COURSE TITLE : NURSING CARE MANAGEMENT

COURSE NUMBER: NCM 103

TARGET POPULATION: LEVEL III STUDENT
TERM: FIRST SEMESTER 2010 - 2011

OBJECTIVES: AFTER THE LECTURE THE STUDENTS WILL BE:

ABLE TO IDENTIFY OR DEFINE COMMON MEDICAL TERMS USED DURING
THE LECTURE
IDENTIFY COMMON ABNORMALITY / CHANGES OF THE CELLULAR
CHARACTERISTICS
COMMON PHYSIOLOGIC AND PSYCHOLOGIC EFFECT TO STRESS AND IDENTIFY
MEASURES TO REDUCE THEM
APPRECIATE THE EFFECTS AND MANAGEMENT OF INFLAMMATION
KNOW HOW TO STRENGHTEN IMMUNITY
IDENTIFY COMMON ALTERATION IN CIRCULATION AND ITS MANAGEMENT

TEACHING STRATEGIES:

LECTURE DISCUSSION
FILM SHOWING
REPORTING
GROUP DYNAMICS

EVALUATIVE MEASURES:

RECITATION
PAPER AND PENCIL EXAMINATION
GROUP DISCUSSION
RESEARCH / ARTICLE WORKS
QUIZ BEE
 CONCEPTS IN ADAPTATION AND HOMEOSTASIS

ADAPTATION a change or alteration designed to assist in adapting to a new situation or

environment

HOMEOSTASIS - a steady state within the body, the stability of the internal environment

STRESS a disruptive condition the occurs in response to adverse influences from the internal or
external environment.

Types of Stressors

1. physical
2. physiologic
3. psychosocial

Classification Of Stressors

1. Day to day frustration or hassle ei. Traffic jam

2. Major complex occurrence involving involving group or nation ei. Terrorism
3. Stressors that occur less frequently and involve fewer people ei. Death or marriage

Psychological Responses to Stress

COGNITIVE MOTIVATIONAL THEORY

cognitive appraisal ( what is at stake & what can be

Lazarus meditating process done )
coping

Coping with the stressful event

cognitive efforts problem focused -aims to make direct changes so that
Lazaruz situation can be manage effectively
behavioral efforts emotion focused tends to lessen the emotional stres
Physiologic Response to Stress

Selye's theory of Adaptation

A. General Adaptation Syndrome (GAS)
Phases:
1. Alarm sympathetic response ( fight or flight), release of cathecolamines and
adrenocorticotropic hormone ACTH
2. Resistance adaptation to noxcious stressor
3. Exhaustion - occurs if the exposure to thje stressor is prolonged

B. Local Adaptation Syndrome (LAS)

-includes inflammatory response and repair process that occur at the local site
of tissue injury

Sympathetic Nervous System Responses increase heart rate, vasoconstriction, increase bp,
increase blood sugar, dilation of pupil, increase mental
activity, cold feet, clammy skin and hands, palpitations, the
person appears tense, muscle are tensed, respiration is
rapid and shallow

Stress at the Cellular Level

Different cells and tissues respond to stimuli with different patterns and rate of responses and some
cells are more vulnerable to one type of stimuli or stressors than the others

ei. Cardiac muscles cells respond to hypoxia more quickly than do smooth muscles cells

Negative Feedback Mechanism throughout the body monitors the internal environment and restore
homeostasis when condition shift out of the normal range

ei. accumulation of lactic acid in an exercised muscle stimulates dilation of blood vessels in the area to
increase blood flow and improve the delivery of oxygen and removal of waste products

Positive Feedback Mechanism - mechanisms are designed to accelerate or enhance the output created
by a stimulus that has already been activated.

