WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING

PERIOPERATIVE NURSING

A. Major Types of Pathologic Process Requiring Surgical
Intervention (OPET)
Obstruction impairment to the flow of vital fluids
(blood,urine,CSF,bile)
Perforation rupture of an organ.
Erosion wearing off of a surface or membrane.
Tumors abnormal new growths.

B. Classification of Surgical Procedure

According to PURPOSE:
Diagnostic to establish the presence of a disease condition. (
e.g biopsy )
Exploratory to determine the extent of disease condition ( e.g
Ex-Lap )
Curative to treat the disease condition.
* Ablative removal of an organ
* Constructive repair of congenitally
defective organ.
* Reconstructive repair of damage organ
Palliative to relieve distressing sign and symptoms, not
necessarily to cure the disease.

According to URGENCY

Classification
Indication for
Examples
Surgery
Emergent patient

- severe
requires immediate
Without delay
bleeding
attention, life threatening
- gunshot/ stab
condition.
wounds
- Fractured skull
Urgent / Imperative
Within 24 to 30 -
kidney
/
patient requires prompt
hours
ureteral stones
attention.
Required patient
Plan within a
- cataract
needs to have surgery.
few weeks or
- thyroid d/o
months
Elective patient should
Failure to have - repair of scar
have surgery.
surgery not
- vaginal repair
catastrophic
Optional patients
Personal
- cosmetic
decision.
preference
surgery

C. Preoperative Meds. 5As
Anxiolitics (Tranquilizers & Sedatives)
* Diazepam ( Valium )
* Lorazepam ( Ativan )
* Diphenhydramine
Analgesics
* Nalbuphine ( Nubain )
Anticholinergics
* Atropine Sulfate
Anti-Ulcer (Proton Pump Inhibitors)
* Omeprazole ( Losec )
* Famotidine
Antibiotics

D. Preoperative Teachings
Incentive Spirometry
Diaphragmatic Breathing
Coughing
Turning
Foot and Leg exercise
Teaching should be done morning/afternoon before the day of
surgery
Best Method: Return Demonstration

E. The Surgical Team

Surgeon

Performance of the operative procedure according to the

needs of the patients.

The primary decision maker regarding surgical technique to

use during the procedure.
Assistant Surgeon

Assists with retracting, hemostasis, suturing and any other

tasks requested by the surgeon to facilitate speed while
maintaining quality during the procedure.
Anesthesiologist

Selects the anesthesia, administers it, intubates the client if

necessary, manages technical problems related to the
administration of anesthetic agents, and supervises the clients
condition throughout the surgical procedure.
Scrub Nurse

Assists with the preparation of the room.

Scrubs, gowns and gloves self and other members of the

surgical team.

Prepares the instrument table and organizes sterile equipment

for functional use.

Assists with the drapping procedure.

Passes instruments to the surgeon and assistants by

anticipating their need.

Counts sponges, needles and instruments.

Monitor practices of aseptic technique in self and others.

Keeps track of irrigations used for calculations of blood loss

Circulating Nurse

Responsible and accountable for all activities occurring during

a surgical procedure including the management of personnel
equipment, supplies and the environment during a surgical
procedure.

Ensure all equipment is working properly.

Guarantees sterility of instruments and supplies.

Monitor the room and team members for breaks in the sterile
technique.

Handles specimens.

Coordinates activities with other departments, such as

radiology and pathology.

F. Principles of Surgical Asepsis

Sterile object remains sterile only when touched by another
sterile object
Only sterile objects may be placed on a sterile field
A sterile object or field out of range of vision or an object held
below a persons waist is contaminated
When a sterile surface comes in contact with a wet,
contaminated surface, the sterile object or field becomes
contaminated by capillary action
Fluid flows in the direction of gravity
The edges of a sterile field or container are considered to be
contaminated (1 inch)

G. PACU/RR Care

Maintaining a Patent Airway
Assessing Status of Circulatory System
Maintaining Adequate Respiratory Function
Assessing Thermoregulatory Status
Maintaining Adequate Fluid Volume
Minimizing Complications of Skin Impairment
Maintaining Safety
Promoting Comfort

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE

WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING


H. Parameter for Discharge from PACU/RR

Activity. Able to obey commands
Respiratory. Easy, noiseless breathing
Circulation. BP within 20mmHg of preop level
Consciousness. Responsive
Color. Pinkish skin and mucus membrane

