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WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                    DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

PERIOPERATIVE NURSING                                                        Signature is obtained with the client’s complete
                                                                             understanding of what to occur.
A. Major Types of Pathologic Process Requiring Surgical                      - adult sign their own operative permit
Intervention (OPET)                                                          - obtained before sedation
   Obstruction – impairment to the flow of vital fluids                      For minors, parents or someone standing in their behalf,
   (blood,urine,CSF,bile)                                                    gives the consent. Note: for a married emancipated minor
   Perforation – rupture of an organ.                                        parental consent is not needed anymore, spouse is accepted
   Erosion – wearing off of a surface or membrane.                           For mentally ill and unconscious patient, consent must be
   Tumors – abnormal new growths.                                            taken from the parents or legal guardian
                                                                             If the patient is unable to write, an “X” is accepted if there is a
B. Classification of Surgical Procedure                                      witness to his mark
                                                                             Secured without pressure and threat
According to PURPOSE:                                                        A witness is desirable – nurse, physician or authorized
  Diagnostic – to establish the presence of a disease condition. (           persons.
  e.g biopsy )                                                               When an emergency situation exists, no consent is necessary
  Exploratory – to determine the extent of disease condition ( e.g           because inaction at such time may cause greater injury.
  Ex-Lap )                                                                   (permission via telephone/cellphone is accepted but must be
  Curative – to treat the disease condition.                                 signed within 24hrs.)
  * Ablative – removal of an organ
  * Constructive – repair of congenitally                              D. Preoperative Meds. 5A’s
                  defective organ.                                     Anxiolitics (Tranquilizers & Sedatives)
  * Reconstructive – repair of damage organ                               * Diazepam ( Valium )
  Palliative – to relieve distressing sign and symptoms, not              * Lorazepam ( Ativan )
  necessarily to cure the disease.                                        * Diphenhydramine
                                                                       Analgesics
According to URGENCY                                                      * Nalbuphine ( Nubain )
                                                                       Anticholinergics
      Classification           Indication for        Examples             * Atropine Sulfate
                                  Surgery                              Anti-Ulcer (Proton Pump Inhibitors)
Emergent – patient                                - severe                * Omeprazole ( Losec )
requires immediate             Without delay      bleeding                * Famotidine
attention, life threatening                       - gunshot/ stab      Antibiotics
condition.                                        wounds
                                                  - Fractured skull    E. Preoperative Teachings
Urgent / Imperative –         Within 24 to 30     -    kidney     /           Incentive Spirometry
patient requires prompt           hours           ureteral stones             Diaphragmatic Breathing
attention.                                                                    Coughing
Required – patient              Plan within a     - cataract                  Turning
needs to have surgery.          few weeks or      - thyroid d/o               Foot and Leg exercise
                                   months                                  Teaching should be done morning/afternoon before the day of
Elective – patient should      Failure to have    - repair of scar         surgery
have surgery.                    surgery not      - vaginal repair         Best Method: Return Demonstration
                                 catastrophic
Optional – patient’s               Personal       - cosmetic           F. The Surgical Team
decision.                         preference      surgery
                                                                       Surgeon
                                                                       •    Performance of the operative procedure according to the
C. Inform Consent
                                                                            needs of the patients.
    Purposes:
                                                                       •    The primary decision maker regarding surgical technique to
       To ensure that the client understand the nature of the
                                                                            use during the procedure.
       treatment including the potential complications and
                                                                       Assistant Surgeon
       disfigurement.
                                                                       •    Assists with retracting, hemostasis, suturing and any other
       To indicate that the client’s decision was made without
                                                                            tasks requested by the surgeon to facilitate speed while
       pressure.
                                                                            maintaining quality during the procedure.
       To protect the client against unauthorized procedure.           Anesthesiologist
       To protect the surgeon and hospital against legal action by a   •    Selects the anesthesia, administers it, intubates the client if
       client who claims that an authorized procedure was                   necessary, manages technical problems related to the
       performed.                                                           administration of anesthetic agents, and supervises the client’s
                                                                            condition throughout the surgical procedure.
   Essential Elements of Informed Consent                              Scrub Nurse
    the diagnosis and explanation of the condition.                   •    Assists with the preparation of the room.
    a fair explanation of the procedure to be done and used and       •    Scrubs, gowns and gloves self and other members of the
      the consequences.                                                     surgical team.
    a description of alternative treatment or procedure.              •    Prepares the instrument table and organizes sterile equipment
    a description of the benefits to be expected.                          for functional use.
    material rights if any.                                           •    Assists with the drapping procedure.
    the prognosis, if the recommended care, procedure is refused.     •    Passes instruments to the surgeon and assistants by
                                                                            anticipating their need.
   Requisites for Validity of Informed Consent                         •    Counts sponges, needles and instruments.
     Written permission is best and legally accepted.                  •    Keeps track of irrigations used for calculations of blood loss

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                      DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

Circulating Nurse                                                          Thrombophlebitis        Early ambulation
•    Responsible and accountable for all activities occurring during                               Anti embolic stocking
     a surgical procedure including the management of personnel                                    Encourage leg exercise
     equipment, supplies and the environment during a surgical                                     Hydrate adequately
     procedure.                                                                                    Avoid any restricting devices
•    Ensure all equipment is working properly.                                                     that impaired circulation
•    Guarantees sterility of instruments and supplies.                                             Avoid massage on the calf of
•    Monitor the room and team members for breaks in the sterile                                   the leg
     technique.                                                                                    Initiate anticoagulant therapy
•    Handles specimens.
                                                                           URINARY
•    Coordinates activities with other departments, such as
                                                                           Urinary Retention       Monitor I & O
     radiology and pathology.
                                                                                                   Interventions to facilitate
                                                                                                   voiding
G. Principles of Surgical Asepsis                                                                  Urinary Catheterization as
                                                                                                   needed
     Sterile object remains sterile only when touched by another
                                                                           Urinary                 Monitor I & O
      sterile object
                                                                           Incontinence
     Only sterile objects may be placed on a sterile field
                                                                           Urinary Tract           Adequate fluid intake
     A sterile object or field out of range of vision or an object held
                                                                           Infection               Early ambulation
      below a person’s waist is contaminated
     When a sterile surface comes in contact with a wet,                                          Aseptic catheterization as
      contaminated surface, the sterile object or field becomes                                    needed
      contaminated by capillary action                                                             Good perineal hygiene
     Fluid flows in the direction of gravity                              GASTRO-INTESTINAL
     The edges of a sterile field or container are considered to be       Nausea and              IV fluids until peristalsis
      contaminated (1 inch)                                                Vomiting                returns
                                                                                                   Progressive diet ( clear liquid
H. PACU/RR Care                                                                                    then full fluids, soft then
                                                                                                   regular diet)
     Maintaining a Patent Airway                                                                  Anti emetics as ordered
     Assessing Status of Circulatory System                               Hiccups                 NGT insertion as needed
     Maintaining Adequate Respiratory Function                                                    Hold breath while taking a
     Assessing Thermoregulatory Status                                                            large swallow of water
     Maintaining Adequate Fluid Volume                                                            Breath in and out on a paper
     Minimizing Complications of Skin Impairment                                                  bag
     Maintaining Safety                                                                           Anti emetics as ordered
     Promoting Comfort                                                    Intestinal              NGT insertion as needed
                                                                           Obstruction             Administered IVF as ordered
I. Parameter for Discharge from PACU/RR                                    ( 3rd-5th day postop)   Prepare for possible surgery
                                                                           Constipation            Adequate hydration
    Activity. Able to obey commands
                                                                                                   High fiber diet
    Respiratory. Easy, noiseless breathing
                                                                                                   Encourage early ambulation
    Circulation. BP within 20mmHg of preop level
                                                                           Paralytic Ileus         Encourage early ambulation
    Consciousness. Responsive
                                                                           WOUND
    Color. Pinkish skin and mucus membrane
                                                                           Wound Infection         Keep wound clean and dry
J. Post Operative Complications                                                                    Surgical aseptic technique
                                                                                                   when changing dressing
       Problem                   Nursing Intervention                                              Antibiotic therapy
                                                                           Wound Dehiscence
RESPIRATORY                                                                                        Apply abdominal binders
                                                                                                   Encourage high protein diet
Pneumonia                     Deep breathing exercises                                             and Vit.C intake
                              Coughing exercise                                                    Keep in bed rest
                              Early ambulation                             Wound Evisceration      Semi-Fowlers, bend knees to
Atelectasis                   Deep breathing exercises                                             relieve tension on the
                              Coughing exercise                                                    abdominal muscles
                              Early ambulation                                                     Splinting on coughing
Pulmonary                     Turning                                                              Cover exposed organ with
Embolism                      Ambulation                                                           sterile , moist saline dressing
                              Anti embolic stockings                                               Reassure, keep him/her quite
                              Compression devises                                                  and relaxed
                              Prevent massaging the lower                                          Prepare for surgery and repair
                              extremities                                                          of wound
CIRCULATION
Hypovolemia                   Fluid and blood replacement
Hemorrhage                    Fluid and blood replacement
                              Vit.k and hemostat
                              Ligation of bleeders
                              Pressure dressing
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                      DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