Cellular Adaptation

Cellular Injury is defined as a disorder in steady state regulation

A. Hypoxia

B. Nutrional imbalance
C. Physical Agents
1. Temperature
2. Radiation and electrical shock
3. Mechanical Trauma

D. Chemical Agents lye, mercury, arsenic, lead

increase in hydrochloric acid = irritates stomach lining
decrease glucose = coma
alcohol breakdown into acetaldehyde toxic to liver cells ( cirrhosis )

E. Infectious Agents viruses, bacteria, fungi, protozoa, nematodes etc

Factors to consider: number of organism, virulence and host's defenses

F. Disordered Immune Response hypoactive increase chance to acquire diseases

hyperactive hypersensitivity disorders

G. Genetics Disorder sickle cell disease, cystic fibrosis, hemophilia, breast cancer, cardiovascular
disease etc

CELLULAR HEALING

Regeneration - ( revive, reproduce) proliferation of cells of the same type as those destroyed
Replacement 1. Primary intention healing
2. Secondary intention healing

STRESS MANAGEMENT

Interventions
Probable Nsg Dx Anxiety, ineffective coping pattern, impaired thought process

Goal - directed toward reducing and controlling stress ans improving coping mechanism

I. PROMOTING A HEALTHY LIFESTYLE

Health Promotion Goal 1. prevention of stress
improve the quality of life
stress control

internal resources healthy eating habits and relaxation tech.

stress reducing methods and
coping enhancements
external resources broad social network
~ level of education should be determined to know the level or approach of health teaching or
strategies of teaching

Health Risk Appraisal identification of habits or lifestyle ei. Smoking ( stop smoking )
 I. COPING ENHANCEMENT STRATEGIES assisting patient to adapt, to perceived
stressors, changes or threat that interfere with
meeting life demands and roles

II. RELAXATION TECHNIQUES

Five Predominant ways of Coping with Illness
1. Trying to be optimistic about the outcome
2. Using social support
3. Using spiritual resources
4. Trying to maintain, control either over the situation or over feelings
5. Trying to accept the situation

TEACHING RELAXATION TECHNIQUES

Goal : to produce a response that counters the stress response

Elements needed during relaxation

1. a quiet environment
2. comfortable position
3. a passive attitude
4. a mental device ( ei. Word, phrases or sound )
A. Progressive Muscle Relaxation
involve tensing and releasing the muscles of the body in sequence and sensing the
difference in feeling

B. Benson's Relaxation Techniques

Steps : 1. Pick a brief phrase or word that reflects your basic belief system
2. Choose a comfortable position
3. Close your eyes
4. Relax your muscles
5. Become aware of your breathing ans star using you selected words
6. Maintain a passive demeanor
7. Continue for a set period of time
8. Practice the techniques twice daily

note: its a combination of meditation and relaxation, if the are distractions ( pain, noise ) do not fight
the distraction instead continue to repeat the focus phrase or words

C. Relaxation with Guided Imagery

is a mindful use of a word, phrase or visual image for the purpose of distracting
situation or consciously taking to relax or reenergize.

D. Other forms of Relaxation

IV. ENHANCING SOCIAL SUPPORT
* cared for and loved
* esteemed and valued
* boost social and emotional support

V. RECOMMENDING SUPPORT AND THERAPY GROUPS

- Support groups exist especially for people in similar stressful situations

- Professional, civic and religious support groups are active in many communities

ALTERATION IN IMMUNOLOGIC SYSTEM

Normal Immunity refers to the body specific protective response to an invading foreign agent or
organism, function as the body defense mechanism against invasion and
allows a rapid response to foreign substances in a specific manner

TYPES OF IMMUNITY

1. Natural ( innate )- is a non specific immunity that is present at birth

2. Acquired ( adaptive ) - develops after birth
Active developed by the persons own body
Passive immunization / breast feeding

Components of Immune system

* bone marrow * neutrophils
* wbc * eosinophils and basophils
*lymphoid tissue ( lymhnode, tonsils, spleen )

Physical and Chemical Barriers

Physical surface barriers intact skin, mucous membrane and cilia of the respiratory tract which
prevents pathogens from gaining access to the body

Chemical barriers mucous, acidic gastric juice secretions, enzymes in the tears ans saliva and
substances in sebaceous and sweat secretions act in a non-specific way to
destroy invading bacteria and fungi

Response to Invasion
When the body is invaded on attacked by bacteria, viruses or other pathogens, it has 3 means of
defense
1. phagocytic immune response
2. humoral / antibody immune response
3. cellular immune response
TYPES OF IMMUNODEFICIENCY