I. Post Operative Complications

Problem
Nursing Intervention

RESPIRATORY

Pneumonia


Atelectasis

Pulmonary
Embolism

CIRCULATION
Hypovolemia
Hemorrhage

Thrombophlebitis








URINARY
Urinary Retention

Urinary
Incontinence
Urinary Tract
Infection

GASTRO-INTESTINAL
Nausea and
Vomiting

Hiccups

Deep breathing exercises

Coughing exercise
Early ambulation
Deep breathing exercises
Coughing exercise
Early ambulation
Turning
Ambulation
Anti embolic stockings
Compression devises
Prevent massaging the lower
extremities

Fluid and blood replacement

Fluid and blood replacement
Vit.k and hemostat
Ligation of bleeders
Pressure dressing
Early ambulation
Anti embolic stocking
Encourage leg exercise
Hydrate adequately
Avoid any restricting devices
that impaired circulation
Avoid massage on the calf of
the leg
Initiate anticoagulant therapy

Monitor I & O
Interventions to facilitate
voiding
Urinary Catheterization as
needed
Monitor I & O
Adequate fluid intake
Early ambulation
Aseptic catheterization as
needed
Good perineal hygiene

IV fluids until peristalsis
returns
Progressive diet ( clear liquid
then full fluids, soft then
regular diet)
Anti emetics as ordered
NGT insertion as needed
Hold breath while taking a
large swallow of water
Breath in and out on a paper
bag
Anti emetics as ordered

Intestinal
Obstruction
( 3rd-5th day postop)
Constipation

Paralytic Ileus
WOUND
Wound Infection

Wound Dehiscence

Wound Evisceration

NGT insertion as needed

Administered IVF as ordered
Prepare for possible surgery
Adequate hydration
High fiber diet
Encourage early ambulation
Encourage early ambulation

Keep wound clean and dry

Surgical aseptic technique
when changing dressing
Antibiotic therapy

Apply abdominal binders
Encourage high protein diet
and Vit.C intake
Keep in bed rest
Semi-Fowlers, bend knees to
relieve tension on the
abdominal muscles
Splinting on coughing
Cover exposed organ with
sterile , moist saline dressing
Reassure, keep him/her quite
and relaxed
Prepare for surgery and repair
of wound

ONCOLOGY NURSING

A. Benign VS Malignant Neoplasm

Characteristic
Benign Neoplasm
Speed Growth
Grows slowly
Usually continues
to grow throughout
life unless
surgically removed
Mode of
Grows by enlarging
Growth
and expanding
Always remains
localized; never
infiltrates
surrounding
tissues
Capsule
Almost always
contained within a
fibrous capsule
Capsule
advantageous
because
encapsulated
tumor can be
removed surgically
Cell
Usually well
characteristics
differentiated

Recurrence
Unusual when
surgically removed
Metastasis
Effect of
Neoplasm

Never occur
Not harmful to host
unless located in
area where it
compresses tissue
or obstructs vital
organs

Malignant Neoplasm
Usually grows rapidly
Tends to grow relentlessly
throughout life

Grows by infiltrating
surrounding tissues
May remain localized (in
situ) but usually infiltrates
other tissues

Never contained within a
capsule
Absence of capsule allows
neoplastic cells to invade
surrounding tissues
Surgical removal of tumor
difficult
Usually poorly
differentiated

Common following surgery
because tumor cells spread
into surrounding tissues
Very common
Always harmful to host
Causes disfigurement,
disrupted organ function,
nutritional imbalances
May result in ulcerations,
sepsis, perforations,

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE

WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING

Prognosis

Very good
Tumor generally
removed surgically

Depends on cell type and

speed of diagnosis
Poor prognosis if cells are
poorly differentiated and
evidence of metastatic
spread exists
Good prognosis indicated if
cells still resemble normal
cells and there is no
evidence of metastasis

B. Recommendations of the American Cancer Society for Early
Cancer Detection
1. For detection of breast cancer
Beginning at age 20, routinely perform monthly breast selfexamination
Women ages 20-39 should have breast examination by a
healthcare provider every 3 years
Women age 40 and older should have a yearly mammogram
and breast self-examination by a healthcare provider

2. For detection of colon and rectal cancer
All persons age 50 and older should have a yearly fecal occult
blood test
Digital rectal examination and flexible sigmoidoscopy should
be done every 5 years
Colonoscopy with barium enema should be done every 10
years

3. For detection of uterine cancer
Yearly papanicolao (Pap) smear for sexually active females and
any female over age 18
At menopause, high-risk women should have an endometrial
tissue sample