ONCOLOGY NURSING                                                                 Yearly papanicolao (Pap) smear for sexually active females and
                                                                                  any female over age 18
A. Benign VS Malignant Neoplasm                                                  At menopause, high-risk women should have an endometrial
                                                                                  tissue sample
Characteristic      Benign Neoplasm       Malignant Neoplasm
Speed Growth        Grows slowly          Usually grows rapidly           4. For detection of prostate cancer
                    Usually continues     Tends to grow relentlessly          At age 50, have a yearly digital rectal examination
                    to grow throughout    throughout life                     At age 50, have a yearly prostate-specific antigen (PSA) test
                    life unless
                    surgically removed                                    C. American Cancer Society’s seven warning signs of cancer
Mode of             Grows by enlarging    Grows by infiltrating           (uses acronym CAUTION US):
Growth              and expanding         surrounding tissues                  1. Change in bowel or bladder habits
                    Always remains        May remain localized (in             2. A sore that does not heal
                    localized; never      situ) but usually infiltrates        3. Unusual bleeding or discharge
                    infiltrates           other tissues                        4. Thickening or lump in breast or elsewhere
                    surrounding                                                5. Indigestions or difficulty in swallowing
                    tissues                                                    6. Obvious change in wart or mole
Capsule             Almost always         Never contained within a            7. Nagging cough or hoarseness
                    contained within a    capsule
                    fibrous capsule       Absence of capsule allows             8. Unexplained Anemia
                    Capsule               neoplastic cells to invade            9. Sudden loss of weight
                    advantageous          surrounding tissues
                    because               Surgical removal of tumor       D. Internal Radiation Therapy (Brachytheraphy)
                    encapsulated          difficult
                    tumor can be                                          Sources of Internal Radiation
                    removed surgically                                     Implanted into affected tissue or body cavity
Cell                Usually well          Usually poorly                   Ingested as a solution
characteristics     differentiated        differentiated                   Injected as a solution into the bloodstream or body cavity
                                                                           Introduced through a catheter into the tumor
Recurrence          Unusual when          Common following surgery
                                                                          Side Effects
                    surgically removed    because tumor cells spread
                                                                                   Fatigue
                                          into surrounding tissues
                                                                                   Anorexia
Metastasis          Never occur           Very common                              Immunosuppression
Effect of           Not harmful to host   Always harmful to host                   Other side effects similar to external radiation
Neoplasm            unless located in     Causes disfigurement,
                    area where it         disrupted organ function,       Client Education
                    compresses tissue     nutritional imbalances           Avoid close contact with others until treatment is completed
                    or obstructs vital    May result in ulcerations,       Maintain daily activities unless contraindicated, allowing for extra
                    organs                sepsis, perforations,                rest periods as needed
Prognosis           Very good             Depends on cell type and         Maintain balanced diet
                    Tumor generally       speed of diagnosis               Maintain fluid intake ensure adequate hydration (2-3 liters/day)
                    removed surgically    Poor prognosis if cells are      If implant is temporary, maintain bedrest to avoid dislodging the
                                          poorly differentiated and            implant.
                                          evidence of metastatic           Excreted body fluids may be radioactive; double-flush toilets after
                                          spread exists                        use
                                          Good prognosis indicated if      Radiation therapy may lead to bone marrow suppression
                                          cells still resemble normal
                                          cells and there is no           Nursing Management
                                          evidence of metastasis           Exposure to small amounts of radiation is possible during close
                                                                              contact with persons receiving internal radiation: understand the
                                                                              principles of protection from exposure to radiation: time, distance,
B. Recommendations of the American Cancer Society for Early                   and shielding
Cancer Detection                                                                Time: minimize time spent in close proximity to the
1. For detection of breast cancer                                                    radiation source; a common standard is to limit contact time
    Beginning at age 20, routinely perform monthly breast self-                     to 30 minutes total per 8-hour shift;
        examination                                                                  Distance: maintain the maximum distance 6 feet possible
    Women ages 20-39 should have breast examination by a                            from the radiation source
        healthcare provider every 3 years                                       Shielding: use lead shields and other precautions to reduce
    Women age 40 and older should have a yearly mammogram                           exposure to radiation
        and breast self-examination by a healthcare provider               Place client in private room
                                                                           Instruct visitors to maintain at least a distance of 6 feet from the
2. For detection of colon and rectal cancer                                   client and limit visitors to 10-30 minutes
   All persons age 50 and older should have a yearly fecal occult         Ensure proper handling and disposal of body fluids, assuring the
       blood test                                                             containers are marked appropriately
   Digital rectal examination and flexible sigmoidoscopy should           Ensure proper handling of bed linens and clothing
       be done every 5 years                                               In the event of a dislodged implant, use long-handled forceps and
   Colonoscopy with barium enema should be done every 10                     place the implant into a lead container; never directly touch the
       years                                                                  implant
                                                                           Do not allow pregnant woman to come into any contact with
3. For detection of uterine cancer                                            radiation

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                      DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)
    If working routinely near radiation sources, wear a monitoring       B. Heart Sound
     device to measure exposure                                                Tricuspid valve (lub) - RT 5th intercostal, medial
    Educate client in all safety measures                                     Mitral valve (lub) - LT 5th intercostal, lateral
                                                                               Aortic semilunar valve (dub) - RT 2nd intercostal
E. External Radiation Therapy (Teletheraphy)                                   Pulmonary semilunar valve (dub) - LT 2nd intercostals

    The radiation oncologist marks specific locations for radiation      S1 - due to closure of the AV(mitral/tricuspid) valves
     treatment using a semipermanent type of ink                          S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves
    Treatment is usually given 15-30 minutes per day, 5 day per          S3 – Ventricular Diastolic Gallop
     week, for 2-7 weeks                                                       Mechanism: vibration resulting from resistance to rapid
    The client does not pose a risk for radiation exposure to other                     ventricular filling secondary to poor compliance
     people                                                               S4 - Atrial Diastolic Gallop
                                                                               Mechanism: vibration resulting from resistance to late
Side Effects                                                                              ventricular filling during atrial systole
      Tissue damage to target area (erythema, sloughing, hemorrhage)     Heart Murmurs
      Ulcerations of oral mucous membranes                                Incompetent / Stenotic Valve
      GIT effects such as nausea, vomiting, and diarrhea                 Pericardial Friction Rub
      Immunosuppression                                                   It is an extra heart sound originating from the pericardial sac
                                                                           Mechanism: Originates from the pericardial sac as it moves
Client Education                                                           Timing: with each heartbeat
 Wash the marked area of the skin with plain water only and pat
    skin dry; do not use soaps, deodorants, lotions, perfumes, powders    C. ECG
    or medications on the site during the duration of the treatment; do
    not wash off the treatment site marks
 Avoid rubbing, scratching, or scrubbing the treatment site; do
    not apply extreme temperatures (Heat or Cold) to the
    treatment site ; if shaving, use only an electric razor
 Wear soft, loose-fitting over the treatment area
 Protect skin from sun exposure during the treatment and for at
    least 1 year after the treatment is completed; when going
    outdoors, use sun-blocking agents with sun protector factor
    (SPF) of at least 15
 Maintain proper rest, diet, and fluid intake as essential to            Cardiac Action Potential
    promoting health and repair of normal tissues                          Depolarization/Contraction/Systole - electrical activation of
                                                                              a cell caused by the influx of sodium into the cell while
                                                                              potassium exits the cell
Nursing Management                                                         Repolarization/Resting/Diastole - return of the cell to the
 Monitor for adverse side effects of radiation                               resting state caused by re-entry of potassium into the cell
    Monitor for significant decreases in white blood cell counts             while sodium exits
    and platelet counts
 Client teaching (refer to later sections for management of              D. CARDIAC Proteins and enzymes
    immunosuppression, thrombocytopenia
                                                                             a.    CK- MB ( creatine kinase)
                                                                                     Most cardiac specific enzymes
CARDIOVASCULAR NURSING                                                               Accurate indicator of myocardial dammage
                                                                                     Elevates in MI within 4 hours, peaks in 18 hours and
A. Heart Circulation                                                                     then declines till 3 days
                                                                                     Normal value is 0-7 U/L or males 50-325 mu/ml
                                                                                                                 Female 50-250 mu/ml
                                                                             b.    Lactic Dehydrogenase (LDH)
                                                                                     Most sensitive indicator of myocardial damage
                                                                                     Elevates in MI in 24 hours, peaks in 48-72 hours
                                                                                         Return to normal in 10-14 days
                                                                                     Normally LDH1 is greater than LDH2
                                                                             c.    Troponin I and T
                                                                                     Troponin I is usually utilized for MI
                                                                                     Elevates within 3-4 hours, peaks in 4-24 hours and
                                                                                         persists for 7 days to 3 weeks!
                                                                                     Normal value for Troponin I is less than 0.6 ng/mL
                                                                                     REMEMBER to AVOID IM injections before obtaining
                                                                                         blood sample!
                                                                                     Early and late diagnosis can be made!
                                                                             d.    Serum Lipids
                                                                                      Lipid profile measures the serum cholesterol,
                                                                                           triglycerides and lipoprotein levels
                                                                                      Cholesterol= 200 mg/dL
                                                                                      Triglycerides- 40- 150 mg/dL
                                                                                      LDH- 130 mg/dL
                                                                                      HDL- 30-70- mg/dL
                                                                                      NPO post midnight (usually 12 hours)


POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                     DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

E. Cardiac Catheterization ( Coronary Angiography /                                                               Keep the drug in a dry
Arteriography )                                                                            ECG: may reveals        place, avoid moisture
 Insertion of a catheter into the heart and surrounding vessels                           ST segment              and exposure to sunlight
 Is an invasive procedure during which physician injects dye                              depression             Change stock every 6
     into coronary arteries and immediately takes a series of x-ray                        T wave inversion        months
     films to assess the structures of the arteries                                                               Offer sips of water
     Pretest: Ensure Consent, assess for allergy to seafood and                                                    before giving sublingual
     iodine, NPO, document weight and height, baseline VS, blood                                                   nitrates,
     tests and document the peripheral pulses
     Intra-test: inform patient of a fluttery feeling as the catheter                                            NTG Nitrol or
     passes through the heart; inform the patient that a feeling of                                              Transdermal patch
     warmth and metallic taste may occur when dye is                                                              Avoid placing near hairy
     administered                                                                                                  areas as it may decrease
     Post-test: Monitor VS and cardiac rhythm                                                                      drug absorption
 Monitor peripheral pulses, color and warmth and sensation of                                                    Avoid rotating
     the extremity distal to insertion site                                                                        transdermal patches.
 Maintain sandbag to the insertion site if required to maintain         Myocardial        Chest pain            Nursing Management
     pressure                                                            Infarction        Usually radiates      Goal: Decrease myocardial
 Monitor for bleeding and hematoma formation                            (MI)              from neck, back,      oxygen demand
                                                                                           shoulder, arms,
F. CVP ( Central Venous Pressure )                                       Death of          jaw & abdominal        Administer narcotic
 Reflects the pressure of the blood in the right atrium.                myocardial        muscles                 analgesic as ordered:
 Engorgement is estimated by the venous column that can be              cells from        (abdominal              Morphine
     observed as it rises from an imagined angle at the point of         inadequate        ischemia): severe      Administer oxygen low
     manubrium ( angle of Louis).                                        oxygenation,      crushing                flow 2-3 L / min
 With normal physiologic condition, the jugular venous column           often caused                             Enforce CBR in semi-
     rises no higher than 2-3 cm above the clavicle with the client in   by sudden         Not usually             fowlers position without
     a sitting position at 45 degree angle.                              complete          relieved by rest or     bathroom privileges
                                                                         blockage of a     by nitroglycerine      Instruct client to avoid
                                                                         coronary                                  forms of valsalva
                                                                         artery            N/V                     maneuver
                                                                                           Dyspnea                Monitor urinary output
                                                                         Characterized     Increase in blood       & report output of less
                                                                         by localized      pressure & pulse        than 30 ml / hr:
                                                                         formation of      Hyperthermia:           indicates decrease
                                                                         necrosis          elevated temp           cardiac output
                                                                         (tissue           Skin: cool, clammy,    Resumption of ADL
                                                                         destruction)      ashen                   particularly sexual
    NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg                              with              Mild restlessness       intercourse: is 4-6 weeks
    To Measure:                                                         subsequent        & apprehension          post cardiac rehab, post
       Patient should be flat with zero point of manometer at the       healing by                                CABG & instruct to:
          same level of the RA which corresponds to the mid-axillary     scar formation    ECG:                   Instruct client to assume
          line of the patient or approx. 5 cm below the sternum.         & fibrosis        ST segment              a non weight bearing
       Fluctuations follow patients respiratory function and will                         elevation               position
          fall on inspiration and rise on expiration due to changes in                     T wave inversion       Client can resume sexual
          intrapulmonary pressure.                                                         Widening of QRS         intercourse: if can climb
       Reading should be obtained at the highest point of                                 complexes               or use the staircase
          fluctuation.
                                                                                                                 The Most Critical Period
G. Coronary Arterial Diseases                                                                                    6-8 hours because majority
                                                                                                                 of death occurs due to
ANGINA                                   Coronary artery bypass                                                  arrhythmia leading to
PECTORIS          Levine’s Sign:         surgery                                                                 premature ventricular
                  initial sign that       Greater and lesser                                                    contractions (PVC)
4 E’s of          shows the hand             saphenous veins are                                                 *Lidocaine: DOC for
Angina            clutching the chest        commonly used for                                                   arrhythmia
Pectoris                                     bypass graft procedures
                  Chest pain:
 Excessive       characterized by       Percutaneuos                    F. Congestive Heart Failure
  physical        sharp stabbing         Transluminal Coronary           Inability of the heart to pump blood towards systemic circulation
  exertion        pain located at sub    Angioplasty (PTCA)
 Exposure to     sterna usually           Mechanical dilation of       I.    Left sided heart failure
  cold            radiates from neck,        the coronary vessel wall           90% - Mitral valve stenosis
  environment     back, arms,                by compresing the                  Pulmonary Symptoms
 Extreme         shoulder and jaw           atheromatous plaque.
  emotional       muscles                                                II.   Right sided heart failure
  response                               Nursing Management:                    Tricuspid valve stenosis
 Excessive       Dyspnea                                                       Venous congestion symptoms
  intake of       Tachycardia            NTG Tablets(sublingual)
  foods or        Palpitations           Give 3 doses interval of 3-
  heavy meal      Diaphoresis            5minutes
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                     DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