A. Primary Immunodeficiency are genetic in origin and are caused by intrinsic defects in the
cells of the immune system ei. Thymic hypoplasia ( T lymphocytes ), Nezelof's syndrome ( B-T
lymphocytes

Treatment
1. Antibiotic therapy
2. Granulocyte transfusion
3. Stem cell transplantation / bone marrow transplantation
4. Immunoglobulin infusion

B. Secondary Immunodeficiency are caused by triggers such as infection with Human

Immunodeficiency Virus ( HIV )

Treatment
1. Early treatment of underlying disease process
2. Teaching patient to avoid or control factors that contribute to immunosuppression
3. Using sound principle of infection controlling
4. Emotional, psychological and spiritual support
 COMMON ALTERATIONS IN CIRCULATION

NORMAL CIRCULATORY DYNAMICS

Systemic circulation and Pulmonary circulation

ATHEROSCLEROSIS AND ARTERIOSCLEROSIS

ATHEROSCLEROSIS it affects the intima of the large and medium sized arteries. These changes
consists of accumulation of lipids, carbohydrates, fibrous tissue on the
intimal layer of the artery

ARTERIOSCLEROSIS - it is the hardening, narrowing and thickening of the arteries

Types of Deposition Commonly affected arteries

1. Fatty streaks Femoral, Popliteal, Aortal and Iliac Arteries
2. Fibrous Plaques

Risk Factors for Atherosclerosis ans Peripheral Arterial Disease

Modifiable Risk Factor

nicotine use - sedentary lifestyle
diet (hyperlipedimia ) - stress
DM - obesity
hyperhomocysteinemia ( protein that promotes coagulation by increasing factor 5 and 9 )
elevated C reactive protein ( marker for cardiovascular inflammation )

Non-Modifiable Risk Factor

age - genetics
gender
Prevention
1. know your serum cholesterol level
2. modify diet- low fat, low sodium, low cholesterol
3. exercise

Possible Clinical Manifestations

> cardio angina and MI
> cerbro TIA
> athesclerosis aorta ----> aneurysm
- atherosclerotic lesions of the extremities

DIAGNOSTICS( Radiologic Interventions)

I. Arteriogram

II. Angioplasty ( percutaneous transluminal angioplasty )

Complication:
1. hematoma
2. embolus
3. dissection separation of the intima of the vessles
4. bleeding
III. Doppler study

IV. Treadmill testing

V. Duplex Ultrasonography

Sign and Symptoms

Claudication pain, pallor, rubor, weak or absent peripheral pulses and ulcerations
MEDICAL MANAGEMENT

Pharmacology:

HMG-CoA Reductase Inhibitors or Statins ei. Atorvastatin ( Lipitor ); Lovastatin ( Mevacor )

Simvastatin ( Zocor )

Bile Acid Sequestrants ei. Cholestyramine ( Prevalite ); Colesevelam ( Welchol )

Cholesterol Absorption Inhibitor ei. Ezetimibe ( Zetia )

SURGICAL MANAGEMENT
1. Inflow Procedure improves blood supply from the aorta into the femoral artery
ei. Lumbar Sympathectomy, Balloon Catheter Dilation

2. Outflow Procedure provides blood flow supply to vessels below the femoral artery
ei. Bypass Grafting. Endarterectomy
NURSING MANAGEMENT
A. Improving Peripheral Arterial Circulation

B. Promoting Vasodilation and Preventing Vascular Compression

C. Relieving Pain

D. Maintaining Tissue Integrity

E. Promoting Home and Community Based Care

PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

Claudications

MEDICAL MANAGEMENT
Pharmacologic Therapy
1. Pentoxifylline ( Trental ) - increases RBC flexibility, anitplatelet effect
2. Cilostazol ( Pletal ) - vasodilation, stops platelet aggregation
3. Clopidogrel ( Plavix ) - prevent thrombus formation

SURGICAL MANAGEMENT
1. Vascular grafting
2. Endarterectomy
3. Arterial bypass

THROMBOANGITIS OBLITERANS ( BUERGERS DISEASE )

Characterized by recurring inflammation of the intermediate ans small arteries and veins of the
lower and in rare cases upper extremities; usually bilateral.

