nurse's notes

BACTERIAL PNEUMONIA - most common when upper respiratory infection during rainy season or winter or spring.

CAUSATIVE AGENT:

• pneumococci
• staphylococcus aureus
• klebsiella pneumonea
• streptococcus hemolyticus
• hemophilus influenzae

SIGNS AND SYMPTOMS:

• sharp pain in the chest and prevent him from deep breath
  
• severe chilling
• high grade fever
• rapid respiration
• expiration punctuated with grunt
• dyspnea- difficulty of breathing
• initially, sputum clear but eventually rusty in color and tenacious
• 
  

TREATMENT AND NURSING MANAGEMENT: As Per doctor's order

• Oxygen Inhalation Therapy-indicated if patient is cyanotic, dyspneic or complain of pain when breathing
• analgesic, antitussive medication - alleviate the harassing cough, reduce the pain of pleurisy
• Antipyretic Drugs- control fever and general malaise and muscular pains
• Anti distension therapy- for severe toxic patient and abdominal distension which impairs the efficiency of respiration
• Nutrition- soft solid food with high caloric value
• Increase fluid intake - milk will do because highly nutritious which is needed by his body. Fluids can liquefy tenacious secretions. Congestive heart failure demands careful supervision of fluid intake because of the danger of excess accumulation of fluid in the tissue and lungs producing pulmonary edema and death
• Elimination- avoid fecal retention by giving low saline enema
• Mouth care- assist to cleanse the mouth and lips
• Communicable disease prevention- observed medical asepsis in handling patient . and proper disposal of used mouth wipes and paper bags
• Monitor vital signs, Blood pressure and daily fluid intake and output and number of stool
  

reference: medical nursing book and my nursing notes

Bronchopneumonia -

• is a pneumonic process in one or more localized area within the bronchi extended to the lungs.
• post operative complication if patient refuse to cough because pain at the operative site when coughing

Prevention:

• For fully awake post operative patient, instruct deep breath frequently
• frequently change position from side to side
  
• patient head should be turn on side to other side
• splint incision or support the operative site and encourage to cough vigorously as much as possible
• frequent suctioning of secretion from mouth for unconscious patient to avoid the accumulation of secretions

reference: medical nursing book and my nursing notes

Pneumonia-

• an inflammation of the lungs
• a complication arises due to inability to cough out secretions
  
• classified according to causative agent like bacterial, viral, or chemical

Factors or circumstances that predisposes to develop pneumonia are the following:

• Aged individuals- who cannot cough effectively to expectorate secretions
• patient with chronic bronchitis or emphysema
• patient with cardiac failure
• patient with pulmonary congestion
• individuals who are intoxicated chemically
• patient who are bedridden for prolonged period in bed- relatively immobile and breath shallowly
• patient unable to cough effectively because of disability- shock or result of sedation with cough suppressing drug
• aspiration of foreign material into the lungs during period of unconsciousness like for example during anesthesia
  

Pulmonary emphysema-

• complex lung disease characterized by disrtuction of the alveoli
• enlargement of distal air space and
• breakdown of alveoli walls

Causes:

• excessive smoking
• air pollution
• progression of chronic respiratory infections
• exposure to air irritants like gasses or chemical pollution
• aged persons are prone due to in ability to move or coughing and failure of frequent deep breathing exercises
• allergy

Sign and Symptoms:

• cough
• dyspnea
• symptoms of infection as fever, chill
  

Management:

• avoid excessive smoking
• avoid exposure to something that make him allergic
• bronchodilators per doctor's order
• anti-microbial agents for infection
• steroids for the inflammatory effects
• oxygen therapy for hypoxemia

Reference : medical nursing books and my nursing notes

CHRONIC BRONCHITIS-

• chronic infection of the lower respiratory tract
• an inflammation of the bronchioles.
  