NURSING MANAGEMENT                                                       5. Bronchoscopy
Goal: increase myocardial contraction                                        This is the direct inspection and observation of the
 Administer medications as ordered                                             larynx, trachea and bronchi through a flexible or rigid
           Cardiac glycosides                                                  bronchoscope.
              Digoxin *Antidote: Digibind                                   Passage of a lighted bronchoscope into the bronchial tree
           Loop diuretics                                                      for direct visualization of the trachea and the
           Bronchodilators                                                     tracheobronchial tree.
           Narcotic analgesics                                                 Diagnostic uses:
              Morphine sulfate                                                  To examine tissues or collect secretions
           Vasodilators                                                         To determine location or pathologic process and
           Anti-arrhythmic agents                                                    collect specimen for biopsy
 Administer O2 inhalation at 3-4 L/minute                                       To evaluate bleeding sites
 Restrict Na and fluids                                                         To determine if a tumor can be resected surgically
 Monitor strictly VS and IO and Breath SoundsWeigh pt daily and
     assess for pitting edema and abdominal girth daily and notify MD            Therapeutic uses
 Provide meticulous skin care                                                    To Remove foreign objects from tracheobronchial tree
 Provide a dietary intake which is low in saturated fats and caffeine            To Excise lesions
                                                                                  To remove tenacious secretions obstructing the
                                                                                            tracheobronchial tree
RESPIRATORY NURSING                                                               To drain abscess
                                                                                  To treat post-operative atelectasis
A. Diagnostic Evaluation
                                                                                 Nursing Interventions BEFORE Bronchoscopy
1. Skin Test: Mantoux Test or Tuberculin Skin Test                                Informed consent/ permit needed
    This is used to determine if a person has been infected or                   Explain procedure to the patient, tell him what to expect,
        has been exposed to the TB bacillus.                                         to help him cope with the unkown
    This utilizes the PPD (Purified Protein Derivatives).                        Atropine (to diminish secretions) is administered one
    The PPD is injected intradermally usually in the inner                          hour before the procedure
        aspect of the lower forearm about 4 inches below the elbow.               About 30 minutes before bronchoscopy, Valium is given
    The test is read 48 to 72 hours after injection.                                to sedate patient and allay anxiety.
    (+) Mantoux Test is induration of 10 mm or more.                             Topical anesthesia is sprayed followed by local
    But for HIV positive clients, induration of about 5 mm is                       anesthesia injected into the larynx
        considered positive                                                       Instruct on NPO for 6-8 hours
                                                                                  Remove dentures, prostheses and contact lenses
2. Pulse Oximeter                                                                 The patient is placed supine with hyperextended neck
    Non-invasive method of continuously monitoring he oxygen                        during the procedure
        saturation of hemoglobin
    A probe or sensor is attached to the fingertip, forehead,                   Nursing Interventions AFTER Bronchoscopy
        earlobe or bridge of the nose                                             Put the patient on Side lying position
    Normal SpO2 = 95% - 100%                                                     Tell patient that the throat may feel sore with .
    < 85% - tissues are not receiving enough O2                                  Check for the return of cough and gag reflex.
                                                                                  Check vasovagal response.
3. Chest X-ray                                                                    Watch for cyanosis, hypotension, tachycardia,
    This is a NON-invasive procedure involving the use of x-rays                    arrythmias, hemoptysis, and dyspnea. These signs and
       with minimal radiation.                                                       symptoms indicate perforation of bronchial tree. Refer
    The nurse instructs the patient to practice the on cue to                       the patient immediately!
       hold his breath and to do deep breathing
    Instruct the client to remove metals from the chest.
    Rule out pregnancy first.

4 . Indirect Bronchography
    A radiopaque medium is instilled directly into the trachea
         and the bronchi and the outline of the entire bronchial tree
         or selected areas may be visualized through x-ray.
    It reveals anomalies of the bronchial tree and is
         important in the diagnosis of bronchiectasis.

        Nursing Interventions BEFORE Bronchogram
         Secure written consent
         Check for allergies to sea foods or iodine or anesthesia
         NPO for 6 to 8 hours                                           6. Sputum Examination
         Pre-op meds: atropine SO4 and valium, topical                        Indicated for microscopic examination of the sputum:
            anesthesia sprayed; followed by local anesthetic                      Gross appearance, Sputum C&S, AFB staining, and for
            injected into larynx. The nurse must have oxygen and                  Cytologic examination/ Papanicolaou examination
            anti spasmodic agents ready.
                                                                                  Nursing Interventions:
      Nursing Interventions AFTER Bronchogram                                           Early morning sputum specimen is to be
        Side-lying position                                                                collected (suctioning or expectoration)
        NPO until cough and gag reflexes returned                                      Rinse mouth with plain water
        Instruct the client to cough and deep breathe client                           Use sterile container.


POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                    DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

                    Sputum specimen for C&S is collected before                    Auscultate lungs to assess for pneumothorax
                     the first dose of anti-microbial therapy.                      Monitor oxygen saturation (SaO2) levels
                    For AFB staining, collect sputum specimen for                  Bed rest
                     three consecutive mornings.                                    Check for expectoration of blood

6. Pulmonary Function Test / Studies                                   C. Chronic Obstructive Pulmonary Diseases
      Non-invasive test
      Measurement of lung volume, ventilation, and diffusing          Chronic Bronchitis            Smoking       Consistent productive
         capacity                                                      (Blue Bloaters)               Air            cough
                                                                       Inflammation of the           pollution     Dyspnea on exertion
                                                                       bronchi due to                               with prolonged
                                                                       hypertrophy or                               expiratory grunt
                                                                       hyperplasia of goblet                       Anorexia and
                                                                       mucous producing cells                       generalized body
                                                                       leading to narrowing of                      malaise
                                                                       smaller airways                             Cyanosis
                                                                                                                   Scattered rales/rhonchi

                                                                       Bronchial Asthma              Allergens     Cough that is productive
                                                                       Reversible inflammatory                     Dyspnea
                                                                       lung condition caused by                    Wheezing on expiration
                                                                       hypersensitivity to                         Tachycardia,
                                                                       allergens leading to                         palpitations and
                                                                       narrowing of smaller                         diaphoresis
                                                                       airways                                     Mild apprehension,
                                                                                                                    restlessness
                                                                                                                   Cyanosis

                                                                       Bronchiectasis                Recurrent     Consistent productive
7. Arterial Blood Gas
                                                                       Permanent dilation of         LRTI           cough
    Assessment of arterial blood for tissue oxygenation,                                                          Dyspnea
                                                                       the bronchus due to           Congenital
        ventilation, and acid-base status                                                                          Presence of cyanosis
                                                                       destruction of muscular       disease
    Arterial puncture is performed on areas where good pulses                                                     Rales and crackles
                                                                       and elastic tissue of the     Presence
        are palpable (radial, brachial, or femoral). Radial artery                                                 Hemoptysis
                                                                       alveolar walls                of tumor
        is the most common site for withdrawal of blood specimen                                                   Anorexia and
                                                                                                     Chest
       Nursing Interventions:
                                                                                                     trauma         generalized body
        Utilize a 10-ml. Pre-heparinized syringe to prevent                                                        malaise
             clotting of specimen                                                                                 
        Soak specimen in a container with ice to prevent              Pulmonary                     Smoking       Productive cough
             hemolysis                                                 Emphysema                     Pollution     Dyspnea at rest
        If ABG monitoring will be done, do Allen’s test to assess     Terminal and                  Hereditary    Prolonged expiratory
             for adequacy of collateral circulation of the hand (the   irreversible stage of         Allergy        grunt
             ulnar arteries)                                           COPD characterized by :                     Resonance to
                                                                                                                    hyperresonance
8. Thoracentesis                                                           Inelasticity of alveoli                 Decreased tactile
    Procedure suing needle aspiration of intrapleural fluid or air        Air trapping                             fremitus
       under local anesthesia                                                                                      Decreased breath
                                                                           Maldistribution of
    Specimen examination or removal of pleural fluid                                                               sounds
                                                                           gasses
       Nursing Intervention BEFORE Thoracentesis                                                                   Barrel chest
                                                                           Overdistention of
        Secure consent                                                                                            Anorexia and
                                                                           thoracic cavity
        Take initial vital signs                                                                                   generalized body
                                                                           (Barrel chest)
        Instruct to remain still, avoid coughing during                                                            malaise
           insertion of the needle                                                                                 Rales or crackles
        Inform patient that pressure sensation will be felt on                                                    Pursed-lip breathing
           insertion of needle

       Nursing Intervention DURING the procedure:                      Nursing Management:
        Reassess the patient                                           Enforce CBR
        Place the patient in the proper position:                      Low inflow O2 admin; high inflow will cause respiratory arrest
               Upright or sitting on the edge of the bed                  * most accurate: venturi mask
               Lying partially on the side, partially on the           Administer medications as ordered
                back                                                            Bronchodilators
                                                                                Antimicrobials
       Nursing Interventions after Thoracentesis                                Corticosteroids (5-10 minutes after bronchodilators)
        Assess the patient’s respiratory status                                Mucolytics/expectorants
        Monitor vital signs frequently                                 Force fluids
        Position the patient on the affected side, as ordered,         Nebulize and suction client as needed
           for at least 1 hour to seal the puncture site                Provide comfortable and humid environment
        Turn on the unaffected side to prevent leakage of              Avoidance of smoking and allergens
           fluid in the thoracic cavity
        Check the puncture site for fluid leakage

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                   DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

