater )
 Main problem : excessive mucus secretion with the airways and recurrent cough
usually related to smoking , pollution and infection.
 Initial Manifestation : Cough with copious sputum
 Laboratory data : ABG reveals respiratory acidosis
 Nursing Diagnosis : Impaired breathing pattern
 Interventions : Increase Humidity
Provide postural drainage before meals
Relieve bronchospasm
Teach the patient about breathing techniques like : blowing
bubbles , blowing a trumpet , blowing a feather in the air
 Complete Heart Block
 Main Problem : altered transmission of wave impulses from the SA node to the
AV node
 Initial Manifestation : Bradycardia
 Laboratory data : ECG reveals prolonged PR interval
 Nursing Diagnosis : Altered tissue perfusion
 Interventions : Monitor patients’ ECG
Prepare patient for pacemaker insertion
A common sign of pacemaker failure is hiccups
Atropine Sulfate is given as a vagolytic
 Congestive Heart failure
 Main Problem : failure of the heart to pump blood to meet oxygen requirements.
 Initial manifestations : Right sided edema , hepatomegaly
Left sided : dyspnea , rales
 Laboratory data : Elevated CVP above 12 mmHG for right sided failure. Elevated
PAP and PCWP for left sided failure
 Nursing diagnosis : altered cardiac output related to impaired contractility
 Interventions : Maintain patient in semi – fowlers position
Administer digitalis and diuretics as ordered
Maintain low sodium and low cholesterol diet
Monitor potassium levels
 Crohn’s Disease ( Regional Enteritis)
 Main Problem : Chronic Inflammatory Disease of the small intestines
 Initial manifestation : Crampy abdominal pain in the right lower quadrant of the
abdomen
 Laboratory data : Barium Swallow reveals “string sign”
 Nursing Diagnosis : Pain and alteration in bowel elimination ;diarrhea
 Interventions : Maintain high protein , high carbohydrate , low fat diet
Administer steroids as ordered

Provide small frequent feeding
Monitor input and output
 Cushing ‘s Syndrome
 Main Problem : Hypersecretrion of the glucocorticoids by the adrenal glands
 Initial Manifestation : Central type or truncal obesity with thin extremities, moon
face , buffalo hump and hirsutism
 Laboratory data : Elevated serum cortisol levels, hypernatremia , hypokalemia ,
hypertension , hyperglycemia
 Nursing Diagnosis : Altered skin integrity related to impaired healing
 Interventions : Maintain patient on high potassium and low sodium diet
Instruct patient that treatment will involve lifelong administration
of glucocorticoid synthesis inhibitors ( Mitotane )
Inform patient about slow wound healing

 Cystitis
 Main problem : inflammation of the urinary bladder
 Initial Manifestation : Frequency and Urgency
 Laboratory data : Culture and sensitivity tests reveal the presence of bacteria
usually E coli
 Nursing diagnosis ; Altered Urinary Elimination
 Interventions :
Increase Oral Fluid Intake Instruct the patient to avoid
bubble baths , silk underwear. Cotton underwear is preferred. Maintain acid ash
diet ; (cheese , cranberry , prunes , plums , poultry , eggs)
 Diabetes Mellitus
 Main Problem : Chronic disorder of cardohydrate , protein and fat metabolism
characterized by an imbalance between insulin supply and demand. Type 1 –
IDDM ( no insulin ) ; Type 2 – NIDDM ( little insulin or insensitivity of cells to
insulin)
 Initial manifestation : Polyuria , Polyphagia , Polydipsia and weight loss
 Laboratory data ; elevated FBS level above 120 mg / dl
 Nursing Diagnosis : Alteration in nutrition
 Interventions :
D-IET : 50-60%cho , 20-30% FATS , 10-20% CHON
I – NSULIN – TYPE 1
A – NTIDIABETIC AGENTS –TYPE 2
B – LOOD SUGAR MONITORING
E - XERCISE
T – RANSPLANT OF PANCREAS

E – NSURE ADEQUATE FOOD INTAKE
S – CRUPULOUS FOOT CARE
STRICT MONITORING FOR
COMPLICATIONS( DKA
for IDDM and HHNKS for NIDDM)
 Diabetes Insipidus
 Main Problem : Hyposecretion of antidiuretic hormone
 Initial manifestation : Polyuria , polydipsia
 Laboratory data : fluid deprivation test confirms the disorder
 Nursing Diagnosis : Fluid Volume Deficit
 Interventions : Maintain Adequate fluid intake
Monitor urine specific gravity
Administer Desmopressin acetate or Vasopressin
intranasally as ordered
 Dementia , Alzheimers
 Irreversible progressive impairment in the patients cognitive functioning, memory
and personality
 Confusion, easy forgetfulness and memory loss( cannot retain or recall recent
information)( confabulates to cover up memory loss)
 Cognitive assessment- deterioration of cognitive ability
Mental status exam – reveals disorientation and recall difficulty. Functional
Dementia Scale shows some degree of dementia
Cortical atrophy seen on MRI / CT scan
 Altered thought processes
 Group therapy and increase social interaction - reminiscence therapy to increase
self esteem )
Provide for a safe , highly structured environment. Maintain consistency and
provide constant orientation
When agitated – redirect focus
Simplify communications , tasks and routines
Diet adequate in folic acid and provide adequate fluids and nutrition
Palliative medical management with:
Anticholinesterase – Tacrine(Cognex), Donepezil (Aricept)
Antipsychotics, Benzodiazepines,Antidepressants and Vitamin E
supplements
1. Clinical manifestations more typical of dementia include all of the following
except:
a. wandering:becoming lost
b. impairment of cognitive functioning
c. memory impairment
d. no personality changes