Signs and Symptoms:

• shortness of breath
• productive cough
  
• dyspnea- difficulty of breathing

PREVENTION:

• Stop smoking or keep away from smokers
• avoid exposure to irritating gasses or chemicals
• any acute upper respiratory infections should be treated at once because infection usually progresses down to lower respiratory then to pulmonary infection
• Always have our body a high resistance against infection by taking fruits that are rich in vitamin C. Vitamin C supplements still have to consult your doctor

.A patient's problem is the production of inflammatory exudates that obstruct his bronchioles causing a persistent productive cough and shortness of breath. Affected bronchioles may damaged and fibrosed resulting EMPHYSEMA AND BRONCHIECTASIS

ACUTE TRACHEOBRONCHITIS- acute inflammation of the mucous membrane of the trachea and the bronchial tree

CAUSES:

• often follows infection of the upper respiratory track
• inhalation of physical and chemical irritants like gasses or other polluted air
• patient with viral infection has a lower resistance and prone to develop secondary bacterial infection

Signs and Symptoms:

• mucopurulent sputum which is secreted by the edematous mucosa of the bronchi
  
• dry irritating cough
• sternal soreness from coughing
• fever
  
• headache
• general malaise
• if progresses , profuse and purulent and cough becomes looser
  

FOR CHILDREN- Acute Tracheobronchitis is serious disease and a child is acutely ill have noisy respiration with inter-costal retraction. Strict nursing monitoring of the child and prompt action for any respiratory obstruction:

FOR AGED are prone to develop Bronchopneumonia as a complication due to their inability to cough out secretions therefore tend to retain the mucopurulent exudate


Nursing Measures:

• bed rest
• increase fluid intake to liquefy the thick tenacious secretion and can be easily expectorate
• hot compress to relieve soreness and pain
• hot drinks may prove soothing
• Fruit juices are rich in Vitamin C will increase resistant against infection
• steam inhalation to loosen secretion and relieve laryngeal and tracheal irritation
• for aged- frequent turning side to side and put in sitting position
  

.

DYSPNEA -difficulty of breathing
it is a symptom common to:

• pulmonary conditions including :
  

1. tracheal and bronchial obstruction due to inflammation
   
2. pleurisy
   
3. tumors of the mediastinum
4. aspirated foreign bodies

• cardiac condition

• anemia

• psychiatric condition as anxiety

• acute disease of the lungs

• parynchymal lesion of the lungs

• atelectasis

Signs and Symptoms

• rapid respiratory rate or reduced
• each breath shallow and deep
  
• appear anxious
• pupils dilated mouth held open
• tongue , lips are dry
• skin become moist and cyanotic

Management:

• Bed rest
• Administration of oxygen inhalation therapy
• Treatment depends on the disease that causes dyspnea

Source:medical nursing book , my nursing notes

COUGH-

• an stimulus produced from an infectious process or from an irritant such as smoke , smog, dust or a gas
• a "watch dog" of the lungs- a protection against the accumulation of secretions in the bronchi or bronchioles
• it indicate pulmonary disease

If COUGH

• is harsh and loud -indicate a disease of the trachea or large bronchi
• is with painful, short dry cough may indicate a lesion of the parenchyma or pleura
• is with profuse amount of purulent sputum, patient may have an infectious process
• there is a gradual increase of sputum over a period of time may the symptom af chronic bronchitis or bronchiectasis
• with pink- tinged mucoid sputum is an indication of lung tumor
• profuse frothy pink material may indicate pulmonary edema

Nursing Measure for patient with cough:

• note the amount, odor, color of sputum
• mouth care and wise selection of food to stimulate his appetite
  
• proper environment - after proper washing of sputum cups, emesis basin should be remove away from his meal arrives to prevent him from loss of appetite emotionally
• encourage citrus fruits to feel a fresher mouth

.

Disease of the ADENOIDS

Disease of the Tonsil

TONSIL

• lymphatic tissue situated on each side of the oropharynx
• it is the common site of infection that may cause nephritis , arthritis

TONSILLITIS- inflammation of the tonsil or tonsils

SIGNS AND SYMPTOMS:

• pain upon swallowing
• enlarged tonsils
• feverish
  

NURSING MEASURES:

• warm saline gargles
• soft diet if pain upon swallowing

'TONSILLECTOMY-is a surgical removal of the tonsil or both tonsils .