C. PNEUMONIA                                                                                 Administer      bronchodilators    15-30
  Inflammation of the lung parenchyma leading to pulmonary                                   minutes before procedure
     consolidation because alveoli is filled with exudates                                Stop if pt. can’t tolerate the procedure
                                                                                          Provide oral care after procedure as it
  I.   Etioilogic Agent                                                                       may affect taste sensitivity
          1. Streptococcus     pneumoniae      (pneumococcal                              Contraindications:
               pneumonia)                                                                      Unstable VS
          2. Hemophilus influenzae (bronchopneumonia)                                          Hemoptysis
          3. Klebsiella pneumoniae                                                             Increased ICP
          4. Diplococcus pneumoniae
                                                                                               Increased IOP (glaucoma)
          5. Escherichia coli
                                                                                12. Provide pt health teaching and d/c planning
          6. Pseudomonas aeruginosa
                                                                                        Avoidance of precipitating factors
                                                                                        Prevention of complications
 II.   Predisposing Factor
                                                                                          Atelectasis
         1. Smoking
                                                                                          Meningitis
         2. Air pollution
                                                                                        Regular compliance to medications
         3. Immunocompromised
                                                                                        Importance of ffup care
                 (+) AIDS
                   Kaposi’s Sarcoma
                   Pneumocystis Carinii Pneumonia
                                                                    HEMATOLOGY NURSING
                        DOC: Zidovudine (Retrovir)
                 Bronchogenic Ca                                   A. Blood Cellular Components
         4. Prolonged immobility (hypostatic pneumonia)
         5. Aspiration of food (aspiration pneumonia)
                                                                    RBC                4-6
         6. Over fatigue
                                                                                       million/mm3
III.   Signs / Symptoms
                                                                    * Hemoglobin       Ave. 12 - 18      iron-containing protein of RBC,
          1. Productive cough, greenish to rusty
                                                                                       g/dL              delivers oxygen to tissue
          2. Dyspnea with prolong expiratory grunt
          3. Fever, chills, anorexia, general body malaise
                                                                    * Hematocrit       F: 36-42%         red cell percentage in whole
          4. Cyanosis
                                                                                       M: 42-48%         blood
          5. Pleuritic friction rub
          6. Rales/crackles on auscultation
          7. Abdominal distention  paralytic ileus
                                                                    WBC                N = 5,000-
                                                                                       10,000/mm3
IV.    NURSING MANAGEMENT
         1. Enforce CBR (consistent to all respi disorders)
                                                                    *Neutrophils       Most common           First line of defense,
         2. Strict respiratory isolation
                                                                                       type of               Helpful in localizing the
         3. Administer medications as ordered
                                                                                       leukocyte but a        infection and in
                 Broad spectrum antibiotics
                                                                                       short lifespan         immobilizing the
                   Penicillin – pneumococcal infections
                                                                                       of only 10-12          pathogens until other
                   Tetracycline
                                                                                       hours                  WBCs arrive
                   Macrolides
                 Anti-pyretics
                 Mucolytics/expectorants
                                                                    *Eosinophils       Lifespan=             Allergic Reaction and
         4. Administer O2 inhalation as ordered
                                                                                       hours to 3 days        Parasitic Invasion
         5. Force fluids to liquefy secretions
         6. Institute pulmonary toilet – measures to promote
                                                                    *Basophils                               they are mediators in
             expectoration of secretions
                                                                                                              inflammatory process.
                 DBE,        Coughing        exercises,     CPT
                  (clapping/vibration),         Turning      and
                                                                    *Monocytes                               largest WBC
                  repositioning
                                                                                                              (macrophage)
         7. Nebulize and suction PRN
                                                                    *Lymphocytes       B Cells
         8. Place client of semi-fowlers to high fowlers
                                                                                       T Cells               Antibody response
         9. Provide a comfortable and humid environment
                                                                                       NK Cells              Immunity
         10. Provide a dietary intake high in CHO, CHON, Calories
                                                                                                             Anti tumor
             and Vit C
         11. Assist in postural drainage
                                                                    Platelets          N = 150-450       Promotes hemostasis →
                 Patient is placed in various position to drain
                                                                                       thousand mm3      prevention of blood loss →
                  secretions via force of gravity
                                                                                                         promote clotting mechanisms
                 Usually, it is the upper lung areas which are
                  drained
                 Nursing management:
                   Monitor VS and BS
                   Best performed before meals/breakfast
                        or 2-3 hours p.c. to prevent
                        gastroesophageal reflux or vomiting
                        (pagkagising maraming secretions diba?
                        Nakukuha?)
                   Encourage DBE

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                   DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

B. Blood Disorder                                                                                    is water soluble and is easily excretable;
                                                                                                     oral forms might develop tolerance.
IRON DEFICIENCY          Monitor for signs of bleeding of all hema                                 Increase caloric intake, CHON, CHO, Fe,
ANEMIA (IDA) –            test including urine, stool and GIT                                        Vit C
chronic microcytic       Enforce CBR so as not to overtire patient                                 Encourage client to use soft bristled
anemia due to            Encourage increased iron diet                                              toothbrush and avoid irritating
inadequate               Avoid tannates in tea and coffee                                           mouthwashes (remember there are
absorption of iron       Administer medications as ordered                                          mouthsores!)
leading to                     Oral iron preparations (300mg OD)                                    Avoid heat application (there is
hypoxemic tissue               NURSING MANAGEMENT                                                    numbness remember?)  may lead to
injury                       1. Administer with meals to lessen                                      burns
                                   GIT irritation
                             2. Use straw for liquid form
                             3. Administer with orange juice or
                                   vitamin C to facilitate absorption     GUT NURSING
                             4. Inform client of SE/monitor for
                                  a.    Anorexia                          A. Causes of Acute Renal Failure
                                  b. Nausea and vomiting
                                  c.    Abdominal pain
                                  d. Diarrhea/constipation
                                  e.    Melena
                                 Parenteral Iron Preparations
                                 NURSING MANAGEMENT
                             1. Administer using z-tract method
                                   to prevent discomfort,
                                   discoloration and leakage
                             2. Avoid massaging of injection site
                                   instead encourage pt. to
                                   ambulate to facilitate absorption
                             3. Monitor SE
                                  a.    Pain at injection site
                                  b. Localized abscess
                                  c.    Lymphadenopathy
                                  d. Fever and chills

APLASTIC                 Enforce complete BR
ANEMIA – stem            Administer O2 inhalation                            Acute Renal Failure            Chronic Renal Failure
cell disorder            Reverse isolation                               Sudden inability of the        Irreversible loss of kidney
leading to bone          Monitor for signs of infection                  kidneys      to      excrete   function
marrow                   Avoid IM, SQ or any venipuncture sites          nitrogenous           waste
depression              instruct: use electric razor when shaving       products, leads to azotemia    PREDISPOSING FACTORS
pancytopenia (all        Medications as ordered                                                             DM and HPN (common
blood cells                    Immunosuppressants via central             STAGES                             causes)
decreased)                    venous catheter                                                               Recurrent pyelonephritis
anemia,                        Anti-lymphocyte globulin (ALG) –           Oliguric phase – passage           Exposure to renal toxins
leucopenia,                    given within 6 days – 3 weeks to           of urine (1-2 weeks)               Tumor
thrombocytopenia               achieve maximum therapeutic effect          UO: <400 ml/cc
                                                                           Hyperkalemia                 STAGES
PERNICIOUS                                                                 Hypernatremia                  Diminished renal reserve
ANEMIA – chronic         Headache, dizziness, dyspnea, palpitation,       Hyperphosphatemia                 volume – asymptomatic,
anemia resulting          cold sensitivity, pallor and generalized body    HYPOCALCEMIA                      normal BUN and CREA
from deficiency of        malaise                                          Hypermagnesemia                Renal insufficiency
intrinsic factor         GIT changes: Mouth sores, Red beefy              Metabolic acidosis             End-stage renal disease
leading to                tongue, Dyspepsia or indigestion, Weight         Elevated BUN, Crea                (ESRD) – presence of
hypochlorhydria           loss, Jaundice                                                                      oliguria, azotemia
(decreased HCl           CNS changes – PA is the most dangerous          Diuretic Phase (2-3
secretion);               form of anemia, Tingling sensation,             weeks)
                          Paresthesia, Ataxia, Psychosis                   Increased passage of
                                                                              urine
                     DIAGNOSTICS                                           Hyperkalemia
                     SCHILLING’S TEST – indicates decreased                Hyponatremia
                     reabsorption of vitamin B12; confirms                 Metabolic acidosis
                     presence of pernicious anemia
                                                                          Convalescent phase (3-12
                     NURSING MANAGEMENT                                   months)
                      Enforce complete bed rest (consistent to            Improvement in
                        all types of anemia)                                  passage of urine
                      Administer Vit B12 injections at                    Characterized by
                        MONTHLY intervals for lifetime as                     complete diuresis
                        ordered; common site: dorso and
                        ventrogluteal, no drug toxicity because it
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                       DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

NURSING MANAGEMENT ARF/CRF                                                ENDOCRINE NURSING
    Enforce CBR
    Admin oxygen inhalation as ordered                                   A. Thyroid Gland Disorders
    High CHO diet low CHON, fats, High vit and minerals                      HYPOTHYROIDISM                 HYPERTHYROIDSM
    Provide meticulous skin care                                         Decreased T3 and T4           Increased T3 and T4
    Wash with warm water                                                 Early Signs                   1. Hyperphagia – increased
    Soap irritates and dries skin                                        1. Weakness and fatigue            appetite
    Meds as ordered                                                      2. Loss of appetite but       2. (+) weight loss d/t
                anti-HPN agents                                               (+) weight gain d/t           increased metabolism
                  Hydralazine (appresoline)                                   increased lipolysis      3. heat intolerance
                       SE: orthostatic hypotension                       3. Dry skin                   4. moist skin
                NaHCO3                                                   4. Cold intolerance           5. diarrhea
                Kayexelate enema                                         5. Constipation               6. increased VS
                Hematinics                                               6. Menorrhagia                7. CNS changes
                Antibiotics                                              Late Signs                              a.   Irritability
                Supplementary vitamins and minerals                      1. Brittleness of hair                  b. agitation
                Phosphate binders                                        2. Non-pitting edema                    c.   Tremors
                Calcium gluconate                                        3. Hoarseness of voice                  d. Restlessness
                                                                          4. Decreased libido                     e.   Insomnia
                                                                          5. Decreased VS                         f.   Hallucinations
B. Nursing Management on Hemodialysis                                     6. CNS changes                8. Goiter
                                                                                a.    Lethargy          9. Exophthalmos
                 Secure consent and explain procedure to client                b. Memory               10. Amenorrhea
                 Maintain strict aseptic technique                                   impairment
                 Obtain baseline data – before and q30 during                  c.    Psychosis
                  procedure                                               1. Monitor STRICTLY VS,       1.    Monitor VS and IO strictly
               VS                                                             IO to determine                to determine presence of
               Wt                                                             presence of                    THYROID STORM/Crisis
               Blood exams – secure all pre-procedure                         MYXEDEMA COMA a          2.    Administer medications
               I/O                                                            complication of severe         as ordered
                                                                               hypothyroidism                a.    Anti-Thyroid Agents:
                  Have client void pre-procedure                              characterized by:                   PTU  toxic effects is
                  Inform pt about bleeding (blood is heparinized)              a.    Severe                       AGRANULOCYTOSIS
                  Monitor for signs of complications (BEDSSH)                        hypotension                  fever and chills, sore
               Bleeding                                                        b. Bradycardia                     throat (throat CS
               Embolism                                                        c.    Bradypnea                    pls!), LEUKOCYTOSIS
               DISEQUILIBRIUM SYNDROME – results from rapid                    d. Hypoventilation                 (CBC pls!)
                loss of nitrogenous waste products particularly UREA            e.    Hypoglycemia           b. Methimazole
                from the brain                                                  f.    Hyponatremia                 (Tapazole)
                HPN                                                            g.    Hypothermia       3.    High calorie diet to
                Disorientation – initial sign                            2. Administer isotonic              correct weight loss
                Nausea and vomiting                                           fluids as ordered        4.    Provide comfortable and
                Anorexia                                                 3. Administer                       cool environment
                Headache                                                      medications as           5.    Institute meticulous skin
                                                                               ordered – thyroid              care
                Paresthesia, peripheral
                                                                               hormones or agents       6.    Maintain side rails
                Numbness
                                                                               (may cause insomnia      7.    Bilateral eye patch to
               Septicemia
                                                                               and heat intolerance)          prevent drying of eyes
               Shock                                                     4. Provide dietary intake     8.    Assist in surgical
               Hepatitis
                                                                               low in calories to             procedure: subtotal
                  Avoid BP taking, phlebotomy, IV meds at the site of
                                                                               prevent weight gain            thyroidectomy
                   fistula, blood extraction to prevent compression
                                                                          5. Institute meticulous
                  Maintain patency of shunt/fistula:
                                                                               skin care                PRE-OP
               Palpate for thrills, auscultate for bruits
                                                                          6. Provide comfortable        Administer lugol’s solutions/
               Instruct that minimal bleeding is expected since blood
                                                                               and warm                 SSRI to promote decreased
                is heparinized
                                                                               environment              vasculature and promote
               Avoid use vasodilators, sedatives, and tranquilizers to
                                                                          7. Forced fluids              atrophy of the thyroid gland to
                prevent hypotension unless ordered
                                                                                                        prevent/minimize bleeding
               Prepare at bedside bulldog clips to prevent embolism
                                                                                                        and hemorrhage
               Auscultate for bruits and palpate for thrills (if (+) 
                patent)
                                                                                                        POST-OP
                                                                                                        WOF signs of THYROID
                                                                                                        STORM  agitation, hyper-
                                                                                                        thermia, HPN. If (+) thyroid
                                                                                                        storm: administer anti-pyretics
                                                                                                        and beta-blockers; VS, IO and
                                                                                                        NVS strictly, siderails up,
                                                                                                        provide hypothermic blanket