 answer : d - in dementia there is personality changes that
interfere with ADL.
 Delirium
 Acute reversible disturbance of consciousness accompanied by a change in
cognition not attributed to pre-existing dementia lasting several hours or days
 Altered psychomotor activity such as apathy, withdrawal and agitation with
disorientation
 Result of a physiologic condition, metabolic imbalance, intoxication, substance
withdrawal, toxic exposure, prescribed medicines or combination . No specific
laboratory test. Multiple tests to rule out or confirm underlying factors
 Altered cerebral perfusion and high risk for injury
 Assess and correct underlying physiologic problem
 Create a structured safe environment
 Decresase sensory stimulation and administer medications as ordered:
 Tranquilizer
 Benzodiazepines
 Cholinesterase inhibitors
 Antipsychotics
 Risperidone(risperdal)

1) Clinical manifestations not typical of delirium :
a) Slowed thought processes , confusion and disorientation
b) Misperception of stimuli and incoherent speech
c) “ sundowner’s syndrome” and dream like state
d) memory impairment , aphasia and apraxia
 answer : d - memory impairment , aphasia and apraxia more
associated with dementia

 Compartment Syndrome
 Pressure within a muscle and its surrounding structures increases causing
circulation impairment or interruption caused by application of dressing, tight
casting, burns, closed fractures and crushing injuries
 Pain increased with stretching and unrelieved by narcotic analgesics
Paresthesias, pallor, pulseless and paralysis
 No specific diagnostic test
 Risk for peripheral neurovascular dysfunction
 Position the affected extremity lower than the heart to increase circulation to the
area

Bivalving or removal of dressings and constrictive coverings from area
Monitor affected extremity and perform neurovascular checks.
1) In patient with complaining of intense pain on the casted extremity unrelieved by
analgesics the nurse would :
a) Ask the patient to wiggle the fingers or toes of the extremity
b) The nurse would refer to patient to the AP for increase in narcotics
c) check for distal pulses and elevate the extremity
d) prepare the client for possible bivalving
 answer d : in compartment syndrome emergency bivalving is the most
appropriate intervention done

 Disseminated Intravascular Coagulation ( DIC )
 Main Problem : Wide spread coagulation all over the body resulting to subsequent
depletion of clotting factors
 Initial Manifestation : petechiae and ecchymosis on the skin , mucous membrane ,
heart lungs and other organs
 Laboratory Data : Prolonged PT and PTT
 Nursing Diagnosis : Risk for Injury
 Interventions : Monitor for signs of bleeding ( tarry stool , hemoptysis ,
nosebleeding )
Administer heparin as ordered.heparin inhibits thrombin thus preventing
further clot formation and allowing coagulation factors to accumulate.
Administer Blood transfusion as ordered
Instruct patient to avoid aspirin and aspirin containing compounds
 Diverticulitis
 Main Problem _ Inflammation of a pouch or saccular dilation in the colon
( diverticula)
 Initial Manifestation : Left lower Quadrant Pain
 Laboratory data : Sigmoidoscopy confirms the diagnosis
 Interventions : Provide Low Fiber Diet ( avoid vegetables) in diverticulitis, high
fiber in Diverticulosis
Administer Metamucil as ordered
Administer meperidine for relief of pain
 Dumping Syndrome
 Main Problem : Rapid emptying of the stomach contents into the small intestine
usually a complication of gastric surgery






Initial manifestations : 3 D’s ( Diarrhea , Diaphoresis , Drowsiness)
Laboratory data : non – specific
Nursing Diagnosis : Altered Elimination
Interventions :
Maintain patient on supine position after
Meals and withold fluids during meals
Maintain high fat , high protein , dry diet, low in simple
sugars ( fat delays emptying of the stomach

 Emphysema (Pink Puffer)
 Main problem : destruction of the alveoli , narrowing of small airways and
trapping of air resulting in loss of lung elasticity
 Initial manifestation : shortness of breath ; barrel chest ( increase in
anteroposterior diameter of the chest ) is a late sign
 Laboratory data : ABG reveals Respiratory Acidosis
 Nursing Diagnosis : Ineffective breathing Pattern
 Interventions :
Keep the patient in orthopneic position / sitting
Administer low flow oxygen
Encourage patient to do pursed lip breathing
Instruct patient to avoid powerful odors , extremes of
temperature, pets , fireplace and feather pillows

 Endocarditis
 Main Problem : Infection of the inner lining of the heart caused by direct invasion
of bacteria leading to deformity of the valve leaflets
 Initial Manifestation : Fever
 Laboratory data : elevated ESR
 Nursing Diagnosis : Altered Cardiac Output
 Interventions :
Record daily weight
Evaluate jugular vein distention, as this signifies the
development of CHF
Instruct the patient to take antibiotics before dental
procedures that can cause bleeding
Avoid sharing of needles
Teach the women in child bearing years the risks of using
IUD’s or other birth control ( source of infection )
 Epileptic Seizure
 Main Problem : Abnormal sudden excessive discharge of electrical activity within
the brain
 Initial Manifestation : Impaired Consciousness
 Laboratory Data : EEG ( abnormal brain waves ) , CT scan reveals brain lesions