SINUSITIS

SINUSITIS-is the inflammation of the mucous membrane of paranasal sinuses
due to viral upper respiratory infection

ACUTE SINUSITIS:
Signs and Symptoms:

• Pain:

1. frontal sinusitis-patient complain of headache in the frontal area
2. ethmoidal sinusitis-patient complain of pain near about the eyes
3. maxillary sinusitis- patient complain of pain is lateral to nose and sometimes accompanied by toothache in the upper corner side.
4. sphenoidal sinusitis- headache in the occipital area

• nasal congestion or discharging- may or may not be present
• patient feels generally miserable quite apart from pain
• fever is present if acute supurative infection

NURSING MEASURES:

• psychological support to a patient in pain
• bed rest
• keep patient comfortably as much as possible to alleviate mssirable feelings
• warm compress.
• proper disposal of tissues or anything used for the discharges

CHRONIC SINUSITIS- usually manifest by the following:

• persistent nasal obstruction due to the discharge and edema of the nasal mucous membrane
• cough produced by constant dripping of discharge back to the naso pharynx
• feeling facial fullness due to presence of nasal discharge
• headache

Upper Respiratory Disorders

RHINITIS

• is inflammatory lesion involving the mucous membrane of the nose
• sometimes due to allergy
• usually due to infection encountered in early stage of measle or other viral infections
• Acute Rhinitis-nasal membrane becomes congested swollen or edematous but this quickly subsides because this originates from the symptom of Chronic Rhinitis
  

NURSING MEASURES:

• cautioned the patient in blowing his nose not too hard and should be slowly
  
• instruct patient to open slightly his mouth while blowing through the nostrils to equalize the pressure
• proper disposal of secretions or discharges from the nose

NASAL OBSTRUCTION -obstruction of air passageway to the nostrils due to :

• deviated septum
• hypertrophy of the turbenate bone from the pressure of nasal polyps
• tumors, scars, adhesion

NURSING MEASURES:

• assist the physician in performing any procedures and be familiarized the solution of cocain and procaine
• be sure instrument are sterilized
• see to it that patient is emotionally and physically prepared for the procedure to be done

FRACTURE OF THE NOSE usually a result of accident or direct violence that deformed which rise the obstruction of air passages.

SIGN AND SYMPTOMS:

• disfigurement
• swelling
• bleeding of the nose and throat

NURSING MEASURES:

• application of ice compress in sitting position for any swelling
  
• assist the doctor in manual realignment
• prepare nasal packing or nasal splint
• prepare or sent patient for roentgenogram if ordered

'

PLASTIC SURGERY OF THE NOSE

• if nose is quite formerly deformed may cause the patient an embarrassment
  
• if deformity cause by congenital disease
• if deformity results from injury and surgery may needed

PRE-OPERATION CARE:

• get a consent of operation from parents or patient itself if at legal age
• psychological support to patient
• remove jewelries, bath and wear hospital gowns
• nothing per oral at least 8 hours before the operation

NURSING MEASURE AFTER THE OPERATION:

• placed flat on bed on his back with head slightly elevated
• ice compress to prevent bleeding, swelling or pain
• observed for any hemorrhage
• call a doctor if there is an exess bleeding and prepare for a new nasal packing, head mirror, nasal speculum, packing forcept for physician 's use
• liquid diet or soft diet
• psychological support to patient, and explain to him that he is attempted to blow his nose due to the packing applied to his nose and be patient untill be remove after 24 hours

STREPTOCOCCAL SORE THROAT- acute bacterial infection of the throat caused by a group of streptococci

SIGN AND SYMPTOMS:

• abrupt onset of sore throat
• chilly sensation
• fever
• headache
• body malaise
• swollen, palpable and tender cervical lymph nodes.

Advise Warm gargles , eat nutritious foods high in vitamin C to increase resistance

.