Causes :
occlusion of the vessels
autoimmune disease ( autoimmune vasculitis )

Aggravating Factor : heavy smoking

DIAGNOSTICS
Duplex Ultrasonography use to document patency of the proximal vessels and to visualize
the extent of distal diseases

Contrast Angiography use to identify proportion of the anatomy

MEDICAL MANAGEMENT
same as Atherosclerosis
NOTE Vasodilators are rarely prescribed because these medications causes dilation of only healthy
vessels; vasodilators may divert blood away from the partially blocked / occluded vessels thus
exacerbating the manifestation of the disease

ANEURYSM

Is a localized sac or dilation formed at a weak point in the wall of the artery

Thoracic Aortic Aneursym athesclerosis

men 40-70 yo
dissecting aneurysm

Clinical Manifestation
pain is the common symptom
dyspnea pressure against the trachea and the main bronchus
hoarseness, weakness or complete loss of voice pressure against laryngeal nerve
dysphagia due to impingement on the esophagus

DIAGNOSTICS
Chest xray
Transesophageal Echocardiography
CT scan
Aortography shows exact location of the Aneurysm
MEDICAL MANAGEMENT

1. Controlling blood pressure antihypertensive medication ei. Hydralazine

2. Vascular graft

Abdominal Aortic Aneurysm

Common Cause : atherosclerosis, congenital weakness and trauma
Common affected area Below the renal arteries ( Infrarenal aneurysm )
Risk Factor genetic predisposition, tobacco use and hypertension

Clinical Manifestations
_ only 40% of patients with abdominal aortic aneurysm have symptoms
_ some complaint that they can fell their heart beating in their abdomen when lying down
_ if emboli is present may lodge to interosseuos or digital arteries so cyanosis & mottling
_ mid or low back pain
_ diminished peripheral pulses

DIAGNOSTICS
- same as Thoracic-

MEDICAL MANAGEMENT

Pharmacologic Therapy
Antihypertensive ACE inhibitor, Betablocker, Diuretics

SURGICAL MANAGEMENT
Resecting the vessel ans sewing a bypass graft in place
Endovascular Grafting transluminal placement and attachment of a sutureless aortic
graft prosthesis

Other Types of Aneurysm

1. Subclavicular
2. Femoral
3. Renal
4. Popliteal
 DISSECTING AORTA

in an aorta disease by arteriosclerosis, a tear develops in the intima or the media degenerates,
resulting in a dissection

PATHOPHYSIOLOGY:

Predisposing Factor : hypertension, blunt chest trauma, cocaine use

increase in the force of left ventricular contraction

heightened shear forces upon the aortic wall

disruption in the intimal wall or layer

dissection results

Clinical Manifestations:

severe persistent pain at the anterior chest or back which extend to the shoulders, epigastric area or
abdomen, pale, sweating and tachycardia

DIAGNOSTICS

Arterigraphy, CT Scan, Transesophageal echocardiography, Dupplex Ultrasound and MRI

MANAGEMENT
- same as Aortic Aneurysm -

ARTERIAL EMBOLISM AND ARTERIAL THROMBOSIS

Thrombosis a condition in which the blood changes from liquid to a solid state and produces a
blood clot. Thrombosis in an artery obstructs the blood flow to the tissue it supplies ei. Brain tissue

Embolism the condition in which an embolus becomes lodge in an artery and obstructs its blood
flow ei. Pulmonary Embolism

Causes: IV insertions like Arteriography, stent placement

Clinical Manifestation:
The symptoms of arterial emboli depends primarily on the site, the organ involved abd the site of the
collateral vessels
6 P's associated with acute embolism are:
1. Pain
2. Pallor
3. Pulselessness
4. Paresthesia
5. Poikilothermia ( coldness )
6. Paralysis

DIAGNOSTICS
Transesophageal Echocardiograhpy, Chest Xray, Arteriography, Duplex Ultrasonography

MANAGEMENT
*Arterial Thrombosis depends on its cause
*Acute embolic occlusion usually requires surgery
Heparin Therapy to prevent development of emboli