 Nurisng Diagnosis : Altered tissue Perfusion
 Interventions: (On seizure precautions)
Maintain Patent Airway
Protect from injury
Do not restrain
Administer valium,drug of choice as prescribed ; & other
anticonvulsants
Oxygen equipment and suction at bedside

 Fractures
 Break in the continuity of the bone due to trauma, bone tumors and osteoporosis
 Acute pain, cyanosis, loss of function, swelling , deformity and crepitus
 Antero posterior lateral X-ray of the area
 Acute pain and impaired physical activity
 Rest
Immobilize
Cold compress and control bleeding
Elevate
Alleviate pain by giving adequate analgesics/narcotics except in presence of head
injury
Prepare patient for reduction and alignment ( Splinting , casting, application of
traction and surgical fixation (CRIF/ORIF)
Provide adequate care for clients with traction
T-rapeze bar overhead
R – equires free – hanging weights
A – nalgesics is given to relieve pain
C – heck circulation (pulse)
T – emperature monitoring
I – nfection prevention
O – utput and intake monitoring
N – utrition( appropriate diet)
S – kin must be checked frequently

1) In management for fractures by closed reduction the bones are:

a)
b)
c)
d)

Realigned through surgical means
May involve removal of damaged bone
Bone replacement with prosthesis
Bones realigned without surgery and cast applied to hold bones in alignment
 Answer : d – closed reduction – bone realignment without surgery

 Glaucoma
 Main problem: increased intraocular pressure due to accumulation of aqueous
humor
 Initial manifestation : Tunnel Vision , Gun Barrel Vision
Closed angle – with pain
 Laboratory Data : Tonometer reading of 25 mm Hg and above
 Nursing Diagnosis : Potential for Injury related to visual impairment
 Interventions : Explain to the patient that glaucoma cannot be cured but it can be
controlled
Administer Miotics ( pilocarpine )
Mydriatics contraindicated(ATSO4)
Instruct patient to avoid activities that can contribute to
increased IOP
Teach patient about trabeculoplasty – creation of an
opening in the trabecular meshwork to increase the outflow
of aqueous humor.

 Gastritis
 Acute and chronic inflammation of gastric mucosa causing edema, hemorrhage
and erosion
 Abdominal cramping, epigastric discomfort, hematemesis and indigestion
 Occult blood in stool and vomitus, decreased Hgb and Hct
Upper GI endoscopy confirms diagnosis when performed within 24 hours of
bleeding
 Acute and chronic pain
Risk for fluid volume defict
Altered nutrition less than body requirements
 Give IVF and antiemetics. Monitor MIO
Provide bland diet in smaller frequent meals
Administer antacids(between meals) and H2 blockers to promote healing,
anticholinergics and Vit B12
Angiography with vasopressin infused in NSS during bleeding

Teach importance of smoking cessation , avoid spicy foods and caffeine, taking
steroids with milk, foods or antacids and to avoid aspirin containing compounds
1) Complications of gastritis include
a) gastric carcinoma and pernicious anemia
b) bleeding and dehydration
c) a and b
d) b only
 answer : b - gastric carcinoma , pernicious anemia,
bleeding and dehydration are complications of gastritis

 Guillain – Barre Syndrome
 Main Problem : acquired acute inflammatory disease of the peripheral nerves
 Initial Manifestation : ascending paralysis , weakness at first
 Laboratory Data :CSF exam reveals elevated total protein
 Nursing Diagnosis: Ineffective Breathing Pattern
 Interventions :
Maintain a patent airway
Monitor for respiratory involvement
Instruct patient to avoid crowded areas
Keep tracheostomy and suction equipment at bedside
 Hemophilia
 Main Problem : Deficiency of clotting factors. Sex –linked recessive trait ( type A
and B ) more common in males. Von Willebrands disease is transmitted to both
male and female offsprings of a carrier
 Initial Manifestation: Hemarthrosis ( bleeding joints)
 Laboratory Data : prolonged Bleeding Time
 Nursing Diagnosis: Altered tissue perfusion
 Interventions : Avoid Aspirin
Control by : Rest
Immoblize
Cold Compress
Elevate
 Hepatic encephalopathy / coma
 Main Problem : Decreasing level of consciousness related to accumulation of
ammonia
 Initial manifestation : personality changes ; flapping tremors (asterexis) common
sign

 Laboratory Data : Elevated serum ammonia
 Nursing Diagnosis : Altered Thought Process
 Interventions : Monitor LOC
Maintain low CHON diet
 Hiatal Hernia
 Main Problem :A portion of the stomach is herniated through the esophageal
hiatus of the diaphragm
 Initial Manifestation: initially asymptomatic , heartburn is a common
complaint
 Laboratory Data: Endoscopy reveals herniation of a part of the stomach
 Nursing Diagnosis : Altered Nutrition
 Interventions : Maintain the patient in an upright position after meals
Instruct patient to avoid bending
Provide small frequent meals
Avoid anticholinergic drugs and coughing
 Hip Fracture
 Main Problem : Break in the continuity of the hip bone
 Initial manifestation: Shortening and external rotation of the affected leg
 Laboratory : Hip X – ray
 Nursing Diagnosis : Impaired Physical Mobility
 Interventions : Prepare the patient for surgery
Postoperatively maintain the legs in abduction by placing a
wedge pillow between legs
Monitor for signs and symptoms of complications
( petechiae over chest indicates fat embolism)