HERPES SIMPLEX INFECTION-commonly produce the familiar herpes labialis

Signs and Symptoms:

• Prodromal period - soreness, burning sensation, swelling in area where lesions will develop
• Small vesicles appear in the mucocutaneous junction of the lips or adjacent skin, single or clustered, may erupt on the lips, tongue, the cheeks and the pharynx
  
• Vesicles rupture- ulceration fuse together in form larger weeping ulcer and last 7-14 days

Nursing Measure:

• increase fluid intake
• encouraged to eat nutritious foods
• encouraged to drink enough fruit juices that are rich in Vitamin C-increase resistance to infection
• proper disposal of used tissue and other material used for the ruptured blisters
• advise regular and oral hygiene to make patient feel comfortable
• carry out prescribe medications intelligently.

'

Source: medical -Surgical Nursing Books

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Cancer Nursing

Cancer is one of the leading cause of death nowadays. It may strikes at any age but may cure at early treatment.

The nurse's role is very important in any team fighting cancer. Public health must have to promote prevention rather than to cure that the early detection and prevention is very effective in decreasing the mortality and morbidity of cancer.

Nurse's responsibility for early detection and avoiding farther stage of cancer.

• encourage to undergo diagnostic procedure
• psychological in spiritual support
• educate to meet the proper nutrition and the amount of fluids that must have to take daily
• carry out treatment and assist to learn the proper taking of treatment of malignancy itself
• assisting the rehabilitation and convalescence of the patient
• follow up all treated patients
• taking the collection of data for records
• assist planning for the care of individual who is not yet terminated

CANCER'S WARNING SIGNAL
C - hange in bowel or bladder habits
A - sore that does not heal
U - nusual bleeding or discharge
T - hickening lump in breast or elsewhere
I - ndigestion or difficulty in swallowing
O - Obvious change of wart or mole
N - agging cough or hoarseness

NURSING MANAGEMENT FOR TERMINAL CANCER

I. Control the carsinogenic growth.

• prepare and assist patient for surgery, radiotherapy, chemotherapy before during and after
• discuss the method of administration, expected side effect and the overall goal of therapy
• give psychological support
• listen and observe patient's anxieties

II. Give medications as prescribed by the doctor, like sedatives, anti histamine and anti emetic.

III. Prevent infection either local or systemic

IV. Maintain fluids and electrolytes because tissue metabolic rate is elevated and need to clear waste from the body

V. Combat anemia by offering bland high calorie and high protein foods

VI. Give low residue for any diarrhea

VII. Minimize nausea and vomiting. Give anti emetic as prescribed by the doctor. Advised oral care

VIII. Alleviate Pain

• evaluate the quality, intensity and duration of pain as well as patient's response to pain
• make patient feel comfortable and encourage turning side to side, moving or walking

IX. To control odor by maintaining overall proper hygiene. Remove the source of odor.

X. Control bleeding, monitor pulse rate, observe and record the amount of blood, put the pressure on the site if accessible.

XI. Prevent constipation, increase fluid intake, fruit juices, give suppositories as prescribed.

XII. Assist the patient to cope up with the situation

• shows to feel that the patient is understood
• develop a supportive relationship with the patient

XIII. Maintain good oral hygiene. Use mouthwash, brush teeth with soft toothbrush every after meal. | 1 comments

CYST

Cyst is an abnormal collection of fluid within a definite sac or wall.

Forms of Cyst

1. Retention Cyst

• called as sebaceous cyst
• when the outlet to a gland becomes black and the gland continues to secrete.

2. Epedermoid Cyst

• remnant of petal organs may secrete a fluid after forming a cyst of considerable size specially when springing from the pelvic organs of the female

2. Extravasation Cyst

• extravasation of blood in the tissues may become surrounded by definite wall

2. Hydatid Cystumor

• cyst that found in the liver formed by parasites especially taenia echinococcus (enchinococcus granulosus) or dog tapeworm.

'
DIFFERENCE BETWEEN BENIGN TUMOR AND MALIGNANT TUMOR

Benign Tumor

• has a mature differentiated type of cell.
• growth can be controlled
• does not recur
  
• usually localized

Malignant Tumor

• embryonic characteristic and poorly differentiated
• growth is uncontrollable and diffused
• has the ability to recur
• can spread to distant sites

.