SURGICAL MANAGEMENT

1. Emergency Embolectomy procedure of choice

2. Percutaneous thrombolectomy Bacchu Trellis Device *********

Pharmacologic Therapy

IV anticoagulation with Heparin

Antithombolytic dissolve embolus (ei. Activase, Retavase )
Note: contraindicated with active internal bleeding, stroke, recent major surgery, uncontrolled
hypertension and pregnancy

NURSING MANAGEMENT
1. The affected part is kept at room temperature and protected from trauma
2. Heating and cooling pads are contraindicated
3. Watch out to patient reaction to heparin therapy ei. bleeding
4. Minimize the number of punctures for inserting IV lines and obtaining blood samples,
IM injections etc.
5. Monitor patients who are on anticoagulant therapy to prevent thrombosis on the affected
artery and to diminish the development of subsequent thrombi at the initiating site
6. Monitor for systemic hemorrhage and mental status
7. Vital signs are monitored esp. pulses

RAYNUAD'S DISEASE
is a form of intermittent arteriolar spasm or vasoconstriction that results in coldness, pain,
and pallor of the finger tips or toes.

# Cause is unknown but theorist say it may occur with obstructive arterial disease, rheumatoid
arthritis. But may be triggered by emotional factors or by unusual sensitivity to cold and trauma
Clinical Manifestations
pallor due to constriction
cyanosis
rubor ( red color) occurs when proper blood circulation returns after vasospasm
Raynuads Phenomenon White, Blue and Red
numbness, tingling sensation and burning pain
atrophy of the skin and muscles
ulcerations and gangrene may rarely occur

MANAGEMENT
Avoid stimuli ei. Cold and tobacco that provokes vasocontriction
Calcium channel blockers ei. Nifedipine may be effective in relieving symptoms
Sympathectomy interupting sympathetic nerves by moving the sympathetic ganglia
Lifestyle modification and patient teaching and stress management
Inform patient about postural hypotension may result from medication ei. Nifedipine

VENOUS DISORDERS

VENOUS THROMBOSIS / DEEP VEIN THROMBOSIS

Factors known : VIRCHOWS TRIAD

1. Stasis of blood 2 Vessel wall injury 3. Altered circulation

ei. - prolong bed rest or
immobilization
-obesity
-history of varicosities
-spinal cord injury
-age, above 60 yo
- trauma or surgery - pregnancy
- central venous catheters - polycythemia
- dialysis access catheter - septicemia
- local vein damage - oral contraceptives
- anticoagulant therapy

HOMAN'S SIGN pain in the calf after the foot is sharply dorsiflexed can be manifested

Complication:
-chronic venous occlusion
-pulmonary emboli from dislodge thrombi
-valvular distraction ei. Venous ulcers and varicosities
-venous obstruction ei. Stasis, edema and venous gangrene

PREVENTION
1. Application of compression stockings
2. Use of intermittent pneumatic compression devices
3. Proper body positioning and exercise
4. Low Molecular Weight Heparin ( LMWH ) or subcutaneous unfractionated Heparin
MEDICAL MANAGEMENT

Pharmacologic Therapy

1. Unfractionated Heparin SQ or intermittent or IV infusion

- prevents extensions of a thrombosis and development of a new
thrombi
- Monitor APTT ( activated partial thromboplastin time )
- Monitor INR ( international normalized ratio )
- Monitor platelet
2. Low Molecular Weight Heparin SQ, action: same as unfractionated heparin plus decrease
bleeding complication and decrease heparin induced
thrombocytopenia ei. Dalparin ( Fragmin ) and
Enoxaparin ( Lovenox )
3. Thrombolytic Therapy - lyses and dissolves thrombi ei. Activase and Retavase
Caution: thrombolytic therapy results in a three fold greater
incidence of bleeding than Heparin

4. Factor Xa Inhibitor SQ, selectively inhibits factor Xa ei. Arixtra

5. Oral Anticoagulants Oral ei. Warfarin ( Coumadin )

- routine coagulation monitoring is essential
- contraindication: bleeding, aneurysm, severe trauma, alcoholism,
hepatic or renal diseases, infection, recent or
impending surgery of spinal cord, brain and
thrombocytopenia