 Hyperparathyroidism
 Main Problem : hypersecretion of the parathyroid hormone
 Initial manifestation : bone pain
 Laboratory Data : elevated serum calcium levels
 Interventions : Prepare the patient for Surgery
Increase oral fluid intake
Provide low calcium diet
Strain all urine
Complication : renal calculi

 Hypertension
 Main Problem : Persistent BP above 140 / systolic and 90 / diastolic
 Initial manifestation : Asymptomatic , occipital headache is a common complaint
 Laboratory data : elevated BP
 Nursing Diagnosis : Altered Tissue Perfusion
 Interventions: Avoid Stimulants
Low salt , low fat diet
Stress reduction techniques
Lifestyle , dietary and behavioral modification
Compliance to HPN pharmacotherapy
Specially maintenance meds
 Hyperthyroidism
 Main Problem : Hypersecretion of thyroid hormones
 Initial manifestation : Fine hand tremors , intolerance to heat is a common
symptom
 Laboratory Data : Elevated T3 and T4
 Interventions : Maintain a high calorie , High CHON Diet
Provide adequate rest
Provide acool environment
Elevate head of bed
Propylthiouracil medication is lifetime
Prepare patient for thyroidectomy
Post thyroidectomy – assess for hemorrhage by slipping the
hand behind the neck

 Hyperlipidemia
 Increased serum levels of two plasma lipids; cholesterol and triglycerides above
200 mg/ dl. Factor causation of atherosclerosis and conductive to arteriosclerosis
 Initially asymptomatic
 Lipid Profile Test – elevated
 Non compliance to therapeutic regimen
 Instruct patient to eat salmon and tuna at least several times a week and increase
intake of high fiber foods
Administer antilipidemic drugs with meals –
Clofibrate ( Atromid-S)
and Cholestyramine ( Cuemid)
1) Management for patients with hyperlipidemia:
a) Diet low in cholesterol and saturated fats

b) Carbohydrate restricted diet
c) A and b
d) A only
 Answer : c – low saturated fat and low cholesterol diet can
maintain serum cholesterol below 140 mg/dl. Carbohydrate
restriction can lower serum triglyceride levels by reducing
lipoprotein derived from carbohydrate
 Hypoparathyroidism
 Main Problem : Hyposecretion of parathyroid hormone
 Initial manifestations : Tingling sensation around the lips and upper extremities
 Laboratory Data : Decreased serum calcium levels
 Nursing Diagnosis : Potential ; altered cardiac output
 Interventions : Assess for increased signs of neuromuscular irritability
( Chvosteks’ and Trousseau’s Sign)
Provide a quiet room , no stimulus
Provide high calcium , low phosphorus diet
 Hypothyroidism
 Main Problem : Hyposecretion of thyroid hormone
 Initial Manifestation : Fatigue , facial edema is a common sign
 Laboratory Data : Decreased T3 and T4 levels
 Nursing Diagnosis : Activity Intolerance
 Interventions : Maintain low calorie , low cholesterol and low saturated fat diet
Provide warm environment and avoid sedatives
Provide frequent rest periods
Instruct patient that administration of synthroid is lifelong

 Hypovolemic shock
 Main Problem : Loss of effective circulating blood volume leading to circulatory
collapse resulting to inadequate tissue perfusion
 Initial manifestation : narrowing pulse pressure
 Diagnostic data ; Decreased BP and Decreased CVP
 Nursing Diagnosis : altered Tissue Perfusion
 Interventions : Maintain patent airway

Keep patient in modified trendelenburg position
Start fluid replacement immediately
Administer vasopressors as ordered
 Hemorrhoids
 Varicosities or outpouching of the veins of the hemorrhoids plexus
 Internal- painless bleeding in defecation
External – intense rectal itching with bleeding and pain upon defecation
 Rectal examination
 Pain related to irritation, pressure, sensitivity in recto-anal area
 Conservative treatment:
Application of hot and cold compress
Analgesic ointment(nupercaine)
Hot sitz bath
Prepare patient for treatment by ligation, injection of sclerosing agent or preop
and post –op care for hemorroidectomy
Position prone post hemorroidectomy,
Watch out for hemorrhage 24 hours to 10 days post-op when sutures are
sloughing off.
Administer laxative, full diet until few hours before anesthetic is given. Stool
softeners and bulk formers(Metamucil)
Increase bulk and fluids
1) Post hemorrhoidectomy nursing care monitoring for potential complication includes
observation for:
a) Bleeding and urinary retention
b) Bleeding and atelectasis
c) Respiratory complications and urinary retention
d) None of the above
 Answer : a – bleeding and urinary retention are possible complications of
hemorrhoidectomy
 Increased intracranial pressure
 Main problem : increase in amount of CNS tissue or CSF fluid leading to an ICP
greater than 15 mmHg
 Initial Manifestation : Widening pulse pressure , decreasing LOC
 Laboratory Data : elevated Blood pressure ( systolic)
 Nursing diagnosis : Potential for ineffective breathing pattern
 Interventions : Keep the patient in high – fowler’s position
Administer dexamethasone and mannitol as ordered to
decrease cerebral edema
Monitor level of consciousness
 Liver Cirrhosis
 Main Problem : Normal liver tissues are replaced with scar tissues






Initial manifestation : edema
Laboratory data : elevated SGOT / SGPT ; AST / ALT
Nursing Diagnosis: Altered Fluid Volume
Interventions : Maintain A low protein diet
Assess the patient for bleeding
Prepare the patient for paracentesis
Weigh the patient daily
Asterixis indicates hepatic encephalopathy