It is a form of paroxysmal difficulty of breathing which is characterized by wheezy breathing.

SIGNS AND SYMPTOMS

• sudden cough
• tightness in the chest
• wheezy breathing
• exhaling is more strenuous and longer duration than inhale which force the patient to sit in upright position
• bluish of skin color and profuse sweating
• weak pulse
• lower extremities are cold
• maybe fever but occasionally pain, nausea and vomiting, sometimes diarrhea
  
• attacks may last for one hour to several hours and this could be fatal
• emotional stress may trigger a patient to asthmatic if he's susceptible
  

NURSING CARE

1. Place patient in a room free from noise
2. Avoid visitors and noisy relatives.
3. Alleviate patient's anxiety and exhaustion.
4. Give mild sedatives as prescribed by the doctor.
5. Use supportive devices like pillows to lie on in upright position comfortably.
   
6. Have positive and calm approach to patient
7. Ensure the patient to sleep well without any disturbance after an attack.
8. Educate patient and relatives to keep away the patient from precipitating factors that triggers future attack.
9. Remove patient from allergic materials.
10. Asthmatic children should provide with best available facilities for good mental and physical hygiene, proper rest, proper nutrition and social readjustment.
11. Control secondary infections

• encourage to eat nutritious foods
• increase fruit juices that are reach in vitamin C to increase resistance against infection
• keep patient away from those infections such as cough and colds
• educate the patient that any bluish discoloration of her skin or nails is abnormal and must report to the physician and not ignore it

.PREVENTION

1. Keep away patient from which material he's sensitive and allergic. i.e. pillows, mattress, cats

EARLY SYMPTOMS:

• hoarseness of voice

LATER SYMPTOMS:

• pain
• obstructed respiration
• difficulty of swallowing
• bleeding and swelling from tumor growth

CAUSES:

• excessive smoking
• too much drinking of alcohol
• vocal straining
• chronic laryngitis

.
NURSING MEASURES FOR PREOPERATIVE CARE:

• psychological preparation (try to alleviate worries; explain that he will lose natural voice completely but assure that there are ways in which he can carry on a normal conversation; tell that there are speech rehabilitation centers for speech therapy)
• get the operation consent from the patient or direct relatives
• oral care plus whole bath should be done
• shave the beard or excess hair near the neck down to the nipple lines
• carry out pre-operative medications

POST OPERATIVE CARE

TRACHEOSTOMY TUBE

• close attention for first 24 hours
• alleviate apprehension of the patient
• provide humidification (heavily saturated mist from a tent or ultrasonic fog or inhalation of nebulized water solution or mucolytic agents)
• secretion should be wiped away carefully and quickly before aspirated by the patient
• watch out for any hemorrhage from the tracheostomy site
• proper aspiration of secretion by sterile rubber

NASO-ESOPHAGEAL CATHETER

• intravenous fluids regulated correctly
• oral feeding start as ordered
• speaking deferred until doctor ordered
• observe for any excessive coughing and hemoptysis
• communication can be translated through writing
• naso-esophangeal can be removed by nurse if the doctor ordered
• teach patient how to feed himself with feeding tube
• oral care must be observed after feeding
• oral feeding starts after the wound is healed

EDEMA OF THE LARYNX

• since larynx is narrow and cannot be stretched, swelling of the laryngeal mucous membrane may close this orifice tightly and causes suffocation to the patient.

ACUTE LARYNGITIS

• is an inflammation of the larynx due to extention of respiratory infection caused by bacterial organisms.

SIGNS AND SYMPTOMS:

• hoarseness of voice
• complete loss of voice
• severe coughing

CHRONIC LARYNGITIS

• an inflammation of the larynx characterized by persistence hoarseness of voice.
• a complication of chronic bronchitis and chronic sinusitis.

CAUSES:

• frequent inhalation of irritating gasses
• excessive intake of alcohol
• too much smoking
• habitual over-use of voice

NURSING MEASURES

• patient should avoid talking or over-use of voice
• treat primary respiratory track infection
• patient should avoid smoking
• patient should avoid drinking alcohol

Source: medical- nursing book and my nursing notes