4. For detection of prostate cancer
At age 50, have a yearly digital rectal examination
At age 50, have a yearly prostate-specific antigen (PSA) test


C. American Cancer Societys seven warning signs of cancer
(uses acronym CAUTION US):

1. Change in bowel or bladder habits

2. A sore that does not heal

3. Unusual bleeding or discharge

4. Thickening or lump in breast or elsewhere

5. Indigestions or difficulty in swallowing

6. Obvious change in wart or mole
7. Nagging cough or hoarseness

8. Unexplained Anemia
9. Sudden loss of weight

D. Internal Radiation Therapy (Brachytheraphy)

Sources of Internal Radiation
Implanted into affected tissue or body cavity
Ingested as a solution
Injected as a solution into the bloodstream or body cavity
Introduced through a catheter into the tumor

Side Effects

Fatigue

Anorexia

Immunosuppression

Other side effects similar to external radiation

Client Education
Avoid close contact with others until treatment is completed
Maintain daily activities unless contraindicated, allowing for extra
rest periods as needed
Maintain balanced diet
Maintain fluid intake ensure adequate hydration (2-3 liters/day)
If implant is temporary, maintain bedrest to avoid dislodging the
implant.
Excreted body fluids may be radioactive; double-flush toilets after
use
Radiation therapy may lead to bone marrow suppression

Nursing Management
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,
and shielding
Time: minimize time spent in close proximity to the
radiation source; a common standard is to limit contact time
to 30 minutes total per 8-hour shift;

Distance: maintain the maximum distance 6 feet possible

from the radiation source
Shielding: use lead shields and other precautions to reduce
exposure to radiation
Place client in private room
Instruct visitors to maintain at least a distance of 6 feet from the
client and limit visitors to 10-30 minutes
Ensure proper handling and disposal of body fluids, assuring the
containers are marked appropriately
Ensure proper handling of bed linens and clothing
In the event of a dislodged implant, use long-handled forceps and
place the implant into a lead container; never directly touch the
implant
Do not allow pregnant woman to come into any contact with
radiation
If working routinely near radiation sources, wear a monitoring
device to measure exposure
Educate client in all safety measures

E. External Radiation Therapy (Teletheraphy)

The radiation oncologist marks specific locations for radiation
treatment using a semipermanent type of ink
Treatment is usually given 15-30 minutes per day, 5 day per
week, for 2-7 weeks
The client does not pose a risk for radiation exposure to other
people

Side Effects
Tissue damage to target area (erythema, sloughing, hemorrhage)
Ulcerations of oral mucous membranes
GIT effects such as nausea, vomiting, and diarrhea
Immunosuppression


Client Education
Wash the marked area of the skin with plain water only and pat
skin dry; do not use soaps, deodorants, lotions, perfumes, powders
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
promoting health and repair of normal tissues

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE

WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING

Nursing Management
Monitor for adverse side effects of radiation
Monitor for significant decreases in white blood cell counts
and platelet counts
Client teaching (refer to later sections for management of
immunosuppression, thrombocytopenia


CARDIOVASCULAR NURSING

A. Heart Circulation

B. Heart Sound

Tricuspid valve (lub) - RT 5th intercostal, medial
Mitral valve (lub) - LT 5th intercostal, lateral
Aortic semilunar valve (dub) - RT 2nd intercostal
Pulmonary semilunar valve (dub) - LT 2nd intercostals

S1 - due to closure of the AV(mitral/tricuspid) valves
S2 - due to the closure of the semi-lunar (pulmonic/aortic) valves
S3 Ventricular Diastolic Gallop
Mechanism: vibration resulting from resistance to rapid
ventricular filling secondary to poor compliance
S4 - Atrial Diastolic Gallop
Mechanism: vibration resulting from resistance to late
ventricular filling during atrial systole
Heart Murmurs
Incompetent / Stenotic Valve
Pericardial Friction Rub
It is an extra heart sound originating from the pericardial sac
Mechanism: Originates from the pericardial sac as it moves
Timing: with each heartbeat

C. ECG

Cardiac Action Potential

Depolarization/Contraction/Systole - electrical activation of
a cell caused by the influx of sodium into the cell while
potassium exits the cell
Repolarization/Resting/Diastole - return of the cell to the
resting state caused by re-entry of potassium into the cell
while sodium exits