 Meniere’s Disease
 Main Problem: Dilation of the endolymphatic system causing degeneration of the
vestibular and cochlear hair cells in the inner ear . It affects cranial nerve VIII
 Initial Manifestations : Vertigo usually described by patients as “ I feel like I’m
spinning “ , I feel as if the room is revolving “
 Laboratory Data : Caloric Stimulation test reveals moderate nystagmus
 Interventions : Priority Safety Keep the patient in supine position during the
attack
Maintain low sodium diet
Encourage the patient ot stop smoking
Keep the room dark when photophobia is present
 Multiple Sclerosis
 Main Problem : Chronic Progressive disease of the CNS characterized by small
patches of demyelination in the brain and spinal cord
 Initial Manifestations : Intentional Tremors and Diplopia
 Laboratory Data : MRI reveals small plaques scattered throughout the CNS
 Nursing Diagnosis : Impaired Physical Mobility related to nuscle weakness ; Risk
for injury
 Interventions : Promote safety of the client
Teach the patient certain stress management techniques
Encourage daily exercise

 Myasthenia Gravis
 Main Problem ; Faulty Neuromuscular transmission of the voluntary muscles of
the body due to a deficiency in acetylcholine receptor sites in the myoneural
junction
 Initial Manifestation : Descending muscle weakness initially manifested by ptosis
 Laboratory Data : CT scan reveals hyperplasia of the thymus gland. Tensilon test ;
increased muscle strength 30 seconds after administration of Endrophonium

 Nursing Diagnosis : Ineffective Breathing Pattern
 Interventions : Maintain Patent Airway
Instruct the patient to avoid quinidine , morphine and
antibiotics since these may trigger muscle weakness.
Instruct the patient to avoid prolonged talking over the
phone especially before meals since this will weaken the
facial muscles which are also used for eating.
 Intestinal obstruction
 Blockage of intestinal lumen causing gas, fluid and digested material substance to
accumulate near the obstruction and increase peristalsis.H2O and electrolytes are
then secreted into the blocked bowel causing inflammation and inhibiting
absorption
 Abdominal distention, cramping pain, decreased or absent bowel sounds
 Abdominal X-ray – increased amount of gas in the bowel
 Acute pain related to abdominal distention
Constipation related to inability of stool to pass through obstructed area
 Place patient on NPO and fluid and electrolyte replacement through IVF infusion
Assess bowel sounds,mio,vs and labs- stoll exams and measure abdominal girth to
assess for distention
Semi-fowlers for comfort , bedrest and quiet envt.
Administer analgesics( Demerol)and antibiotics(Gentamycin)
Teach and monitor pre-op and post –op care for bowel resection with or without
anastomosis
Avoid constipating food
GI decompression using NGT, Miller abbott or cantor tubes maintained position
and low intermittent suction
1) The priority nursing diagnosis for patients with bowel obstruction are Constipation
related to inability of stool to pass through obstructed area and:
a) Fluid volume deficit, potential for
b) Pain
c) High risk for infection
d) Potential for non – compliance
 Answer : b : pain is an immediate problem the other choices are potential
problems.
 Myocardial Infarction
 Main Problem : Destruction of the cardiac tissue due to reduced coronary blood
flow
 Initial Manifestation : lower sternal pain not relieved by rest and nitroglycerine ,
characterized as crushing or excruciating
 Laboratory Data : Elevated CPK and Troponin , ECG reveals ST segment
elevation or depression and T wave inversion

 Nursing Diagnosis : Pain related to decreased tissue oxygenation
Interventions: Morphine / Demerol to relieve pain
Oxygen Administration
Nitroglycerine
Aspirin
Position in semi-fowler’s
Maintain low fat , low cholesterol and low sodium diet
 Osteoporosis
 Main Problem : Loss of bone matrix leading to bone weakness predisposing it to
fractures. Usually associated with smoking , menopause , immobility and
hyperparathyroidism
 Initial manifestation : asymptomatic
 Laboratory Data : X- ray reveals decrease in bone density
 Nursing Diagnosis : Potential for Injury
 Interventions ; Increase Vit D and Calcium in the diet
Estrogen replacement therapy for post menopausal women
Encourage patient to perform active weight bearing exercises like brisk
walking , jumping rope , hiking , tennis and bal;lroom dancing.
Swimming does not meet criteria for resistance needed for prevention of
osteoporosis
 Metabolic acidosis
 state of excess acid accumulation and deficient base bicarbonate
 drowsiness and Kussmauls respiration, CNS depression, lethargy and stupor
 ABG reveals pH < 7.35 and HCO3 level < 24 mEq / L
 Assess and correct underlying cause
Watch out for increased serum potassium,frequent monitoring of vital signs , labs
and level of consciousness
Keep sodium bicarbonate ready and institute seizure precautions.
Teach urine and blood tests for sugar or acetone.
Encourage strict adherence to OHA or insulin therapy
1) Hyperglycemia in patients with IDDM can cause what metabolic imbalance:
a) Metabolic acidosis
b) Metabolic alkalosis
c) All of the above
d) None of the above
 Answer : a – excess production of metabolic acids such as hyrglycemia in patients
with IDDM warrants use of fats which liberates ketone bodies which is a
metabolic acid precipitates metabolic acidosis.