                                                                                                        WOF: inadvertent or
                                                                                                        accidental removal of
POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE
WHAT YOU SHOULD KNOW BEFORE THE PNLE
                                   DECEMBER 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)

                             parathyroid gland 
                             hypocalcemia or tetany [(+)
                             trousseu’s signs, (+) chvostek’s
                             Give Ca Gluc slowly to
                             prevent arrhythmia and
                             arrest

                             WOF accidental laryngeal
                             nerve damage  hoarness of
                             voice  instruct client to talk
                             immediately post-op  if (+)
                             notify MD

                             WOF signs of bleeding  (+)
                             feeling of fullness at incision
                             site, (+) soiled dressings at
                             back or nape area, notify MD

                             WOF signs of laryngeal spasm
                              DOB and SOB  prep trache
                             set

                             9.  Hormonal Replacement
                                 therapy for life
                             10. importance of FFup care
                             11. wearing of medic-alert
                                 bracelet

B. Insulin Therapy

I.    Types of Insulin
      A. Rapid (SAI) – clear, peak: 2-4 hours , Regular insulin
      B. Intermediate AI – NPH (Non-Protamine Hagedorn) –
          cloudy, peak : 6-12 hours
      C. Long AI – Ultra lente – cloudy, peak 12-24 hours

II.   Nursing Management
      A. Administer insulin at room temp to prevent
          lipodystrophy atrophy/hypertrophy of SQ tissue
      B. Insulin only refrigerated once opened
      C. Avoid shaking insulin, roll between palms only
      D. Accuracy of administration is important
      E. Rotate insulin sites to prevent lipodystrophy
      F. Use short bore needle gauge 25-26
      G. No need to aspirate
      H. Administer insulin 45/90 degrees angle depending on
          amount to pt’s SQ tissue
      I.  Most accessible route: abdomen
      J.  Aspirate CLEAR before CLOUDY to prevent
          contamination and promote accurate calibration
      K. Monitor for local complications:
          1. Allergic reactions
          2. Lipodystrophy
          3. SOMOGYI’S PHENOMENON – rebound effect of insulin
               characterized by hypoglycemia, hyperglycemia




POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE
*Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on
the possible topics that might be part of the upcoming Dec 2012 PNLE

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Dec 2012 NLE TIPS MS (A)