D. Cardiac Catheterization ( Coronary Angiography /
Arteriography )
Insertion of a catheter into the heart and surrounding vessels
Is an invasive procedure during which physician injects dye
into coronary arteries and immediately takes a series of x-ray
films to assess the structures of the arteries
Pretest: Ensure Consent, assess for allergy to seafood and
iodine, NPO, document weight and height, baseline VS, blood
tests and document the peripheral pulses
Intra-test: inform patient of a fluttery feeling as the catheter
passes through the heart; inform the patient that a feeling of
warmth and metallic taste may occur when dye is
administered
Post-test: Monitor VS and cardiac rhythm
Monitor peripheral pulses, color and warmth and sensation of
the extremity distal to insertion site
Maintain sandbag to the insertion site if required to maintain
pressure
Monitor for bleeding and hematoma formation


E. Coronary Arterial Diseases

ANGINA

Coronary artery bypass
PECTORIS
Levines Sign:
surgery
Greater and lesser

initial sign that
saphenous veins are
4 Es of
shows the hand
commonly used for
Angina
clutching the chest
bypass graft procedures
Pectoris



Chest pain:
Percutaneuos
Excessive
characterized by
Transluminal Coronary
physical
sharp stabbing
exertion
pain located at sub Angioplasty (PTCA)
Mechanical dilation of
Exposure to
sterna usually
cold
the coronary vessel wall
radiates from neck,
by compresing the
environment
back, arms,
atheromatous plaque.
Extreme
shoulder and jaw
emotional

muscles
response
Nursing Management:

Excessive

Dyspnea
intake of
NTG Tablets(sublingual)
Tachycardia
foods or
Give 3 doses interval of 3-
Palpitations
heavy meal
5minutes
Diaphoresis

Keep the drug in a dry

place, avoid moisture
ECG: may reveals
and exposure to sunlight
ST segment
Change stock every 6
depression
months
T wave inversion
Offer sips of water
before giving sublingual
nitrates,

NTG Nitrol or
Transdermal patch
Avoid placing near hairy
areas as it may decrease
drug absorption
Avoid rotating
transdermal patches.

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE

WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING

Myocardial
Infarction
(MI)

Death of
myocardial
cells from
inadequate
oxygenation,
often caused
by sudden
complete
blockage of a
coronary
artery

Characterized
by localized
formation of
necrosis
(tissue
destruction)
with
subsequent
healing by
scar formation
& fibrosis

Chest pain
Usually radiates
from neck, back,
shoulder, arms,
jaw & abdominal
muscles
(abdominal
ischemia): severe
crushing

Not usually
relieved by rest or
by nitroglycerine

N/V
Dyspnea
Increase in blood
pressure & pulse
Hyperthermia:
elevated temp
Skin: cool, clammy,
ashen
Mild restlessness
& apprehension

ECG:
ST segment
elevation
T wave inversion
Widening of QRS
complexes

Nursing Management
Goal: Decrease myocardial
oxygen demand

Administer narcotic
analgesic as ordered:
Morphine
Administer oxygen low
flow 2-3 L / min
Enforce CBR in semi-
fowlers position without
bathroom privileges
Instruct client to avoid
forms of valsalva
maneuver
Monitor urinary output
& report output of less
than 30 ml / hr:
indicates decrease
cardiac output
Resumption of ADL
particularly sexual
intercourse: is 4-6 weeks
post cardiac rehab, post
CABG & instruct to:
Instruct client to assume
a non weight bearing
position
Client can resume sexual
intercourse: if can climb
or use the staircase

The Most Critical Period
6-8 hours because majority
of death occurs due to
arrhythmia leading to
premature ventricular
contractions (PVC)
*Lidocaine: DOC for
arrhythmia

F. Congestive Heart Failure
Inability of the heart to pump blood towards systemic circulation

I.
Left sided heart failure
90% - Mitral valve stenosis
Pulmonary Symptoms

II. Right sided heart failure
Tricuspid valve stenosis
Venous congestion symptoms

NURSING MANAGEMENT
Goal: increase myocardial contraction
Administer medications as ordered

Cardiac glycosides
Digoxin *Antidote: Digibind

Loop diuretics

Bronchodilators

Narcotic analgesics
Morphine sulfate

Vasodilators

Anti-arrhythmic agents
Administer O2 inhalation at 3-4 L/minute
Restrict Na and fluids
Monitor strictly VS and IO and Breath SoundsWeigh pt daily and
assess for pitting edema and abdominal girth daily and notify MD
Provide meticulous skin care
Provide a dietary intake which is low in saturated fats and caffeine