 Metabolic Alkalosis
 Clinical state marked by decreased amounts of acid and increased amounts of
base bicarbonate
 Confusion, hypoventilation, irritability, picking at bedlinens and twitching
 ABG pH . 7.45 and Bicarbonate level > 28 mEq / L
 High risk for injury related to metabolic alkalosis
Alteration in tissue perfusion and Impaired gas exchange
 Assess and Treat underlying cause
 Measure I and O and watch out for tachycardia and hypotension indicating
hypokalemia
Avoid the use of alkaline agents such as antacids, bicarbonate of soda and no
administration of IVF with increased concentration of bicarbonate or lactate
Acidifying agent- ammonium Chloride IV and potassium Chloride – supplements
IV ( not given to clients with hepatic and renal diseases and given on slow
infusions to prevent hemolysis)

1) Most appropriate nursing intervention to correct metabolic alkalosis is to:
a) infuse Potassium chloride
b) Use of antacids and bicarbonate of soda
c) IVF with bicarbonates and lactate
d) All of the above
 Answer : a - Infusion of acidifying agents are beneficial to counteract metabolic
alkalosis
 Respiratory alkalosis
 Deficiency of CO2 in the blood as indicated by decreased PaCO2 caused by
alveolar hyperventilation which elevates blood Ph.
 Deep rapid breathing > 40 bpm( cardinal)
Circumoral or peripheral paresthesias
Carpopedal spasms and lightheadedness
 ABG – Pa CO2 < 35 mHg
Ineffective breathing pattern
 Eradicate underlying condition by treatment of CNS disease, fever, sepsis or
removal of ingested toxins
Teach effective deep breathing into a paper bag
Watch out for twitching and cardiac arrythmias
Monitor ABG’S and serum electrolyte levels

1) Common management for respiratory alkalosis includes:
a) Oxygenation by nasal cannula
b) Oxygen delivery by face mask at 10 LPM
c) Teach deep breathing in a paper bag
d) Encourage patient to breathe deeply in a pursed lip manner

 Respiratory Acidosis
 Acid – base disturbance characterized by excess CO2 in the blood( hypercapnia)
>45 mmHg resulting from reduced alveolar ventilation
 Restlessness and confusion
 ABG – Ph below normal < 7.35 ; pCO2 > 45
Ineffective breathing pattern
 Monitor pulmonary function tests
 Prepare patient for intubation and /or mechanical ventilation if with hypoxemia,
decreased level of consciousness and respiratory distress.
Administer antibiotics, sodium bicarbonate and bronchodilators as needed
Chest physiotherapy, suctioning and O2 with humidification
Eradicate underlyingt cause by intubation and Mech. Ventilation, removal of
foreign body and dialysis to remove toxic drugs.
1) Respiratory acid – base imbalance caused by retention of CO2 which combines with
H2O to form carbonic acid H2CO3 includes the following disorders except:
a) COPD and Asthma
b) hyperventilation
c) CNS depression
d) Pulmonary edema and respiratory paralysis
 Answer : b – hyperventilation causes alkalosis

 Pancreatitis
 Main Problem : Autodigestion of the pancreas
 Initial Manifestation : Periumbilical Pain
 Laboratory Data : Elevated Serum Amylase

 Interventions : Administer Demerol to relieve pain. Morphine contraindicated as
it causes spasm of the spincter of oddi
Maintain low fat diet , patient on NPO during acute phase
Instruct patient to avoid coffee and alcohol
 Parkinson ‘ s Disease
 Main Problem : Progressive Neurologic Disorder affecting the brain centers
responsible for control and regulation of movement due to depletion of dopamine
 Initial manifestation : Bradykinesia
 Laboratory data : No Specific
 Interventions ; Maintain Exercise program
Maintain a low protein diet at daytime and high protein at
night because absorption of levodopa which is usually
taken at daytime is slowed down by intake of high protein
foods and vitamin B6
Institute safety measures ( rubber soled shoes , low heels
and grab bars )
Prepare patient for stereotaxic thalamotomy , surgery done
to decrease tremors

 Peptic Ulcer Disease , Duodenal
 Main Problem : Increased in HCL acid levels in the stomach
 Initial manifestation : Right Epigastric Pain which occurs 2-3 hours after meals
usually at night and is relieved by eating
 Laboratory Data : Gastric Analysis reveals elevated HCL
 Nursing diagnosis : Potential for fluid volume deficit
 Interventions : Maintain high fat , high carbohydrate and low protein diet. Instruct
patient to avoid spicy and caffeine containing foods , alcohol and smoking
 Peptic Ulcer Disease , Gastric
 Main Problem : Weak Gastric Mucosa
 Initial Manifestation : Left epigastric pain which occurs 30 minutes – 1 hour after
meals usually at day time and is relieved by vomiting
 Laboratory Data : Endoscopy reveals ulcer usually in the lesser curvature of the
stomach
 Nursing Diagnosis : Potential for fluid volume deficit
 Interventions ; Maintain High fat , high carbohydrate and low protein diet
Instruct the patient to avoid spicy , caffeine containing foods , alcohol and
smoking

Administer antacids separately from other drugs that the patient is taking , as
ordered.
Prepare patient for surgery ( Billroth 1 , 2 or gastrectomy or vagotomy)