  • 1. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) PERIOPERATIVE NURSING Signature is obtained with the client’s complete understanding of what to occur. A. Major Types of Pathologic Process Requiring Surgical - adult sign their own operative permit Intervention (OPET) - obtained before sedation Obstruction – impairment to the flow of vital fluids For minors, parents or someone standing in their behalf, (blood,urine,CSF,bile) gives the consent. Note: for a married emancipated minor Perforation – rupture of an organ. parental consent is not needed anymore, spouse is accepted Erosion – wearing off of a surface or membrane. For mentally ill and unconscious patient, consent must be Tumors – abnormal new growths. taken from the parents or legal guardian If the patient is unable to write, an “X” is accepted if there is a B. Classification of Surgical Procedure witness to his mark Secured without pressure and threat According to PURPOSE: A witness is desirable – nurse, physician or authorized Diagnostic – to establish the presence of a disease condition. ( persons. e.g biopsy ) When an emergency situation exists, no consent is necessary Exploratory – to determine the extent of disease condition ( e.g because inaction at such time may cause greater injury. Ex-Lap ) (permission via telephone/cellphone is accepted but must be Curative – to treat the disease condition. signed within 24hrs.) * Ablative – removal of an organ * Constructive – repair of congenitally D. Preoperative Meds. 5A’s defective organ. Anxiolitics (Tranquilizers & Sedatives) * Reconstructive – repair of damage organ * Diazepam ( Valium ) Palliative – to relieve distressing sign and symptoms, not * Lorazepam ( Ativan ) necessarily to cure the disease. * Diphenhydramine Analgesics According to URGENCY * Nalbuphine ( Nubain ) Anticholinergics Classification Indication for Examples * Atropine Sulfate Surgery Anti-Ulcer (Proton Pump Inhibitors) Emergent – patient - severe * Omeprazole ( Losec ) requires immediate Without delay bleeding * Famotidine attention, life threatening - gunshot/ stab Antibiotics condition. wounds - Fractured skull E. Preoperative Teachings Urgent / Imperative – Within 24 to 30 - kidney /  Incentive Spirometry patient requires prompt hours ureteral stones  Diaphragmatic Breathing attention.  Coughing Required – patient Plan within a - cataract  Turning needs to have surgery. few weeks or - thyroid d/o  Foot and Leg exercise months Teaching should be done morning/afternoon before the day of Elective – patient should Failure to have - repair of scar surgery have surgery. surgery not - vaginal repair Best Method: Return Demonstration catastrophic Optional – patient’s Personal - cosmetic F. The Surgical Team decision. preference surgery Surgeon • Performance of the operative procedure according to the C. Inform Consent needs of the patients. Purposes: • The primary decision maker regarding surgical technique to To ensure that the client understand the nature of the use during the procedure. treatment including the potential complications and Assistant Surgeon disfigurement. • Assists with retracting, hemostasis, suturing and any other To indicate that the client’s decision was made without tasks requested by the surgeon to facilitate speed while pressure. maintaining quality during the procedure. To protect the client against unauthorized procedure. Anesthesiologist To protect the surgeon and hospital against legal action by a • Selects the anesthesia, administers it, intubates the client if client who claims that an authorized procedure was necessary, manages technical problems related to the performed. administration of anesthetic agents, and supervises the client’s condition throughout the surgical procedure. Essential Elements of Informed Consent Scrub Nurse  the diagnosis and explanation of the condition. • Assists with the preparation of the room.  a fair explanation of the procedure to be done and used and • Scrubs, gowns and gloves self and other members of the the consequences. surgical team.  a description of alternative treatment or procedure. • Prepares the instrument table and organizes sterile equipment  a description of the benefits to be expected. for functional use.  material rights if any. • Assists with the drapping procedure.  the prognosis, if the recommended care, procedure is refused. • Passes instruments to the surgeon and assistants by anticipating their need. Requisites for Validity of Informed Consent • Counts sponges, needles and instruments. Written permission is best and legally accepted. • Keeps track of irrigations used for calculations of blood loss POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 2. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) Circulating Nurse Thrombophlebitis Early ambulation • Responsible and accountable for all activities occurring during Anti embolic stocking a surgical procedure including the management of personnel Encourage leg exercise equipment, supplies and the environment during a surgical Hydrate adequately procedure. Avoid any restricting devices • Ensure all equipment is working properly. that impaired circulation • Guarantees sterility of instruments and supplies. Avoid massage on the calf of • Monitor the room and team members for breaks in the sterile the leg technique. Initiate anticoagulant therapy • Handles specimens. URINARY • Coordinates activities with other departments, such as Urinary Retention Monitor I & O radiology and pathology. Interventions to facilitate voiding G. Principles of Surgical Asepsis Urinary Catheterization as needed  Sterile object remains sterile only when touched by another Urinary Monitor I & O sterile object Incontinence  Only sterile objects may be placed on a sterile field Urinary Tract Adequate fluid intake  A sterile object or field out of range of vision or an object held Infection Early ambulation below a person’s waist is contaminated  When a sterile surface comes in contact with a wet, Aseptic catheterization as contaminated surface, the sterile object or field becomes needed contaminated by capillary action Good perineal hygiene  Fluid flows in the direction of gravity GASTRO-INTESTINAL  The edges of a sterile field or container are considered to be Nausea and IV fluids until peristalsis contaminated (1 inch) Vomiting returns Progressive diet ( clear liquid H. PACU/RR Care then full fluids, soft then regular diet)  Maintaining a Patent Airway Anti emetics as ordered  Assessing Status of Circulatory System Hiccups NGT insertion as needed  Maintaining Adequate Respiratory Function Hold breath while taking a  Assessing Thermoregulatory Status large swallow of water  Maintaining Adequate Fluid Volume Breath in and out on a paper  Minimizing Complications of Skin Impairment bag  Maintaining Safety Anti emetics as ordered  Promoting Comfort Intestinal NGT insertion as needed Obstruction Administered IVF as ordered I. Parameter for Discharge from PACU/RR ( 3rd-5th day postop) Prepare for possible surgery Constipation Adequate hydration Activity. Able to obey commands High fiber diet Respiratory. Easy, noiseless breathing Encourage early ambulation Circulation. BP within 20mmHg of preop level Paralytic Ileus Encourage early ambulation Consciousness. Responsive WOUND Color. Pinkish skin and mucus membrane Wound Infection Keep wound clean and dry J. Post Operative Complications Surgical aseptic technique when changing dressing Problem Nursing Intervention Antibiotic therapy Wound Dehiscence RESPIRATORY Apply abdominal binders Encourage high protein diet Pneumonia Deep breathing exercises and Vit.C intake Coughing exercise Keep in bed rest Early ambulation Wound Evisceration Semi-Fowlers, bend knees to Atelectasis Deep breathing exercises relieve tension on the Coughing exercise abdominal muscles Early ambulation Splinting on coughing Pulmonary Turning Cover exposed organ with Embolism Ambulation sterile , moist saline dressing Anti embolic stockings Reassure, keep him/her quite Compression devises and relaxed Prevent massaging the lower Prepare for surgery and repair extremities of wound CIRCULATION Hypovolemia Fluid and blood replacement Hemorrhage Fluid and blood replacement Vit.k and hemostat Ligation of bleeders Pressure dressing POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 3. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) ONCOLOGY NURSING  Yearly papanicolao (Pap) smear for sexually active females and any female over age 18 A. Benign VS Malignant Neoplasm  At menopause, high-risk women should have an endometrial tissue sample Characteristic Benign Neoplasm Malignant Neoplasm Speed Growth Grows slowly Usually grows rapidly 4. For detection of prostate cancer Usually continues Tends to grow relentlessly  At age 50, have a yearly digital rectal examination to grow throughout throughout life  At age 50, have a yearly prostate-specific antigen (PSA) test life unless surgically removed C. American Cancer Society’s seven warning signs of cancer Mode of Grows by enlarging Grows by infiltrating (uses acronym CAUTION US): Growth and expanding surrounding tissues 1. Change in bowel or bladder habits Always remains May remain localized (in 2. A sore that does not heal localized; never situ) but usually infiltrates 3. Unusual bleeding or discharge infiltrates other tissues 4. Thickening or lump in breast or elsewhere surrounding 5. Indigestions or difficulty in swallowing tissues 6. Obvious change in wart or mole Capsule Almost always Never contained within a 7. Nagging cough or hoarseness contained within a capsule fibrous capsule Absence of capsule allows 8. Unexplained Anemia Capsule neoplastic cells to invade 9. Sudden loss of weight advantageous surrounding tissues because Surgical removal of tumor D. Internal Radiation Therapy (Brachytheraphy) encapsulated difficult tumor can be Sources of Internal Radiation removed surgically  Implanted into affected tissue or body cavity Cell Usually well Usually poorly  Ingested as a solution characteristics differentiated differentiated  Injected as a solution into the bloodstream or body cavity  Introduced through a catheter into the tumor Recurrence Unusual when Common following surgery Side Effects surgically removed because tumor cells spread  Fatigue into surrounding tissues  Anorexia Metastasis Never occur Very common  Immunosuppression Effect of Not harmful to host Always harmful to host  Other side effects similar to external radiation Neoplasm unless located in Causes disfigurement, area where it disrupted organ function, Client Education compresses tissue nutritional imbalances  Avoid close contact with others until treatment is completed or obstructs vital May result in ulcerations,  Maintain daily activities unless contraindicated, allowing for extra organs sepsis, perforations, rest periods as needed Prognosis Very good Depends on cell type and  Maintain balanced diet Tumor generally speed of diagnosis  Maintain fluid intake ensure adequate hydration (2-3 liters/day) removed surgically Poor prognosis if cells are  If implant is temporary, maintain bedrest to avoid dislodging the poorly differentiated and implant. evidence of metastatic  Excreted body fluids may be radioactive; double-flush toilets after spread exists use Good prognosis indicated if  Radiation therapy may lead to bone marrow suppression cells still resemble normal cells and there is no Nursing Management evidence of metastasis  Exposure to small amounts of radiation is possible during close contact with persons receiving internal radiation: understand the principles of protection from exposure to radiation: time, distance, B. Recommendations of the American Cancer Society for Early and shielding Cancer Detection  Time: minimize time spent in close proximity to the 1. For detection of breast cancer radiation source; a common standard is to limit contact time  Beginning at age 20, routinely perform monthly breast self- to 30 minutes total per 8-hour shift; examination  Distance: maintain the maximum distance 6 feet possible  Women ages 20-39 should have breast examination by a from the radiation source healthcare provider every 3 years  Shielding: use lead shields and other precautions to reduce  Women age 40 and older should have a yearly mammogram exposure to radiation and breast self-examination by a healthcare provider  Place client in private room  Instruct visitors to maintain at least a distance of 6 feet from the 2. For detection of colon and rectal cancer client and limit visitors to 10-30 minutes  All persons age 50 and older should have a yearly fecal occult  Ensure proper handling and disposal of body fluids, assuring the blood test containers are marked appropriately  Digital rectal examination and flexible sigmoidoscopy should  Ensure proper handling of bed linens and clothing be done every 5 years  In the event of a dislodged implant, use long-handled forceps and  Colonoscopy with barium enema should be done every 10 place the implant into a lead container; never directly touch the years implant  Do not allow pregnant woman to come into any contact with 3. For detection of uterine cancer radiation POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 4. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)  If working routinely near radiation sources, wear a monitoring B. Heart Sound device to measure exposure  Tricuspid valve (lub) - RT 5th intercostal, medial  Educate client in all safety measures  Mitral valve (lub) - LT 5th intercostal, lateral  Aortic semilunar valve (dub) - RT 2nd intercostal E. External Radiation Therapy (Teletheraphy)  Pulmonary semilunar valve (dub) - LT 2nd intercostals  The radiation oncologist marks specific locations for radiation S1 - due to closure of the AV(mitral/tricuspid) valves treatment using a semipermanent type of ink S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves  Treatment is usually given 15-30 minutes per day, 5 day per S3 – Ventricular Diastolic Gallop week, for 2-7 weeks Mechanism: vibration resulting from resistance to rapid  The client does not pose a risk for radiation exposure to other ventricular filling secondary to poor compliance people S4 - Atrial Diastolic Gallop Mechanism: vibration resulting from resistance to late Side Effects ventricular filling during atrial systole  Tissue damage to target area (erythema, sloughing, hemorrhage) Heart Murmurs  Ulcerations of oral mucous membranes  Incompetent / Stenotic Valve  GIT effects such as nausea, vomiting, and diarrhea Pericardial Friction Rub  Immunosuppression  It is an extra heart sound originating from the pericardial sac  Mechanism: Originates from the pericardial sac as it moves Client Education  Timing: with each heartbeat  Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders C. ECG or medications on the site during the duration of the treatment; do not wash off the treatment site marks  Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor  Wear soft, loose-fitting over the treatment area  Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun-blocking agents with sun protector factor (SPF) of at least 15  Maintain proper rest, diet, and fluid intake as essential to Cardiac Action Potential promoting health and repair of normal tissues  Depolarization/Contraction/Systole - electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell Nursing Management  Repolarization/Resting/Diastole - return of the cell to the  Monitor for adverse side effects of radiation resting state caused by re-entry of potassium into the cell  Monitor for significant decreases in white blood cell counts while sodium exits and platelet counts  Client teaching (refer to later sections for management of D. CARDIAC Proteins and enzymes immunosuppression, thrombocytopenia a. CK- MB ( creatine kinase)  Most cardiac specific enzymes CARDIOVASCULAR NURSING  Accurate indicator of myocardial dammage  Elevates in MI within 4 hours, peaks in 18 hours and A. Heart Circulation then declines till 3 days  Normal value is 0-7 U/L or males 50-325 mu/ml Female 50-250 mu/ml b. Lactic Dehydrogenase (LDH)  Most sensitive indicator of myocardial damage  Elevates in MI in 24 hours, peaks in 48-72 hours Return to normal in 10-14 days  Normally LDH1 is greater than LDH2 c. Troponin I and T  Troponin I is usually utilized for MI  Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks!  Normal value for Troponin I is less than 0.6 ng/mL  REMEMBER to AVOID IM injections before obtaining blood sample!  Early and late diagnosis can be made! d. Serum Lipids  Lipid profile measures the serum cholesterol, triglycerides and lipoprotein levels  Cholesterol= 200 mg/dL  Triglycerides- 40- 150 mg/dL  LDH- 130 mg/dL  HDL- 30-70- mg/dL  NPO post midnight (usually 12 hours) POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 5. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) E. Cardiac Catheterization ( Coronary Angiography /  Keep the drug in a dry Arteriography ) ECG: may reveals place, avoid moisture  Insertion of a catheter into the heart and surrounding vessels ST segment and exposure to sunlight  Is an invasive procedure during which physician injects dye depression  Change stock every 6 into coronary arteries and immediately takes a series of x-ray T wave inversion months films to assess the structures of the arteries  Offer sips of water Pretest: Ensure Consent, assess for allergy to seafood and before giving sublingual iodine, NPO, document weight and height, baseline VS, blood nitrates, tests and document the peripheral pulses Intra-test: inform patient of a fluttery feeling as the catheter NTG Nitrol or passes through the heart; inform the patient that a feeling of Transdermal patch warmth and metallic taste may occur when dye is  Avoid placing near hairy administered areas as it may decrease Post-test: Monitor VS and cardiac rhythm drug absorption  Monitor peripheral pulses, color and warmth and sensation of  Avoid rotating the extremity distal to insertion site transdermal patches.  Maintain sandbag to the insertion site if required to maintain Myocardial Chest pain Nursing Management pressure Infarction Usually radiates Goal: Decrease myocardial  Monitor for bleeding and hematoma formation (MI) from neck, back, oxygen demand shoulder, arms, F. CVP ( Central Venous Pressure ) Death of jaw & abdominal  Administer narcotic  Reflects the pressure of the blood in the right atrium. myocardial muscles analgesic as ordered:  Engorgement is estimated by the venous column that can be cells from (abdominal Morphine observed as it rises from an imagined angle at the point of inadequate ischemia): severe  Administer oxygen low manubrium ( angle of Louis). oxygenation, crushing flow 2-3 L / min  With normal physiologic condition, the jugular venous column often caused  Enforce CBR in semi- rises no higher than 2-3 cm above the clavicle with the client in by sudden Not usually fowlers position without a sitting position at 45 degree angle. complete relieved by rest or bathroom privileges blockage of a by nitroglycerine  Instruct client to avoid coronary forms of valsalva artery N/V maneuver Dyspnea  Monitor urinary output Characterized Increase in blood & report output of less by localized pressure & pulse than 30 ml / hr: formation of Hyperthermia: indicates decrease necrosis elevated temp cardiac output (tissue Skin: cool, clammy,  Resumption of ADL destruction) ashen particularly sexual  NORMAL CVP is 2 -8 cm H20 or 2-6 mm Hg with Mild restlessness intercourse: is 4-6 weeks  To Measure: subsequent & apprehension post cardiac rehab, post  Patient should be flat with zero point of manometer at the healing by CABG & instruct to: same level of the RA which corresponds to the mid-axillary scar formation ECG:  Instruct client to assume line of the patient or approx. 5 cm below the sternum. & fibrosis ST segment a non weight bearing  Fluctuations follow patients respiratory function and will elevation position fall on inspiration and rise on expiration due to changes in T wave inversion  Client can resume sexual intrapulmonary pressure. Widening of QRS intercourse: if can climb  Reading should be obtained at the highest point of complexes or use the staircase fluctuation. The Most Critical Period G. Coronary Arterial Diseases 6-8 hours because majority of death occurs due to ANGINA Coronary artery bypass arrhythmia leading to PECTORIS Levine’s Sign: surgery premature ventricular initial sign that  Greater and lesser contractions (PVC) 4 E’s of shows the hand saphenous veins are *Lidocaine: DOC for Angina clutching the chest commonly used for arrhythmia Pectoris bypass graft procedures Chest pain:  Excessive characterized by Percutaneuos F. Congestive Heart Failure physical sharp stabbing Transluminal Coronary Inability of the heart to pump blood towards systemic circulation exertion pain located at sub Angioplasty (PTCA)  Exposure to sterna usually  Mechanical dilation of I. Left sided heart failure cold radiates from neck, the coronary vessel wall  90% - Mitral valve stenosis environment back, arms, by compresing the  Pulmonary Symptoms  Extreme shoulder and jaw atheromatous plaque. emotional muscles II. Right sided heart failure response Nursing Management:  Tricuspid valve stenosis  Excessive Dyspnea  Venous congestion symptoms intake of Tachycardia NTG Tablets(sublingual) foods or Palpitations Give 3 doses interval of 3- heavy meal Diaphoresis 5minutes POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 6. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) NURSING MANAGEMENT 5. Bronchoscopy Goal: increase myocardial contraction  This is the direct inspection and observation of the  Administer medications as ordered larynx, trachea and bronchi through a flexible or rigid  Cardiac glycosides bronchoscope.  Digoxin *Antidote: Digibind  Passage of a lighted bronchoscope into the bronchial tree  Loop diuretics for direct visualization of the trachea and the  Bronchodilators tracheobronchial tree.  Narcotic analgesics Diagnostic uses:  Morphine sulfate  To examine tissues or collect secretions  Vasodilators  To determine location or pathologic process and  Anti-arrhythmic agents collect specimen for biopsy  Administer O2 inhalation at 3-4 L/minute  To evaluate bleeding sites  Restrict Na and fluids  To determine if a tumor can be resected surgically  Monitor strictly VS and IO and Breath SoundsWeigh pt daily and assess for pitting edema and abdominal girth daily and notify MD Therapeutic uses  Provide meticulous skin care  To Remove foreign objects from tracheobronchial tree  Provide a dietary intake which is low in saturated fats and caffeine  To Excise lesions  To remove tenacious secretions obstructing the tracheobronchial tree RESPIRATORY NURSING  To drain abscess  To treat post-operative atelectasis A. Diagnostic Evaluation Nursing Interventions BEFORE Bronchoscopy 1. Skin Test: Mantoux Test or Tuberculin Skin Test  Informed consent/ permit needed  This is used to determine if a person has been infected or  Explain procedure to the patient, tell him what to expect, has been exposed to the TB bacillus. to help him cope with the unkown  This utilizes the PPD (Purified Protein Derivatives).  Atropine (to diminish secretions) is administered one  The PPD is injected intradermally usually in the inner hour before the procedure aspect of the lower forearm about 4 inches below the elbow.  About 30 minutes before bronchoscopy, Valium is given  The test is read 48 to 72 hours after injection. to sedate patient and allay anxiety.  (+) Mantoux Test is induration of 10 mm or more.  Topical anesthesia is sprayed followed by local  But for HIV positive clients, induration of about 5 mm is anesthesia injected into the larynx considered positive  Instruct on NPO for 6-8 hours  Remove dentures, prostheses and contact lenses 2. Pulse Oximeter  The patient is placed supine with hyperextended neck  Non-invasive method of continuously monitoring he oxygen during the procedure saturation of hemoglobin  A probe or sensor is attached to the fingertip, forehead, Nursing Interventions AFTER Bronchoscopy earlobe or bridge of the nose  Put the patient on Side lying position  Normal SpO2 = 95% - 100%  Tell patient that the throat may feel sore with .  < 85% - tissues are not receiving enough O2  Check for the return of cough and gag reflex.  Check vasovagal response. 3. Chest X-ray  Watch for cyanosis, hypotension, tachycardia,  This is a NON-invasive procedure involving the use of x-rays arrythmias, hemoptysis, and dyspnea. These signs and with minimal radiation. symptoms indicate perforation of bronchial tree. Refer  The nurse instructs the patient to practice the on cue to the patient immediately! hold his breath and to do deep breathing  Instruct the client to remove metals from the chest.  Rule out pregnancy first. 4 . Indirect Bronchography  A radiopaque medium is instilled directly into the trachea and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray.  It reveals anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis. Nursing Interventions BEFORE Bronchogram  Secure written consent  Check for allergies to sea foods or iodine or anesthesia  NPO for 6 to 8 hours 6. Sputum Examination  Pre-op meds: atropine SO4 and valium, topical  Indicated for microscopic examination of the sputum: anesthesia sprayed; followed by local anesthetic Gross appearance, Sputum C&S, AFB staining, and for injected into larynx. The nurse must have oxygen and Cytologic examination/ Papanicolaou examination anti spasmodic agents ready.  Nursing Interventions: Nursing Interventions AFTER Bronchogram  Early morning sputum specimen is to be  Side-lying position collected (suctioning or expectoration)  NPO until cough and gag reflexes returned  Rinse mouth with plain water  Instruct the client to cough and deep breathe client  Use sterile container. POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 7. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A)  Sputum specimen for C&S is collected before  Auscultate lungs to assess for pneumothorax the first dose of anti-microbial therapy.  Monitor oxygen saturation (SaO2) levels  For AFB staining, collect sputum specimen for  Bed rest three consecutive mornings.  Check for expectoration of blood 6. Pulmonary Function Test / Studies C. Chronic Obstructive Pulmonary Diseases  Non-invasive test  Measurement of lung volume, ventilation, and diffusing Chronic Bronchitis Smoking  Consistent productive capacity (Blue Bloaters) Air cough Inflammation of the pollution  Dyspnea on exertion bronchi due to with prolonged hypertrophy or expiratory grunt hyperplasia of goblet  Anorexia and mucous producing cells generalized body leading to narrowing of malaise smaller airways  Cyanosis  Scattered rales/rhonchi Bronchial Asthma Allergens  Cough that is productive Reversible inflammatory  Dyspnea lung condition caused by  Wheezing on expiration hypersensitivity to  Tachycardia, allergens leading to palpitations and narrowing of smaller diaphoresis airways  Mild apprehension, restlessness  Cyanosis Bronchiectasis Recurrent  Consistent productive 7. Arterial Blood Gas Permanent dilation of LRTI cough  Assessment of arterial blood for tissue oxygenation,  Dyspnea the bronchus due to Congenital ventilation, and acid-base status  Presence of cyanosis destruction of muscular disease  Arterial puncture is performed on areas where good pulses  Rales and crackles and elastic tissue of the Presence are palpable (radial, brachial, or femoral). Radial artery  Hemoptysis alveolar walls of tumor is the most common site for withdrawal of blood specimen  Anorexia and Chest Nursing Interventions: trauma generalized body  Utilize a 10-ml. Pre-heparinized syringe to prevent malaise clotting of specimen   Soak specimen in a container with ice to prevent Pulmonary Smoking  Productive cough hemolysis Emphysema Pollution  Dyspnea at rest  If ABG monitoring will be done, do Allen’s test to assess Terminal and Hereditary  Prolonged expiratory for adequacy of collateral circulation of the hand (the irreversible stage of Allergy grunt ulnar arteries) COPD characterized by :  Resonance to hyperresonance 8. Thoracentesis Inelasticity of alveoli  Decreased tactile  Procedure suing needle aspiration of intrapleural fluid or air Air trapping fremitus under local anesthesia  Decreased breath Maldistribution of  Specimen examination or removal of pleural fluid sounds gasses Nursing Intervention BEFORE Thoracentesis  Barrel chest Overdistention of  Secure consent  Anorexia and thoracic cavity  Take initial vital signs generalized body (Barrel chest)  Instruct to remain still, avoid coughing during malaise insertion of the needle  Rales or crackles  Inform patient that pressure sensation will be felt on  Pursed-lip breathing insertion of needle Nursing Intervention DURING the procedure: Nursing Management:  Reassess the patient  Enforce CBR  Place the patient in the proper position:  Low inflow O2 admin; high inflow will cause respiratory arrest  Upright or sitting on the edge of the bed * most accurate: venturi mask  Lying partially on the side, partially on the  Administer medications as ordered back Bronchodilators Antimicrobials Nursing Interventions after Thoracentesis Corticosteroids (5-10 minutes after bronchodilators)  Assess the patient’s respiratory status Mucolytics/expectorants  Monitor vital signs frequently  Force fluids  Position the patient on the affected side, as ordered,  Nebulize and suction client as needed for at least 1 hour to seal the puncture site  Provide comfortable and humid environment  Turn on the unaffected side to prevent leakage of  Avoidance of smoking and allergens fluid in the thoracic cavity  Check the puncture site for fluid leakage POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 8. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) C. PNEUMONIA  Administer bronchodilators 15-30  Inflammation of the lung parenchyma leading to pulmonary minutes before procedure consolidation because alveoli is filled with exudates  Stop if pt. can’t tolerate the procedure  Provide oral care after procedure as it I. Etioilogic Agent may affect taste sensitivity 1. Streptococcus pneumoniae (pneumococcal  Contraindications: pneumonia)  Unstable VS 2. Hemophilus influenzae (bronchopneumonia)  Hemoptysis 3. Klebsiella pneumoniae  Increased ICP 4. Diplococcus pneumoniae  Increased IOP (glaucoma) 5. Escherichia coli 12. Provide pt health teaching and d/c planning 6. Pseudomonas aeruginosa  Avoidance of precipitating factors  Prevention of complications II. Predisposing Factor  Atelectasis 1. Smoking  Meningitis 2. Air pollution  Regular compliance to medications 3. Immunocompromised  Importance of ffup care  (+) AIDS  Kaposi’s Sarcoma  Pneumocystis Carinii Pneumonia HEMATOLOGY NURSING  DOC: Zidovudine (Retrovir)  Bronchogenic Ca A. Blood Cellular Components 4. Prolonged immobility (hypostatic pneumonia) 5. Aspiration of food (aspiration pneumonia) RBC 4-6 6. Over fatigue million/mm3 III. Signs / Symptoms * Hemoglobin Ave. 12 - 18 iron-containing protein of RBC, 1. Productive cough, greenish to rusty g/dL delivers oxygen to tissue 2. Dyspnea with prolong expiratory grunt 3. Fever, chills, anorexia, general body malaise * Hematocrit F: 36-42% red cell percentage in whole 4. Cyanosis M: 42-48% blood 5. Pleuritic friction rub 6. Rales/crackles on auscultation 7. Abdominal distention  paralytic ileus WBC N = 5,000- 10,000/mm3 IV. NURSING MANAGEMENT 1. Enforce CBR (consistent to all respi disorders) *Neutrophils Most common  First line of defense, 2. Strict respiratory isolation type of  Helpful in localizing the 3. Administer medications as ordered leukocyte but a infection and in  Broad spectrum antibiotics short lifespan immobilizing the  Penicillin – pneumococcal infections of only 10-12 pathogens until other  Tetracycline hours WBCs arrive  Macrolides  Anti-pyretics  Mucolytics/expectorants *Eosinophils Lifespan=  Allergic Reaction and 4. Administer O2 inhalation as ordered hours to 3 days Parasitic Invasion 5. Force fluids to liquefy secretions 6. Institute pulmonary toilet – measures to promote *Basophils  they are mediators in expectoration of secretions inflammatory process.  DBE, Coughing exercises, CPT (clapping/vibration), Turning and *Monocytes  largest WBC repositioning (macrophage) 7. Nebulize and suction PRN *Lymphocytes B Cells 8. Place client of semi-fowlers to high fowlers T Cells  Antibody response 9. Provide a comfortable and humid environment NK Cells  Immunity 10. Provide a dietary intake high in CHO, CHON, Calories  Anti tumor and Vit C 11. Assist in postural drainage Platelets N = 150-450 Promotes hemostasis →  Patient is placed in various position to drain thousand mm3 prevention of blood loss → secretions via force of gravity promote clotting mechanisms  Usually, it is the upper lung areas which are drained  Nursing management:  Monitor VS and BS  Best performed before meals/breakfast or 2-3 hours p.c. to prevent gastroesophageal reflux or vomiting (pagkagising maraming secretions diba? Nakukuha?)  Encourage DBE POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 9. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) B. Blood Disorder is water soluble and is easily excretable; oral forms might develop tolerance. IRON DEFICIENCY  Monitor for signs of bleeding of all hema  Increase caloric intake, CHON, CHO, Fe, ANEMIA (IDA) – test including urine, stool and GIT Vit C chronic microcytic  Enforce CBR so as not to overtire patient  Encourage client to use soft bristled anemia due to  Encourage increased iron diet toothbrush and avoid irritating inadequate  Avoid tannates in tea and coffee mouthwashes (remember there are absorption of iron  Administer medications as ordered mouthsores!) leading to Oral iron preparations (300mg OD)  Avoid heat application (there is hypoxemic tissue NURSING MANAGEMENT numbness remember?)  may lead to injury 1. Administer with meals to lessen burns GIT irritation 2. Use straw for liquid form 3. Administer with orange juice or vitamin C to facilitate absorption GUT NURSING 4. Inform client of SE/monitor for a. Anorexia A. Causes of Acute Renal Failure b. Nausea and vomiting c. Abdominal pain d. Diarrhea/constipation e. Melena Parenteral Iron Preparations NURSING MANAGEMENT 1. Administer using z-tract method to prevent discomfort, discoloration and leakage 2. Avoid massaging of injection site instead encourage pt. to ambulate to facilitate absorption 3. Monitor SE a. Pain at injection site b. Localized abscess c. Lymphadenopathy d. Fever and chills APLASTIC  Enforce complete BR ANEMIA – stem  Administer O2 inhalation Acute Renal Failure Chronic Renal Failure cell disorder  Reverse isolation Sudden inability of the Irreversible loss of kidney leading to bone  Monitor for signs of infection kidneys to excrete function marrow  Avoid IM, SQ or any venipuncture sites nitrogenous waste depression   instruct: use electric razor when shaving products, leads to azotemia PREDISPOSING FACTORS pancytopenia (all  Medications as ordered DM and HPN (common blood cells Immunosuppressants via central STAGES causes) decreased)  venous catheter Recurrent pyelonephritis anemia, Anti-lymphocyte globulin (ALG) – Oliguric phase – passage Exposure to renal toxins leucopenia, given within 6 days – 3 weeks to of urine (1-2 weeks) Tumor thrombocytopenia achieve maximum therapeutic effect  UO: <400 ml/cc  Hyperkalemia STAGES PERNICIOUS  Hypernatremia  Diminished renal reserve ANEMIA – chronic  Headache, dizziness, dyspnea, palpitation,  Hyperphosphatemia volume – asymptomatic, anemia resulting cold sensitivity, pallor and generalized body  HYPOCALCEMIA normal BUN and CREA from deficiency of malaise  Hypermagnesemia  Renal insufficiency intrinsic factor  GIT changes: Mouth sores, Red beefy  Metabolic acidosis  End-stage renal disease leading to tongue, Dyspepsia or indigestion, Weight  Elevated BUN, Crea (ESRD) – presence of hypochlorhydria loss, Jaundice oliguria, azotemia (decreased HCl  CNS changes – PA is the most dangerous Diuretic Phase (2-3 secretion); form of anemia, Tingling sensation, weeks) Paresthesia, Ataxia, Psychosis  Increased passage of urine DIAGNOSTICS  Hyperkalemia SCHILLING’S TEST – indicates decreased  Hyponatremia reabsorption of vitamin B12; confirms  Metabolic acidosis presence of pernicious anemia Convalescent phase (3-12 NURSING MANAGEMENT months)  Enforce complete bed rest (consistent to  Improvement in all types of anemia) passage of urine  Administer Vit B12 injections at  Characterized by MONTHLY intervals for lifetime as complete diuresis ordered; common site: dorso and ventrogluteal, no drug toxicity because it POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 10. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) NURSING MANAGEMENT ARF/CRF ENDOCRINE NURSING  Enforce CBR  Admin oxygen inhalation as ordered A. Thyroid Gland Disorders  High CHO diet low CHON, fats, High vit and minerals HYPOTHYROIDISM HYPERTHYROIDSM  Provide meticulous skin care Decreased T3 and T4 Increased T3 and T4  Wash with warm water Early Signs 1. Hyperphagia – increased  Soap irritates and dries skin 1. Weakness and fatigue appetite  Meds as ordered 2. Loss of appetite but 2. (+) weight loss d/t  anti-HPN agents (+) weight gain d/t increased metabolism  Hydralazine (appresoline) increased lipolysis 3. heat intolerance  SE: orthostatic hypotension 3. Dry skin 4. moist skin  NaHCO3 4. Cold intolerance 5. diarrhea  Kayexelate enema 5. Constipation 6. increased VS  Hematinics 6. Menorrhagia 7. CNS changes  Antibiotics Late Signs a. Irritability  Supplementary vitamins and minerals 1. Brittleness of hair b. agitation  Phosphate binders 2. Non-pitting edema c. Tremors  Calcium gluconate 3. Hoarseness of voice d. Restlessness 4. Decreased libido e. Insomnia 5. Decreased VS f. Hallucinations B. Nursing Management on Hemodialysis 6. CNS changes 8. Goiter a. Lethargy 9. Exophthalmos  Secure consent and explain procedure to client b. Memory 10. Amenorrhea  Maintain strict aseptic technique impairment  Obtain baseline data – before and q30 during c. Psychosis procedure 1. Monitor STRICTLY VS, 1. Monitor VS and IO strictly  VS IO to determine to determine presence of  Wt presence of THYROID STORM/Crisis  Blood exams – secure all pre-procedure MYXEDEMA COMA a 2. Administer medications  I/O complication of severe as ordered hypothyroidism a. Anti-Thyroid Agents:  Have client void pre-procedure characterized by: PTU  toxic effects is  Inform pt about bleeding (blood is heparinized) a. Severe AGRANULOCYTOSIS  Monitor for signs of complications (BEDSSH) hypotension fever and chills, sore  Bleeding b. Bradycardia throat (throat CS  Embolism c. Bradypnea pls!), LEUKOCYTOSIS  DISEQUILIBRIUM SYNDROME – results from rapid d. Hypoventilation (CBC pls!) loss of nitrogenous waste products particularly UREA e. Hypoglycemia b. Methimazole from the brain f. Hyponatremia (Tapazole)  HPN g. Hypothermia 3. High calorie diet to  Disorientation – initial sign 2. Administer isotonic correct weight loss  Nausea and vomiting fluids as ordered 4. Provide comfortable and  Anorexia 3. Administer cool environment  Headache medications as 5. Institute meticulous skin ordered – thyroid care  Paresthesia, peripheral hormones or agents 6. Maintain side rails  Numbness (may cause insomnia 7. Bilateral eye patch to  Septicemia and heat intolerance) prevent drying of eyes  Shock 4. Provide dietary intake 8. Assist in surgical  Hepatitis low in calories to procedure: subtotal  Avoid BP taking, phlebotomy, IV meds at the site of prevent weight gain thyroidectomy fistula, blood extraction to prevent compression 5. Institute meticulous  Maintain patency of shunt/fistula: skin care PRE-OP  Palpate for thrills, auscultate for bruits 6. Provide comfortable Administer lugol’s solutions/  Instruct that minimal bleeding is expected since blood and warm SSRI to promote decreased is heparinized environment vasculature and promote  Avoid use vasodilators, sedatives, and tranquilizers to 7. Forced fluids atrophy of the thyroid gland to prevent hypotension unless ordered prevent/minimize bleeding  Prepare at bedside bulldog clips to prevent embolism and hemorrhage  Auscultate for bruits and palpate for thrills (if (+)  patent) POST-OP WOF signs of THYROID STORM  agitation, hyper- thermia, HPN. If (+) thyroid storm: administer anti-pyretics and beta-blockers; VS, IO and NVS strictly, siderails up, provide hypothermic blanket WOF: inadvertent or accidental removal of POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE
  • 11. WHAT YOU SHOULD KNOW BEFORE THE PNLE DECEMBER 2012 PNLE PEARLS OF SUCCESS PART 6: MEDICAL AND SURGICAL HEALTH NURSING (A) parathyroid gland  hypocalcemia or tetany [(+) trousseu’s signs, (+) chvostek’s Give Ca Gluc slowly to prevent arrhythmia and arrest WOF accidental laryngeal nerve damage  hoarness of voice  instruct client to talk immediately post-op  if (+) notify MD WOF signs of bleeding  (+) feeling of fullness at incision site, (+) soiled dressings at back or nape area, notify MD WOF signs of laryngeal spasm  DOB and SOB  prep trache set 9. Hormonal Replacement therapy for life 10. importance of FFup care 11. wearing of medic-alert bracelet B. Insulin Therapy I. Types of Insulin A. Rapid (SAI) – clear, peak: 2-4 hours , Regular insulin B. Intermediate AI – NPH (Non-Protamine Hagedorn) – cloudy, peak : 6-12 hours C. Long AI – Ultra lente – cloudy, peak 12-24 hours II. Nursing Management A. Administer insulin at room temp to prevent lipodystrophy atrophy/hypertrophy of SQ tissue B. Insulin only refrigerated once opened C. Avoid shaking insulin, roll between palms only D. Accuracy of administration is important E. Rotate insulin sites to prevent lipodystrophy F. Use short bore needle gauge 25-26 G. No need to aspirate H. Administer insulin 45/90 degrees angle depending on amount to pt’s SQ tissue I. Most accessible route: abdomen J. Aspirate CLEAR before CLOUDY to prevent contamination and promote accurate calibration K. Monitor for local complications: 1. Allergic reactions 2. Lipodystrophy 3. SOMOGYI’S PHENOMENON – rebound effect of insulin characterized by hypoglycemia, hyperglycemia POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING DEC 2012 PNLE *Patterned on the previous board exams from December 2006 – July 2012… the purpose of this note is to GUIDE students on the possible topics that might be part of the upcoming Dec 2012 PNLE