SURGICAL MANAGEMENT
- Thrombectomy removal of the thrombus. Vena cava filter may be in place at the surgical
time to filter / traps large emboli and prevent pulmonary embolism

- Balloon Angioplasty and Stent placement can be performed

NURSING MANAGEMENT
1. Monitor bleeding tendencies
2. Kidney and liver functions are closely monitored
3. Monitor hematologic studies ei. Hct level, coagulation time, platelet count, prothrombin time
4. Close monitoring of drug therapy: proper time, know drugs that potentiates or inhibit the
therapy
5. Providing comfort bed rest, elevation of the affected extremity to reduce swelling, elastic
compression stockings and analgesic therapy
6. Compression Therapy elastic compression stockings, usually are prescribed for patients with
venous insufficiency

7. Encourage exercise repetitive dorsiflexion of the foot, active and passive leg exercises
particularly involving the calf muscles should be encourage.
- gradual and early ambulation
- refrain from sitting or standing too long
 CHRONIC VENOUS INSUFFICIENCY

results from obstruction of the venous valves in the legs or a reflux of blood through the
valves

Manifestations
When the calves in the deep veins become incompetent after a thrombus has formed, post thrombotic
syndrome may develop.

Chronic venous stasis, edema, pain and stasis dermatitis, dilated superficial veins, stasis ulcer may
develop as a result of the rupture of small skin veins

Complication : Venous Ulcerations

MANAGEMENT

Goal: reducing venous stasis and preventing ulcerations

1. Elevate legs and application of elastic compression stockings , 15 to 30 min q 2 hrs

2. Discourage prolong sitting and standing and crossing legs
3. Avoid constrictive garments
4. Legs should be protected from trauma and skin care is rendered
 VARICOSE VEINS
are abnormally dilated, tortuous superficial veins caused by incompetent venous valves
commonly affected are veins in the lower extremities

People who are at risk : - sales people, hair stylist, teachers, nurses and ancillary medical personnel
and construction
*hereditary weakness of the vein wall
*pregnancy due to increase blood volume, increase pressure by the uterus
hormonal effect
Manifestation
dull aches, muscle cramping, increase muscle fatigue in the lower legs, ankle edema and a
feeling of heaviness of the legs and appearance of a tortuous superficial veins

DIAGNOSTICS
Venography injecting a radiopaque contrast
Duplex scan measure the severity of valvular reflux

Prevention
same as venous insufficiency -

MEDICAL MANAGEMENT
1. Ligation and stripping of varicose veins

2. Thermal Ablation A. Radiofrequency Ablation - use of electric contrast

B. Laser Ablation uses laser fiber tip that seals the veins
Caution: *Compression stocking are applied for 48hrs post ablation
*Ambulation should be encouraged for at last 3weeks and should have
compression stockings
*No swimming for 3weeks

3. Sclerotherapy involve injection of an irritant chemical into a vein to produce phlebitis and
fibrosis thereby obliterating the lumen of the veins, performed on small veins

MANAGEMENT

1. Ambulation is encouraged as soon as possible.

2. Elastic compression stockings are worm continuously for about 1week
3. Standing and sitting are discouraged
4. Elevated foot part of the bed when lying
5. Analgesic may be given to reduce pain
6. Dressing at the surgical sites NO application of skin lotion until the site is healed
 LYMPHATIC DISORDERS

LYMPHAGITIS AND LYMPHADENITIS

LYMPHAGITIS in an acute inflammation of the lymphatic channels caused by infectious

organism usually hemolytic Streptococcus

Clinical Manifestation
*Lymphnodes along the coarse of lymphatic channels becomes enlarged, red and tender
( Acute Lymphadenitis )
*may form an abcess ( Suppurative Lymphadenitis )
*recurrent episodes may have Lymphadema

MANAGEMENT

1. Antibiotic therapy
2. Elastic stocking compression or sleeve to prevent edema

LYPHEDEMA A. Primary ( Congenital Malformation )

ei. Lyphedema Praecox- cause by
hypoplasia of the lymphatic
system tissue swelling occurs in the extremities
because of an increase quantity of lymph