 Raynauds disease
 Main Problem : VAsospastic condition of arteries of the hands tha occurs with
exposure to cold or stress
 Initial Manifestation : Intermittent arteriolar vasoconstriction
 Laboratory Data : Allen’s test reveals circulatory problems
 Nursing Diagnosis : Altered Tissue Perfusion
 Interventions : Avoid cold weather
 Wear leather gloves when getting anything from the refrigerator
 Stop smoking
 Administer vasodilators as ordered
 Renal Colic ( Urolithiasis)
 Main Problem : Presence of renal stone in the urinary system
 Initial manifestation : Sudden severe pain that leads to shock, unrelieved by
analgesics
 Laboratory Data : IVP reveals the presence of stone
 Nursing diagnosis : Pain
 Interventions : Strain all patients urine , to assess if the patient is passing out
stones
Increase Oral Fluid Intake
Prepare Patient for Extracorporeal Shock Wave Lithotripsy- area
submerged in water and electrically generated shock wave directed to the
location of the stone. Pain medications given to minimize pain
Maintain patient on low sodium , low protein diet
 Renal Failure , Acute
 Main Problem : Abrupt reversible cessation of renal function as a result of
trauma , allergy and kidney stones
 Initial Manifestation : Oliguria ( U.O. , 400 ml / 24 hours )
 Laboratory data : elevated BUN and creatinine
 Nursing Diagnosis : Alteration in Urinary Elimination
Fluid and electrolyte imbalance

 Interventions : Monitor Intake and output
Maintain a low protein , high carbohydrate , low sodium
diet and fluid restricted during the oliguric phase and high
protein , high calorie and fluid replacement during diuretic
phase
 Renal Failure , Chronic
 Main Problem : Irreversible slow or progressive failure of the kidneys to function
that results in death unless treatment is instituted
 Initial manifestation : GI manifestations like anorexia , nausea and vomiting
 Laboratory Data : Elevated serum creatinine level and low urine creatinine
clearance
 Nursing Diagnosis : Alteration in urinary elimination
Fluid Volume Excess
 Interventions : Maintain low protein , low sodium , low potassium diet
Prepare patient for hemodialysis / peritoneal dialysis and monitor
for complications
Monitor for signs and symptoms of anemia
Administer Epogen , diuretics and antihypertensives as ordered

 Pulmonary Embolism
 Obstruction of blood flow to pulmonary vessels by an undissolved substance( air,
fat, emboli,thrombus) resulting in pulmonary hypertension and possible
iinfarction
 Sudden onset of dyspnea, tachypnea, crackles and chest pain
 ABG – hypoxemia; pulmonary angiography shows location of embolism and
filing defect
CXR – shows pneumoconstriction pulmonary arterial dilation
Lung scan shows VQ mismatch
Ineffective tissue perfusion; cardiopulmonary
 Monitor ABG and watch out for respiratory distress and assess cardiovascular
status and CVP
Irregular pulse – arrhythmia caused by hypoxemia
Hyperthermia – pulmonary embolism caused by thrombophlebitis

Monitor lab studies – maintain PTT at 1 ½ to 2 times control in patient with
heparin – PT at 1 ½ to 2 times control or INR at 2 -3 in patient receiving
coumadin
Place patient in fowlers position, suction and administer IVF, analgesics,
anticoagulants, diuretics and fibrinolytics as ordered
1) The nursing diagnosis with least significance for patients with pulmonary embolism is:
a) Altered pattern of breathing related to dyspnea
b) Impaired gas exchange related to decreased diffusion
c) Pain related to pleural irritation
d) Anxiety related to hypoxia
 Answer : d – physiological needs first

 Pulmonary Edema
 A condition characterized by excessive amount of fluid in the alveoli and
pulmonary interstitial tissues which tends to interfere with effective diffusion of
gases
 Dyspnea, orthopnea, crackles paroxysmal nocturnal dyspnea and pink frothy
sputum
 Pulmonary function tests decreased VQ ratios, ABG’s indicate hypoxemia
 Impaired gas exchange related to right to left shunting and decreased V/Q ratios
Fluid volume excess related to left ventricular failure in cardiogenic pulmonary
edema
Decreased cardiac output related to left ventricular failure in cardiogenic
pulmonary edema
 Monitor blood gases
If on ventilator , suction frequently. Maintain oxygenation with ventilator( on
PEEP) or nasal cannula
Restrict fluids and sodium for edema
Administer inotropic drugs(Dopamine and dobutamine) and diuretics in
cardiogenic pulmonary edema
Prevent pulmonary infection with strict asepsis
Maintain nutrition with parenteral or enteral feedings
1) An example of a drug used in pulmonary edema to decrease circulating fluid volume
a) Dopamine ( Intropin)
b) Dobutamine ( Dobutrex)
c) Lasix( Furosemide)
d) Digoxin ( Digitoxin)
 Answer : c – furosemide is a diuretic which decreases fluid volume by
increasing renal water excretion