RESPIRATORY NURSING

A. Chronic Obstructive Pulmonary Diseases

Consistent productive
Chronic Bronchitis
Smoking
cough
(Blue Bloaters)
Air
Dyspnea on exertion
Inflammation of the
pollution
with prolonged
bronchi due to

expiratory grunt
hypertrophy or
Anorexia and
hyperplasia of goblet
generalized body
mucous producing cells
malaise
leading to narrowing of
Cyanosis
smaller airways
Scattered rales/rhonchi

Cough that is productive
Bronchial Asthma
Allergens
Dyspnea
Reversible inflammatory
Wheezing on expiration
lung condition caused by
Tachycardia,
hypersensitivity to
palpitations and
allergens leading to
diaphoresis
narrowing of smaller
Mild apprehension,
airways
restlessness
Cyanosis
Bronchiectasis
Permanent dilation of
the bronchus due to
destruction of muscular
and elastic tissue of the
alveolar walls

Recurrent
LRTI
Congenital
disease
Presence
of tumor
Chest
trauma

Pulmonary
Emphysema
Terminal and
irreversible stage of
COPD characterized by :

Inelasticity of alveoli
Air trapping
Maldistribution of
gasses
Overdistention of
thoracic cavity
(Barrel chest)

Smoking
Pollution
Hereditary
Allergy

Consistent productive
cough
Dyspnea
Presence of cyanosis
Rales and crackles
Hemoptysis
Anorexia and
generalized body
malaise

Productive cough
Dyspnea at rest
Prolonged expiratory
grunt
Resonance to
hyperresonance
Decreased tactile
fremitus
Decreased breath
sounds
Barrel chest
Anorexia and
generalized body
malaise
Rales or crackles
Pursed-lip breathing

Nursing Management:
Enforce CBR
Low inflow O2 admin; high inflow will cause respiratory arrest
* most accurate: venturi mask
Administer medications as ordered
Bronchodilators
Antimicrobials
Corticosteroids (5-10 minutes after bronchodilators)
Mucolytics/expectorants
Force fluids
Nebulize and suction client as needed
Provide comfortable and humid environment
Avoidance of smoking and allergens

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE

WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING

HEMATOLOGY NURSING

A. Blood Cellular Components

RBC
4-6

million/mm3


* Hemoglobin Ave. 12 - 18

g/dL


* Hematocrit
F: 36-42%
M: 42-48%



WBC
N = 5,000-

10,000/mm3


*Neutrophils
Most common

type of

leukocyte but a

short lifespan

of only 10-12

hours




*Eosinophils
Lifespan=

hours to 3 days


*Basophils





*Monocytes



*Lymphocytes B Cells

T Cells
NK Cells

Platelets

N = 150-450
thousand mm3

B. Blood Disorder

IRON DEFICIENCY
ANEMIA (IDA)
chronic microcytic
anemia due to
inadequate
absorption of iron
leading to
hypoxemic tissue
injury

3.



iron-containing protein of RBC,
delivers oxygen to tissue

red cell percentage in whole
blood

First line of defense,

Helpful in localizing the
infection and in
immobilizing the
pathogens until other
WBCs arrive
Allergic Reaction and
Parasitic Invasion

APLASTIC
Enforce complete BR
ANEMIA stem
Administer O2 inhalation
cell disorder
Reverse isolation
leading to bone
Monitor for signs of infection
marrow
Avoid IM, SQ or any venipuncture sites
depression
instruct: use electric razor when shaving
pancytopenia (all
Medications as ordered
blood cells

Immunosuppressants via central

decreased)
venous catheter
anemia,

Anti-lymphocyte globulin (ALG)

leucopenia,
given within 6 days 3 weeks to
thrombocytopenia
achieve maximum therapeutic effect


GUT NURSING

A. Causes of Acute Renal Failure

they are mediators in

inflammatory process.
largest WBC
(macrophage)

Antibody response
Immunity
Anti tumor

Promotes hemostasis
prevention of blood loss
promote clotting mechanisms

Monitor for signs of bleeding of all hema

test including urine, stool and GIT
Enforce CBR so as not to overtire patient
Encourage increased iron diet
Avoid tannates in tea and coffee
Administer medications as ordered
Oral iron preparations (300mg OD)
NURSING MANAGEMENT
1.
Administer with meals to lessen
GIT irritation
2.
Use straw for liquid form
3.
Administer with orange juice or
vitamin C to facilitate absorption
4.
Inform client of SE/monitor for
a.
Anorexia
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
Monitor SE
a.
Pain at injection site
b.
Localized abscess
c.
Lymphadenopathy
d.
Fever and chills