B. Secondary ( Acquired Obstruction )

commonly seen in patient after axillary
node dissection ei. Breast cancer

Clinical manifestation
*edema is soft pitting if it progresses becomes firm and non-pitting and unresponsive to
treatment

ELEPHANTIASIS obstruction caused by parasite ( filaria )

Clinical Manifestation
*swelling of extremities, high fever and chills. Persistent edema or swelling will lead to chronic
fibrosis,thickening of the subcutaneous tissue and hypertrophy of the skin

MEDICAL MANAGEMENT
Goal: reduce and control edema and prevent infections

Interventions:
1. Active/passive exercise , assist in moving fluid into the bloodstream
2. External compress devices compression stockings and sleeves
3. If severe edema is present let patient rest and elevate legs
4. Manual lymphatic drainage is a highly specialized massage technique designed to direct or shift the
congested lymph through functioning lymphatics that have preserve drainage
5. Proper skin care
6. Antibiotic therapy and diuretic
 CELLULITIS

occurs when an entry point through normal skin barriers allow bacteria to enter and relase
their toxins in the subcutaneous tissues
ofter misdiagnosed, usually as recurrent thrombophlebitis or chronic venous insufficiency

MANAGEMENT
1. Antibiotic therapy IV antibiotic
2. Skin hygiene and patient education
3. Elevate affected area above heart level, apply warm and moist pack to the site every 2-4hrs.
Caution for patient with DM

MANAGEMENT OF PATIENT WITH HYPERTENSION

Hypertension is a systolic blood pressure greater then 140mmhg and a diastolic pressure greater
than 90mmhg. Sometimes called as a Silent Killer

Classification of Hypertension

BP Classification Systolic BP Diastolic BP

Normal < 120 and < 80
Prehypertension 120 139 or 80 89
Stage 1 hypertension 140 159 or 90 99
Stage 2 hypertension > 160 or > 100

Primary HPN ( unidentified cause )

Kinds

Secondary HPN ( identified cause ) ei. narrowing of renal arteries, renal

parenchymal disease, certain medications,
pregnancy and coarctation of the Aorta

Risk Factors
cigarette smoking * atherosclerosis and arteriosclerosis
alcoholism * high level of cholesterol
stress * age above 50 yo
renal problem increase reabsorption of sodium and water
patient with DM
obesity
genetics
Clinical Manifestation
1. Some may be asymptomatic for month and years however when specific sign and sypmtoms
appear they usually indicate vascular damage
2. Retinal damage hemorrhage
3. MI and Angina is a common consequence of HPN
4. Left ventricular hypertrophy
5. Increase S+BUN and creatinine indicates kidney failure
6. TIA or cerebrovascular may worsen for patient with uncontrolled HPN
7. Occipital headache, blurring of vision, dizziness/vertigo, faintness, nausea and vomiting and
epistaxis

DIAGNOSTICS
ECG
Electrocardiography
Blood chemistry ei. Na and K, BUN and creatinine, glucose and cholesterol levels
Urinalysis
2D echo

MEDICAL MANAGEMENT
Goal: to prevent complication and death, lower blood pressure

Pharmacology ( SEE SCHEMATIC DIAGRAM )

 ***** SEE TABLE OF ANTIHYPERTENSIVE MEDICATIONS ******

Early detection
preventive measure is better then curative
controlling rather than curing

INCREASING KNOWLEDGE
1. Patient needs to know all about HPN
2. How lifestyle and medication are important to the regimen
3. Dietary instruction low Na, low fat, high in fruits and vegetable

4. Regular and gradual gradient in physical activity or exercise

5. Limit or Prohibit alcohol intake and tobacco consumption
6. Weight control and stress reduction techniques
7. Regular monitoring of pulse and blood pressure, teach caregiver at home and patient to
monitor
8. Involve the family members and friends in conducting health teachings
9. Strict adherence to medications; tell patient its action, side effects and who to refer if side or
adverse effects occurs
10. For elderly clients: simplify instructions, write instructions a piece of paper clear and simple
11. Regular check up with the physician and blood chemistry monitoring including physical
assessment should be made from time to time to prevent complications