 Pneumothorax
 A restrictive respiratory disease occurs when air enters the pleural space as a
result of pulmonary lesion, neoplasms, accidental or surgical opening through the
chest wall. Collapse of the lung due to air in the pleural space.
 Hemothorax – blood
 Hydrothorax – water
 Pyothorax – pus and exudates
 Acute symptoms of dyspnea and paradoxical chest movement( absent or restricted
movement on the affected side with decreased or absent breath sounds , may lead
to mediastinal shift)
 Lung scan shows VQ ratio mismatches
 CXR showing decreased perfusion
ABG showing hypoxemia
 Monitor PFT’s and prepare patient for thoracentesis and observe for
complications of chest tube placements ( constant bubbling in the water seal
chamber– indicates leak; 3 days post insertion can indicate lung re-expansion)
Place patient in high fowlers position and place on O2 therapy as indicated.
Instruct patient to do valsalva maneuver during chest tube removal.
1) The following are measures to promote adequate respirations and maintain proper
function of the drainage bottle system:
a) Prevent movement to prevent displacement of the tube
b) Keep drainage bottles below chest level and position patient flat on bed
c) Constant clamping of the tubes
d) Milking not routinely done
 Answer : d – patient is positioned in semi- fowlers,drainage bottles below
chest level, milking not routinely done as it increases negative pressure,
clamping of the tube done only when bottles are broken or must be raised
above the chest.
 Systemic Lupus Erythematosus
 Chronic autoimmune multi-system disorder with periods of exacerbation and
remission and increased production of antibodies to cellular DNA results in
inflammatory process involving veins and arteries causing pain swelling and
tissue damage.
 Pancytopenia and butterfly rash on the face, palmar erythema, psychosis and
impaired cognitive function migratory pain and swelling, hypertension & carditis
 Positive rheumatoid factor and ANA test positive
 ESR elevated and serum globulins elevated

Urine chemistry – proteinuria and hematuria
 High risk for injury
 Diet high in iron , CHON, vita.C
Hemodialysis and kidney transplant if renal failure occurs
Increase rest and sleep
Monitor musculo skeletal, renal and cardiopulmonary status
Administer antiemetics , and antidiarrheals
Encourage expression of body image change
Avoid infections, injury, sunlight exposure, OTC meds, oral contraceptives, hair
spray and color
Give medications as ordered – analgesics , anti-emetics, anti-rheumatics,
cytotoxic drugs, steroids and NSAIDS.
1) Complications of SLE includes peripheral vascular disease which can be a
cause of
a. Loss of limbs
b. COPD
c. Congestive heart failure
d. Stroke
 Answer : a – PVD as a complication of SLE can lead to
peripjeral tisuue necrosis which warrants amputation

 Urinary Tract Infection
 Infection of the urinary tract as a result of urethral ascend of bacteria usually
caused by E. Coli.
Cystitis – inflammation of the urinary bladder
Pyelonephritis
 inflammation of the kidney and its pelvis
 Flank pain, with frequency,burning and urgency
Chills , muscle spasm, dysuria
 Urinalysis and urine C/ S confirms causative agent
 Pain alteration in comfort
 Stress the importance of medication compliance and bedrest during acute
phase
Relieve flank pain with analgesics , rest massage and external heat application
Sulfonamides and broad spectrum antibiotics, urinary antiseptics ( Bactrim ,
Septra) and
urinary analgesics ( Pyridium)
Increase oral fluid intake up to 4 liters per day and follow up urinalysis every
two weeks for a month then monthly until urine is sterile.

1.)the following statement is true about pyelonephritis except
a. may follow cystitis
b. clinical manifestation includes costovertebral angle tenderness
c. most commonly caused by E coli
d. all of the above
 answer : d – all statements are descriptive of pyelonephritis
 Retinal Detachment
 Main Problem : Separation of the sensory retina from the pigment epithelium of
the retine
 Initial manifestation : Visual floaters described by patients as cobwebs or curtain
in eyes
 Nursing Diagnosis : Potential for Injury
 Interventions : Immediate Bedrest
Position patient with the affected side towards the bed , so gravity may
help put the detached retina back into place .
Avoid coughing ,sneezing and straining prepare the patient for eye
surgery.
 Spinal Cord Injury
 Main Problem : Partial or complete disruption of nerve tracts and neurons
resulting in paralysis and sensory loss
 Initial manifestation : Depends on the level of injury
Cervical : Quadriplegia
Thoracic : Paraplegia
Lumbar : Paraplegia
 Laboratory Data : X – Ray reveals the location and extent of injury
 Nursing Diagnosis : Ineffective Breathing Pattern , Impaired Physical
Mobility
 Interventions : Avoid hyperflexion and hyperextension of the spine . log roll
the patient
Keep a catheter at the bedside to prevent bladder distention which
may stimulate autonomic dysreflexia

 Syndrome of Inappropriate antidiuretic Hormone (SIADH)
 Main Problem : Inappropriate continued release of antidiuretic hormone
resulting in water intoxication

 Initial Manifestation : Mental Confusion
 Laboratory Data : Hyponatremia – Na , 120 mEq / L
 Nursing Diagnosis : Fluid Volume Excess
Fluid and electrolyte imbalance
 Interventions : Fluid Restriction
Assess for signs and symptoms of hyponatremia
 Ulcerative Colitis
 Main Problem : Ulceration of the mucosa of the lower colon and rectum
 Initial manifestation : Bloody Mucoid Diarrhea
 Laboratory data : Barium enema reveals lesions
Altered Bowel Elimination ; diarrhea
 Interventions : Avoid dairy products
Maintain Low Residue and High protein Diet , avoid cold
fluids
Teach patients about familial predisposition
GOODLUCK AND GOD BLESS…JLO

ABC's of MEDICAL and SURGICAL NURSING

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (7)

Similaire à ABC's of MEDICAL and SURGICAL NURSING

Similaire à ABC's of MEDICAL and SURGICAL NURSING (20)

Dernier

Dernier (20)

ABC's of MEDICAL and SURGICAL NURSING