B. Nursing Management on Hemodialysis

Secure consent and explain procedure to client

Maintain strict aseptic technique

Obtain baseline data before and q30 during procedure

VS
Wt
Blood exams secure all pre-procedure
I/O

Have client void pre-procedure

Inform pt about bleeding (blood is heparinized)

Monitor for signs of complications (BEDSSH)

Bleeding
Embolism
DISEQUILIBRIUM SYNDROME results from rapid
loss of nitrogenous waste products particularly UREA
from the brain
HPN
Disorientation initial sign
Nausea and vomiting
Anorexia
Headache
Paresthesia, peripheral
Numbness
Septicemia
Shock

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE

WHAT YOU SHOULD KNOW BEFORE THE PNLE

JULY 2012 PNLE PEARLS OF SUCCESS

PART 6: MEDICAL AND SURGICAL HEALTH NURSING

Hepatitis
Avoid BP taking, phlebotomy, IV meds at the site of fistula,
blood extraction to prevent compression
Maintain patency of shunt/fistula:
Palpate for thrills, auscultate for bruits
Instruct that minimal bleeding is expected since blood
is heparinized
Avoid use vasodilators, sedatives, and tranquilizers to
prevent hypotension unless ordered
Prepare at bedside bulldog clips to prevent embolism
Auscultate for bruits and palpate for thrills (if (+)
patent)

ENDOCRINE NURSING

A. Thyroid Gland Disorders
HYPOTHYROIDISM
Decreased T3 and T4
Early Signs
1.
Weakness and fatigue
2.
Loss of appetite but
(+) weight gain d/t
increased lipolysis
3.
Dry skin
4.
Cold intolerance
5.
Constipation
6.
Menorrhagia
Late Signs
1.
Brittleness of hair
2.
Non-pitting edema
3.
Hoarseness of voice
4.
Decreased libido
5.
Decreased VS
6.
CNS changes
a.
Lethargy
b.
Memory
impairment
c.
Psychosis
1.
Monitor STRICTLY VS,
IO to determine
presence of
MYXEDEMA COMA a
complication of severe
hypothyroidism
characterized by:
a.
Severe
hypotension
b.
Bradycardia
c.
Bradypnea
d.
Hypoventilation
e.
Hypoglycemia
f.
Hyponatremia
g.
Hypothermia
2.
Administer isotonic
fluids as ordered
3.
Administer
medications as
ordered thyroid
hormones or agents
(may cause insomnia
and heat intolerance)
4.
Provide dietary intake
low in calories to
prevent weight gain
5.
Institute meticulous
skin care
6.
Provide comfortable
and warm
environment

HYPERTHYROIDSM
Increased T3 and T4
1.
Hyperphagia increased
appetite
2.
(+) weight loss d/t
increased metabolism
3.
heat intolerance
4.
moist skin
5.
diarrhea
6.
increased VS
7.
CNS changes
a.
Irritability
b.
agitation
c.
Tremors
d.
Restlessness
e.
Insomnia
f.
Hallucinations
8.
Goiter
9.
Exophthalmos
10. Amenorrhea
1.

Monitor VS and IO strictly

to determine presence of
THYROID STORM/Crisis
2.
Administer medications
as ordered
a.
Anti-Thyroid Agents:
PTU toxic effects is
AGRANULOCYTOSIS
fever and chills, sore
throat (throat CS
pls!), LEUKOCYTOSIS
(CBC pls!)
b.
Methimazole
(Tapazole)
3.
High calorie diet to
correct weight loss
4.
Provide comfortable and
cool environment
5.
Institute meticulous skin
care
6.
Maintain side rails
7.
Bilateral eye patch to
prevent drying of eyes
8.
Assist in surgical
procedure: subtotal
thyroidectomy
9.

PRE-OP
Administer lugols solutions/
SSRI to promote decreased
vasculature and promote

7.

Forced fluids

atrophy of the thyroid gland to

prevent/minimize bleeding
and hemorrhage

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
parathyroid gland
hypocalcemia or tetany [(+)
trousseus signs, (+) chvosteks
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

10. Hormonal Replacement
therapy for life
11. importance of FFup care
12. 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 pts 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.
SOMOGYIS PHENOMENON rebound effect of insulin
characterized by hypoglycemia, hyperglycemia

POSSIBLE TOPICS ON MEDICAL AND SURGICAL HEALTH NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 December 2011 the purpose of this note is to GUIDE
students on the possible topics that might be part of the upcoming July 2012 PNLE